Learning objectives · Web viewTrauma Abdominal pain Change in bowel habit Abdominal distension...

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