2.4 Examination of Gastrointestinal System 2.4.1 Examination of the Note: non-routine parts are denoted by a (small font) but they should be noted if you observe them. Setting: □ Positioning: supine with head resting on a pillow46 □ Exposure: nipple to pubic symphysis ± mid-thigh (if it is a surgical case, need to look for ) Approach: □ General examination → General appearance: - Bedside: equipment, treatment devices - Body habitus: weight loss, cachexia, obesity, (↑muscle bulk) - Mental state: orientation - (Skin changes) → Face: - Eyes: , pallor, (Bitot’s spot, Kayser-Fleischer rings, xanthelasma, periorbital purpura) - Salivary glands: parotid gland, submandibular gland - Mouth: hydration status, (fetor, tongue (coating, lingua nigra, geographic tongue, leukoplakia, glossitis, macroglossia), mucosa (gum hypertrophy, pigmentation, ulcers)) → Neck and chest: spider naevus, gynaecomastia, cervical lymphadenopathy → Upper limb: - Arms: spider naevus, (bruising, scratch marks) - Axilla: lymphadenopathy, (acanthosis nigricans) - Hands: clubbing, leukonychia, palmar erythaema, Dupuytren’s contracture, asterixis, (blue lununae) → Legs: ankle oedema, (ankle pigmentation, bruising) □ Inspection of abdomen: → Shape: normal, scaphoid, distended (5S) → Umbilicus: buried, everted, inverted → Skin lesions: striae, scars, stomas, fistulae, (Cullen’s sign, Grey-Turner’s sign, pigmentation) → Dilated veins: caput medusa vs IVC obstruction → Movement: asymmetrical movement with respiration, epigastric pulsation, visible peristalsis → Cough impulse (in surgical examination) □ Palpation of abdomen: superficial, deep for any mass, tenderness ± peritoneal signs □ : → Palpation: lower border → : upper and lower border □ Spleen: → Palpation: along Gardner’s line, hooking at Rt lateral position → Percussion: along Gardner’s line □ Kidneys: → Palpation: bimanual, ballottement

46 This helps relax the abdomen and facilitates abdominal palpation.

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□ Go back to any mass previously detected: site, size, shape, surface, edge, consistency, tenderness, pulsatility □ : → Inspection: distension with bulging flanks, ankle oedema → Shifting dullness (if ≥1L fluid) → Fluid thrill (if fluid under tension) □ Auscultation: → Bowel sounds at four quadrants → Bruits: liver, renal, aortic → Succussion splash □ Other examination: examination of orifices, PR examination

A. General Examination 1. General Appearance Bedside:

□ Equipment: ventilator, O2 therapy, cardiac monitor □ Tubes and drains: IV access, chest drain, Foley’s catheter, central venous catheter, NG tube, PTBD tube, PEG tube □ Others: specimen bottles

Vitals: BP/P, RR, body temperature

General status of the patient: □ Any distress □ Weight loss and cachexia: → Muscle wasting → Loose skin folds hanging from abdomen and limbs → recent weight loss → May be related to malignancy, organ failure (a/w ↓appetite) or malabsorption (a/w ↑appetite) □ Obesity: may result in non-alcoholic steatohepatitis → liver derangement □ Mental state: orientation to time, place and person → hepatic encephalopathy

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(Skin): Condition Skin presentation GI association

- Slate grey or brown-bronze pigmentation - - Predominance for UV-exposed - Signs of chronic liver disease sites eg. face Haemochromatosis

- ‘Sunkissed’ brown pigmentation - - Predominance for UV-exposed - sites, palmar creases, nipples, - Fatigue and weight loss pressure areas, mouth Addison’s disease

- Brown-to-black velvety - GI carcinomas elevations of epidermis - GI lymphoma - Due to confluent papillomas - Endocrinopathies (acromegaly, - Usually in axillae or neck DM, others) Acanthosis nigricans

- Pruritic chronic papulovesicular eruptions - Coeliac disease47 - Usually symmetrically on

extensor surfaces Dermatitis herpetiformis

- Fragile vesicles - Alcoholic liver disease - On exposed areas of skin - Hepatitis C - Heals with scarring Porphyria cutanea tarda

- Thick skin with tense tethering - GERD - Calcinosis - GI motility disorders - Raynaud’s phenomenon - Small bowel bacterial overgrowth - Sclerodactyly with malabsorption - Telangiectasia Scleroderma 2. Face

47 Coeliac disease is exceedingly uncommon in Asians.

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Cushingoid facies may occur 2o to prolonged steroid use in liver or renal transplantation a. Eyes Jaundice: yellow discolouration of sclerae and skin □ Ask pt to look down to observe sclera above iris48 □ Indicates hyperbilirubinaemia → D/dx: prehepatic, hepatic, posthepatic □ Look for signs specific for obstructive jaundice → Greenish jaundice (bile regurgitation) → Xanthelasma (↓Ch excretion) → Xanthomas (↓Ch excretion) → Scratch marks (pruritus due to retention of bile acid content) Pallor indicating anaemia Xanthelasmata: yellowish plaques in subcutaneous tissues in periorbital region □ Indicates hypercholesterolaemia □ May occur in cholestasis, esp primary biliary cirrhosis □ A/w ↑lipoprotein X and cholesterol in plasma

