Clinical examination of the digestive system Flashcards
CLINICAL EXAMINATION
OF THE ABDOMEN
The patient should have an empty bladder.
The patient’ s position: in a supine position, with a pillow for the
head and perhaps another under the knees.
Have the patient keep arms at the sides or folded across the chest.
Before you begin palpation, ask the patient to point to any areas of
pain and examine these areas last.
Warm your hands and stethoscope, and avoid long fingernails.
Approach slowly and avoid quick unexpected movements. Watch
the patient’s face closely for any signs of pain or discomfort.
Distract the patient if necessary with conversation or quest
CLINICAL EXAMINATION OF THE ABDOMEN
- INSPECTION
- AUSCULTATION
- PALPATION
- PERCUSSION
General survey
Patient’s appearance – pain / agitation / confusion
Body habitus – obese / low BMI / cachectic
Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal
(cholecystectomy)
Jaundice – cirrhosis / hepatitis
Bruising – may suggest abnormal coagulation – e.g. secondary to liver failure
Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
Abdominal distention – ascites / bowel distension / large masses
Excoriations – pruritus – cholestasis
Inspection Hands
Koilonychia – spooning of the nails – chronic iron deficiency
Leukonychia – whitened nail bed – hypoalbuminemia (liver failure / enteropathy)
Palmar erythema – reddening of palms – liver disease / pregnancy
Dupuytren’s contracture: Thickening of the palmar fascia Associated with alcohol excess
/ family history
Hepatic flapping tremor:
Ask patient to stretch out arms, with hands dorsiflexed and fingers outstretched
Ask them to hold their hands in that position for 15 seconds
The hands will flap (flex/extend at the wrist) in an irregular fashion if positive
Causes include – hepatic encephalopathy
Mouth
Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency
Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency
Mouth ulcers – Crohn’s disease / coeliac disease
Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency
Neck
Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy
Chest
Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease
Gynaecomastia – overdevelopment of male mammary glands (pseudofeminisation) – liver cirrhosis / spironolactone
Hair loss – pseudofeminisation/ malnourishment / iron deficiency anaemia
INSPECTION OF THE ABDOMEN
Examiner position: standing/sitting at the right side of the bed the abdomen view should be tangentially THE CONTOUR OF THE ABDOMEN THE UMBILICUS THE ABDOMINAL SKIN THE VEINS of the ANTERIOR ABDOMEN WALL Visible PERISTALTIS Visible PULSATIONS
Inspection
slide 11-14
INSPECTION – ABDOMEN CONFIGURATION
Normal abdomen appearance:
normally flat or slightly scaphoid and symmetrical
abdominal wall moves out with inspiration
No organs or masses visible
The rectus muscle:
their margins can be visible in muscular people
“diastasis recti” – midline separation
INSPECTION – ABDOMEN CONFIGURATION
Pathological changing of abdomen configuration
+ slide 16
BULGING, PROTUBERENT
– fat, gas, ascites, intra-abdominal tumors, fetus
LOCALIZED BULGING
– produces asymmetry
– enlarged/distended organs, abnormal mass, hernias
FLAT, IMMOBILE ABDOMEN
– peritonitis
STOMAS
ileostomy in the right iliac fossa;
a transverse colostomy in the left hypochondrium;
a sigmoid colostomy in the left iliac fossa
INSPECTION OF THE ABDOMEN
THE UMBILICUS
+ slide 18
– symmetrically indented into the abdominal wall
– an everted umbilicus - always abnormal:
causes: ascites, herniation of bowel or fat
– umbilical drainage of fluid:
ascitic fluid (massive ascites), feculent material (enteric fistulas)
– umbilical stones: dirt and desquamated epidermis (neglected toilet)
– umbilical nodules
lipomas, Sister Mary Joseph’ nodule (malignant umbilical tumor)
INSPECTION OF THE ABDOMEN
THE ABDOMINAL SKIN
+ slide 20,21
– skin color, especially in the lower abdomen
GRAY-TURNER s
– brusings of the flanks due to retroperitoneal hemorrhage
CULLEN sign – bruising of the periumbilical skin
– SCARS
– Abdominal stretch marks – rapid distension of the abdomen
INSPECTION OF THE ABDOMEN
THE VEINS of the ANTERIOR ABDOMINAL WALL
– usually not visible , exception thin/older people – visible : generalized distension of the abdomen, portal hypertension inferior vena cava obstruction
INSPECTION OF THE ABDOMEN
Visible PERISTALTIS
– usually not visible , esc. very thin/emaciated people
– abnormal in people with normal adiposity
– causes: INTESTINAL OBSTRUCTION
INSPECTION OF THE ABDOMEN
Visible PULSATIONS
– pulsation of the AORTA in the the epigastric area
– not abnormal in: thin/older people
– tortuous aorta, aortic aneurysm,
AUSCULTATION OF THE ABDOMEN
ARTERIAL SOUNDS - BRUIT
VENOUS SOUNDS
BOWEL SOUNDS ( INTESTINAL SOUNDS)
AUSCULTATION OF THE ABDOMEN
ARTERIAL SOUNDS (BRUITS)
+ slide 26,27
– variably harsh sounds, they occur in tempo with the pulse.
– cause:
increased turbulence of aterial blood flow
the massive blood flow through very vascular tumors
– over the aorta:
extensive atherosclerosis, extreme tortuosity of the aorta, an aortic aneurysm.
– the renal arteries:.
often best heard in the flanks.
usually an abnormal finding signifying renal arterial stenosis
– over the liver: hepatoma or an angioma
– over the spleen: hemangioma, other vascular tumour, splenic artery bruit
AUSCULTATION OF THE ABDOMEN VENOUS SOUNDS (HUMS)
– uncommon, always abnormal.
– more or less continuous, usually softer and lower-pitched than a bruit
– signifies portal-systemic shunting of venous flow when portal flow is obstructed
– in the upper abdomen especially in the area of the liver itself, over and above the umbilicus
AUSCULTATION OF THE ABDOMEN INTESTINAL SOUNDS (BOWEL SOUNDS)
– produced by the movement of a gas-fluid mixture through the gut.
they persist in fasting most bowel sounds are generated by the small intestine the incidence and loudness related to: quantity of swallowed air
and the time since the last meal
– LOUD BOWEL SOUNDS + cramping abdominal pain/abdominal
distension partial bowel obstruction
– ABSENCE OF BOWEL SOUNDS: intestinal atony or ileus
– “TINKLING” bowel sounds: bowel obstruction
AUSCULTATION OF THE ABDOMEN SUCCUSSION SPLASH (HIPPOCRATES)
– sudden movement of the abdomen - hear the splash at the fluid-gas interface when large volume of fluid and air collected in the stomach.
in a normal person after a large meal and fluid;
long after meals( over 3 hours) in cases of gastric outlet obstruction
PALPATION OF THE ABDOMEN
discover the size and shape of normally palpable organs,
find normally impalpable organs,
discover palpable masses that are not normally present,
detect the location and degree of tenderness.
LIGHT (SURVEY) palpation
DEEP palpation
PALPATION OF THE ABDOMEN
LIGHT (SURVEY) palpation (I)
identifying abdominal tenderness, muscular resistance, and some superficial organs and masses.
to reassure and relax the patient
TENDERNESS
- always start in the opposite site of the painful area (last to examine)
- extreme tenderness → use gentle percussion
