Year 1 MBChB

Clinical Skills Session

Gastrointestinal examination

Reviewed & ratified by: Mr C Halloran and Dr P Collins Consultant Gastroenterologists

Dr V Taylor-Jones, Ms C Tierney

August 2018

Gastrointestinal Examination

Learning objectives

o To understand the anatomy and physiology of the gastrointestinal system

o To link anatomy and physiology and apply it to the practical skill

o To understand reasons for undertaking gastrointestinal examination

o To be able to carry out elements of a gastrointestinal examination

Theory and background

A full gastrointestinal (G.I.) examination may include examination of the groins, external genitalia and rectum,

depending on the patient presentation and findings.

If a swelling or enlargement of an organ (organomegaly) is suspected or if you find a pulsatile swelling, please seek

immediate advice from a qualified professional.

Indications for abdominal examination

The following list of reasons is by no means exhaustive, a patient may present with;

o Vomiting

o Trauma

o Abdominal pain

o Change in bowel habit

o Abdominal distension

o Change in appetite

o Anaemia

o Swelling

o Weight loss

o Tenesmus (a continual or recurrent inclination to evacuate the bowels).

o Jaundice (when your skin and the whites of your eyes turn yellow. It can be a sign of something serious,

such as liver disease)

Dividing the abdomen into regions

Conventionally the abdomen is divided into 9 regions, there are 4 dividing lines:

midclavicular (2) - vertical

subcostal - upper horizontal

Trans-tubercular - lower horizontal

The 9 regions will each contain their own important organs helping to make diagnosis easier. Think about what

organs are in each of the 9 regions? Answers are at the end of the presentation.

Dividing lines for the nine regions of the abdomen

Upper border of abdomen

The costal margin (rib margin)

demarcates the chest from the

abdomen superiorly

Lower border of abdomen

This is delineated by the

transtubercular line

Alternative to 9 regions is to split abdomen into quadrants

The right environment

The room that the examination is taking place in should be private, with the examination couch off set from the

centre of the room. Within the room there should be a further area with curtains / screens around, offering privacy

to the patient whilst they disrobe and wear a clean gown or cover with a blanket to preserve modesty, while they

are examined. There should be a good light source that will adequately illuminate the area being examined.

As this is an intimate examination a chaperone will be present.

o There should be handwashing facilities.

Ideally the patient should be relaxed and in a warm environment, they should lie flat on their back, with hands by

their sides or a single pillow under their head. Hips and knees may be flexed to relax abdominal muscles if

necessary.

The abdomen should be exposed (the whole upper torso to the suprapubic area – inguinal and genital areas are

covered until they are to be examined).

The examiner should position him/herself to be on a level with the abdominal surface.

Patient safety

Prior to any clinical examination a detailed history should be taken from the patient, this will enable you to tailor

the examination to the patients presenting complaint and additional symptoms the patient may elude to when you

elicit a full history. For guidance on history taking please click MBCHB students – Year 1 – History taking.

General Inspection

1. This can be undertaken with the patient upright, check the patient’s general appearance (demeanour, pallor, jaundice, cachexia (weakness and wasting of the body due to severe chronic illness), etc) Include vital signs, check RR, SPO2, temperature, as appropriate. (See vital signs study guide).

Specific inspection

Check the patient’s mouth, teeth, tongue and breath, for example for hydration status, any bleeding, ulcerations,

redness, or any oral or dental infections.

Inspection of the torso should be done with the patient supine, observe for;

o Look for spider naevi [see prep but covered in more detail in 2nd year]

o Gynaecomastia in males [see prep but covered in more detail in 2nd year]

o Scars

o Rashes

o Distension

o Swellings

o Visible peristalsis

o Abdominal wall movement

o Dilated veins [covered in more detail in 2nd year]

Causes of abdominal distension

Flatus (gas) – taut abdomen which is compressible

Faeces – firm to hard mass take note of position as may be normal finding

Fluid (ascites) – taut abdomen which may be non-compressible dependant on volume

Fat – soft and compressible

Foetus – obstetric palpation will be taught in later year

Fairly big tumours - firm to hard mass

Percussion

When percussing the general abdomen all areas should be percussed and should sound resonant.

