GI examination Flashcards
what are the clinical signs to look for during general inspection in a GI examination?
- age
- confusion
- pain
- obvious scars
- abdominal distension
- pallor
- jaundice
- hyperpigmentation
- oedema
- cachexia
- hernias
- body habitus
- perspiration
- discomfort
- breathing
- consciousness
what is cachexia?
ongoing muscle loss that’s not entirely reversed with nutritional supplementation; commonly associated with underlying malignancy and advanced malignancy
what objects and equipment should be looked for during general inspection?
- stoma bag
- surgical drains (location and type/volume of contents)
- feeding tubes
- ECG leads, medications, TPN, catheters, IV access
- mobility aids
- vital signs
- FBC
- prescriptions
what should be inspected during hand inspection?
- palms
- nail signs
- finger clubbing
- asterixis
what should be looked for in the palms during hand inspection?
- pallor
- palmar erythema
- Dupuytren’s contracture
what should be looked for in the nails during hand inspection?
- koilonychia
- leukonychia
- Terry’s nails/leukonychia totalis
what is koilonychia?
spoon shaped nails, associated with iron deficiency anaemia
what is leukonychia?
whitening of the nail bed, associated with hypoalbuminaemia; small isolated white patches or striae are often seen in nail plates of normal people in response to minor trauma to the germinal matrix
what are Terry’s nails?
leukonychia totalis; whitening of the entire nail occurs with hypoalbuminaemia
what is finger clubbing?
involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed
what are the likely causes of finger clubbing in a GI examination?
IBD, coeliac disease, UC, Crohn’s, liver cirrhosis, lymphoma of the GI tract
how do you assess for finger clubbing?
- ask patient to place the nails of their index fingers back to back
- you should observe a small diamond-shaped window (Schamroth’s window)
- when finger clubbing develops, this window is lost
what is Schamroth’s window?
a small diamond-shaped window seen when nails of both index fingers are placed back to back; this is lost in finger clubbing
what is asterixis?
type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands
what are the likely causes of asterixis in a GI examination?
hepatic encephalopathy (due to hyperammonaemia), uraemia secondary to renal failure, or CO2 retention secondary to type 2 respiratory failure
how do you assess for asterixis?
- ask the patient to stretch their arms out in front of them for 15 seconds
- ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds
- observe for evidence of asterixis
- a coarse flapping tremor suggests liver failure with failure of ammonia metabolism to urea
what should be palpated in hand palpation?
- temperature
- radial pulse
- Dupuytren’s contracture
what is Dupuytren’s contracture?
involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which will cause contracture deformities of the fingers and thumb; fibrosis and shortening of the palmar aponeurosis
what should be looked for in arm inspection?
- bruising
- excoriations
- needle track marks
what should be looked for in axilla inspection?
- acanthosis nigricans
- hair loss
what is acanthosis nigricans?
darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign and associated with insulin resistance or GI malignancy
what should be looked for in face inspection?
telangiectasia (hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu syndrome)) affecting the face, oral mucosa, GI tract, lungs, liver and brain
what should be looked for in eye inspection?
- conjunctival pallor
- jaundice
- corneal arcus
- xanthelasma
- Kayser-Fleischer rings
- perilimbal injection
what is corneal arcus?
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over 60
what are Kayser-Fleischer rings?
dark rings that encircle the iris, associated with Wilson’s disease
what is perilimbal injection?
inflammation of the area of conjunctiva adjacent to the iris; sign of anterior uveitis, which can be associated with IBD; other features of anterior uveitis are photophobia, ocular pain and reduced visual acuity
what should be looked for in mouth inspection?
- angular stomatitis
- glossitis
- oral candidiasis
- aphthous ulceration
- hyperpigmented macules
- telangiectasia
- dehydration
- halitosis (bad breath)
what is angular stomatitis?
common inflammatory condition affecting the mouth corners, can be caused by iron deficiency; may be caused by deficiency of vitamin B6, B12, folate or iron
what is glossitis?
smooth erythmatous enlargement of the tongue associated with iron, B12 and folate deficiency; painful glossitis is seen in vitamin B12 or folate deficiency, usually painless in iron-deficiency
what is oral candidiasis?
associated with immunosuppression; characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa
what is aphthous ulceration?
round or oval ulcers occurring on the mucous membranes inside the mouth; typically benign but can be associated with iron, B12 and folate deficiency and Crohn’s disease
what are hyperpigmented macules?
pathognomonic for Peutz-Jeghers syndrome, an AD disorder that results in polyps in the GI tract
what is looked for in neck inspection?
