Gastrointestinal System Examination:

Gastrointestinal System Examination:

History - Gastrointestinal System

Pain and discomfort




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• SOCRATES
  
 • Character: colicky [in waves] vs. not.
  • Alleviating, exacerbating factors: meals, any certain foods, vomiting, exercise, antacids, stress, defecation, flatus.
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• Pain dz hallmarks:
  • Colicky (GI or ureter obstruction). Small bowel: 3min. cycle. Large: 10min. cycle.
  • Localized, relieved by staying still (peritonitis).
  • Burning, relieved by food or antacid (heartburn).
  • Steady pain, relieved by sitting up, leaning forward (pancreatic).
  • Severe pain for hours, prior attacks (biliary).
  • Constant pain overlying severe pain radiating to groin (renal).
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Dysphagia




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• Location of food sticking.
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• Intermittent vs. worsens during meal vs. eases during meal.
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• Cannot initiate swallow vs. choking on swallow.
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• Painful vs. painless.
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• Painful on swallowing: "odynophagia" (inflammatory processes).
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• Solids worse vs. liquids worse.
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• Changes since onset.
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Nausea, vomiting and reflux




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• Timing of vomit:
  • Morning (pregnant, raised ICP, ethanol).
  • 1hr post-meal (gastric outlet obstruction,  gastroparesis).
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• Vomit contents:
  • Blood.
  • Bile.
  • Old food (pyloric stenosis) vs. new food.

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• Colour:
  • Yellow-green (bile, from obstruction).
  • Coffee grounds (altered blood).
  • Hematemesis.
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• Projectile (pyloric stenosis, raised ICP).
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• GERD, acid regurgitation:
  • Relieved by raising head of bed.
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Stools




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• Frequency: constipated vs. diarrheic.
  • And what would be your normal frequency for yourself?
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• Amount.
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• Blood: melena [black stool], hematochezia [bright red stool].
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• Pale, fatty, buoyant stool (steatorrhea 2° to fat malabsorption).
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• Odour.
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• Mucous: mixed with stool or not.
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• Consistency: hard vs. soft, watery.
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• Painfulness of defecation.
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• Needing to strain alot on defecation.
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Other systemic




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• Wasting, weight loss vs. gain.
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• Anemia, jaundice, bronze diabetes. See
Skin Colors Reference.
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• Lethargy (liver dz).
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• Abdominal swelling.
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Past medical, surgical history




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• Current complaint in the past.
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• Post-op from a recent operation (anesthetic s/e, damaged GI).
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• IBD.
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• Ulcers.
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• Past surgeries, treatments.
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Family history




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• Current complaint in family member (acute: food poisoning).
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• Heritable bowel dz.
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Social history




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• Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew] (ulcers).
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• Alcohol (cirrhosis, gastritis).
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• Occupation (hepatitis), others at workplace with similar.
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• Stress level (ulcers).
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• Toxin exposure (liver dz).
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• Travel, sex, IV, tattoo use (hepatitis).
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Drug history




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• Laxatives.
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• Indigestion medications.
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• NSAIDs (GI bleed).
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• Liver-damaging drugs.
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• Steroids.
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• Allergies.
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• Allergic reactions to drugs.
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Systems




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• Dark urine (jaundice).
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• RHF signs (nutmeg liver).
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Examination - Gastrointestinal System

Environment

• NG tube.
• Feeding tube.
• Cans of special food.

General appearance

• Colors:
  • Anemic (iron malabsorption, hemorrhage, CA).
  • Jaundiced (liver dz).
  • Hyperpigmented (hemochromatosis).
  • See Skin Colors Reference.
• Hydration and nutrition.
• Weight loss vs. gain, wasting.
• Shocked.
• Postural hypotension.

Nails

• CLUBBING (UC or Crohn's, Biliary cirrhosis, GI malabsorption).
• Koilonychia (iron deficiency 2° to GI bleeding).
• Leuconychia (hypoalbuminism 2° to cirrhosis).
• Muehrke's lines (hypoalbuminism 2° to cirrhosis).
• Blue lunulae (Wilson's).
• Nicotine stains (some GI CA's).
• See Nails Reference.

