Year 1 MBChB
Clinical Skills Session
Gastrointestinal examination
Reviewed & ratified by: Mr C Halloran and Dr P Collins Consultant Gastroenterologists
Dr V Taylor-Jones, Ms C Tierney
August 2018
Gastrointestinal Examination
Learning objectives
o To understand the anatomy and physiology of the gastrointestinal system
o To link anatomy and physiology and apply it to the practical skill
o To understand reasons for undertaking gastrointestinal examination
o To be able to carry out elements of a gastrointestinal examination
Theory and background
A full gastrointestinal (G.I.) examination may include examination of the groins, external genitalia and rectum,
depending on the patient presentation and findings.
If a swelling or enlargement of an organ (organomegaly) is suspected or if you find a pulsatile swelling, please seek
immediate advice from a qualified professional.
Indications for abdominal examination
The following list of reasons is by no means exhaustive, a patient may present with;
o Vomiting
o Trauma
o Abdominal pain
o Change in bowel habit
o Abdominal distension
o Change in appetite
o Anaemia
o Swelling
o Weight loss
o Tenesmus (a continual or recurrent inclination to evacuate the bowels).
o Jaundice (when your skin and the whites of your eyes turn yellow. It can be a sign of something serious,
such as liver disease)
Dividing the abdomen into regions
Conventionally the abdomen is divided into 9 regions, there are 4 dividing lines:
midclavicular (2) - vertical
subcostal - upper horizontal
Trans-tubercular - lower horizontal
The 9 regions will each contain their own important organs helping to make diagnosis easier. Think about what
organs are in each of the 9 regions? Answers are at the end of the presentation.
Dividing lines for the nine regions of the abdomen
Upper border of abdomen
The costal margin (rib margin)
demarcates the chest from the
abdomen superiorly
Lower border of abdomen
This is delineated by the
transtubercular line
Alternative to 9 regions is to split abdomen into quadrants
The right environment
The room that the examination is taking place in should be private, with the examination couch off set from the
centre of the room. Within the room there should be a further area with curtains / screens around, offering privacy
to the patient whilst they disrobe and wear a clean gown or cover with a blanket to preserve modesty, while they
are examined. There should be a good light source that will adequately illuminate the area being examined.
As this is an intimate examination a chaperone will be present.
o There should be handwashing facilities.
Ideally the patient should be relaxed and in a warm environment, they should lie flat on their back, with hands by
their sides or a single pillow under their head. Hips and knees may be flexed to relax abdominal muscles if
necessary.
The abdomen should be exposed (the whole upper torso to the suprapubic area – inguinal and genital areas are
covered until they are to be examined).
The examiner should position him/herself to be on a level with the abdominal surface.
Patient safety
Prior to any clinical examination a detailed history should be taken from the patient, this will enable you to tailor
the examination to the patients presenting complaint and additional symptoms the patient may elude to when you
elicit a full history. For guidance on history taking please click MBCHB students – Year 1 – History taking.
General Inspection
1. This can be undertaken with the patient upright, check the patient’s general appearance (demeanour, pallor, jaundice, cachexia (weakness and wasting of the body due to severe chronic illness), etc) Include vital signs, check RR, SPO2, temperature, as appropriate. (See vital signs study guide).
Specific inspection
Check the patient’s mouth, teeth, tongue and breath, for example for hydration status, any bleeding, ulcerations,
redness, or any oral or dental infections.
Inspection of the torso should be done with the patient supine, observe for;
o Look for spider naevi [see prep but covered in more detail in 2nd year]
o Gynaecomastia in males [see prep but covered in more detail in 2nd year]
o Scars
o Rashes
o Distension
o Swellings
o Visible peristalsis
o Abdominal wall movement
o Dilated veins [covered in more detail in 2nd year]
Causes of abdominal distension
Flatus (gas) – taut abdomen which is compressible
Faeces – firm to hard mass take note of position as may be normal finding
Fluid (ascites) – taut abdomen which may be non-compressible dependant on volume
Fat – soft and compressible
Foetus – obstetric palpation will be taught in later year
Fairly big tumours - firm to hard mass
Percussion
When percussing the general abdomen all areas should be percussed and should sound resonant.
