TRIPASS XR تري باس

 Specificity 40–96%

Palpation in the left iliac fossa produces pain in the right iliac fossa

Iliopsoas Retroileal appendicitis, iliopsoas abscess,

perinephric abscess

Ask the patient to flex their thigh against the resistance of your hand; a painful

response indicates an inflammatory process involving the right psoas muscle

Grey Turner’s

and Cullen’s

Haemorrhagic pancreatitis, aortic rupture and

ruptured ectopic pregnancy (see Fig. 6.25)

Bleeding into the falciform ligament; bruising develops around the umbilicus

(Cullen) or in the loins (Grey Turner)

Aorta

Liver edge

Lower pole of

right kidney

Hard faeces

Rectus abdominis

and its tendinous

insertions

Normal colon Small lymph

nodes Distended

bladder

Fig. 6.13 Palpable masses that may be physiological rather than

pathological.

close to the costal margin, missing the edge of the liver or

spleen.

Hepatomegaly

Examination sequence

• Place your hand flat on the skin of the right iliac fossa.

• Point your fingers upwards and your index and middle

fingers lateral to the rectus muscle, so that your fingertips

lie parallel to the rectus sheath (Fig. 6.14). Keep your hand

stationary.

• Ask the patient to breathe in deeply through the mouth.

• Feel for the liver edge as it descends on inspiration.

• Move your hand progressively up the abdomen,

1 cm at a time, between each breath the patient

takes, until you reach the costal margin or detect the

liver edge.

The physical examination • 107

6

• the lower pole of the right kidney in the right flank

• faecal scybala (hardened masses of faeces) in the sigmoid

colon in the left iliac fossa

• a full bladder arising out of the pelvis in the suprapubic

region.

The normal liver is identified as an area of dullness to percussion

over the right anterior chest between the fifth rib and the costal

margin.

The liver may be enlarged (Fig. 6.15A) or displaced downwards

by hyperinflated lungs.

Hepatic enlargement can result from chronic parenchymal

liver disease from any cause (Box 6.10). The liver is enlarged in

early cirrhosis but often shrunken in advanced cirrhosis. Fatty

liver (hepatic steatosis) can cause marked hepatomegaly. Hepatic

enlargement due to metastatic tumour is hard and irregular. An

enlarged left lobe may be felt in the epigastrium or even the left

hypochondrium. In right heart failure the congested liver is usually

soft and tender; a pulsatile liver indicates tricuspid regurgitation.

A bruit over the liver may be heard in acute alcoholic hepatitis,

hepatocellular cancer and arteriovenous malformation. The most

• If you feel a liver edge, describe:

• size

• surface: smooth or irregular

• edge: smooth or irregular; define the medial border

• consistency: soft or hard

• tenderness

• pulsatility.

• To examine for gallbladder tenderness, ask the patient to

breathe in deeply, then gently palpate the right upper

quadrant in the mid-clavicular line.

Percussion

Examination sequence

• Ask the patient to hold their breath in full expiration.

• Percuss downwards from the right fifth intercostal space in

the mid-clavicular line, listening for dullness indicating the

upper border of the liver.

• Measure the distance in centimetres below the costal

margin in the mid-clavicular line or from the upper border

of dullness to the palpable liver edge.

In the normal abdomen, you may feel:

• the liver edge below the right costal margin

• the aorta as a pulsatile swelling above the umbilicus

Fig. 6.14 Palpation of the liver.

6.10 Causes of hepatomegaly

Chronic parenchymal liver disease

• Alcoholic liver disease

• Hepatic steatosis

• Autoimmune hepatitis

• Viral hepatitis

• Primary biliary cirrhosis

Malignancy

• Primary hepatocellular cancer • Secondary metastatic cancer

Right heart failure

Haematological disorders

• Lymphoma

• Leukaemia

• Myelofibrosis

• Polycythaemia

Rarities

• Amyloidosis

• Budd–Chiari syndrome

• Sarcoidosis

• Glycogen storage disorders

Costal margin

Liver edge Costal margin

Tip enlargement

Moderate enlargement

Marked enlargement

Mild enlargement

Moderate

enlargement

Marked

enlargement

A B

Fig. 6.15 Patterns of progressive enlargement of liver and of spleen. A Direction of enlargement of the liver. B Direction of enlargement of the

spleen. The spleen moves downwards and medially during inspiration.