(Kayser-Fleischer rings): brownish-green rings at periphery of cornea □ Indicates Wilson’s disease (may also appear in some cholestatic liver diseases) □ Usually present by the time neurological S/S appears □ Mechanism: deposits of excess copper in cornea Bitot’s spot: yellow keratinized areas on sclera □ Indicates vitamin A deficiency → Malabsorption → Malnutrition □ May progress into retinal damage or blindness Iritis may occur in irritable bowel disease □ Features: irregular pupil (posterior synechiae), red eye esp around iris (perilimbic flush), pus in anterior chamber in eye (hypopyon) Periorbital purpura (‘black eye syndrome’): □ Characteristically occur following proctosigmoidoscopy for Ix of GI bleeding □ May occur spontaneously □ Indicates amyloidosis → Amyloid binds factor X → coagulopathy → Traditional proctosigmoidoscopy carried out with face pressed down onto bed → triggers bilateral ecchymosis

48 Jaundice should not be examined at medial or lateral corners of sclera.

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b. Salivary Glands (Parotid glands): □ Palpate for enlargement: → Ask pt to clench teeth to tighten masseter → Normal = impalpable → Enlarged = palpable behind masseter and in front of ear □ Bimanual palpation for parotid duct □ Palpation in mouth for parotid calculus: → May be found at parotid papilla (opposite to upper 2nd molar) □ Look for associated facial nerve palsy if pathology detected D/dx of parotid gland enlargement (Submandibular glands): □ Bimanual palpation for enlargement: Bilateral: → Gloved index finger on floor of mouth beside the tongue - Mumps (may be unil.) → Another hand behind body of mandible - Sarcoidosis (painless) → Feel for enlargement - Lymphoma (painless) → D/dx: calculus, chronic liver disease 49 - Mikulicz syndrome (painless)

- Alcoholism (fatty infiltration) c. Mouth - Malnutrition Hydration status: most important concern in GI examination - Severe dehydration (Fetor ()): Unilateral: □ Ask pt to exhale through the mouth while you sniff a little of exhaled air □ Poor oral hygiene - Mixed parotid tumour (occ. bilateral) □ Fetor hepaticus: sweet smell - Tumour infiltration → Indicates severe hepatocellular disease (late sign) → Mechanism: loss of liver methionine demethylation function - Duct blockage → excretion of methylmercaptans through lungs → Severe fetor hepaticus indicates precomatose condition □ Ketosis: sickly sweet smell → Indicates diabetic ketoacidosis □ Uraemic fetor: fishy ammonia smell → Indicates uraemia □ Putrid smell: → Due to anaerobic chest infection with large amounts of sputum □ Alcohol and cigarette smoking (Tongue): □ Coating over tongue: thickened epithelium with bacterial debris and food particles → Often more marked posteriorly (↓mobility, ↓rate of papillae desquamation) → Common in smokers or with respiratory tract infections → Rarely a sign of severe diseases □ Lingua nigra: dark brown discolouration on dorsal surface of tongue → Cause: posterior extension of filiform papillae with keratin accumulation → Completely benign condition → Black tongue can also arise from bismuth compounds □ Geographic tongue: map-like areas of smooth, red depapillation migrating over time → Not painful and tends to come and go → Arising from mucosal inflammation

→ Usually completely benign but can indicate riboflavin (B2) deficiency □ Leukoplakia: white-coloured thickening of mucosa of tongue and mouth

49 Mikulicz’s syndrome refers to a benign enlargement of parotid, lacrimal and submandibular glands. Histology shows marked lymphoplasmacytic infiltration with follicle formation. It is associated with Sjogren’s syndrome or IgG4-related disease

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→ A premalignant condition → Causes: ‘5S’ - Sore teeth (poor dental hygiene) - Smoking - Spirits - Sepsis - Syphilis - No apparent cause → Can also be found on larynx, anus and vulva □ Glossitis: smooth tongue surface ± erythema → May present with shallow ulceration in later stages

→ Indicates nutritional deficiencies, eg. Fe, B9, B12 - Alcoholics (common) - Carcinoid syndrome - Elderly people → Mechanism: rapid turnover of tongue mucosal cells → particularly sensitive to nutritional deficiencies □ Macroglossia: enlargement of the tongue → Congenital conditions, eg. Down syndrome → Endocrine diseases, eg. acromegaly → Tumour infiltration, eg. haemangioma, lymphangioma → Amyloidosis infiltration

(Mucosa): Causes of oral ulcers: □ Gum hypertrophy may be due to Common: → Gingivitis, eg. smoking, calculus, plaque, Vincent’s angina → Drugs: phenytoin, phenobarbital, cyclosporine, CCB - Aphthous ulcer → Scurvy: spongy, red, swollen and irregular gums that bleed easily - Trauma → Leukaemia (usually monocytic) - Drugs, eg. steroids → Pregnancy Uncommon: □ Pigmentation may be due to - GI: Crohn’s disease, ulcerative → Lead or bismuth poisoning colitis, coeliac disease → blue-black line on gingival margin - Rheum: Behcet’s syndrome, Reiter’s → Haemochromatosis syndrome → blue-grey pigmentation on hard palate - Erythema multiforme → Drugs (antimalarials, OC pills) → brown or black areas of pigmentation - Infection: anywhere in the mouth Viral (VZV, HSV) → Melanosis in Peutz-Jegher syndrome Bacterial (syphilis, TB) → Addison’s disease - Self-inflicted → blotches of dark brown pigment anywhere in the mouth → Malignant melanoma → raised, painless black lesions anywhere in the mouth □ Aphthous ulcers (most common) → Small painful mucosal vesicle → May break down to form a painful shallow ulceration that heals w/o scarring → Usually does NOT indicate serious underlying disease → May occur in Crohn’s disease or coeliac disease □ HIV-associated ulcers □ Angular stomatitis: cracks at corners of mouth

