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Year 2 MBChB

Clinical Skills Session

Gastrointestinal examination

Reviewed by:

Mr C Halloran – Gastroenterology System lead

Dr P Collins – Consultant Gastroenterologist

Dr A Clarke - GP

August 2018

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Learning objectives.

To revise anatomy and physiology of the GI system

To link the anatomy and physiology to the examination

To be able to perform a GI examination including an understanding of the common abnormalities and

examination of appropriate lymph nodes

Theory and background.

The gastrointestinal system is composed of two groups of organs: the gastrointestinal tract (GI) and the

accessory digestive organs.

The gastrointestinal (GI) tract or alimentary canal is a continuum that extends from the mouth to the anus

through the ventral body cavity (comprised of thoracic and abdominopelvic cavities). Organs of the

gastrointestinal tract include the mouth, most of the pharynx, oesophagus, stomach, small and large intestine.

The accessory digestive organs are the teeth, tongue, salivary glands, liver, gallbladder and pancreas.

The function of the gastrointestinal tract is to take a bolus of food; masticate it, swallow it, digest it, absorb it

and to expel the unwanted products.

The abdominal cavity

The abdominal cavity is bordered by the pelvis (inferiorly,) the diaphragm (superiorly) and laterally by the walls

of the torso. For the purpose of identifying abnormalities the abdomen is divided into either 4 quadrants or 9

regions (see illustrations below).

Four quadrants of the abdomen

In clinical notes

quadrants are usually

used to describe

where pathology may

reside. Usually a body

of text is used to

describe the location

and a simple picture or

diagram is employed

to ensure there is no

ambiguity.

Nine regions of the

abdomen

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Adapted from http://cnx.org/contents/17e4eea8-a005-45af-b835f756a014cd48@3

Indications for a gastrointestinal examination.

The decision as to which examinations will be performed is always based upon the patient’s history. There are

many indications for performing the gastrointestinal examination some examples are:

o Chronic / acute vomiting

o Changes in bowel habits including constipation or diarrhoea

o Blood or mucus evident in faeces

o Unexplained weight loss which may be due to malabsorption or malignancy

o Chronic / acute abdominal or rectal pain

o Abdominal distension

o Jaundice

o Abnormal blood

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Pain associated with gastrointestinal disorders

Acute appendicitis

Nausea, vomiting, central abdominal pain that later shifts to right iliac fossa

Fever, tenderness, guarding or palpable mass in right iliac fossa, pelvic peritonitis on rectal examination

Perforated peptic ulcer with acute peritonitis

Vomiting at onset associated with severe acute-onset abdominal pain, previous history of dyspepsia, ulcer disease, non-steroidal anti-inflammatory drugs or glucocorticoid therapy

Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distension and absent bowel sounds

Acute pancreatitis

Anorexia, nausea, vomiting, constant severe epigastric pain, previous alcohol abuse/cholelithiasis

Fever, periumbilical or loin bruising, epigastric tenderness, variable guarding, reduced or absent bowel sounds

Ruptured aortic aneurysm

Sudden onset of severe, tearing back/loin/abdominal pain, hypotension and past history of vascular disease and/or high blood pressure

Shock and hypotension, pulsatile, tender, abdominal mass, asymmetrical femoral pulses

Acute mesenteric ischaemia

Anorexia, nausea, vomiting, bloody diarrhoea, constant abdominal pain, previous history of vascular disease and/or high blood pressure

Atrial fibrillation, heart failure, asymmetrical peripheral pulses, absent bowel sounds, variable tenderness and guarding

Intestinal obstruction

Colicky central abdominal pain, nausea, vomiting and constipation

Surgical scars, hernias, mass, distension, visible peristalsis, increased bowel sounds

Ruptured ectopic pregnancy

Premenopausal female, delayed or missed menstrual period, hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip pain, ‘prune juice’-like vaginal discharge

Suprapubic tenderness, periumbilical bruising, pain and tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Pelvic inflammatory disease

Sexually active young female, previous history of sexually transmitted infection, recent gynaecological procedure, pregnancy or use of intrauterine contraceptive device, irregular menstruation, dyspareunia, lower or central abdominal pain, backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis syndrome)

Fever, vaginal discharge, pelvic peritonitis causing tenderness on rectal examination, right upper quadrant tenderness (perihepatitis), pain/tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Timing

During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. For example, in acute appendicitis, pain is initially periumbilical (visceral pain) and moves to the right iliac fossa (somatic pain) when localised inflammation of the parietal peritoneum becomes established.

