Gastrointestinal Examination

Examining a patient's GI system involves much more than just the abdomen and when performing a GI exam, it is important to remember that many gastrointestinal conditions can have effects outwith the GI tract. It is also important to establish a systematic approach to examining a patient, as with any examination and to practice, practice, practice.

To begin with, as in any examination, you should wash your hands, introduce yourself to the patient, explain the examination and obtain consent. While traditionally 'nipples to knees' exposure was taught, it is mostly unnecessary and xiphisternum to pubic symphysis should suffice. 

General assessment

Firstly, you should assess the patient from the 'end of the bed'. This doesn't mean you should literally stand at the end of the bed but it means you should observe the patient's general appearance- whether it seems like they are comfortable or at rest, whether they are in obvious pain and distressed and whether they have any noticeable pallor or jaundice. Is there obvious wasting? If so, this could be evidence of a malignancy/ malabsorption/ liver failure, etc. It is important to check for presence of any catheters, drips, drains, oxygen masks, and so on as this may give an idea of the patient's condition.

Hands, Wrists, Arms

To start the actual 'hands on' examination then the hands would actually be a good place to start. Be on the patient's right side and check for:

• Dupuytren's contracture- a fixed flexion contracture of the hand. May be due to chronic liver disease/ diabetes/ trauma/ phenytoin treatment or could be familial.
• Tendon xanthomata- yellow cholesterol-rich deposits over the tendons of the hands, indicative of hyperlipidaemia.
• Palmar erythema- reddening of the thenar and hypothenar eminences. Common in chronic liver disease but also in several other conditions such as thyrotoxicosis, rheumatoid arthritis and also in pregnancy

When looking at the nails, the following signs are important to remember:

• Finger clubbing- this deformity of the fingernails is associated with numerous conditions, some of them relevant to GI examination (think IBD, lymphoma, liver cirrhosis, coeliac disease) and while there are numerous methods to illicit whether fingernails are clubbed or not, in practice you shouldn't waste too much time debating this if it isn't immediately obvious.
• Leuconychia- this means 'white nails' and is indicative of hypoalbuminaemia (possibly due to chronic liver disease, for example).
• Koilonycia- nails lose their convex shape, becoming flat or even concave- so called 'spoon nails'. This indicates iron-deficiency anaemia and so may be a sign of gastrointestinal bleeding.

Moving up to the wrist, the radial pulse should be palpated briefly to give an indication of CV function and then you should check for a flapping tremor (asterixis). This is done by asking the patient to put their arms out straight and then to cock their wrists back (ie. wrist extension). The hands may be seen to 'flap' and this may indicate hepatic encephalopathy or renal/respiratory failure. 

Moving up the arms, check for bruising which may indicate previous cannulisation, a great degree of bruising may indicate chronic liver disease and poor synthetic function of clotting factors/ thrombocytopaenia/ falls. Also check for IVDU marks which if present may indicate a risk of Hep B or Hep C infection.

Head and neck

Next you should examine the face and there are numerous signs which may potentially be observed here. Firstly is there an obvious Cushingoid appearance (moon face, hirsutism, acne,etc.) or are the parotid glands enlarged? Both these factors may indicate chronic alcoholic excess. Looking at the eyes the following signs should be considered:

• Scleral icterus- a yellowing of the sclera which indicates the patient is jaundiced. This implies a serum bilirubin of >35micromol/l but realistically jaundice may not be noticed till the bilirubin climbs higher.
• Corneal arcus and xanthelasma- as with tendon xanthomata, these signs indicate hyperlipidaemia. Corneal arcus is seen as a white ring round the iris and xanthelasma are yellowish deposits around the eyes.
• Episcleritis and conjunctivitis- may indicate IBD. Conjunctivitis is inflammation of the outermost layer of the eye and inner eyelid surface while episcleritis is inflammation of the area between the conjunctiva and the sclera: the episclera.
• Conjunctival pallor- indicates anaemia.

Moving down to the mouth, check for the following:

• Oral candidiasis- tends to indicate some degree of immunodeficiency (for which there are numerous possible causes).
• Angular stomatitis and glossitis- seen as inflammation at the edge of the mouth and a large smooth tongue, respectively. These signs suggest iron/ folic acid/ vitamin B₁₂ deficiency.
• Apthous ulcers- painful open sores in the mouth, associated with IBD (Crohn's in particular).
• Fetor hepaticus- the patient's breath smells sweet and musty (sometimes described as 'mousy'). This is due to presence of mercaptans in the breath and is a sign of hepatic failure.

After the head and face, you should check for signs of lymphadenopathy in the neck. Remember to ask the patient if they have any pain in their neck first and then palpate systematically, remembering to check for presence of Virchow's node, which is a left supraclavicular node that is often palpable in gastric cancer classically (Troisier's sign).

