The document outlines a comprehensive guide for conducting a gastrointestinal examination by Dr. Anas Aljundi, emphasizing the importance of initial interactions, patient appearance, vital signs, and specific examination techniques. It details steps for assessing the hands, face, thorax, and abdomen, including inspection, palpation, and auscultation for various conditions like hepatomegaly and splenomegaly. The protocol concludes with guidelines for examining the groin, external genitalia, lymph nodes, anal area, and lower limbs.

1. Gastrointestinal Examination
Dr. Anas Aljundi
Teaching Assistant – Alquds University
29/3/2020

2. General Things
General things to do in every examination:
1- Greeting
2- Introduce yourself
3- Take PERMISSION
4- Make sure there’s PRIVACY
5- Good light and wash your hands ( high-gel)

3. General LOOK
ABCDE:
• A: Appearance of the patient:
does he look well, in pain, distressed?
• B: Body-built of the patient:
Over-weight or under-weight ? Comment only if obvious.
• C: Consciousness/Color:
Oriented ( place, person and time? ); color: cyanosed?
Jaundiced? Other like plethoric ( like?), bronze-like color (
like?)
• D: Decubitus:
Sitting comfortably? Putting his hands on region of his
abdomen and doesn’t move (like )? Can’t stand still ( like? )
• E: Environment:
Does he connected to cannula? NG-tube? Foley’s catheter?
Cardiac monitoring etc…?

4. General LOOK
Simple example:
the patient looked well, conscious, oriented ( to
time, place and person), jaundiced, not in pain, not
distressed, not cyanosed, not pale or dehydrated.
She was sitting comfortably in her bed, connected
to cannula in her left arm.

5. Start from HANDS
• Examine both hands together, inspect the dorsal
then palmar aspect of both hands, and look for:
2- Koilonychia
(brittle, flat, spoon
shaped- nails in??)
1- Sweaty? Warm? Dry? Cold?

6. Start from HANDS
4- Clubbing (GI causes? Grading? )
3- Leukonychia (white spots on
the nails, due to ???).

7. Start from HANDS
5- Palmar Erythema: in?
6- Pallor of palmar crease
7- Dupuytren’s contracutre

8. Start from HANDS
8- Tremor: - Essential
tremor
- Flapping Tremor ( Asterixis
): in?
9- You may find
muscle wasting

9. Don't Forget VITAL SIGNS
• Vital signs are IMPORTANT;
don’t forget them.
• 1- Pulse: Rhythm? Rate? Volume?
• 2- Respiratory Rate: normal?
• 3- Blood Pressure
• 4- Temperature

10. Examine the FACE
• 1- Eyes: - Jaundice (definition?)
- Pallor of Conjunctiva
• 2- Mouth- Angular chelitits
- Jaundice
- Stomatitis

11. Examine the FACE
• 2- Mouth- Atrophic glossitis ( pale smooth
tongue in….? )
- Aphthous ulcer
- Beefy raw tongue in…
- Halitosis/Fetor hepaticus
- Bilateral Parotid swelling

12. Examine the THORAX
1- Spider Naevi: up to 5 normal
in young healthy woman.
2- Gynecomastia:
3- Loss of hair in..?

13. Examine the ABDOMEN
• POSITION: SUPINE; flat with
arms by his sides. One pillow under
his head to relax his abdomen.
• EXPOSURE: From nipple to midthigh but
for the patient's dignity this is enough
exposure.
• MOVE TO THE END of the bed
and INSPECT the abdomen:

14. INSPECTION
• The horizontal lines:
- Transpyloric (at the level of L1) - mid way between suprasternal notch
and symphesis pubis.
- Transtubercular: Between the upper borders of the two iliac crests.
• The vertical lines:
between the mid- clavicular point and mid- inguinal points.
1- SHAPE of the abdomen:
- normally flat or slightly scaphoid.
- Causes of abdominal distention: 6 F’s

15. INSPECTION
2- Symmetry.
3- Moves with respiration:
pattern of breathing?
paradoxical?
4- Umbilicus:
Inverted? Everted? Centralized?
Obvious discharge?

16. INSPECTION
5- Hair distribution
6- Visible veins
7- Visible Masses

17. INSPECTION
8- Striae
9- Skin lesions
Hyperpigmented/hypopigmented
spots?
- Cullen’s Sign/Grey-turner sign
- Fox sign

18. INSPECTION
10- Visible pulsation
Normal in thin patient.
Can be seen in AAA
11- Visible peristalsis
12- Stomas:

19. INSPECTION
13- Umbilical vs
paraumbilical hernia?

20. INSPECTION
14- Scars
15- Don’t forget
inguinal orifices.

21. PALPATION
Superficial palpation: ask the patient for any
tender or painful area and then start palpating
the nine quadrants away from that region. It’s for
patient’s confidence, temperature, tenderness,
superficial masses and guarding ( if the guarding
is voluntary, it will subside by flexing the knees or
by distraction).

22. PALPATION
Deep palpation: for deep masses and
organomegally

23. PALPATION
- If you found RIF tenderness; what further signs you are looking for:
1- Rebound Tenderness. 2- Rovsing Sign.
3- Psoas sign 4- Obturator sign

24. PALPATION
- If you found RUQ tenderness; what further signs you are looking for:
Murphy’s Sign:

25. Hepatomegaly

26. Hepatomegaly
If you feel the edge, then it could be: Enlarged or displaced (lung hyperinflation).
So what to do?

27. Hepatomegaly

28. Splenomegaly

29. Splenomegaly

30. Splenomegaly
Also:
8- You can’t get
above spleen but
you can in kidney
( Fingers can’t be
insinuated btn costal
margin and spleen )

31. Kidney enlargement

32. AAA palpation
AAA: above the umbilicus, press firmly, assess for pulsation and expansibility.

33. PERCUSSION
For Ascites:

34. PERCUSSION
For Ascites:

35. PERCUSSION
Causes of Ascites:

36. AUSCULTATION

37. AUSCULTATION

38. AUSCULTATION

39. Finally
I would like to continue my examination
to examine:
1. Groin and external genitalia examination
2. LN examination including supraclavicular nodes.
3. Anal Examination ( inspection first then PR )
4. Lower limbs for edema and other signs: pyoderma
gangerosum