→ Indicates nutritional deficiencies incl. B6, B9, B12, iron

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□ Candidiasis: creamy white curd-like patches → Removed only with difficulty and leave a bleeding surface → May spread to oesophagus → , → Causes: - Immunosuppression, eg. steroids, chemo, alcoholism, underlying I/C state, haematological malignancy - Broad-spectrum Abx (↓normal oral flora) - Faulty oral hygiene - Fe deficiency - Diabetes mellitus → Chronic mucocutaneous candidiasis: distinct syndrome with recurrent or persistent oral thrush, fingernail or toenail bed infection and skin involvement - Usually result of T-cell immunodeficiency - ~50% associated with endocrinopathy, eg. hypoPTH, hypothyroidism, Addison’s disease

3. Neck and Chest Don’t forget to look both anterior and posterior side of chest and neck Spider naevus (angioma): □ Central arteriole from which radiate numerous small vessels □ Confirmed by pressing on central arteriole → Should result in blanching of whole lesion → Release → rapid refilling from centre to legs □ Site: SVC drainage areas, i.e. arms, neck, chest → Can be found in oral and nasal mucous membrane → Rarely found below nipples □ Possible causes: → Normal variation → Cirrhosis (esp if ≥3 or new spider naevus formation) → Pregnancy (2nd to 5th month) → Hepatitis (may occur transiently in viral hepatitis) → Rheumatoid arthritis → Scleroderma □ Mechanism: traditionally attributed to oestrogen excess (vasodilator) □ Common mimics: → Cherry angioma (Campbell de Morgan spots): - Elevated red circular lesions - Occurs on abdomen or anterior chest - Do not blanch upon pressure - Very common and benign → Venous stars: - On dorsum of feet, legs, back and lower chest over main tributaries to a large vein - Not obliterated by pressure - Cause: chronic venous insufficiency

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Gynaecomastia: enlargement of male breasts □ Not necessarily bilateral and may be tender □ Confirmed by feeling under nipple for genuine breast tissues (cf fat) □ D/dx: → Healthy adolescence → Chronic liver disease50, esp alcoholic cirrhosis and chronic autoimmune hepatitis → Alcoholism51 → Chronic starvation (↓gonadotropin and testosterone production) → Oestrogen-secreting testicular tumours → Drugs, eg. spironolactone, digoxin, cimetidine Cervical lymphadenopathy: palpate L supraclavicular node ± other cervical nodes □ D/dx: infections (esp TB), malignancies □ Troisier’s sign: large Lt supraclavicular (Virchow’s) node + CA stomach

4. Upper Limbs a. Arms The forearm should always be exposed Spider naevi (refer to ‘neck and chest’ above) Arteriovenous fistula in haemodialysis □ Usually prominent and a/w palpable thrills Scratch marks may indicate obstructive jaundice □ Mechanism: retention of unknown substance secreted in bile → pruiritus □ Commonly the presenting feature of primary biliary cirrhosis before other signs are apparent (Bruising) may be related to underlying liver diseases □ Ecchymoses: large bruises >1cm → Indicates clotting factor abnormalities - Hepatocellular damage → ↓clotting factor synthesis - Obstructive jaundice → ↓bile acid for vitamin K absorption □ Petechiae: small bruises <3mm52 → Indicates thrombocytopenia - Chronic alcoholism → BM depression → thrombocytopenia - Portal hypertension → hypersplenism - Severe liver diseases (esp acute hepatic necrosis) → DIC (Axilla): □ Inspect for acanthosis nigricans □ Palpate for lymphadenopathy

50 This is thought to be due to changes in oestradiol-to-testosterone ratio or spironolactone treatment for ascites. 51 Alcoholism can damage Leydig cells and cause gynaecomastia without liver disease. 52 Bruises between 0.3cm and 1cm are called purpura.

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b. Hands Clubbing associated with a number of GI causes □ Cirrhosis (up to 1/3) (AV shunting in lungs of unknown cause → cyanosis) □ Inflammatory bowel diseases (long-standing nutritional depletion) □ Coeliac disease (long-standing nutritional depletion)

Leukonychia: whitish opacification of nail beds □ Indicates hypoalbuminaemia □ Mechanism: compression of capillary flow by ECF □ May present as: → Terry’s nails: only a thin rim of pink nail bed at the top of nail → Muehrcke’s lines: transverse white lines of leukonychia Palmar erythema: reddening of palms of the hands □ Site: thenar/hypothenar eminence sparing the centre □ Mechanism: attributed to ↑oestrogen level (?) □ D/dx: → Chronic liver diseases → Pregnancy → Rheumatoid arthritis → Thyrotoxicosis → Polycythaemia → Chronic febrile illness → Chronic leukaemia Dupuytren’s contracture: visible, palpable thickening and contraction of palmar fascia causing permanent flexion □ Site: → First affects 4th and 5th tendons of fingers → Can involve any fingers and toes → Often bilateral □ Mechanism: unknown, palmar fascia found to contain ↑xanthine □ D/dx: → Normal, esp in manual workers → Cirrhosis, esp alcohol-related → DM → Systemic fibrosclerosing syndromes53

53 Systemic fibrosclerosing syndrome refers to a series of fibrosclerosing diseases associated with IgG4, including Riedel’s thyroiditis.

