Year 1 MBChB
Clinical Skills Session
Gastrointestinal examination
Reviewed & ratified by:
Dr C Halloran and Dr P Collins Consultant Gastroenterologists
Dr V Taylor-Jones, Ms C Tierney
Gastrointestinal Examination
Learning objectives
To understand the anatomy and physiology of the gastrointestinal system
To link anatomy and physiology and apply it to the practical skill
To understand reasons for undertaking gastrointestinal examination
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.
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;
Vomiting
Trauma
Abdominal pain
Change in bowel habit
Abdominal distension
Change in appetite
Anaemia
Swelling
Weight loss
Tenesmus
Jaundice
Cardiac failure
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
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. This prevents anyone being unnecessarily exposed if somebody inadvertently enters the room.
There should be a good light source that will adequately illuminate the area being examined.
There should be screens offering privacy to the patient whilst they disrobe with a clean gown or blanket available to preserve modesty.
If any samples or swabs are being taken, ensure you know how to complete the paperwork and forward those samples etc. to the correct lab.
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
General Inspection
This can be undertaken with the patient upright, check the patients general appearance (demeanour, pallor, jaundice, cachexia, etc)
Include vital signs, check BP, pulse, RR, temperature, urine output/ urinalysis as appropriate.
Specific inspection
Check the patients mouth, teeth, tongue and breath, for example for hydration status, or any oral or dental infections.
Inspection of the torso should be done with the patient supine, observe for;
Scars
Rashes
Distension
Swellings
Visible peristalsis
Abdominal wall movement
Dilated veins [covered in more detail in 2nd year]
Look for spider naevi (only on the anterior and posterior chest wall) [covered in more detail in 2nd year]
Gynaecomastia in males [covered in more detail in 2nd year]
Causes of abdominal distension
Flatus (gas)
Faeces
Fluid (ascites)
Fat
Foetus
Fairly big tumours
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 that the liver, spleen and bladder are dull but the kidneys will be resonant due to them being retroperitoneal.
Palpation
There are 3 elements of abdominal palpation:
Superficial palpation
Deep palpation
Specific organ palpation
When palpating, movement of the examining hand should be slow and deliberate (no wiggling).
Superficial Palpation
Always start palpation away from any site of pain and always observe patients face for signs of discomfort.
Palpate all abdominal regions systematically, preferably at the same height as the patient.
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 deep 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;
Liver
Spleen
Kidneys
This is done by using the radial margin of the index finger to move from the furthest direction enlargement can occur, towards the position the organ normally lies to detect enlargement.
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;
The liver descends towards right iliac fossa on inspiration
The spleen descends inferio-medially on inspiration towards the right iliac fossa
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.
In view of the direction of enlargement, palpation for the spleen should commence well away from the costal margin in the right iliac area
Use the flat of the palmar surface of fingers in a dipping motion to palpate through the abdominal wall.
The patient is asked to take a deep breath in and pressure is applied by the examiners 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.
The other hand with fingers flat placed below the costal margin, lateral to the rectus muscle
One hand under the patients flank, fingers in the renal angle (between posterior costal margin and spine)
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;-
Use the tip of the finger
The blow is delivered by a sharp wrist movement
Strike the middle phalanx firmly, two to three taps only.
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, note 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.
Once you hear sounds, think are they;
Normal?
Underactive?
Over-active?
Peer Feedback
Video
Glossary
Borborygmus Bowel sounds
Distension Swelling
G.I. Gastrointestinal
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.
03 Y1 Abdominal
examination peer feedback new 2016.docx
Palpation only.mp4