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GASTROINTESTINAL SYSTEM EXAMINATION

1. HISTORY TAKING POINTS

A. Presenting Complaints

1. Abdominal Pain
Site:

• Epigastric: Peptic ulcer, GERD, Pancreatitis, MI (referred)
• Right hypochondrium: Cholelithiasis, Acute cholecystitis, Liver abscess
• Left hypochondrium: Splenic infarct, Splenomegaly-related traction
• Periumbilical: Early appendicitis, Small bowel pathology, Mesenteric ischemia
• Right iliac fossa: Appendicitis, Crohn’s disease, Cecal carcinoma
• Left iliac fossa: Diverticulitis, Sigmoid volvulus, Colorectal carcinoma
• Suprapubic: Cystitis, Pelvic abscess, IBS

Character:

• Colicky: Intestinal obstruction, ureteric colic, biliary colic
• Dull aching: Chronic liver disease, malignancy, splenic pathology
• Burning: GERD, PUD
• Stabbing: Pancreatitis, perforation, vascular causes
• Radiating to back: Pancreatitis, AAA rupture, posterior duodenal ulcer
• Pain relief on bending forward: Pancreatitis

Severity:

• Severe, sudden: Perforation, mesenteric ischemia, pancreatitis
• Intermittent: IBS, functional dyspepsia
• Nocturnal awakening: Peptic ulcer, malignancy

2. Nausea & Vomiting

• Early morning vomiting: Raised ICP, Pregnancy, Alcohol gastritis
• Post-prandial vomiting: Gastric outlet obstruction
• Feculent vomiting: Distal small bowel obstruction
• Bilious vomiting: Obstruction distal to ampulla

3. Dysphagia

• Solids progressing to liquids: Malignancy, peptic stricture
• Both solids and liquids from onset: Achalasia, esophageal spasm
• Intermittent: Esophageal spasm, web

4. Odynophagia

• Infective esophagitis (Candida, CMV, HSV), corrosive ingestion, pill esophagitis

5. Regurgitation / Heartburn

• GERD, Zenker diverticulum, achalasia

6. Hematemesis / Malena / PR bleeding

• Bright red vomiting: Mallory-Weiss tear, Varices
• Coffee ground vomitus: Peptic ulcer
• Black tarry stools: Upper GI bleed
• Fresh PR bleeding: Hemorrhoids, Anal fissure, Diverticulosis, Rectal carcinoma

7. Altered Bowel Habits

• Diarrhea: IBS-D, IBD, Malabsorption, Infection
• Constipation: IBS-C, Hypothyroidism, Obstruction, Hirschsprung’s
• Alternating diarrhea & constipation: Colonic malignancy, IBS

8. Weight Loss

• With good appetite: Diabetes, Malabsorption, Hyperthyroidism
• With anorexia: Malignancy, chronic infections, depression

9. Jaundice

• Painful: Gallstones, cholangitis
• Painless progressive: Pancreatic carcinoma, CBD obstruction
• Intermittent: Hemolysis, Gilbert’s syndrome

10. Abdominal Distension

• Sudden: Volvulus, Obstruction
• Gradual: Ascites, Tumor, Organomegaly

11. Pruritus, Skin Changes

• Cholestasis, Primary biliary cholangitis, Cirrhosis

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B. Past History

• Previous surgeries: Gastrectomy, Cholecystectomy
• TB, Alcohol use, Hepatitis
• History of similar complaints
• Medications: NSAIDs, antacids, laxatives

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C. Personal & Dietary History

• Alcohol, Smoking
• High-fat diet, Red meat intake
• Recent travel, Outside food
• Bowel habits

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D. Family History

• IBD, Colorectal carcinoma, Peptic ulcer disease, Wilson's disease

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2. CLINICAL EXAMINATION POINTS

A. General Examination

• Nutritional status: Cachexia, temporal wasting
• Icterus: Conjunctival, generalized
• Pallor: Anemia due to chronic GI bleed
• Skin: Spider angioma, palmar erythema, scratch marks
• Nail: Leukonychia, clubbing (IBD, Cirrhosis), koilonychia
• Lymphadenopathy: Virchow node (gastric carcinoma), Sister Mary Joseph nodule (umbilical, metastasis)

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B. Abdominal Examination

Inspection

• Shape: Scaphoid (malnutrition), distended (ascites, obstruction)
• Umbilicus: Inverted, everted, displaced
• Visible peristalsis: Gastric outlet obstruction
• Dilated veins: Portal hypertension (caput medusae), IVC obstruction
• Surgical scars, hernia

Palpation

Superficial Palpation:

• Guarding, rigidity: Peritonitis
• Localized tenderness:
  • RIF: Appendicitis
  • LUQ: Splenic infarct
  • Epigastrium: Pancreatitis, PUD

Deep Palpation:

• Organomegaly:
  • Liver: Surface, edge, consistency, tenderness
  • Spleen: Notch, mobility
  • Kidney: Bimanual palpation
• Masses: Mobility, surface, pulsatility

Special Signs:

• Murphy’s sign: Cholecystitis
• Rovsing’s sign, Psoas sign: Appendicitis
• Fluid thrill, shifting dullness: Ascites

Percussion

• Liver span: Shrunk (cirrhosis), enlarged (Hepatitis)
• Shifting dullness, fluid thrill: Ascites
• Traube’s space dullness: Splenomegaly

Auscultation

• Bowel sounds:
  • Hyperactive: Obstruction, gastroenteritis
  • Absent: Ileus, peritonitis
• Bruits: Abdominal aorta aneurysm, renal artery stenosis

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C. Per Rectal Examination

• Masses: Rectal carcinoma
• Tenderness: Proctitis
• Melena, fresh blood
• Sphincter tone

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D. Other Systemic Examination

• CNS: Hepatic encephalopathy signs (flap, altered sensorium)
• Respiratory: Pleural effusion (hepatic hydrothorax)
• CVS: High output state in chronic liver disease

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3. Advanced Clinical Clues & Differential Diagnosis Pattern Recognition

Tender hepatomegaly: Hepatitis, Budd-Chiari, hepatic congestion
Firm, nodular liver: Cirrhosis, metastatic liver disease
Mass in epigastrium moving with respiration: Liver, left lobe enlargement
Shifting dullness with engorged veins: Ascites secondary to portal hypertension
Palpable gallbladder with jaundice (Courvoisier's sign): Malignancy of pancreas, CBD
Painless progressive jaundice + cachexia: Pancreatic carcinoma
Hepatosplenomegaly + pancytopenia: Portal hypertension, lymphoma
Ascites + low protein: Cirrhosis
Ascites + high protein: Malignancy, TB
Mass per rectum with bleeding: Rectal carcinoma
Visible peristalsis: Pyloric stenosis, obstruction
Generalized abdominal tenderness + rigidity: Peritonitis

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