Year 1 MBChB

Clinical Skills Session

Gastrointestinal examination

Written by: The Clinical Skills Lecture Team

Reviewed & ratified by: Professor C Halloran (Gastroenterology System Lead) and Dr P Collins Consultant Gastroenterologists

August 2019

Gastrointestinal Examination

Learning objectives

o To revise the anatomy and physiology of the gastrointestinal system

o To link anatomy and physiology 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

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

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

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 (Need to be pretty big!)

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

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

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.

Report any abnormalities.

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.