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Gastrointestinal System Examination:



Gastrointestinal System Examination:



History - Gastrointestinal System
Pain and discomfort
  • SOCRATES
    • Character: colicky [in waves] vs. not.
    • Alleviating, exacerbating factors: meals, any certain foods, vomiting, exercise, antacids, stress, defecation, flatus.
  • 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).
Dysphagia
  • Location of food sticking.
  • Intermittent vs. worsens during meal vs. eases during meal.
  • Cannot initiate swallow vs. choking on swallow.
  • Painful vs. painless.
  • Painful on swallowing: "odynophagia" (inflammatory processes).
  • Solids worse vs. liquids worse.
  • Changes since onset.
Nausea, vomiting and reflux
  • Timing of vomit:
    • Morning (pregnant, raised ICP, ethanol).
    • 1hr post-meal (gastric outlet obstruction,  gastroparesis).
  • Vomit contents:
    • Blood.
    • Bile.
    • Old food (pyloric stenosis) vs. new food.
  • Colour:
    • Yellow-green (bile, from obstruction).
    • Coffee grounds (altered blood).
    • Hematemesis.
  • Projectile (pyloric stenosis, raised ICP).
  • GERD, acid regurgitation:
    • Relieved by raising head of bed.
Stools
  • Frequency: constipated vs. diarrheic.
    • And what would be your normal frequency for yourself?
  • Amount.
  • Blood: melena [black stool], hematochezia [bright red stool].
  • Pale, fatty, buoyant stool (steatorrhea 2° to fat malabsorption).
  • Odour.
  • Mucous: mixed with stool or not.
  • Consistency: hard vs. soft, watery.
  • Painfulness of defecation.
  • Needing to strain alot on defecation.
Other systemic
  • Wasting, weight loss vs. gain.
  • Anemia, jaundice, bronze diabetes. SeeSkin Colors Reference.
  • Lethargy (liver dz).
  • Abdominal swelling.
Past medical, surgical history
  • Current complaint in the past.
  • Post-op from a recent operation (anesthetic s/e, damaged GI).
  • IBD.
  • Ulcers.
  • Past surgeries, treatments.
Family history
  • Current complaint in family member (acute: food poisoning).
  • Heritable bowel dz.
Social history
  • Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew] (ulcers).
  • Alcohol (cirrhosis, gastritis).
  • Occupation (hepatitis), others at workplace with similar.
  • Stress level (ulcers).
  • Toxin exposure (liver dz).
  • Travel, sex, IV, tattoo use (hepatitis).
Drug history
  • Laxatives.
  • Indigestion medications.
  • NSAIDs (GI bleed).
  • Liver-damaging drugs.
  • Steroids.
  • Allergies.
  • Allergic reactions to drugs.
Systems
  • Dark urine (jaundice).
  • RHF signs (nutmeg liver).
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. 
  •  
  • Source: www.doctorshangout.com

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