GASTROINTESTINAL

EXAMINATION
Introduction
The mnemonic WIPER can be used:
• W- Wash hand and don PPE where appropriate
• I- Introduce yourself and confirm patients details
• P- Explain procedure and gain consent or permission
• E- Expose patient appropriately
• R- reposition patient (45 degree or flat)
Introduction
Inspect the patient from the end of the bed whilst at rest, looking for clinical
signs suggestive of underlying pathology:
• Patient’s general wellbeing
• Age
• Confusion: often a feature of end-stage liver disease, known as hepatic
encephalopathy.
• Pain
• Obvious scars: may provide clues regarding previous abdominal surgery.
• Abdominal distention: may suggest the presence of ascites or underlying
bowel obstruction and/or organomegaly.
Introduction
• Pallor
• Jaundice
• Oedema: typically presents as swelling of the limbs (e.g. pedal
oedema) or abdomen (i.e. ascites) and is often associated with liver
cirrhosis.
• Cachexia
• Hernias
Objects and equipment
Inspect for any objects or equipment on or around the patient such as
• Stoma bags
• Surgical drains
• Feeding tubes
• Other medical equipment: ECG leads, oxygen, vomitus pot, catheters
and intravenous access.
• Mobility aids
The hand
• Check for:
Pallor
• Palmar erythema
• Dupuytren’s contracture

• Asterixis or flapping tremor caused by hyperammonaemia in patients

with hepatic encephalopathy
• Temperature
Nail

• Koilonychia: spoon-shaped nails, associated with iron deficiency

anaemia (e.g. malabsorption in Crohn’s disease).
• Leukonychia: whitening of the nail bed, associated with
hypoalbuminaemia (e.g. end-stage liver disease)
• Finger clubbing
Stages of nail clubbing
• STAGE I - increased sponginess of the nail fold.

• STAGE II - obliteration of the angle between the nail and the nail fold.

• STAGE III - increased convexity of the nail in both directions

longitudinally and transversely.

• STAGE IV - Bulbous swelling of the distal end of the finger

Arms and axilla
Inspect the patient’s arms and axilla for the following:
• Bruising: may suggest underlying clotting abnormalities secondary to liver
disease.
• Excoriations: scratch marks that may be caused by the patient trying to relieve
pruritis. In the context of an abdominal examination, this may suggest
underlying cholestasis.
• Acanthosis nigricans: darkening and thickening of the axillary skin which can
be associated with insulin resistance (e.g. type 2 diabetes mellitus) or
gastrointestinal malignancy (most commonly stomach cancer).
• Hair loss: loss of axillary hair associated with iron-deficiency anaemia and
malnutrition.
Eyes
• Conjunctival pallor.
• Jaundice.
• Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes
associated with hypercholesterolaemia.
• Kayser-Fleischer rings: dark rings that encircle the iris associated with
Wilson’s disease.
Mouth and tongue
• Angular stomatitis: a common inflammatory condition affecting the
corners of the mouth.
• Glossitis: smooth erythematous enlargement of the tongue
associated with iron, B12 and folate deficiency (e.g. malabsorption
secondary to inflammatory bowel disease).
• Oral candidiasis: a fungal infection commonly associated with
immunosuppression
Neck
The left supraclavicular lymph node is also known as Virchow’s node.
It receives lymphatic drainage from the abdominal cavity
Enlargement of Virchow’s node can be one of the first clinical signs of
metastatic intrabdominal malignancy (most commonly gastric cancer).
Chest
Spider naevi: skin lesions that have
a central red papule with fine red
lines extending radially caused by
increased levels of circulating
oestrogen. They are commonly
associated with liver cirrhosis,
pregnancy or in women taking the
combined oral contraceptive pill. If
more than 5 are present it is more
likely to be associated with
pathology such as liver cirrhosis.
Chest
• Gynaecomastia: enlargement of male breast tissue caused by
increased levels of circulating oestrogen (e.g. liver cirrhosis). Other
causes include medications such as digoxin and spironolactone.
• Hair loss: also caused by increased levels of circulating oestrogen.
General malnourishment can also result in hair loss.
Abdominal examination
The sequence of abdominal examination includes:
• Inspection
• Palpation
• Percussion
• Auscultation
Abdominal inspection

