Examination of GIT

Examination of GIT consist of Examination of : 1- Oral cavity. 2- Abdomen. 3- Rectum.

Oral examination

Lips

Gums

Teeth

Tongue

Palate

Breath

Lips Color• Blue • Pale Cyanosis Anemia Ulceration • Syphilis

Inflammation

• Iron deficiency• Vit. B12 deficiency

Gums Colour Blue line(Lead poisoning)

Bleeding Acute leukemia

Swollen Scurvy Pregnancy

Teeth Hutchison’s teeth

(Congenital syphilis)

Tongue Colour Blue (cyanosis) Red (Nicotinic poisoning) Pale (anemia) Black (taken iron supplement)

Blue tongue

Tremors Nervousness, Parkinsonism

Size of tongue Macroglossia (cretins) Tremors

Dry

Surface of tongue Dry tongue (dehydration) Bald tongue(Anemia) Furred tongue Macroglossia

smooth

(smoking, mouth breathing) Ulceration

(Whooping cough, T.B.) Macroglossia

furred ulceration

Abdomnal examinationI. InspectionII. Palpation III. PercussionIV. Auscultation

Inspection Visual observation of the body in the

course of a medical examination. Contour of the abdomen

Flat Rounded Scaphoid protuberant

Movements of the abdomen Abnormal movement (Appendicitis ,Peritonitis)

Bulging Left abdomen (spleen) Right abdomen (liver) Lumber region (kidney)

Pulsation in abdomen bulging

Epigastrial pulsation in (Nervousness Enlarged right ventricle)

Prominent veins ( Portal hypertension ,Obstruction of inferior vena cava)

Pigmentation of abdomen wall ( chronic pancreatitis , Addison disease)

Peristaltic waves Obstruction, inflammation

Pubic hair Male pattern(convex) Female pattern(concave)

Umbilicus• position Normal (central) Ovarian tumour(Shifted upward)

• Shape Inverted (normally) Evertion/ ptosis (asites & hernia)

Scars and striae• Pinkish(Cushing’s syndrome)

Palpation physical examination in medical diagnosis by pressure of the hand or fingers to the surface of the body especially to determine the condition (as of size or consistency) of an under lying part or organ .

Typesi. Superficialii. Deepiii. Bimanualiv. Dipping Superficial It should be graded as follows: Grade1 (pain on touching) Grade2(facial expression shows feeling of pain)

Grade3 (patient move his diseased part when touched)

Grade4 (not allow the doctor to touch)

Palpable mass Area Number Size Mobility Pulsation Location

Scheme for palpation of abdomen Left iliac fossa. Left lumber area (for left kidney) Left hypocondrium(for spleen) Right lumber area (for right kidney) Right hypochondrium(for liver & gall bladder) Right iliac fossa & hypogastrium(for urinary bladder & uterus) Umbilical area(for aortic ,Para-aortic & mesenteric lymph node)

Palpation of Visceras Liver Standard Method The patient must be lying in the supine position with hip

and knee flexed. Ask the patient to take a deep breath. The examiner moves his right hand from the right iliac

Fossa gradually upwards until you may feel the edge of the liver. Alternate Method This method is useful when the patient is obese. Stand by the patient's chest. “Hook" your fingers just below the costal margin

and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers

In the liver we palpate the Character of edge (smooth,sharp,irregular or thickened) Surface of liver (smooth or nodular) Tenderness (Liver congestion, infective hepatitis) Pulsation (Tricuspid Incompetence)

Spleen Spleen can be palpated by the following methods

Classical methodThe patient is put in the supine position and palpated from the right iliac fossa to the left hypochondriac region. The edge of the spleen may be felt on deep inspiration.

Bimanual method The patient is put in the right lateral position, one hand of the examiner is put over the lower chest and the spleen is palpated with the other hand. A soft spleen which may be missed by classical method may be palpated by this method.

Hooking method The patient is put in the right lateral position and the examiner stands on the left side and feels the spleen by hooking his fingers over the left costal margin.

