GASTROINTESTINAL TRACT

EXAMINATION

Debie Dahlia
 Objective
Know about step in physical examination of GI
tract

Know about technique and tips

Know about interpretation of each finding

Know about clinical implementation for each

patients
 Principal of History taking and Physical
Examination of GI tract
70% of diagnoses
can be made based on history alone.

90% of diagnoses
can be made based on history and physical exam.

Diagnostic tests
often confirm what is found during the history and physical
examination .
 General principles of GI tract
Examiniation

Good light
Relaxed patient
Full exposure of abdomen
Have the patient empty their bladder before
examination
Have the patient lie in a comfortable, flat,
supine position
Have them keep their arms at their sides or
folded on the chest
 General principles of exam
Before the exam, ask the patient to identify painful areas so
that you can examine those areas last

During the exam pay attention to their facial expression to

assess for Use warm hand, warm stethoscope, and have short
finger nails

Approach the patient slowly and deliberately explaining what

you will be doing
sign of discomfort
 General principles of exam
Stand right side of the bed

Exam with right hand

Head just a little elevated

Ask the patient to keep the mouth partially open and breathe
gently

Take a spare bed sheet and drape it over their lower body
such that it just covers the upper edge of their underwear
 General principles of exam

If muscles remain tense, patient may be asked to rest feet

on table with hips and knees flexed
 General principles of exam

If the patient is ticklish or frightened

Initially use the patients hand under yours as you palpate
When patient calms then use your hands to palpate.
Watch the patients face for discomfort.
Think Anatomically
 Think Anatomically

When looking, listening, feeling and percussing

Imagine what organs live in the area that you are examining.
Nine Regions
Physical Examination of the Abdomen

Inspection

Auscultation

Percussion

Palpation

Special Tests
 Inspection

Abdominal examination
 Appearance of the abdomen

Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
 Symmetrical in shape

Scaphoid or flat in young Slightly full but not distended in

patients of normal weight older age group due to poor
muscle tone or in subjects who
are mildly overweight
 Appreciation of abdominal contours

Standing at the foot of the

table and looking up
towards the patient's
head.

ask the patient to breathe

normally while you are
doing so.
 Appearance of the abdomen

Global abdominal enlargement is usually caused by air, fluid,

or fat.
 Appearance of the abdomen

Localized enlargement probably distend GB space occupying

lesion, hepatomegaly.
 An aortic aneurysm

Palpable mass
Patient feeling of pulsation
 An aortic aneurysm

1 in 10 men over 65 may have some enlargement of the

abdominal aorta.
About 1 in 100 will have a large aneurysm requiring surgery.
 Appearance of the abdomen
(Skin)

Abnormal venous patterns

Abnormal discoloration
Umbilicus is Hollow
Striae
 Appearance of the abdomen
(Skin)

Tattoos
Scars can be drawn on schematic diagrams of the abdomen (a
picture is worth a thousand words).
 Cullens sign

Ecchymosis periumbilically.
Intraperitoneal hemorrhage ruptured ectopic pregnancy,
hemorrhagic pancreatitis, ruptured abdominal aortic
aneurysm
 Visible Pulsations
More conspicuous in the In those who have a mass
thin than in the fat joining the aorta to the
anterior abdominal wall.
Greater in the old than in
the young. Insufisiensi katup
trikuspidalis
In those with an aortic
aneurysm
 Appearance of the abdomen Patient's
movement

Patients with kidney stones will frequently writhe on the

examination table,

unable to find comfortable position

Patients with peritonitis prefer to lie very still as any motion

causes further peritoneal irritation and pain.
 Auscultation

Abdominal examination
 Auscultation

Bowel sounds

Vascular sounds (bruits)

Friction Rubs
Auscultation for bowel sounds

It is performed before percussion or

palpation
 Auscultation for bowel sounds

Normal sounds are due to

peristaltic activity.

Peristalsis:
A progressive wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
 Auscultation for bowel sounds

Bowel sounds lend

supporting information to
other findings but
are not pathognomonic
for any particular process.
 Auscultation

Diaphragm of stethoscope used

Skin depressed to approximately 1 cm

Listening in one spot is usually sufficient

Listening for 15-20 or 30-60 seconds

Bowel sounds cannot be said to be absent unless they are

not heard after listening for 3-5 minutes.
 Three things about bowel sound

Are bowel sounds present?