108 • The gastrointestinal system

Splenomegaly

The spleen has to enlarge threefold before it becomes palpable,

so a palpable spleen always indicates splenomegaly. It enlarges

from under the left costal margin down and medially towards the

umbilicus (Fig. 6.15B). A characteristic notch may be palpable

midway along its leading edge, helping differentiate it from an

enlarged left kidney (Box 6.12).

Examination sequence

• Place your hand over the patient’s umbilicus. With your

hand stationary, ask the patient to inhale deeply through

the mouth.

• Feel for the splenic edge as it descends on inspiration.

• Move your hand diagonally upwards towards the left

hypochondrium (Fig. 6.16A), 1 cm at a time between each

breath the patient takes.

• Feel the costal margin along its length, as the position of

the spleen tip is variable.

• If you cannot feel the splenic edge, palpate with your right

hand, placing your left hand behind the patient’s left lower

common reason for an audible bruit over the liver, however, is

a transmitted heart murmur. Liver failure produces additional

symptoms of encephalopathy, which can be graded (Box 6.11).

Resonance below the fifth intercostal space suggests

hyperinflated lungs or occasionally the interposition of the

transverse colon between the liver and the diaphragm (Chilaiditi’s

sign).

In a patient with right upper quadrant pain, test for Murphy’s

sign (see Box 6.9); a positive modestly increases the probability

of acute cholecystitis. Palpable distension of the gallbladder is

rare and has a characteristic globular shape. It results from

either obstruction of the cystic duct, as in mucocoele or

empyema of the gallbladder, or obstruction of the common

bile duct with a patent cystic duct, as in pancreatic cancer. In

a jaundiced patient a palpable gallbladder is likely to be due to

extrahepatic obstruction, such as from pancreatic cancer or,

very rarely, gallstones (Courvoisier’s sign). In gallstone disease

the gallbladder may be tender but impalpable because of fibrosis

of the gallbladder wall.

Reproduced from Conn HO, Leevy CM, Vlahcevic ZR, et al. Comparison of

lactulose and neomycin in the treatment of chronic portal-systemic

encephalopathy. A double blind controlled trial. Gastroenterology 1977;

72(4):573, with permission from Elsevier Inc.

6.11 Grading of hepatic encephalopathy (West Haven)

Stage State of consciousness

0 No change in personality or behaviour

No asterixis (flapping tremor)

1 Impaired concentration and attention span

Sleep disturbance, slurred speech

Euphoria or depression

Asterixis present

2 Lethargy, drowsiness, apathy or aggression

Disorientation, inappropriate behaviour, slurred speech

3 Confusion and disorientation, bizarre behaviour

Drowsiness or stupor

Asterixis usually absent

4 Comatose with no response to voice commands

Minimal or absent response to painful stimuli

6.12 Differentiating a palpable spleen from the left kidney

Distinguishing feature Spleen Kidney

Mass is smooth and

regular in shape

More likely Polycystic kidneys

are bilateral irregular

masses

Mass descends in

inspiration

Yes, travels

superficially

and diagonally

Yes, moves deeply

and vertically

Ability to feel deep to

the mass

Yes No

Palpable notch on the

medial surface

Yes No

Bilateral masses

palpable

No Sometimes, e.g.

polycystic kidneys

Percussion resonant

over the mass

No Sometimes

Mass extends beyond

the midline

Sometimes No (except with

horseshoe kidney)

Fig. 6.16 Palpation of the spleen. A Initial palpation for the splenic edge moving diagonally from the umbilicus to the left hypochondrium. B If the

spleen is impalpable by the method shown in A, use your left hand to pull the ribcage forward and elevate the spleen, making it more likely to be palpable

by your right hand.

The physical examination • 109

6

• Keep your finger on the site of dullness in the flank and

ask the patient to turn on to their opposite side.

• Pause for 10 seconds to allow any ascites to gravitate,

then percuss again. If the area of dullness is now

resonant, shifting dullness is present, indicating ascites.

Fluid thrill

• If the abdomen is tensely distended and you are uncertain

whether ascites is present, feel for a fluid thrill.

• Place the palm of your left hand flat against the left side of

the patient’s abdomen and flick a finger of your right hand

against the right side of the abdomen.