When you percuss over the abdominal organs you would expect the liver, spleen and bladder to be dull. The
kidneys will be resonant due to being retroperitoneal with air filled bowel lying over them.
Palpation
There are 3 elements of abdominal palpation:
o Superficial palpation
o Deep palpation
o Specific organ palpation
When palpating, movement of the examining hand should be slow and deliberate (no ‘wiggling’ as this would cause
pain).
Palpation is performed with the flat of the fingers, using the knuckles or (metacarpal pharyngeal) joints as a pivot
on the abdomen.
Superficial Palpation
Always start palpation away from any site of pain and
always observe patient’s face for signs of discomfort.
Palpate the abdominal regions systematically,
preferably at the same height as the patient’s
abdomen.
Superficial palpation is using a light pressure to assess
for tone, tenderness and any obvious abnormalities.
Assessing muscle tone with superficial palpation
During superficial palpation gentle pressure is applied to the abdominal wall allowing the examiner to depress the
anterior wall of the abdomen as the muscles relax, assessing the patient for abdominal pain and other
abnormalities.
Deep palpation
Deep palpation is using firm pressure to assess for
swellings or abnormalities. This must be done with
the palmar aspect of the fingers and you should be
on the same level as the abdomen.
Specific Organ Palpation
These organs are routinely palpated;
o Liver
o Spleen
o Kidneys
This is from the furthest direction enlargement can
occur, towards the position the organ normally lies
to detect enlargement, as explained below.
Palpation of organs
When palpating organs feel for the edges, the edges
provide a better contrast between surrounding
organs/tissues and the organ.
Palpation of organs may be assisted by assessment
of mobility in relation to respiration, this is because
the diaphragm moves down on inspiration, pushing
abdominal organs downwards. If the liver or spleen
are enlarged they may be felt below the costal margin.
o The liver descends towards right iliac fossa on inspiration
o The spleen descends inferio-medially on inspiration towards the right iliac fossa
o The kidneys descend on inspiration
Palpation of the liver
The liver lies predominantly under the ribs on the right side, although it does
cross the mid-line.
The inferior border of the liver lies approximately parallel with the costal margin
(the lower edge of the rib cage).
How liver moves on inspiration
The liver moves inferiorly on inspiration.
How the liver enlarges
Enlargement of the liver also occurs in an
inferior direction
How the liver is palpated
In view of the direction of enlargement, palpation for the liver should commence well
away from the costal margin in the right iliac area. The thumb is extended to
expose the lateral margin of the index finger
The hand is positioned so that the lateral margin of the index finger is parallel with the costal margin.
The patient is asked to take a deep breath in and pressure is applied to the
abdominal wall by the examining hand. If the liver is not palpated, the
examining hand is moved closer to the costal margin by about 1 cm and the
patient is asked to repeat deep inspiration.
The process is repeated until the hand reaches the costal margin or
the inferior edge of the liver is palpated. A normal liver is
impalpable or palpated close to the costal
margin
An enlarged liver may be palpated distal to the costal margin and the
distance is measured in cm from the costal margin.
Palpation of the spleen
The spleen lies entirely under the ribs on the left side
A normal spleen is approximately fist sized and the long axis of the
spleen lies along the line of the 10th rib.
Position of spleen in health
The spleen moves inferio-medially on inspiration,
even on deep inspiration the normal spleen cannot be felt on palpation
To be palpable the spleen must enlarge to at least twice normal size
Position of an enlarged spleen
Enlargement of the spleen occurs in an
inferio-medial direction, a massive spleen
may extend into the right lower abdomen.
With a very large spleen, you may be able to
palpate the distinctive splenic notch
Palpation of the spleen
Palpation for the spleen is facilitated by placing
the left hand under and behind the lower left rib
and pulling upwards and towards you (the
examiner). This may encourage an enlarged spleen,
otherwise not palpable, to appear beyond the costal margin on inspiration.
