3 Gastrointestinal Examination Notes

Jack’s Notes CLINICAL SKILLS
GASTROINTESTINAL EXAMINATION
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INTRODUCTION & CONSENT

• Patient introduction
• Consent
POSITIONING
• Lying flat on the bed with a pillow, chest and abdomen exposed
o Relaxes abdominal muscles and facilitates palpation
GENERAL APPEARANCE
• Appears well/ unwell
• Fatigue/ Malaise - Hepatitis
• Drowsy/ obtunded/ Disorientated– Hepatic Encephalopathy,
Acute/Fulminant Hepatitis
• Discomfort/ Pain
o Rolling around on bed unable to get comfortable – Renal Stone
o Pain out of proportion to signs – Ischaemic bowel
o Lying very still – peritoneal irritation
• Body Habitus (Weight/ Height and BMI)
o Cachectic – Liver Failure, Cancer, Malabsorption
o Underweight – Malnutrition
o Obese – Fatty Liver
• Colour
o Pale – Anaemia (haemolytic, bleed, malabsorption)
o Jaundice Pre-hepatic, Hepatic, Obstructive
o Bronzing – Haemochromatosis
§ Haemosiderin stimulates melanin production
o Skin pigmentation – Malabsorption
§ Sunkissed Addison’s type pigmentation of nipples, palmar
creases, pressure areas, mouth
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• Rash
o Malignancy
o Autoimmune
o Acanthosis Nigricans – brown-black velvety elevations of epidermis
in axillae and neck
§ DM mainly
§ GI Carcinoma (rarely)
§ Lymphoma
o Peutz-Jeghers Syndrome – heredity increased risk of harmatomatous
polyps in GI
§ Freckle-like spots around mouth and on buccal mucosa, and
fingers/ toes.
• Discrete, brown-black
lesions)
o Dermatitis Herpetiformis – pruritic
vesicles on knees, elbows, buttocks
§ Coeliac Disease
• IBD Skin Manifestations
o Pyoderma gangrenosum
§ Painful pustules/nodules become
ulcers that progressively grow.
NOT infectious. Form of
Neutrophilic dermatoses
§ Also associated with other
autoimmune disorders
o Erythema Nodosum
§ Associated with other diseases,
drugs and pregnancy
o Clubbing
o Mouth (aphthous) ulcers Erythema Nodosum
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Dermatitis Herpetiformis
Acanthosis Nigricans 5
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VITAL SIGNS
• HR
o Rate
§ Tachycardia (infection/ pain)
§ Bradycardia
o Rhythm
§ Regular
§ Irregular
o Volume/ Character
§ Collapsing (Bounding) – severe anaemia
§ Weak
• RR
o Tachypnoea
o Shallow breathing
• BP
o Hypertensive
o Hypotensive
o Postural variations - shock
• Temperature
o Afebrile
o Febrile – acute viral hepatitis, cholecystitis, ascending cholangitis,
appendicitis, IBD, diverticulitis, pancreatitis, gastroenteritis, e.g.
o Hypothermic – severe sepsis
• BMI
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HANDS/ NAILS
PALMS
• Temperature
o Warm
o Cool
o Sweaty
o Dry
• Palmar erythema
o Reddening of the palms, mainly thenar and hypothenar eminences,
due to increased vasodilation, triggered by accumulated peripheral
oestrogens that has a proliferative effect on endometrial capillary
density, and thus is thought to effect vessels in the palm in a similar
manner
§ Chronic liver disease/ Cirrhosis
§ Thyrotoxicosis
§ Rheumatoid Arthritis
§ Polycythaemia
• Pallor of Creases
o Anaemia – haemolytic, slow
bleed, malabsorption, chronic
disease
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Dupuytren’s Contracture
o Visible and palpable thickening of
Palmar Fascia mainly impacting
index finger causing permanent
flexion. Palmar fascia contain
abnormally large amounts of
xanthine and this may be related
to its pathogenesis.
§ Chronic alcohol use
§ Genetic/ Family Hx
§ Intense labour work
• Tremor
o Enhancement of normal physiological tremor caused by a trigger. It
occurs due to the oscillation of agonist and antagonists muscle groups
due to the combined effects of firing motor neurons, synchronisation of
muscle spindle feedback, and mechanical properties of the limb.
Enhanced physiological tremor is caused by increased catecholamines
which increase the twitch force of motor units
o Alcoholism – withdrawal (to other drugs as well)
o Hyperthyroidism, hypoglycaemia, anxiety/fear, sympathomimetics
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• Hepatic Flap (Asterixis)

