GI Exam Flashcards
Why might palmar erythema, spider naevi, gynacoemastia and Leukonychia occur?
Palmar erythema and spider naevi are due to excess oestrogen associated with reduced hepatic breakdown of sex steroids. Women may have up to five spider naevi in health; palmar erythema and spider naevi are normal during pregnancy. In men these signs suggest chronic liver disease.
Gynaecomastia with loss of body hair and testicular atrophy may occur due to reduced breakdown of oestrogen so.
Leukonychia, caused by hypoalbuminaemia, may also occur in protein calorie malnutrition (Krashiorkor), malabsorption due to protein-losing enteropathy e.g. coeliac disease or heavy and prolonged proteinuria (nephrotic syndrome).
Finger clubbing is associated with liver cirrhosis, inflammatory bowel disease and malabsorption syndromes.
In a jaundiced patient with spider naevi, palmar erythema and ascites all strongly suggests chronic liver disease rather than obstructive jaundice.
What are signs of liver failure?
Fetor hepaticus: stale, mousy smell of the volatile amine, dimethyl sulphate on the breath. Evidence of portosystemic shunting with or without encephalopathy
Flapping tremor of outstretched arms with hands dorsiflexed (asterixis). Occurs with hepatic encephalopathy. NB: check for 15 seconds
Mental state varies from drowsiness with day/night pattern reversed, through confusion and disorientation, to unresponsive coma.
Late neurological features include spasticity and extension of the arms and legs, extensor plantar reflexes
What are Dupuytren’s Contracture and bilateral Parotid swelling associated with?
Dupuytren’s Contracture (of the palmar fascia) is linked with alcohol-related chronic liver disease. More commonly, however, it is familial (autosomal dominant with variable penetrance) or associated with conditions causing microvascular pathology e.g. Diabetes Mellitus, smoking, hyperlipidaemia and HIV infection.
Bilateral parotid swelling due to sialoadenosis of the salivary glands may be a feature of chronic alcohol abuse or bulimia associated with recurrent vomiting
What do visible veins suggest?
Abnormally prominent veins on the abdominal wall suggest portal hypertension or vena cava obstruction. In portal hypertension, recanalisation of the umbilical vein along the falciparum ligament produces distended veins which drain away from the umbilicus - ‘caput medusae’.
The umbilicus may appear distended and bluish due to an umbilical varix.
An umbilical hernia is a distended and everted umbilicus which does not appear vascular and may have a palpable cough impulse.
Dilated tortuous veins with blood flow superiorly are collateral veins due to obstruction of the inferior vena cava.
Rarely, superior vena cava obstruction gives rise to similar distended abdominal veins, but which all flow inferiorly.
What indicates tenderness may be due to anxiety?
Tenderness in several areas on minimal pressure may be due to generalised peritonitis but is more often due to anxiety.
Severe superficial pain with no tenderness on deep palpation or pain that disappears if the patient is distracted also suggests anxiety.
What is voluntary and involuntary guarding?
Voluntary contraction of the abdominal muscles when palpation provokes pain.
Involuntary guarding is the reflex contraction of the abdominal muscles when there is inflammation of the parietal peritoneum.
If the whole peritoneum is inflamed (generalised peritonitis) due to a perforated viscus, the abdominal wall no longer moves with respiration; breathing becomes increasing thoracic and the anterior abdominal wall muscles are held rigid (board-like rigidity).
Why is the site of tenderness important? What is rebound tenderness?
Tenderness in the epigastrium suggests peptic ulcer.
In the right hypochondrium, suggests cholecystitis.
In the left iliac fossa, diverticulitis.
In the right iliac fossa, appendicitis or Crohn’s ileitis,
Rebound tenderness is a sign of intra-abdominal disease but not necessarily of parietal peritoneal inflammation (peritonism). Ask the patient to cough or gently percuss the abdomen to elicit any pain or tenderness, rapidly removing your hand after deep palpation increases the pain.
How would you feel for gallbladder tenderness (in cholecystitis)? What would indicate acute cholecystitis?
Ask the patient to breathe in deeply and gently palpation the right upper quadrant of the abdomen in the mid-clavicular line. As the liver descends, the inflamed gallbladder contacts the fingertips, causing pain and the sudden arrest of respiration.