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If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised appendix abscess develops, with a palpable mass and localised pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the initial diagnosis was wrong or that complications have developed. In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with abdominal tenderness suggests intestinal ischaemia, as in strangulated hernia, and is an indication for urgent surgical intervention.

Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute appendicitis, cholecystitis or diverticulitis.

Exacerbating and relieving factors

Pain exacerbated by movement or coughing suggests inflammation. Patients tend to lie still to avoid exacerbating the pain. People with colic typically move around or draw their knees up towards the chest during spasms.

Severity

Excruciating pain, poorly relieved by opioid analgesia, suggests an ischaemic vascular event, such as bowel infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by potent analgesia is more typical of acute pancreatitis or peritonitis secondary to a ruptured viscus.

Equipment required to perform the examination

Hand wash

Stethoscope

Alcohol swabs to clean stethoscope

Patient safety.

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date

of birth, if available please check this with the name band and written documentation and the NHS/ hospital

number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure

the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that

you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,

especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection-

prevention/tools/hand-hygiene/en/

This procedure may require the presence of a chaperone. That is someone who is familiar with the examination

and can ensure that nothing inappropriate occurs by either party. The chaperone can be a useful resource, not

just being present to ensure the patient is treated appropriately, but to help and support the patient.

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 2 – History taking.

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General Inspection

Look at the patient and their environment at the beginning of the examination.

In the environment there may be many indicators of possible gastrointestinal conditions including:

o Vomit bowls

o Medications related to GI system

o Supplemental nutrition including tube feeding paraphernalia

o Uneaten meals

o Odours such as vomit, faeces, hepatic fetor and pear drops (associated with diabetes)

o Commode

o Alcohol containers

The patient may show some signs of possible gastrointestinal disease such as:

o Cachexia: wasting of the body due to severe chronic illness.

o Vomit or faecal soiling of bed linen or clothing.

o Signs of pain including facial expression and patient positioning

o A change in colour such as yellow (jaundice) associated with hepatobiliary conditions, pallor due to anaemia

which may be secondary to bleeding into the bowel or a flushed appearance secondary to inflammation /

infection and scars.

Specific Inspection

Moving on we will now look closely at the patient for signs of gastrointestinal disease. Adopting a systematic

approach we look at the:

Hands (see hand and nail study guide)

Look for nail signs which may develop over a period of time and indicate a chronic disease process. These signs

may include:

o Clubbing – Not specific for gastrointestinal disease but occurs with chronic disease. The tips of the

fingers take on a bulbous (swollen) appearance.

o Koilonychia – another sign of chronic disease. Koilonychia is commonly termed as spooning. It occurs

secondary to a chronic iron deficiency anaemia which may be secondary to dietary influences or chronic

bowel problems such as ulcerative colitis.

o Leukonychia – white nails due to problems associated with protein metabolism

o Nicotine tar staining – indicating chronic / heavy smoking

o Pale nail beds which may indicate acute / chronic anaemia

We will also assess for asterixis, also known as metabolic or liver flap: ask the patient to stretch out their arms,

abduct their fingers and cock their wrists back and to hold this position for at least 15 seconds; if the patient is

unable to maintain this position and the hands “flap” this is known as asterixis. This flapping (tremor) may be

due to liver or respiratory conditions so again is not specific to gastrointestinal conditions. However, all

examination findings are considered together when looking to make your diagnosis.

You should also take this opportunity to check all the patient’s vital signs including ACVPU or Glasgow coma

scale (should hepatic encephalopathy be suspected) and capillary refill time in the case of sepsis or shock.

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Face, mouth and neck

Look at the face:

o Are the scleras of the eyes jaundiced? - jaundice will be evident in the sclera much earlier than the skin in

hepatobiliary conditions

o Are the tarsal conjunctiva (lining of the eye lids) pink or are they pale which may indicate chronic or acute

anaemia.

o Is there inflammation evident at the corners of the mouth (angular cheilitis / angular stomatitis) which can

be associated with some of the inflammatory bowel diseases, diabetes, cancer, oral thrush and certain

medications?

Look in the mouth (the start of the GI system) ensuring you look under the tongue:

o Is the mouth well hydrated? Dehydration may be a sign of poor oral intake, acute kidney injury or

chronic vomiting / diarrhoea.