o Ask patient to raise arms at 90o with wrists extended and palms straight
facing forward for 15 seconds; push against palms to maintain
extension
o Observe sporadic bilateral nonsynchronous flexion/ extension of
wrists and metacarpophalangeal joints –
distinguish from general tremor
§ Hepatic Encephalopathy
§ Cardiac/ Respiratory Failure – CO2
retention
§ Renal Failure
§ Hypoglycaemia, Hypokalaemia,
Hypomagnesemia, barbiturate
intoxication, stroke
o Thought to be due to the interference with the
inflow of joint position sense of information to
the reticular formation in the brainstem due to
encephalopathy damage. Dysfunction in the
basal ganglia, thalamocortical loop, and slowed
oscillations in the primary motor cortex. Causing
failure of diencephalic motor centres regulating
muscle tone between agonist vs antagonists.
NAILS
• Clubbing
o Increased peripheral digital vasodilation and altered megakaryocyte
and platelet function and aggravation
o Chronic Liver Disease/ Cirrhosis
o Inflammatory Bowel Disease Terry Nails
o Coeliac Disease
• Leukonychia
o Whitening of nails – can be
§ Partial: punctuate, longitudinal or
striate/ transverse
§ Complete: Terry’s Nails – complete
white nail with distal pink/brown rim at
the top of nail bed
o Usually thumb and index nail most commonly
involved
§ Hypoalbuminaemia
• Compression of blood flow due
to increased fluid in ECF from micro-oedema
§ Chronic Liver Disease/ Cirrhosis
§ Many diseases – CKD, HF, DM, Hyperthyroidism, trauma,
chemotherapy
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• Muehrcke’s Lines
o Transverse white lines on nails
§ Hypoalbuminaemia – localised oedematous state in nailbeds
cause increased pressure leading to blanching
• Blue Lanulae
o Wilsons Disease
• Koilonychia (Spoon Nails) – dry, brittle, spoon shaped nails; loss of

longitudinal and lateral convexity of the nail; associated with soft nail bed
matrix causing weakness; potentially due to poor perfusion, disrupting nail
bed CT regeneration
o Iron deficiency
o Soft nails from chronic occupational exposure
o Fungal infection, Raynaud’s, Psoriasis
Koilonychia
Blue Lanulae
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ARMS
• Ecchymosis/ Petechiae
o Thrombocytopenia/ Reduced Clotting Factors in
Chronic Liver Disease
o Obstructive Jaundice – restricting absorption of fatty
vitamins (VitK)
o Splenomegaly causing hypersplenism resulting in
hyper sequestration of platelets
• Scratch Marks/ Jaundice

o Icterus is thought to be caused of retention of an unknown substance
that is normally excreted with bile’ not by the bile salt retention itself
§ Jaundice (primarily Cholestatic)
§ Primary Biliary Cholangiopathy – can be a first sign
• Acanthosis Nigricans - brown-black velvety

elevations of epidermis in axillae and neck –
T2DM, Obesity, Metabolic Syndrome/NASH,
Cushing’s, Acromegaly, PCOS, GI malignancy
(rare)
• Dermatitis Herpetiformis – coeliac disease –