If present, are they frequent or sparse (i.e.quantity)?
What Is the nature of the sounds (i.e.quality)?
 Bowel sound decrease
Inflammatory processes of the serosa

After abdominal surgery

In response to narcotic analgesics or

anesthesia.
 Auscultation for bowel sounds

Inflammation of the intestinal mucosa will cause hyperactive

bowel sounds.
 Auscultation for bowel sounds

Processes which lead to intestinal obstruction

initially cause frequent bowel sounds, referred to as
"rushes."
 Auscultation for bowel sounds

Rushes" means as the intestines trying to force their

content through a tight opening.
 Auscultation for bowel sounds

Rushes" is followed by decreased sound, called "tinkles,"

and then silence.
 Auscultation for vascular sounds (bruits)
Aortic (midline between
umbilicus and xiphoid

Renal (two inches superior to

and two inches lateral to
umbilicus)

Common iliac (midway

between umbilicus and
midpoint of inguinal
ligament)
 Auscultation for vascular sounds (bruits)

Presence of a bruit on the renal artery

would lend supporting evidence for the existence of renal

artery stenosis.

When listening for bruits, you will need to press down

quite firmly as the renal arteries are retroperitoneal
structures.
 Friction rubs (rare)

Right and left upper

quandrants

indicates inflammation of
the capsule of the liver or
spleen (infection or
infarction).
 Percussion

Abdominal examination
 Tujuan Perkusi Abdomen
1. Konfirmasi pembesaran hati & limpa

1. Ada tidaknya nyeri ketok

1. Diagnosis adanya cairan atau massa padat

 Percussion (technique)

joint of third finger (pleximeter) pressed firmly on the

abdomen
remainder of hand not touching the abdomen
 There are two basic sounds with
Percussion

Tympanitic (drum-like) sounds produced by percussing

over air filled structures.
 There are two basic sounds with
Percussion

Dull sounds that occur when a solid structure (e.g. liver) or

fluid (e.g. ascites) lies beneath the region being examined.
The two solid organs are percussable in the
normal patient

Liver: will be entirely covered by the ribs. Occasionally, an edge

may protrude 1-2 centimeter below the costal margin.
Spleen: The spleen is smaller and is entirely protected by the
ribs.
 To determine the size of the liver

Measure the liver span by percussing hepatic dullness from

above (lung) and below (bowel).
A normal liver span is 6 to 12 cm in the mid-clavicular line.
 To determine the size of the liver

Start just below the right breast in a line with the middle
of the clavicle. Percussion in this area should produce a
relatively resonant note.
 To determine the size of the liver

Move your hand down a few centimeters than you will be

over the liver, which will produce a duller sounding tone.
 To determine the size of the liver

Continue downward until the sound changes once again. At

this point, you will have reached the inferior margin of the
liver.
 Examination of Liver (Percussion)

Upper margin is noted by first dull percussion note

Lower margin is noted by first tympanitic note
 Examination of Spleen
(Percussion)
Percussion at Castells Spot
Castells Spot identified
Left anterior axillary line identified
Left lower costal margin identified

Percussion at Castells Spot while patient inhales and

exhales deeply

Dull tone indicates possible splenomegaly

 Spleen percussion

Enlarged spleen produce a dull tone, in the left upper

quadrant percussion but should then be verified by
palpation.
 Palpation

Abdominal examination
 Abdominal Palpation

Technique Liver edge

Spleen tip
Light
Kidneys
Deep Aorta
Masses
 Abdominal palpation

To palpate four quadrants superficially from LLQ

counterclockwise
Light Palpation
 Light Palpation

First warm your hands by rubbing them together before

placing them on the patient.
Abdominal wall depressed approximately 1 cm
 Abdominal palpation

Use pads of three fingers of one hand and a light, gentle to

examine abdomen
 Palpation (light)

Any areas of pain or tenderness are reserved for evaluation

at the end of the exam
 Light Palpation

Mostly looking for areas of tenderness

Tenderness is a physical exam finding a reflex occurs
(muscle splinting, wide eyes, moaning, teeth gritting).
 Palpation
Light palpation assesses

Muscle tone Cutaneous hypersensitivity

(suggests peritoneal irritation)
Deep Palpation
 Palpation (deep)

Entire palm
Either one- or two
handed technique
is acceptable
 Deep Palpation
Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
 Palpation

Palpate deeply with

finger pads (do not dig
in with finger tips)
 Deep Palpation
Palpate tender areas
last
Try to identify
abdominal masses or
areas of deep
tenderness
 Two handed technique
When deep
palpation is difficult,
examiner may want
to use left hand
placed over right
hand to help exert
pressure
 Palpation (deep)