Hands

• Asterixis (PSE 2° to alcoholism):
  • Pt. stretches out hands in policeman's stop position, fingers spread out.
  • Coarse flapping tremor, "liver flap", is seen.
• Pallor of palmar creases (anemia 2° to blood loss, malabsorption).
• Palmar erythema (cirrhosis).
• Dupuytren's contracture [fibrosis, contracture of palm's fascia, usu contracting ring finger] (alcoholism, manual labor).
• Palmar xanthomata [yellow deposists on palm of hand] (Type III hyperlipidemia).
• Tendon xanthomata [yellow deposits on dorsum of hand, arm] (Type II hyperlipidemia).

Arms

• Scratch marks (itch from jaundice).
• Spider naevi (alcoholism).
• Bruising (clotting factors 2° to liver damage).
• Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III hyperlipidemia).

        Fig- pider naevi

Eyes

• Cornea rings (Wilson's).
• Sclera: jaundice.
• Iritis: IBD.
• Xanthelasma [yellow plaque periobital deposits] (elevated cholesterol).

Mouth

• Temporalis muscle wasting.
• Lips:
  • Telangiectasia (Osler-Weber-Rendu)
  • Brown freckles (Peutz-Jeghers).
• Breath:
  • Fetor hepaticus (alcoholism).
  • Ethanol.
• Mouth:
  • Ulcers (Crohn's, coeliac dz).
  • White candida patches (spread down throat).
  • Cracks at mouth edges (iron deficiency anemia).
• Teeth:
  • Cavities (acid 2° to vomiting).
  • Nicotine stains.
• Gums:
  • Hypertrophy.
  • Bleeding.
  • Gingivitis.
• Tongue:
  • Leucoplakia (smoke, spirits, sepsis, syphilis, sore teeth).
  • Atrophic glossitis [withered tongue] (deficiencies, Plummer-Vinson).
  • Macroglossia (B12 deficiency).

Neck, chest, back

• Cervical nodes:
  • Supraclavicular nodes for Virchow's node (lung CA, GI malignancy).
  • See Nodes Reference.
• Gynecomastia (chronic liver dz).
• Hair loss (chronic liver dz).
• Back: neurofibromas.

Abdomen: inspection

• Pt is supine, abdomen visible from nipples to pubic symphysis.
• Scars. See Abdominal Scar Reference.
• Stoma from surgery, trauma.
• PEG (dysphagia, usu. 2º to neurological damage, like stroke).
• Distension (fat, fetus, feces, flatus, fluid, full-sized tumors).
• Local swellings (enlarged organs, hernia). See Examining A Mass Reference.
• Pulsations (AAA).
• Peristalsis visible (thin person, intestinal obstruction).
• Skin:
  • Herpes zoster (abdominal pain).
  • Grey-Turner's sign [discolored skin] (acute pancreatitis).
• Striae:
  • Regular striae (ascities, pregnancy, weight loss).
  • Purple, wide striae (Cushings).
• Dilated veins location:
  • Anterior leg (IVC block).
  • Caput medusae (portal HTN).
  • Costal margin (normal).
• Dilated vein flow direction. Test by occluding with fingers:
  • Flows superior (IVC block).
  • Flows inferior (SVC block).
  • Navel radiation (portal HTN).
• Umbilicus:
  • Sister Joseph nodule (metastatic tumor).
  • Cullen's "black eye" (acute pancreatitis, extensive hemoperitoneum).
• Groin: brown freckles (Peutz-Jeghers).
• Squat to pt's stomach level, and watch for asymmetrical movement during breathing (mass, large liver).

Palpate general abdominal

• Warm hands.
• Ask pt if any part tender: examine that last.
• Abdominal muscles relaxed, pt bends knees if necessary.
• Light palpation.
• Deep palpation.
• Note rigidity, rebound tenderness, involuntary guarding (peritonitis).
• Record mass characteristics. See Examining A Mass Reference.
• Distinguish abdominal wall mass from intrabdominal mass:
  • Pt folds arms and sits halfway up.
  • Wall mass if size is same,  tenderness same or greater.

