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GI Examination 1. Introduce, ask permission and wash hands 2. Patient lying flat and undress nipples to knees 3.

General look: High/ Low body mass Low-: -loss of appetite, dysphagia, vomiting, ageusia (loss of taste). -Weight loss despite normal appetite suggests thyrotoxicosis or malignancy. High: -hypothyroidism, fluid retention if rapid (due to congestive heart failure or ascites, drugs, or steroids, fat.

State of hydration Fever Distress Pain

dd- oesophagitis, GORD, gastritis, peptic ulcer, pancreatitis, appendicitis, renal stones, gall stones, constipation, diverticulitis diverticulum, IBS or retrosternal pain.

Muscle wasting Peripheral oedema Anaemia Abdominal distension Jaundice

Due to haematemesis- vomiting blood, or melaena Ascites Due to increased bilirubin deposition. Breakdown product of Hb. Yellow discolouration of skin and sclera. Causes are pre-hepatic, hepatic, post-hepatic

4. Hands Clubbing Enlargement of CT in the terminal phalanges of the digits. Alteration of nail bed angle Whitening of nail bed due to hypoalbuminemia Spoon shaped nails Transverse white lines seen in hypoalbuminaemic states Bluish discolouration of normal lanulae Redness of palms UC/CD/Coeliacs disease

Leuconychia

Koilonychia Muehrckes lines Blue lanulae Palmar erythema

Malnutrition, malabsorption, hepatic disease, nephritic syndrome Chronic anaemia- usually Fe deficiency Severe liver cirrhosis Wilsons disease Chronic liver disease, pregnancy, OCP, RA, polycythaemia, thyrotoxicosis Alcoholic liver disease or manual workers, DM

Dupuytrens contracture

Thickening and fibrous contraction of the palmar fascia

GI Examination 5. Flapping tremor/ Asterixis. Sign of liver failure i.e. hepatic encephalopathy presents with confusion and drowsiness. 6. Upper limb Bruising -Hepatocellular damaging and resulting coagulation disorder -Thrombocytopenia due to hypersplenism. -Marrow suppression with alcohol Possibly a sign of thrombocytoenia Late manifestation of malnutrition, or chronic liver disease Early cholestasis

Petechiae Muscle wasting

Pin prick bleeds that dont blanche with pressure. Overlying skin hanging loosely

Excoriations AV fistulae or haemodialysis catheters

Scratch marks suggests pruritis

7. The axillae Lymphodenopathy Acanthosis Nigracans

Thickened, blackening of the skin

Intra-abdominal malignancy

8. Face: Eyes and Mouth Eyes: Jaundice Yellow discolouration of sclera. Ask to pull down lower eyelid and ask patient to look down. Pallor of conjunctivae Hb breakdown product (bilirubin) deposition Bleeding- oesophageal varices or insidious and occult bleeding from a colonic polyp. Malabsorption of Fe, folate, Vit B12 e.g. alcoholism, illness, Suggest prolonged cholestasis i.e. blockage of bile drainage likeliest cause is primary biliary cirrhosis. Sign of thiamine, vit b12 and Fe deficiencies IBD, Coeliacs, Reiters syndrome Pregnancy, scurvy,

Eyes: Anaemia

Eyes: Xanthelasma

Raised yellow lesions build up of lipid under the skin

Mouth: Angular stomatitis Gums Breath

Tongue

Reddening and inflammation at the cornea of the mouth Look for ulcers -and hypertrophy -Fetor hepaticus= sweet smelling -Ketosis = sickly sweet- pear drop -Uraemia = fishy smell -Glossitis smooth erythematous swelling of tongue

-Fe, folate, vit b12 deficiencies

GI Examination - Macroglossia enlarged tongue -Amyloidosis, hypothyroidism, acromegaly,downs syndrome and neoplasia -Premalignant condition caused by smoking, poor dental hygiene, alcohol, sepsis, and syphilis.

-Leukoplakia- white coloured thickening of the tongue and oral mucous membranes

9. Neck - Cervical and supraclavicular LNs - Virchows node- supraclavicular node on the left hand side, if enlarged is Troisiers signsuggestive of gastric malignancy 10. Inspection of Chest Spider naevi Gynaecomastia Telangiectasia. More than 5 pathological and suggestive of Enlargement of breast tissue in males. Increased circulating oestrogens and decreased testosterone production leading to feminisation in men. Increased oestrogen production in men Chronic liver disease Chronic liver disease, Pituitary disease, Drugs, hypothalamic disease. Klinefelters, Thyrotoxicosis Chronic liver disease

