Abdominal Flashcards
What clinical signs should you look for at the beginning of the abdo exam
Age
Confusion
Pain
Scars
Distension
Colour (pallor, jaundice, hyperpigmentation)
Oedema (from liver cirrhosis in abdo usually)
Cachexia
Hernias
Which hernias may be visible from the end of the bed
(e.g. umbilical/incisional hernia). Asking the patient to cough will usually cause hernias to become more pronounced.
What is hyperpigmentation
bronzing of the skin associated with haemochromatosis.
Why is age important in an abdo exam
patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as inflammatory bowel disease (IBD) and older patients more likely to have chronic liver disease and malignancy.
What are features of hepatic encephalopathy
confusion
What objects should you look out for at the beginning of an abdo exam (8)
Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa).
Surgical drains: note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus).
Feeding tubes: (e.g. nasogastric/nasojejunal) is the patient currently being fed.
Other medical equipment: ECG leads, medications, total parenteral nutrition, catheters (note volume/colour of urine) and intravenous access.
Mobility aids
Vital signs
Fluid balance
Prescriptions
Which parts of the upper limb should you examine during the gastro exam
Palms
Nails
Wrist
Arm
Axillae
What are you looking for on the palms in a gastro exam
Pallor: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).
Palmar erythema: a redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).
Dupuytren’s contracture (eg genetics, excessive alcohol use, increasing age, male gender and diabetes.)
What should you look for on the nails in a gastro exam
Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).
Leukonychia: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy)
Clubbing: most likely to appear in an abdominal OSCE station include inflammatory bowel disease, coeliac disease, liver cirrhosis and lymphoma of the gastrointestinal tract.
What do you look for in a patient’s wrists in an abdo exam
Asterixis
Pulse (radial)
Temperature
In the context of an abdominal examination, the most likely underlying cause of asterixis is …?
either hepatic encephalopathy (due to hyperammonaemia)
or
uraemia secondary to renal failure.
CO2 retention secondary to type 2 respiratory failure is another possible cause of asterixis.
What do you look for on the arms of a patient in a gastro exam? (3)
What does each suggest?
Bruising: may suggest underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis).
Excoriations: scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis.
Needle track marks: important to note as intravenous drug use can be associated with an increased risk of viral hepatitis.
What do you look for in the axillae in a gastro exam
What do each indicate
Acanthosis nigricans: darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).
Hair loss: loss of axillary hair associated with iron-deficiency anaemia and malnutrition.
What do you look for in the eyes of a patient in gastro (6)
Conjunctival pallor: suggestive of underlying anaemia.
Jaundice: most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).
Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis).
Perilimbal injection
What is perilimbal injection
What disease is it associated with and what other clinical features are associated
inflammation of the area of conjunctiva adjacent to the iris.
a sign of anterior uveitis, which can be associated with inflammatory bowel disease.
Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity.
What do you look for when looking at a gastro patient’s mouth (5)
Why are each important
Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency (e.g. gastrointestinal malignancy, malabsorption).
Glossitis: smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).
Oral candidiasis: a fungal infection commonly associated with immunosuppression.
Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.
Hyperpigmented macules:
What is oral candidiasis characterised by
It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
Why are hyperpigmented macules important
pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.
What should you do after examining the face in a gastro patient
Palpate for lymphadenopathy:
Palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s node on the left for evidence of lymphadenopathy.
Which lymph nodes are important for the GI tract
Why
The left supraclavicular lymph node (known as Virchow’s node) - receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer).
The right supraclavicular lymph node - receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).
What are the 3 signs to look out for on the chest in a gastro exam
What do each suggest
Spider naevi: commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the combined oral contraceptive pill. If more than 5 are present it is more likely to be associated with pathology such as liver cirrhosis.
Gynaecomastia: enlargement of male breast tissue caused by increased levels of circulating oestrogen (e.g. liver cirrhosis). Other causes include medications such as digoxin and spironolactone.
Hair loss: also caused by increased levels of circulating oestrogen. General malnourishment can also result in hair loss.
What is spider naevi
skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen.
How should a patient be positioned when examining the abdomen
Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed for abdominal inspection and subsequent palpation.
Expose torso and pull down trousers
What things do you look for when inspecting the abdomen in a gastro exam
Scars: there are many different types of abdominal scars that can provide clues as to the patient’s past surgical history (see image below for examples).
Abdominal distension: can be caused by a wide range of pathology including the six f’s
Caput medusae: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).
Striae (stretch marks): caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).
Hernias: ask the patient to cough and observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).
Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).
Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).
What can abdominal distension be caused by
6 f’s: fat, fluid, flatus, faeces, fetus or fulminant mass
2 late signs of haemorrhagic pancreatitis
Cullen’s sign: bruising of the tissue surrounding the umbilicus 7
Grey-Turner’s sign: bruising in the flanks
What 4 features of a stoma should you note
Location: this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, ileostomies and urostomies are typically located in the right iliac fossa).
Contents: can be stool (e.g. colostomy or ileostomy) or urine (e.g. urostomy).
Consistency of stool: note if it is liquid (ileostomy) or solid (colostomy).
Spout: colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout.
What 3 things should you do before palpating a patient’s abdomen
The patient should already be positioned lying flat on the bed.
Ask the patient if they are aware of any areas of abdominal pain (if present, examine these areas last).
Kneel beside the patient to carry out palpation and observe their face throughout the examination for signs of discomfort.
What should you palpate on the abdomen
light palpation
deep palpation
Palpate the liver
Palpate the gallbladder
Palpate the spleen
Ballot the kidneys
Palpate the aorta
Palpate the bladder
What are you looking for when lightly palpating the abdomen (6)
What does each mean
Tenderness: note the abdominal region(s) involved and the severity of the pain.
Rebound tenderness: said to be present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain. This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).
Voluntary guarding: contraction of the abdominal muscles in response to pain
Involuntary guarding/rigidity: involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis).
Rovsing’s sign: palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa. This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa.
Masses: large or superficial masses (e.g. hernias) may be noted on light palpation.
If any masses are identified during deep palpation, assess the following characteristics… (5)
Location: note which of the nine abdominal regions the mass located within.
Size and shape: assess the approximate size and shape of the mass.
Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).
Mobility: assess if the mass appears to be attached to superficial or underlying structures.
Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).
How do you palpate the liver
- Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
- Ask the patient to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).
- Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.
- As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.
If you are able to identify the liver edge, you should assess which characteristics? (4)
What does each mean
Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.
Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.
Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)
Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.
Give some causes of hepatomegaly
Hepatitis (infective and non-infective)
Hepatocellular carcinoma
Hepatic metastases
Wilson’s disease
Haemochromatosis
Leukaemia
Myeloma
Glandular fever
Primary biliary cirrhosis
Tricuspid regurgitation
Haemolytic anaemia
Is the gall bladder usually palpable?
No
If the gallbladder is palpable it suggests enlargement secondary to biliary flow obstruction (e.g. pancreatic malignancy, gallstones) and/or infection (e.g. cholecystitis).
How do you palpate the gall bladder
Palpation of the gallbladder can be attempted at the right costal margin, in the mid-clavicular line (the tip of the 9th rib). If the gallbladder is enlarged, a well-defined round mass that moves with respiration may be noted.