(NICE guidance https://www.evidence.nhs.uk/search?q=diarrhoea+and+vomiting+in+adults)

o Ulceration of the oral mucosa may be associated with chronic inflammatory bowel conditions.

o Whilst examining the face and oral cavity any odours on the breath such as a faecal odour may indicate

a bowel obstruction, hepatic fetor (sweet musty smell) indicating liver disease not to be confused with

pear drops which are associated with diabetes may be easier to identify.

Lymph nodes in the head and neck

As part of a gastrointestinal examination you should palpate the deep and superficial cervical supra and infra

clavicular, axillary and inguinal lymph nodes. An enlarged left supra clavicular lymph node (Virchow’s node /

Troiser’s sign) may be associated with metastatic spread of an abdominal malignancy.

Inspection of the torso

The majority of inspection of the torso may be done with the patient lying supine with hands by their sides and

a single pillow under their head. It is important that the abdominal muscles are relaxed, even raising the head

slightly can increase abdominal tone, to relax a taught abdomen you can get the patient to flex their hips and

knees (“can you bend your knees and bring your feet towards their bottom”).

The patient’s torso should be exposed to the suprapubic region - inguinal and genital areas should remain

covered until they are to be examined.

If the patient is sat up at this point you may wish to inspect the patient’s back before laying them flat.

o Scars must be identified and the reason for the scar. If the patient has had previous abdominal surgery this

may help to rule out or indicate some possible causes of abdominal symptoms such as “adhesions”.

o Spider naevi / telangiectasia (swollen blood vessels which appear as a red central spot with reddish blood

vessels which spread out from this central spot) may be associated with liver disease and an increase in

oestrogen levels in the blood stream. The presence of more than 5 on the torso is abnormal.

o Gynecomastia (breast tissue in male patients) may also develop as it is associated with liver disease and an

increase in oestrogen levels.

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o Abdominal distension (gross swelling) which can be remembered as the 6 F’s.

o Flatus (gas) – taut abdomen which is compressible

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

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

o Fat – soft and compressible

o Foetus – obstetric palpation will be taught in later year

o Fairly big tumours - firm to hard mass

o Rashes - shingles may be a cause of pain and psoriasis may be associated with chronic inflammatory bowel

disorders.

o Dilated veins on the torso or around the umbilicus may be associated with increased pressure in the vena

cava due to restricted flow through the liver in liver disease.

o Abnormal abdominal movement i.e. visible peristalsis in bowel obstruction or pulsation which may indicate

an abdominal aortic aneurysm (AAA).

Palpation of the abdominal wall

As the examiner you should position yourself to be on level with the abdominal surface, either use a chair or

stoop to achieve this. The reason you should be level with the abdomen is to ensure you DO NOT apply too

much pressure when palpating what may already be a painful / tender abdomen. Secondary to this you will be

able to look across the abdomen for swellings and it will be less intimidating for the patient as you will not be

standing over them.

If the patient has complained of abdominal pain or tenderness you should start your palpation away from the

affected area and move towards it palpating the tender area last.

Throughout abdominal palpation you should observe the patient’s face for visual signs of pain; as on occasion

patients will not verbally complain of pain but visually you can see the pain on their face as you palpate. This

observation could give you key clinical signs that may be missed had you not observed the patients face.

There are 3 elements of abdominal palpation:

o Superficial palpation is performed to determine the tone of the abdominal wall muscles which can become

tense (contract) due to pain, infection or inflammation in order to protect the underlying structures within

the abdomen.

o Deep palpation is performed to identify possible abnormal masses within the abdominal / peritoneal cavity.

o Specific organ palpation is used to identify potential enlargement of the liver, spleen and kidneys.

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Superficial Palpation

Superficial palpation is performed by placing the flat of the hand onto the abdominal wall and lightly pressing

against the abdominal muscles to determine if they remain soft and relaxed. All regions of the abdomen must

be covered in a systematic manner and the examining hand should remain in contact with the abdominal wall

throughout. The technique is used to determine if any of the following signs are evident;

o Pain elicited during palpation is an important finding as other signs may not be evident in the early stages of

a condition.

o Guarding is the contraction of the abdominal muscles in response to pressure being applied over an area of

infection / inflammation. The muscles tense in response to the pressure applied by the examiner’s hand to

protect the underlying structures from further insult.

o Rigidity is the contraction of the abdominal muscles in response to infection / inflammatory changes within

the abdominal / peritoneal cavity. This contraction is evident prior to any palpation and the abdomen will be

“rock” hard. Normal abdominal movement with respiration will be absent. Rigidity is a concerning sign and

should be reported to a senior upon immediately

If an abnormal finding is evident relate it to the region of the abdomen being palpated and document its

position.

