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
RESISTENCE TO PRESSURE
- identify local area of increased resistance to palpation
- sign of peritoneal inflammation
- differentiate between VOLUNTARY and INVOLUNTARY guarding
- GENERALIZED INCREASED RESISTENCE TO
PRESSURE
- VOLUNTARY GUARDING
- ABDOMEN IN TENSION: GAS, ASCITES
- PERITONEAL GENERALIZED IRRITATION:
= usually chemical peritonitis
= “board-like” abdomen
PALPATION OF THE ABDOMEN
LIGHT (SURVEY) palpation (II)
- if cutaneous eruptions are nodular or sore.
- palpate subcutaneous nodules: soft (lipomas), hard (fibromas, malignant tumors),tender (superficial abscesses, hematomas).
- feel along scars: tender/indicating local infection/contain wire sutures/tender firm nodules (neuromas)/soft compressible masses (hernias)
- palpate the umbilicus for nodules/hernias and assess the size of the umbilical ring
PALPATION OF THE ABDOMEN
DEEP palpation Assess (I)
Assess each of the 9 regions again, but with greater pressure applied during palpation.
.tehnique:
one hand but better both hands in deep palpation.
use your dominant hand to feel and your subordinate hand to exert pressure.
ballottement = using your subordinate hand to press a movable organ into a
position where your dominant hand can feel it
PALPATION OF THE ABDOMEN
DEEP palpation (II)
For delineating ABDOMINAL MASSES and TENDERNESS:
ABDOMINAL PALPABLE MASSES
- causes:
inflammatory (diverticulitis of the colon)
vascular (an aneurysm of the abdominal aorta)
neoplastic (carcinoma of the colon, ovarian benign/malignant tumors)
obstructive (a distended bladder or dilated loop of bowel)
pregnant uterus
features needed to be define in any abdominal mass
- Size
- Location
- shape
- mobility
- Surface /Edge
- Consistency
- pulsatility
- Thrills, bruits
PALPATION OF THE ABDOMEN
DEEP palpation
TENDERNESS
- asses:
1. degree
2. moderate or severe : inflammatory state.
3. slight/no tender: tumors/solid organs enlarged by noninflammatory processes
4. location
5. the location of the point of maximal tenderness suggests the organ of origin
6. depth
7. superficial/deep tenderness
8. cutaneous hyperesthesia: radicular neuropathic pain
9. rebound tenderness
10. referred tenderness
11. crepitus
PALPATION OF THE ABDOMEN
TENDERNESS
- asses:
1. rebound tenderness (Blumberg’s sign) - sign of peritoneal irritation- pain is worsened on releasing the pressure – peritonitis
- generalized rebound tenderness: perforation of a viscus referred tenderness
2. referred tenderness - very deep compression in one area produces pain remote from that area
- appendicitis: compression of the left-lower quadrant elicits pain in the cecal area
- gastric or duodenal ulcers: pain in the upper abdomen with lower abdominal compression
3. crepitus - surgical/accidental trauma
- subcutaneous infection with gas-producing organisms
- migration of gas from the thoracic wall, other parts of the body, a fractured rib that has penetrated the lung → little/no abdominal tenderness with the crepitus
PERCUSSION OF THE ABDOMEN
+ slide 42 , 43
- To find ASCITES
- to MEASURE organs or distended viscera,
Liver – percuss up from RIF then down from right side of chest to determine the size of the liver
Spleen – percuss up from LIF moving towards the left
hypochondrium to assess for splenomegaly
Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant))
3.to explore TENDERNESS when it is too severe to be explored by palpation
PERCUSSION OF THE ABDOMEN
FINDINGS
1.RESONANCE – normal abdomen
right hypocondrium resonance:
– CHILAIDITI Sd.- colon interposition between the liver and abdominal wall
– SITUS INVERSUS (liver dullness on left, gastric air bubble on right)
2.TYMPANY
– excess of gas: BLOATING
– protuberant abdomen tympanitic all over: INTESTINAL OBSTRUCTION
PERCUSSION OF THE ABDOMEN
DULLNESS
+ slide 45
- superior margin of a dull lower abdomen CONVEX:
DISTENDED BLADDER,
PREGNANT UTERUS,
LARGE TUMOR - superior margin of a dull area in the lower abdomen: CONCAVE ASCITE
PERCUSSION OF THE ABDOMEN
ASCITES
- MODERATE DEGREES OF ASCITES: SHIFTING DULLNESS
Shifting dullness
- Percuss from the centre of the abdomen to the flank until dullness is noted
- Keep your finger on the spot at which the percussion note became dull
- Ask patient to roll onto the opposite side to which you have detected the dullness
- Keep the patient on their side for 30 seconds
- Repeat your percussion in the same spot
- If fluid was present (ascites) then the area that was previously dull should now be resonant
- If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)
PERCUSSION OF THE ABDOMEN
ASCITES
- MASSIVE ASCITES: FLUID THRILL (WAVE)
SPECIFIC CLINICAL EXAMINATION LIVER PALPATION OF THE LIVER - tehnique: \+ slide 50,51
A.
