Examination Of The Gastrointestinal System

Dr.Essmat Gemaey

K S U

Outlines The Abdomen Abdominal Anatomy The History and Physical in Perspective Physical Examination of the Abdomen Inspection Auscultation Percussion Palpation Using a glucometer

Objectives

After completion of this session the students should be able to:•Revise knowledge of anatomy and physiology •Obtain health history about gastrointestinal system•Demonstrate physical examination • Differentiate between normal and abnormal findings

Anatomy Liver-fills most of the Liver-fills most of the

RUQ and extends RUQ and extends across to L MCL to across to L MCL to

LUQLUQGB-RUQGB-RUQSmall intestine all Small intestine all quadsquadspancreas RUQ, LUQpancreas RUQ, LUQR and L kidney RUQ R and L kidney RUQ LUQLUQStomach LUQStomach LUQPart of ascending Part of ascending colon all quadscolon all quads

Right Upper Quadrant (RUQ)Left Upper Quadrant () LUQ

Liver: right lobeLiver: left lobeGallbladderSpleen

Stomach: pylorusStomachDuodenum: parts 1-3Jejunum and proximal ileum

Pancreas: headPancreas: body and tailRight suprarenal gland Left kidney

Right kidneyLeft suprarenal glandRight colic (hepatic) flexureLeft colic (splenic) flexure

Ascending colon: superior partTransverse colon: left halfTransverse colon: right halfDescending colon: superior part

Right Lower Quadrant (RLQ)Left Lower Quadrant (LLQ)CecumSigmoid colon

Verniform appendixDescending colon: inferior partMost of ileumLeft ovary

Ascending colon: inferior partLeft uterine tubeRight ovary Left ureter: abdominal part

Right uterine tubeLeft spermatic cord:Right ureter: abdominal partabdominal part

Right spermatic cord:Uterus (if enlarged)Abdominal partUrinary bladder (if very full)

Uterus (if enlarged)Urinary bladder (if very full)

Anatomic Landmarks and Descriptions

Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ) Midline:

Epigastric Periumbilical Suprapubic

Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint.

The abdomen is conventionally divided into 9 regions:

RH = right hypochondrium E = epigastrium LH = left hypochondrium RL = right lumbar LL = left lumbar U = umbilical RI = right iliac fossa LI = left iliac fossa SP = suprapubic region

MC Mid-clavicular lineSP= Subcostal Plane

TP=Transtubercular Plane

Overview of the Abdominal Examination

Make sure that the patient is comfortable, then “look, listen, then feel”.

Inspection Auscultation Percussion Palpation

The details of the advanced abdominal examination are well described in the benchmarks.

General Considerations

The patient should have an empty bladder. The patient should be lying supine on the exam

table and appropriately draped. The examination room must be quiet to perform

adequate auscultation and percussion. Watch the patient's face for signs of discomfort

during the examination.

Equipment NeededA Stethoscope Ruler Portable light

Patient position

Thepatient should be flat in the bed, with one pillow and legs/arms straight.

Patient exposure

The patient should be exposed from their nipples to the symphysis pubis.

The inguinal regions and external genitalia are also part of the full examination, but can be exposed at the appropriate time.

General inspection Inspect the abdomen for any:

Scars?Distension?

Dilated veins?Movement

(Pulsation? Peristaltic waves? Variation with respiration?)

Stomas present?

Inspection

Skin: Describe or diagram location

Scars, Rashes, Veins

Striae (silver or purple)

Hernia

Peristalsis

Contour of AbdomenRound, Flat, Protuberant,

BulgesUmbilicus

Contour and LocationInflammationPulsations

Inspection Stand back and examine the abdomen

from the end of the bed. Although keeping an open mind, try to think what

you would expect to find given the examination so far.

Umbilicus

Shape and location

Conti. Look at the shape of the abdomen. Generalised distension of the

abdomen is caused by one of the five F’s, namely• Fluid (ascites)• Foetus• Faeces• Fat• Flatus A localised area of distension may be a mass, a loop of bowel or

an enlarged organ. If there is a localized bulge, try to think of what organs lie in that position in the abdomen.

Auscultation

Auscultation is done before percussion and palpation since those maneuvers could potentially change the frequency and character of bowel tones.

With the diaphragm component of your stethoscope - auscultate the abdomen only long enough to hear bowel sounds and secondly to exclude any bruits.

Primarily you are listening for bowel sounds. Specifically listen for the pitch & frequency of the bowel sounds (Which

can be either normal, tinkling, absent or reduced) When the bowel is obstructed, bowel sounds can

become high pitched & frequent ~ classically called ‘tinkling bowel sounds’. Bowels sounds may become absent or reduced – for example in peritonitis, when there is widespread intra abdominal inflammation and loss of normal motility

You may also want to listen for bruits over the abdominal aorta & renal arteries.

In addition to bowel sounds, abdominal bruits are sometimes heard. Listen over the aorta, renal, and iliac arteries.

Bruits confined to systole do not necessarily indicate disease.

Don't be fooled by a heart murmur transmitted to the abdomen.

Percussion for the lower edge of the liver

Percuss the patients abdomen from the RIF to the right hypochondium for the lower edge of the liver.

Percussion over the liver produces a dull note.

In a normal abdomen you should not be able to percuss the lower edge of the liver.

If you do detect a lower edge of the liver in the abdomen you should then percuss to determine the position of the upper border of the liver

you need to determine if the liver is either enlarged or displaced byrespiratory disease).

To do this, percuss from the right mid clavicular region and gradually work your way down to the right costal margin.

The upper border of the liver is normally in the right 5th intercostal space

Percussion for the lower edge of the spleen

Percuss from the RIF to the left hypochondium - for the lower edge of the spleen.