Palpate liver

• Find edge:
  • Dr's R hand held still at base of RLQ, parallel to costal margin.
  • Ask pt. to breathe slowly.
  • During each inspiration, see if liver edge strikes radial edge of index finger.
  • During each expiration, Dr's hand moves superiorly 2cm.
• Palpate liver surface, edge:
  • Hard vs. soft.
  • Regular vs. irregular.
  • Tender vs. not.
  • Pulsatile (tricuspid incompetence) vs. not.
• Find top border by percussing down R midclavicular line [normal: 5th rib in midclavicular line].
• Calculate span [normal span: 12.5cm].
• Assess for the presence of the Riedel’s lobe (a small tongue like projection from the inferior surface of the right lobe ) . May be enlarged and confused with a mass.

Causes of hepatomegaly :

-Liver disease : Acute hepatitis , alcoholic liver dis , infiltrative liver dis, fatty liver , HCC , metastatic dis.

-Congestive : right sided heart failure

-Hematological : Thalacemia  , leukemia ,

-Infectious :    Viral : Hepatitis , EBV,HIV

                        Bacterial : TB, Brucillosis ,

  Paracitic : Leshmaniasis ,     malaria           

-Infiltratetive : Amylodosis , lymphoma, sarcoidosis

-Rheumatological dis : SLE , RA

-Endocrine : Acromegaly , Thyrotoxocisis.

Palpate gallbladder

• Dr's fingers placed perpendicular to R costal margin near midline, then moved medial to lateral to palpate.
• Do Murphy's sign: cessation of inspiration upon palpation.
  • Murphy's point: costal margin in midclavicular line.
  • Courvoisier's law: Stones= stays small since scarred.

Causes of gallbladder enlargement :

With jaundice :

• Ca of head of pancreas
• Ca of ampulla
• Mucocele of the gallbladder

   Without Jaundice :

• Ca gallbladder
• Acute cholecystitis

Palpate spleen

• Bimanual technique:
  • Dr's L hand posterolaterally, below pt's L ribs, compressing on rib cage.
  • Dr's R hand below pt's umbilicus, parallel to L costal margin.
  • Advance R hand superiorly to L costal margin.
  • 1.5x-2x enlarged spleen is palpable.
  • If miss spleen, roll pt. towards Dr. (so pt lies on pt's R side) and repeat palpation.
• Alternatively: palpate like liver edge with just R hand, starting from RLQ diagonally over to LUQ.
• Alternatively: combine the two methods: start to palpate from RLQ like liver edge with just R hand, but then as get closer, reach with L hand around to pt's L ribcage and pull, while continuing advancing with R hand. 
• Assess spleen characteristics [these also help differentiate from kidney]:
  • Size
  • Shape, notch vs. no notch.
  • Percussion dullness vs. not.
  • Moves on respiration vs. not.
• Can get above it vs. Not

OR

Spleen Palpation (4 methods)’

 Method #1

o begin palpation in the RLQ

o direct the patient's breathing by telling them when to take a

deep breath and when to exhale

o while proceeding diagonally towards the Left Upper Quadrant

(LUQ), try to palpate the spleen edge during each inspiratory

Phase

Method #2

o place your Left hand under patient’s Left posterior lower rib cage & pull the

towards the costal margin.

o with your Right hand, begin palpation in the RLQ

o direct the patient's breathing by telling them when to take a

deep breath and when to exhale

o while proceeding diagonally towards the LUQ, try to palpate the

spleen edge during each inspiratory phase

Method #3

o place the patient’s Left fist under their Left posterior chest

o with your Right hand, begin palpation in the RLQ

o direct the patient's breathing by telling them when to take a

deep breath and when to exhale

o while proceeding diagonally towards the LUQ, try to palpate the

spleen edge during each inspiratory phase

Method #4

 –The Hooking maneuver of Middleton (optional)

o place the patient’s Left fist under their Left posterior chest

o position yourself on the patient’s Left side, facing the patient’s

feet

o using both hands, curl your fingers under the patient’s Left

costal margin

o ask the patient to take a long, deep breath à attempt to

palpate the spleen with your fingertips.