rare but persistent immunobullous disease.
Symmetrical distribution, lesions most commonly on the scalp, shoulders,
buttocks, elbows, knees. Characterised by extremely itchy papules and
vesicles on normal or erythemic skin. Blisters are often eroded and crusted.
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• Spider Naevi
o Oestrogenic vasodilation of central arteriole
from which radiate numerous small vessels
that look like spider legs. Range from up to
0.5cm in diameter
§ Excess oestrogen – known to have
dilating effect on spiral arterioles in
endometrium thus this mechanism is
thought to mimic
o Distribution is in the area drained by SVC –
arms, neck, chest.
Spider Naevi
o Can occasionally bleed
o Blanching from pressure in centre arteriole
o >3 is abnormal
§ Cirrhosis – relating to severity (alcohol, hepatitis)
§ Pregnancy
§ Thyrotoxicosis (rare)
• Muscle Wasting/ Proximal Myopathy

o Malabsorption
o Chronic Liver Disease
o Alcoholism
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FACE
EYES
• Xanthelasma
o Sharply demarcated yellowish deposits of cholesterol in the dermis
§ Dyslipidaemia
§ Familial hypercholesterolaemia
§ Primary Biliary Cholangiopathy
• Scleral Jaundice
o Yellowing of the sclera due to jaundice. Often icterus before skin.
§ Jaundice – Pre-Hepatic, Hepatic, Obstructive
• Iritis – inflammation of iris
o Extraintestinal manifestation of IBD
• Uveitis – inflammation of uvea (vascular layer of eye) – includes iris, ciliary
body and choroid
• Episcleritis – inflammation of the episcleral, the tissue just under the outer
skin of the whites of the eye
• Bitot Spots – severe Vitamin A deficiency due to malabsorption/malnutrition
• Kayser-Fleischer Rings
o Dark golden brownish-green ring that encircle the iris due to copper
deposition in the inner surface of cornea (Descemet’s layer). Copper is
deposited in complexes with sulphur giving its characteristic
appearance.
§ Wilson’s Disease
Iritis
Uveitis
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Kayser-Fleischer Rings Bitot Spots
Uveitis
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CHEEK
• Parotid Gland Enlargement
o Ask patient to clench masseter. Palpate masseter and feel for enlarged
parotid gland behind the masseter and in front of the ear. Normally, the
parotid gland cannot be palpated; only in disease.
§ Alcoholism – fatty deposition in parotids due to altered lipid
metabolism from chronic alcoholism. Can occur in absence of
Liver Disease/ Cirrhosis
§ Other causes: Mumps, other infections, cysts, tumours, salivary
obstruction
LIPS
• Angular Stomatitis (or Cheilitis – inflammation of lips)
o Inflammation and cracking of the corner of the mouth (stomatitis)/ lips
(cheilitis) – maculopapular and vesicular lesions
§ Deficiencies in Iron, Folate and B12 due to reduced nutrients
required for cell turnover of keratinocytes and mucosal cells
§ Extraintestinal Manifestation of IBD (Crohn’s)
§ Other causes: contact dermatitis from dribbling saliva, dry lips,
infection (impetigo, candida, staph, cold sores (herpes))
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• Brown-Black Lesions around mouth and Buccal Mucosa (Perioral

Pigmentation)
o Peutz-Jeghers Syndrome
§ Hereditary increase likelihood of harmatomatous polyps in GI
Telangiectasia
• Telangiectasia around Mouth