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Asterixis (hepatic flap): □ Ask pt to stretch out arms in front, separate fingers and extend wrists for 15s □ Push on pt’s finger to keep them extended and observe for any flapping tremor □ Asterixis: → Bilateral jerky, irregular flexion-extension movement at wrist and MCP joints → Rhythm not synchronous on each side → Often accompanied with lateral movement of fingers □ D/dx: indicates inability to maintain posture → Hepatic encephalopathy → Cardiac, respiratory and renal failure → HypoGly, hypoK, hypoMg, barbiturate poisoning □ Mechanism: interference with proprioceptive inflow to reticular formation → rhythmical lapses of postural muscle tone □ Occasionally can involve arms, neck, tongue, jaws, eyelids → demonstrated when pt shuts eye forcefully or protrude tongue Other causes of tremors: □ Wilson’s disease □ Alcoholism (fine-resting tremor) □ Other causes, eg. Parkinson’s, essential tremor Blue lunulae indicating Wilson’s disease

5. Lower Limbs Ankle oedema: press for ~1-2s and palpate for a dimpling □ Bilateral: hypoalbuminaemia, heart failure □ Unilateral: chronic venous insufficiency, DVT (Ankle pigmentation ± leg ulcers) can result from hypersplenism (Bruises)

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6. Stigmata of Chronic Liver Diseases Do not miss them during general examination!! Generalized signs: □ Jaundice → hyperbilirubinaemia □ Fetor hepaticus → porto-systemic shunting □ Easy bruising, purpura → coagulopathy □ Hepatic encephalopathy → hepatic dysfunction Hand signs: □ Clubbing → ↑AV shunting □ Leukonychia → hypoalbuminaemia □ Palmar erythema → ↑oestrogen □ Dupuytren’s contracture → xanthine deposits □ Flapping tremor (asterixis) → hepatic encephalopathy Leg signs: □ Ankle oedema → hypoalbuminaemia □ Ankle pigmentation ± leg ulcers → Associated with hypersplenism → Can regress after splenectomy Abdominal signs: □ Hepatomegaly □ → portal hypertension □ Ascites → portal hypertension □ Caput medusa → portal hypertension Signs related to ↑oestrogen: □ Spider angioma □ Scattered telangiectasia = ‘paper money skin’ → Cause: dilated capillaries → Same significance as spider angioma □ Changes in body hair distribution □ Testicular atrophy with ↓libido and potency □ Gynaecomastia Signs specific for obstructive jaundice: □ Greenish jaundice □ Xanthelasma □ Xanthomas □ Scratch marks

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B. Examination of the Abdomen Setting: □ Exposure: nipple to pubic symphysis □ Position: supine with head on pillow 1. Inspection Shape: □ Normal □ Scaphoid: scooped out (in thin people) □ Distended due to → Fat: gross obesity → Fluid: ascites → Foetus: pregnancy → Flatus: gaseous distension due to bowel obstruction → Faeces → Full-sized tumours → Full bladder → False pregnancy Umbilicus to differentiate between different causes of □ Buried indicates obesity (distension = subcutaneous fat) □ Bulging/everted indicates ↑intra-abdominal pressure → Ascites: bulging flanks54 with umbilicus everted or resembling horizontal slit → Pelvic mass: umbilicus pointing upwards Obvious swelling may indicate □ : suprapubic (bladder, uterus), subcostal (liver, spleen) □ Hernias Scars: □ Mercedes Benz scar in liver transplant □ Rooftop (Chevron) scar in gastrectomy, esophagectomy, hepatectomy, bilateral adrenalectomy or Whipple’s □ Kocher scar in gallbladder and biliary tract surgeries □ Nephrectomy scar in nephrectomy55 □ Midline laparotomy scar in most abdominal operations □ Paramedian scar in spleen, kidney and adrenal operations □ Lanz incision (at McBurnley’s point) in appendicectomy □ Hockey-stick incision in transplanted kidney □ Pfannenstiel incision in Caesarian section and pelvic surgeries

54 Bulging flanks are particularly prominent in ascites as fluid accumulation mainly occurs in the dependent part of abdomen. 55 Note that the kidney is NOT removed in renal transplantation. If removed, it may be due to cystic complications in PCKD.

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Don’t miss the following: □ Tenckhoff catheter or scar for peritoneal dialysis □ Laparoscopic scars esp paraumbilical ones (easily missed) □ Subcutaneous haematoma due to subcutaneous injections

→ Most commonly insulin, LMWH and B12 injections

Skin lesions: □ Striae: whitish/pinkish linear marks with wrinkled appearance → Indicates acute abdominal distension - Whitish in eg. pregnancy, ascites, recent weight gain - Purplish56 in Cushing’s syndrome → Mechanism: acute stretching results in rupture of skin elastic fibres □ Stomas indicating lower GI resection → One-piece (bag attached to skin, whole piece changed) vs two-piece (bag separated from flange attaching to skin, only need to change the bag) → Colostomy (LLQ, firm brown faecal output), → Ileostomy (RLQ, watery greenish output) → Jejunostomy (LUQ) → Gastrostomy (epigastric, with feeding tube) □ Fistulae □ Sister Mary Joseph nodule: metastatic tumour deposit at umbilicus → Reason: umbilicus is the closest site of peritoneum from the skin □ Cullen’s sign: faintly blue discolouration near the umbilicus → Indicates extensive haemoperitoneum → Commonly occur in acute pancreatitis □ Grey-Turner’s sign: faintly blue discolouration at flanks → Indicates retroperitoneal haemorrhage → Commonly occur in acute pancreatitis □ Pigmentation in pregnancy and Addison’s disease □ Radicular vesicular rash associated with herpes zoster

56 Purplish striae only occur in Cushing’s syndrome as ↑cortisol is associated with ↑protein breakdown and therefore capillary weakness.

