Gastrointestinal Examination
- Exposing the patient
- General inspection – from the end of the bed
- Inspection of
- The hands
- The face
- The neck
- The abdomen
- Palpation
- Percussion
- Auscultation
Close inspection
Inspection should be performed at the level of the abdomen.
- Scars
Previous surgery/trauma
Comment on the location of the scar.
- Right subcostal
- Right paramedian
- Midline
- Nephrectomy
- Gridiron (appendicectomy)
- Laporoscopic
- Left paramedian
- Suprapubic/Pfannenstiel
- Left inguinal
- Distension
Fat/Fluid/Fetus/Flatus/Faeces/Big tumour
- Hernia
Protrusion of an intra-abdominal structure through an abnormal opening - this may occur because of previous surgery, incisional hernia.
- Pulsations
An expanding central pulsation in the epigastrium suggests an abdominal aortic aneurysm [AAA]. In normal thin people the abdominal aorta may be seen to pulsate.
- Striae
Due to stretching of the abdominal wall - pregnancy, ascites, chronic liver disease and chronic steroid usage result in striae.
- Prominent Veins
The direction of venous flow should be assessed.
- Occlude the vein by compressing it with a finger.
- Use a second finger to empty it, by pressing along its course.
- When the vein has drained, keep the two fingers compressing it, about 5 cm apart.
- Lift the first finger.
- If the vein refills, the flow is in that direction.
- Veins above and below the umbilicus should be assessed.
Prominent veins with flow AWAY from the umbilicus are called caput medusae. They are the result of blood flow from the portal to systemic system in patients with portal hypertension.
With inferior vena caval obstruction, usually due to a tumour or thrombus, the abdominal veins enlarge to provide collateral blood flow. The direction of flow is then upwards towards the heart.
Cullen’s sign: Discoloration of the umbilicus with a faintly bluish hue is rarely found in cases of extensive haemoperitoneum and acute
pancreatitis [the umbilical 'black eye'].
Grey Turner’s sign: Skin discoloration may also rarely occur in the flanks in severe cases of acute pancreatitis.
Palpation
The examiner should kneel down to palpate the abdomen.
Ask the patient if any particular area is tender and examine this area last.
Abdomen divided into 9 areas,
Right hypochondrium/Epigastrium/Left hypochondrium
Right flank or lumbar/Umbilical/Left flank or lumbar
Right iliac fossa/Hypogastrium or Suprapubic/Left iliac fossa
Palpation in each region is performed with the palmar surface of the fingers.
To palpate the edges of organs/masses the lateral surface of the forefinger is used.
Light palpation
Palpate using light pressure in each region.
All the movements of the hands should occur at the metacarpophalangeal joints.
Note the presence of any tenderness or lumps.
Deep palpation
This is used to detect deeper masses and to define those already discovered.
Any intra-abdominal mass must be carefully described.
- Site
- Size [may be measured]
- Shape
- Surface [regular or irregular]
- Skin [erythematous/unchanged/puckered]
- Texture [hard/soft/firm]
- Temperature
- Tenderness
- Transilluminable
- Tethered [to overlying/underlying structures]
- Mobility [move with inspiration]
- Pulsatility
- Borders [all palpable/can you get above it?]
Findings -
Guarding: Due to contraction of the abdominal muscles
May result from tenderness or anxiety
Can be voluntary or involuntary
Rigidity: Constant involuntary contraction of the abdominal muscles
Associated with tenderness and indicates peritoneal
irritation/peritonitis
Rebound tenderness: Strongly suggests the presence of peritonitis.
Compress abdominal wall slowly and release rapidly
A sudden stab of pain results which may make patient wince
The liver
Begin in the right iliac fossa with the examining hand aligned parallel to the right costal margin. Ask the patient to breathe in and out slowly through the mouth. During inspiration the hand is held still and the lateral margin of the forefinger waits for the liver edge to strike it. On expiration the hand is advanced by 1-2cms closer to the right costal margin.
If the liver edge is identified the surface of the liver should be felt. It may be hard or soft, tender or non-tender, regular or irregular and pulsatile or non-pulsatile.
Percussion of liver
The right side of the abdomen should be percussed from the right iliac fossa to the right costal margin along the midclavicular line. Dullness defines the liver’s lower border. If the liver is palpable the total liver span is measured. Percuss down along the right midclavicular line until liver dullness is detected. The normal upper border is the 5th rib. The normal span is less than 12.5cm. The normal liver edge may be just palpable below the right costal margin on deep inspiration especially in thin people.
