Examination of Gastrointestinal System

EXAMINATION OF
GASTROINTESTINAL SYSTEM
Oral cavity
A torch, a tongue depressor and a pair of gloves are necessary for examination
1. Hydration status
2.Fetor (bad breath)
sweet smell severe hepatocellular

disease
sickly sweet smell diabetic ketoacidosis
fishy ammonia smell uremia

Putrid smell Due to anaerobic chest
infection with large
amounts of sputum
TONGUE
ask the patient to stick out their tongue and inspect :-
Leukoplakia: white-coloured thickening of

mucosa of tongue and mouth
Glossitis :
Indicates nutritional deficiencies, eg. Fe, B9, B12
and alcoholics
Candidiasis :
Creamy white curd-like patches .
Causes: -alcoholism, Broad-spectrum Abx
(↓normal oral flora) Faulty oral hygiene ,
Diabetes mellitus
• Geographic tongue: indicate riboflavin (B2) deficiency
• Lingua nigra → Black tongue can arise from bismuth compounds/fungal

infections
• ulcers → due to trauma / infection
• Thickened epithelium with bacterial debris and food particles → Common

in smokers or with respiratory tract infection
•
Teeth and Gums
Nicotine staining present in patients who smoke
Gum hypertrophy may be due to smoking,

Drugs: phenytoin, phenobarbital, Scurvy
LIPS
Angular stomatitis: cracks at corners of mouth →
Indicates nutritional deficiencies incl. B6, B9, B12,
iron
Ulcerations : trauma / infections
ABDOMINAL REGIONS
CLINICAL EXAMINATION
• INSPECTION
• AUSCULTATION
• PALPATION
• PERCUSSION
INSPECTION
Position
 Introduce yourself
 Take verbal consent
 Patient : should lie flat on his back with leg extended
 Examiner : stand on the right side of patient
Exposure
Xiphisternum to Symphysis pubis
Inspection : Contour of
abdomen
Generalised fullness or distension may be due
to fat /fluid / flatus /faeces/fetus
Localised distension –
Symmetrical : small bowel obstruction
Asymmetrical : gross enlargement of spleen
liver kidney .
Scaphoid abdomen : advanced stages of
starvation & malignant disease .
Movement of abdomen
1. Respiratory movements
2. Peristalsis
3. Pulsations
 Normal : gentle rise in abdominal wall during inspiration

fall during expiration .
 Movements should be equal in both sides
 Absent abdominal wall movements : peritonitis
 Diaphragmatic paralysis : abdominal wall rise in expiration
Peristaltic movement
 Not normally present .
 Strongly indicate intestinal obstruction .
For eg. hypertrophic pyloric stenosis : left hypochondrium and epigastric
region to right lumbar region.
PULSATIONS
• Normally pulsations are not visible over abdomen .
• Conditions in which pulsations are visible :

Eg .Transmitted pulsation : from a tumor overlying the aorta
Eg .Right ventricular pulsation : seen in epigastrium & corresponds to apex
beat .
Umblicus
Normal : retracted and inverted
Distance between xiphisternum and
umblicus is equal the distance between
umblicus and symphysis pubis .
 everted umblicus : umblical
hernia / ascites
Inspection : skin
Look for Hernial sites like —
(i) Inguinal
(ii) Spigelian
(iii) Umbilical
(Iv) Epigastric
(v) Incisional hernia
PALPATION
 Patient : Lying supine with arms loosely at the sides
 Head and neck supported by upto two pillows
 Knees and hips flexed to prevent undue rigidity
Forearm should be kept horizontal along the level of
abdomen so that fingers are placed flat on abdominal wall
Make sure hands are gentle and warm
Steps for palpation
Superficial
 Tenderness
 Rebound
 Guarding
 Rigidity
Deep palpation
 Masses
 Organs
Tenderness is pain on pressure.
 It is commonly found in inflammatory lesions of the viscera and the
surrounding peritoneum. Eg. In the right iliac fossa - Appendicitis (Mc
Burney's Point)
Rebound tenderness : pain on releasing pressure .
GUARDING RIGIDITY
Voluntary Involuntary
Due to underlying
pathology
Can be relaxed by
explaining the patient that
you will be carefull and will
try not to cause any undue
pressure / pain during
examination .
Liver palpation
• Stand right to the patient
• Start in right illiac fossa and move upwards
• Hand aligned parallel to Rt costal margin
and avoid rectus muscle.
• Hand stationary during inspiration and
moves during expiration.
• Liver moves down during inspiration .
It can be felt by the radial border of index
finger.
If palpable, then note
• Edge: sharp vs rounded
• Surface: regular, well-defined, smooth (normal) vs nodular (HCC or polycystic liver)
• Consistency: soft (normal) vs firm (cirrhotic) vs hard (HCC or metastasis)
Spleen palpation
Classical method
Stand to the right of the patient
Patient in supine position
Start from right illiac fossa to left
hypochondriac region
Edge of spleen felt during deep
inspiration
Bimanual method
Stand to the right of the
patient
Put patient in right
lateral position
Left hand of examiner is
put over lower rib cage
and the spleen is palpated
with other hand.
Hooking method
The patient is put in right
lateral position
the examiner stands on
the left side and feels the
spleen by hooking his
fingers over the left costal
margin.
Dipping method
• This method is used when there is severe ascites .
• Put the patient in supine position and palpate as in the classical method
except that dip fingers into the abdomen with each palpation, so that the
fluid is displaced temporarily to the side.
Kidney palpation
Right kidney
Stand to the right of the