Some clinicians prefer the patient to roll onto their right side to achieve the same effect.
Use the flat of the palmar surface of
finger tips in a dipping motion to
palpate through the abdominal wall.
In view of the direction of enlargement,
palpation for the spleen should
commence well away from the costal
margin in the right iliac area
The patient is asked to take a deep breath in and
pressure is applied by the examiner’s hand to the
abdominal wall.
If the spleen is not palpated, the examining hand is moved closer to the costal margin by about 1-2 cm. If the
spleen is not palpated the patient is asked to repeat deep inspiration and the process is repeated.
The process is repeated until the spleen is palpated or the costal margin reached, a
normal spleen will not be palpable.
An enlarged spleen may be palpated distal to the costal margin and the distance is
measured in cm from the costal margin.
Palpation of the kidneys
The kidneys extend from the twelfth thoracic vertebrae
to the third lumbar vertebrae. They are not normally
palpable in health. The right kidney is lower than the
left due to the position of the liver and in health they
have a firm consistency with a smooth surface.
Renal angle
The kidneys are retroperitoneal organs and therefore
deep bimanual palpation is required. On preparing for
examination, position the patient close to the edge of the
bed, then tuck one hand under the patient so that the
finger tips nestle in the renal angle.
One hand under the patient’s flank,
fingers in the renal angle (between
posterior costal margin and spine)
The other hand with fingers flat placed
below the costal margin, lateral to the
rectus muscle Hands should be opposite one another
Ask the patient to breathe in deeply and press the
fingers of both hands firmly together. The rounded
lower pole of the kidney may be felt passing between
the opposing fingers as the patient breaths in and out.
Differentiating kidneys from other organs/masses
The kidneys can be “balloted” this a technique where by
a structure that is not fixed can be patted between the
examining hands.
Percussion
Remember percussion technique;-
o Use the tip of the finger
o The blow is delivered by a sharp wrist movement
o Strike the middle phalanx firmly, two to three taps only.
o Remove the striking finger immediately
Routinely percuss for the liver
Routinely percuss from the chest down to the
Abdomen, which is resonant to dull
Repeat from iliac fossa to costal margin again this should be
resonant to dull.
Percussion
Once the liver has been percussed, routinely percuss all other areas of
the abdomen to note if there is any pain or tenderness on percussion.
Auscultation
Bowel sounds – Borborygmus
Bowels sounds are gurgling noises made by air/ liquid moving through
the bowel.
Listen in any area of the abdomen and bowel sounds should be heard, but when examining a patient, listen for 2-3
minutes (or until sounds heard) in the lower right quadrant.
If no sound is heard listen elsewhere on the abdomen for a further 2-3 minutes.
If no sound is heard report the absent bowel sounds immediately to a qualified health care professional.
Answers to the question - what organs are in the 9 regions?
Right hypochondrium – small intestine, right kidney, gallbladder, liver
Left hypochondrium – pancreas, left kidney, colon, spleen
Epigastrium – spleen, pancreas, duodenum, liver, stomach
Right lumbar region – right colon, liver gallbladder
Left lumbar region – left kidney, descending colon
Umbilical – duodenum, ileum, jejunum, umbilicus
Right iliac – caecum, appendix
Left iliac – sigmoid colon, descending colon
Suprapubic – female reproductive organs, sigmoid colon, urinary bladder
Glossary
Borborygmus – Bowel sounds
Cachexia - weakness and wasting of the body due to severe chronic illness Distension – Swelling
G.I. – Gastrointestinal
Jaundice -when your skin and the whites of your eyes turn yellow. It can be a sign of something serious, such as
liver disease
Left lower quadrant – LLQ
Left upper quadrant – LUQ
Organomegaly – Swelling or enlargement of an organ
Right lower quadrant – RLQ
Right upper quadrant – RUQ
Tenesmus – a continual or recurrent inclination to evacuate the bowels.