THE GASTROINTESTINAL SYSTEM
PHYSICAL EXAMINATION

Overview
 The abdominal examination should include the following:
 - General inspection from the end of the bed.
 - General examination of:
 o Hands / pulse
 o Face
 o Lymph nodes
 - Examination of the abdomen.
 o Inspection
 o Palpation
 o Percussion
 o Auscultation

Exam of the Abdomen
Anatomy Observation Auscultation Percussion Palpation
Findings Associated
with
Advanced Liver
Disease

Preparation
 - Introduce yourself to the patient if you have not
already done so and check the identity of the patient
 - Wash your hands
 - Ask the patients permission to carry out the
examination
 - Give a brief explanation to the patient before you
start. Further explanation/instructions can be given as
you proceed.

Equipment

 o Stethoscope

Patient position
 o Ideally the patient should be lying flat with the head
propped on a single pillow and the arms at the sides.
 o When you are ready to examine the abdomen it should
be exposed from above the costal margins to the level
of the symphysis pubis.

Draping the Abdomen

General Observations
 Check visually from the end of the bed. Note:
 o Obvious discomfort/pain, breathlessness, distension
 o Colour

Hands
 - Inspect both hands; nails, back and then palms.
 o You should be able to recognise, and know the
significance of, the following: anaemia, dehydration,
clubbing, leukonychia, koilonychia, palmar erythema,
Dupuytren's contracture, spider-naevi.
 - Feel the radial pulse. Note the rate, rhythm and volume
 - Check for hepatic flap of liver failure (if appropriate)
 o Ask patient to stretch arms out in front of them with the
wrists dorsi flexed and fingers extended.
 o Look for irregular, jerky flexion/extension at the wrists
and MCP joints

Eyes
 - Gently pull down lower eyelids and ask the patient to
look up. Inspect for:
 o pale conjunctiva of anaemia
 o yellow sclera of jaundice – ideally in natural light

Mouth
 - Ask patient to open their mouth. Inspect the teeth,
tongue, gums and inner surface of the cheeks
 o You should be able to recognise, and know the
significance of, the following: ulcers, candidiasis,
changes to the tongue e.g. glossitis, macroglossia,
 - Note any obvious odour of the patients breath e.g.
Fetor hepaticus, ketosis, uraemia

Neck
 - Palpate for enlarged lymph nodes, first from the front,
then back/right.
 o Occipital
 o Post-auricular
 o Pre-auricular
 o Submandibular
 o Submental
 o Anterior and posterior cervical
 o Supraclavicular (check for Virchow’s Node)

Note
 Virchow’s Node – An enlarged supraclavicular lymph
node on the left-hand side. Suggestive of gastric
malignancy

The Abdomen
Think Anatomically

Quadrants of the Abdomen

INSPECTION
 With the abdomen exposed, look carefully for
 - Scars, abdominal distension, focal swelling, asymmetry
 - You should be able to recognise, and know the
significance of, the following: dilated/prominent veins,
visible peristalsis, obvious pulsation, skin discolouration.
 - Note the location and nature of any surgical stomas

Various Causes of Abdominal
Distension

Obese abdomen

Hepatomegaly

Ascites

Markedly enlarged gall bladder
(labeled "GB")

Umbilical Hernia

Same umbilical hernia while
patient performs valsalva
maneuver

PALPATION
 You should be at the same level as the patient to
palpate the abdomen, looking at the patients face for
any signs of discomfort
 The abdomen should be examined by light (superficial)
and deep palpation in all 9 areas before examining
specific organs. The order they are examined in does
not matter. Remember to examine any areas of
tenderness last. Ask the patient if they have any pain
before commencing.

