GIT H & PPresenting symptoms 1) Abdominal pain.2) Appetite or weight change.3) Nausea and vomiting.4) Heartburn and acid regurgitation.5) Dysphagia.6) Diarrhea.7) Constipation.8) Mucus.9) Bleeding.10) Jaundice.11) Pruritis.12) Abdominal swelling.13) Lethargy.

Abdominal painAsk about …1) Frequency and duration (acute or chronic).

N.B. if the pain is chronic you should ask about the daily pattern of pain (is it more at day or night?).

2) Site and radiation.-If radiates to back may be pancreatic disease or penetrating peptic ulcer.- If radiates to shoulder may be diaphragmatic irritation.- If radiates to neck may be gastroesophageal reflux.

3) Character and pattern, either: A) Colicky1 (which comes and goes in waves). B) Steady (spasmotic).

4) Aggrevating and relieving factors .-If relieved by antacid, food or vomitting due to peptic ulcer

1 Colicky: A sharp visceral pain resulting from torsion, obstruction, or smooth muscle spasm of a hollow or tubular organ.

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pain or gastroesophageal reflux.- If relieved by defecation or passage of flatus due to colonic disease.* If relieved by rolling around due to colicky pain.* If relieved by lie due to peritonitis.

5) Associated symptoms.

Pattern of pain1) Peptic ulcer disease (1/2 – 2 hours).

It is a burning pain in the epigastrium. It occurs at night and wakes the patient from sleep. It is

associated with upper GI bleeding.2) Pancreatic pain (more than 2 hours).

It is steady epigastric pain and relieved by sitting up and leaning forward. It is associated with vomitting and paralytic ileus.

3) Biliary pain (4 – 24 hours). It is rarely colicky. It is epigastric pain caused by cystic

duct obstruction. It may progress and cause cholecystitis and the pain is shifted to the right upper quadrant.

4) Renal colic. This is colicky pain in the renal angle. Radiates toward the

groin. Associated with vomiting,hematuria and dysuria.5) Bowel obstruction

This is a colicky pain.A) In small intestine due to periumbilical pain.B) In large intestine due to anywhere.

Small bowel obstruction is more frequent pain (with cycle every 2-3 min), large bowel obstruction (10-15 min).

It is associated with vomiting, constipation and abdominal distension.

Appetite or weight loss1) appetite + weight due to malignancy or depression.

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2) appetite + weight due to malabsorption or hypermetabolic state (thyrotoxicosis).

Nausea and vomiting Nausea : is sensation of wanting to vomit. Symptoms :

1) acute symptoms:GIT infection (S. aureus), small bowel obstruction.2) Chronic symptoms:A) Peptic ulcer disease with gastric obstruction.B) Motor disorders (as gastroparesis).C) Acute hepatobiliary disease and alcoholism.D) Psychologenic vomiting.E) intracranial pressure (rarely).

The timing of vomiting can be helpful, e.g.1) If vomiting delayed more than one hour after meal is

typical of gastric outlet obstruction and gastroparesis.2) Early morning vomiting before eating is typical of

pregnancy, alcoholism and intracranial pressure.

Also contents of vomitus must be asked:1) Bile indicates open connection between the duodenum and

stomach.2) Old food indicates gastric outlet obstruction.3) Blood indicates ulceration.

Heartburn and regurgitation Definition of heartburn: It is burning pain or

discomfort in retrosternal area that occurs after the meals,lying on left side.

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-The patient experiences a sour or bitter taste coming up into the mouth.

Cause: Regurgitation of stomach contents (acidic) into oesophagus.

Aggrevated by: 1) bending, stooping or lying supine.2) Alcohol, chocolate, caffeine, a fatty meal, theophylline, calcium channel blockers and anticholinergic drugs.

Relieved by: antacids. Note:Waterbrush : refers to excessive secretion of saliva into the mouth and should not be confused with regurgitation, it may occur rarely in patient with peptic ulcer disease or esophagitis.

Dysphagia Definition : The difficulty in swallowing and may

occur with solid or liquid. Causes of dysphagia: (Table 5.2 p146)

Odynophagia Definition: painful swallowing. Cause: severe inflammation of the esophagusOccur in: 1) infectious esophagitis (candidias, herpes simplex).

2) peptic ulceration of esophagus. 3)esophageal perforation.

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Pharyngeal dysphagia Definition: difficulty in initiating swallowing or complaining of fluid regurgitating into the nose. The cause: neurogenical disease (motor neuron disease as bulbar palsy).