• If you feel a ripple against your left hand, ask an assistant

or the patient to place the edge of their hand on the

midline of the abdomen (Fig. 6.18). This prevents

transmission of the impulse via the skin rather than

through the ascites. If you still feel a ripple against your left

hand, a fluid thrill is present (detected only in gross

ascites).

Causes of ascites are shown in Box 6.14.

Auscultation

Examination sequence

• With the patient supine, place your stethoscope diaphragm

to the right of the umbilicus and do not move it.

• Listen for up to 2 minutes before concluding that bowel

sounds are absent.

• Listen above the umbilicus over the aorta for arterial bruits.

6.13 Causes of splenomegaly

Haematological disorders

• Lymphoma and lymphatic

leukaemias

• Myeloproliferative diseases,

polycythaemia rubra vera and

myelofibrosis

• Haemolytic anaemia,

congenital spherocytosis

Portal hypertension

Infections

• Glandular fever

• Malaria, kala-azar

(leishmaniasis)

• Bacterial endocarditis

• Brucellosis, tuberculosis,

salmonellosis

Rheumatological conditions

• Rheumatoid arthritis (Felty’s

syndrome)

• Systemic lupus erythematosus

Rarities

• Sarcoidosis

• Amyloidosis

• Glycogen storage disorders

ribs and pulling the ribcage forward (Fig. 6.16B), or ask

the patient to roll towards you and on to their right side

and repeat the above.

• Feel along the left costal margin and percuss over the

lateral chest wall. The normal spleen causes dullness to

percussion posterior to the left mid-axillary line beneath

the 9th–11th ribs.

There are many causes of splenomegaly (Box 6.13).

Massive enlargement in the developed world is usually due

to myeloproliferative disease or haematological malignancy;

worldwide, malaria is a common cause.

Important causes of hepatosplenomegaly include lymphoma

or myeloproliferative disorders, cirrhosis with portal hypertension,

amyloidosis, sarcoidosis and glycogen storage disease.

Ascites

Ascites is the accumulation of intraperitoneal fluid (see Fig. 6.6).

Examination sequence

Shifting dullness

• With the patient supine, percuss from the midline out to

the flanks (Fig. 6.17). Note any change from resonant to

dull, along with areas of dullness and resonance.

Fig. 6.17 Percussing for ascites. A and B Percuss towards the flank from resonant to dull. C Then ask the patient to roll on to their other side. In

ascites the note then becomes resonant.

Fig. 6.18 Eliciting a fluid thrill.

110 • The gastrointestinal system

characteristics, and attempt to differentiate between direct and

indirect inguinal hernias.

Examination sequence

• Examine the groin with the patient standing upright.

• Inspect the inguinal and femoral canals and the scrotum

for any lumps or bulges.

• Ask the patient to cough; look for an impulse over the

femoral or inguinal canal and scrotum.

• Identify the anatomical relationships between the bulge,

the pubic tubercle and the inguinal ligament to distinguish

a femoral from an inguinal hernia.

• Palpate the external inguinal ring and along the inguinal

canal for possible muscle defects. Ask the patient to

cough and feel for a cough impulse.

• Now ask the patient to lie down and establish whether the

hernia reduces spontaneously.

• If so, press two fingers over the internal inguinal ring at the

mid-inguinal point and ask the patient to cough or stand

up while you maintain pressure over the internal inguinal

ring. If the hernia reappears, it is a direct hernia. If it can be

prevented from reappearing, it is an indirect inguinal hernia.

• Examine the opposite side to exclude the possibility of

asymptomatic hernias.

An indirect inguinal hernia bulges through the internal ring and

follows the course of the inguinal canal. It may extend beyond

the external ring and enter the scrotum. Indirect hernias comprise

85% of all hernias and are more common in younger men.

A direct inguinal hernia forms at a site of muscle weakness in

the posterior wall of the inguinal canal and rarely extends into the

scrotum. It is more common in older men and women (Fig. 6.20).

A femoral hernia projects through the femoral ring and into the

femoral canal. Inguinal hernias are palpable above and medial

to the pubic tubercle. Femoral hernias are palpable below the

inguinal ligament and lateral to the pubic tubercle.

In a reducible hernia the contents can be returned to the

abdominal cavity, spontaneously or by manipulation; if they

cannot, the hernia is irreducible. An abdominal hernia has a

covering sac of peritoneum and the neck of the hernia is a

common site of compression of the contents (Fig. 6.21). If the

• Now listen 2–3 cm above and lateral to the umbilicus for

bruits from renal artery stenosis.

