Clinical Signs &

Examination
of the GIT DR. Abdel
Rahman A
Mokhtar
Professor of
internal Medicine
2015
Clinical Assessment
Clinical Assessment
 UPPER GI Symptoms
Dyspepsia
 Lower GI Symptoms
Act Problems :
Symptoms related to the GI Adenexae
And Now Our Featured Presentation
 Be carefull!!
Introduce yourself before examination
Outpatient clinic should not be crowded
Only one person with the patient, close relative
Be calm and cool
Do not shout, be angry or talk with sarcastic words
Always have the records on the files
Always give detailed information for the
diagnosis & the treatment
 General Physical Examination
Always before the abdominal
examination
Upper part of the patients body
should be naked
Outpatient room should be warm
Be at the right side of the patient
All your belongings should be ready
White coat
Light source
ruler
Pencil, notebook etc.
Enough day light
Hands should be warm and clean
Clinical Assessment
 1 ) Astigmata of chronic liver disease.

2) Systemic manifestations of a GI disease.

3) Astigmata of Systemic diseases involving the GIT & or the liver.

4) Functional consequences of the GI disease. (Nutritional status dehydration

metabolic consequences , functional status in case of liver disease etc. ) .
1 ) Astigmata of chronic liver
disease.
1 ) Astigmata of chronic liver disease.
Terry's nails.
first reported this nail finding in 1954 in
association with patients who had hepatic
cirrhosis.
.
In 1984, Holzberg and colleagues revised the
original describtion of Terry's nails to what is
used today.
The affected nails have a nail bed that is white Type 2 DM, CHF,
or light pink with a distal transverse band chronic RF, and
measuring 0.5 to 3.0 mm in width that is pink to cirrhosis as well as
brown in color. aging are common
The lunula of the nail may or may not be causes of Terry's nails .
present. The degree of pallor of the nail bed The pathogenesis is
and the darkness of the distal band can vary believed to involve
based on how long the underlying systemic
changes in the
disease has affected the patient.
microvascular system.
Gynecomastia
2) Systemic manifestations of a GI disease.
Erythema Nodosum
 Pyoderma
Gangrenosum
Extra-intestinal
manifestations of
Crhon`s disease
3) Astigmata of Systemic diseases involving the GIT & or
the liver.
Wilson`s disease
Haemochromatosis
Autoimmune disease
Thyroid disorder
4) Functional consequences of the GI disease. (Nutritional
status dehydration metabolic consequences , functional status in case
of liver diseas etc. ) .
 Angular Stomatitis
an inflammatory lesion at the labial
commissure
GI related causes:
Celiac disease
Fe, B vit. deficiency
Crohns disease
Plummer-Vinson syndrome
 The appearance of geographic tongue is variable from one
person to the next and changes over time. The LAST image
shows fissured tongue combined with geographic tongue. It is
common for these two conditions to coexist in B12 deficiency.
 The loss of the filiform papillae is known as
atrophic glossitis, and it may be caused by
several different factor The loss of the filiform
papillae is known as atrophic glossitis, and it
may be caused by several different factors.
 Glossitis
inflammation of the tongue

GI related causes
Pernisious anemia
Pemphigus vulgaris
Iron deficiency anemia
 Iron Def Anaemia
spooning & koilonychia

Koilonychia (from the Greek: koilos-, hollow, onikh-, nail), also known as spoon
nails, is a nail disease that can be a sign of hypochromic anemia, especially iron
deficiency anaemia.
Clinical Assessment
Clinical Assessment
Think Anatomically
Anatomy

42
 Exam Order
Inspection
Palpation
Percussion
Auscultation

44
 Inspection
- Visible pulsation.
External Genitalia.
.Inspection of the back
.PR
 Palpation :
Dipping Method
 Auscultation:
Others :
 Percussion:
Abdominal masses for air and fluid.
 Inspection
- Visible pulsation.
Findings of inspection

- Contour
- Skin
- Umbilicus
 Contour of the abdomen

Is it flat or Scaphoid
(Normally slightly
convex from side to side
and up down.)?
Distended?
If enlarged, does this
appear symmetric?
 Symmetrical in shape

slightly full but not distended in older age

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

Standing at the foot of

the table and looking up
towards the patient's head.
Lower yourself until the
anterior abdominal wall
and ask the patient to
breath 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.
Abdomen - Ascites
Abdomen-Obese
Abdomen-Hernia
 Skin
Hair distribution.
Dilated veins.
Pigmentation &
Rashes.
Scars.
Sinuses & fistulas.
Striae.
 Striae
Stretch marks are a light
silver hue.
Pregnancy and obese
individuals
Cushings syndrome
(more purple or pink).
 Pigmentation & Rashes.

Cullens sign
Ecchymosis periumbilically.
(intraperitoneal hemorrhage
ruptured ectopic pregnancy,
hemorrhagic pancreatitis..)

Grey Turner sign

Ecchymosis of flanks.
(retroperitoneal
hemorrhage such as
hemorrhagic
pancreatitis)
 Pigmentation & Rashes.