Spleen Percussion (3 methods):   

·          Percussion of Traube's Space

o boundaries -Left mid axillary line, 6th rib, costal margin

o this area should be resonant on percussion

o dullness indicates possible splenic enlargement

• Percussion by Castell’s method

o percuss in the lowest Left intercostal space in the anterior

axillary line (usually the 8th or 9th IC space

o this space should remain resonant during full inspiration or expiration.

o dullness on full inspiration indicates possible splenic

enlargement (a positive Castell’s sign)

·          Percussion by Nixon’s method (optional)

o place the patient in Right lateral decubitus.so that spleen lies over colon & stomach. Percussion begins at the lower level of pulm. Resonance in the posr. Axillary line & proceeds diagonally towards the lower mid anterior costal margin. The upper border of dullness is normally 6-8 cm above the costal margin. Dullness greater than 8cms in an adult indicate splenic enlargement.

Palpate kidneys

• Dr's L heel of hand slipped under pt's R loin, L fingers under R back.
• R hand held over RUQ.
• Dr flexes L MCPs in renal angle.
• Dr R hand feels strike as kidneys float anteriorly. 
• Repeat for other side.

Auscultate stomach

• Perform on empty stomach.
• Stethoscope on epigastrium.
• Then shake both iliac crests. 
• While shaking, listen to splash from retained fluid.
• Audible splash called "succussion splash" (ulcer or gastric CA).

Palpate pancreas

• Palpate for a round, fixed, swelling above umbilicus that doesn't move with inspiration (pseudocyst, acute pancreatitis, CA in thin pt).

Palpate aorta

• Palpate in midline, superior to umbilicus.
• Dr's 2 fingers on outer margins of aorta, watch if if fingers diverge (AAA).
• Normally felt in thin pt.

Palpate bowel

• Sigmoid usu. palpable in severe constipation.
• Whether indents (feces) or doesn't indent (masses).
• Sometimes can feel CA, megarectum.

Palpate bladder

• Ask pt when last urinated, and whether was complete emptying..
• Usually palpable if full, usually not palpable if empty.
• Look for palpable, empty bladder (swelling).

Palpate testes

• Atrophy (liver dz).

Abdomen: percussion

• Liver border for loss of of dullness (necrosis, perforated bowel).
• Spleen for splenomegaly.
• Kidneys.
• Bladder for enlarged bladder, pelvic mass.
• Percuss masses. See Examining A Mass Reference.

Abdomen percussion: ascites

• Shifting dullness:
  • The Dr's percussing finger placed vertically, so Dr's finger pointing toward pt's legs.
  • Starting at midline, percuss laterally to dullness on L flank, and mark site of dullness with non-permanent marker.
  • Roll pt towards Dr., so pt now laying on R side.
  • Pt stays lying on R side for 30min, then repercuss while still lying on R side.
  • Ascites present if the dullness has moved medially (ie the point of dullness is now resonant).
  • Optionally: percuss laterally on both R and L flanks, and mark both before rolling pt, so can assess them both moving.
• Dipping:
  • Flex MCP joint fast to displace fluid and palpate a mass.
• Fluid thrill:
  • Dr. puts hands on each of pt's flanks.
  • If obese, pt places pt's lateral edge of hand, vertically on midline at umbicus.
  • Dr. flicks hand on right flank, by quickly flexing MCPs.
  • Ascites if Dr feels resulting thrill on left flank.

Abdomen: auscultation

• Below umbilicus to assess bowel sounds for:
  • Rushing sound called "borborygmi" (diarrhea).
  • No sound for 3 minutes (ileus, paralysis).
  • "Tinkling" sound (obstructed bowel).
• Above umbilicus for:
  • AAA bruit.
  • Venus hum [blood flowing in caput medusae] (portal HTN).
• R and L above umbilicus for renal artery stenosis.
• Over liver for:
  • Friction rub [grating during breathing] (peritonitis, Fitz-Hugh-Curtis, others).
  • Bruit (CA, alcoholic hepatitis).
• Over spleen for splenic rub (splenic infarct).