Special consideration: A) If the patient complains of food sticking in the esophagus cause of esophageal blocking.B) If the patient has intermittent dysphagia or only with the first few swallows of food either : 1- Lower esophageal ring. 2- Esophageal spasm.C) If the patient complains of progressive difficulty in swallowing : 1- Stricture. 2- Carcinoma. 3- Achalasia.D) If the patient can not swallow both solid and liquids due to 1- Achalasia. 2- Esophageal spasm.E) if associated with heartburn gastro-oesophgeal reflex with straction formation.

Diarrhea Definition : The increased frequency of stool passage

(more than 3 times/day) or change in consistency of stool to loose and watery.Note: Some patients pass small amounts of formed stool more than 3 times a day because of an increased desire to defecate. Also, the stools are not loose and stool volume is not

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increased. This is not true diarrhea. It may occur in :1) Local rectal pathology.2) Incomplete rectal emptying.3) Psychological disturbances.

Acute diarrhea is mostly caused by infection, but if chronic, has large No. of causes.

Diarrhea is divided into: different groups based on the likely disturbances of physiology..

1) Secretory diarrhea: A) Diarrhea is of high volume (more than one litre per day).B) Persist when the patient fasts.C) There is no pus or blood and stool is not excessively fatty.D) Causes: (The net secretion in the colon exceeds its absorption) 1- Infections .. 1) E. coli. 2)staphylococcus aureus. 3)vibrio cholerae. 2- Hormonal.. 1) vasoactive intestinal polypeptide. 2 2) secreting tumor. 3) zollinger-ellison syndrome. 4) carcinoid syndrome. 3-Villous adenoma.

2) Osmotic diarrhea:A) Large volume of stools related to ingestion of food.B) Disappears with fasting.D) Cause: (excessive solute drag) 1- Lactose intolerance. 2- Magnesium antacid. 3- After gastric surgery.

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4) Abnormal intestinal motility: e.g. thyrotoxicosis, irritable bowel syndrome.

5) Exudative diarrhea: A) Occurs when there is inflammation of colon.B) Stools are of small volume but frequent and associated with blood or mucus.C) Cause: 1- Inflammation bowel disease. 2- Colon cancer.

6) Malabsorption (leads to steatorrhea)A) Steatorrhea: The presence of more than 7g of fat in a 24 hours stool collection.B) Stool is fatty, pale, extremely smelly, float in the toilet and difficult to flush away.

Constipation Definition:Passage of :1- Infrequent stools (fewer than 3 times a week), or2- hard stools, or3- stool that are difficult to evacuate.

Causes of constipation: (can occur with acute or chronic onset)1) Habitual neglect of impulse to evacuate that leads to accumulation of dry large faeces , rectal distension , make the patient less aware of rectal fullness.- It is the most common cause of chronic constipation.

2) Ingestion of drugs As antidepressant ,codeine, calcium and aluminum antacids.3) Metabolic or endocrine disorders E.g. hypothyroidism, hypercalcemia, DM, pheochromocytoma or hypokalemia.4) Neurological disorders E.g… 1)aganglionosis. 2) autonomic neuropathy.

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3) multiple sclerosis. 4)hirschyprung’s disease of spinal cord injury.5) After partial colonic obstruction from carcinoma.6) Slow colonic transit with the absence of structural disease. This may occur more common in young women.

Causes of difficult evacuation:1- Disorders of the pelvic floor, muscles or nerves.2- Anorectal disease (e.g. fissure or stricture). Patient with this problem may complain of straining, feeling of oral blockage or need to self digitate.

Irritable bowel syndrome:Definition: abnormally increased motility of the small and large intestines, generally associated with emotional stress and abdominal pain in the absence of structural defect.

Diagnosed by reporting 2 or more of the following:1) Abdominal pain relieved by defecation.2) Looser of more frequent stool with the onset of abdominal pain.3) Passage of mucus per rectum.4) Feeling of incomplete emptying of rectum following defecation and visible abdominal distension.

Mucus Causes of passage of mucus per rectum:1) Solitary rectal ulcer.2) Fistula3) villous adenoma.4) Irritable bowel syndrome

Bleeding Forms of bleeding:1) Haematemesis (vomiting blood).

A) It indicates that the site of bleeding is proximal to or at the duodenum.B) It is commonly due to chronic peptic ulcer particularly

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duodenal ulcer. Acute peptic ulcer often bleeds without abdominal pain.

2) Melena (passage of jet black stools). It usually results from bleeding from upper GIT. Although right-sided colonic and small bowel lesion can cause bleeding.

3) Haematochesia (bright red blood per rectum). Causes of Haematochesia: 1) Hemorrhoids. 2) Local anorectal diseases.

