1. Gastrointestinal System Examination
• Surface markings
• Liver upper border 5th ICS right on full exp
lower border at costal margin on full
inspiration
• Spleen behind left 9,10,11 ribs, posterior to
MCL
• Kidneys upper pole lies deep to the 12th rib
posteriorly, 7 cm from the midline, the right
is 2-3 cm lower than the left.
zaw aung 1

2. • Abdomen can be divided into nine regions by
the
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3. Characteristics of pain (SOCRATES)
pain
• Site somatic pain well localised sprained ankle
viseral pain diffused angina pectoris
• Onset
• Character describe by adjectives—sharp/dull, Burning/ tingling, boring/stabbing,
crushing/tugging. Use the patient own description.
• Radiation
• Associated symptoms
• Timing Since onset
Episodic duration and frequency of attacks
continuous any changes in severity
• Exacerbation and relieving factors relation to food or specific activities or
postures
effect of medication
• Severity subjective
variation by day or night ,week or month
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4. Symptoms and definitions
General
• Anorexia  loss of appetite
• Weight loss  significant >3 kg in 6 months
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5. Upper GI
• Dysphagia
Difficulty in swallowing
Ask for
Is dysphagia painful or painless
Is dysphagia intermittent or progressive
How long
Is there a previous history of dysphagia or heartburn.
Is the dysphagia for solids or liquids or both
What level does food stick
Is there complete obstruction with food regurgitation.
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6. Causes of dysphagia
• Oral Painful mouth ulcers -- tonsillitis,
pharyngitis
• Neurological -- CVA, bulbar or pseudobulbar
• palsy
• Neuromuscular---myasthenia gravis, achalasia,
pharyngeal pouch
• Mechanical ----- oesophageal cancer, peptic
oesophagitis, scleroderma,
benign stricture, compression
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7. Heartburn and reflux symptoms
• Heartburn ---- burning, hot retrostenal
discomfort which radiate upwards .
Commonnest cause is reflux oesophagitis.
• acid reflux---regurgitation of gastric acid
produce a sour taste in the mouth.
• Water brash sudden onset of excessive saliva
in the mouth is due to reflex salivation, may
occur in peptic ulcer disease.
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8. dyspepsia
• Dyspepsia is the pain or discomfort centred in
the upper abdomen.
• Indigestion is a term used for ill-defined
symptoms from the upper GIT.
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9. • Nausea sensation of feeling sick.
• Vomiting is the expulsion of gastric contents via the mouth.
• Causes of vomiting
• GI causes
peptic ulcer, GOO, obstruction of GI tract.
gastroenteritis, cholecystitis, pancreatitis,
hepatitis
Non-alimentary causes of vomiting
neurological  ICP, vestibular disorder, migraine,
vasovagal syncope, shock, fear and severe
pain.
Drugs alcohol, opioids, theophyllines, digoxin, cytotoxic
agents, antidepressants
metabolic/endocrine pregnancy, DKA, renal failure, liver failure, adrenal
failure and hypercalcaemia.
psychological anorexia nervosa, bulimia
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10. Questions to be asked for vomiting
• Medication history.
• vomiting +/- nausea.
• Associated with abdominal pain.
• Abdominal pain relieved by vomiting.
• Vomiting related to meal-times, early morning
or late evening.
• Vomitus bile-stained, bloodstained or
faeculent.
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11. Haematemesis and malaena
• Haematemesis vomiting of blood. Fresh and
red, or dark brown coffee grounds colour.
• Malaena tarry and shinny black with
characteristic odour stool.
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12. Abdominal distension
• Causes
• fat obese
• Flatus obstruction, pseudo-obstruction
• Faeces obstruction, constipation
• Fluid ascites, tumours, distended bladder
• Fetus
• Functional bloating
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13. ascites
• Common cirrhosis with portal hypertension
malignancy with peritoneal spread
CCF
• Uncommon hepatic or portal vein occlusion
constrictive pericarditis
hypoproteinaemia
peritonitis
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14. jaundice
• Yellowish discoloration of the skin, sclerae and
mucus membranes due to
hyperbilirubinaemia.
• Levels of bilirubin >50 umol/L
• Causes prehepatic jaundice ( haemolytic)
hepatic ( hepatocellular)
post-hepatic (obstructive)
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15. History for jaundice
• Appetite and weight change
• Abdominal pain, altered bowel habit
• GI bleeding
• Pruritus, dark color urine, rigors
• Drugs and alcohol history
• Past medical/surgical history
• Previous jaundice or hepatitis
• Blood transfusion
• Family history
• Sexual/contact history
• Travel history and immunisations
• Skin tatoo.
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16. History taking
Alarm features
• Persistent vomiting
• Dysphagia
• Fever
• Weight loss
• GI bleeding
• Anaemia
• Painless, watery, high-volume diarrhoea
• Nocturnal symptoms disturbing sleep.
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17. • Always investigate alarms symptoms
particularly those over >50 years.
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18. Past history
• History of similar problems/symptoms may
suggest the diagnosis.
• Ask about previous abdominal surgery, X-rays,
scans and other investigations
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19. Drug History
• Prescribed medications, over-the-counter
medications, herbal preparations and
indigenous medicines.
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20. Family history
• Inflammation bowel disease is more common
in patients with a family history of either
Crohn’s disease or ulcerative colitis.
• Colorectal cancer in a first degree relative
increase the risk of colorectal cancer and
polyps.
• PU is familial.
• Gilbert’s disease, haemochromatosis, Wilson’s
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21. Social history
• Dietary history and assess the approximate intake
of calories and sources of essential nutrients.
• Specific food intolerance
• Alcohol consumption in units
• Smoking
• Any mental stress
• Risk factors for hepatitis.
• Foreign travelling.
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22. Physical Examination
• General examination
• nutritional state record the height, weight, waist
circumference and the patient’s body mass index.
• Obesity truncal or generalised.
• Abdominal striae
• Loose skin fold
• Stigmata of iron deficiency, koilonychia, angular
stomatitis and atrophic glossitis.
• Muscle wasting.
• Fever.
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23. hands
• Clubbing
• Koilonychia
• Signs of liver disease –leukonychia
- palmer erythema
- flapping tremors
-
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24. face
• Pallor
• Jaundice
• Spider naevi
• Parotid swelling
• Mouth- angular stomatitis, glossitis, teeth and
gums
• Neck goitre, neck glands
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25. Legs
• Oedema
• Pyoderma gangrenosum
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26. zaw aung 26

