Abdominal Exam- Extra points

Question 1

Why should you ask the patient to tilt their head forward and put their chin on their chest

Answer 1

• Ask the patient to lift their head and put their chin against their chest - this allows you to check for:
o Hernia
o Divarication of the recti (the rectus muscles stretch and are pulled apart)

Question 2

What are the key features of clubbing

Answer 2

o Features of clubbing: ABCD
• Loss of Angle between the nail and nailbed
• Bogginess of nail bed
• Increase in longitudinal Curvature
• Drumstick appearance
o NOTE: when inspecting the hands for clubbing, it is worth squeezing the ends of the fingers to feel bogginess

Question 3

What are the causes of palmar erythema

Answer 3

o	Caused by:
•	Chronic liver disease 
	Caused by increased oestrogen associated with reduced hepatic breakdown of sex steroids 
•	Pregnancy (normal)
•	Idiopathic
•	Thyrotoxicosis
•	Polycythaemia
•	Connective tissue disorder e.g. SLE

Question 4

What are the causes of dupytren’s contractures

Answer 4

o	Caused by:
•	Usually idiopathic
o	More common in:
•	Alcohol dependence/liver cirrhosis
•	Epilepsy 
•	Diabetes 
•	Familial

Question 5

What is hepatic encephalopathy

Answer 5

o Hepatic Encephalopathy = cerebral dysfunction which results from the accumulation of toxics substances that are usually removed by the liver (e.g. ammonia)

Question 6

What should you look for when checking the pulse

Answer 6

o Look for an AV fistula for haemodialysis

Question 7

What is Wilson’s disease

Answer 7

o Caused by Wilson’s Disease = autosomal recessive genetic disorder in which copper accumulates in the liver, basal ganglia and eyes

Question 8

Describe some of the causes of the mouth signs

Answer 8

• Angular Stomatitis
o Iron deficiency

• Aphthous Ulcers
o Crohn’s Disease
o Coeliac Disease
o Immunocompromised e.g. HIV

• Scurvy (vitamin C deficiency)
o Soft haemorrhagic gums

• Buccal Pigmentation
o Haemochromatosis
o Peutz-Jeghers Syndrome

• Autosomal dominant condition where multiple hamartogenous polyps with low malignant potential affect the GI tract

Question 9

Describe some other mouth signs to look out for

Answer 9

• Other things to look for:
o Hydration status
o Glossitis (an inflamed tongue will be smooth with loss of papillae)
• PAINFUL - when due to B12/folate deficiency
• PAINLESS - when due to iron deficiency
o Hallitosis (bad breath due to decomposing debris or carious teeth)
o Fetor hepaticus (mousy odour) - caused by the accumulation of volatile aromatic substances in the blood due to defective hepatic metabolism

Question 10

What are the causes of spider naevi

Answer 10

o They are usually asymptomatic and usually resolve if liver function improves, or when COCP use stops/after childbirth
o Caused by:
• Chronic liver disease
• Pregnancy
• Combined Oral Contraceptive Pill (COCP)

Question 11

Describe gynaecomastia

Answer 11

o Benign enlargement of male breast tissue
o In liver disease it is caused by reduced hepatic breakdown of oestrogens
o Caused by:
• Puberty/old age
• Liver cirrhosis
• Drugs e.g. spironolactone, testicular tumour

Question 12

Describe the surgical scars relevant to the abdomen exam

Answer 12

o Midline Laparotomy = diagnostic, acute abdomen of unknown cause, trauma
o Left Paramedian = anterior rectal resection
o Lanz = appendicectomy or coecal operation
o Pfannensteil = C-section/hysterectomy/other pelvic operation
o Gridiron = appendicectomy
o Kochers = cholecystectomy

Question 13

What is cholestatic pruritus

Answer 13

o NOTE: cholestasis can lead to cholestatic pruritis, which occurs due to interactions of serum bile acids with opioidergic nerves

Cholestatic pruritus is the sensation of itch due to nearly any liver disease

Question 14

What are the main causes of ascites

Answer 14

• Accumulation of fluid (lymphatic) in the peritoneal cavity, causing abdominal swelling
• Caused by:
 Liver cirrhosis and portal hypertension
 Intra-abdominal malignancy with peritoneal spread
 Right-sided heart failure/congestive cardiac failure
 Nephrotic syndrome

Question 15

What is Sister Mary Joseph’s nodule

Answer 15

o Sister Mary Joseph’s Nodule = caused by visceral malignancy metastasising to the umbilicus

Question 16

Describe campbell de morgan spots

Answer 16

o Campbell de Morgan spots = dilated capillaries (normal finding)

Question 17

Describe the signs associated with acute severe pancreatitis

Answer 17

Grey Turner’s Sign:
 Bruising of the flank indicating retroperitoneal haemorrhage