Causes of GI bleeding (table 5.3. p149)

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Jaundice Definition: yellow discoloration of sclera or skin,

usually noted by the relatives before patient does. This is due to presence of excess bilirubin depositing in skin of sclera.

Symptom checklist with jaundice :1) Ask about colour of urine and stools.

- Pale stools and dark urine occur with obstructive or cholecystolic jaundice.

2) Ask about abdominal pain, e.g. gallstones can cause biliary pain and jaundice.

Changes in urine & faesces with jaundice (table 5.19 p189).

Pruritus Definition: itching of the skin, may be either

generalized or localized. Cholestatic liver disease can cause pruritis that tends to be

worse over the extremities. Causes of pruritus (table 12.5 p 467).

Abdominal swelling Will be discussed latter.

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Lethargy Definition: tiredness and easy fatigability. It is a

common symptom for patients with acute or chronic liver disease.

Cause: anemia due to GIT or chronic inflammatory disease.

Past history : A) Surgical history

The following can occur during surgical procedures:1) Jaundice from anesthesia (multiple uses of halothane).2) Hypoxemia of liver cells (hypotension during the

operation or postoperative period).3) Direct damage of bile duct.B) past illness

1) History of remitting epigastric pain in patient present with severe abdominal pain may indicate peptic ulcer has been perforated.

2) History of inflammatory bowel disease is very important because it is a chronic disease that tends to increase.C) treatment history

1) Bleeding from acute or chronic damage to GIT can be caused by NSAID drugs.

2) Acute hepatitis can be caused by the following:1- Halothane. 2- Phenytoin. 3-chlorothiazide.

3) Cholestasis can be caused by hypersensitivity reaction to the following:

1-Chlorpromazine. 2- phenothiazines .3- sulphonamides. 4- sulphonylurease. 5-phenylbutazone. 6- rifampicin.

7- nitrofurantoin. 8- anabolic steroids and contraceptive pill cause dose-related cholestasis.

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4) Fatty liver caused by:1) alcohol use. 2 ) tetracycline. 3) valporic acid. 4) amiodarone.

5) Acute liver cell necrosis may occur by over dose of paracetamol.

Social history : Patient occupations: This may be relevant. E.g.1) Healthy care workers may be exposed to hepatitis.2) Toxin exposure also by important in chronic liver disease

(carbon tetrachloride, vinyl chloride). Travel history: is important especially where hepatitis

is endemic or other diseases. Blood transfusion history or history of any

injection is important .e.g hepatitis B or C can be transferred in this way.

Family history: Family history of bowel cancer or inflammatory bowel

disease is important. A positive family history of jaundice, anemia, splenectomy

or cholecystectomy may occur in patient with hemolytic anemia or familial hyperbilirubinemia.

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Begging a physical examination

(1) introduction ,privacy & positioning: (alwys tell the PT what you are doing).

)2 (General inspection ł (appearance): - appearance: well or ill (face, foot, hand, eye ,mouth, Higden, dental care). - body built: obese, thin, cachexic - color : pale, cyanotic, jaundice. - Distreast: respiratory And cardic (stridulous , tachypnoic , upset, comfortable) - environment: IV line ,BP, catheter, and ECG.

NOTE: the general inspection ∏-which is related to the ill system- could be done here also.

(3) Vital singes: BP, Temp, respiratory rate, pulse ( regulatory, rate.

)4 (exposure of the needed area: this could be done after the general inspection .∏

(5)on the ill system :general inspection ∏ (related to the ill system), inspection, palpation, precaution auscultation

The GIT examination

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Positioning the patient Lying flat with head resting on one pillow. This relaxes the

abdominal muscles and facilitates abdominal palpation.General appearance1) Jaundice.2) Weight and wasting :

A) It may result of GIT malignancy or alcoholic chirrosis.B) Note any folds of loose skin hanging from the abdomen and limbs (indicates recent weight loss).C) Obesity can cause fatty infiltration of liver (non-alcoholic steatohepatitis).D) Anabolic steroids can induce increase in muscle bulk but also induce liver tumours.

3) Skin: look if there is..A) Pigmentation: either1) Generalized : because of chronic liver disease as hemochromatosis (because hemosiderin stimulates melanocytes to produce melanin).2) Addisonian type (sunkissed pigmentation) : because of malabsorption. It occurs in the nipple, palmar creases, pressure areas and mouth.B) Peutz-Jeghers syndrome:Discrete, brown-black lesions around the mouth, on the buccal mucosa, fingers and toes are associated with hamartomas of the small bowel and colon which can present with bleeding or intussusception.C) Acanthosis nigricans:These are brown to black elevations of the epidermis due to papillomas and found in axillae and nape of neck and associated with GIT carcinoma, lymphoma, acromegaly and diabetes millitus.D) Hereditary hemorrhagic telangectasis:Multiple telangiectasia found in lips and tongue. It is associated with arteriovenous malformation in the liver.E) Porphyria cutanea tarda:Fragile vesicles appear on exposed areas of the skin and heal with scarring. The urine is dark. It is associated with

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alcoholism, liver disease and hepatitis C.F) Systemic sclerosisTense tethering of the skin and is associated with gastroesophageal reflux.