• Listen over the liver for bruits.

• Test for a succussion splash; this sounds like a half-filled

water bottle being shaken. Explain the procedure to the

patient, then shake their abdomen by rocking their pelvis

using both hands.

Normal bowel sounds are gurgling noises from the normal

peristaltic activity of the gut. They normally occur every 5–10

seconds but the frequency varies.

Absence of bowel sounds implies paralytic ileus or peritonitis.

In intestinal obstruction, bowel sounds occur with increased

frequency and volume, and have a high-pitched, tinkling quality.

Bruits suggest an atheromatous or aneurysmal aorta or superior

mesenteric artery stenosis. A friction rub, which sounds like

rubbing your dry fingers together, may be heard over the liver

(perihepatitis) or spleen (perisplenitis). An audible splash more than

4 hours after the patient has eaten or drunk anything indicates

delayed gastric emptying, as in pyloric stenosis.

Hernias

The inguinal canal extends from the pubic tubercle to the

anterior superior iliac spine (Fig. 6.19). It has an internal ring at

the mid-inguinal point (midway between the pubic symphysis

and the anterior superior iliac spine) and an external ring at the

pubic tubercle. The femoral canal lies below the inguinal ligament

and lateral to the pubic tubercle.

Hernias are common and typically occur at openings of the

abdominal wall, such as the inguinal, femoral and obturator

canals, the umbilicus and the oesophageal hiatus. They may

also occur at sites of weakness of the abdominal wall, as in

previous surgical incisions.

An external abdominal hernia is an abnormal protrusion of bowel

and/or omentum from the abdominal cavity. External hernias are

more obvious when the pressure within the abdomen rises, such

as when the patient is standing, coughing or straining at stool.

Internal hernias occur through defects of the mesentery or into

the retroperitoneal space and are not visible.

An impulse can often be felt in a hernia during coughing

(cough impulse). Identify a hernia from its anatomical site and

6.14 Causes of ascites

Diagnosis Comment

Common

Hepatic cirrhosis with portal

hypertension

Transudate

Intra-abdominal malignancy with

peritoneal spread

Exudate, cytology may be

positive

Uncommon

Hepatic vein occlusion (Budd–Chiari

syndrome)

Transudate in acute phase

Constrictive pericarditis and right

heart failure

Check jugular venous pressure

and listen for pericardial rub

Hypoproteinaemia (nephrotic

syndrome, protein-losing

enteropathy)

Transudate

Tuberculous peritonitis Low glucose content

Pancreatitis, pancreatic duct

disruption

Very high amylase content

Anterior

superior

iliac spine

Inguinal

ligament

Internal

inguinal ring

External

inguinal ring

Spermatic

cord

Femoral

artery

Femoral

vein

Pubic

tubercle

Femoral canal

Fig. 6.19 Anatomy of the inguinal canal and femoral sheath.

The physical examination • 111

6

on coughing or on conscious contraction by the patient. Beyond

the anal canal, the rectum passes upwards and backwards along

the curve of the sacrum.

Spasm of the external anal sphincter is common in anxious

patients. When associated with local pain, it is probably due to

an anal fissure (a mucosal tear). If you suspect an anal fissure,

give the patient a local anaesthetic suppository 10 minutes

before the examination to reduce the pain and spasm, and to

aid examination.

Examination sequence

• Explain what you are going to do and why it is necessary,

and ask for permission to proceed. Tell the patient that the

examination may be uncomfortable but should not be

painful.

• Offer a chaperone; record a refusal. Make a note of the

name of the chaperone.

• Position the patient in the left lateral position with their

buttocks at the edge of the couch, their knees drawn

up to their chest and their heels clear of the perineum

(Fig. 6.22).

• Put on gloves and examine the perianal skin, using an

effective light source.

• Look for skin lesions, external haemorrhoids, fissures and

fistulae.

• Lubricate your index finger with water-based gel.

• Place the pulp of your forefinger on the anal margin and

apply steady pressure on the sphincter to push your

finger gently through the anal canal into the rectum

(Fig. 6.23).

• If anal spasm occurs, ask the patient to breathe in

deeply and relax. If necessary, use a local anaesthetic

suppository or gel before trying again. If pain persists,

examination under general anaesthesia may be

necessary.

