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Gastrointestinal System Examination

• Surface markings• Liver upper border 5th ICS right on full exp lower border at costal margin on full inspiration• Spleen behind left 9,10,11 ribs, posterior to MCL• Kidneys upper pole lies deep to the 12th rib posteriorly, 7 cm from the midline, the right is 2-3 cm lower than the left.

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• Abdomen can be divided into nine regions by the

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Characteristics of pain (SOCRATES)pain

• Site somatic pain well localised sprained ankle

viseral pain diffused angina pectoris• Onset • Character describe by adjectives—sharp/dull, Burning/ tingling, boring/stabbing,

crushing/tugging. Use the patient own description.• Radiation• Associated symptoms • Timing Since onset

Episodic duration and frequency of attacks

continuous any changes in severity• Exacerbation and relieving factors relation to food or specific activities or

postures

effect of medication• Severity subjective

variation by day or night ,week or month

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Symptoms and definitions

General• Anorexia loss of appetite• Weight loss significant >3 kg in 6 months

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Upper GI

• DysphagiaDifficulty in swallowingAsk forIs dysphagia painful or painlessIs dysphagia intermittent or progressiveHow long Is there a previous history of dysphagia or heartburn.Is the dysphagia for solids or liquids or bothWhat level does food stickIs there complete obstruction with food regurgitation.

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Causes of dysphagia

• Oral Painful mouth ulcers -- tonsillitis, pharyngitis• Neurological -- CVA, bulbar or pseudobulbar• palsy• Neuromuscular---myasthenia gravis, achalasia, pharyngeal pouch• Mechanical ----- oesophageal cancer, peptic oesophagitis, scleroderma, benign stricture, compression

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Heartburn and reflux symptoms

• Heartburn ---- burning, hot retrostenal discomfort which radiate upwards . Commonnest cause is reflux oesophagitis.

• acid reflux---regurgitation of gastric acid produce a sour taste in the mouth.

• Water brash sudden onset of excessive saliva in the mouth is due to reflex salivation, may occur in peptic ulcer disease.

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dyspepsia

• Dyspepsia is the pain or discomfort centred in the upper abdomen.

• Indigestion is a term used for ill-defined symptoms from the upper GIT.

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• Nausea sensation of feeling sick.• Vomiting is the expulsion of gastric contents via the mouth.• Causes of vomiting• GI causes peptic ulcer, GOO, obstruction of GI tract. gastroenteritis, cholecystitis, pancreatitis, hepatitis Non-alimentary causes of vomiting neurological ICP, vestibular disorder, migraine, vasovagal syncope, shock, fear and severe pain. Drugs alcohol, opioids, theophyllines, digoxin, cytotoxic agents, antidepressants metabolic/endocrine pregnancy, DKA, renal failure, liver failure, adrenal failure and hypercalcaemia. psychological anorexia nervosa, bulimia

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Questions to be asked for vomiting

• Medication history.• vomiting +/- nausea.• Associated with abdominal pain.• Abdominal pain relieved by vomiting.• Vomiting related to meal-times, early morning

or late evening.• Vomitus bile-stained, bloodstained or

faeculent.

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Haematemesis and malaena

• Haematemesis vomiting of blood. Fresh and red, or dark brown coffee grounds colour.

• Malaena tarry and shinny black with characteristic odour stool.

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Abdominal distension

• Causes• fat obese• Flatus obstruction, pseudo-obstruction• Faeces obstruction, constipation• Fluid ascites, tumours, distended bladder• Fetus• Functional bloating

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ascites

• Common cirrhosis with portal hypertension malignancy with peritoneal spread CCF• Uncommon hepatic or portal vein occlusion constrictive pericarditis hypoproteinaemia peritonitis

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jaundice

• Yellowish discoloration of the skin, sclerae and mucus membranes due to hyperbilirubinaemia.

• Levels of bilirubin >50 umol/L• Causes prehepatic jaundice ( haemolytic) hepatic ( hepatocellular) post-hepatic (obstructive)

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History for jaundice• Appetite and weight change • Abdominal pain, altered bowel habit• GI bleeding• Pruritus, dark color urine, rigors• Drugs and alcohol history • Past medical/surgical history• Previous jaundice or hepatitis• Blood transfusion • Family history• Sexual/contact history• Travel history and immunisations• Skin tatoo.

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History taking

Alarm features• Persistent vomiting• Dysphagia• Fever• Weight loss• GI bleeding• Anaemia• Painless, watery, high-volume diarrhoea• Nocturnal symptoms disturbing sleep.

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• Always investigate alarms symptoms particularly those over >50 years.

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Past history

• History of similar problems/symptoms may suggest the diagnosis.

• Ask about previous abdominal surgery, X-rays, scans and other investigations

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Drug History

• Prescribed medications, over-the-counter medications, herbal preparations and indigenous medicines.

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Family history

• Inflammation bowel disease is more common in patients with a family history of either Crohn’s disease or ulcerative colitis.

• Colorectal cancer in a first degree relative increase the risk of colorectal cancer and polyps.

• PU is familial.• Gilbert’s disease, haemochromatosis, Wilson’s

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Social history

• Dietary history and assess the approximate intake of calories and sources of essential nutrients.

• Specific food intolerance• Alcohol consumption in units• Smoking• Any mental stress• Risk factors for hepatitis.• Foreign travelling.

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Physical Examination

• General examination• nutritional state record the height, weight, waist

circumference and the patient’s body mass index.• Obesity truncal or generalised.• Abdominal striae• Loose skin fold• Stigmata of iron deficiency, koilonychia, angular

stomatitis and atrophic glossitis.• Muscle wasting.• Fever.

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hands

• Clubbing• Koilonychia• Signs of liver disease –leukonychia - palmer erythema - flapping tremors -

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face

• Pallor• Jaundice• Spider naevi• Parotid swelling• Mouth- angular stomatitis, glossitis, teeth and

gums• Neck goitre, neck glands

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Legs

• Oedema• Pyoderma gangrenosum

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Abdomen

• Normal appearance flat, scaphoid and symmetrical.

• Normal findings liver edge may be felt below the right costal margin.

• Aorta may be palpable as pulsatile swelling.• Lower pole of the right kidney may be palpable.• Faecal mass may be palpable.• Distended bladder

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Inspection• Skin striae, bruising or scratch marks.• distended veins superior vena cava, inferior vena cava and, portal

hypertension (caput medusae).• Distension of abdomen. Generalised or localised. • Scars and stomas• Movements normal movements- still, silent abdomen in generalised

peritonitis.• Epigastric palpation.• Visible peristalsis GOO, distal small bowel obstruction, normal very

thin, elderly patients.• Pigmentation of skin -linea nigra• -erythema ab igne -- brown mottled pigmentation

on the skin of abdominal wall.

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Palpation, Percussion, Auscultation

• Light palpation tenderness rebound tenderness palpable mass• Deep palpation enlarged organs, liver, spleen, kidneys, gall

bladder.• Percussion liver, spleen, shifting dullness fluid thrill.• Auscultation bowel sounds, aorta (above umbilicus), renal bruits, liver bruits, rub succussion splash.

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