A general examination is performed, with particular emphasis on the examination of all lymph nodes and noting the presence of anaemia or jaundice. Detailed examination of the gastrointestinal tract starts with the mouth and tongue before examining the abdomen. Examination of the abdomen (Acute abdomen, Liver disease,)
The organs found in a normal abdomen are shown in a normal CT scan.
Abdominal distension, whether due to flatus, fat, fetus, fluid or faeces, must be looked for. Lordosis may give the appearance of a distended abdomen; it is a common feature of the ‘abdominal distension’ seen in functional bowel disease.
The abdominal organs may be felt in some normal subjects but this is not common and such organs are usually only just palpable. Any palpable mass is carefully felt to decide which organs are involved and also to evaluate its size, shape and consistency and whether it moves with respiration. The hernial orifices should be examined if intestinal obstruction is suspected.
A succussion splash suggests gastric outlet obstruction if the patient has not drunk for 2-3 hours; the splash of fluid in the stomach can be heard with a stethoscope laid on the abdomen when the patient is moved.
This is performed in the usual way to detect the area of dullness caused by the liver and spleen, and possibly bladder enlargement. The presence of fluid in the peritoneal cavity, i.e. ascites, is detected by shifting dullness. The percussion note changes from resonance to dullness when the patient is moved from one side to the other. It is a
good physical sign if performed carefully but 1-2 litres of fluid must be present to elicit it. A fluid ‘thrill’ can be elicited, but is not always helpful. A large ovarian cyst can sometimes produce an enlarged abdomen, but the dullness is more centrally placed than in ascites. Auscultation Auscultation is not of great value in gastrointestinal disease, apart from in the evaluation of the acute abdomen. Abdominal bruits are often present in normal subjects, but these are not clinically significant. Intestinal sounds
do not help in diagnosis.
Examination of the rectum and sigmoid
Digital examination of the rectum should be performed in most patients with gastrointestinal symptoms and in all patients with a change in bowel habit. The anus should be inspected for anal tags, external haemorrhoids, fissures or fistulas. In males, the prostate projects into the rectum anteriorly and its size and consistency should be noted. In women the cervix or uterus may be felt anteriorly.
SIGMOIDOSCOPY (Practical box 4.1). should, in hospital, be part of the routine examination in all cases of diarrhoea and in patients with lower abdominal symptoms such as a change in bowel habit or bleeding.
PROCTOSCOPY (Practical box 4.1) is performed in all patients with a history of bright red blood per rectum; the narrow sigmoidoscope does not distend the lumen and haemorrhoids can be missed.
The rigid sigmoidoscope allows inspection of only the lower 2G-25 ern of the bowel, but a 70 cm flexible fibreoptic sigmoidoscope allows much more bowel to be visualized. It also can be readily used in the outpatient department after minimal bowel preparation (a disposable enema). Seventy per cent of colonic neoplasms occur within the range of the flexible sigmoidoscope.
This .can be occasionally useful to confirm the patient’s symptoms, e.g. passing of blood or steatorrhoea. The shape and size may be helpful, e.g. rabbity stools in the irritable bowel syndrome. Stool charts for recording frequency and volume of defecation are useful in inpatients to follow the progress of diarrhoea.