The chest

Next the chest and back should be examined. There are 3 things to look out for here:

• Gynaecomastia- presence of palpable breast tissue in men. Remember, it has to be palpable! This is another of those signs that has numerous causes, such as chronic liver disease, testicular failure, treatment with certain drugs (such as spironolactone), etc.
• Loss of secondary sexual hair- People are obviously hairy to different extents and so checking for hair in the axilla is handy when assessing this. May indicate chronic liver disease.
• Spider naevi- small dilated blood vessels, typically with a central red spot and radiating vessels. Spider naevi will typically blanch when pressure is applied to the centre and then refill from the centre outward- this is important to check if something is a spider naevus or something else. Spider naevi are only found in the distribution of the superior vena cava and 5 is suggestive of chronic liver disease.

 

The abdomen 

 

Now, you should move onto the abdomen and it is important for this stage of the examination that you have the patient lay flat on their back with their arms at their sides. Upon inspection is the abdomen distended? Abdominal distension is caused by one or more of the '5 Fs': Fat, Fluid, Faeces, Foetus, Flatus. Large masses may also cause distension however. Note any abdominal scars (which may give an indication of previous medical and surgical history). Look for caput medusa (dilated veins radiating from the umbilicus outwards), this may be a sign of portal hypertension but in practice is rarely seen and so is of limited use.

Before beginning palpation of the abdomen, ask the patient if they have any abdominal discomfort. Get down on one knee (still on the patient's right side) and begin palpating each of the 9 abdominal areas, starting off with light palpation and then moving on to deeper palpation, remembering to start away from any tender area and to keep watching the patient's face to check if they are in any discomfort.

The next step is to check for hepatomegaly. This is done by asking the patient to take deep breaths in and out through their mouth and, starting in the right iliac fossa, move upwards towards the right costal margin. You should feel for the liver edge during inspiration and move your hand upwards during expiration. If the liver is enlarged, you may feel the liver edge hit the edge of your fingers as it descends during inspiration. Next percuss the upper and lower hepatic borders, establishing the upper border in women can be done down the axilla or just medial to the sternum for purposes of modesty and practicality.

Checking for splenomegaly is done in a similar way, with the patient still taking deep breaths and again starting in the right iliac fossa but this time you should move upwards towards the left costal margin and again feeling during inspiration/ moving during expiration. If you do not feel the spleen then this can be repeated with the patient lying on their right hand side and your left hand pulling the patient's left lower ribs forwards.

You should then ballot each of the kidneys. This is done with one hand posterior to the kidney and the other anterior to it (just lateral to the rectus abdominus ) and then pushing upwards with the posterior hand. If the kidneys are enlarged (or in thin patients/ children), you may be able to feel the kidney with the anterior hand.

It is also worth palpating for potential abdominal aorta aneurysms. This is done with 2 hands above the umbilicus. This is done as an AAA may cause abdominal symptoms.

The next step of the abdominal exam is percussion for shifting dullness. This is a test for the presence of ascites and  if shifting dullness is present this indicates ascitic fluid of 1.5l or more is present. This should be done by percussing from the patient's midline towards their left flank and leaving the finger at the first point where the tone changes from resonant to dull. After rolling the patient towards you wait a few seconds and then percuss again. This test is positive if the same spot is now resonant (indicating fluid has shifted). Percussion is towards the left flank to avoid the dullness associated with the liver.

To finish the abdominal examination, auscultate for bowel sounds. This should be done adjacent to the umbilicus. Note the presence/absence and character of the bowel sounds. It may be possible to hear renal bruits (lateral and superior to the umbilicus) associated with renal artery disease or a liver bruit (if you felt a liver edge) which may be associated with hepatocellular carcinoma, AV malformation or transjugular intrahepatic portosystemic stent-shunt (TIPSS). However, do not spend too much time trying to illicit these signs if not immediately obvious (or if there is no reason they would be present).

The legs
  
Moving on from the abdomen and down to the legs, there are a few things to check for:

• Ankle oedema- typically 'pitting' oedema. Press lightly with a finger on the side of the ankle for a few seconds and then remove the pressure, noting whether the depression remains.
• Erythema nodosum- tender red nodules, usually observed on the shins. May indicate IBD.
• Pyoderma gangrenosum- deep ulcers on the legs as a result of tissue necrosis. Scars may be present from previous pyoderma. Pyoderma gangrenosum may occur in association with IBD or rheumatoid arthritis.

What's left?

To finish the GI examination, perform an examination of the external genitalia (testicular atrophy may be present in chronic liver disease), hernial orifices and then perform a PR exam (to check for presence of any rectal masses, etc.) and remember to check the observations chart for other clinical details such as oxygen saturation, BP, temperature, etc.