1.Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of
your right index finger)
- Press your hand into the abdomen as you ask the patient to take a deep breath
- Feel for a step, as the liver edge passes below your hand
- If you don’t feel anything, repeat the process with your hand 1-2 cm higher
B. - appose the fingertips of your dominant hand, curve them slightly, and press them firmly against the abdomen.
- align your fingertips at approximately 90 degrees to the line of the anticipated liver margin, with one fingertip pressed against the rib margin.
- ask the patient to breath deeply while you move the line of your fingertips first cephalocaudal to find the liver margin and then centrally and laterally to explore the extent of palpability transversely
SPECIFIC CLINICAL EXAMINATION LIVER PALPATION OF THE LIVER - tehnique: \+ slide 53
C. - when massive ascites impedes palpation of the liver and spleen:
- you tap very forcefully over the organ leaving your fingers pressed firmly at the point where the tap was delivered
- you can feel the organ bounce back against the abdominal wall after a slight delay.
- asses:
1. SIZE
2. SURFACE - smooth or irregular
3. EDGE - smooth or irregular
4. CONSISTENCY - soft or hard
5. if it is TENDER
6. if it is PULSATILE
7. whether there is an AUDIBLE BRUIT
SPECIFIC CLINICAL EXAMINATION
SPLEEN
PALPATION OF THE SPLEEN
- tehnique:
+ slide 55,56
A. WITH THE PATIENT IN A SUPINE POSITION
- put your subordinate hand under the left rib cage and pull it forward
- place your dominant hand in the right flank and probe gently while the patient breathes deeply
B. WITH THE PATIENT IN RIGHT DECUBITUS
- place the patient on his right side with his torso flexed, knees and hips flexed.
- move to the left side of the abdomen, standing behind the patient
- place your hands with your palms against the left costal margin and your fingers arched into the left hypochondrium
- probe progressively deeply along the fossa, asking the patient to breath deeply
while you hold your fingers in position all along the fossa
SPECIFIC CLINICAL EXAMINATION
SPLEEN EXAMINATION
- SIZE: normal spleen it is not palpable
- it moves with respiration: enlarged spleen moves little with respiration
- CONSISTENCY:
- soft: viral infections
- very firm: infiltrative diseases
SURFACE: usually smooth
- TENDERNESS: variable
- very tender: the enlargement has been RAPID, in ABCESS, in INFARCTION
- slightly or not at all tender: chronic splenomegaly - SPLENIC BRUIT
Gallbladder
- The gallbladder is not usually palpable.
- An enlarged gallbladder suggests obstruction to biliary flow/infection (cholecystitis).
- Perform palpation at the right costal margin, mid-clavicular line (9th rib tip)
- If enlarged, a rounded mass moving with respiration may be palpated (note any tenderness).
- Murphy’s sign: Place your hand in the area noted above (right costal margin, mid-clavicular line) Ask the patient to take a deep breath
- As the gallbladder is pushed down into your hand
the patient may suddenly develop pain and stop inspiring. - If this occurs and there is no discomfort in the same location on the left side of the abdomen then this is known as a positive
- Murphy’s sign, which is suggestive of cholecystitis
Murphy’s sign is suggestive of
cholecystitis