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Dilated veins: □ Determine direction of flow at inferior abdomen using two fingers → Downward → portal hypertension → Upward → IVC obstruction □ Stand up → ↑prominence □ Caput medusa: engorged paraumbilical veins → Indicates portal hypertension → Blood flow: portal blood → ligamentum teres → umbilicus → other superficial veins □ Dilated thoracoepigastric veins: → Indicates IVC obstruction → Blood flow: supf epigastric v. → thoracoepigastric v. → lateral thoracic v.

Movement: □ Squat down at the end of bed such that abdomen is at eye level □ Ask pt to take slow deep breaths and look for → Asymmetrical movement → mass → Lack of movement → peritonitis □ Epigastric pulsation due to AAA or normal pulsation in thin patients □ Visible peristalsis due to → Normal in very thin patients → Intestinal obstruction - Pyloric obstruction: slow Lt to Rt wave of movement passing across upper abdomen - Distal small bowel obstruction: ‘ladder’ pattern of wave-like movements at centre

Cough impulse: only done in surgical examination □ Make sure the groin is exposed (exposure to mid-thigh) □ Ask pt to cough → Look for any bulges at umbilicus (umbilical), scars (incisional) and groin (inguinal and femoral) regions → Pain indicates peritonitis

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2. Surface Anatomy

Transpyloric plane (L1-2): □ Plane joining tip of 9th costal cartilage □ Left: renal hilum (above), pylorus □ Midline: L1-2, origin of SMA, conus medullaris □ Right: neck of pancreas, D1, fundus of gallbladder, renal hilum (below)

3. Palpation Setting: □ Ask pt to relax abdomen (bend knees if necessary) □ Ask for any tenderness → begin in the region most distal from the pain and tell pt you will be more careful when examining that part □ Make sure hands are gentle and warm □ Palpate with palms of the hand with fingers acting together □ Sit or kneel down such that your hand is at the same level as the abdomen

Procedure: at each quadrant of abdomen, perform □ Superficial palpation with one hand → Hand moulded to shape of abdominal wall → Movement at MCP joint only → Detect any tenderness, mass, pulsation □ Deep palpation with two hands → Detect deeper masses → Define the abnormalities already discovered □ Organ-specific palpation (see later section)

Findings:

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□ Mass: note any masses and state that you would go back to examine them after organ examination □ Tenderness: look for other peritoneal signs (guarding, rigidity, rebound tenderness, ↓bowel sounds) □ Guarding: involuntary contraction of abdominal muscles upon palpation → Always associated with tenderness → +ve → suggestive of peritonitis □ Rebound tenderness: → Slowly press on the area of tenderness → Warn the patient that you are going to let go → Let go quickly and watch pt’s facial expression → +ve → strongly suggestive of peritonitis □ Rigidity: → Involuntary contraction of entire abdominal wall against palpation → Indicates generalized peritonitis □ Murphy’s sign if you find RUQ tenderness ± peritoneal sign (see below, usually only when prompted)

Principle for palpating for other organs: □ Ask pt to move abdominal organs by deep breathing □ Palpating hand kept still to ‘catch’ descending organs during inspiration □ Align finger parallel to border of organ □ Move along axis of expansion during expiration

4. Liver Surface anatomy: □ Upper border: Rt 5th ICS (full expiration) □ Lower border: Rt costal margin at MCL (full inspiration)

Palpation: □ Hand aligned to Rt costal margin and avoid rectus muscle □ Start in RLQ and palpate up along MCL □ Hand stationary during inspiration and moves during expiration □ Repeat at midline (for left lobe enlargement) □ Detect presence of palpable liver57 due to → Hepatomegaly (see table below) → Low-lying liver: hyperinflated lungs, subdiaphragmatic collections → Riedel’s lobe: tongue-like projection of liver from inferior surface of Rt lobe - Normal variant - D/dx enlarged gallbladder or Rt kidney □ Note position of lower border if palpable

57 The mere fact that the liver is palpable does not mean that it is enlarged. It can be pushed down by hyperinflated lungs.