- enlargement of the left supraclavicular lymph node (Virchow’s node)
- Troisier’s sign
- enlargement of the right supraclavicular lymph node
- palpate the supraclavicular fossa on each side
what is Trosier’s sign?
an enlarged left supraclavicular lymph node (Virchow’s node) due to a metastasis from an intraabdominal malignancy
what is Virchow’s node?
left supraclavicular lymph node
what is looked for in chest inspection?
- spider naevi
- gynaecomastia
- hair loss (caused by increased oestrogen or general malnourishment)
what are spider naevi?
skin lesions that have a central red papule with fine red lines extending radially caused by increased oestrogen
what is gynaecomastia?
enlargement of male breast tissue caused by increased levels of oestrogen or medications
what should be looked for in abdominal inspection?
- scars
- loose skin or stretch marks
- shape and symmetry
- movement during breathing
- visible swellings, masses, peristalsis, aortic pulsation
- distended veins
- abdominal distension
- caput medusae
- striae
- hernias
- Cullen’s sign
- Grey-Turner’s sign
what are the 5 Fs that can cause abdominal distension?
fat, fluid, flatus, faeces, fetus or fulminant mass
what are caput medusae?
engorged paraumbilical veins associated with portal hypertension
what is Cullen’s sign?
bruising of the umbilicus associated with haemorrhagic pancreatitis
what is Grey-Turner’s sign?
bruising in the flanks associated with haemorrhagic pancreatitis
what areas should be closely inspected/palpated?
- hand inspection
- hand palpation
- arm inspection
- axilla inspection
- face inspection
- eye inspection
- mouth inspection
- neck inspection/palpation
- chest inspection
- abdominal inspection
what components of the stoma should be assessed?
- location
- contents (stool or urine)
- consistency of stool (liquid or solid)
- spout (colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout)
how should you prepare for abdominal palpation?
- patient should be lying flat on the bed
- ask the patient if they’re aware of any areas of abdominal pain
- kneel beside patient and observe face throughout for signs of discomfort
what is done in light palpation of the abdomen? what should be felt for?
- lightly palpate each of the 9 abdominal regions
- tenderness
- rebound tenderness
- guarding
- Roysing’s sign
- masses
what is rebound tenderness?
present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain; non-specific, unreliable sign which may be associated with peritonitis
what is guarding?
involuntary tension in the abdominal muscles that occurs on palpation, associated with peritonitis
what is Roysing’s sign?
palpation of the LIF causes pain to be experienced in the RIF; suggestive of peritonitis but not particularly reliable
what structures should be palpated?
- light and deep palpation of the abdomen
- liver
- gallbladder
- spleen
- kidneys (balloting)
- aorta
- bladder
- inguinal nodes
what is done in deep palpation of the abdomen?
- apply greater pressure
- visualise the underlying masses by asking patient to raise their head and shoulders off the pillow; masses within the abdominal wall become more prominent when recti are contracted, and intraabdominal masses become less prominent
- warn of discomfort
- assess masses
- if stomach appears distended, perform a succussion splash
what is a succussion splash?
shake the stomach briskly from side to side whilst listening for a sloshing sound
how is the liver palpated?
- begin palpation in the RIF, starting at the edge of the SIS, using the flat edge of your hand (radial side of your right index finger)
- ask 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 1-2cm superiorly from the RIF each time towards the right costal margin
- assess characteristics of liver edge
what characteristics of the liver edge should be assessed?
- degree of extension below the costal margin (if greater than 2cm this suggests hepatomegaly)
- consistency of the liver edge (nodular consistency suggests cirrhosis)
- tenderness (may suggest hepatitis or cholecystitis)
- pulsatility (associated with tricuspid regurgitation)
what is Courvoisier’s law?
states that in the presence of a palpable gallbladder, jaundice is not likely to be due to gallstones
what are causes of hepatomegaly?
- hepatitis
- hepatocellular carcinoma
- hepatic metastases
- Wilson’s disease
- haemochromatosis
- leukaemia
- myeloma
- glandular fever
- primary biliary cirrhosis
- tricuspid regurgitation
- haemolytic anaemia
how is the gallbladder palpated?
- usually not palpable
- if it is palpable, it suggests enlargement secondary to biliary flow obstruction/infection
- palpate at the right costal margin, in the midclavicular line (tip of 9th rib)
- if enlarged, a well-defined round mass that moves with respiration may be noted
what is Murphy’s sign? how is it elicited?
- position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge
- ask the patient to take a deep breath
- if the patient suddenly stops mid-breath due to pain, this suggests cholecystitis (positive pain)
how is the spleen palpated?