Deep palpation

Deep palpation is performed using a similar technique as that for superficial palpation but pressing deeply

through the abdominal (muscle) wall to palpate for any abnormal masses or swelling of the abdominal organs. If

a mass is palpated describe it by the region of the abdomen being palpated, the underlying structures / organs

and document it’s size (in cms), shape, depth (superficial or deep), surface (smooth or irregular), consistency

(hard, firm, soft or fluid), edge (defined or diffuse) or if it is pulsating (if a pulsating mass is found ensure you

inform a senior member of staff and do not continue with the examination until the patient has been seen).

To determine if the mass is in the abdominal wall or in the abdomen itself you can ask the patient to raise their

head, this will cause the muscles to contract and allow you to differentiate whether the mass is on the wall or

within the abdomen itself.

Use the flat of the palmar

surface of fingers to palpate

through the abdominal wall

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Specific Organ Palpation

Specific organ palpation technique is used to identify any

enlargement of the liver, spleen or kidneys (organomegaly).

The patient is asked to relax and take deep breaths at a steady

rate which may be determined by the examiner. However, care

must be taken to ensure the patient is not stressed by the rate

of respiration required as this may lead to light-headedness.

Palpation of the liver

The liver lies under the ribs on the right side with a small

portion of the liver crossing the mid-line. The lower most edge

of the liver lies just above but deep to the costal margin (the

lower edge of the rib cage). The liver descends inferiorly towards the right iliac fossa on inspiration and we use

this movement to feel for the inferior border of the liver as it moves downwards. In normal health the liver is

usually impalpable as it remains above the costal margin.

The liver may become enlarged for a number of reasons including fatty liver disease, alcohol liver disease, cysts,

infection, cirrhosis, cancer and cardiac failure.

How to palpate an enlarged liver

Palpation for the liver should commence in the right iliac fossa as this theoretically is the fullest extent to which

the liver may enlarge. The hand is positioned in the right iliac fossa so that the lateral border of the index finger

is parallel with the costal margin. The thumb is extended to fully

expose the lateral border of the index finger.

Pressure is applied onto the abdominal wall by the examining

hand and the patient is asked to take a deep breath in. As the

diaphragm pushes the liver downwards the edge of an enlarged

liver will be felt “hitting” the lateral border of the index finger on

inspiration. If the liver edge is not felt, the examining hand is

moved closer to the right costal margin by about 1 cm.

The process is then repeated until the liver edge is palpated or the

costal margin reached. If the liver edge is felt then the distance

from the right costal margin is measured and recorded in cm.

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How to palpate an enlarged spleen

Palpation for the spleen should commence in the right iliac

fossa as this theoretically is the fullest extent to which the

spleen may enlarge. Place one hand under the patients ribs

on the left and pull across towards their right. Your other

hand is then positioned in the right iliac fossa so that the tips

point towards the normal anatomical position of the spleen.

The thumb is extended to prevent it interfering with the

positioning of the hand.

Pressure is applied to the abdominal wall by the examining

hand and the patient is asked to take a deep breath in. As the

diaphragm pushes the spleen downwards and medially the

edge of an enlarged spleen will be felt “hitting” the finger

tips. When very large you may also be able to palpate the

distinctive splenic notch. If the spleen is not felt, the

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

The process is repeated until the spleen is palpated or the costal margin reached. If the spleen is felt then the

distance from the left costal margin is measured and recorded in cm.

Palpation of the kidneys

The kidneys are situated in the renal angle which

extends from the twelfth thoracic vertebrae to

the third lumbar vertebrae. The right kidney is

slightly lower than the left due to the position of

the liver. The kidneys descend inferiorly on

inspiration and we feel for the kidneys as they

descend. The kidneys are retroperitoneal organs

and a deep bimanual technique of palpation is

required. Not normally palpable unless the

patient is thin.

How to palpate for enlarged kidneys

Place the palmar surface of your left hand under the patients flank and the finger tips into the renal angle

(between posterior costal margin and spine). Your right hand should be placed with fingers flat onto the

abdominal wall in opposition of your left.