o Hereditary Haemorrhagic Telangiectasia
§ Mutation in TGF-β causing
structural defects in vessel walls
leading to postcapillary pooling
and the formation of small and
large arteriovenous shunts.
Common cause for epistaxis.
• Presence of mouth telangiectasia can indicate
arteriovenous shunts in GI and potential cause of
chronic GI Bleed causing Iron Deficiency Anaemia
• BCC, SCC, vesicles on lips
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• Observe for the Parotid Duct opening by pushing the tongue out of the way,
adjacent to 2nd molar
o The Submandibular gland may be palpable in Chronic Liver disease
or if there is a calculus
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TONGUE
• Black Tongue (Lingua nigra)
o Elongation of papillae over the posterior aspect of tongue and appears
dark brown-black due to excess keratin
o Benign – mainly aesthetic issue
• Geographical Tongue
o Slowly changing red rings and lines that occur on the surface of the
tongue
o Can be sign of Vit B12 deficiency and seen in anaemia
o Occurs in psoriasis, T1DM, RA, Atopic dermatitis, hormonal
disturbances
• Leucoplakia
o White coloured thickening of mucosa of tongue and mouth
o Caused by
§ Poor dental hygiene
§ Carcinoma – early malignancy sign
§ Smoking
§ Oral lichen planus
§ Infection – Candidiasis, Sepsis
§ Syphilis
§ Idiopathic
• Atrophic Glossitis
o Smooth appearance of the tongue which may be erythematous
o Occurs due to atrophy of papillae and in later stages there may be
shallow ulceration
o Nutritional deficiencies – tongue is sensitive due to rapid cell turnover
§ Iron, folate, Vitamin B group
§ Alcoholics
o Elderly for unknown reasons
• Macroglossia
o Down syndrome
o Acromegaly, Hypothyroidism
Black Tongue
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Leucoplakia
Geographical
Tongue
Glossitis
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MOUTH, GUMS & TEETH

• Gingival Hypertrophy
(mainly Crohn’s)
o Leukemia
• Gum Bleeding/ Mucosal Petechiae

• Fetor Hepaticus
o Late sign of severe Liver Failure
(breath of death) due to Portal HTN
where portosystemic shunting
allows thiol, methylmercaptans
(derived from methionine AA),
ketones and ammonia to pass Receding Gums
directly into the lungs without being
metabolised by liver – resulting in
sweet, faecal smell
• Mouth Ulcers (Aphthous Ulcers)

o Painful mucosal ulcers in
nonkeratinized areas of mouth.
Mechanism not known,
multifactorial and may involve innate/humoral immune responses
o Leukemia
o Infection – Candida, Herpes simplex, EBV, Varicella, HIV
o Stress and Trauma (biting lip)
o Iron deficiency, Folate and VitB12 def, malnutrition
o Food and Toothpaste hypersensitivity
o Drugs – chemotherapy, steroids, methotrexate
• Receding Gums
o Periodontal disease
o Overbrushing
o Scurvy
• Poor dentition
• Infection – tonsilitis, pharyngitis, Candidiasis
e.g.
Tonsillitis
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Pharyngitis
Tonsillitis – Kissing Tonsils
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NECK & CHEST