4) Mental state: See if the patient is stuporous or comatosed because of

hepatic encephalopathy due to fulminant hepatitis (acute liver failure) or cirrhosis (chronic liver failure).

The hand The abnormalities here indicate chronic liver disease.

The nails1) Leuconychia1:

-Occurs in hypoalbuminemia.-Mechanism is unknown (It may be that compression of capillary flow by extracellular fluid is the explanation).- Thumb and index are more affected.N.B.1- Muehrcke’s lines (transverse white lines) can occur in hypoalbuminemia. 2- Blue lunulae may be seen with Wilson’s disease.

2) Clubbing : Caused by cirrhosis, inflammatory bowel disease and celiac disease. It is associated with cyanosis.

The palm1) Palmar erythema (liver palms):

Definition: It is reddening affecting thenar and hypothenar eminences, and sole of the foot. Causes: 1.chronic liver disease. 2.pregnancy. 3.thyrotoxicosis, or

1 In Mosby encyclopedia: a benign, congenital condition in which white patches appear under the nails. Trauma, infection, and many systemic disorders can cause white spots or streaks on nails. A common cause is the presence of air bubbles under the nails.

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4.chronic leukemia. Also, it can be normal.2) Anemia:- Inspect the palmar crease for pallor. -It is caused by GIT blood loss, malabsorption of folate and vit B 12, hemolysis or chronic disease.

3)Dupuytren’s contracture: Definition: It is a visible and palpable thickening and contraction of the palmar fascia causing permenant flexion most often of ring finger. It is bilateral and occasionally affects the feet.

4) Xanthine : is in the palmar fascia (this may be related to the pathogenesis). Cause: associated with alcoholism (not liver disease) also it could be familial.

5)Hepatic flap (asterixis): Examination: tell the patient to extend his hands and

separate his fingers for 15 seconds and if the hands shakes it indicates asterixis.* It may occur in other places as arms, neck, tongue, jaws or eyelids.* It is usually bilateral, tends to be absent at rest, and is brought on by sustained posture.

Cause: Interference with the inflow of joint position sense information to the reticular formation in the brainstem.

Occur in: 1.hepatic encephalopathy. 2.cardiac.3. respiratory. 4.renal failure 5.hypoglycemia. 6.hypokalemia, 7.hypomagnesemia. 8.barbiturate intoxication.

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The arms1) Bruising:

A) Ecchymosis1 (large bruise):is due to clotting abnormality. Causes of clotting abnormality (related to GIT):A) Liver damage can interfere with protein synthesis and therefore the production of all clotting factors (except factor VIII made in Reticuloendothelial system).B) Obstructive jaundice results in a shortage of bile acids in the intestine, and therefore may reduce absorption of vitamin K which is essential for the production of clotting factors II, VII, IX and X.B) Petechiae (pinhead sized bruises): Caused by:1- Chronic alcohol consumption result in bone marrow depression causing thrombocytopenia which cause petechiae.2- Splenomegaly secondary to portal hypertension can cause hypersplenism which result in destruction of platelets in spleen.3- Acute hepatic necrosis.

2) Muscle wasting : because of alcohol.

3) Scratch marks due to pruritus found in patient with obstructive or cholestatic jaundice in primary biliary cirrhosis.

1 Ecchymosis: discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls.

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4) Spider naevi: Definition: Central arteriole from which small vessels radiate. Found in area drained by superior vena cava (arms, neck, and chest wall). Examination: Pressure applied with a pointed object to the central arteriole causes blanching of the whole lesion. Rapid refilling occurs on release of pressure. -The finding of more than 2 spider naevi is likely to be abnormal. Cause: Not known (may be related to estrogen which is a vasodilator).Occur in: cirrhosis, viral hepatitis or pregnancy.Differential diagnosis: * Campell de Morgan spots, venous stars and hereditary hemorrhagic telangiectasia.* Campell de Morgan spots are elevated red circular lesions occur on abdomen or the front of the chest. They don’t blanch on pressure.* Venous stars occur on the dorsum of feet, legs, back and lower chest. They occur because of venous pressure and they aren’t obliterated by pressure.* Telangectasiae resemble spider naevi.