Pressure is applied to the abdominal wall by the right hand and the left lifted to meet it. The patient is asked to

take a deep breath in. As the diaphragm pushes the kidneys downwards the rounded lower pole of an enlarged

kidney may be felt passing between the opposing fingers as the patient breaths in and out.

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The kidneys are then “balloted”. The kidney is moved by pressure from behind, allowing it to be palpated

between the hands so that its size, shape, and mobility may be determined

Percussion

Before palpating the abdomen you should percuss for the size and position of the liver. You can either percuss

down from the right clavicle until you find the superior border when dullness is noted, then up from the right

inguinal region until the lower border is found. Alternately you may percuss up from the right inguinal region

identify the lower border of the liver and continue upwards until the note changes indicating the superior

border.

If a mass is palpated percussion allows us to determine the boundaries of a mass and also to determine the

consistency i.e. gas, fluid or solid tissue. The overall percussion note found over the abdomen is resonance as in

the supine position any fluid in the bowel settles to the patients back and gases rise to the anterior surfaces of

the bowel.

Routine percussion is performed for the purposes of identifying the superior border of the liver and the inferior

border. Starting in the midclavicular line percuss down from the right clavicle until the note becomes dull (this

should identify the superior border of the liver). Once the superior border is identified percuss up from the right

iliac fossa until the lower border is identified (the normal abdomen is resonant when the patient is lying supine).

If a mass or organomegaly was detected during the examination of the abdomen, then percussion is performed

to determine the borders.

There may be an area of dullness evident on the left side where the descending colon lies due to the presence of

faecal matter.

Percussion Tenderness (when pain is elicited during percussion) indicates an inflammatory process within the

abdominal / peritoneal cavity i.e. peritonitis or appendicitis.

Shifting dullness is a sign elicited when the patient has ascites (fluid in the peritoneal cavity). With the patient

supine percuss the whole abdomen. Note the distribution of dullness and resonance. Then place the patient on

their side and wait for 30-60 seconds. Percuss the abdomen again this time systematically starting from the

lower side (in contact with the couch) and move towards the upper side. If 500ml or more of ascitic fluid is

present in the peritoneal cavity you should pick up consistently dull sounds from the lower side and resonance

from the upper side. The level of dull sounds represents the amount of ascetic fluid present.

In a positive shifting dullness test there will be consistently dull percussion sounds from the lower side and

resonant sounds from the top side. The level of dullness represents the level of ascetic fluid present. In a

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negative shifting dullness tests there would be little difference noted in the percussion sounds compared with

the supine position.

Auscultation

Auscultation for bowel sounds may be considered if organomegaly is present or signs / symptoms suggest

disruption of normal bowel activity has occurred. Not all clinicians will routinely auscultate the abdomen.

To auscultate for bowel sounds; place the head of the stethoscope onto the abdominal wall in the right lower

quadrant and listen. The right lower quadrant is where sounds are more frequently and therefore more likely to

be heard. Do not move the position of the stethoscope for 2 minutes or until bowel sounds are heard. After this

time if NO bowel sounds are heard the stethoscope may be moved to another position and listen again for a

further 2 minutes.

o Normal bowel sounds are termed as borborygmi, these are low to medium pitched grumbles associated

with the passage of fluid and gases through the bowel as peristalsis occurs. Sounds should occur at least

every 2 – 4 minutes in health, but the frequency will increase after a meal or in the case of an acute bowel

obstruction as the peristaltic action of the bowel tries to clear the obstruction.

o Increased bowel sounds may be an indication of inflammation, infection, recent intake of food, partial

obstruction or the initial stages of acute obstruction –the sounds increase in frequency and become higher

in pitch as the peristaltic action of the bowel increases to try to move the obstruction along.

o Tinkling bowel sounds may be an indication of acute obstruction. They are increased in frequency and

higher in pitch due to the increased peristaltic action of the bowel trying to move the obstruction along.

o “Absent” bowel sounds occur if an obstruction is complete. Complete obstruction may lead to necrosis and

as a result peristaltic action may cease (ileus). If after 4 minutes of listening in a variety of places on the

abdomen you have not heard bowel sounds contact a senior member of the health care team. You may hear

referred heart and breath sounds if bowel sounds are absent.

o Whilst auscultating the abdomen you should take the opportunity to listen for abdominal bruits as detailed

within your cardiovascular examination study guide.