• Cervical Lymph Nodes
o Enlarged in infection of
mouth/ pharynx or
oropharyngeal malignancy
• Supraclavicular Lymph Nodes
o Enlarged left
supraclavicular nodes
(Virchow’s Nodes)
secondary to GI
malignancy
o TB in developing countries
o Ask patient to shrug
shoulders and palpate
subclaclavicuarly
• Gynaecomastia
o Enlargement of breast tissue in males
o Due to Chronic Liver Disease (oestrogen excess) or medications
(spironolactone, e.g.)
• Spider Naevi
o >3 on chest is abnormal.
o Mechanism described above
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ABDOMEN
INSPECTION
Skin Inspection
• Scars
o Previous surgeries
• Presence of stoma bag, fistulae
• Visible distension
o Fat, Fluid, Foetus, Flatus, Faeces, Filthy big tumour
• Umbilicus
o Buried in fat – excess adipose
o Tense skin appearance and everted
or pointing down umbilicus – ascites
• Local swelling
• Pulsations
o AAA – pulsation in epigastrium
Visible Peristalsis
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• Prominent Veins
o Portal HTN (Caput Medusae)– blood tracks away from umbilicus
o IVC obstruction – tumour/ thrombosis/ severe ascites – blood tracks
towards heart
• Hernia
• Visible Peristalsis
o Intestinal obstruction
o Pyloric obstruction due to Peptic ulceration or tumour or congenital
• Skin lesions
o Herpes Zoster (shingles)
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• Striae
o Distention severe enough to
rupture elastic fibres in skin
§ Ascites
§ Pregnancy
§ Recent weight gain
§ Cushing’s Syndrome
• Cullen’s Sign
o Faint blue discolouration (bruising) of umbilicus from extensive
hemoperitoneum – methealbumin (haem + albumin complex) giving brown
appearance trapped in subcutaneous fat around umbilicus. The
retroperitoneum is connected to the gastro-hepatic ligament, then the
falciform ligament, and finally to the round ligament which tracks to the
abdominal wall, around the umbilicus. Thus, haemorrhage in the
retroperitoneum is able to move along these ligaments to the
abdominal wall, producing ecchymosis
§ Severe Acute Pancreatitis
§ Perforated duodenal ulcer
§ Ruptured spleen
§ Ruptured Ectopic Pregnancy
§ Extensive abdominal bleeding – AAA rupture, abdominal
trauma/surgery, perforated duodenal ulcer, HCC
• Grey-Turner Sign
o Bruising/ oedema seepage of blood and methealbumin in
subcutaneous fat of the flanks, side of chest and ribs as blood tracks
from retroperitoneal abdomen layer. A defect in the transversalis fascia
allows blood from the posterior pararenal space to move to the
abdominal wall musculature. [turn patient on side to see TURNERs sign]
• Severe Acute Pancreatitis and any of the above
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Observe for Abdominal Mass

