Gastrointestinal examinations

• Abdominal examination

  Inspection and peripheral signs

  Position:

  • Patient flat with 1 pillow, top off, and trousers down to pubic symphysis.

  End of bed observation:

  • Weight loss (cachexia).
  • Abdominal distention. Causes are the 5Fs: fat, fluid (ascites), faeces (constipation), flatus, fetus. Is it central (viscous), or at the flanks (more fluid)?
  • Obvious jaundice.
  • Respiratory rate and pattern.

  Hands:

  • Perfusion/temperature.
  • Clubbing: IBD, cirrhosis, coeliac, GI lymphoma.
  • Nails: leukonychia (white areas: ↓albumin), koilonychia (spoon-shaped nails: iron-deficiency anaemia).
  • Palmar erythema and Dupuytren's contracture may be seen in chronic liver disease (CLD). Dupuytren's is also linked to phenytoin use and diabetes.

  Arm:

  • Pulse and BP.
  • Hepatic encephalopathy can cause flapping tremor: ask them to stick hands out and cock wrists. The co-ordinated extensor contraction and flexor relaxation required is not maintained, and as the hand drops they consciously jerk it back, producing an irregular, coarse flap. Same mechanism and appearance as a hypercapnic flap.

  Head and neck:

  • Check for JVP with bed at 45°.
  • Skin: spider naevi (and check on chest). >5 suggests alcoholic liver disease (ALD).
  • Eyes: have them look up and pull down 1 lower eyelid to check for anaemia and jaundice.
  • Mouth: dry mucosa if hypovolaemic. Also look for signs of IBD and coeliac: ulcers, angular stomatitis (↓iron), glossitis (↓B12).

  Shoulder:

  • Virchow's node in the left supraclavicular area: gastric cancer.
  • Sit them up and feel neck nodes from behind (can do this at the end).

  Abdomen (closer inspection):

  • Distention, scars, masses, or caput medusae (portal HTN).
  • Ask "Do you have any scars I can't see?"

  Palpation

  Pain and masses

  Palpate 9 regions gently for tenderness:

  • If patient reports pain, start away from it e.g. right iliac fossa pain, start in left iliac fossa then work up left side, up middle, then down right.
  • Crouch down so eyes at abdo level, but keep and eye on face for tenderness. Also note guarding and rebound tenderness.

  Palpate 9 regions deeply for masses.

  Organomegaly

  Palpate for organomegaly (shouldn't be able to feel any of them):

  • Liver: starting in the right lower quadrant and moving up, have them breath in as you push in with flat fingers, feeling for liver edge with medial border of index finger.
  • Spleen: as with the liver, starting in the suprapubic region and moving up diagonally towards the left upper quadrant.
  • Kidneys: ballot for enlarged or tender kidneys, with one hand behind pushing up against flat hand on front.
  • Aorta: at the umbilical level, place both hands slightly lateral to the midline and push in deeply. Feel for a pulsatile, expansile mass suggesting aneurysm.

  Comment if normal:

  • "The abdomen was soft and non-tender throughout with no organomegaly felt".

  Percussion

  Percuss for organomegaly:

  • Percuss up from the RIF for liver size, then down from the 2nd intercostal space, along the mid-clavicular line.
  • Percuss from RIF towards LUQ for spleen size.

  Percuss for ascites:

  • From mid-line to flank. If dullness noted at flank, have them roll towards you, wait 10 seconds, and tap again to see if dullness has shifted, suggesting ascites.

  Auscultate

  Bruits:

  • Aorta: 3 cm above umbilicus.
  • Left and right renal arteries: 3 cm either side of a point 3 cm above umbilicus.

  Bowel sounds:

  • Vary, can be every 1-2 seconds, or up to every 10 seconds.
  • No sound: paralytic ileus, peritonitis.
  • Tinkling/high pitched sound: obstruction.

  Closing the exam

  Peripheries:

  • Check ankles for swelling.
  • Sit up and examine nodes in neck.

  Other things to check:

  • Hernial orifices, PR/DRE, external genitalia.
  • Urine dip.

• Digital rectal examination (DRE)

  Aka PR (per rectum) exam.

  Indications:

  • Bowel symptoms.
  • Prostate disease, including urinary symptoms.
  • Checking neurological function.

  Start and inspect:

  • Explain what you are going to do and ask for permission to proceed. Offer chaperone, and record in notes. Explain it may be uncomfortable but should not be painful.
  • Allow patient to undress privately: ask them to undress below waist, then cover themselves with blanket.
  • Position patient in left lateral position with buttocks at edge of couch, knees drawn up to chest, and heels clear of the perineum.
  • With gloves, examine perianal skin: any skin lesions, external haemorrhoids, or fistulae?

  Insert:

  • Lubricate index finger with water-based gel.
  • "I will now introduce my finger"
  • Place forefinger on anal margin – with pulp facing up to their head, and nail down to their feet – and with steady pressure on sphincter push gently through anal canal into rectum.
  • If anal spasm is encountered, ask patient to breathe in deeply and relax. If there are still problems, give local anaesthetic suppository, and if continued problems, consider examination under general anaesthetic (if the examination is really necessary).

  Inside rectum:

  • Ask patient to squeeze your finger with anal muscles and note any weakness.
  • Palpate systematically around the entire rectum. Note any abnormality and examine any mass. If abnormality found, record distance from anus and % of rectal circumference involved.
  • Rotate finger so pulp is facing anterior rectum: identify the uterine cervix in women and prostate in men. Assess the size, shape and consistency of the prostate and comment on tenderness and sulcus.
  • If rectum contains faeces (usually soft and mobile, but can be hard) but you suspect a tumour (usually hard and fixed), re-examine after the patient has defecated.

  Warn then slowly withdraw your finger:

  • Examine glove for stool colour and the presence of blood or mucus.
  • Reassure them it's over, allow them to dress privately, then discuss findings.

• Hernia examination

  Wear gloves and ask patient to undress below waist. Offer chaperone.

  Look:

  • Examine groin with patient standing. Inspect inguinal and femoral canals, and scrotum for any lumps/bulges.
  • Ask patient to cough and look for an impulse. Note the location. Classically, inguinal hernias are relatively medial and above the inguinal ligament, while femoral hernias are more lateral and below the inguinal ligament.

  Feel:

  • Palpate along the inguinal canal, from the pubic tubercle to the middle of the inguinal ligament.
  • Ask the patient to cough and feel for an impulse.
  • Percuss and auscultate the lump.
  • If a lump is felt in the scrotum, can you get above it?

  Ask the patient to lie down:

  • Observe if the hernia reduces spontaneously. Ask the patient if they can do it.
  • Direct vs. indirect inguinal hernias. Reduce the hernia, press 2 fingers over the internal inguinal ring (mid-inguinal ligament) and ask patient to cough or stand while you continue to press. If it's direct, it re-appears. In practice, it is difficult to reliably distinguish between the two, and it doesn't affect clinical management.

  Examine the opposite side (if not already done) to exclude the possibility of asymptomatic hernias.