Gastrointestinal Tract

omar soboh M.D

 Internal Anatomy
• The gastrointestinal tract consists of the mouth,
oropharynx, esophagus, and the organs of the
abdominal cavity
• Inside the abdominal cavity all the internal organs
are called the viscera.
• The solid viscera are those that maintain a
characteristic shape (liver, pancreas, spleen, adrenal
glands, kidneys, and ovaries).
• The lower edge of the liver and the right kidney
normally may be palpable.
 Internal Anatomy
• The shape of the hollow viscera (stomach, gallbladder, small
intestine, colon, Bladder, , and uterus) depends on the
contents. They usually are not palpable, although you may feel
a colon distended with feces or a bladder distended with
urine.
• The stomach is just below the diaphragm, between the liver
and spleen.
• The gallbladder rests under the posterior surface of the liver,
just lateral to the right MCL.
• The small intestine is located in all four quadrants. It extends
from the pyloric valve of the stomach to the ileocecal valve in
the right lower quadrant (RLQ), where it joins the colon.
 Spleen
• The spleen is a soft mass of lymphatic tissue
on the posterolateral wall of the abdominal
cavity, immediately under the diaphragm.
• It lies obliquely with its long axis behind and
parallel to the 10th rib, lateral to the
midaxillary line. Its width extends from the 9th
to the 11th rib, about 7 cm. It is not palpable
normally. If it becomes enlarged, its lower pole
moves downward and toward the midline.
 Pancreas
• The pancreas is a soft, lobulated gland located
behind the stomach. It stretches obliquely
across the posterior abdominal wall to the left
upper quadrant.
 Kidneys
• The bean-shaped kidneys are retroperitoneal,
or posterior to the abdominal contents. They
are well protected by the posterior ribs and
musculature. The 12th rib forms an angle with
the vertebral column, the costovertebral angle.
• The left kidney lies here at the 11th and 12th
ribs. Because of the placement of the liver, the
right kidney rests 1 to 2 cm lower than the left
kidney and sometimes may be palpable.
 The Abdomen
• The abdominal wall is divided into four
quadrants by a vertical and a horizontal line
bisecting the umbilicus.
The anatomic location of the organs by
quadrants is:
 Subjective Data
1. Appetite
2. Dysphagia
3. Food intolerance
4. Abdominal pain
5. Nausea/vomiting
6. Bowel habits
7. Past abdominal history
8. Medications
9. Nutritional assessment
 Subjective Data
• Anorexia is a loss of appetite from GI disease as a side effect
to some medications, with pregnancy, or with mental health
disorders.
• Dysphagia occurs with disorders of the throat or esophagus.
• Food intolerance (e.g., lactase deficiency resulting in
bloating or excessive gas after taking milk products).
• Heartburn , a burning sensation in esophagus and stomach,
from reflux of gastric acid.
• Eructation (belching).
• Hematemesis occurs with stomach or duodenal ulcers and
esophageal varices.
Abdominal Pain
 Alarming signs
• Weight loss
• Loss of appetite
• Age above 50
• Blood in stool or black stool
• Anemia
 Physical Examination
• Equipment Needed:
• Tongue blade
• Stethoscope
• Gloves
• Lubricant
• Hemoccult developer
• Magic marker
• Tape or ruler marked in centimeters
• Covering for the patient
 Physical Examination
 Preparation:
• The lighting should include a strong overhead light and a secondary stand light.
Expose the abdomen so it is fully visible. Drape the genitalia and female breasts.
• The following measures enhance abdominal wall relaxation:
 The person should have emptied the bladder, saving a urine specimen if needed.
 Keep the room warm to avoid chilling and tensing of muscles.
 Position the person supine, with the head on a pillow, the knees bent or on pillow, and
the arms at the sides or across the chest. (Note: Discourage the person from placing
his or her arms over the head because this tenses abdominal musculature.)
 To avoid abdominal tensing, the stethoscope endpiece must be warm, your hands
must be warm, and your fingernails must be very short.
 Inquire about any painful areas. Examine such an area last to avoid any muscle
guarding.
 Finally learn to use distraction: Enhance muscle relaxation through breathing
exercises; emotive imagery; your low, soothing voice; engaging in conversation; or
having the person relate his or her abdominal history while you palpate.
 Normal Range of Findings Abnormal Findings

Inspect general appearance

Temporal wasting may indicate a

nutritional deficit/ malignancy.
Inspect the face.
• Inspect for temporal wasting. Jaundice: liver or pancreases
• Inspect the skin around the mouth and oral Pale: UGIB
mucosa.
• Smell the patient’s breath. Oral ulcers: IBD
• Inspect the skin and conjunctiva for jaundice
Inspect hands and nails.
• Assess for palmar erythema palmar erythema : Cirrhosis
 Normal Range of Findings Abnormal Findings