• Kneel down to observe abdomen at eye level and ask patient to take a deep
breath in and out – observe for asymmetrical movement indicating a mass
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PALPATION
• Warm hands, gentle technique,
encourage patient to breathe gently
through mouth – palmar surface of
fingers, movement mainly through
metacarpophalangeal joints and
hand moulded to shape of abdomen
o MUST be relaxed for successful
palpation
§ Bend knees to relax
abdominal wall
• Leave tender areas LAST
• Watch patients face for pain/ wincing
and feel for rigidity – involuntary
contraction of localised abdominal
muscles upon palpation due to
peritoneal irritation/ pain. Relaxing does
not stop rigidity.
• Guarding: voluntary contraction of
entire abdominal wall to avoid pain. Ask
patient to relax and guarding of
abdominal muscles will not occur
LIGHT PALPATION
• Palpate gently and lightly in all 9 quadrants
• Feel for any masses/ lumps and rigidity
• Observe for pain
o On palpation
o Rebound tenderness pain
DEEP PALPATION
• Palpate deeply and more firmly in all 9 quadrants
• Feel for deeper masses/ defining and characterising masses
• Observe for pain
o On palpation on deeper/ more firmer pressure
o Rigidity
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REFERRED PAIN
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PALPATION OF ORGANS
• Liver
o Hands aligned parallel to the right costal margin gently begin to palpate
the liver with edge of hand
o Start at the Right Iliac Fossa and as the patient INHALES press into
the abdomen towards clavicles. As the patient EXHALES move
hand upwards 1-2cm
§ Liver should strike your fingers/ edge of hand
§ Normal to NOT feel liver and some healthy people can have
slightly palpable liver. Although usually due to hepatomegaly,
feeling it further down than normal
§ If edge is palpable, note:
• Consistency – cirrhosis
• Tender/ Non-Tender (Murphy’s/ Hepatitis)
• Regular/ Irregular
• Pulsatile/ Non-Pulsatile – Tricuspid regurgitation from R
HF
§ Normal lower border of liver sits under the costal margin
o Ptosis of the liver may cause palpable liver below costal margin
although it is NOT hepatomegaly
§ Emphysema/ COPD, Asthma or subdiaphragmatic collection
can pull liver down making its lower edge below the costal
margin despite its normal size
• Percussing Liver Span
o The normal upper margin of the liver sits at the level of 6th
intercostal space in the midclavicular line
§ Percussion will transition from resonance (lung) to dullness
(liver)
§ Continue percussing until resonance is heard again
(abdomen/air)
§ NORMAL LIVER SPAN: 8-13cm
• Clinical estimate typically 2-5cm underestimated
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• Spleen
o The spleen is also normally NOT palpable
o The spleen lies against the diaphragm, under the area of Rib 9-10 in
the Left Hypochondrium.
§ It enlarges inferiorly and medially
o TWO handed technique: Place left hand posterolaterally over the
patient’s left lower ribs and pull medially, enabling excess loose
skin fold over the costal margin. Place the right hand in the RLQ
below the umbilicus keeping fingers parallel to the left costal
margin. Palpate during inspiration.
§ Do not start palpating too close to the costal margin or you may
miss a large spleen
§ If the spleen is NOT palpable and you are EXPECTING
splenomegaly, roll the patient to their right side and repeat
palpation.
§ General rule: spleen becomes palpable as it becomes 1.5-2x
enlarged
§ Moderately sensitivity with high specificity
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• Kidney
o Bimanual Method: Patient lies flat on their back. Slide your left hand
underneath the patients back to rest the heel of the hand under
the loin. Keep the fingers free to flex at the metacarpophalangeal
joints in the area of the renal angle. It is important that the posterior
hand is placed almost as far posterior as the spine and not just the
flank.
§ The flexing fingers can push the contents of the abdomen
anteriorly – balloting the kidney
§ Place other hand over the RUQ directly opposing your hand
and fingers on the anterior abdomen
§ Ballot the kidney – flex wrist sharply upwards and feel for
upwards motion on the other hand
• NORMAL not to feel anything
• PALPABLE: kidney is pushed upwards and feels like a
swelling with a rounded lower pole and medial dent
(hilum)
o Commonest cause of enlarged Kidney is Polycystic Kidney Disease
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• Aorta
o Arterial pulsation from the abdominal aorta may be present, usually in
the epigastrium in thin healthy people
o Press firmly with pads of fingers, using both hands, just left of the
midline of the abdomen
§ Measure the width of the pulsation gently with two fingers by
aligning these parallel to the aorta and placing them at the
outermost palpable margins
• With an AAA, the pulsation is expansile (enlarges with
systole)
• >5cm it requires repair
• Bowel
o In thin people who are faecal overloaded, the sigmoid colon may be
palpable
§ Faeces can be indented by the examiners finger
§ In chronic constipation, the enlarged rectum containing impacted
stool may be felt above the symphysis pubis, filling a
variable part of the pelvis in the midline
o Rarely carcinoma of the bowel is palpable
• Bladder
o An empty bladder is not palpable
o Urinary retention and a full bladder may be palpable above the
pubic symphysis
§ Usually regular, smooth, firm and oval shaped
§ May reach as high as the umbilicus
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PERCUSSION
Percussion is used to define the size and nature of organs and masses, but it is
most useful for detecting fluid in the peritoneal cavity, and for eliciting
tenderness in patients with peritonitis.
The percussion note over most of the abdomen and out to the flanks is
resonant, due to air in the intestines.
• Ascites
o When peritoneal fluid (ascites) collects, the influence of gravity causes
the ascites to accumulate first in the flanks in a supine patient –
causing dull percussion
o Thus, relatively early sign of ascites (2L), a dull percussion is noted in
the flanks
o When ascites is gross, the abdomen distends and the flanks bulge and
umbilical eversion occurs, however, an area of central resonance will
always stay
o Percussion: Starting in the midline with the fingers pointing
towards the feet, the percussion note is tested out towards the
flanks on each side
• Tympanic Percussion
o A loud, high pitched drum like reverberation that is heard upon
percussing a cavity full of air – gaseous distension of bowel, indicating
obstruction
• Shifting Dullness
o If dullness is detected perform Shifting Dullness Test
o Mark the point of dullness in supine position and then have the
patient roll towards you. Wait 30sec-1 min for fluid to migrate and re-
perform percussion.
§ Shifting Dullness is present if the area of dullness from supine
has changed to become resonance
– the fluid has migrated down to the
other side of flanks
• Fluid Thrill
o Ask patient to place medial edges of both
palms firmly on the centre of abdomen
with fingers pointing to each other
o Flick one side of the abdominal wall with
your finger and feel for a thrill by placing
the other hand on the opposite side of the
abdominal wall
§ Only in severe ascites
Causes of ascites: cirrhosis, CHF, myxoedema, IBD,

