Table 7: Gastrointestinal Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| General Inspection | ||||||
| Contour + symmetry of entire abdomen and specific areas:periumbilical Bulging flanks | Identify masses, bulging, asymmetry, distension, herniation Ascites | Appropriate draping, patient positioning and lighting to ensure relaxation of abdomen | Tumour, organomegaly, ascites, pregnancy, bowel obstruction, obesity/cachexia | Distension as a sign of bowel obstruction +ve LR 9.6 McGee, 2001, p623. Bulging flanks: +ve LR 1.9 –ve LR 0.4 McGee, 2001, p607. | 3 | 4 |
| Skin: colour, lesions, scars, striae | Identify signs of various abdominal pathology | Surgical scars Ecchymosis Obesity Ostomy | Cullen and Turner’s signs are rare McGee, 2001, p589-90. | 3 | 4 | |
| Dilated veins | Stigmata of liver disease | Portal hypertension | Spider nevi +LR 4.7 Dilated veins in the setting of jaundice predictive for hepatocellular disease: +LR 17.5 McGee, 2001, p85. | 3 | 4 | |
| Pulsations | Identify vascular pathology | Aortic pulsation, possible aneurysm | 3 | 4 | ||
| Visible movement | Identify pregnancy visible peristalsis | Observe movement with respiration or spontaneously | Fetal movement Bowel obstruction Lack of movement suggests peritoneal irritation | Visible peristalsis +ve LR 18.8 McGee, 2001, p623. McGee, 2001, p620. | 1 | 4 |
| General Auscultation | ||||||
| Bowel sounds | Detecting bowel pathology | Use diaphragm auscultate anywhere for any duration McGee, 2001, p636. All 4 quadrants Orient, 2000, p431. | For Dx of small bowel obstruction Peritonitis | +ve LR 5 McGee, 2001, p623. McGee, 2001, p620. useless, Orient, 2000, p432: presence or absence of sounds is not diagnostic except……. | 3 | 4 |
| Bruits | Vascular pathology, Aortic Renovascular (advanced skill identification of flow in transplanted kidney) | Midline, between xiphoid and epigastrium Epigastrium/ both flanks | Diagnosis of AAA Detection of atherosclerosis Diagnosis of renovascular hypertension | McGee, 2001, p635. : not useful LR +ve 38.9 McGee, 2001, p635. Turnbull, 1995. | 3 | 4 |
| Rubs | See Liver | |||||
| Hums | See Liver | |||||
| General Percussion | ||||||
| Tenderness | Tenderness on percussion e.g. RLQ with appendicitis | Recognize peritonitis | 3 | 4 | ||
| Tympany and dullness | Identify abnormal areas of tympany and dullness | Percuss 4 quadrants of abdomen | Detect abnormal masses in abdomen Suprapubic dullness for bladder distension/pregnancy | Unreliable McGee, 2001, p604. | 2 | 3 |
| Shifting dullness See ascites | ||||||
| General Palpation | ||||||
| Light and deep Detecting rebound + guarding | Identify AAA > 3 cm Detect masses, organomegaly or tenderness Identify causes of acute abdominal pain | Identify pulsatile mass, usually in epigastrium McGee, 2001, p606. Abdominal relaxation, systematic approach e.g. clockwise from RUQ; light palpation first, then deep; leaving painful areas to last | To detect tumour, mass, peritonitis Bowel obstruction Appendicitis Peritonitis | +ve LR 7.6 McGee, 2001, p603. Palpation specifically directed at AAA will detect most aneurysms that require surgery, but will not rule out. Lederle, 1999. Not useful McGee, 2001, p623. McBurney’s point +ve LR 3.4 McGee, 2001, p621. Rigidity +ve LR 5. 1 McGee, 2001, p620. | 3 | 4 |
| Ascites | Bulging flanks Shifting dullness Fluid wave Flank dullness Puddle test | Described in McGee, 2001, p604-05. | Presence/absence of fluid in the abdomen | +ve LR 1.9
-ve LR 0.4 McGee, 2001, p607. Absence of edema argues against abdominal distension being ascites -ve LR 0.2 McGee, 2001, p607 The strength of the evidence is limited by lack of information regarding volume of ascites being detectable by different techniques See also Williams, 1992. Shifting dullness +ve LR 2.3 –ve LR 0.4 McGee, 2001, p607. Fluid wave +ve LR 5 -ve LR 0.5 McGee, 2001, p607. Flank dullness -ve LR 0.3 +ve LR Not useful McGee, 2001, p607. | 2 | 4 |
| Liver Examination | ||||||
| Inspect: Obvious organomegaly and stigmata of liver disease, ex: Spider nevi, palmar erythema, dilated abdominal veins, jaundice | Stigmata in setting of jaundiced patient | McGee, 2001, p85. | 2 | 4 | ||