• Scars.
• Abdominal distension: can be caused by a wide range of pathology including the six f’s
(fat, fluid, flatus, faeces, fetus or fulminant mass).
• Caput medusae: engorged paraumbilical veins associated with portal hypertension
(e.g. liver cirrhosis).
• Striae (stretch marks)
• Hernias
• Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with
haemorrhagic pancreatitis
• Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis
Palpation
It involves light and deep palpation
• Light palpation is to elicit areas of tenderness
• Deep palpation is to elicit for characteristics of any mass noted on
physical examination and for palpating for abdominal organs
• Always the site of tenderness should be asked from the patient and
palpated last and check patient’s facial expression for pain
Some terminologies

• Tenderness is the objective expression of pain from palpation.

• Rebound tenderness is the elicitation of tenderness by rapidly removing
the examining hand.
• Rigidity is the involuntary tightening of the abdominal musculature that
occurs in response to underlying inflammation.
• Guarding is a voluntary contraction of the abdominal wall musculature to
avoid pain.
• Guarding tends to be generalized over the entire abdomen, whereas
rigidity involves only the inflamed area.
• Guarding can often be overcome by having the patient purposely relax
the muscles but rigidity cannot be.
Characterizing a mass
If a mass is noted on deep palpation assess the following characteristics
• Location: note which of the nine abdominal regions the mass located
within.
• Size and shape: assess the approximate size and shape of the mass.
• Consistency: assess the consistency of the mass (e.g. smooth, soft,
hard, irregular).
• Mobility: assess if the mass appears to be attached to superficial or
underlying structures.
• Pulsatility: note if the mass feels pulsatile, suggestive of vascular
origin
The liver
• The pads of the finger tips of the right hand and start palpating from
the right iliac fossa and work your way upwards
• The upper border of the liver is usually located 1cm above the upper
border of the right 5th rib in the midclavicular line.
• In right heart failure, the liver is enlarged, soft and tender. Pressure
over the liver may distend thejugular veins. This is called the hepato-
jugular reflex
Causes of hepatomegaly

• Hepatitis (infective and non-infective)

• Hepatocellular carcinoma
• Hepatic metastases
• Wilson’s disease
• Leukaemia
• Tricuspid regurgitation
The gall bladder
• The gall bladder is not palpable unless enlarged and it may then be
felt
• Palpation of the gallbladder can be attempted at the right costal
margin, in the mid-clavicular line (the tip of the 9th rib)
• If the patient suddenly stops mid-breath due to pain, this suggests the
presence of cholecystitis (known as “Murphy’s sign positive”).
The spleen
• The palpation of the spleen is started from the right iliac fossa with
the pulps of the right fingers and work your way diagonally upwards
to the left costal margin.
• This is because the spleen enlarges towards the right iliac fossa.
Some causes of splenomegaly include:
• Portal hypertension secondary to liver cirrhosis
• Congestive heart failure
• Splenic metastases
The kidney
• The kidneys are palpated bimanually
• In healthy individuals, the kidneys are not usually ballotable, however,
in patients with a low body mass index, the inferior pole can
sometimes be palpated during inspiration.
Percussion
To detect ascites:
• Shifting dullness
• Fluid thrill
Auscultation
• Bowel sounds: listen over the right iliac fossa.
it can be normal, reduced(In paralytic ileus) or increased(in intestinal
obstruction)
Bruits:
• Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here
may be associated with an abdominal aortic aneurysm.
• Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly
lateral to the midline on each side. A bruit in this location may be
associated with renal artery stenosis.
Groin and external ganitalia
• The groin should be examined for any swellings(lymphadenopathy or
hernias)
• The external genitalia should be examined for any abnormalities
Digital rectal examination
• The patient is placed in the left lateral position with hips and knees
flexed
• The anus and perineum are inspected in good light by lifting the right
buttock and noting the presence of any fissures, skin tags,
dermatological conditions, infestations or external haemorrhoids.
• The examining finger then sweeps round the rectum to palpate
surrounding structures to assess the state of the mucosa and to search
for specific lesions
• The prostate is checked in males and the cervix in females
• The examining finger is inspected upon removal
references
• T.C ANKRAH
• https://geekymedics.com/abdominal-examination/