Cullen’s Sign:
 Oedema and bruising of subcutaneous fatty tissue around umbilicus caused by enzymes tracking down falciform ligament

Question 18

Describe the role of anxiety in abdomen tenderness

Answer 18

• NOTE: anxiety may contribute to tenderness - note the pattern of tenderness and if it is distractable or not

Question 19

What are the causes of hepatomegaly

Answer 19

o Causes of Hepatomegaly:
• Alcoholic liver disease
• Carcinoma - primary or metastatic
• Chronic Cardiac Failure
• Infectious (hepatitis B or C virus)
• Autoimmune (primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis)
• Infiltrative (amyloid, myeloproliferative disorder)

Question 20

What are the causes of splenomegaly

Answer 20

o	Causes of Splenomegaly:
•	Infections (EBV, CMV) 
•	Tropical infections (malaria)
•	Myeloproliferative disorders (CML, MF)
•	Portal hypertension (causes congestive splenomegaly)

Question 21

What are the causes of renal enlargement

Answer 21

• Polycystic Kidney Disease
• Renal cell carcinoma
• Hydronephrosis
• Tuberous sclerosis (rare multi-system genetic disease that causes benign tumours to grow in the brain and in other vital organs(
o NOTE: the kidneys may be palpable in thin people without pathology

Question 22

Summarise palpation of the aorta

Answer 22

o Place your hands on either side of the umbilicus and push down to palpate the aorta
o Check whether the aorta is pulsatile AND expansile
o Expansile = the fingers are pushed outwards
o NOTE: in very skinny people, the aorta may be palpable and it will be pulsatile but it will NOT be expansile
o Abdominal Aortic Aneurysms (AAA) typically occur in people > 60 yrs
o Surgery is performed when the diameter of the aorta is > 5 cm

Question 23

Describe some other important signs on palpation

Answer 23

• Important Signs on Palpation
o McBurney’s point tenderness: tenderness at 1/3 of the distance between the ASIS and the umbilicus = likely appendicitis
o Murphy’s Sign: arresting inspiration on palpation of the gallbladder due to tenderness (i.e. in the right hypochondrium) = cholecystitis
o Courvoisier’s Law: jaundice + palpable non-tender gallbladder = likely due to malignancy, NOT gallstones

Question 24

Summarise auscultation of the abdomen

Answer 24

• Listen around the umbilicus for bowel sounds (you should hear gurgling sounds every 5-10 seconds)
• REDUCED frequency of bowel sounds - suggests a lack of intestinal activity e.g. paralytic ileus in generalised peritonitis
• INCREASED frequency of bowel sounds - suggests increased intestinal activity e.g. gastroenteritis
• ‘Tinkling’ (high pitched) bowel sounds - suggest bowel obstruction
• IMPORTANT: bowel sounds can be very irregular so you need to listen for at least 1 minute to get a true picture

Question 25

What are spider naevi due to

Answer 25

A spider naevus is a telengeastic arteriole in the skin with radiating capillary branches.
They occur in chronic liver disease due to obstruction of the superior vena cava

Question 26

What should you do if you suspect hepatic encephalopathy

Answer 26

Carry out a mini-mental test:

Date today (dat/month/year)
Date of brith
Name of reigning monarch
Date of WW1
Recognise 2 people or objects
Count backwards from 20
Recall an address

Question 27

Where should you look for jaundice in the mouth

Answer 27

The palate

Question 28

What is another mouth sign

Answer 28

Furring or dirtiness of the tongue

Question 29

How can you distinguish between different types of stoma

Answer 29

If flushed against the skin- colostomy

If stoma protrudes from the skin in form of sprout- ileostomy or ileal conduit

Question 30

Describe the bowel sounds in bowel obstruction

Answer 30

High pitched and tinkling

Question 31

Describe halitosis

Answer 31

Halitosis (bad breath) is a common symptom and is due to poor oral hygiene, anxiety (often when halitosis is more apparent to the patient than real) or rarer causes, such as oesophageal stricture and pulmonary sepsis.

Question 32

What is indigestion

Answer 32

‘Indigestion’ is common: 80% of the population will suffer from this symptom at some time. Dyspepsia is an inexact term used to describe a number of upper abdominal symptoms such as heartburn, acidity, pain or discomfort, nausea, wind, fullness or belching. Patients who use the term ‘indigestion’ may also be describing lower gastrointestinal symptoms such as constipation or the presence of undigested vegetable material in the stool, so obtaining a precise history is necessary.

Question 33

Describe the red flags associated with dyspepsia

Answer 33

Features of dyspepsia that are suggestive of serious diseases such as cancer are known as ‘alarm’ symptoms. They include:
• dysphagia
• weight loss
• vomiting
• anorexia
• haematemesis or melaena.
Patients aged ≥55 years who demonstrate these features have a higher possibility of significant gastrointestinal pathology and should be investigated on an urgent basis.