• Ask the patient to squeeze your finger with their

anal muscles and note any weakness of sphincter

contraction.

Fig. 6.20 Right inguinal hernia.

Obstructed

proximal bowel

Collapsed

distal bowel

Covering of

hernia sac Contents of sac (small bowel in

this example)

Neck of hernia

Fig. 6.21 Hernia: anatomical structure.

hernia contains bowel, obstruction may occur. If the blood supply

to the contents of the hernia (bowel or omentum) is restricted,

the hernia is strangulated. It is tense, tender and has no cough

impulse, there may be bowel obstruction and, later, signs of

sepsis and shock. A strangulated hernia is a surgical emergency

and, if left untreated, will lead to bowel infarction and peritonitis.

Rectal examination

Digital examination of the rectum is important (Box 6.15). Do

not avoid it because you or the patient finds it disagreeable. The

patient’s verbal consent is needed, however, and the examination

should be carried out in the presence of a chaperone.

The normal rectum is usually empty and smooth-walled, with

the coccyx and sacrum lying posteriorly. In the male, anterior

to the rectum from below upwards, lie the membranous urethra,

the prostate and the base of the bladder. The normal prostate

is smooth and firm, with lateral lobes and a median groove

between them. In the female, the vagina and cervix lie anteriorly.

The upper end of the anal canal is marked by the puborectalis

muscle, which is readily palpable and contracts as a reflex action

6.15 Indications for rectal examination

Alimentary

• Suspected appendicitis, pelvic abscess, peritonitis, lower

abdominal pain

• Diarrhoea, constipation, tenesmus or anorectal pain

• Rectal bleeding or iron deficiency anaemia

• Unexplained weight loss

• Bimanual examination of lower abdominal mass for diagnosis or

staging

• Malignancies of unknown origin

Genitourinary

• Assessment of prostate in prostatism or suspected prostatic cancer

• Dysuria, frequency, haematuria, epididymo-orchitis

• Replacement for vaginal examination when this would be

inappropriate

Miscellaneous

• Unexplained bone pain, backache or lumbosacral nerve root pain

• Pyrexia of unknown origin

• Abdominal, pelvic or spinal trauma

112 • The gastrointestinal system

Fig. 6.22 The correct position of the patient before a rectal

examination.

Fig. 6.23 Rectal examination. The correct method for inserting your

index finger in rectal examination.

� � � �

Fig. 6.24 Examination of the rectum. A and B Insert your finger, then rotate your hand. C The most prominent feature in the female is the cervix.

D The most prominent feature in the male is the prostate.

6.16 Causes of abnormal stool appearance

Stool appearance Cause

Abnormally pale Biliary obstruction

Pale and greasy Steatorrhoea

Black and tarry (melaena) Bleeding from the upper

gastrointestinal tract

Grey/black Oral iron or bismuth therapy

Silvery Steatorrhoea plus upper gastrointestinal

bleeding, e.g. pancreatic cancer

Fresh blood in or on stool Large bowel, rectal or anal bleeding

Stool mixed with pus Infective colitis or inflammatory bowel

disease

Rice-water stool (watery

with mucus and cell debris)

Cholera

• Palpate systematically around the entire rectum; note any

abnormality and examine any mass (Fig. 6.24). Record the

percentage of the rectal circumference involved by disease

and its distance from the anus.

• Identify the uterine cervix in women and the prostate in

men; assess the size, shape and consistency of the

prostate and note any tenderness.

• If the rectum contains faeces and you are in doubt about

palpable masses, repeat the examination after the patient

has defecated.

• Slowly withdraw your finger. Examine it for stool colour

and the presence of blood or mucus (Box 6.16).

Haemorrhoids (‘piles’, congested venous plexuses around the

anal canal) are usually palpable if thrombosed. In patients with

chronic constipation the rectum is often loaded with faeces.

Faecal masses are frequently palpable, should be movable and

can be indented. In women a retroverted uterus and the normal

cervix are often palpable through the anterior rectal wall and a

vaginal tampon may be confusing. Cancer of the lower rectum

is palpable as a mucosal irregularity. Obstructing cancer of the

upper rectum may produce ballooning of the empty rectal cavity

below. Metastases or colonic tumours within the pelvis may

be mistaken for faeces and vice versa. Lateralised tenderness

suggests pelvic peritonitis. Gynaecological malignancy may cause

a ‘frozen pelvis’ with a hard, rigid feel to the pelvic organs due

to extensive peritoneal disease, such as post-radiotherapy or

in metastatic cervical or ovarian cancer.