27. zaw aung 27

28. Abdomen
• Normal appearance flat, scaphoid and
symmetrical.
• Normal findings liver edge may be felt below the
right costal margin.
• Aorta may be palpable as pulsatile swelling.
• Lower pole of the right kidney may be palpable.
• Faecal mass may be palpable.
• Distended bladder
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29. Inspection
• Skin striae, bruising or scratch marks.
• distended veins superior vena cava, inferior vena cava and, portal
hypertension (caput medusae).
• Distension of abdomen. Generalised or localised.
• Scars and stomas
• Movements normal movements- still, silent abdomen in
generalised peritonitis.
• Epigastric palpation.
• Visible peristalsis GOO, distal small bowel obstruction, normal
very thin, elderly patients.
• Pigmentation of skin -linea nigra
• -erythema ab igne -- brown mottled
pigmentation on the skin of abdominal wall.
zaw aung 29

30. Palpation, Percussion, Auscultation
• Light palpation tenderness
rebound tenderness
palpable mass
• Deep palpation enlarged organs,
liver, spleen, kidneys, gall
bladder.
• Percussion liver, spleen, shifting dullness
fluid thrill.
• Auscultation bowel sounds, aorta (above
umbilicus), renal bruits, liver bruits, rub
succussion splash.
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31. zaw aung 31