Groin, hernias, rectal

• Palpate lymph nodes: See Inguinal Nodes.
• See Hernia Examination below.
• See Rectal Examination below. 

Legs

• Edema.
• Bruising.
• Tuboeruptive xanthomata [yellow deposists on elbows, knees] (Type III hyperlipidemia).
• If chronic liver disease, See Neurological Examination.
• Toenails and foot showing same symptoms as Fingernails and Hands. 

Per Rectal

Setting up

• Describe procedure to pt.
• Pt. in Sim position: on table, lying on L side, knees up towards chest, facing away from Dr.
• Gloves on.

External inspection

• Piles.
• Skin tags (normal, Crohn's, hemorhoids).
• Rectal prolapse.
• Anal fissure.
• Fistula.
• Anal warts.
• Carcinoma.
• Signs of incontinence, diarrhea.

External inspection: straining

• Ask pt. to strain.
• Rectal prolapse upon straining.
• Hemorrhoid prolapse.
• Incontinence.
• Ask if straining is painful.

Internal palpation

• Lubricate index finger.
• Insert finger slowly, assessing external sphincter tone as enter.
• Male: palpate prostate [anterior of rectum]:
  • Hard nodule (prostate cancer).
  • Tender (prostatitis).
• Female: palpate cervix [anterior of rectum]:
  • Mass in pouch of Douglas.
• Rotate finger, palpating along left, posterior, right walls.
• Withdraw finger.
• Wipe lubricant off pt.
• Ask if was significant pain during examination. 

Stool examination

• Inspect withdrawn fingertip for:
  • Blood, melena.
  • Stool color.
  • Pus.
  • Mucous.
• If indicated, do a fecal occult blood test: blue result means blood.

Hernia Examination

1.       Inguinal hernia

Inspect

• Is pt. male (predisposing factor).
• Pt's lifting muscles, ascities (predisposing factors).
• Pt. stands, exposed area visible.
• Swellings.
• Swellings: bilateral (direct) or unilateral (indirect).
• Swellings: only appear on standing?
• Swelling location: above or below inguinal ligament. See Inguinal Canal Reference.
• Hernia surgical scars.
• External genitalia, including undescended testicle (DDx).
• Ask pt. to reduce hernia themselves.
• Pt. coughs to highlight hernia.

Palpate

• Ask pt. about tenderness first.
• See Inguinal Canal Reference for landmarks.
• Inguinal hernia goes in inguinal canal.
• Palpate mass, scrotal ones can be done up scrotum with little finger.
• Optionally can cough here while little finger up scrotum to feel an impulse on end of finger (indirect) vs. superior part of finger.
• See whether can reduce it back up through the inguinal ring to reduce it.

Palpate: cough impulse

• Reduce.
• Hold two fingers on internal ring.
• Pt. coughs while holding fingers on ring.
• See if hernia  can extrude around elsewhere (direct) or stays reduced (indirect).

Direct vs. indirect summary

• Bilateral (direct) vs. unilateral (indirect).
• Strangulation concern (indirect) vs. rarely strangulate (direct). Usually obstruction precedes strangulation (except Richter's).
• Through inguinal ring (indirect) vs. around inguinal ring (direct).

2.       Femoral hernia

Inspect

• Is pt female? [predisposing factor].
• Pt. stands, exposed area visible.
• Swellings.
• Swellings: only appear on standing?
• Reddening.
• Hernia surgical scars.
• External genitalia.
• Ask pt. to reduce hernia themselves.
• Pt. coughs to highlight hernia, though may not appear in femorals.
• Whether hernia goes through Hasselbach's triangle. See Inguinal Canal Reference.

Palpate

• Ask pt. about tenderness first.
• Femoral 'neck' is usually palpated inferior and lateral to pubic tubercle.
• Femorals more likely to be irreducible than inguinals.
• Can have pt. cough while palpating, reducing.
• Don't confuse with firm lymph node, femoral vein. 
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• Source: www.doctorshangout.com