If you detect the lower edge - there is no need to percuss for the upper border - i.e. splenomegaly is present.

Percussion for a fluid level Percuss from the midline to the flanks on both sides. If you detect a dull note (or from palpation you suspect the patients abdomen is distended) this may represent a fluid level & you may want to examine for "shifting dullness & fluid thrill" (This will be further explained in the CSEC & at your attachments)

PALPATION

Before you palpate the patients abdomen ask if they are in any pain and if so leave this area to last. Also ask the patient to inform you if they experience any pain during the examination

CONTI. Place your extended hand - flat

on the patients abdomen. Gently press the patients abdomen by flexing the meta-carpal joints (MCPs). Slowly progress around the nine regions. Observe the patients face for any sign of discomfort.

During this part of the examination you are assessing for:

i) Tenderness

ii) Guarding: This is an involuntary reflex contraction of the muscles of the abdominal wall overlying an inflamed

viscus and peritoneum. It produces local rigidity and indicates localised peritonitis. The spasms of the muscle will prevent palpation of the underlying viscus. Guarding is seen for example in acute appendicitis

iii) Rigidity: Generalised or “board like” rigidity is an indication of generalised peritonitis. It is an extension of guarding with involvement of all the muscles of the abdominal wall.The patient may also manifest “rebound tenderness” where deep palpation is associated with pain but even more pain when the palpating hand is suddenly withdrawn.

Deep palpation Usually with one hand (however some doctors find it useful to use two hands) the examiner should now press deeper in all nine regions (you may want to spend a little extra time in the epigastric region to feel for any pulsation). This is used to detect for any masses and more deep seated pain. If you do detect a mass then assess for:

location size presence of tenderness surface characteristics consistency & whether it is pulsatile?

You should now palpate for the lower edge of the liver.

In a normal abdomen you should not be able to palpate this lower edge.

It is important to note that the liver moves inferiorly during inspiration.

Therefore start by placing the radial aspect of you index finger over the patients RIF region –

ask the patient to breath in & out. During the expiratory phase, move your fingers in to position & during inspiration hold your finger steady. With every breath gradually work your way up to the patients right costal margin.

You are feeling for the edge of the liver hitting your finger. If you do feel a liver edge you then should ascertain

The distance from the liver edge & the costal margin (best measured in centimeters)

Presence of nodule(s)? Tenderness present? Consistency (hard or soft?)

Palpation for the lower edge of the spleen

In adults the spleen tends to enlarge diagonally from the left hypochondrium to the RIF. You should ask the patient if they can turn slightly on to their right side. With your non-examining hand, you should also splint the left lower ribs from behind, to fix the spleen, making it more easy to palpate anteriorly.

You should now palpate for the lower edge of the liver.

In a normal abdomen you should not be able to palpate this lower edge.

It is important to note that the liver moves inferiorly during inspiration.

Therefore start by placing the radial aspect of you index finger over the patients RIF region –

ask the patient to breath in & out. During the expiratory phase, move your fingers in to position & during inspiration hold your finger steady. With every breath gradually work your way up to the patients right costal margin.

You should now palpate for the lower edge of the liver.

In a normal abdomen you should not be able to palpate this lower edge.

It is important to note that the liver moves inferiorly during inspiration.

Aorta

Palpate between umbilicus and xyphoidUsing your opposing thumb and finger,

palpate the pulsation slightly L of midline. Normal is 2.5 to 4 cm in width.

Assess width Lateral pulsation – suggestive of aortic

aneurysm

Special Procedure

Rebound tenderness)

Blumberg’s sign) – hold your hand 90º or perpendicular to the abdomen. Push down slowly and deeply; then lift up quickly. A normal response is no pain. Pain is indicative of appendicitis.

Using a glucometer

INTRODUCTION and INFORMED CONSENT

HAND WASHING Both student and patient

EQUIPMENT Glucometer(with working

batteries!) Testing sticks (that are in

date!) & calibrating chip Cotton wool, gloves Lancet, sharps bin

Each box of testing strips should have a ‘chip’ inside. This is to calibrate the glucometer with the testing sticks, therefore inset this chip prior to switching on the glucometer.

After switching on the glucometer, you should see the machine go through a few checks. On the digital readout, you will get a prompt to insert a glucometer test strip. Make sure you insert this strip the right way round

Following this you will hear a beep and observe another visual prompt to obtain a blood sample.

In order to increase your chances of getting a better ‘droplet’ of blood, ask the patient to squeeze their finger, making sure that this is below the level of their heart. Warming the patient’s hands in lukewarm water may also increase blood flow.

Generally we recommend obtaining a sample of capillary blood from the side of the finger rather than the pulp of the digit. Prior to taking the sample ask the patient to clean the area with cotton wool. Lancets come in all shapes and sizes. Some lancets are spring loaded, if this is the case prime the lancet. Hold over the lateral border of the selected digit and ‘fire!’ Initially you might not see any blood. If this is the case encourage the patient to ‘milk their finger’ to draw more blood. This will usually produce a droplet of blood for testing. If not you may have to repeat the process on a different finger. Generally have the patient tilt their finger ‘upside down’ so a nice droplet will form. Now introduce the testing strip to the droplet of blood. The strip will absorb the blood and a bleep will sound when you have added enough.

After this bleep, the glucometer will analyse and process the sample. Ask the patient to press the lanced area with a piece of cotton wool. After a few moments you will hear a further bleep and the glucose monitor should display the result.

Finally clean up your mess! Sharps in the sharp bin and non sharp clinical waste into a clinical waste bag.

Thank the patient. Following this, record the result