Examination of hernias

Hernias are common and typically occur at openings of the abdominal wall, such as the inguinal, femoral and

obturator canals, the umbilicus and the oesophageal hiatus. They may also occur at sites of weakness of the

abdominal wall, as in previous surgical incisions. An external abdominal hernia is an abnormal protrusion of

bowel and/or omentum from the abdominal cavity. External hernias are more obvious when the pressure within

the abdomen rises, such as when the patient is standing, coughing or straining at stool. Internal hernias occur

through defects of the mesentery or into the retroperitoneal space and are not visible. An impulse can often be

felt in a hernia during coughing (cough impulse). Identify a hernia from its anatomical site and characteristics,

and attempt to differentiate between direct and indirect inguinal hernias.

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Examine the groin with the patient standing upright. Inspect the inguinal and femoral canals and the scrotum for

any lumps or bulges. Ask the patient to cough; look for an impulse over the femoral or inguinal canal and

scrotum. Identify the anatomical relationships between the bulge, the pubic tubercle and the inguinal ligament

to distinguish a femoral from an inguinal hernia. Palpate the external inguinal ring and along the inguinal canal

for possible muscle defects. Ask the patient to cough and feel for a cough impulse. Now ask the patient to lie

down and establish whether the hernia reduces spontaneously. If so, press two fingers over the internal inguinal

ring at the mid-inguinal point and ask the patient to cough or stand up while you maintain pressure over the

internal inguinal ring. If the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is

an indirect inguinal hernia. Examine the opposite side to exclude the possibility of asymptomatic hernias.

An indirect inguinal hernia bulges through the internal ring and follows the course of the inguinal canal. It may

extend beyond the external ring and enter the scrotum. Indirect hernias comprise 85% of all hernias and are

more common in younger men.

A direct inguinal hernia forms at a site of muscle weakness in the posterior wall of the inguinal canal and rarely

extends into the scrotum. It is more common in older men and women

A femoral hernia projects through the

femoral ring and into the femoral canal.

Inguinal hernias are palpable above and

medial to the pubic tubercle. Femoral

hernias are palpable below the inguinal

ligament and lateral to the pubic tubercle.

In a reducible hernia the contents can be

returned to the abdominal cavity, spontaneously or by manipulation; if they cannot, the hernia is irreducible

(incarcerated). An abdominal hernia has a covering sac of peritoneum and the neck of the hernia is a common

site of compression of the contents. If the hernia contains bowel, obstruction may occur. If the blood supply to

the contents of the hernia (bowel or omentum) is restricted, the hernia is strangulated. It is tense, tender and

has no cough impulse, there may be bowel obstruction and, later, signs of sepsis and shock. A strangulated

hernia is a surgical emergency and, if left untreated, will lead to bowel infarction and peritonitis.

Recording your findings

Macleod's Clinical Examination 14th Ed 2018

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Don’t forget when recording your findings to include the patient identifiers, date (and time), your signature and

print your name at the end.

When documenting or describing your findings remember to comment on inspection describing the position of

any abnormalities seen, the tone of the abdominal wall and any sign such as guarding or rigidity, any masses

found, findings of percussion and auscultation.

Remember to describe your findings as fully as possible: e.g. size, position (relative to the regions or quadrants

as previously described) and the shape of a swelling etc.

A diagram may often be useful in written notes (see below)

Special examination techniques for self-directed study

McBurney's sign

Deep tenderness at a point approx’ 2 inches from the anterior superior iliac spine on a line between the

umbilicus and the anterior superior iliac spine (McBurney’s point) is indicative of late stage acute appendicitis

with an increase in the risk of rupture.

Aaron's sign

Referred pain felt in the epigastrium upon continuous firm pressure over McBurney's point. It is indicative of

appendicitis.

Obturator sign

Flexing the right hip and knee, then internally rotation the right hip will cause an increase in abdominal pain in

appendicitis.

Palpable mass

Umbilicus Appendicectomy scar

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Murphy’s sign

Placing fingers or thumb under right costal cartilage and asking the patient to breathe in. If there is an increase

in pain +/- catching breath then this is indicative of cholecystitis.

Rosving’s Sign

Pressure over the patient's left lower quadrant causes pain in the right lower quadrant in appendicitis.

However this test is unreliable with a sensitivity of 30.1%.

https://www.bmj.com/rapid-response/2011/11/03/rovsings-sign-0

Further Reading

Innes, J Alastair, BSc PhD FRCP(Ed); Dover, Anna R, PhD FRCP(Ed); Fairhurst, Karen, PhD FRCGP. Macleod's

Clinical Examination, Fourteenth Edition