GI Examination Flashcards
What are the stages of the GI examination?
Intro
Hands and Arms
Eyes
Face and Mouth
Chest Wall
Abdominal Exam prep
Abdomen Inspection
Abdominal Palpation
Palpation of individual organs
Percussion of abdomen
Auscultation of abdomen
ISHRUG
Completion
What is involved in the hands and arms stage of the Gastro exam?
Examine the hands for:
o Colour
▪ Pallor of the palmar creases suggests anaemia
▪ Palmar erythema (2° to increased circulating oestrogens in liver disease) o Temperature
o Clubbing (GI causes include hepatic cirrhosis, ulcerative colitis, Crohn’s disease and Coeliac disease)
o Leukonychia. Leukonychia partialis: small isolated white patches or striae are often seen in the nail plates of normal persons in response to minor trauma to the germinal matrix. However, striae affecting all of the nail beds can occur following a course of chemotherapy, for example. Terry’s nails or leukonychia totalis: Whitening of the entire nail occurs with hypoalbuminaemia (e.g. nephrotic syndrome, liver failure, protein malabsorption and protein-losing enteropathies).
o Koilonychia (spoon-shaped nails, suggesting chronic iron-deficiency)
o Spider naevi (single central arteriole with radiating dilated capillaries). Occur in 15-20% of healthy individuals but multiple spider naevi suggest underlying liver disease with increased circulating oestrogens. 99% occur on the upper trunk, head, neck and arms. Only 1% occur below the umbilicus.
o Dupuytren’s contracture (fibrosis and shortening of the palmar aponeurosis). Usually idiopathic or familial but there is a possible unproven association with trauma, diabetes, epilepsy, alcoholism and liver disease. o Asterixis (liver flap). Ask the patient to hyperextend their wrists and maintain the position for 15 seconds (5 seconds will suffice in the OSCE). A coarse flapping tremor suggests liver failure with failure of ammonia metabolism to urea. However, asterixis can also be seen in renal failure and in respiratory failure with CO2 retention.
- Check the patients pulse and blood pressure.
- Examine the forearms for muscle wasting and for scratches suggestive of pruritis (itching).
What is involved in eyes stage of gastro exam?
Examine the eyes for: o Jaundice o Anaemia (subconjunctival pallor) o Xanthelasma o Corneal Arcus o Kayser-Fleischer rings (Wilson’s disease). These are brown rings that encircle the iris, resulting from copper deposition. In the early stages they are best seen with a slit lamp, but later they can be seen with the naked eye.
What is involved in the face and mouth stage of the gastro exam?
• Examine the face for telangiectasia (Hereditary Haemorrhagic Telangiectasia (HHT / Osler-Weber-Rendu syndrome) affects the face, oral mucosa, GI tract, lungs, liver and brain, resulting in recurrent haemorrhage)
• Examine the mouth for:
o Telangiectasia (HHT – see above)
o Pigmentation (Peutz-Jegher syndrome, associated with small bowel hamartomas) o Angular stomatitis (sore corners of mouth), which may be caused by deficiency of Vitamin B6, B12, folate or iron.
o Glossitis, an abnormal smooth red appearance of the tongue. Painful glossitis is seen in Vitamin B12 or folate deficiency whereas glossitis due to irondeficiency tends to be painless.
o Dehydration
o Halitosis (bad breath)
o Dental caries
o Ulcers (can be associated with Vitamin B12 deficiency, iron-deficiency, Crohn’s disease, Coeliac disease)
What is involved in the chest wall stage of the gastro exam?
o Spider naevi o Gynaecomastia (male breast development) – may be due to increased circulating oestrogens in liver failure. • Palpate the lymph nodes in the neck and supraclavicular fossae. (N.B. Troisier’s sign is an enlarged left supraclavicular lymph node (Virchow’s node) due to a metastasis from an intra-abdominal malignancy).
How to start the abdominal exam?
Ask the patient to sit forward so that you can inspect the skin of their posterior abdominal wall for scars, swellings or any other clinical findings.
• Ask the patient to lie flat with one pillow, if tolerated, arms by their sides.
What is involved in the inspection of the abdomen in a gastro exam?
o Scars. Skin – sudden weight loss will result in loose folds of skin, sudden weight gain may cause striae (stretch marks). Note any skin lesions.
o Shape and symmetry o Movement during breathing (diaphragmatic ventilation usually ceases with acute peritonitis and ventilation is then via movement of the chest wall)
o Visible swellings and masses
o Visible peristalsis
o Visible aortic pulsation
o Distended veins (may indicate inferior vena cava obstruction or portal hypertension)
o Think about the 5 F’s of abdominal distension:
▪ Fluid (ascites)
▪ Faeces (constipation)
▪ Flatus (subacute intestinal obstruction)
▪ Foetus (pregnancy)
▪ Fat (obesity)
What is involved in the palpation stage of the abdominal exam?
• Palpate the nine regions of the abdominal wall gently and systematically, whilst observing the patients face. Assess for areas of tenderness, guarding, rigidity etc.
