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.
Wash your hands using the Ayliffe technique
Introduce yourself and give your name and grade
“Hi, my name is John Smith and I am a 4th year medical student”
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”
“Would this be ok with you?”
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.
Clarify patients identity by confirming name and asking for their DOB
Initially lie the patient at 45 degrees and expose them from waist up
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 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 the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.
Tachycardia/tachypnoea (signs of sepsis)
Irregular (AF)
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)
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 the patient supine on the bed. Make sure they are comfortable.
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
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
Palpate then percuss for hepatomegaly.
Causes of hepatomegaly - ETOH, high BMI
Palpate then percuss for splenomegaly
Palpate loin areas for kidneys
Palpate the abdomen centrally for the abdominal aorta. Expansile mass may be suggestive of an aneurysm.
Percuss the abdomen for shifting dullness which suggests ascites.
Causes of ascites - ETOH, malignancy, cirrohsis
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)
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?”
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.”
Explain to the examiner what tests and investigations you would perform
Urine
Bloods tests
CRP / ESR - signs of inflammation
Erect CXR
AXR