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Percussion: □ Finger should be parallel to proposed margin of dullness □ Percuss from nipple down along MCL for upper border □ Percuss from RLQ up along MCL for lower border if liver is not palpable

Note the following (6.5 items): □ Lower border at MCL and midline □ Upper border at MCL → Liver span from upper and lower border - Normal = 10-12cm along MCL - Increased = hepatomegaly - Decreased = advanced cirrhosis, acute hepatic necrosis □ If palpable, then note → Edge: sharp vs rounded → Surface: regular, well-defined, smooth (normal) vs nodular58 (HCC or polycystic liver) → Consistency: soft (normal) vs firm (cirrhotic) vs hard (HCC or metastasis) → Tenderness → Bruit: only if suspect - Compression of aorta due to large liver59 - Vascular tumour, eg. HCC or hemangioma (bruit heard over entire liver) - Alcoholic hepatitis (bruit heard over entire liver)

Differential diagnosis of hepatomegaly: □ Enlargement of liver parenchyma: Memory device for hepatomegaly: → Fatty liver (ALD or NAFLD): firm, smooth Either the liver itself is enlarged, that there’s something else inside the liver, → Storage diseases, eg. glycogen storage disease, or something connected to liver is has haemochromatosis abnormally high pressure → Hepatitis (swollen hepatocytes) □ Infiltrative lesions: Possibilities of different sizes of liver: → HCC: hard, nodular liver with bruit (± chronic liver disease stigmata) Mild: hepatitis, biliary obstruction Moderate: haemochromatosis, haematological → Metastasis: hard, nodular liver with bruit o disease, NAFLD, amyloidosis (± features of 1 tumour) Massive: malignancy, alcoholic liver disease, → Haematological causes: chronic leukaemia, lymphoma, MPD MPD, Rt HF → Infiltration, eg. amyloidosis → Polycystic liver: firm, nodular □ ‘Occlusive’ lesions: D/dx of → Right heart failure: firm, smooth, tender, Chronic liver disease ± pulsatile (if TR) Haematological diseases → Biliary obstruction, eg. PBC, biliary atresia Infiltrative, eg. amyloidosis 5. Spleen Infections, eg. infectious mononucleosis, CMV

58 Cirrhotic nodules should be too small to be palpable. 59 If bruit is due to aorta compression by liver, then turning patient to left lateral position should ↓intensity as the liver is shifted away from the aorta

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Surface anatomy: □ Normal: 9th to 11th rib, posterior to MAL □ Enlarged along Gardner’s line (Rt iliac fossa → umbilicus → tip of 10th costal cartilage → Rt anterior axillary fold) Palpation: □ Use tip of finger and palpate along Gardner’s line up to costal margin □ If splenomegaly is suspected but spleen not palpable → Turn pt to Rt lateral position → Hook the spleen with left hand at lower rib cage - Apply firm pressure medial and downward - Aim: limit lower rib cage expansion60 → Dipping (ballottement) in case of ascites - Jabbing motion with stiffened fingers - Push spleen down and wait for it to float up - Note that spleen may ‘float’ to a more lateral position in presence of ascites → ballot more laterally □ Notched if splenomegaly >10cm Percussion along the Gardner’s line D/dx by size: (acc. to Prof YL Kwong) □ Massive: CML, MF □ Moderate: portal hypertension, haematological malignancy □ Minimal: haemolytic anaemia (thal intermedia), autoimmune cytopenia (ITP, AIHA) D/dx by incidence: (acc. to Prof YL Kwong) □ Common: → Haematological malignancy, eg. lymphoma, leukaemia, MPN → Portal hypertension, eg. cirrhosis, splenic v. obstruction → Haemolytic anaemia, eg. thal intermedia, HBH D/dx of splenomegaly: disease, AIHA, hereditary spherocytosis - Infiltration: amyloidosis, haemat □ Rare: malignancies (eg. CML) → Chronic inflammatory or A/I disease - Hyperfunctioning: → Infections, eg. IE, schistosomiasis, malaria Immunity: infections (malaria, viral), □ Extremely uncommon: autoimmune (RA, SLE, PAN) Extramed haematopoiesis: marrow → Certain CAs,eg. splenic lymphoma with villous lymphocytes, infiltration (leukaemia, MF), marrow hairy cell leukaemia damage (radiation, toxins) → Certain infections, eg. hepatosplenic candidiasis, chronic Haemolysis: spherocytosis, Hbpathies, malaria infection sickle cell anaemia → Storage diseases - Congestion: cirrhosis, portal vein thrombosis 6. Kidneys The 3Ms suggest causes of massive splenomegaly. Surface anatomy: □ Position: T12-L3, 7cm from midline □ Hilum at transpyloric lane (L1-2)

60 In small spleen enlargement, the spleen enlarges superiorly and posteriorly. Limiting Lt lower rib cage movement means that more of ↑intrathoracic pressure is being directed inferiorly at the diaphragm (i.e. the spleen), making the spleen more prominent.

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□ Rt kidney 2-3cm lower than left Palpation: □ Bimanually to trap the lower pole on inspiration → Lt hand at renal angle61 → Rt hand at subcostal area □ If palpable, attempt balloting62 → Lt hand ‘throw’ → press sharply at renal angle → Rt hand ‘feel’ at subcostal area □ Palpable kidney → a swelling with rounded lower pole and medial dent (hilum) □ Lower pole of Rt kidney may be palpable in thin, healthy people Differentiating between spleen and Lt kidney: □ Spleen is anterior to kidney → Bimanual (kidney) vs anterior palpation (spleen) → Subcostal gap present for kidney (kidneys enlarge anteriorly vs spleen enlarges along Gardner’s line) → Resonant63 (kidney) vs dull on percussion (spleen) □ Spleen is notched medially when enlarged >10cm □ BOTH moves with respiration