5) Palpate axillae for lymphadenopathy.

6) Look for acanthosis negricans.

The face (eye, parotid, mouth, neck and chest)The eyes1) Jaundice .2) Anemia .3) Kayser-Fleischer rings .

These are brownish green rings occurring at the periphery of the cornea due to deposits of copper. It found in Wilson’s disease.

4) Iritis : seen in inflammatory bowel disease.

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5) Xanthelasma : are yellowish plaques in the subcutaneous tissue in the periorbital region. Serum cholesterol is . It is seen in patient with primary biliary cirrhosis.

6) Periorbital purpura (black eye syndrome) sign of amyloidosis.

Parotids Examination: Ask the patient to clench the teeth so that

massters muscles is palpable. Then you palpate the parotid behind the muscle and in front of the ear.- It is normally impalpable.

Parotidomegaly is associated with alcoholism due to fatty infiltration secondary to alcohol toxicity.

Tender swollen parotid suggests the diagnosis of parotitis.

The mouth1) Teeth and breath: (Tables5.8 p161)

Check: - Real or false teeth. If false, remove it. -Gums if there is hypertrophy or pigmentation. -Decayed teeth may be responsible for fetor.N.B. fetor hepaticus (sweet smell of the breath). - It is indication of severe hepatocellular disease due to methylmercaptans. -Severe fetor hepaticus fills the patient’s room and indicates a precomatose condition in many cases.

2) The tongue:A) Coating : thickened epithelium with bacterial debris and food particles especially in smokers. It occurs frequently in respiratory tract infections but is not related to any abdominal disorder.B) Lingua nigra (black tongue) due to elongation of papillae over the post. part of the tongue which appear dark because of accumulation of keratin. Bismuth compounds may cause a black tongue.C) Geographical tongue:- Red rings and lines occur on surface of tongue. It may be sign of riboflavin (vit B2) deficiency.

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D) Leucoplakia: white coloured thickening of the mucosa. Causes include: 1.sore teeth. 2.smoking, 3.spirits. 4.sepsis or syphilis. (ssssss). N.B. leucoplakia can occur in vulva, anus and larynx.E) Glossitis:Smooth appearance of the tongue which may also be erythromatous. The appearance is due to atrophy of the papillae. Causes are : deficiencies of iron, folate and vit B12. Glossitis is common in alcoholics and can occur in carcinoid syndrome.F) Macroglossia (enlargement of the tongue) occur in:1) Down’s syndrome.2) Acromegaly.3) Hemangioma or lymphoma.4) Amyloidosis.

3) Mouth ulcers: -It heal without scarring.- The commonest type is aphthous ulceration.- Causes are: 1.crohn’s disease. 2.coeliac disease .and 3.AIDS (but the mechanism is not known).N.B. Angular stomatitis : refers to cracks at the corners of the mouth because of vit B6, B12, folate and iron deficiency.

4) Candidiasis: It causes the appearance of creamy white curd-like patches in the mouth which are removed only with difficulty and leave a bleeding surfaces.- It may spread to esophagus causing dysphagia and odynophagia. Causes include: immunosuppression, antibiotics which inhibit the normal oral flora, oral hygiene, iron deficiency and DM.

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The neck and chest It is important to feel for supraclavicular nodes especially

on the left side. These may be involved with gastric or other gastrointestinal malignancy or with lung cancer.

Troisier's sign: The presence of large supraclavicular node in combination with carcinoma of the stomach.

Gynecomastia may be a sign of chronic liver disease or cirrhosis or chronic active hepatitis. Another causes include: use of spironolactone.

The abdomen InspectionPositioning:

The patient should lie flat on the bed with one pillow under the head and abdomen exposed from nipples to symphysis pubis.

Look for the following :1) Abdominal scars : indicate previous surgery or

trauma. Surgical scars may be:A) laparoscopic surgical scars (around umbilicus).B) Fistulae.C) Stromas (end-colostomy, loop colostomy or ileostomy).

2) Generalized abdominal distension : Causes of distension :1- Fat (gross obesity).2- Fetus.3- Flatus (gageous extension due to bowel obstruction).4- Faeces.5- Fluid (Ascites).6- Filthy big tumour (e.g. ovarian tumour).7- Phantom pregnancy.

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3) Shape of umbilicus : gives sign for underlying causes e.g. a) Umbilicus in shallow, everted and pushed downward in case of ascitis. b) Umbilicus is pushed upward by the uterus in case of pregnancy also may result from huge ovarian cyst. c) Umbilicus buried in fat suggests that the patient eat too much.

4) Local swellings : indicate enlargement of one of abdominal or pelvic organs.