Inspect the Abdomen: Contour

The contour describes the nutritional state and Scaphoid abdomen caves in.
normally ranges from flat to rounded. Protuberant abdomen, abdominal
distention.
 Normal Range of Findings Abnormal Findings

Inspect the Abdomen: Symmetry

The abdomen should be symmetric bilaterally. Note Bulges, masses.
any localized bulging, visible mass, or asymmetric Hernia—Protrusion of abdominal
shape. viscera through abnormal opening in
muscle wall.
Sister Mary Joseph nodule is a hard
nodule in umbilicus that occurs with
metastatic cancer of stomach, large
intestine, ovary. or pancreas.
Ask the person to take a deep breath to further Note any localized bulging.
highlight any change. The abdomen should stay Hernia or enlarged liver or spleen may
smooth and symmetric. show.
 Normal Range of Findings Abnormal Findings

Inspect the Abdomen: Umbilicus

Normally it is midline and inverted, with no sign of Everted with ascites or underlying
discoloration, inflammation, or hernia. It becomes Mass or hernia . ( increased
everted and pushed upward with pregnancy. intraabdominal pressure)

The umbilicus is a common site for piercings in Deeply sunken with obesity.
young women. The site should not be red or crusted.
 Normal Range of Findings Abnormal Findings

Inspect the Abdomen: Skin

The surface is smooth and even, with homogeneous Redness with localized inflammation.
color. This is a good area to judge pigment because it Jaundice (shows best in natural daylight).
is often protected from sun. Skin glistening and taut with ascites.
One common pigment change is striae—silvery Striae look purple-blue with Cushing
white, linear marks. They occur when elastic fibers in syndrome (excess adrenocortical
the reticular layer of the skin are broken after rapid hormone causes the skin to be fragile
or prolonged stretching as in pregnancy or excessive and easily broken from normal
weight gain. stretching).
Pigmented nevi (moles)—circumscribed brown Unusual color or change in shape of
macular or papular areas— are common on the mole.
abdomen. Petechiae.
Veins usually are not seen, but a fine venous Prominent, dilated veins occur with
network may be visible in thin portal hypertension, cirrhosis, ascites, or
persons. vena caval obstruction.
Good skin turgor reflects healthy nutrition. Gently Poor turgor occurs with dehydration,
pinch up a fold of skin; then release to note the which often accompanies GI disease.
immediate return of the skin to original position.
 Normal Range of Findings Abnormal Findings

Inspect the Abdomen: Pulsation or Movement

Normally you may see the pulsations from the aorta Marked pulsation of aorta occurs with
beneath the skin in the epigastric area, particularly widened pulse pressure (e.g.,
in thin people with good muscle wall relaxation. hypertension, aortic insufficiency,
Respiratory movement also shows in the abdomen, thyrotoxicosis) and aortic aneurysm.
particularly in males.
 Normal Range of Findings Abnormal Findings

Auscultate Bowel Sounds

Note the character and frequency of bowel sounds. Two distinct patterns of abnormal bowel
They originate from the movement of air and fluid sounds may occur:
through the stomach and large and small intestine. 1. Hyperactive sounds are loud,
Depending on the time elapsed since eating, a wide highpitched, rushing sounds that signal
range of normal sounds can occur. Bowel sounds are increased motility.
high-pitched, gurgling, cascading sounds, occurring 2. Hypoactive or absent sounds follow
irregularly anywhere from 5 to 30 times per minute. abdominal surgery or with inflammation
In addition, because the sounds radiate widely over of the peritoneum.
the abdomen, the gurgle you hear in the RLQ may
originate in the stomach. Therefore listening in all
four quadrants usually is not necessary. Just judge if
they are present or are hypoactive or hyperactive.
One type of hyperactive bowel sounds is fairly
common: hyperperistalsis, when you feel your
“stomach growling,” termed borborygmus. A
perfectly “silent abdomen” is uncommon; you must
listen for 5 minutes by your watch before deciding
if bowel sounds are completely absent.
 Normal Range of Findings Abnormal Findings

Auscultate Vascular Sounds:

As you listen to the abdomen, note the presence of Note location, pitch, and timing of a
any vascular sounds or bruits. Using firmer pressure, vascular sound.
check over the aorta, renal arteries, iliac, and A systolic bruit is a pulsatile blowing
femoral arteries, especially in people with sound and occurs with stenosis or
hypertension. Usually no such sound is present. occlusion of an artery.
Venous hum and peritoneal friction
rub are rare.
 Normal Range of Findings Abnormal Findings

Percuss General Tympany, Liver Span, and Splenic Dullness:

Percuss to assess the relative density of abdominal contents, to locate organs, and to screen for
abnormal fluid or masses.