Benign prostatic hyperplasia often produces palpable

symmetrical enlargement, but not if the hyperplasia is confined

Investigations • 113

6

• Remove the obturator and carefully examine the anal canal

under good illumination, noting any abnormality. Check for

fissures, particularly if the patient reports pain during the

procedure.

• Ask the patient to strain down as you slowly withdraw the

instrument to detect any degree of rectal prolapse and the

presence and severity of any haemorrhoids.

Proctoscopic examination of the anus and lower rectum can

confirm or exclude the presence of haemorrhoids, anal fissures

and rectal prolapse. Rectal mucosa looks like buccal mucosa,

apart from the presence of prominent submucosal veins. During

straining, haemorrhoids distend with blood and may prolapse. If

the degree of protrusion is more than 3–4 cm, a rectal prolapse

may be present.

Investigations

Selecting the relevant investigation depends on the clinical problem

revealed on history and examination. Investigations are costly

and many carry risks, so choose tests capable of distinguishing

the likely diagnoses and prioritise the most decisive ones (Box

6.17 and Figs 6.26–30).

to the median lobe. A hard, irregular or asymmetrical gland with

no palpable median groove suggests prostate cancer. Tenderness

accompanied by a change in the consistency of the gland may

be caused by prostatitis or prostatic abscess. The prostate is

abnormally small in hypogonadism.

Proctoscopy

Proctoscopy is visual examination of the anal canal; it is an invasive

procedure and should only be practised after appropriate training.

Always undertake digital rectal examination first. If examination

of the rectal mucosa is required, perform flexible sigmoidoscopy

rather than proctoscopy.

Examination sequence

• Place the patient in the left lateral position, as for digital

rectal examination.

• With gloved hands, separate the buttocks with the

forefinger and thumb of one hand. With your other hand,

gently insert a lubricated proctoscope with its obturator in

place into the anal canal and rectum in the direction of the

umbilicus.

A B

Fig. 6.25 Acute pancreatitis. A Bruising over the flanks (Grey Turner’s sign). B Bruising round the umbilicus (Cullen’s sign).

6.17 Investigations in gastrointestinal and hepatobiliary disease

Investigation Indication/comment

Clinical samples

Stool:

Faecal occult blood Gastrointestinal haemorrhage; sensitive but not specific; used as population screening tool

for colorectal cancer

Faecal calprotectin Inflammatory bowel disease – raised

Urine: dipstick or biochemistry Jaundice (see Box 6.7)

Acute abdominal pain

Ascitic fluid: diagnostic tap Clear/straw-coloured – normal

Uniformly blood-stained – malignancy

Turbid – infection

Chylous – lymphatic obstruction

High protein (exudate) – inflammation or malignancy

Low protein (transudate) – cirrhosis and portal hypertension

Continued

114 • The gastrointestinal system

6.17 Investigations in gastrointestinal and hepatobiliary disease—cont’d

Investigation Indication/comment

Radiology

Chest X-ray Suspected acute abdomen, suspected perforated viscus or subphrenic abscess

Pneumonia, free air beneath diaphragm, pleural effusion, elevated diaphragm

Abdominal X-ray Intestinal obstruction, perforation, renal colic

Fluid levels, air above liver, urinary tract stones

Barium meal Rarely indicated unless gastroscopy not possible and there is suspicion of pharyngeal or

gastric outlet obstruction on clinical symptoms (dysphagia or vomiting)

Oesophageal obstruction (endoscopy preferable, especially if previous gastric surgery)

Small bowel follow-through Subacute small bowel obstruction, duodenal diverticulosis

Small bowel magnetic resonance imaging or magnetic

resonance enteroclysis (real-time imaging of liquid

moving through the small bowel)

Crohn’s disease, lymphoma, obscure gastrointestinal bleeding

CT colonography Altered bowel habit, iron deficiency anaemia, rectal bleeding: alternative to colonoscopy in

the frail, sick patient, if colonoscopy is unsuccessful or if not acceptable to patient to

diagnose colon cancer, inflammatory bowel disease or diverticular disease; useful in colon

cancer screening

Abdominal ultrasound scan Biliary colic, jaundice, pancreatitis, malignancy

Gallstones, liver metastases, cholestasis, pancreatic calcification, subphrenic abscess

