Gastrointestinal Examination
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- Karin Stephens
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1 1. General inspection (end of bed) Patient: - Jaundice? - General well being - Attitude of patient - Mental state - encephalopathy Gastrointestinal Examination Around the bed - Specific diet e.g. diabetic, vomit bowl, dialysis filter 2. Hands - Clubbing (GI lymphoma, liver cirrhosis, malabsorption coeliacs, inflammatory bowel disease) - Peripheral cyanosis - Capillary refill time (<3-4s) - Leuconychia (hypoalbuminaemia) - Koilonychia (Fe deficiency) - Beaus lines - Palmar erythema (cirrhosis, pregnancy, thyrotoxicosis, rheumatoid arthritis) - Dupuytrens contracture - Palmar crease pigmentation (Addisions) - ASTERIXIS (hepatic, renal, respiratory failure; salicylate overdose) 3. Radial pulse - Rate tachycardia with GI blood loss - Low volume with hypovolaemia 4. Blood Pressure 5. Arms - Spider naevi - Bruising - Wasting - Scratch marks 6. Face and eyes - Conjunctival pallor anaemia - Scleral jaundice - Kaiser Fleischer rings Wilsons - Xanthelasma Primary biliary cirrhosis - Parotid enlargement -? alcohol
2 7. Mouth - Lips Angular stomatitis/cheilosis Leucoplakia Localised pigmentation (Peutz Jeghers syndrome) - Gums - Tongue Gingivitis, bleeding Hypertrophy Pigmentation Atrophic glossitis B12 or Fe deficiency Furring leucoplakia 8. Neck - Cervical lymphadenopathy - Left supraclavicular fossa Virchovs node 9. Chest Inspection - Spider naevi liver failure, high oestrogen states - Gynaecomastia - Loss of hair 10. Abdomen inspection - Shape and movements with respiration. - Ask patient to suck in and blow out tummy to assess for peritonism - Distension (umbilical eversion) Localised mass, dilated bowel loop, organomegaly Generalised fluid, fat, fetus, flatus, faeces - Scars - Striae rapid weight gain, post partum, Cushings (red-purple) - Visible peristalsis bowel obstruction - Distended veins portal hypertension caput medusae - Divarication of the rectus or other hernias (lift legs off bed or cough) 11. Abdominal palpation kneel to level of abdomen - Superficial palpation assess tenderness and guarding
3 - Deep palpation abnormal masses size, consistency, shape, mobility for abdominal aortic aneurysm Pulsatile and expansile 12. Liver measure enlargement below costal margin in the mid-clavicular line Enlargement Soft and tender hepatitis or heart failure Firm and nodular early cirrhosis, metastasis or hepatocellular carcinoma Percuss from resonance to dull Potential displacement due to emphysematous lungs - Auscultation Friction rub Scratch test 13. Gall bladder - If palpable in presence of jaundice, not stones = Courvoisier - Inspiratory catch cholecystitis = Murphys sign 14. Spleen Start in right iliac fossa May need to turn patient to their right Dull to percussion - Auscultation Friction rub over infarct - Splenomegaly Huge chronic myeloid leukaemia, myelofibrosis, kala-azar, lymphoma Moderate haemolytic anaemia, portal hypertension, storage disease e.g. Gauchers Small infective endocarditis, infectious mononucleosis, typhoid - Hepatosplenomegaly Chronic leukaemia Myelofibrosis
4 15. Kidneys Cirrhosis with portal hypertiension Ballotment observing fullness in the flanks Normally resonant due to bowel overlying the retroperitoneal organs - Palpable kidneys Unilateral: carcinoma, hydronephrosis, cyst, hypertrophy Bilateral: PCKD, bilateral hydronephrosis, amyloidosis - Kidney vs Spleen Bimanual ballotment of kidney Notch of spleen Kidney resonant, spleen dull to percussion Kidney enlarges downwards, spleen towards right iliac fossa Palpate above kidney 16. Ascites Elicit horseshoe pattern of dullness Elicit shifting dullness (roll patient towards you) - Fluid thrill 17. Auscultation of abdomen - Bowel sounds Obstruction frequent, loud, high pitched, tinkling sounds Paralytic ileus absent sounds - Bruit Aortic (above umbilicus) Renal Iliac 18. Groin - Examine external genitalia - Examine for lymphadenopathy - Examine hernial orifices (+/- standing) 19. Digital rectal examination 20. Legs
5 - Inspection Swelling Purpura, bruising Cyanosis Toe clubbing? pitting ankle oedema Peripheral neuropathy (alcohol) 21. Additional tests - Basic observations: Blood pressure, temperature, respiratory rate, oxygen saturation - Urinalysis bilirubin - Faeces examination e.g. FOB, microscopy, culture
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