Gastrointestinal Examination Flashcards
From the End of the Bed
Ask patient to raise head off bed to detect abdominal or inguinal hernias. You can also assess nutritional status - record height, weight and waist circumference and calculate BMI.
Inspect the Nails
- Clubbing – increase in angle between nail and the nail bed and longitudinal curvature of the nail – can be caused by cirrhosis, inflammatory bowel disease or malabsorption.
- Pitting of the nail – small depressions on the surface of the nail which can be caused by psoriasis.
- Leuconychia – opaque white nails - low albumin caused by chronic liver disease or nephrotic syndrome.
- Koilonychia – brittle, flat and spoon shaped nails caused by a longstanding iron deficiency anaemia
Inspect the Hands
- Hydration – skin turgor and nail capillary refill time.
- Palmar erythema – a sign of liver failure or chronic liver disease (this can be normal in pregnancy).
- Dupuytrens contracture – painless thickening of the palmar aponeurosis which leads to an abnormality of the little and ring fingers. Idiopathic or caused by alcoholic cirrhosis and can be corrected surgically.
- Asterixis – a course flapping tremor when the hands are extended - found in hepatic encephalopathy.
Inspect the Eyes
- Jaundice – can be seen on the sclera but is often more obvious on the palate (under the tongue).
- Anaemia – conjunctival pallor can be seen – can be caused by GI bleeding or anaemia of chronic disease.
Inspect the Mouth
- Angular stomatitis - occurs at the angles of the mouth and can be caused by an iron or riboflavin deficiency or due to poorly fitting dentures which leads to constant dribbling of saliva.
- Ulceration – apthous ulcers are found in Crohn’s disease or could be a sign of an oral candida infection.
- Tongue abnormalities – dryness suggests dehydration, furriness suggests the presence of an infection and a smooth or clean tongue is due to atrophy of the papillae caused by iron or vitamin B12 deficiency.
- Breath – smell can be alcohol, sickly ‘fetor hepaticus’ of liver failure or sweet smell of ketoacidosis.
Examine the Neck
Lymphadenopathy - examine the submental (medial jaw), submandibular (lateral jaw), tonsilar (at the angle of the jaw), occipital (at the base of the skull), preauricular (in front of ear), postauricular (behind ear), cervical (anterior to SCM) and supraclavicular (above the clavicle – Virchow’s node) lymph nodes.
Inspect the Chest and Abdomen
- Spider naevus – a telangiectasic arteriole (small dilated vessels) near to the surface of the skin with radiating branches - >5 spider naevi located near to the vena cava is a sign of chronic liver disease.
- Gynaecomastia – enlargement of the breasts due to increased circulating oestrogens in liver disease.
- Surgical scars – e.g. midline scars for general access, right subcostal scar for gallbladder surgery, McBurney’s scar for appendectomy, suprapubic scar for bladder, prostate or gynaecological surgery.
- Caput medusa – dilated veins from the umbilicus as a result of cirrhosis and portal hypertension.
Palpate the Abdomen
- Ask the patient to show you where the pain is and start palpation away from this point. Observe the patients reaction during light palpation for tenderness and deep palpation to detect masses.
- Tenderness – can due to anxiety or voluntary guarding – voluntary contraction of abdominal muscles in response to pain or involuntary guarding – reflex contraction due to inflammation of the parietal peritoneum. Rebound tenderness – rapidly removing your hand after deep palpation increases the pain – a sign of intra-abdominal disease but not necessarily peritonism.
- Palpable masses – is the mass in the anterior abdominal wall – ask the patient to lift legs off the bed and will still be present whereas intra-abdominal mass will disappear. Is the mass an enlarged organ or separate – could be a tumour, abscess or palpable faeces (can usually be indented with a finger).
Hepatomegaly Causes
Chronic parenchymal liver disease (alcoholic liver disease, viral hepatitis, autoimmune hepatitis or primary biliary cirrhosis), malignancy (primary or secondary), right heart failure, haematological disorders (lymphoma, leukaemia, myelofibrosis) or rare causes (amyloid or sarcoidosis).
Splenomegaly Causes
The spleen is enlarged 3 times before it is palpable.
Haematological disorders (lymphoma, lymphatic leukaemia, myeloproliferative disorder or haemolytic anaemia), portal hypertension, infections (glandular fever, malaria, brucellosis or tuberculosis), rheumatological conditions (rheumatoid arthritis or SLE) and rare causes (amyloidosis or sarcoidosis).
Percuss the Abdomen
- Start percussing in the midline and progress inferiorly – start of dullness indicates top of bladder.
- Start in the midline and progress laterally – dullness laterally suggests the presence of ascites.
- Shifting dullness to test for ascites: percuss laterally and ask the patient to roll away from you. Sound will become resonant and will return to a dull sound if the patient rolls back towards you
- Fluid thrill – place hand in midline, flick side of abdomen, feel for movement on opposite side
Auscultate the Abdomen
- Must listen for a full minute before deciding bowel sounds are absent. If the bowel is obstructed the sounds can be described as high pitched and tinkling
- Listen over the abdominal aorta and liver to detect bruie which may suggest hepatitis.
Report the Examination
- I have performed an abdominal examination on mrs ? a ? year old lady who did not present with any symptoms of abdominal disease.
- The patient appeared comfortable at rest and on general inspection I did not find evidence of abdominal pathology.
- On inspection of the hands I found clubbing but no other peripheral or central signs of abdominal pathology such as leukonychia, koilonychia or jaundice.
- Virchows node was not palpable and there were no signs of abdominal pathology on the chest such as spider naevi or gyneacomastia.
- On both superficial and deep palpation I did not feel any abnormalities and I was unable to palpate the liver, spleen or kidneys.
- On percussion I found no evidence of hepatomegaly, splenomegaly or ascites.
- Auscultation was normal – bowel sounds were present and I found no evidence of renal artery or aortic bruits.
- So in summary this is a ? year old lady with clubbing but otherwise a completely normal abdominal examination.’
Hepatitis A
A single strand RNA virus. Transmission is faecal-oral associated with summer instutional outbreaks and point source outbreaks following faecal contamination of water or food e.g. oysters. The risk of symptomatic disease increases with age.
- Clinical features – a flu like illness followed by jaundice and usually an uneventful recovery.
- Diagnosis – anti-HAV IgM is diagnostic - it appears before jaundice and persists for 3 months.
- Treatment and prevention – symptomatic treatment and support are usually all that’s necessary. Adequate sanitation and good personal hygiene will reduce transmission of HAV.
Hepatitis B
A small double stranded DNA virus transmitted by parenteral, congenital or sexual routes.
- Clinical features – a 6 month incubation period before the development of acute hepatitis (ranging from mild to severe). Fulminant (severe) disease carries a 1-2% mortality and 10% of patients develop chronic hepatitis complicated by cirrhosis and hepatocellular carcinoma.
- Treatment and prevention – nucleoside analogues (e.g. lamivudine or famciclovir) can be combined with interferon α to treat chronic hepatitis. High risk individuals are immunised with recombinant HBV vaccine. Blood donations are screened and needle exchange programs help.
