Gastrointestinal System Assessment

Question 1

What are you assessing for when assessing the hands?

Answer 1

> Clubbing: Schamroth’s Window (BMJ, 2019).

> Koilonychia: inverted nails, Fe deficient (5.4%), haemachromatosis (49%) - Rathod & Sonthalia, 2020).

> Leukonychia (hypoalbuminaemia), Palmar Erythema, Spider Naevei: liver disease.

> Nicotine staining: cardio-resp disease.

> Osler’s Nodes: tender, purple/pink nodules on distal phalanges.

> Janeway Leision’s: erythematous papule’s palms/feet. (Parashar, 2022).

> Asterixis: T2RF, liver disease (think hepatic encephalopathy).

> Small Muscle Wastage: ^frail, T1 root damage by apical lung tumour (Macleod, 2018).

Question 2

Arm assessment in relation to the GI System.

Answer 2

> Petechiae: vasculitis, chronic liver disease.

> Track marks: ^risk hepatitis.

> Spider Naevei: ^levels of oestrogen, can occur in pregnancy. 5+ cirrhosis.

> Bruising: clotting abnormalities, liver disease.

> Arteriovenous Fistulas: renal failure (metabolic/electrolyte abnormalities).

Question 3

Face assessment in relation to the GI System.

Answer 3

> Conjunctiva: Anaemia, jaundice.

> Cholesterol: Xanthelasma, Arcus Senilis.

> Kayer-Fleischer Rings: dark/brown rings in eyes -> Wilson’s disease, abnormal copper processing in the liver.

> Malar Flushing: CO2 retention due to mitral valve stenosis.

Question 4

How do you assess for Jugular Vein Distention?

Answer 4

> Pt at 45 deg.

> Turn head away from me.

> Measure height from sternal angel to height of JVD.

> Significant if >4cm.

> Hepatojugular reflex if unable to see ordinarily.

Question 5

Assessing for Lymphadenopathy.

Answer 5

> Auricular, Cervical, Submandibular, Submental & Supraclavicular.

> Inflamed secondary to infection, malignancy (Maini & Nagali, 2022).

> Virchow’s Node: intra-abdominal Ca. Seen in pulmonary adenocarcinoma due to mets through the thoracic duct (Zdilla et al., 2019).

Question 6

Abdominal Wall Inspection.

Answer 6

> Distention - F’s (Fat, Foetus, Fluid in Ascites, Flatus, Faeces, Free Fluid (bleeding).

> Scars & Stomas: surgery, abdo pathology hx.

> Spider Naevei: liver disease.

> Caput Medusa: portal HTN, liver disease (late sign).

> Cullen’s: acute pancreatitis (late), 37% mortality (Mookadam).

> Grey Turner’s: pancreatitis, retroperitoneal haem (AAA, trauma) - (Wong, 2021).

Question 7

Why should you auscultate the abdomen before palpation or percussion?

Answer 7

> May falsely alter bowel sounds by dislodging faecal matter or gas.

> Evidence suggests it can put the pt at ease.

> Ferguson, 2019.

Question 8

Abdominal Auscultation Findings.

Answer 8

> Normal - gurgling.

> Obstruction: tinkling, ^freq/vol/pitch.

> Absent: ileus, disruption of bowels normal propulsive ability due peristaltic malfunction, may suggest peritonitis. Bowel obstruction.

> Absent - must listen for 2-3 minutes per quadrant.

Question 9

Abdominal Palpation.

Answer 9

> Light to deep.

> Tenderness & Rebound Tenderness: non-specific.

> Voluntary Guarding: abdo muscle contraction due to pain.

> Involuntary Guarding: invol tension of muscles on palpation, suggests peritonitis.

> Masses: hard (Ca?), assess mobility, consistency, pulsatile? DO NOT PALPATE A PULSATILE MASS!!!

Question 10

Abdominal Percussion.

Answer 10

> 9 regions starting away from pain.

> Air in bowels will be hyperesonant.

> Stony dull in the suprapubic region - full bladder.

> Faecal loading in colon - dull.

> Shifting dullness - ascites?

Question 11

Describe the tests for appendicitis.

Answer 11

> Rovsing’s Sign: palpate the LLQ -> RLQ pain (peritoneal irritation).

> Obturator: internal/external rotation of flexed R hip, RLQ pain, appendix is deep in hemipelvis.

> Psoas: R hip extension -> RLQ pain, lift leg against resistance.

> McBurney’s point: 1/3 of the way from the iliac crest between umbilicus. Palpation=pain+.

Question 12

Describe the tests for acute cholecystitis.

Answer 12

> Murphy’s Sign.

> R costal margin, mid-clavicular, palpate & ask the patient to inspire.

> +ve sign if patient winces & stops inspiration due to irritation of the gall bladder.