Push as deeply as
patient will allow
without significant
discomfort
 Normal structure that may be palpable

Sigmoid colon Distended bladder

Liver Gravid and non-gravid
Kidney uterus
Abdominal aorta Xyphoid process
Iliac artery spleen
Abdominal pain and Tenderness
 Type of abdominal pain

Visceral pain Somatic pain

 Visceral pain
This is pain that arises
from an organic lesion
or functional
disturbance within an
abdominal viscus (dull,
poorly localized, and
difficult for the patient
to characterize).
 Somatic pain
Painful lesion of the
skin
Sharp, bright, and well
localized
Indicates involvement
of parietal peritoneum
or the abdominal wall
itself
 Tenderness
If there is tenderness
determine the point of
maximum tenderness
and its distribution
 Abdominal muscle spasm
Voluntary guarding Involuntary guarding
Tensing abdominal Muscular spasm or
muscles due to patient rigidity due to
anxiety, ticklishness, or peritoneal inflammation
to prevent palpation to May be localized (early
a painful area appendicitis )or diffuse
(perforated bowel)
 Board-like rigidity
If abdominal wall is
palpated as obviously
tense, even as rigid as a
board, board-like
rigidity is so called. Is
caused by the spasm of
abdominal muscle due
to peritoneal irritation.
Liver palpation
 Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the mid-
clavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
 Liver palpation
(Standard Method)
Ask the patient to
take a deep breath.

Palpating hand is
held steady while
patient inhales
 Liver palpation
(Standard Method)
Palpating hand is
lifted and moved
while the patient
breathes out
 Hepatomegaly
More than 1cm below
the costal margin
An exception is a
congenitally large right
lobe of the liver
 Hepatojugular reflux sign
If you press the liver,
you will find the dilated
jugular vein becomes
more bulged or
distended, as from the
enlargement of liver
passive congestion
resulted from right
failure.
Spleen palpation
 Spleen palpation

Seldom palpable in
normal adults. Causes
include COPD, and deep
inspiratory descent of
the diaphragm.
 Spleen palpation

Support lower left rib

cage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
 Spleen palpation

Palpate upwards toward

spleen with finger tips
of right hand, starting
below left costal
margin.
Have the patient take a
deep breath.
 Examination of Spleen (Palpation)

Deep technique used

Starting point is RLQ,
proceeding to LUQ
Kidney palpation
 Kidney palpation
Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
 Examination of Kidney
Patient take a deep
breath.
Feel lower pole of
kidney and try to
capture it between your
hands.
 Examination of Kidney

Right kidney may be felt to slip between hands

during exhalation
 Special exam

Abdominal examination
 Special exam
Murphys Sign Re bound
McBurneys Tenderness
Point Costovertebral
Rovsings Sign tenderness
Psoas Sign Shifting Dullness
Obturator Sign Fluid wave
 Murphys Sign (acute cholecystitis)

Examiners hand is at
middle inferior border
of liver.
Patient is asked to take
deep inspiration.
If positive patient will
experience pain and will
stop short of full
inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
 McBurneys Point

Localized tenderness
Just below midpoint of
line between right
anterior iliac crest and
umbilicus.
 McBurneys Point (Common Causes)
Appendicitis
Incarcerated or strangulated
hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory disease
Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
 Rovsings Sign

Patient will experience

right lower quadrant
pain (in region of
McBurneys Point)
when left lower
quadrant is palpated.
 Costo vertebral Tenderness
(Often with renal disease)
Use the heel of your
closed fist to strike
the patient firmly over
the costovertebral
angles.
Compare the left and
right sides.
Warn the patient Patient sit up on the exam table
 Shifting Dullness
(For peritoneal fluid)

Percuss from anterior

abdomen laterally to
outline areas of
dullness noted
 Examination for Shifting Dullness

Patient rolled slightly

toward the examined
side; movement of the
dull point medially is
described as shifting
dullness and suggests
ascites
Shifting Dullness
Fluid wave
CONCLUSION

- abdominal exam : inspection, auscultation,

papation, and perkusion.

- Do the exam carefully and completely

avoid mistake / misdiagnosis.
 Rujukan
1. Prof .dr.W.Herdin Sibuea, SpPD. Pedoman
dasar anamnesisi dan pemeriksaaan jasmani
, Sagung Seto, Jakarta.
2. HMS. Markum. Penuntun Anamnesis dan
Pemeriksaan Fisik. Pusat Penerbitan
Departemen Ilmu Penyakit Dalam FK UI.
Jakarta
3. http://www.mediafire.com/?nsoca8ypiu05cgl