5) Hernia : protrusion of intrabdominal structures through abnormal opening.Causes of hernia:1) Previous surgery weakening abdominal wall (incisional hernia).2) Congenital abdominal wall defect.3) Chronic increase in intra-abdominal pressure.

6) Prominent veins : can be seen on abdominal wall.- If it is present you should detect direction of the vein.- How can you detect direction of prominent vein? (see fig 5.10 p165). First block the vein by one finger then, empty the blood using the second finger away from the first finger. Remove the 2nd finger. If refilling occur this indicate that the direction towards the blocking finger (first finger).- Test the prominent veins separately below and above the umbilicus.

- The direction of veins can be:1) Away from umbilicus (called caput madusae).- Occurs in case of portal hypertension… How?- In portal hypertension there is a portosystemic shunt occurs through umbilical veins that become engorged.2) Upward toward the heart.Occurs in case of inferior vena caval obstruction due to tumour or thrombosis and sometimes due to tense ascitis.

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7) Visible pulsation : An expending central pulsation in the epigastrium suggests abdominal aortic aneurysm.

8) Visible peristalsis :-May occur in normal very thin people occasionally.- Usually suggest intestinal obstruction.- In pylori obstruction due to peptic ulceration or tumour it appears as a slow wave passing across upper abdomen from left to right.-In the distal small intestine obstruction the same movement occurs in the center of abdomen.

9) Skin lesions :1) Vesicles of herpes zoster- has a radicular pattern (localised to one side of abdomen in area distributed by single nerve root).2) Sister Joseph nodule: Metastatic tumour deposit in the umbilicus.3) Discoloration of umbilicus with faint bluish stain (Cullen’s sign occurs in case of extensive haemoperitonium and acute pancreatitis).4) Discoloration of skin in the flanks (Grey-Turner’s sign) occurs in severe cases of acute pancreatitis.

10) Striae :-Pink linear marks with wrinkled appearance of the skin produced by stretching of abdominal wall severe enough to cause rupture of the elastic fibers.- When these wide and purple coloured it may be caused by Cushing’s syndrome. Also, striae can be caused by ascitis, pregnancy or recent loss of weight.

11) Last thing! squat down beside the bed so, your eyes at the level of patient’s abdomen. Ask the patient to take deep breath. Look for evidence of asymmetrical movement indicating pregnancy or mass.

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Palpation Note on examination:

-Reassure the patient that the exam will not be painful and use warm hands.-Ask the patient if any area is tender and examine it last.- If necessary, ask the patient to bend the knees to relax the abdominal wall muscles.-For palpation of the edges of organ, the lateral surface of the forefinger is the most sensitive part of the hand.

4 types of palpation:1) Superficial: for any mass , movement is at metacarpophalangeal joints.2) Deep: for liver and spleen.3) Bimanual : for kidney.4) dipping : for colon.

N.B. 1) Guarding of the abdomen: it is resistance to palpation due to contraction of abdominal muscle which may result from tenderness or anxiety and may be voluntary or involuntary (peritonitis).2) Rigidity:Constant involuntary contraction of abdominal muscle associated with tenderness and indicates peritoneal irritation.3) Rebound tenderness:-When u press over the abdomen slowly and then u release ur hand rapidly, a sudden pain is felt (stabbing) and this is a sign for peritonitis.

The liver palpation …1) Put ur hand parallel to the right costal margin and begin ur

palpation in the right iliac fossa.2) Ask the patient to breath in and out slowly through the

mouth. With each expiration, the hand is advanced by 1 or 2 cm closer to the right costal margin.

Note: 1) The edge of the liver may be hard or soft, tender or non-

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tender, regular or irregular and pulsatile or non-pulsatile.2) Normal edge is soft and regular with sharply defined border and the surface of the liver is smooth.- The normal upper border of the liver is at the level of the 6 th

rib in about the midclavicular line.-The normal span is less than 12.5 cm.- Other causes of a normal but palpable liver include ptosis due to 1.emphysema. 2. asthma. 3.subdiaphragmatic collection, 4. a Riedel’s lobe.Riedel’s lobe: is a tongue- like projection of the liver from the right lobes inferior surface.

The gallbladder Th gallbladder is palpable below the right costal margin

where this crosses the lateral border of the rectus muscles. Note:

1) If biliary obstruction or acute cholecystitis is suspected, the examining hand should be oriented perpendicular to the costal margin, feeling from medial to lateral.2) If gallbladder is palpable, it will be felt as a bulbous, focal rounded mass which moves downwards on inspiration.3) Murphy’s sign should be sought if cholecystitis is suspected. On taking a deep breath, the patient catches his breath when an inflamed gallbladder presses on the examiner’s hand which is lying at the costal margin.4) Courvoisier’s law : if gallbladder is enlarged and the patient is jaundice, the cause is unlikely to be gallstones. Rather, carcinoma of the pancreas or lower biliary tree resulting in obstructive jaundice.