- begin palpation in the RIF, starting at the edge of the SIS, using the flat edge of your hand
- ask patient to take a deep breath and as they begin, palpate the abdomen with your fingers aligned with left costal margin
- feel for a step as the splenic edge passes below your hand during inspiration
- repeat this process of palpation moving 1-2cm superiorly from the RIF each time towards the left costal margin
- as you advance toward the left costal margin using your right hand to palpate for splenomegaly, place your left hand posteriorly and roll the patient slightly toward you
when does splenomegaly become palpable?
once the spleen has enlarged to 2-3 times its normal size
what are causes of splenomegaly?
- portal hypertension secondary to liver cirrhosis
- haemolytic anaemia
- congestive heart failure
- splenic metastases
- glandular fever
how do you ballot the kidneys?
- anterior hand should press deeply, lateral to the margin of the rectus muscle in the upper quadrant
- posterior hand placed in costovertebral (renal) angle and should be used to lift the kidney up against the anterior hand
- place your left hand behind the patient’s back, below the ribs and underneath the right flank
- place your right hand on the anterior abdominal wall just below the right costal margin in the right flank
- push your fingers together, pressing upwards with your left hand and downwards with your right
- if kidney is ballotable, describe its size and consistency
- repeat process on other side
how can you distinguish a palpable kidney from a spleen?
attempt to insert your hand between the upper pole of the kidney and the costal margin, which can be done if the mass is renal but not if it’s the spleen; the spleen has a notch which may be palpable; the spleen is not balloteable
what are causes of bilaterally enlarged ballotable kidneys?
PKD or amyloidosis
what are causes of a unilaterally enlarged ballotable kidneys?
renal tumour
how can you palpate the aorta?
- using both hands, perform deep palpation just superior to the umbilicus in the midline
- in healthy people, your hands should begin to move superiorly with each pulsation
- if your hands move outwards, it suggests the presence of an expansile mass e.g. AAA
how can you palpate the bladder?
- before doing this, allow patient to go to the toilet
- warn the patient that palpation may be uncomfortable and bring a sudden urge to urinate
- a distended bladder can be palpated in the suprapubic area arising from behind the pubic symphysis
- in healthy people, it’s not palpable
where can a distended bladder be palpated?
in the suprapubic area arising from behind the pubic symphysis; it will be impossible to feel the lower border of the mass behind the pubis
what structures should be percussed?
- liver
- spleen
- bladder
- assess shifting dullness
how can you percuss the liver?
- percuss upwards of 1-2cm at a time from the RIF towards the right costal margin until it changes from resonant to dull (indicates the lower liver border)
- continue to percuss upwards 1-2cm at a time until the note changes from dull to resonant indicating the upper border
- determine its size
- consider normal surface markings of superior liver border (6th rib in midinspiration)
how can you percuss the spleen?
- percuss upwards 1-2cm at a time from the RIF towards the left costal margin until the note changes from resonant to dull
- percuss the area of the lowest intercostal space in the left anterior axillary line
- if note changes from resonant to dull on full inspiration, the Castell sign is positive
how can you percuss the bladder?
- percuss downwards in the midline from the umbilical region towards the pubic symphysis
- a distended bladder will be dull to percussion, allowing you to approximate its border
how can you assess the presence of ascites?
percussion can identify it by assessing shifting dullness
how can you assess shifting dullness?
- percuss from the umbilical region to the patient’s left flank; if dullness is noted, this may suggest presence of ascites
- whilst keeping your fingers over the area at which the percussion note became dull, ask patient to roll onto their right side (towards you for stability)
- keep the patient on their right side for 30 seconds and then repeat percussion over the same area
- if ascites is present, the area that was previously dull should now be resonant (dullness has shifted)
what structures should be auscultated?
- assess bowel sounds
2. listen for bruits
how can you assess bowel sounds?
- auscultate over at least 2 positions on the abdomen
2. to be able to say a patient has absent bowel sounds you need to auscultate for at least 3 minutes
what types of bowel sounds?
- normal: gurgling
- tinkling: associated with bowel obstruction
- absent: suggests ileus
how can you auscultate for bruits? where do you listen for different types of bruits?
- auscultate over the aorta and renal arteries
- aortic bruits: auscultate 1-2cm superior to the umbilicus
- renal bruits: auscultate 1-2cm superior to the umbilicus and slightly lateral to the midline on each side
- femoral bruits
what should you look for in the legs?
assess lower legs for evidence of pitting oedema
what is ISHRUG?
- inguinal lymph nodes
- stools
- hernial orifices (femoral and inguinal)
- rectal examination
- urinalysis
- genitalia
what further assessments and investigations should be suggested at the end of a GI examination?
- check hernial orifices
- perform DRE
- perform examination of the external genitalia