In a patient with right upper quadrant pain, a positive Murphy’s sign modestly increases the probability of acute cholecystitis
What is jaundice and a palpable gallbladder likely to be due to
Extrahepatic obstruction e.g. From pancreatic cancer or more rarely, gallstones (Courvoisier’s Sign)
Palpable distance of the gallbladder has a characteristic globular shape. It is rare and results from either obstruction of the cystic duct, as in a mucocoele or emphysema of the gallbladder, or obstruction of the common bile duct (providing the cystic duct is patent) as in pancreatic cancer.
In gallstone disease the gallbladder may be render but impalpable because of fibrosis of the gallbladder wall.
What are causes of Hepatomegaly?
Chronic parenchymal liver disease: alcoholic liver disease (sometimes with liver bruits), hepatic steatosis, autoimmune hepatitis, viral hepatitis, primary biliary cirrhosis
Malignancy: primary hepatocellular cancer (liver bruits may be heard), secondary metastatic cancer (hard and irregular enlargement)
Right heart failure: congested liver is usually soft and tender, a pulsatile liver may indicate regurgitation, bruit may indicate aertiovenous malformation
Haematological disorders: lymphoma, leukaemia, myelofibrosis, polycythaemia
Rarities: amyloidosis, sarcoidosis, Glycogen storage disorders, Budd-chiari syndrome
NB: resonance below the fifth intercostal space suggests emphysema or occasionally the interposition of the transverse colon between the liver and diaphragm (Chilaiditi’s sign)
Remember the spleen descends down and medically during inspiration. It has to increase in size threefold before it becomes palpable.
What are the causes of splenomegaly?
Haematological disorders: lymphoma and lymphatic leukaemias, myeloproliferative diseases, haemolytic anaemia, congenital spherocytosis, polycythaemia rubra Vera, myelofibrosis
Portal hypertension
Infections: glandular fever, malaria, brucellosis, TB, bacterial endocarditis
Rheumatological conditions: Rheumatoid arthritis (Felty syndrome: RA, splenomegaly and neutropenia), lupus
Rarities: sarcoidosis, amyloidosis, glycogen storage disorders
What is ascites? What would indicate it?
Accumulation of intraperitoneal fluid
Causes: intra-abdominal malignancy, chronic liver disease, severe heart failure, nephrotic syndrome, hypoproteinaemia
Don’t forget to wait 10 seconds in shifting dullness
Fluid thrill is only detected in gross ascites: place palm of left hand flat against the left side of the patient’s abdomen and flick a finger of your fight hand against the right side of the abdomen. If you feel a ripple, place the edge of patient’s hand on the midline to prevent transmission of the impulse through the skin rather than through the ascites. If you still feel a ripple, a fluid thrill is present.
Weight gain, increased abdominal faith and shifting dullness together strongly suggest ascites.
What are the causes of hepatosplenomegaly
Lymphoma
Myeloproliferative diseases
Cirrhosis with portal hypertension
Amyloidosis, sarcoidosis, glycogen storage disease
Listen for bowel sounds for up to 2 minutes before concluding they are absent. Bowel sounds are gurgling noises from the normal peristaltic activity of the gut. They normally occur every 5-10 seconds but the frequency varies.
What are abnormal findings?
Absence of bowel sounds implies paralytic ileum or peritonitis.
In intestinal obstruction, bowel sounds occur with increased frequency and volume and have a high-pitched tinkling quality.
Bruits suggest an atheromatous or aneurysmal aorta or superior mesenteric artery stenosis.
A friction rub, which sounds like rubbing your dry fingers together, may be heard over the liver (peri-hepatitis) or spleen (peri-splenitis).
An audible splash more than 4 hours after the patient has eaten or drunk anything includes delayed gastric emptying e.g. Pyloric stenosis.
What would you consider as part of your general examination?
Look around bedside for treatments or adjuncts – sick bowls /feeding tubes /stoma bags /drains
Patients appearance – in pain? / agitated? / confused?
Observation chart – note abnormalities – e.g. pyrexia / hypotension / tachycardia etc
Body habitus – healthy / obese/ low BMI / cachectic
Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy)
Jaundice – indicates likely liver disease – cirrhosis / hepatitis
Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
Abdominal distention – ascites / bowel distension / large masses
Masses – may suggest malignancy / organomegaly
Dressings – may be covering wound sites – infection / bleeding
Tattoos / needle track marks – have increased suspicion for blood borne viruses (e.g. Hepatitis B/C)