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The spleen - It’s edge should be sought below the umbilicus in the midline initially.

-2 hands technique is recommended :Left hand is placed posterolaterally over the left lower ribs and the right hand is placed on the abdomen parallel to the left costal margin.- Don’t begin from costal margin, somewhat far and as u progress by ur right hand, increase pressure by ur left hand.- If spleen in not palpable, let the patient lie near to u and start palpation.

Causes of Hepatomegaly , Splenomegaly & Hepatosplenomegaly

Hepatomegaly Splenomegaly Hepatosplenomegaly

Congestive heart failure

Leukemia Infectious mononucleosis

Fatty infiltration (e.g. alcohol liver

disease)

Hemolytic anemia Myelofibrosis

Congenital Riedel’s lobe

Portal hypertension Polycythemia

Viral hepatitis Rheumatoid arthritis

Hepatic cirrhosis

Malignancy Infections e.g. malaria, bacterial

endocarditis

Lymphoma

Amyloidosis, sarcoidosis

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The kidneyTo palpate the right kidney

Right kidney: put ur left hand in the back by which the heel of the hands should be in the loin and ur hands push the kidney forward and ur right hand should be in the right upper quadrant.When palpable, the kidney feels like a swelling with rounded lower pole and a medial dent (hilum).

How to differentiate between spleen and kidney?1) The spleen has no palpable upper border. So u can’t feel the space between the spleen and costal margin.2) The spleen, unlike the kidney, has a notch which may be palpable.3) The spleen moves inferomedialy on inspiration while the kidney moves inferiorly.4) The spleen is dull but kidney is resonant because kidneys lie posterior to loops of gas filled bowel.5) Friction-rub may be heard over the spleen, but never over the kidney because it is too posterior.

Other abdominal masses: Causes of abdominal masses (Table 5.14 p174).

We should look for the following:1) Stomach and duodenum :

The presence or absence of tenderness while palpating the epigastrium is not helpful in making diagnosis of peptic ulcer.The succussion splash (sign of hipocrates) may occasionally present in patient with gastric outlet obstruction, grasp one iliac crest with each hand and place your stethoscope close to epigastrium when shake the patient vigorously from side to side. You will hear a splashing noise due to excessive retained fluid in an obstructed stomach.N.B. The test is not useful if the patient has just drunk a pint of milk or other fluid for ulcers so you should wait 3 hours to examine him again.

2) Pancreas: A large pancreatic pseudocyst following acute pancreatitis

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may be palpable as round swelling above umbilicus. It is characteristically: 1) Tense. 2) Not descend with inspiration. 3) Fixed. Pancreatic carcinoma may be palpable in thin patients.

3) Aorta: Arterial pulsation from abdominal aorta may be present in the epigastrium in normal thin people. - The normal width of abdominal aorta is about 3 cm. So, measure the width first. Then measure the width of pulsation. With aortic aneurysm the pulsation expansile (it enlarged with the systole).- If an abdominal aortic aneurysm is larger than 5 cm in diameter it usually indicates surgical repair.

4) Bowel: The sigmoid colon is often palpable in severe constipated patient with soft abdominal wall and hard feces.- Rarely, carcinoma of the bowel may be palpable.-In the examination of children or adults with chronic constipation a megarectum, the enlarged rectum containing stool may be felt above symphysis pubis.

5) Bladder: An empty bladder is impalpable. If there is urinary retention, the upper border of the bladder may palpable above symphysis pubis. The lower border is impalpable. The swelling is typically regular, smooth, firm and oval shaped. It sometimes may reach the umbilicus. To differentiate between bladder and other pelvic enlargement,The patient should empty the bladder.

6) Inguinal lymph nodes: There are 2 groups. One along the inguinal ligament and the other along the femoral vessels.

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7) Testes: Testicular atrophy occur in chronic liver disease (alcoholic liver disease, haemochromatosis). Its mechanism due to falling of testosterone level.

8) Anterior abdominal wall:- Some causes of anterior abdominal wall masses (Table 5.15p175)- We should differentiate between ant. abdominal masses and intra-abdominal masses. To do this, ask the patient to fold the arms across the upper chest and sit halfway up. An intra-abdominal mass disappears or decreases in size but ant. Abdominal mass will remain unchanged. This test called (carnett’s test). -We should also differentiate between pain arise from abdominal wall and intrabdominal pain. To do this feel for an area of localized tenderness that reproduce pain while the patient in supine. If this found, ask the patient to fold the arms across the upper chest and sit half way up. Palpate again. If tenderness disappear this suggest the pain in abdominal cavity but if tenderness persist or is greater this suggest ant. Abdominal pain. N.B. carnett’s test may be positive when there is visceral disease

with the involvement of parietal peritoneum producing inflammation (e.g. appendicitis).

