Leicester Medical School
THE GASTROINTESTINAL SYSTEM
PHYSICAL EXAMINATION
Overview
The abdominal examination should include the following:
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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
Preparation
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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.
General Observations
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Hands
Check visually from the end of the bed. Note:
o Obvious discomfort/pain, breathlessness, distension
o Colour
o Items around the bed (e.g. catheter bag, IV fluids)
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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 dorsiflexed 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
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Neck
-
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
Virchow’s Node – An
enlarged
supraclavicular lymph
node on the left-hand
side. Suggestive of
gastric malignancy.
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)
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
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
Practice Tip!
is rebound tenderness
The liver edge is sometimes
palpable just below the
Deep Palpation
costal margin at the height
- Re-examine using the same technique but now using
of inspiration in normal
more pressure
healthy individuals.
- Note any masses or structural abnormality
Practice your technique on
- Masses should be described in terms of site, size, shape,
your colleagues
surface, consistency, mobility, movement with respiration,
tenderness and pulsatility
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
Practice Tip!
extends in centimetres
The right kidney lies a
o Is the surface smooth or irregular?
little lower than the left.
o Is there any tenderness?
The lower pole of the
right kidney may be
The Spleen
palpable in normal, thin
- Start palpation from the right iliac fossa moving diagonally
individuals.
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.
Rebound Tenderness –
- The spleen has a distinctive ‘notch’ which can help
pain is worse when you
to differentiate it from other structures in
release pressure on the
splenomegaly
abdomen than when you
press down – this is a
sign of peritoneal
The Kidneys
irritation
-
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.
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 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
PERCUSSION
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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’
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.
Ballotting the Kidney
This demonstrates the
mobility of the kidney helping to confirm what
the structure is.
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.
Practice Tip!
Practise listening to as
many abdomens as
possible to recognise the
range of sounds produced
by normal peristalsis
Fluid Thrill
Place your left hand flat against the left 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 right side of the abdomen with the right hand
- Feel for a ripple of fluid against the left hand
AUSCULTATION
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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
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
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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
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.