patient
Place right hand anteriorily in
right lumbar region and left
hand posteriorily in right loin
Push forward with left hand ,
lift right hand inward and
upward
Lower pole of kidney can be
felt between the two hands and
can be ballotted
Left kidney
Left kidney is not palpable unless
low in position or enlarged .
PERCUSSION TECHNIQUE
This technique allow you to evalute the size of

some of the organs and to detect the presence of
excess fluid or air .
Middle finger of left hand is placed on the part to
be percussed .
Slight hyperextension of distal interphalangeal
joint.
Blow at the back of DIP by sharp wrist
movements .
Notes elicited
Tympanic – predominent due to gas in GI tract .
Hyperresonant
Dull - organs , fluids .
TIDAL PERCUSSION : LIVER
Start from the 2nd right intercostal

space. Go vertically down
Dull note at the 5th right intercostal

space in the midclavicular line is the
normal upper border .
The dullness extend upto lower border

found just below the right costal
margin .
Normal span of liver 10-12 cm in men

8-11 cm in women
Percusssion : spleen
Percussion of traube’s space
This area should be resonant on percussion .
Dullness indicate possible splenic enlargement .
Percussion by castell’s method

Percuss in lower left intercostal space anterior axillary
line .
This area should be resonant on percussion .
Dullness indicate possible splenic enlargement .
( castell sign )
Shifting dullness
In normal individual flanks are
resonant .
Percuss laterally from midline
untill dullness is detected
now turn the patient to left or
right lateral decubitus position ,
the previous dull area over the
flank become resonant.
About 1000 ml of fluid should

be present to elicitate this sign .
FLUID THRILL
Place the palm of your left
hand against the left side of
abdomen
Ask the patient to put edge of

the hand on the midline of the
abdomen
Flick the finger against the

right side of the abdomen
If ripples are felt upon flickring
we call it fluid thrill.
 felt when fluid is >2lt
Puddle sign
Patient is to lie prone for
5 minutes and then goes
on all four limbs so that
middle portion of of
abdomen is dependent.
Now percuss around
umblicus and elicitate
dullness
Previously resonant area
become dull if minimal
fluid is present .
 for fluid as little as 120
ml
Auscultation
Bowel sounds :
Bowel sounds are intermittent low pitched gurgles generated by

contractions of the muscular walls of the gut and the resultant vibration of
the gut wall produced by movement of a gas-fluid mixture through the gut.
Occur one ever 5-10 sec.
Place the diaphragm of the stethoscope to the right of umblicus .
Listen in one site on the abdomen until bowel sounds are heard do not
move from site to site .
Auscultate for 2 min before concluding that no bowel sounds are present .
Absent bowel sounds : paralytic ileus / peritonitis
Increased bowel sounds : intestinal obstruction .

Bruits
These are variable harsh due to
turbulence in arterial flow.
Auscultate aortic bruit midline

between umblicus and xiphoid
Renal bruits : two inches superior

and lateral to umblicus
Common illac : midway between

umblicus and midpoint of inguinal
ligament .
Venous hum
Venous hum is continuous, softer
and lower pitched than bruit.
 It signifies portal systemic shunting

of venous flow when portal flow is
obstructed.
It is usually heard over the liver

area and umbilicus.
Refrences
• Hutchison’s clinical methods
• Macleod clinical examination
Thank you

Examination of Gastrointestinal System

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EXAMINATION OF

sweet smell severe hepatocellular

fishy ammonia smell uremia

Leukoplakia: white-coloured thickening of

• Lingua nigra → Black tongue can arise from bismuth compounds/fungal

• ulcers → due to trauma / infection

• Thickened epithelium with bacterial debris and food particles → Common

Nicotine staining present in patients who smoke

Gum hypertrophy may be due to smoking,

 Normal : gentle rise in abdominal wall during inspiration

• Normally pulsations are not visible over abdomen .

• Conditions in which pulsations are visible :

Rebound tenderness : pain on releasing pressure .

Stand to the right of the

This technique allow you to evalute the size of

Start from the 2nd right intercostal

Dull note at the 5th right intercostal

The dullness extend upto lower border

Normal span of liver 10-12 cm in men

Percussion by castell’s method

About 1000 ml of fluid should

Ask the patient to put edge of

Flick the finger against the

Bowel sounds are intermittent low pitched gurgles generated by

Occur one ever 5-10 sec.

Place the diaphragm of the stethoscope to the right of umblicus .

Absent bowel sounds : paralytic ileus / peritonitis

Increased bowel sounds : intestinal obstruction .

Auscultate aortic bruit midline

Renal bruits : two inches superior

Common illac : midway between

 It signifies portal systemic shunting

It is usually heard over the liver

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