First percuss lightly in all four quadrants to Dullness occurs over a distended
determine the prevailing amount of bladder, organs, adipose tissue, fluid, or a
tympany and dullness. Move clockwise. Tympany mass.
should predominate because air in the intestines
rises to the surface when the person is supine. Hyperresonance is present with
gaseous distention.
Next percuss to map out the boundaries of certain
organs. Measure the height of the liver in the right
MCL.
 Normal Range of Findings Abnormal Findings

Percussion
Liver span Splenic dullness may be heard from the
Spleen span 6th to the 10th ribs
 Normal Range of Findings Abnormal Findings

Percuss General Tympany, Liver Span, and Splenic Dullness: Special Procedures
At times you may suspect that a person has ascites Ascites occurs with heart failure,
because of a distended abdomen, bulging flanks, portal hypertension, cirrhosis, hepatitis,
and an umbilicus that is protruding and displaced pancreatitis, and cancer.
downward. You can differentiate ascites from
gaseous distention by performing two percussion
tests.
1. Fluid wave.
2. Shifting Dullness.
 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Light and Deep Palpation

Begin with light palpation. With the first four fingers Muscle guarding.
close together, depress the skin about 1 cm. Make a Rigidity.
gentle rotary motion, sliding the fingers and skin Large masses.
together. Then lift the fingers (do not drag them) and Tenderness.
move clockwise to the next location around the Skin temperature
abdomen.
Now perform deep palpation using the technique
described earlier but push down about 5 to 8 cm.
Moving clockwise, explore the entire abdomen.

Painful area last

 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Light and Deep Palpation

To overcome the resistance of a very large or obese Tenderness occurs with local
abdomen, use a bimanual technique. Place your two inflammation, inflammation of the
hands on top of one another. The top hand does the peritoneum or underlying organ, and
pushing; the bottom hand is relaxed and can with an enlarged organ.
concentrate on the sense of palpation. With either
technique note the location, size, consistency, and
mobility of any palpable organs and the presence of
any abnormal enlargement, tenderness, or masses.
Mild tenderness normally is present when palpating
the sigmoid colon. Any other tenderness should be
investigated.

Palpate for rebound tenderness: It usually indicates

peritoneal irritation/appendicitis.

Palpate for inspiratory arrest (Murphy’s sign): acute

cholecystitis
 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Light and Deep Palpation

If you identify a mass, first distinguish it from a
normally palpable structure or an enlarged organ.
Then note the following:
1. Location
2. Size
3. Shape
4. Consistency (soft, firm, hard)
5. Surface (smooth, nodular)
6. Mobility (including movement with respirations)
7. Tenderness
 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Liver

Palpate for specific organs, beginning with the liver Except with a depressed diaphragm, a
in the RLQ. Place right hand on the RLQ, with fingers liver palpated more than 1 to 2 cm below
parallel to the midline. Push deeply down and the right costal margin is enlarged.
toward the right costal margin. Ask the person to Record the number of centimeters it
breathe slowly. With every exhalation, descends and note its consistency (hard,
move palpating hand up 1 or 2 cm. It is normal to nodular) and tenderness.
feel the edge of the liver bump your fingertips as the
diaphragm pushes it down during inhalation. It
feels like a firm, regular ridge. Often the liver is not
palpable and you feel nothing firm.
 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Spleen

Normally the spleen is not palpable and must be The spleen enlarges with mononucleosis,
enlarged 3 times its normal size to be felt. To search trauma, leukemias and lymphomas,
for it, reach your left hand over the abdomen and portal hypertension, and HIV infection.
behind the left side at the 11th and 12th ribs. Lift up An enlarged spleen is friable and can
for support. Place right hand obliquely on the RLQ rupture easily with overpalpation.
with the fingers pointing toward the left axilla and
just inferior to the rib margin. Push hand deeply
down and under the left costal margin and ask the
person to take a deep breath. You should feel
nothing firm.
 Normal Range of Findings Abnormal Findings

Palpate Surface and Deep Areas: Kidneys

Ballotable test : Enlarged kidney. ( polycystic kidney)
Search for the right kidney by placing your hands Kidney mass.
together in a at the person’s right flank. Press two
hands together firmly (you need deeper palpation
than that used with the liver or spleen) and ask the
person to take a deep breath. In most people you
will feel no change. Occasionally you may feel the
lower pole of the right kidney as a round, smooth
mass that slides between your fingers. Either
condition is normal.
 Normal Range of Findings Abnormal Findings

Iliopsoas Muscle Test.