Question 34

Outline some causes of vomiting

Answer 34

• Any gastrointestinal disease • Infections:
– Viral (influenza, norovirus)
– Bacterial (pertussis, urinary infection) • Central nervous system disease:
– Raised intracranial pressure
– Vestibular disturbance, e.g. motion sickness – Migraine
• Metabolic:
– Uraemia
– Hypercalcaemia

Question 35

What causes vomiting

Answer 35

Vomiting is regulated by a complex reflex involving central neural control centres, located in the lateral reticular formation of the medulla, which are stimulated by the chemoreceptor trigger zones (CTZs) in the floor of the fourth ventricle, and also by vagal afferents from the gut. The central zones are directly stimulated by toxins, drugs, motion sickness and metabolic disturbances. Raised intracranial pressure has a direct effect on the vomiting centre, leading to vomiting. Luminal toxins, inflammation and mechanical obstruction are local gastrointestinal causes of vomiting.

Question 36

Summarise nausea and some other types of vomiting

Answer 36

Nausea is a feeling of wanting to vomit, often associated with autonomic effects, including salivation, pallor and sweating. It frequently precedes actual vomiting. Retching is a strong, involuntary, unproductive effort to vomit, associated with abdominal muscle contraction but without expulsion of gastric contents through the mouth.
Faeculent vomiting suggests low intestinal obstruction or the presence of a gastrocolic fistula.
Haematemesis is vomiting of fresh or altered blood (‘coffee-grounds’) (see pp. 384–387).
Early morning nausea and vomiting are seen in pregnancy, alcohol dependence and some metabolic disorders (e.g. uraemia).
Persistent nausea alone is often stress-related and is not due to gastrointestinal disease.

Question 37

Describe flatulence

Answer 37

This term describes excessive wind. It is used to indicate belching, abdominal distension, gurgling and the passage of flatus per rectum. Swallowing air (aerophagia) is described on page 430. Some of the swallowed air passes into the intestine, where most of it is absorbed, but some remains to be passed rectally. Colonic bacterial breakdown of non-absorbed carbohydrate also produces gas. Rectal flatus thus consists of nitrogen, carbon dioxide, hydrogen and methane. It is normal to pass rectal flatus up to 20 times/day. Causes of increased gas production and intake include a high-fibre diet and carbonated drinks.

Question 38

Describe some key facts of diarrhoea

Answer 38

• A single episode of diarrhoea is commonly due to dietary indiscretion or anxiety. • Large-volume, watery stools always have an organic cause.
• Bloody diarrhoea implies colonic and/or rectal disease.
• Acute diarrhoea lasting 2–3 days is most often due to an infective cause.
• Inflammatory bowel disease should be considered for severe or prolonged symptoms.

• Stool cultures should be taken to exclude an infective cause.

Question 39

When do patients often consider themselves constipated

Answer 39

Patients often consider themselves constipated if their bowels are not open on most days, though normal stool frequency is very variable, from 3 times daily to 3 times a week. The difficult passage of hard stool is also regarded as constipation, irrespective of stool frequency. Constipation with hard stools is rarely due to organic colonic disease

Question 40

Summarise abdominal pain

Answer 40

Organic abdominal pain is stimulated mainly by the stretching of smooth muscle or organ capsules. Severe acute abdominal pain can be caused by a large number of gastrointestinal conditions, and normally presents as an emergency (see pp. 432–435). An apparent ‘acute abdomen’ can occasionally be due to referred pain from the chest, as in pneumonia, or to metabolic causes, such as diabetic ketoacidosis or porphyria.
Check:
• site (Fig. 13.2), intensity, character, duration and frequency of the pain

• aggravating and relieving factors
• associated symptoms, including non-gastrointestinal symptoms

Question 41

Describe upper abdominal pain

Answer 41

Epigastric pain is very common and is often related to food intake. Although functional dyspepsia is the most common diagnosis, the symptoms of peptic ulcer disease can be identical. Heartburn (a burning pain behind the sternum) is a common symptom of gastro- oesophageal reflux.

Right hypochondrial pain may originate from the gall bladder or biliary tract. Biliary pain can also be epigastric. Biliary pain is typically intermittent and severe, lasts a few hours and remits spontaneously, to recur weeks or months later. Hepatic congestion (e.g. in hepatitis or cardiac failure) and sometimes peptic ulcer disease can present with pain in the right hypochondrium. Chronic, persistent or constant pain in the right (or left) hypochondrium in a well-looking patient is a frequent functional symptom; this chronic pain is not due to gall bladder disease

Question 42

Describe lower abdominal pain

Answer 42

Pain in the left iliac fossa may be colonic in origin (e.g. acute diverticulitis) but chronic pain is most commonly associated with functional bowel disorders.
Lower abdominal pain in women occurs in a number of gynaecological disorders and the differentiation from gastrointestinal disease may be difficult.
Pain in the right iliac fossa may be due to acute appendicitis or ileocaecal disease, but may also commonly be functional.
Proctalgia fugax is a severe pain deep in the rectum that comes on suddenly but lasts only for a short time. It is not due to organic disease.

