Gastrointestinal Examination Flashcards
Is IBD more commonly diagnosed in younger or older patients?
Younger
Is chronic liver disease more commonly diagnosed in younger or older patients?
Older
Confusion is often a feature of which end-stage GI pathology?
End-stage liver disease (hepatic encephalopathy)
What is hepatic encephalopathy?
Refers to changes in the brain that occur in patients with advanced, acute or chronic liver disease. It is one of the major complications of cirrhosis.
This is due to the build-up of toxins in the brain.
Abdominal distension can suggest the presence of which GI pathologies?
- Ascites
- Underlying bowel obstruction
- Organomegaly
Pallor can suggest an underlying anaemia. What are some potential GI causes of anaemia?
- Malnutrition
- GI bleeding
Which GI pathologies can cause jaundice?
- Acute hepatitis
- Liver cirrhosis
- Cholangitis (inflammation of bile duct system)
- Pancreatic cancer
How would hyperpigmentation present?
A bronzing of the skin
Which GI disease is hyperpigmentation of the skin associated with?
Haemochromatosis (iron build up)
In the context of an abdominal examination OSCE station, what pathology is oedema (pedal/ascites) associated with?
Liver cirrhosis
Which 2 major GI pathologies is cachexia associated with?
- Malignancy (stomach/bowel/pancreatic)
- Advanced liver failure
Where is a colostomy bag typically located?
In the left iliac fossa
Where is an ileostomy bag typically located?
In the right iliac fossa
Which 3 signs should you inspect the palms of the hand for during an abdominal exam?
1) Pallor
2) Palmar erythema
3) Dupuytren’s contracture
What is palmar erythema?
A redness involving the heel of the palm
When can palmar erythema be a normal finding?
During pregnancy
In which GI pathology is palmar erythema seen?
Chronic liver disease
Which 2 signs are you inspecting the nails for during a GI exam?
1) Koilonychia
2) Leukonychia
What is koilonychia?
Spoon shaped nails
Which condition is koilonychia associated with?
Iron deficiency anaemia (e.g. malabsorption in Crohn’s disease)
What is leukonychia?
Whitening of the nail bed
What condition is leukonychia associated with?
Hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy)
In an abdominal OSCE station, which 4 GI pathologies are finger clubbing assoicated with?
1) IBD
2) Coeliac disease
3) Liver cirrhosis
4) Lymphoma of the GI tract
In the context of an abdominal examination, what are the 3 most likely underlying causes of asterixis (flapping tremor)?
1) Hepatic encephalopathy (due to hyperammonaemia)
2) Uraemia (2ary to renal failure)
3) CO2 retention (2ary to type 2 respiratory failure)
Which 3 signs are you palpating for during inspection of the hands in an abdominal examination?
1) Temperature
2) Radial pulse
3) Dupuytren’s contracture
What is Dupuytren’s contracture?
Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.
What are the major factors associated with the development of Dupuytren’s contracture?
- Genetic
- Excessive alcohol use
- Increasing age
- Male gender
- Diabetes
How do you assess a patient’s hand for Dupuytren’s contracture?
Support the patient’s hand and palpate the palm to detect bands of thickened palmar fascia that feel cord-like.
When assessing the patient’s arms, what could bruising indicate in an OSCE abdominal examination?
underlying clotting abnormalities 2ary to liver disease (e.g. cirrhosis)
When assessing a patient’s arms, what could scratch marks indicate in an OSCE abdominal exam?
Sratch marks that may be caused by the patient trying to relieve pruritis –> suggests underlying cholestasis.
Intravenous drug use can be associated with an increased risk of which disease relevant to an abdo exam?
Viral hepatitis
Which 2 major signs are you looking for when examining the patient’s axillae?
1) Acanthosis nigricans
2) Hair loss
What is acanthosis nigricans?
Darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin
What can acanthosis nigricans indicate?
- Can be benign (most commonly in dark-skinned individuals)
- Can be associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).