When you percuss over the abdominal organs you would expect the liver, spleen and bladder to be dull. The

kidneys will be resonant due to being retroperitoneal with air filled bowel lying over them.

Palpation

There are 3 elements of abdominal palpation:

o Superficial palpation

o Deep palpation

o Specific organ palpation

When palpating, movement of the examining hand should be slow and deliberate (no ‘wiggling’ as this would cause

pain).

Palpation is performed with the flat of the fingers, using the knuckles or (metacarpal pharyngeal) joints as a pivot

on the abdomen.

Superficial Palpation

Always start palpation away from any site of pain and

always observe patient’s face for signs of discomfort.

Palpate the abdominal regions systematically,

preferably at the same height as the patient’s

abdomen.

Superficial palpation is using a light pressure to assess

for tone, tenderness and any obvious abnormalities.

Assessing muscle tone with superficial palpation

During superficial palpation gentle pressure is applied to the abdominal wall allowing the examiner to depress the

anterior wall of the abdomen as the muscles relax, assessing the patient for abdominal pain and other

abnormalities.

Deep palpation

Deep palpation is using firm pressure to assess for

swellings or abnormalities. This must be done with

the palmar aspect of the fingers and you should be

on the same level as the abdomen.

Specific Organ Palpation

These organs are routinely palpated;

o Liver

o Spleen

o Kidneys

This is from the furthest direction enlargement can

occur, towards the position the organ normally lies

to detect enlargement, as explained below.

Palpation of organs

When palpating organs feel for the edges, the edges

provide a better contrast between surrounding

organs/tissues and the organ.

Palpation of organs may be assisted by assessment

of mobility in relation to respiration, this is because

the diaphragm moves down on inspiration, pushing

abdominal organs downwards. If the liver or spleen

are enlarged they may be felt below the costal margin.

o The liver descends towards right iliac fossa on inspiration

o The spleen descends inferio-medially on inspiration towards the right iliac fossa

o The kidneys descend on inspiration

Palpation of the liver

The liver lies predominantly under the ribs on the right side, although it does

cross the mid-line.

The inferior border of the liver lies approximately parallel with the costal margin

(the lower edge of the rib cage).

How liver moves on inspiration

The liver moves inferiorly on inspiration.

How the liver enlarges

Enlargement of the liver also occurs in an

inferior direction

How the liver is palpated

In view of the direction of enlargement, palpation for the liver should commence well

away from the costal margin in the right iliac area. The thumb is extended to

expose the lateral margin of the index finger

The hand is positioned so that the lateral margin of the index finger is parallel with the costal margin.

The patient is asked to take a deep breath in and pressure is applied to the

abdominal wall by the examining hand. If the liver is not palpated, the

examining hand is moved closer to the costal margin by about 1 cm and the

patient is asked to repeat deep inspiration.

The process is repeated until the hand reaches the costal margin or

the inferior edge of the liver is palpated. A normal liver is

impalpable or palpated close to the costal

margin

An enlarged liver may be palpated distal to the costal margin and the

distance is measured in cm from the costal margin.

Palpation of the spleen

The spleen lies entirely under the ribs on the left side

A normal spleen is approximately fist sized and the long axis of the

spleen lies along the line of the 10th rib.

Position of spleen in health

The spleen moves inferio-medially on inspiration,

even on deep inspiration the normal spleen cannot be felt on palpation

To be palpable the spleen must enlarge to at least twice normal size

Position of an enlarged spleen

Enlargement of the spleen occurs in an

inferio-medial direction, a massive spleen

may extend into the right lower abdomen.

With a very large spleen, you may be able to

palpate the distinctive splenic notch

Palpation of the spleen

Palpation for the spleen is facilitated by placing

the left hand under and behind the lower left rib

and pulling upwards and towards you (the

examiner). This may encourage an enlarged spleen,

otherwise not palpable, to appear beyond the costal margin on inspiration.