Abdominal CT Acute abdomen, suspected pancreatic or renal mass, tumour staging, abdominal aortic

aneurysm

Confirms or excludes metastatic disease and leaking from aortic aneurysm

MR cholangiopancreatography (MRCP) Obstructive jaundice, acute and chronic pancreatitis

Pelvic ultrasound scan Pelvic masses, inflammatory diseases, ectopic pregnancy, polycystic ovary syndrome

Pelvic structures and abnormalities

Ascitic fluid

Invasive procedures

Upper gastrointestinal endoscopy Dysphagia, dyspepsia, gastrointestinal bleeding, gastric ulcer, malabsorption

Gastric and/or duodenal biopsies are useful

Lower gastrointestinal endoscopy (colonoscopy) Rectal bleeding, obscure gastrointestinal bleeding, altered bowel habit, iron deficiency

anaemia

Able to biopsy lesions and remove polyps

Video capsule endoscopy Obscure gastrointestinal bleeding with bidirectional negative endoscopies, suspected small

bowel disease (vascular malformations, inflammatory bowel disease)

Endoscopic retrograde cholangiopancreatography (ERCP) Obstructive jaundice, acute and chronic pancreatitis

Mainly therapeutic role

Stenting strictures and removing stones

Endoscopic ultrasound ± fine-needle aspiration (FNA) or

Tru-Cut needle biopsy

Staging of upper gastrointestinal or pancreatobiliary cancer

Drainage of pancreatic pseudocysts

Laparoscopy Suspected appendicitis or perforated viscus, suspected ectopic pregnancy, chronic pelvic

pain (e.g. due to endometriosis or pelvic inflammatory disease), suspected ovarian disease

(e.g. ruptured ovarian cyst), peritoneal and liver disease

Ultrasound- or CT-guided aspiration cytology and biopsy Liver metastases, intra-abdominal or retroperitoneal tumours

Liver biopsy Parenchymal disease of liver

Tissue biopsy by percutaneous, transjugular or laparoscopic route

Others

Pancreatic function tests Stool elastase, pancreolauryl test

CT, computed tomography.

Investigations • 115

6

A

B

C

Fig. 6.26 Radiography in gastrointestinal disease. A Air under the

diaphragm on chest X-ray due to a perforated duodenal ulcer. B Dilated

small bowel due to acute intestinal obstruction. C Dilated loop of large

bowel due to sigmoid volvulus.

A

B

Fig. 6.27 Ultrasound scan of the gallbladder. A, Thick-walled

gallbladder containing gallstones. B, Posterior acoustic shadowing.

B

A

Fig. 6.28 Gastrointestinal endoscopy. A Gastric ulcer. B Gastric

varices.

116 • The gastrointestinal system

Fig. 6.29 Colonoscopy. Colon cancer.

A

Fig. 6.30 Computed tomogram of the pelvis. A, Diverticular abscess.

OSCE example 1: Abdominal pain and diarrhoea

Mr Reid, 29 years old, presents with a 6-month history of anorexia, 7 kg weight loss, abdominal pains and diarrhoea (liquid stool). He underwent

appendicectomy 4 months ago following severe right iliac fossa pain.

Please examine the gastrointestinal system

• Introduce yourself and clean your hands.

• Start with a general inspection: body habitus, signs of dehydration, fever and pallor.

• Inspect the hands: palmar erythema, finger clubbing, leuconychia, koilonychia, nicotine stains and swollen finger or wrist joints.

• Inspect the face: signs of anaemia (pallor, angular stomatitis), swollen lips and aphthous mouth ulcers.

• Inspect the skin: erythema nodosum or pyoderma gangrenosum.

• Inspect the abdomen: laparotomy scars or skin fistulae.

• Palpate for right iliac fossa tenderness or the presence of a firm, non-tender mass.

• Offer to examine the perianal area for the presence of dusky blue discoloration, oedematous skin tags and the presence of fissures, fistulae or

ulcerations.

• Thank the patient and clean your hands.

Summarise your findings

This 29-year-old man with a history of weight loss and diarrhoea appears comfortable at rest but looks thin. He has a recently healed appendicectomy

scar, mild periumbilical and left iliac fossa tenderness, and normal bowel sounds.