hypoalbuminaemia (nephrotic syndrome), obstruction
from lymphoma, hepatic vein thrombosis (Budd-Chari
Syndrome) e.g.
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AUSCULTATION
• Bowel Sounds
o Place the diaphragm of stethoscope just below the umbilicus
Bowel sounds can be heard over all parts of the abdomen in
healthy people – soft, gurgling character and occur intermittently
§ Poorly localised and thus little point in listening to them in more
than one place
§ Most sounds originate from the stomach, some from the
large bowel and the rest from the small intestine
o Descriptions such as “decreased” or “increased” are meaningless
because the sounds vary depending on when a meal was last eaten
o COMPLETE ABSENCE of bowel sounds over a 4 minute period
indicates paralytic ileus – complete absence of peristalsis in a
paralysed bowel
§ Obstruction, infection, peritonitis, trauma/ surgery (Post Op),
hypokalaemia, vascular ischaemia, drugs
o TINKLING: Bowel Obstruction causes a hyperactive, louder high-
pitched sound with a tinkling quality due to the presence of air and
liquid under pressure due to a muscular propulsive reflex of the bowel
attempting to overcome the obstruction – Early ‘obstructed bowel
sounds’. Presence of normal bowel sounds makes obstruction unlikely
o Intestinal rush (Hyperactive bowel sounds) occur in diarrhoea, IBD,
food hypersensitivity, gastroenteritis, or prior to obstruction – loud, fast
gurgling sounds and can be audible without stethoscope sometimes
• Bruits
o Uncommonly, an arterial systolic bruit in the liver can be heard –
higher pitched than a venous hum and is not continuous and is well
localised. Due to HCC or acute alcohol hepatitis due to arteriovenous
malformation
o Renal Bruits are also uncommon – heard on either side of the midline
above the umbilicus. Indicates renal arterial sclerosis/stenosis
• Friction Rubs
o Indicate abnormality in parietal and visceral peritoneum due to
inflammation – although are rare and non-specific
o May be audible over spleen or liver
o Produce a rough creaking or grattling noise heard as the patient
breaths
§ Causes: HCC, Metastasis in liver, liver abscess, recent liver
biopsy, liver infarct, gonococcal or chlamydial perihepatitis
o Splenic rub indicates splenic infarct
• Venous Hums
o A continuous, low-pitched, soft murmur that may become louder with
inspiration and diminish when more pressure is applied with the
stethoscope. Typically heard between the xiphisternum and the
umbilicus in Portal HTN – but is rare
§ Large volumes of blood flowing in the umbilical or paraumbilical
veins in the falciform ligament are responsible – channel blood
from the left portal vein to the epigastric/ internal mammary
veins in the abdominal wall
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SPECIAL TESTS
• Rovsing’s Sign (Appendicitis/ any Peritonitis)
o Press fingers in the LLQ and withdraw
§ POSITIVE: pain in the right iliac fossa is elicited during left sided
pressure (7-68% sensitivity; 58-96% specificity)
• Pushing contents on left side towards right triggering
peritoneal irritation
• Rebound Tenderness (Appendicitis/ any Peritonitis)