Perform the iliopsoas muscle test when the acute When the iliopsoas muscle is inflamed
abdominal pain of appendicitis is suspected. With (which occurs with an inflamed or
the person supine, lift the right leg straight up, perforated appendix), pain is felt in the
flexing at the hip; then push down over the lower RLQ.
part of the right thigh as the person tries to hold the
leg up. When the test is negative, the person feels
no change.
For the obturator test, lift the person’s right leg, An inflamed appendix irritates the
flexing at the hip, and 90 degrees at the knee. Hold obturator muscle, and this leg movement
his or her ankle and rotate the leg internally and produces pain.
externally. There should be no pain. This test is less
specific.
 Remember
• A rectal examination should be performed on
both males and females who present with
abdominal pain.
• A pelvic examination should be performed on
females complaining of abdominal pain.
 Air or Gas
• Inspection. Single round curve.
• Auscultation. Depends on cause of gas (e.g.,
decreased or absent bowel sounds with ileus);
hyperactive with early intestinal obstruction.
• Percussion. Tympany over large area.
• Palpation. May have muscle spasm of
abdominal wall. Maybe tender or not.
 Ascites
• Inspection. Single curve. Everted umbilicus. Bulging
flanks when supine. Taut, glistening skin; recent
weight gain; increase in abdominal girth.
• Auscultation. Normal bowel sounds over intestines.
Diminished over ascitic fluid.
• Percussion. Tympany at top where intestines float.
Dull over fluid. Produces fluid wave and shifting
dullness.
• Palpation. Taut skin and increased intra-abdominal
pressure limit palpation.
 Tumor
• Inspection. Localized distention.
• Auscultation. Normal bowel sounds.
• Percussion. Dull over mass if reaches up to
skin surface.
• Palpation. Define borders. Distinguish from
enlarged organ or normally palpable structure.
 Ovarian Cyst (Large)
• Inspection. Curve in lower half of abdomen,
midline. Everted umbilicus.
• Auscultation. Normal bowel sounds over upper
abdomen where intestines pushed superiorly.
• Percussion. Top dull over fluid. Intestines
pushed superiorly. Large cyst produces fluid
wave and shifting dullness.
• Palpation. Transmits aortic pulsation, whereas
ascites does not.
 Pregnancy
• Inspection. Umbilicus protruding. Breasts
engorged.
• Auscultation. Fetal heart tones. Bowel sounds
diminished.
• Percussion. Tympany over intestines. Dull over
enlarging uterus.
• Palpation. Fetal parts. Fetal movements.
 Clinical Portrait of Intestinal Obstruction
• History of previous abdominal surgery with adhesions
• Vomiting
• Absence of stool or gas passage
• Distended abdomen (after 2nd day)
• X-ray shows dilated air-filled loops of small bowel with multiple air-fluid levels
• Hyperactive bowel sounds in early obstruction;
• Hypoactive or silent in late obstruction
• Dehydration and loss of electrolytes
• Accumulation of fluid and gas in bowel proximal (above) to obstruction
• Colicky pain from strong peristalsis above the obstruction
• Fever
• Pressure from excess fluid and gas may leaking fluid into peritoneum
• Hypovolemic shock ( BP, pulse, cool skin if left untreated)
 Umbilical Hernia
• This is a soft, skin-covered mass, the protrusion of the omentum
or intestine through a weakness or incomplete closure in the
umbilical ring. It is accentuated by increased intra-abdominal
pressure as with crying, coughing, vomiting, or straining; but the
bowel rarely incarcerates or strangulates.
• More common in premature infants. Most resolve
spontaneously by 1 year; parents should avoid affixing a belt or
coin at the hernia because this will not help closure and may
cause contact dermatitis.
• In an adult it occurs with pregnancy, chronic ascites, or chronic
intrathoracic pressure (e.g., asthma, chronic bronchitis).
 Epigastric Hernia
• Protrusion of abdominal structures presents
as a small, fatty nodule at epigastrium in
midline, through the linea alba. Usually one
can feel it rather than observe it. May be
palpable only when standing.
 Incisional Hernia
• A bulge near an old operative scar that may
not show when person is supine but is
apparent when the person increases intra-
abdominal pressure by a sit-up, by standing,
or by the Valsalva maneuver.
 Summary Checklist: Abdomen
Examination
 1. Inspection
• Contour
• Symmetry
• Umbilicus
• Skin
• Pulsation or movement
• Hair distribution
• 2. Auscultation
• Bowel sounds
• Note any vascular sounds
• 3. Percussion
• Percuss all four quadrants
• Percuss borders of liver, spleen
• 4. Palpation
• Light palpation in all four quadrants
• Deeper palpation in all four quadrants
• Palpate for liver, spleen, kidneys