Sister Mary Joseph nodule:

Skin metastasis of gastric ca

Cafe au lait sign

 Evaluate venous return states

Place index finger side

by side over a vein and
press laterally, milking
vein.
Release one finger and
time refill, repeat with
other finger. Venous
return is in direction of
faster filling.
Upward flow direction indicates IVC obstruction
Collateral veins ve Caput medusa
Outward flow pattern from umbilicus in all directions ? Portal HTN
Scars
 Inspection
- Visible pulsation.
- Subcostal angle.
- Diverication of the recti.
- Hernial orifices.
 You should define the lesion and its location when
you find a lesion.

Subcostal angle.
Diverification of the recti.
Hernias
ncisisonal
Umblical
nguinal
Others
Hernias
 Inspection
- Visible pulsation.
- Visible
pulsation.
- Visible
peristalsis,
- Movement with
respiration.
 Visible Pulsations
More conspicuous in the In those with an aortic
thin than in the fat aneurysm and tortuous
Greater in the old than in aorta
the young. In those who have a mass
Increased in thyrotoxicosis, joining the aorta to the
hypertension, or aortic anterior abdominal wall.
regurgitation)
 Visible Peristalsis
Gastric peristalsis Intestinal peristalsis
is commonly seen in partial and
in neonates with chronic intestinal
congenital obstruction
hypertrophic Colonic obstruction
pyloric stenosis is usually not
manifest as visible
peristalsis
 Abdominal respiration

Abdominal respiration
Increases at lower lung function
Decreases at large ascitis
Peritonitis
 Auscultation:
Others :
Others :
- Friction rubs
- Scratch for the liver border.
- Pregnant lady for ( Fetal Ht S,
Uterine souffle , umb suffle )
Auscultation for bowel sounds

It is performed before percussion or

palpation
 Auscultation for bowel sounds

Bowel sounds lend

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

Bowel sounds at 4 quadrants

Listen for 2 miutes

Hyperactive bowel sounds

Postprandial physiologic
Laksatif consumption
Diare
Early mechanical obstruction

Hypoactive/Paralitik ileus
Adinamic ileus
Peritonitis
Venous hums

Both systolic and diastolic sounds

Portal hypertension
Collatersal circulation
Hepatoma

Arterial Bruits:
Abdominal aorta : Aneurysm, plaque
Renal arteria: Stenosis
 Friction Rubs
On the liver side
After liver biopsy
Acute Budd-Chiari syndrome
Perihepatitis with gynecologic infections
Hepatoma localised at he capsule of the liver

On the Spleen Side

Spleen infarction
Subcapsuller hematoma after trauma
 Palpation :
Dipping Method
 Abdominal Physical Exam
Palpation
Start farthest from pain and move towards it
9 topographic areas :
Light palpation
Deep palpation

87
 Palpation
Superficial Palpation:
How is the situation at
the abdomen?
Are there any sensitive
sides
Any mass
Ant dull
Localizations
 Deep palpation:

Sensitive sides
Patient has defence ?
Muscular defense
Abdominal guarding
automically
Rebound
Rigidity

Mass lesions
Rough ,mooth,
subcutan, deep, with
pain, or painless
 Abdominal Physical Exam
Palpation - Left Upper Quadrant
Liver: left lobe
Spleen
Stomach
Jejunum and proximal ileum
Pancreas: body and tail
Left kidney
Left suprarenal gland
Left colic (splenic) flexure
Transverse colon: left half
Descending colon: superior
part

90
 Liver Palpation

Diameter
Midclavicular 6-12 cm right lobe
4-8 cm left lobe
Use midsternal line for left lobe
Rough ,fibrotic, smooth
Any pain
Nodler, irregler
 Large Hepatomegaly

Amiloidosis
Malign infiltration
Polycystic liver
Congestive Heart Failure
Hepatojuguler reflax
Faty liver
Spleen Palpation
Kidney Palpation
 Huge Splenomegaly

Schistosomiasis.
CML infiltration
Non-Hogkin lymphoma
Kala azar Disease (Leismaniasis)
Agnogenic Myeloid Metaplasia
 Percussion:
Abdominal masses for air and fluid.
 Percussion

Organs
Liver
Midclavicular line and
2. intercostal
Through the
midclavicular line
Total vertical diamter
of hte liver, right lobe
12 cm, left lobe 8 cm
Ascites
 Other methods of Ascites
examination
Fluid thrill
Ballotman for solid organs
 Abdominal Physical Exam
Practice- 20 Minutes
Inspection Palpate
General palpation
Contour Liver
Skin Gallbladder
Movement Spleen
R and L kidneys
Auscultation Abdominal aorta
Bowel sounds Inguinal lymph nodes
Vascular sounds Special:
Murphys sign
Percussion McBurneys point
Abdomen for masses or fluid Rovsings sign
Psoas sign
Liver span
Obturator sign
Spleen Rebound tenderness
Gastric bubble CVA tenderness

102