D/dx of palpable kidneys Unilateral palpable kidney: - Normal – Rt kidney, compensatory hypertrophy of single kidney - Vascular – acute renal vein thrombosis - Infection – pyelonephritis, renal abscess, pyonephrosis - Neoplasm – RCC - Congenital – polycystic kidney (with asymmetrical enlargement) - Hydronephrosis Bilateral palpable kidney: - Unilateral causes occurring bilaterally - Endocrine – diabetic nephropathy (common), acromegaly64 - Infiltrative – amyloid, lymphoma 7. Approach to Palpable Mass Aim: □ Where does it come from? □ Is it pathological? Describe the mass:

61 The renal angle is formed by the erector spinae muscles and lowest palpable rib. 62 Strictly speaking, ballottement should be reserved for palpation of an organ or mass with a dipping movement in case of ascites or obesity. However, the ‘throwing’ of kidney is traditionally also called ballotting. 63 The kidney is behind the splenic flexure, therefore percussion over it is usually resonant. The spleen, however, is anterior to it. 64 Diabetes results in impaired vasodilation, leading to hyperfiltration and enlarged kidneys in early stages.

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□ Tenderness □ Site: → Region involved? – think the organs nearby → Can you get above it? – liver, spleen, kidneys, stomach → Can you get below it? – pelvic origin (bladder, uterus, ovary, upper rectum) → Intra-abdominal? – ask pt to cross arms and lift head and shoulder off pillow - Disappears/↓size → intra-abdominal - Unchanged → abdominal wall → Retroperitoneal? – try to ballot for the mass □ Size: measure at two dimensions □ Shape: may be distorted when enlarged (esp GI tract or retroperitoneal masses) □ Surface, edge, consistency: → Malignant: hard, irregular and nodular → Cystic: regular, round, smooth and tense → Inflammatory: solid, ill-defined and tender □ Mobility and attachment: → With inspiration D/dx in terms of mobility of masses → With palpation With inspiration but Liver, spleen, kidneys, □ Pulsatility for midline masses not with palpation gallbladder, distal stomach → Place two hands parallel to aorta next to Small bowels, transverse With palpation but the mass colon, mesentery cysts, not with inspiration 65 → Outward mov’t = expansile greater omentum, uterus → Upward mov’t = transmitted - Retroperitoneal mass Comment on what structures do you think it is (eg. pancreas) Note that some normal structures may become - Advanced tumour spread to abdominal palpable Completely fixed walls or abdominal organs - Swelling from severe chronic inflammation

a. Possible Causes of Abdominal Masses

65 For example, a lower abdominal mass with side-to-side mobility is uterine in origin (eg. fibroid, gravid fetus) but not bladder.

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Liver: Liver Spleen: Massive: malignancy, ALD, TR, Rt HF Stomach: Massive: CML, myelofibrosis Moderate: haematological malignancy, CA stomach, pyloric stenosis Moderate: haematological malignancy, haematochromatosis, amyloidosis portal hypertension Transverse colon: Small: biliary obstruction, early Mild: haemolytic anaemia, autoimmune cirrhosis, biliary obstruction CA, diverticular mass/abscess, faeces cytopenia Gallbladder: Pancreas: Stomach Malignant biliary obstruction, acute Pseudocyst, tumour Descending colon: , empyema, Mirizzi Aorta: CA, diverticular mass/abscess, faeces syndrome AAA Kidneys Ascending colon: Retroperitoneal LNs: CA, diverticular mass/abscess, faeces Lymphoma, other abdominal Kidneys malignancies Kidneys Liver Spleen RCC, hydronephrosis, cyst, amyloidosis, Stomach Kidneys adrenals Small intestines: Descending colon Adrenals Obstruction, mesenteric cysts Liver Pancreas Ascending colon Aorta Retroperitoneal LNs Caecum/appendix: Bladder Descending colon Appendiceal mass/abscess, CA, AROU, CROU O/G distended caecum Uterus Urogenital Terminal ileum Gravid uterus, fibroids, tumour Crohn’s ileitis, TB ileitis Ovaries O/G Cyst, tumour Ovarian cyst, tumours, fibroids Rectum Urogenital CA Transplanted kidneys, undescended testis Liver: RUQ, moves with respiration, cannot get above, dull on percussion Spleen: LUQ, moves with respiration, cannot get above, dull on percussion, notched if >10cm Kidneys: bilateral flanks, bimanually palpable, can get above, resonant on percussion

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Gallbladder: □ Anatomy: → Rt MCL at transpyloric plane → Below Rt costal margin where it crosses lateral border of RA □ Palpation: same manner as liver → Normal → not palpable → Enlarged → bulbous, focal, rounded mass, move downwards on inspiration □ Murphy’s sign: → Hand below costal margin and ask pt to take a deep breath → Positive: patient catches breath when inflamed gallbladder presses on examiner’s hand D/dx of palpable gallbladder: - Indicates cholecystitis With jaundice: □ Courvoisier’s law: in pt with enlarged gallbladder and jaundice, - CA head of pancreas → Gallstone is unlikely the cause - CA ampulla of Vater (gallbladder usually already chronically fibrosed) - In-situ CBD stone → Malignant obstruction more likely Without jaundice: (eg. CA pancreas, CA ampulla of Vater) - Mucocele/empyema of gallbladder → Exceptions: - CA gallbladder (stony hard, irregular swelling) - In situ CBD stones, eg. from RPC - Acute cholecystitis - Double stones at CBD and cystic duct - Mirizzi syndrome: inflammation due to cystic duct or gallbladder neck stone causes obstruction of CBD - Recurrent pyogenic cholangitis

