1. UWE Bristol Gastro-intestinal examination
Anna Neary

2. Gastro-intestinal examination
Introduction
This activity looks at the examination of the gastrointestinal system as a part of a systematic patient assessment. You will need to have completed the consultation models and the history taking activities prior to commencing the physical examination and documentation activities.
In this activity, you will:
1. Overview of the anatomy of the gastrointestinal tract.
2. Consider a systematic approach to the gastrointestinal examination.
3. Determine the elements of a general survey.
4. Explore the skills required to perform an examination i.e. Inspection, palpation and ascultation

3. Gastro-intestinal examination
Anatomy
The gastrointestinal tracts starts at the mouth and finishes at the anus, it includes the oesophagus, stomach, duodenum, small and large bowel and rectum.
Food once swallowed enters the stomach and the start of digestion occurs. It passes through the duodenum and small bowel, where fluid from the pancreas and bile from the liver breakdown complex sugars, fats and proteins. These are then ready to be absorbed through the small bowel mucosa.
The large bowel absorbs water and electrolytes.
Peristaltic contraction moves the faecal bolus to the rectum.
Dividing the abdomen into four quadrants enable you to visualise the abdominal structures.

4. Gastro-intestinal examination
Dividing the Abdomen into four quadrants:

5. Gastro-intestinal examination
Left Upper Quadrant (LUQ)
Left lobe of liver
Stomach
Body and tail of the pancreas
Splenic flexure of the colon
Portions of the transverse and descending colon.
Left Lower Quadrant (LLQ)
Lower portion of the descending colon
Sigmoid colon
Right Upper Quadrant (RUQ)
Right lobe of liver
Gallbladder
Pylorus
Duodenum
Head of the pancreas
Hepatic flexure of the colon
Portions of the ascending and transverse colon.
Right Lower Quadrant (RLQ)
Caecum and appendix
Lower portion of the ascending colon
Iloecaecal junction

6. Gastro-intestinal examination
Systematic Examination
There are three aspects to consider when carrying out a systematic examination:
LOOK: inspect
FEEL: palpate and percuss
LISTEN: auscultate

7. Gastro-intestinal examination
General Survey
First you need to take time to look at your patients overall appearance , remembering the importance of basic assessment i.e. airway, breathing, circulation, disability and exposure and move on only when there is no immediate intervention in these areas. Also consider whether your patient appears to be alert or confused or aggressive. You will need to check their blood pressure in both arms, heart rate, respiratory rate and pulse. Look at hands, check for signs of cyanosis and any nail deformities.
Does you patient look pale, sweaty, are there any signs of cyanosis, are there signs of any shortness of breath?
Think about other factors, is your patient thin or obese are they anxious.
It is important to recognise that in patients who report upper gastro-intestinal pain a cardiac cause is excluded, so ensure that you take a detailed history and explore possible risk factors. Check for peripheral oedema. This survey will then become your opening words for the examination section in your documentation.

8. Gastro-intestinal examination
Some of the hand abnormalities that you may find with patients
who have gastrointestinal disease are outlined below:
Clubbing – swelling of the soft tissue at the nail base, can be due to hypoxia and congenital heart disease, lung disease, inflammatory bowel disease and malignancies.
Terry’s nails – transverse bands of white that cover the nail, pink at the distal aspect, this commonly associated with liver disease.
Koilonychia – this is thin spooned shaped nails with edges turning upwards, this is associated with anaemia, chronic infections, Raynaud’s disease and malnutrition.
Palmar erythema - redness to the palms of the hand, can be a sign of liver disease.
Jaundice – yellow or orange hue colour to skin is a sign of liver disease.

9. Gastro-intestinal examination
Inspection
Look inside mouth, teeth, tongue and buccal mucosa for ulcerations and bleeding.
Look at eyes for signs of anaemia and jaundice
Look at the abdomen and observe for symmetry, check for bumps, bulges, masses, scars, striae (stretch marks), swellings, distension and distended veins. Note the shape and contours, the abdomen should be flat to rounded in people with an average weight.
Look at the abdomen from all angles including from the side looking for pulsations. Shining a light can aid this process as uneven contours can be detected
Check the umbilicus this should be inverted and midline. Pregnancy, ascites, hernia or underlying mass may cause the umbilicus to protrude.