Loss of axillary hair can be associated with which condition?
Iron-deficiency anaemia and malnutrition
Which 6 clinical signs are you examining the eyes for during an abdo exam?
1) Conjunctival pallor
2) Jaundice
3) Corneal arcus
4) Xanthelasma
5) Kayser-Fleischer rings
6) Perilimbal injection
What is 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 patients under 50, what could corneal arcus indicate?
Underlying hypercholesterolaemia
What are xanthelasmas?
yellow, raised cholesterol-rich deposits around the eyes
What condition are xanthelasmas associated with?
hypercholesterolaemia
What are Kayser-Fleischer rings?
Dark rings that encircle the iris
What condition are Kayser-Fleischer rings associated with?
Wilson’s disease - abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues including the liver causing cirrhosis
What is perilimbal injection?
Inflammation of the area of conjunctiva adjacent to the iris
What is perilimbal injection associated with?
Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease.
What are some other clinical features of anterior uveitis?
- photophobia
- ocular pain
- reduced visual acuity
Which 5 clinical signs are you inspecting the mouth for during a GI examination?
1) Angular stomatitis
2) Glossitis
3) Oral candidiasis
4) Aphthous ulceration
5) Hyperpigmented macules
What is angular stomatitis?
a common inflammatory condition affecting the corners of the mouth
Which deficiency can cause angular stomatitis?
Iron deficiency e.g. gastrointestinal malignancy, malabsorption
What is glossitis?
Smooth erythematous enlargement of the tongue
Which deficiencies does glossitis indicate?
Iron, B12 and folate (e.g. malabsorption secondary to inflammatory bowel disease)
What is aphthous ulceration?
Round or oval ulcers occurring on the mucous membranes inside the mouth
Cause of aphthous ulcers?
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.
Which IBD is associated with aphthous ulcers?
Crohn’s disease
Define pathognomonic
(of a sign or symptom) specifically characteristic or indicative of a particular disease or condition.
Which disease is hyperpigmented macules pathognomonic for?
Peutz-Jeghers syndrome
What is Peutz-Jeghers syndrome?
an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.
Which area of the body drains into the left supraclavicular lymph node?
The abdominal cavity
What is the left supraclavicular lymph node also known as?
Virchow’s node
Enlargement of which lymph node can be one of the first clinical signs of metastatic intrabdominal malignancy?
Virchow’s node (the left supraclavicular lymph node)
Which intrabdominal malignancy is the most common diagnosis for enlargement of Virchow’s node?
Gastric cancer
Where does the right supraclavicular lymph node receives lymphatic drainage from?
The thorax
Which malignancy can lymphadenopathy of the right supraclavicular lymph node indicate?
Metastatic oesophageal cancer (as well as malignancy from other thoracic viscera)
Which 3 clinical signs are you inspecting the chest for during a GI examination?
1) Spider naevi
2) Gynaecomastia
3) Hair loss
What are spider naevi caused by?
Increased levels of circulating oestrogen
Which GI pathology is increased levels of circulating oestrogen associated with?
liver cirrhosis (if more than 5 are present it is more likely to be associated with pathology such as liver cirrhosis)
When can increased levels of oestrogen be a normal finding?
Pregnancy
Combined oral contraceptive pill
What is gynaecomastia caused by?
Increased levels of circulating oestrogen (e.g. liver cirrhosis)
Which 2 medications can lead to gynaecomastia?
1) Digoxin
2) Spironolactone
What is (chest) hair loss caused by?
Increased oestrogen
Malnourishment
What are spider naevi, hair loss and gynaecomastia all caused by?
Increased levels of circulating oestrogen
How should the patient be positioned for the abdominal inspection/palpation/percussion/auscultation?
Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed.
Which 7 clinical signs are you inspecting the abdomen for during abdominal inspection of a GI examination?
1) Scars
2) Striae (stretch marks)
3) Abdominal distension
4) Caput medusae
5) Hernias
6) Cullen’s sign
7) Grey-Turner’s sign
What are the ‘6 f’s’ potentially causing abdominal distension?