The Gallbladder
It is occasionally palpable below the right costal margin where this crosses the lateral border of the rectus muscles. If acute cholecystitis or biliary obstruction is suspected, the examining hand should be orientated perpendicular to the costal margin, feeling from medial to lateral. If palpable the gallbladder will be a rounded mass which moves downward on inspiration.
Murphy’s sign: On taking a deep breath the patient catches his or her breath when an inflammed gallbladder [cholecystitis] presses on the examiners hand which is lying at the costal margin.
Courvoisiers law: If the gallbladder is enlarged and the patient is jaundiced the cause is unlikely to be gallstones. Carcinoma of the pancreas or lower biliary tree resulting in obstructive jaundice is likely to be present. The gallbladder with stones is usually chronically fibrosed and therefore incapable of enlargement. Remember at least 50% of dilated gallbladders are impalpable.
The Spleen
The spleen enlarges inferiorly and medially. Begin with the examining hand in the right iliac fossa and with the same technique used to examine for the liver slowly move the hand towards the left costal margin.
If the spleen is not palpable a two-handed technique is recommended. The left hand is placed posterolaterally over the left lower ribs and the right hand is placed on the abdomen parallel to the left costal margin. This enables a slightly enlarged soft spleen to be felt as it moves down towards the right iliac fossa.
If the spleen is not palpable the patient is rolled onto the right side towards the examiner and palpation is repeated. Begin palpation close to the left costal margin. Splenomegaly becomes just detectable if the spleen is one-and-a-half to two times enlarged.
Percussion of spleen
Percuss from the right iliac fossa to the left costal margin.
The Kidneys
The bimanual method is used.
To palpate the right kidney the examiners left hand slides underneath the back to rest with the heel of the hand under the right loin. The fingers remain free to flex at the metacarpophalangeal joints in the area of the renal angle. The examiners right hand is placed over the right upper quadrant.
Ballotting
Press over the renal angle by flexing the fingers of the posterior hand. The kidney can be felt to float upward and strike the anterior hand.
To palpate the left kidney the examiners left hand slides underneath the back to rest with the heel of the hand under the left loin. The fingers remain free to flex at the metacarpophalangeal joints in the area of the renal angle. The examiners right hand is placed over the left upper quadrant.
The lower pole of the right kidney may be palpable in thin, normal people. Both kidneys move downwards with inspiration.
Percussion
We do not percuss the kidneys as there will usually be a resonant area due to overlying gas
Features distinguishing a kidney from a spleen
Kidney | Spleen |
Enlarges inferiorly | Enlarges inferomedially |
Moves inferiorly with respiration | Moves inferomedially with respiration |
It has no notch | It has a notch (may be palpable) |
It has a palpable upper border | It has no palpable upper border |
It is resonant to percussion | It is dull to percussion |
Other Abdominal Masses
Abdominal aortic aneurysm: Examine for pulsatile, expansile mass – Inspect, palpate and auscultate
Bladder: In urinary retention the swelling is typically regular, smooth, firm and oval shaped. The bladder may reach as high as the umbilicus. Insertion of a urinary catheter will empty the bladder.
Palpation of the testes and inguinal lymph nodes are also part of the abdominal examination.
Ascites
2-3 litres of ascites are present before this is clinically detected. Usually the percussion note over the abdomen is resonant due to air in the bowel. When peritoneal fluid [ascites] collects, this accumulates in the flanks due to gravity in a supine patient. When 2-3 litres of ascites are present the abdomen will be dull to percussion in the flanks. As fluid accumulates abdominal distension and umbilical eversion occur. The dullness is then detectable closer to the midline.
Shifting dullness
Percuss out to the left flank until dullness is reached. Keeping your finger over this area ask the patient to roll towards you. Gravity will cause the fluid to move to the right side of the abdomen [wait 15-20 seconds].
Percussion is repeated and shifting dullness is present if the area of dullness has changed to become resonant.
Fluid thrill
This may be present when very large amounts of ascites are present. One of the examiners hands is placed flat on the patients flank. The other hand then flicks the other flank. A shock wave is transmitted to the palpating hand. The patient can be asked to help by placing a hand in the midline of the abdomen to prevent any ripple from passing through the fat of the anterior abdominal wall.
Auscultation
Bowel sounds
Place the diaphragm of the stethoscope over the lower abdomen. Bowel sounds can be heard intermittently. They should be described as either present or absent. Bowel sounds are usually readily audible. If bowel sounds are inaudible, ileus may be suspected.
Rectal examination
The abdominal examination is not complete without the performance of a rectal examination.
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