Gastrointestinal Examination

The examination of the abdomen (or Gastrointestinal exam) is an examination that looks for signs of pathology within the gastrointestinal (GI) tract. The GI exam does not simply focus on the abdomen but is also a systemic clinical examination of the patient. It is also one of the core aspects of any OSCE exams. In the real world any patient that is admitted into the hospital needs to have a gastrointestinal exam completed. Often patients with abdominal pain, malaena or haematemesis will need specific focus on their gastrointestinal system due to the nature of their presenting complaint.

Washes hands

Wash your hands using the Ayliffe technique

Introduce yourself

Introduce yourself and give your name and grade

   “Hi, my name is John Smith and I am a 4th year medical student”

Describe examination

Explain what examination you are performing and what this involves

“I have been asked to perform a Gastrointestinal examination on you today. This involves having a look at your hands and face, and having a feel of your tummy”

Gain verbal consent

“Would this be ok with you?”

Offer a chaperone

Ask if they would like a chaperone

  “The exam involves you having to remove your upper garment. Would you like a chaperone for the exam?”

NB - Ask if the patient would like to use the toilet before the start of the exam as you will be pressing on their bladder. It’s a nice thing to do and you’ll gain Brownie Points in an exam situation for showing compassion.

Check patient details

Clarify patients identity by confirming name and asking for their DOB

Positioning patient at 45 degrees

Initially lie the patient at 45 degrees and expose them from waist up 

End of bed inspection

Inspect the patient from the end of the bed and look for the following:

  • Patient - Note any tachypnoea, cachexia, jaundice or ascites.

  • Adjuncts - eg. any supplemental O2 (%), IV lines, infusions, catheter

  • Paraphernalia - eg. kidney dish, commode

Inspect the hands

Inspect the hands and check for stigmata of chronic GI disease

  • Skin

    • Bronze skin  (Haemochromatosis)

    • Yellow ( Jaundice)

    • Tar staining (Smoker)

    • Spider naevi (Abnormal >2, caused by COCP, pregnancy, alcoholic cirrhosis, hepatic cirrhosis)

    • Palmar erythema (liver cirrhosis, Wilson’s disease, Hemochromatosis)

    • Dupuytren’s contracture (Liver cirrhosis, phenytoin, pregnancy, manual labour, trauma)

  • Temperature

    • Cold hands - ?Raynauds (Scleroderma)

  • Nails

    • Clubbing - Ulcerative colitis (UC), Crohns disease, primary biliary cirrhosis (PBC), liver cirrhosis, achalasia

    • Yellow nails -  jaundice, tar staining

    • Koilonychia - iron deficiency

    • Leuconychia - hypoalbuminaemia, chronic liver disease

Check pulse and respiratory rate

    Check the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.

  • Tachycardia/tachypnoea (signs of sepsis)

  • Irregular (AF)

Check for “Liver flap”

Ask the patients to put their hands in front of them and check for tremor. Then ask them to cock their wrists back as if they were stopping traffic. Check for any flapping.

  • Asterixis (Encephalopathy)

  • Tremor (Delirium Tremens)

Inspect the face and neck

Next, inspect their eyes, mouth and neck for the following.

  • Eyes

    • Pale conjunctiva (anaemia)

    • Yellow (Jaundice)

    • Kayser-Fleischer ring (Wilson’s disease (early stages only seen with slit lamp))

  • Mouth

    • Poor dentition (Scurvy)

    • Gingivitis (Scurvy)

    • Apthous ulcers (Crohn’s > UC)

    • Glositis [large tongue] -(iron deficiency)

    • Angular cheilitis [cuts to edge of lips]  (iron deficiency)

  • Neck

    • Raised JVP (SVC obstruction, Hepatovenous obstruction)

    • Lymphadenopathy (Lymphoma, Virchow’s Node - GI malignancy)

Position patient at 180 deg

Position the patient supine on the bed. Make sure they are comfortable. 

General Inspection

Inspect the abdomen again more closely and look for the following:

  • Skin

    • Yellow (Jaundice)

    • Caputs Medusa (Liver cirrhosis)

    • Pyoderma gangrenosum (IBD)

    • Spider naevi (Abnormal >2, caused by COCP, pregnancy, alcoholic cirrhosis, hepatic cirrhosis)

  • Shape

    • Distension (6 F’s - fat/fluid/flatus/faeces/foetus/flipping big tumour)

    • Masses (Lye flat and take a sky line view of the abdomen)

  • Scar

  • Stoma

Palpation of the abdomen

Palpate the abdomen making sure you are at the level of the abdomen. Palpate lightly initially and then move on to deep palpation. Make sure you palpate the 9 areas of the abdomen. NB - start away from the site of pain. Look at the patient's face for signs of pain/discomfort.

  • right hypochondriac - liver, gallbladder

  • epigastric region - pancreas, duodenum, stomach

  • left hypochondriac - stomach, spleen

  • Right lumbar region - Right kidney, ureter, hepatic flexure of large bowel

  • umbilical region - pancreas, bowel

  • Left lumbar region - Left kidney, ureter,

  • Right iliac region - Apendix, right ovary (female), renal transplant

  • Suprapubic region - Bladder, uterus (female)

  • Left iliac region - Sigmoid colon, left ovary (female), renal transplant

Examine for hepatomegaly

Palpate then percuss for hepatomegaly.

  • Causes of hepatomegaly - ETOH, high BMI

Examine for splenomegaly

Palpate then percuss for splenomegaly

  •     Causes of splenomegaly - Infective, malignancy or secondary to liver disease

Examine loin area

Palpate loin areas for kidneys

Examine abdominal aorta

Palpate the abdomen centrally for the abdominal aorta. Expansile mass may be suggestive of an aneurysm.

Examine for ascites

Percuss the abdomen for shifting dullness which suggests ascites.

  • Causes of ascites - ETOH, malignancy, cirrohsis

Auscultate the abdomen

Listen to the abdomen for the following

  • Bowel sounds - active (Normal/increased/decreased/nil)

  • Pitch - high pitched bowel sounds and tinkling are signs of small bowel obstruction

  • Aortic and renal bruits (Mickey mouse sign)

Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

State other exams for completion

Turn to the examiner and state what else you would do to complete the exam
“To complete the examination I would check the groin area for any masses such as hernias. I would also also perform a digital rectal exam.”

State what tests you would perform

Explain to the examiner what tests and investigations you would perform

  • Urine

    • Dip/MC&S - infection
    • Pregnancy test - female of reproductive age
  • Bloods tests

    • FBC - anaemia/infection
    • U&E - baseline, AKI
    • LFT - hepatobiliary picture, hepatitis
    • CRP / ESR - signs of inflammation

  • Erect CXR

    • Air under diaphragm
  • AXR

    • Small or large bowel dilatation
    • Renal stone
    • Gallstone