Gastroenterology Examination Flashcards
What might you take note of round the bed or surroundings in the gastro exam?
- Indwelling drains / catheters?
- Any PCA (Patient controlled analgesia)
- IV infusions
What general observations about the patient might you note down in a gastro exam?
- Mental state / agitation - encephalopathy
- Level of distress and whether in pain
- Nutritional state - sarcopenia, cachexia
- Respiratory distress / tachypnea
- Pallor
- Jaundice
What can you look for in the patient’s hands and nails? What is the relevance of these signs?
o Clubbing - associated with inflammatory bowel disease, primary biliary cholitis, cirrhosis and malabsorption including coeliac disease.
o Leukonychia totalis (white nails/white nail bed) - due to hypoalbuminaemia e.g. in coeliac disease, CLD, nephrotic syndrome. Note: may also see hypoalbuminaemia in sepsis!
o Koilonychia (spooning of nails) - due to chronic iron deficiency from e.g. IBD, gastrointestinal bleeding and coeliac disease.
- Hands
o Pallor of palmar creases
o Palmar erythema (reddening of thenar and hypothenar eminences) - due to reduced breakdown of circulating sex hormones including oestrogens. Also found in pregnancy, thyrotoxicosis, polycythaemia.
o Dupuytren’s contracture (thickening of palmar flexor tendons) - associated with alcoholism, may be familial and occurs with trauma/heavy machinery use. - Liver flap/asterixis - jerky assymetrical movements of wrists and fingers - due to hepatic encephalopathy. Also in renal failure, hypoglycaemia, hypokalaemia, cardiac or respiratory failure.
- Fine resting tremor - inhaler use or alcohol withdrawal.
What signs can you look for in the arms in a gastro exam? Relevance?
- Needle marks
- Bruising - may suggest clotting abnormality, late sign of liver disease. Obstructive jaundice may affect vitK absorption from small intestine. Chronic alcoholism may result in thrombocytopenia and lead to petechiae on skin.
- Tattoos
- Scratch marks - liver disease or primary biliary cirrhosis.
- Paucity of axillary hair
What signs might you look for in the eyes relating to gastroenterology? Relevance.
- Pallor including conjunctivae - anaemia
- Jaundice (sclera)
- Iritis - may be present in IBD.
- Kayser Fleischer rings - brownish-green rings occurring at periphery of cornea associated with Wilson’s disease (aberrant copper storage causes cirrhosis).
How do you distinguish jaundice caused by liver disease vs obstructive jaundice?
More likely to have spidernaevi, palmar erythema, ascites, palpable spleen and dilated abdominal veins in liver disease.
What signs in or around the mouth might you look for in a gastroenterology examination?
- Foeter - alcohol, liver disease or acute appendicitis.
- Dentition and gums
- Aphthous ulcers - associated with Crohn’s disease, coeliac disease, HIV infection or idiopathic.
- Tongue hydration and glossitis - “beefy” tongue indicates dietary deficiency e.g. folate, iron, vitamin B especially B12. This is because the tongue has rapid turnover of mucosal cells.
- Pigmentation of buccal cavity
- Angular stomatitis/chelitis - cracks at corners of mouth - deficiencies of vitamin B6, B12, iron and folate.
- Teleangiectasia
What might you look for during the abdominal exam in the neck and chest/back? Relevance?
- Palpate the cervical and supraclavicular lymph nodes, looking particularly for Virchow’s node in the left supraclavicular fossa (Trosier’s sign).
- Bruising
- Spidernaevi - normal up to 5, attributed to excess oestrogen but not a clear correlation between number of spidernaevi and oestrogen levels. Associated with cirrhosis, viral hepatitis, pregnancy.
- Gynaecomastia in males - causes include cirrhosis particular, particularly alcohol, chronic autoimmune hepatitis, drugs like spironolactone, cannabis, digoxin and cimetidine.
- Hair loss
What should you look for on observation of the abdomen during a gastro exam? Relevance?
- Changes in shape and symmetry of abdomen.
- Scars
- Presence of drains/catheters.
- Muscle wasting, loose folds of skin - recent weight loss.
- Distension and bulging flanks - several causes.
- Skin colour/bruising/abdominal hernias/scratch marks. Bruising may indicate retroperitoneal or intraperitoneal haemorrhage. Retroperitoneal bleeding may be a sign of pancreatitis (3%).Bruising may be associated w/ intrahepatic haemorrhage, liver abscess, ischaemia bowel, ruptured spleen, rectus sheath hematoma, liver biopsy, ruptured aortic aneurysm, perforated duodenal ulcer or coronary angioplasty.
- Visible peristaslsis - bowel obstruction. May also be an abdominal aortic aneurysm.
- Caput medusa - prominent arrangement around the umbilicus via the left portal vein, paraumbilical veins and abdominal wall veins. Auscultation over here – reveals continuous humming sound.
- Aortic pulsation
What types of scars does abdominal surgery use? Give examples of when these might be used?
- Midline laparotomy - AAA, laparotomy
- Paramedian - colectomy.
- Transverse
- Subcostal – cholecystectomy
- McBurney – Appendectomy
- Pfannestiel – C-section, postatectomy
What are some causes of abdominal distension?
5 “F”s
- Fat
- Fluid (ascites)
- Foetus or pelvic mass (umbilicus points up in pregnancy or pelvic mass).
- Flatus - bowel obstruction: painful and acute.
- Faeces
Tumour
Causes of ascites?
- Chronic liver disease
- Ovarian cancer seeding into the peritoneum. Other cancers.
- Chronic renal disease
- Pancreatitis
- Heart failure
How do you palpate the abdomen? What are checking for?
Ask patient about pain before and during palpation.
Use flat of your right hand, begin palpation away from the site of pain. Encourage breathing to try and keep the abdominal wall relaxed. Maintain hand in horizontal plane.
- Palpate lightly in each of 9 regions of abdomen watching patient’s face: look for signs of pain, discomfort and distress.
- Palpate deeply using flat of hand. Observe your hands and check patient’s face periodically.
- Check for guarding, rebound tenderness, masses and organ enlargement. Percuss any mass found.
What is guarding?
Resistance to palpation due to contraction of the abdominal wall. Involuntary -suggests peritoneal irritation. A rigid abdomen is always associated with tenderness – generalised peritoneal inflammation.
What is rebound tenderness?
Elicited by slowly palpating the abdominal wall and then suddenly withdrawing the examining hand. It is likely the patient will find this painful and experience a sudden sharp pain suggests peritonitis. Increasingly surgeons discourage use of this sign due to the discomfort caused to the patient.