Loss of axillary hair

11. Inspection of the abdomen Scars Abdominal distension Focal swellings Prominent vasculature

Fat. Fluid. Fetus. Faeces. Flatus. Flipping big tumour Ascites is fluid in the peritoneal cavity -Milk the veins to determine direction of blood flow within them. -Inferior flow suggests superior vena cava obstruction -Superior flow of blood suggests inferior vena cava obstruction Flow radiating out from the umbilicus (caput medusa) indicates portal vein HTN (porto-systemic shunting occurs through the umbilical veins which become engorged. A pulsatile, expanding mass in the epigastrium may be an AAA. Usually seen in thin, fit, young individuals. A very obvious peristalsis seen as rippling movements beneath the skin and may indicate intestinal obstruction. Caused by changes in the tension of the abdominal wall. Seen in ascites -Cullens sign discolouration at the umbilicus and

Obvious pulsations Peristaltic waves

Striae Skin discolouration

GI Examination surrounding skin -Grey-Turners sign- discolouration at the flanks. BOTH indicate retroperitoneal blood, usually seen in pancreatitis May be from large bowel, small bowel or renal tract. -Colostomy usually in LIF. Bag cont. Semi-solid to formed stool -Ileostomy usually in RIF. Bag cont. Semi-formed/iquid stool. -Urostomy usually in RIF. Bag cont urine -Nephrostomy usually at the flank and temporary.

Stomas/Fistulae

12. Palpation 12.1 Light palpation

GI Examination -Squat by bed so patients abdomen is at eye level. Watch patients face. Ask if there is any pain and start away from pain. Palpate four quadrants with finger tips and palmar aspects of fingers. -If there is pain check if it is when you are pressing down, or letting go i.e. rebound tenderness -If abdominal muscles seem tense generalised or local? Ask patient to bend knees a little to relax the abdominal muscles. An involuntary tension in the abdominal muscles to protect the underlying organs is called guarding. Peritonitis pain on light palpation, rebound tenderness, involuntary guarding, pain recurring with slight movement of the examining hand, absent bowel sounds. 12.2 Deep palpation - Palpate with more pressure. Check for abdominal masses or structural abnormalities. If mass is palpated describe exact location, size, shape, surface, consistency, mobility, movement with resp, tenderness, and whether it is pulsatile or not. 13. Palpating abdominal organs 13.1 Liver Normal liver extends 5th IC space on right of midline to costal margin. -Using R hand start palpating in the RIF to ribs. Keep Index finger in line with costal margin. With each inward breath palpate, feel for liver edge. -Note cm size, nature of liver edge- smooth or irregular? Tenderness? Pulsatile liver? BIG liver: Alcohol, RHF, Neoplasia (primary, met, myeloproliferative disorders,leukaemia, lymphoma), Chronic liver disease, Infections, Amyloidosis, Biliary obstruction, Haemochromotosis. 13.2 Gallbladder Lies in the right costal margin at the tip of the 9th rib at the lateral border of the rectus abdominis. Normally only palpable if enlarged due to biliary obstruction or acute cholecystitis. -Felt as a bulbous, focal, rounded mass which moves with inspiration. -Murphys sign Sign of cholecystitis pain on palpation over the gallbladder during deep inspiration. Only positive if there is no pain on the left at the same position. -Courvoisiers law in the presence of jaundice, a palpable gallbladder is probably NOT caused by gallstones. 13.3 Spleen Roughly size of clenched fist. Largest lymphatic organ. Normally hidden behind left costal cartilages and is impalpable. Enlargement occurs downwards extending into LUQ. -L hand goes under the patient to support rib cage posterolaterally. Palpate with R hand. -Start palpation just below umbilicus in the midline and work towards the left costal margin asking patient to take a deep breath in and feel for movement of spleen. -The inferior edge of spleen has a notch centrally- differentiates spleen from other masses. -If spleen is felt measure distance to the costal border in cms. -If spleen is NOT felt, roll patient onto their right side and repeat.

GI Examination Splenomegaly -Massive (>8cm): malaria -Moderate (4-8cm) portal HTN secondary to cirrhosis -Mild: infectious hepatitis, portal HTN secondary to cirrhosis, RA, sarcoidosis 13.4 Kidneys -Bimanually ballot 13.5 Aorta -Palpated in the midline above umbilicus, position fingers of each hand either side f the outermost palpable margins. Measure distance between fingers. Normal is 2-3cm. 14. Percussion Determines size and nature of enlarged organs or masses. Testing for shifting dullness- ascites Eliciting rebound tenderness

14.1 Shifting dullness -Percuss centrally laterally until dullness is detected (air-fluid level). Keep finger there and ask the patient to roll onto opposite side (if dullness detected on R, patient rolls onto L). Hold position for 30sec and repeat percussion moving laterally central. -If dullness is truly an air-fluid level, the fluid will move by gravity away from the marked spot and the previously dull area will be resonant. 15. Asculatation 15.1 Bowel sounds -Normal- low-pitched/ gurgling/intermittent -High-pitched tinkling- suggestive of partial or total bowel obstruction -Absent sounds- for 2 mins suggesting complete lack of peristalsis i.e. paralytic ileus or peritonitis. 15.2 Bruits Turbulent flow- AAA