> 80% diagnostic accuracy, 34% in the elderly. (Salati & Al Kadi, 2012).

Question 13

Kidney Tenderness Assessment.

Answer 13

> Costovertebral Angle.

> Place hand at bottom of the 11th rib, hit your hand.

> Tender = +ve sign for pyelonephritis & ureteral stones.

> Journal of General and Family Medicine.

Question 14

List some non-GI causes of abdominal pain.

Answer 14

> MI.

> Pleurisy.

> DKA.

> Ovarian Torsion.

> Testicular Torsion.

> Ectopic Pregnancy.

> (Macleod, 2018).

Question 15

Pain Assessment in the GI System.

Answer 15

> SOCRATES.

> Referred Pain: pain away from site of origin due to interconnecting neural pathways (Murray, 2009).

> Migratory Pain: as in appendicitis.

Question 16

Social history to gain in the GI system.

Answer 16

> Diet.

> Alcohol.

> Drugs.

> Food intolerance.

> Smoking.

> Stress (exacerbates IBS & Dyspepsia).

> Foreign Travel: D&V etc, Travellers Diarrhoea from Asia (NHS).

Question 17

Aortic Dissection.

Answer 17

> S/S:
LOC, syncope, unequal BP/HR, sudden severe abdo/lower back pain, tearing/ripping, SOB, FAST symptoms.

> Obs:
red. GCS, red. BP, ^RR/HR, cold, clammy.

> IPPA:
bruising, pain on palpation, distention.

> Vomit/faeces:
haematemesis, Malena.

> Abnormal presentation:
discoloured legs.

> Stats:
50% dead before hospital (BMJ).

Question 18

Ruptured Aortic Aneurysm.

Answer 18

> S/S:
Pulsatile mass, pale, clammy, LOC, abdo pain, dizzy, SOB, back pain into legs.

> Obs:
Red. GCS, ^HR/BP, red. BP, guarding, circulatory collapse.

> IPPA:
Cullen’s, pulsatile mass, hyporesonance.

> Vomit & Faeces:
Haematemesis, diarrhoea.

> Stats:
Nearly always fatal. 3000 deaths p/a in UK (NICE).

Question 19

Pancreatitis.

Answer 19

> S/S:
RUQ/epigastric pain into back, N/V, fever, tachy, jaundice.

> Acute or chronic.

> Stats:
50% caused by gallstones.
25% caused by alcohol.
5% mortality rate.
(NICE).

Question 20

Hepatitis.

Answer 20

> S/S:
Jaundice, fever, fatigue, red. appetite, N/V, abdo pain, dark urine, joint pain, haematemesis.

> Obs:
HTN in chronic. Hypotensive in acute. ^RR/HR.

> IPPA: Distention, tender, ascites, hepatomegaly.

> Neuro: toxins build up -> hepatic encephalopathy ( British Liver Trust).

Question 21

Urinary Tract Infections.

Answer 21

> S/S:
Dark/foul smelling urine, haematuria, polyuria, dysuria, fever, signs of sepsis, confusion, delirium.

> Urosepsis:
31% of sepsis cases are urinary in origin.
20-40% overall mortality rate.
Incidence ^ w/ age.
(Dreger et al., 2015).

Question 22

Appendicitis.

Answer 22

> S/S:
Umbilical to RLQ migratory pain, N/V, Diarrhoea, constipation, put themselves in foetal position.

> Tests:
McBurney’s point, Rovsing’s, Obturator, Psoas, Rebound Tenderness.

> Stats:
50,000 admissions p/a (NHS).

Question 23

Cholecystitis.

Answer 23

> S/S:
Fever, N/V, clammy, jaundice, sudden sharp RUQ pain into R shoulder, deep insp worsens.

> Gallstones:
Often a trigger.
Risk Factors for GS - 5 F’s - female, fat, forty+, fertile, fair complexion.

> Fatty Meals:
Recent fatty meal can precipitate pain.

> Murphy’s:
80% accuracy, 34% in elderly - Salati & Al Kadi (2012).

Question 24

Describe the term ‘acute abdomen’.

Answer 24

> Rapid onset of severe symptoms.

> That may indicate a life-threatening abdo pathology.

> Conditions inc:
Cholecystitis, appendicitis, pancreatitis, peptic ulcer, intestinal ischaemia, renal calculi, retention, AAA, torsions.

> Red Flags:
Hypotensive, red. GCS, shocked pt, systemically unwell, dehydrated, rigid abdo, haematemesis/melena, testicular/ovarian pathology.

Question 25

Renal Calculi.

Answer 25

> S/S:
Depends on stone size, N/V, pain in flanks/groin (maybe intermittent), men may have testicle pain, fever, clammy, haematuria, UTI.

> Types:
Calcium most common, uric acid stones.

> Men 40+ high risk.