Light Palpation
 - Gently palpate all nine areas
 - Start away from known pain.
 - Hold your hand flat, and gently press in by extending
at the MCP joints to palpate
 with the palmar surface of your finger - not digging in
with your finger tips.
 - If there is pain on light palpation, try and determine if
this is rebound tenderness

Deep Palpation
 - Re-examine using the same technique but now using
more pressure
 - Note any masses or structural abnormality
 - Masses should be described in terms of site, size,
shape, surface, consistency, mobility, movement with
respiration, tenderness and pulsatility

 Rebound Tenderness – pain is worse when you release
pressure on the abdomen than when you press down –
this is a sign of peritoneal irritation

 The Liver
 - The liver is not normally palpable.
 - Start palpation from the right iliac fossa using the same technique as before
but angle your hand so that the index finger is aligned with the costal margin
 - Ask the patient to take breaths in and out as you proceed, and feel for the
descending liver edge on inspiration
 - If the liver is not felt move your hand 1-2cm superiorly toward the right
hypochondrium during expiration, ready to apply gentle pressure again during
inspiration
 - Repeat this process until the liver edge is palpated or you reach the costal
margin.
 - Describe your findings
 o Note how far beyond the costal margin the liver extends in centimetres
 o Is the surface smooth or irregular?
 o Is there any tenderness?

Practice Tip!
 The liver edge is sometimes palpable just below the
costal margin at the height of inspiration in normal
healthy individuals.
 Practice your technique on your colleagues

 The Spleen
 - Start palpation from the right iliac fossa moving
diagonally toward the left hypochondrium
 - Ask the patient to take breaths in and out as you
proceed and use the same technique as for the liver
 - Describe your findings as for the liver.
 - In healthy individuals the spleen is not palpable. It
enlarges along the line of the 9th rib and moves
downwards and inwards on inspiration.
 - The spleen has a distinctive ‘notch’ which can help to
differentiate it from other structures in splenomegaly

 The Kidneys
 - The kidneys are not normally palpable; however, you may feel the
lower pole of the right kidney in a thin person.
 - Place your left hand behind the patients back just below the ribs at
the right hand side
 - Place your right hand on the abdomen below the right costal margin
just lateral to the rectus abdominis.
 - Ask the patient to breathe out and push your hands together firmly
(but gently)
 - Ask the patient to breathe in. You may feel the lower pole of the
kidney moving down between the hands
 - If this happens try to ‘Ballot’ or push the kidney back and forward
between your hands
 - Repeat for the left kidney by leaning over and placing the left hand
under the left loin.

 Ballotting the Kidney
 This demonstrates the mobility of the kidney - helping
to confirm what the structure is.

Practice Tip!
 The right kidney lies a little lower than the left. The
lower pole of the right kidney may be palpable in
normal, thin individuals.

 Bladder
 - Palpable suprapubically if full
 - Start palpation from umbilicus with index finger
horizontal and proceed inferiorly toward symphysis
pubis

 Aorta
 - Palpate in the vertical midline of abdomen above the
umbilicus.
 - Place the fingers on either side of the outer margins,
feeling for pulsation
 - Normal diameter is 2-3cm
 - Palpable in most healthy people.

PERCUSSION
 - You should percuss any lumps or masses identified on
palpation to determine their size and nature
 - Percuss individual organs to help determine their size
(you may see some clinicians percuss the 9 regions)
 - If the abdomen appears distended and you suspect the
presence of ascites test for ‘shifting dullness’ and ‘fluid
thrill’

 Tympanitic (drum-like) sounds produced by percussing
over air filled structures.
 Dull sounds that occur when a solid structure (e.g. liver)
or fluid (e.g. ascites) lies beneath the region being
examined.

 Percussion may reveal enlargement of the spleen that is
not detectable on palpation. This is because the spleen
would have to be 2-3 times its normal size to be
palpable on abdominal examination

 The Liver
 - Percuss from right iliac fossa upwards
 - Identify both the lower and upper borders of the liver
 - Note the length in centimetres at the midclavicular
line

 The Spleen
 - Percuss from the right iliac fossa diagonally toward the
left hypochondrium
 - Continue percussing over the ribs toward the
midaxillary line and lower left ribs for dullness.

 Bladder
 - Begin percussing from just above the umbilicus with
the finger positioned horizontally on the abdomen
 - Percuss inferiorly toward the symphysis pubis.