o Deeply palpate RLQ in McBurney’s Point slowly, followed by rapid
release of pressure
§ POSITIVE: patient winces when pressure is released
• Peritoneal irritation from releasing pressure (40-95%
sensitivity and 20-89% specificity)
• Psoas Sign (Retro-caecal Appendicitis/ psoas abcess)
o Place your hand above the patients right knee and ask them to raise
their thigh against your hand
§ POSITIVE: contraction of pushing thigh up increases pain in
abdomen (Sensitivity 13-42%; Specificity 79-97%)
• Contraction of psoas major,
which borders the
peritoneal cavity thus
stretching (hyperextending
hip) or contraction (flexion
of hip) causes friction
against irritated peritoneum
• Obturator Sign (Appendicitis)
o Flex the patients right thigh at the hip
and have the knee bent. Now,
internally rotate the leg at the hip by
pulling foot out laterally
§ POSITIVE: Right hypogastric pain
elicited (94% specificity for appendicitis/
8% sensitivity)
• Inflamed appendix may
come in contact with
obturator internus muscle
and thus movement causes friction
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• Murphy’s Sign (Cholecystitis)

o Place right hand in the right costal margin just lateral to the lateral
border of the rectus abdominus muscle
o On taking a deep breath, the patient catches their breath when an
inflamed gall bladder (cholecystitis) is present (48-99% sensitivity; 48-
79% specificity)
§ General pain on palpation is not necessarily positive – it is the
action of wincing and catching their breath due to sudden pain
o On another note, the Gallbladder may sometimes be palpable upon
Liver palpation
§ Unlike the liver edge, the gallbladder (if palpable) will be
bulbous, focal round mass that moves downward on inspiration
§ Cause: Biliary obstruction or acute cholecystitis
• Courvoisier’s Law: if the gallbladder is enlarged and the
patient is jaundiced, the cause is unlikely to be gallstones
but instead Pancreatic Carcinoma or Lower Biliary Tree
Carcinoma causing obstructive jaundice
o Because chronic gallstones in the gallbladder
causes fibrosis thus is incapable of enlargement
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• Murphy’s Punch (Pyelonephritis)

o Place one open hand over the costovertebral angle – follow
subcostal margin anteriorly to posteriorly – and gently punch with the
ulnar side of clenched fist of other hand
§ Kidneys are partially protected by the ribs thus punching
costovertebral joint and angle over the kidney will cause irritation
to the kidney
• POSITIVE: punch elicits pain – pyelonephritis or
hydronephrosis
51
LEGS
• Bruising
• Oedema
o Hypoalbuminaemia
• Erythema Nodosum
o IBD
• Pyoderma Gangrenosum
• Scratch marks
• Palpate the inguinal Lymph Nodes
AN ABDOMINAL EXAMINATION NOT COMPLETE

WITHOUT A HERNIA, RECTAL, VAGINAL AND EXTERNAL
GENITALIA EXAMINATION.
52
APPENDIX OF FIGURES
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3 Gastrointestinal Examination Notes

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3 Gastrointestinal Examination Notes

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Jack’s Notes CLINICAL SKILLS

INTRODUCTION & CONSENT

• Hepatic Flap (Asterixis)

• Koilonychia (Spoon Nails) – dry, brittle, spoon shaped nails; loss of

• Scratch Marks/ Jaundice

• Acanthosis Nigricans - brown-black velvety

• Dermatitis Herpetiformis – coeliac disease –

• Muscle Wasting/ Proximal Myopathy

Kayser-Fleischer Rings Bitot Spots

• Brown-Black Lesions around mouth and Buccal Mucosa (Perioral

• Telangiectasia around Mouth

• BCC, SCC, vesicles on lips

MOUTH, GUMS & TEETH

• Gum Bleeding/ Mucosal Petechiae

• Mouth Ulcers (Aphthous Ulcers)

Tonsillitis – Kissing Tonsils

NECK & CHEST

Observe for Abdominal Mass

Causes of ascites: cirrhosis, CHF, myxoedema, IBD,

• Rebound Tenderness (Appendicitis/ any Peritonitis)

• Murphy’s Sign (Cholecystitis)

• Murphy’s Punch (Pyelonephritis)

• Palpate the inguinal Lymph Nodes

AN ABDOMINAL EXAMINATION NOT COMPLETE

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