• Repeat, using deeper palpation. Visualise the underlying anatomy whilst you are palpating. Assess for any masses. Determine whether masses are intra-abdominal by asking the patient to raise their head and shoulders off the pillow. Masses within the abdominal wall become more prominent when the recti are contracted, whereas intraabdominal masses become less prominent. Assess size, surface, shape, edge, consistency, tenderness of any masses.
o If the stomach appears distended, perform a succussion splash (shake the stomach briskly from side to side whilst listening for a sloshing sound)
What is involved in the individual organ palpation stage of the abdominal exam?
o Liver. Palpation for the liver should commence in the right iliac fossa. The patient should be asked to take a deep breath whilst the examining hand palpates deeply to feel the descending edge of the liver being pushed down by the diaphragm. Whilst the patient breathes out, the examining hand should be withdrawn and repositioned slightly nearer the costal margin, whereupon the process should be repeated. The liver can normally be palpated up to 1cm below the right costal margin on deep inspiration. The gallbladder is not usually palpable unless enlarged. (N.B. Courvoisier’s Law states that in the presence of a palpable gallbladder, jaundice is not likely to be due to gallstones).
o Spleen. This is not normally palpable unless enlarged. Palpation should begin in the right iliac fossa and advance toward the left costal margin, whilst the patient takes deep breaths. As you advance toward the left costal margin using your right hand to palpate for splenomegaly, place your left hand posteriorly and roll the patient slightly toward you. This may bring the tip of a moderately enlarged spleen closer to your palpating fingers and increase the chance of detection. Splenomegaly only becomes palpable once the spleen has enlarged to 2-3 times its normal size.
o Kidneys - should be examined by ballottement. The anterior hand should press deeply, lateral to the margin of the rectus muscle in the upper quadrant of the abdomen. The posterior hand should be placed in the costovertebral (renal) angle and should be used to lift the kidney up against the anterior hand repeatedly. An enlarged kidney should be detectable by the anterior examining hand. The lower pole of the right kidney may be palpable in thin normal people. The left kidney is rarely palpable. To distinguish a palpable kidney from a spleen, you should attempt to insert your hand between the upper pole of the kidney and the costal margin, which can be done if the mass is renal but not if it is the spleen. Also, the spleen has a notch which may be palpable; and the spleen is not ballotteable.
o Full bladder. Palpate the suprapubic region for a full bladder. If the bladder is full, it will be impossible to feel the lower border of the mass behind the pubis and pressure on the bladder will make the patient want to urinate.
o Aorta and femoral pulses. The normal aortic pulsation may be felt, especially in a thin person. However, if the aorta is expansile, this suggests aneurysmal dilatation.
- Check for Murphy’s sign by asking the patient to breathe out and then gently placing the hand below the right costal margin in the mid-clavicular line (the approximate location of the gallbladder). If inspiration is prevented by the inflamed gallbladder coming into contact with the examiners fingers, the test is considered positive. A positive test also requires no pain on performing the manoeuvre on the patient’s left hand side. This test is done when suspecting acute cholecystitis in a patient.
- Palpate the inguinal nodes ( Not required in OSCE Examinations)
What is involved in the percussion of the abdomen in the gastro exam?
o Liver (percuss from resonant to dull, from below and above). When percussing, consider the normal surface markings of the superior border of the liver (6th rib in mid-inspiration). This can be displaced downwards in respiratory diseases such as emphysema giving a false impression of hepatomegaly.
o Spleen. Castell’s method: With the patient in full inspiration and then full expiration, percuss the area of the lowest intercostal space (eighth or ninth) in the left anterior axillary line. If the note changes from resonant on full expiration to dull on full inspiration, the sign is regarded as positive. The resonant note heard upon full expiration is likely to be due to the air-filled stomach or splenic flexure of the colon. When the patient inspires, the spleen moves inferiorly along the posterolateral abdominal wall. If the spleen is enlarged and the inferior pole reaches the eighth or ninth intercostal space, a dull percussion note will be heard, indicating splenomegaly.
o Bladder – dull percussion note if enlarged. o If you suspect ascites, test for shifting dullness (percuss from the centre toward the left flank. If a dull note is heard, keep the finger in position and roll the patient onto their right side. Wait 10 seconds for the fluid to redistribute. If the note becomes resonant, percuss back towards the umbilicus until the note becomes dull i.e. shifting dullness)
What is involved in the auscultation of the abdomen in the gastro exam?
o Are bowel sounds present and normal, present but abnormal (e.g. tinkling in small intestinal obstruction), or absent (paralytic ileus e.g. in peritonitis)?
o Listen for aortic and femoral bruits
What is involved in ISHRUG in the gastro exam?
The end-pieces are recalled by the mnemonic ISHRUG. In the OSCE, you should omit these but should state a list to the examiner, without prompting, at the conclusion of your physical examination.
o Inguinal lymph nodes
o Stools – examine the stools if clinically indicated
o Hernial orifices (femoral and inguinal)
o Rectal examination (always with a chaperone)
o Urine – obtain urinalysis
o Genitalia (examine the male external genitalia). A vaginal examination may be indicated in parous or sexually active females (only when clinically indicated and always with a chaperone)