Dipping This method is used when there is severe ascites which may mask an enlarged spleen. The patient is put in the supine position and examiner palpates as in the classical method except that he dips his fingers into the abdomen with each palpation, so that the fluid is displaced temporarily to the side facilitating palpation of the spleen.

Gall BladderThe gall bladder is normally  not palpable. When distended, it is palpated as a firm, smooth, rounded or globular swelling with distinct borders just lateral to the rectus abdominis muscle.

Causes of enlarged gall-bladderCarcinoma of the head of the pancreas Carcinoma of the gall-bladderMalignant obstruction of the common bile duct.

Murphy’s signAsk the patient to take breath and the same time theFinger are pressed upward underneath the right costal margin.The gall bladder will move down as diaphragmatic descends during Inspiration.

Courvoisier’s Law In jaundice gall bladder will not palpable because due to chronic inflammationIt’s walls will become fibrotic.

KidneysThe patient is put in the supine position, without pillow, with his knees flexed. Both kidney are palpated by standing on respective side i.e., on left side to Palpate left kidney& on right side to palpate right kidney. First palpate left kidney and then right.

Left kidneyThe left kidney is palpated by keeping the left hand Posteriorly in the loin and the right hand anteriorly In the left lumbar region. Then the patient takes a Breath, the left hand is pressed forward and the right Hand backwards, upwards and inwards.

Right kidneyThe right kidney is likewise are not palpable  because of overlying liver , unless placed low in position or enlarged. Its lower pole is felt as a rounded firm swelling between both the hands and can be pushed back and forwards between two hands. This procedure is called “balloting”.

Murphy’s renal punchPatient should be made to sit on the bed with back toward the doctor.Now with the thumb, a sudden “punch” is given at the angle between the vertebral column and last rib (renal angle). And palpate the tenderness.

Psoas SignThis is a test for appendicitis. Place your hand above the patient's right knee. Ask the patient to flex the right hip against resistance. Increased abdominal pain indicates a positive psoas sign.

Obturator SignThis is a test for appendicitis. Raise the patient's right leg with the knee flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign

Percussion The act or technique of tapping the surface of a body part to learn the condition of the parts beneath by the resulting sound.

Commonly three method are used for percussion Fluid thrill method Shifting dullness Cystic thrill Puddle sign

Fluid thrill method Patient in supine position Ask an assistant to place the ulnar Border

of his hand vertical in the midline over the anterior abdomen wall. Place one hand on the left flank and flick or tap the opposite flank. A fluid thrill or wave is felts a definite and unmistakable impulse

by hand over the patient’s left flank.

Fluid thrill is felt only when there is a large amount of ascitic fluid which is under tension.

Shifting dullness Patient in supine position Percuss laterally from midline keeping finger in longitudinal axis until dullness is detected. Keep the hand there & ask the patient to turn on other side. Percuss again in this new position. If the dull note has become resonant then ascitic fluid is probably present. Repeat the method on the opposite side for confirmation.

Cystic thrill Patient in supine position. Put three finger index , middle & ring finger of left hand over swelling. Index and ring finger should be adherent to the skin. Now with middle finger of right hand strike the middle finger of left hand. In this , a thrill will be felt by other two fingers which were kept adherent to swelling.

Puddle sign Patient in knee-chest position so that fluid gravitates down to

The anterior abdomen wall. The stethoscope is placed over the abdomen in the midline and the

Anterior abdominal wall is flicked for a puddle sound. Can detect small quantities of fluid as much as 120 ml.

AuscultationThe process of listening to sounds that are produced in the body.

Types Direct auscultation Indirect auscultation

Sound Normal (Gurgle) 7-8 /min.  Increase (intestinal obstruction) Absent (Paralytic ileus) Succussion splash

 

Rectal examination Inspection of the anal region is done in a good light. By placing the patient in semi-prone position. A glove lubricated finger is put into the anal canal and palpation is done for New growth Thrombosed pile Ulcer Enlargement of prostate