Suggest a differential diagnosis

The differential diagnosis is Crohn’s disease and irritable bowel syndrome.

Suggest initial investigations

Full blood count, C-reactive protein, liver function tests, urea, creatinine and electrolytes, iron studies, vitamin B12 and folate levels, ileocolonoscopy and

small bowel magnetic resonance imaging, faecal calprotectin.

Investigations • 117

6

OSCE example 2: Jaundice

Mr MacDonald, a 61-year-old retired salesman, presents with increasing tiredness and loss of appetite over 4 months. Two weeks ago he noticed dark

urine and pale stools, and his friends have remarked that his eyes have become yellow. He has drunk a litre of whisky a day for the last 5 years,

although recently he has cut down to a bottle of whisky every 3 days.

Please examine this patient’s abdomen

• Introduce yourself and clean your hands.

• Unless prompted otherwise, proceed to peripheral examination prior to concentrating on the abdomen.

• Carry out a general inspection: body habitus, evidence of malnutrition, pallor or jaundice, scratch marks on the forearm and back, bruising.

• Examine the hands: palmar erythema, finger clubbing, leuconychia, Dupuytren’s contractures.

• Check for flapping tremor.

• Examine the face: telangiectasias, xanthelasmas, bilateral parotid enlargement and jaundice (yellow sclera of the eyes and skin).

• Smell for alcohol or fetor hepaticus.

• Inspect the neck and chest for spider naevi, gynaecomastia; look for axillary and chest hair loss.

• Inspect the abdomen for distension, everted umbilicus, caput medusae or scars of recent drain insertion.

• Palpate and percuss the abdomen for hepatomegaly and splenomegaly.

• Percuss for shifting dullness.

• Auscultate for hepatic bruits.

• Look for peripheral oedema.

• Thank the patient and your clean hands.

Summarise your findings

This patient is jaundiced with multiple spider naevi on the chest and abdomen. He has generalised abdominal swelling with shifting dullness and a firm

liver edge palpable 2 cm below the costal margin.

Suggest a differential diagnosis

The differential diagnosis is alcoholic cirrhosis, chronic hepatitis and hepatoma.

Suggested initial investigations

Liver function tests, ferritin, viral hepatitis screen, full blood count and prothrombin time, urea, creatinine and electrolytes, alpha-fetoprotein, abdominal

ultrasound scan and upper digestive endoscopy (to check for oesophagogastric varices).

Integrated examination sequence for the gastrointestinal system

• Position the patient: supine and comfortable on the examination couch. Expose the abdomen from the xiphisternum to the pubic symphysis.

• Inspection: start with general observation, then inspect the skin, face, neck and chest, and finally the abdomen.

• Palpation:

• Begin with light, superficial palpation away from any site of pain, then repeat with deeper palpation.

• Describe any mass and decide whether there is an enlarged abdominal organ.

• Palpation for hepatomegaly:

• Ask the patient to breathe in deeply through the mouth and feel for descent of the liver edge on inspiration.

• Move your hand progressively up the abdomen, between each breath, until you reach the costal margin or detect the liver edge.

• Percussion to confirm hepatomegaly:

• Ask the patient to hold their breath in full expiration.

• Percuss for liver dullness and measure the distance in centimetres below the costal margin.

• Palpation and percussion for splenomegaly:

• Start with your hand over the umbilicus, moving diagonally up and left to feel for the splenic edge as it descends and moves towards the midline

on inspiration.

• Check for ascites (shifting dullness):

• Percuss from the midline out to the flanks for dullness.

• Keep your finger on the site of dullness in the flank; ask the patient to turn on to their opposite side and then percuss again. If the area of

dullness is now resonant, shifting dullness is present.

• Check for a fluid thrill:

• Place the palm of your left hand flat against the left side of the patient’s abdomen and flick a finger of your right hand against the right side of

the abdomen. If you still feel a ripple against your left hand, a fluid thrill is present.

• Auscultation:

• Listen to the right of the umbilicus for bowel sounds, above the umbilicus over the aorta for arterial bruits, lateral to the umbilicus for bruits from

renal artery stenosis, and over the liver for hepatic bruits.

• Check for peripheral oedema.

• Consider a rectal examination (always with a chaperone).

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7

The nervous system

Richard Davenport

Hadi Manji

Anatomy and physiology 120