 Shifting Dullness
 - Percuss from the centre of the abdomen laterally with the
fingers positioned longitudinally until dullness is detected.
 - Keep your finger pressed there (or mark the spot with a
pen) as you
 - Ask the patient to roll on to the opposite side to where
you have marked
 - Wait at least 30 seconds
 - Repeat percussion moving from this point back toward
centre
 - If the dullness was an air/fluid level, the previously dull
 area will now be resonant as fluid is moved away by
gravity.

 Ascites and Shifting Dullness
 Ascites is free fluid within the peritoneum. With the
patient lying on their back, gravity will cause the fluid
to move toward the patients back and the bowel will
float centrally. When the patient is rolled to onto their
side, the fluid will be moved by gravity to the side they
are lying on. On percussion any dullness caused by the
presence of fluid will also move.

 Fluid Thrill
 - Place your left hand flat against the right side of the patients
abdomen
 - Ask the patient to place the edge of one hand longitudinally on
midline of abdomen to prevent transmission of the impulse via the
skin
 - Tap on the left side of the abdomen with the right hand
 - Feel for a ripple of fluid against the left hand

AUSCULTATION
 Bowel Sounds
 - Listen with the diaphragm of the stethoscope just
below the umbilicus
 - Describe findings you should be able to recognise and
understand the significance of:
 o Normal, ‘tinkling’ and absent bowel sounds. You may
have to listen for a while
 if the sounds are quiet

AUSCULTATION
 Bruits
 - Listen with the diaphragm of the stethoscope for
turbulent blood flow
 o Over the aorta, just above the umbilicus
 o Over the renal arteries – just above and to either side
of the umbilicus
 o Over the liver

Completing the Examination
 - Cover patient /assist to redress if necessary
 - Thank the patient
 - For completion you should also consider:
 o Examination of hernial orifices
 o Digital Rectal Examination
 o Examination of external genitalia
 - Bed side tests
 o Blood Pressure and Temperature
 o Urine dipstick

Findings Commonly Associated
With Advanced Liver Disease
 Chronic liver disease usually results from years of
inflammation, which ultimately leads to fibrosis and
decline in function. Histologically, this is referred to as
Cirrhosis. This can be driven by a number of different
processes, most commonly chronic alcohol use, viral
hepatitis (B or C) or hemachromatosis (the complete list
is much longer). It's important to realize that a cirrhotic
liver can be markedly enlarged (in which case it may be
palpable) or shrunken and fibrotic (non-palpable).

 Hyperbilirubinemia: The diseased liver may be unable to
conjugate or secrete bilirubin appropriately. This can
lead to
 Icterus - Yellow discoloration of the sclera.
 Jaundice - Yellow discoloration of the skin.
 Bilirubinuria - Golden-brown coloration of the urine.

Icterus

Jaundice

 Ascites: Portal vein hypertension results from increased
resistance to blood flow through an inflamed and
fibrotic liver. This can lead to ascites, accumulation of
fluid in the peritoneal cavity.

Ascites

 Increased Systemic Estrogen Levels: The liver may
become unable to process particular hormones, leading
to their peripheral conversion into estrogen. High levels
promote:
 Breast development (gynecomastia).
 Spider Angiomata - dilated arterioles most often visible on
the skin of the upper chest.
 Testicular atrophy.

Gynecomastia

Spider

 Lower Extremity Edema: Impaired synthesis of the
protein albumin leads to lower intravascular oncotic
pressure and resultant leakage of fluid into soft tissues.
This is particularly evident in the lower extremities

Edema

 Varices: In the setting of portal hypertension, blood
"finds" alternative pathways back to the heart that do
not pass through the liver. The most common is via the
splenic and short gastric veins, which pass through the
esophageal venous plexus enroute to the SVC. This
causes esophageal varices which can bleed profoundly,
though these are not apparent on physical examination.
A much less common path utilizes the recanalized
umbilical vein, which directs blood through dilated
superficial veins in the abdominal wall. These are
visible on inspection of the abdomen and are known as
Caput Medusae.