Fat
Fluid
Flatus
Faeces
Fetus
Fulminant mass
What is flatus?
gas in or from the stomach or intestines, produced by swallowing air or by bacterial fermentation.
What is fulminant mass?
A mass that occurs suddenly and escalates quickly
What are caput medusae?
Engorged paraumbilical veins
What are caput medusae associated with?
Portal hypertension (e.g. liver cirrhosis)
What are striae caused by?
Caused by tearing during the rapid growth or overstretching of skin
In which conditions can striae be present?
- Obesity
- Pregnancy
- Ascites
- Cushing’s syndrome
- Intrabdominal malignancy
How can you inspect for hernias during a GI examination?
ask the patient to cough and observe for any protrusions through the abdominal wall
What is Cullen’s sign?
Bruising of the tissue surrounding the umbilicus
What is Cullen’s sign a late sign of?
Haemorrhagic pancreatitis
What is Grey-Turner’s sign?
Bruising in the flanks
What is Grey-Turner’s sign a late sign of?
Haemorrhagic pancreatitis
Where are colostomy bags typically located?
Left iliac fossa
Where are ileostomy and urostomy bags typically located?
Right iliac fossa
Do colostomy bags have a spout?
No, are flush to skin (ileostomy bags do)
Name the 9 areas of the abdomen from top left to right bottom
1) Right hypochondrium
2) Epigastrium
3) Left hypochondrium
4) Right flank
5) Umbilical region
6) Left flank
7) Right iliac fossa
8) Suprapubic region
9) Left iliac fossa
Before beginning the abdominal palpation, what should you ask the patient?
Ask the patient if they are aware of any areas of abdominal pain (if present, examine these areas last).
Which 5 clinical signs are you examining for during palpation of the abdomen?
1) Tenderness
2) Rebound tenderness
3) Guarding
4) Rovsing’s sign
5) Masses
What is rebound tenderness?
When the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain
What does rebound tenderness indicate?
This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).
What is guarding?
Involuntary tension in the abdominal muscles that occurs on palpation
What is guarding associated with?
Peritonitis (e.g. appendicitis, diverticulitis)
What is Rovsing’s sign?
Palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa.
What does Rovsing’s sign indicate?
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.
If any masses are identified during deep palpation, which characteristics should be assessed?
- 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).
If a mass feels pulsatile, what is this suggestive of?
Suggestive of vascular aetiology (e.g. abdominal aortic aneurysm)
In which region of the abdomen do you begin palpation of the liver?
Right iliac fossa (at the edge of the superior iliac spine)
Describe the steps when palpating 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
- Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.
What does a palpable liver edge in the right iliac fossa (during inspiration) indicate?
Gross hepatomegaly
When may the liver edge becme palpable in healthy individuals?
As you get close to the costal margin (typically 1-2 cm below it)
If you are able to identify the liver edge, which characteristics of it should you assess?
- Degree of extension below the costal margin
- Consistency of the liver edge
- Tenderness
- Pulsatility
If the liver edge extends more than 2cm below the costal margin, what does this suggest?
Hepatomegaly
If there is a nodular consistency of the liver edge, what does this suggest?
Cirrhosis
What could hepatic tenderness during a liver palpation indicate?
Hepatitis or cholecystitis (as you may be palpating the gallbladder)
What is pulsatile hepatomegaly during liver palpation associated with?
Tricuspid regurgitation
Name 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
In healthy individuals is the gallbladder palpable or not?
Not usually palapble
If the gallbladder is palpable, what does this suggest?
Enlargement secondary to biliary flow obstruction and/or infection
What 2 conditions typically cause biliary flow obstruction?
1) gallstones
2) pancreatic malignancy
What is cholecystitis?
Inflammation of the gallbladder
At which location of the abdomen can palpation of the gallbladder be attempted?
At the right costal margin in the mid-clavicular line (tip of the 9th rib)
