Clinical Gastro

• SOCRATES 
• Site 
• Onset of pain 
• Character 
• Radiation 
• Association 
• Time course 
• Exacerbating/Relieving factors 
• Severity

Feeling of fullness after food, belching and heart burn

Transpyloric plane - drawn midway between the suprasternal notch and the symphysis pubis (xiphisternum and umbilicus). This also corresponds to a plane drawn one hands breadth (of patient) below the xiphisternal junction.  The plane in most cases cuts through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra.

Trans tubercular plane - drawn by joining the tubercle of the iliac crest on either side. The tubercle of the iliac crest is found out by palpating backward from the anterior superior iliac spine where the tubercle is palpated in the iliac crest and usually lies 5 cm behind the anterior superior iliac spine.

The vertical planes are drawn on either side by joining the midclavicular point and the midinguinal point.

• Gastric - large peristaltic waves seen in the epigastrium, umbilical or as low as hypogastrium moving from left to right.
• Small intestinal - seen in central abdomen showing in step ladder pattern.
• Transverse colon - seen in the right hypochondrium, epigastrium, umbilical and left hypochondriac region moving from right to left

• • In portal hypertension - away from the umbilicus in both segments of the vein below and above the umbilicus.
• • In inferior vena cava obstruction, the flow will be from below to up in both segments of the vein.
• • In superior vena cava obstruction, the flow will be from above to down in both segments of the vein

• „ Acute cholecystitis
• „ Mucocele
• „ Empyema
• „ Carcinoma gallbladder
• „ Carcinoma of head of pancreas (Courvoisier’s law).

• In Moynihan’s method for elicitation of Murphy’s sign, the patient lies supine. Place the left hand on the right costal margin so that the thumb lies over the region of the fundus of gallbladder (area just lateral to the junction of the lateral border of right rectus abdominis and the tip of the right 9th costal cartilage). Exert moderate pressure with the thumb and ask the patient to take deep breaths.
• At the height of inspiration when the inflamed gallbladder impinges on the thumb there will be a catch in breath and patient will wince with pain. The Murphy’s sign is said to be positive.

This can be demonstrated by Puddle sign. Percuss around the umbilicus with the patient in knee elbow position. About 100 mL of free fluid should be present for Puddle sign to be positive.

• This can be done by head rising or leg rising test (Carnett’s test).
• Ask the patient to keep his hands over his chest and ask him to lift his head and shoulder off the pillow. If the swelling disappears or becomes less prominent then the swelling is intraabdominal.
• If the swelling becomes more prominent or remains the same then the swelling is parietal.
• For lower abdominal swelling this can be ascertained by leg rising test. Patient lies supine and is asked to lift both the legs from the bed. The interpretation is same as for head rising test.

• The intra-abdominal swelling may be intraperitoneal or retroperitoneal. Examine the lump in knee elbow position.
• If the lump disappears or becomes less prominent then it is a retroperitoneal swelling.
• If the lump becomes more prominent or remains the same then it is intraperitoneal