| Percussion | Size, span of liver | Percuss upper and lower liver borders, use in conjunction with palpation to establish span | Establish liver size | Based on percussion, clinicians’ estimates disagree on liver size by 8 cm Blendis, 1970. Absolute size of liver underestimated McGee, 2001, p596. | 3 | 4 |
| Palpation | Establish liver edge | Abnormal texture/contour indicates pathology | If liver edge is detectable below costal margin +ve LR is 233 –ve LR 0.5 McGee, 2001, p597. 50% of livers that extend below CM are not palpable McGee, 2001, p597. | 3 | 4 | |
| consistency | Cirrhosis | Likely influences ability to palpate : cirrhotic livers that extend below costal margin are palpable 95% of time McGee, 2001, p597-8. | 1 | 2 | ||
| tenderness | Inflammation | 2 | 2 | |||
| (Advanced skill to identify pulsatility) | Sign of tricuspid regurgitation | In patients with pansystolic murmur and pulsatile liver +ve LR 3.9 for moderate to severe TR | 1 | 1 | ||
| Auscultation Rub Hum | Inflammation of liver | Auscultate over liver | Hepatoma, liver mass Portal hypertension | 10% of patients with liver mets had rub McGee, 2001, p636. | 1 | 2 |
| Gallbladder Special tests | ||||||
| Murphy's sign | Cholecystitis | Tender gallbladder indicates acute choleycystitis | +ve LR 2.0 (modest) McGee, 2001, p622. | 3 | 4 | |
| Courvoisier’s sign | Enlarged gall bladder | Palpable non-tender gallbladder in jaundiced patient | Extrinsic gall bladder obstruction | +ve LR 26 (99% spec) McGee, 2001, p601. | 1 | 3 |
| Spleen Examination | ||||||
| Inspection | See general | |||||
| Palpation | Splenomegaly | +ve LR 9.6 -ve LR 0.6 McGee, 2001, p597. If palpable it’s there If it’s not palpable, might be there +ve LR 2.0 McGee, 2001, p600-1. | 3 | 4 | ||
| Percussion | Percussion of Traube’s space Castell’s method | +ve LR 1.9 –ve LR 0. 7. McGee, 2001, p597. (no consensus on the relative merits of these 2 tests) If percussion is +ve, might be real, if –ve could still be there | 3 | 4 | ||
| Kidney | ||||||
| Inspection | (advanced skill: polycystic kidneys in children ) | Advanced skill | ||||
| Percussion | Renal tenderness | Costophrenic angle tenderness | 2 | 4 | ||
| Palpation | Renal mass | 2 | 4 | |||
| Rectal Exam | ||||||
| Inspection | Identify hemorrhoids, fissures, foreign bodies, ulcers, skin tags, tumours | Left lateral position | 3 | 4 | ||
| Palpation | ||||||
| Anus + Rectal mucosa Tenderness Masses Sphincter tone | Detect:Inflammation tumours neurologic deficit (spinal) | 2% of patients with pelvic mass and inflammation have rectal tenderness Dixon, 1991. | 2 | 4 | ||
| Prostate Tenderness Irregularity of surface Asymmetry | Detect: Prostatitis Tumour | Detection of prostate tumour | Orient, 2000, p478. | 2 | 4 | |
| Inguinal | ||||||
| Inspection Bulging masses | Identify hernias Lymph nodes, masses aneurysm | Examine Supine Standing Coughing/bearing down | 2-3 | 4 | ||
| Auscultation of femoral artery | Identify bruits | Listen for bruits | 3 | 4 | ||
| Palpation | Identify pulsations, tenderness, masses, and reducibility | 3 | 4 | |||
References
- Blendis LM, et al. Observer variation in the clinical and radiological assessment of hepatosplenomegaly. Br.Med.J. 1970 Mar 21;1(5698):727-730.
- Dixon JM, et al. Rectal examination in patients with pain in the right lower quadrant of the abdomen. BMJ 1991 Feb 16;302(6773):386-388.
- Lederle FA, et al. The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA 1999 Jan 6;281(1):77-82.
- McGee SR. Evidence-based physical diagnosis. Philadelphia, PA: Saunders; 2001.
- Orient JM, Sapira JD. Sapira's art & science of bedside diagnosis. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
- Sullivan S, et al. The clinical estimation of liver size: a comparison of techniques and an analysis of the source of error. Br.Med.J. 1976 Oct 30;2(6043):1042-1043.
- Turnbull JM. The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension? JAMA 1995 Oct 25;274(16):1299-1301.
- Williams JW,Jr, et al. The rational clinical examination. Does this patient have ascites? How to divine fluid in the abdomen. JAMA 1992 May 20;267(19):2645-2648.
- Zoli M, et al. Physical examination of the liver: is it still worth it? Am.J.Gastroenterol. 1995 Sep;90(9):1428-1432.