Stomach: □ CA stomach: rarely felt, hard, irregular mass in epigastric region Pancreas: fixed, does not move with respiration □ Pancreatic pseudocyst: firm mass with indistinct lower edge, fixed to respiration, resonant on percussion □ CA pancreas (rarely) AAA: □ Place two hands parallel to aorta at outermost palpable margins of a pulsatile mass □ Moves outward → expansile pulsation → AAA □ Note that arterial pulsation may be palpable at epigastrium in thin healthy people

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Faeces: at flanks/lower epigastrium, firm/hard but indentable, usually multiple Bladder: enlarged in AROU or CROU □ Cannot feel lower border □ Can extend up to umbilicus □ Regular, smooth, oval shaped □ Urge to micturate when pressed □ Dull on percussion Ovarian cyst: □ Smooth, spherical, distinct outline □ Cannot get below □ May be mobile side-to-side but not up and down □ Dull to percussion Fibroid: □ Firm or hard, bosselated □ Cannot get below □ Dull on percussion 8. Ascites Anatomy: □ Fluid first accumulates in the flanks → flank dullness □ Gross ascites → distended abdomen + bulging flanks □ Bowels float → central resonance always persist Inspection: □ Abdominal distension with bulging flanks □ Ankle oedema Shifting dullness: □ Percuss away from midline towards Lt flank → mark position of dullness □ Ask pt to turn towards you (Rt side) → wait for 30s to 1min □ Percuss again to demonstrate resonance → shifting dullness □ Try to percuss slightly upward and then downward to detect the new fluid level □ Can be detected only if there is ≥1L of fluid Fluid thrill: □ Ask pt to place medial edge of hand at midline □ Flick the side of abdominal wall with the other hand placed on the other side of abdomen □ Fluid thrill = pulsation felt by hand on the other abdominal wall □ Insensitive – only detects fluid under tension Dipping: detect mass in presence of gross ascites □ Hand placed flat on abdomen □ Fingers flexed at MCP joints rapidly to displace fluid □ Esp useful in detecting hepatomegaly and splenomegaly in ascites

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D/dx for generalized distension: □ Gross ascites □ Large ovarian cyst □ Intestinal obstruction

9. Auscultation Bowel sounds: listen next to the umbilicus (over small bowels) □ Normal → soft, gurgling character → Occurring intermittently → Can be heard over all four quadrants □ Paralytic ileus → complete absence (>4-min period)66 → Usually due to previous intra-abdominal processes □ Bowel obstruction → louder, higher pitched with a tinkling quality □ ↑motility (eg. diarrhoea) → borborygmus → Loud gurgling sounds audible without stethoscope Bruits: high-pitched, not continuous, well-localized □ Liver bruit over a palpable liver → HCC → Alcoholic hepatitis → Compression of aorta (relieved by turning to Lt lateral position) □ Renal bruit in a young pt with hypertension at 5cm above umbilicus (at transpyloric plane) → Renal artery stenosis □ Aortic bruit between umbilicus and xiphisternum Succussion splash if gastric outlet obstruction suspected □ Place stethoscope over epigastrium □ Grasp one iliac crest with each hand and shake pt vigorously from side to side □ Splashing sounds → gastric outlet obstruction → Reason: excessive fluid retained in an obstructed stomach □ N/A if pt has just drunk a large amount of fluid C. Other Relevant Examinations To complete the examination, I would □ Examine all hernia orifices □ Perform a digital rectal examination Other systems as indicated □ CVS if cardiac cirrhosis is suspected □ Breast and chest examination if metastatic hepatomegaly is suspected

66 As bowels are dilated and filled with fluid, you may be able to detect heart sounds in the abdomen.

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2.4.2 Digital Rectal Examination Setting: □ Position: left lateral decubitus position with hip and knee flexed to 90o (Other positions: lithotomy, knee-chest, prone jackknife) □ Exposure: entire buttock, drape over genitals □ Obtain consent and wear a pair of gloves Inspection: □ Gently part the buttocks to expose anal verge and natal cleft □ Inspect perianal skin for inflammation, excoriation, faecal soiling and anal warts □ Inspect anal opening for scars, fistula openings, skin tags and external haemorrhoids □ Ask pt to bear down or cough and inspect for → Organ prolapse: rectal, vaginal → Urine leak Palpation: □ Apply KY jelly onto gloved index finger and crouch down □ Apply pressure on anal verge to relax the sphincter → If there is any pain, stop immediately (fissure or abscess) □ Slowly insert finger with finger directed posteriorly following the sacral curve □ Test the anal tone by asking pt to squeeze your fingers with his/her anal muscles □ Palpate the rectal mucosa systematically for mucosal and extramucosal masses by → Palpate posterior wall at 6 o’clock → Supination to 12 o’clock to palpate Rt rectal wall → Pronate to 12 o’clock to palpate Lt rectal wall → Further pronation to palpate anterior wall □ At anterior wall, palpate for → Prostate (M) for - Size: 3.5cm = 2fb - Consistency: soft, firm, hard - Median groove: obliteration indicates malignancy - Tenderness: prostatitis - Hard nodules → Retroverted uterus (F) □ Slowly withdraw your finger and inspect for colour and consistency of stools on gloved finger

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