Some clinicians prefer the patient to roll onto their right side to achieve the same effect.

Use the flat of the palmar surface of

finger tips in a dipping motion to

palpate through the abdominal wall.

In view of the direction of enlargement,

palpation for the spleen should

commence well away from the costal

margin in the right iliac area

The patient is asked to take a deep breath in and

pressure is applied by the examiner’s hand to the

abdominal wall.

If the spleen is not palpated, the examining hand is moved closer to the costal margin by about 1-2 cm. If the

spleen is not palpated the patient is asked to repeat deep inspiration and the process is repeated.

The process is repeated until the spleen is palpated or the costal margin reached, a

normal spleen will not be palpable.

An enlarged spleen may be palpated distal to the costal margin and the distance is

measured in cm from the costal margin.

Palpation of the kidneys

The kidneys extend from the twelfth thoracic vertebrae

to the third lumbar vertebrae. They are not normally

palpable in health. The right kidney is lower than the

left due to the position of the liver and in health they

have a firm consistency with a smooth surface.

Renal angle

The kidneys are retroperitoneal organs and therefore

deep bimanual palpation is required. On preparing for

examination, position the patient close to the edge of the

bed, then tuck one hand under the patient so that the

finger tips nestle in the renal angle.

One hand under the patient’s flank,

fingers in the renal angle (between

posterior costal margin and spine)

The other hand with fingers flat placed

below the costal margin, lateral to the

rectus muscle Hands should be opposite one another

Ask the patient to breathe in deeply and press the

fingers of both hands firmly together. The rounded

lower pole of the kidney may be felt passing between

the opposing fingers as the patient breaths in and out.

Differentiating kidneys from other organs/masses

The kidneys can be “balloted” this a technique where by

a structure that is not fixed can be patted between the

examining hands.

Percussion

Remember percussion technique;-

o Use the tip of the finger

o The blow is delivered by a sharp wrist movement

o Strike the middle phalanx firmly, two to three taps only.

o Remove the striking finger immediately

Routinely percuss for the liver

Routinely percuss from the chest down to the

Abdomen, which is resonant to dull

Repeat from iliac fossa to costal margin again this should be

resonant to dull.

Percussion

Once the liver has been percussed, routinely percuss all other areas of

the abdomen to note if there is any pain or tenderness on percussion.

Auscultation

Bowel sounds – Borborygmus

Bowels sounds are gurgling noises made by air/ liquid moving through

the bowel.

Listen in any area of the abdomen and bowel sounds should be heard, but when examining a patient, listen for 2-3

minutes (or until sounds heard) in the lower right quadrant.

If no sound is heard listen elsewhere on the abdomen for a further 2-3 minutes.

If no sound is heard report the absent bowel sounds immediately to a qualified health care professional.

Answers to the question - what organs are in the 9 regions?

Right hypochondrium – small intestine, right kidney, gallbladder, liver

Left hypochondrium – pancreas, left kidney, colon, spleen

Epigastrium – spleen, pancreas, duodenum, liver, stomach

Right lumbar region – right colon, liver gallbladder

Left lumbar region – left kidney, descending colon

Umbilical – duodenum, ileum, jejunum, umbilicus

Right iliac – caecum, appendix

Left iliac – sigmoid colon, descending colon

Suprapubic – female reproductive organs, sigmoid colon, urinary bladder

Glossary

Borborygmus – Bowel sounds

Cachexia - weakness and wasting of the body due to severe chronic illness Distension – Swelling

G.I. – Gastrointestinal

Jaundice -when your skin and the whites of your eyes turn yellow. It can be a sign of something serious, such as

liver disease

Left lower quadrant – LLQ

Left upper quadrant – LUQ

Organomegaly – Swelling or enlargement of an organ

Right lower quadrant – RLQ

Right upper quadrant – RUQ

Tenesmus – a continual or recurrent inclination to evacuate the bowels.