Percussion

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LiverExamination: (for liver span) Lower border The right side of the abdomen should be percussed in the midclavicular line up to the right costal margin until dullness is encountered. Upper border Percussing down the midclavicular line. Loss of normal liver dullness may occur in:1) Massive hepatic necrosis.2) Free gas in peritoneal cavity (e.g. perforated bowel).

Spleen Percussion over the left costal margin will detect

splenomegaly if spleen is impalpable. Also, if the percussion is dull over the left lower ribs in mid-axillary line, suggest splenomegaly.

Kidneys Percussion over the right or left subcostal mass

distinguishes hepatic or splenic masses from renal masses. Renal masses percussion usually resonant unless sometimes renal masses may overly the bowel.

Bladder Supra pubic dullness may indicate upper border of an

enlarged bladder or pelvic mass.

Ascitis In normal abdomen percussion is resonant over most of the

abdomen due to air in the intestine. Ascites detected by 2 signs :

1) Shifting dullness: Percuss out to the flank until dullness is reached. Mark this point and the patient should be rolled toward you. Wait 30 seconds to minute to let fluid more inside the abdominal

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cavity and percussion repeated over the marked point note that dullness has changed to become resonant over marked point.

2) Fluid thrill : Ask the patient to place the edge of the palm firmly on the center of abdomen. Place one hand over the abdomen and with the other hand flick the other side of abdomen. The thrill will be felt on the hand placed over the abdominal wall. Fluid thrill may also occur when there is massive ovarian cyst or a pregnancy with hydramnios.

Dipping technique : Used when massive ascitis develop because abdominal masses may be difficult to be felt by direct palpation .- The hand placed flat on the abdomen, the fingers are flexed at the metacarpopharyngeal joints rapidly so as to displace the underlying fluid. This enables the fingers to reach a mass covered in ascitic fluid.

Classification of ascitis by serum albumin (table 5.16. p177).

Auscaltation We should look for the following:1) Bowel sounds :

* Bowel sounds can be heard over all parts of abdomen in normal healthy people (have a soft gurgling characters occur only intermittently). Bowel sounds should be described as either present or absent.* Paralytic ileus : Complete absence of bowel sound over a 3 min period.

The bowel obstruction : produces a louder and more high pitched sound with a tinkling quality due to presence of air and liquid (obstructed bowel sound). * Diarrhea : Intestinal hurry or rush that occurs in diarrheal states causes also loud gurgling sound (often

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audible without stethoscope). These sounds are called borborygmi.

2) Friction rubs :-These indicates an abnormality of parietal and visceral peritoneum due to inflammation. They may be audible over liver or spleen as rough creaking or grating noise heard as the patient breathes.- Hepatic causes includes:1) Tumour within the liver (hepatocellular or metastasis).2) Liver abscess.3) Recent liver biopsy.4) Liver infarction.5) Inflammation of liver capsule that cause gonoccocal or chlamydial perihepatitis (Fitz-Hugh-Curtis syndrome). Splenic rub indicates splenic infarction.

3) Venous hums: Area of venous hums :1) Typically heard between the xiphisternum and umbilicus in cases of portal hypertension. It may radiates to the chest or or over the liver. Cause: Large volumes of blood flowing in the umbilical or para-umbilical veins through falciform ligament.2) Over the large vessels such as inf. mesenteric vein or after portacaval shunting. Sometimes a thrill is detectable over the site of maximum intensity of the hum.1

4) Bruits: Arterial systolic bruits can be heard over the liver in the

following: 1) Hepatocellular cancer. 2) Acute alchoholic hepatitis.

1 Cruveihier-Baumgarten syndrome is the association of a venous hum at the umbilicus and dilated abdominal vein. It is almost always due to cirrhosis of the liver. The presence of venous hum or a caput madusae suggest that the site of parotal obstruction is intrahepatic rather than portal vein itself.

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3) With an arteriovenous malformation. 4) Transiently after liver biopsy.

A bruit heard over the spleen in the followings:1) Tumor of the body of pancreas.2) Splenic arteriovenous fistula.

A bruit heard on either side of midline above the umbilicus may indicate renal artery stenosis.

A bruit in epigastrium can be heard in patient with chronic intestinal ischemia that result from mesenteric arterial stenosis can also be heard normally.

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