Question 43

Describe abdominal wall pain

Answer 43

Persistent abdominal pain with localized tenderness, which is not relieved by tensing the abdominal muscles, is probably from the abdominal wall itself. Causes are thought to include nerve entrapment, external hernias, and entrapment of internal viscera (commonly omentum) within traumatic or surgical alterations of abdominal wall musculature.

Question 44

Summarise anorexia and weight loss

Answer 44

Anorexia describes reduced appetite. It is common in systemic disease and may be seen in psychiatric disorders. Anorexia often accompanies cancer but is usually a late symptom and not of diagnostic help. Weight loss is almost always due to reduced food intake and is a frequent accompaniment of gastrointestinal diseases. Weight loss in malabsorption disorders is primarily due to anorexia. Weight loss with a normal or increased dietary intake only occurs with hyperthyroidism and other catabolic states. Weight loss should always be assessed objectively, as patients’ impressions are unreliable.

Question 45

Summarise palpation

Answer 45

Feel for palpable masses or abdominal tenderness. All abdominal quadrants should be palpated in turn, followed by deeper palpations; remember to watch the patient’s face for signs of pain or discomfort. Evaluate any palpable mass and note its size, shape and consistency and whether it moves with respiration, to decide which organ is involved. Some abdominal organs may be just palpable normally, usually in thin people (Fig. 13.3). Riedel’s lobe is an anatomical variant consisting of a palpable enlargement of the lateral portion of the right lobe of the liver. The hernial orifices should be examined if intestinal obstruction is suspected.

Question 46

What is ascites

Answer 46

Ascites is a term for excess fluid in the peritoneal cavity. It is detected clinically by central abdominal resonance caused by gas within small bowel loops, with dullness in the flanks that shifts when the patient lies on their side. This ‘shifting dullness’ is a reliable physical sign, if 1–2 L of fluid are present.

Question 47

Summarise auscultation

Answer 47

Auscultation is not of great value in abdominal disease, except for evaluation of bowel sounds in the acute abdomen (see p. 433). Abdominal bruits are often present in normal subjects and are rarely clinically significant.
A succussion splash suggests gastric outlet obstruction if the patient has not drunk for 2–3 hours. The splash of fluid in the stomach can be heard with a stethoscope laid on the abdomen when the patient is moved.

Question 48

Summarise examination of the rectum

Answer 48

A digital examination of the rectum should be performed in all patients with a change in bowel habit or rectal bleeding, and prior to endoscopic examination of the rectum.
• Proctoscopy (Box 13.3) is performed in all patients with a history of bright red rectal
bleeding to look for anorectal pathology such as haemorrhoids; a rigid sigmoidoscope is too narrow and long to enable adequate examination of the anal canal.

Question 49

Describe proctoscopy

Answer 49

• The proctoscope is passed into the anus and the obturator is removed.
• The patient strains down as the proctoscope is removed.
• Haemorrhoids are seen as purplish veins in the left lateral, right posterior or right anterior position.
• Fissures may also be seen, but pain often prevents the procedure from being performed

Question 50

What is sigmoidoscopy

Answer 50

Sigmoidoscopy, either flexible or rigid, is part of the routine hospital examination in cases of diarrhoea and in patients with lower abdominal symptoms such as a change in bowel habit or rectal bleeding.

Question 51

Describe the differences between rigid and flexible sigmoidoscopy

Answer 51

Rigid sigmoidoscopy can visualize the distal 20–25 cm of large bowel, whereas flexible sigmoidoscopy (FS) can reach up to the splenic flexure (60 cm), and is typically performed in the endoscopy unit after evacuation of the distal colon using an enema or suppository. Rigid sigmoidoscopy is more mobile and is easily performed on the ward or in the outpatient department. Most rectal bleeding is due to benign anorectal disease (haemorrhoids or fissure in ano) and an otherwise normal FS can be reassuring and avoids over-investigation. Up to 60% of colonic neoplasms occur within the range of FS and FS is therefore used as screening test for colorectal cancer in asymptomatic average-risk individuals.

Question 52

Summarise stool examination

Answer 52

It is useful to confirm a patient’s account (e.g. passing of blood or steatorrhoea). The shape and size may be helpful (e.g. ‘rabbit dropping’ or ribbon-like stools in irritable bowel syndrome). Stool charts for recording consistency and frequency of defecation are useful in inpatients to follow the progress of diarrhoea, particularly in the management of severe colitis. The Bristol Stool Chart is commonly used in the UK