10. Gastro-intestinal examination
The signs and symptoms that would alert you to a patient who
has a gastro-intestinal disease are:
Abdominal pain
Constipation
Nausea and vomiting
Diarrhoea
Liver flap (patient holds their hands out in front for 30 seconds with wrists bent back),
Spider naevi
Jaundice
Ulcerations to mouth
The likely causes of generalised abdominal distension what
are:
Fat
Flatus
Foetus
Faeces
Fluid
Fatal tumour

11. Gastro-intestinal examination
Palpation
Palpate the abdomen using light (depress approx 1.5cm) then deep ( depress approx 5 – 7.5cm) palpation. You are assessing the size, shape, position and tenderness of major organs and to detect masses and fluid. The abdomen should be soft and non-tender as you palpate all four quadrants. Note any lumps or bumps, masses and areas of tenderness or resistance.
Light palpation
Deep palpation

12. Gastro-intestinal examination
Palpation of liver
Palpation of the liver should be performed by placing your hand on the right upper quadrant, with index finger in line with the costal angle.
Ask the patient to breath in and push hand inwards and upwards. A liver edge should be felt.
It should feel smooth and firm and rounded. A solid, nobbly edge may suggest cirrhosis.

13. Gastro-intestinal examination
Palpation of spleen
A spleen is not palpable unless it is enlarged.
Use your left hand under left lower rib cage, position finger tips so they point to axilla and press inwards and upwards.
You can also ask the patient to take a deep breath and feel again.

14. Gastro-intestinal examination
Palpation of the
kidneys
To examine the kidneys place hand on right side of abdomen below the costal margin, above the umbilicus and the left hand under the back below the liver.
Press firmly up with the left hand and down with right.
Repeat on the left hand side.
If enlarged the kidney will be palpable.

15. Gastro-intestinal examination
Palpation of aorta
Press firmly in the upper abdomen, midline and feel for pulsations.
The normal width of the aortas pulsations is 3cm or more
pulsations that are expansile suggests an abdominal aortic
aneurysm.
The measurement does not include the thickness of the abdominal
wall, this can be difficult to feel in obese patients.

16. Gastro-intestinal examination
Percussion
Percussion is use to detect the size and location of organs and air or fluid in the stomach or bowel. Percuss in a systematic manner (1-9). Place middle finger flat on the abdomen starting in the right upper quadrant, using your dominant hand tap the middle finger with the tip of your finger. There are two sounds that will be heard, over the abdomen, dullness when percussing on a solid organ or mass and tympany when percussing over a hollow air-filled organ.

17. Gastro-intestinal examination
Percussion of liver
When percussing the liver you are measuring it’s size, start at the right mid-clavicular line where you will start with lung resonance and percuss down the sound changes to dullness.
Then percuss up starting in the mid clavicular line level with umbilicus and note where the sound changes. Measure between these two points .
In an adult liver span ranges from 6 to 12 cm. Size is gender, height and age dependant, e.g. females, shorter people and people over 80 years old will have smaller livers.

18. Gastro-intestinal examination
Percussion of spleen
The spleen is positioned behind the midaxillary line, when percussing anteriorly, if dullness is found an enlarged spleen is suggested.

19. Gastro-intestinal examination
Percussion of the Renal angle
Percuss the renal angle with your fist with moderate force.
Tenderness here can suggest kidney inflammation.

20. Gastro-intestinal examination
Auscultation
Bowels sounds need to be listened for in all four quadrants with the diaphragm of the stethoscope, listen in a systematic manner starting in the right upper quadrant (1-9). Place the stethoscope on the abdominal wall and listen until a bowel sound is heard, listen for 1-3 minutes if there are no sounds.
Bowel sounds are high-pitched and gurgling noises, they are irregular and vary in frequency, pitch and intensity about 5 and 30 times a minute. Listen for a minute, if you think bowel sound are absent listen for longer.

21. Gastro-intestinal examination
Summary
You have now reached the end of this activity. Here is a summary of the main points:
It is important to know the anatomy of the gastrointestinal tract prior to any examination of the gastrointestinal system.
Examine the abdomen using a systematic approach i.e. general survey, inspection, palpation and auscultation.
Have an understanding of the normal sounds heard when ausultating the abdomen.

22. Gastro-intestinal examination
References
Browes,N et al (2005) Browes introduction to the symptoms and signs of surgical disease. Fourth Edition . Hodder Arnold. London
Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s Clinical Examination. Churchill Livingstone
Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012) Bates’ Nursing Guide to Physical Examination and History Taking. First Edition. Lippincott, Williams and Wilkins.
Rushforth, H (2009) Assessment made incredibly easy. First UK Edition. Lippincott, Williams and Wilkins.
Tortora, G and Derrickson, B (2010) Essentials of anatomy and physiology. Wiley Plus

23. Gastro-intestinal examination
Guided learning (Duration: 2 hour)
Identify a patient in practice and under the supervision of an Advanced Nurse Practitioner or doctor, watch a gastrointestinal examination and then perform a gastrointestinal examination. Use the templates provided as an aid memoir.
Discuss your findings with the ANP or doctor.
Research common gastrointestinal conditions for coeliac disease and colorectal cancer.
Write a reflective piece of work about a patient you have seen and the guidelines you have learnt.
You will also be able to attend a day long face to face skills workshop to complement this learning activity