Gastrointestinal System (GIT) History Taking and clinical examination
GASTROINTESTINAL SYSTEM HISTORY TAKING
1. Patient Demographics
- Name, Age, Sex, Occupation, Address
- Why relevant:
- Age: Infantile hypertrophic pyloric stenosis (infants), appendicitis (children), gallstones/peptic ulcer (adults), malignancy (elderly)
- Sex: Gallstones more in females, alcoholic liver disease more in males
- Occupation: Chemical exposure (liver disease), sedentary lifestyle (constipation)
- Address: Endemic hepatitis A/E areas, cholera outbreaks
- Why relevant:
2. Chief Complaint(s) with Duration
- State in patient’s words, then translate to medical terms.
- Example: “Pain in upper stomach since 3 days” → “Epigastric pain × 3 days”
- Clinical relevance: Duration helps differentiate acute (e.g., acute appendicitis) from chronic (e.g., peptic ulcer disease) conditions.
3. History of Presenting Illness
A. Symptom Analysis (SOCRATES / OLD CARTS)
1. Abdominal Pain
- Location:
- RUQ → Acute cholecystitis, hepatitis
- Epigastrium → Gastritis, peptic ulcer, pancreatitis
- Periumbilical → Early appendicitis, small bowel pathology
- LLQ → Sigmoid diverticulitis, colitis
- Generalized → Peritonitis, gastroenteritis
- Onset: Sudden (perforation, ischemia) vs gradual (gastritis, tumor)
- Character: Colicky (intestinal obstruction), burning (GERD), dull ache (hepatitis)
- Radiation:
- To back → Pancreatitis, posterior penetrating ulcer
- To shoulder → Diaphragmatic irritation (subphrenic abscess)
- Relation to meals:
- Pain after meals → Gastric ulcer
- Pain relieved by meals → Duodenal ulcer
- Relieving factors: Leaning forward (pancreatitis), vomiting (pyloric obstruction)
- Associated symptoms: Vomiting (gastritis), jaundice (hepatitis), fever (cholecystitis)
2. Vomiting
- Timing:
- Early morning → Raised ICP or pregnancy
- Immediately after meals → Gastric outlet obstruction
- Hours after meals → Gastroparesis
- Content:
- Food particles → Delayed gastric emptying
- Bilious → Obstruction distal to pylorus
- Coffee-ground → Gastric/duodenal ulcer bleed
- Fresh blood → Mallory–Weiss tear, variceal bleed
- Feculent → Distal intestinal obstruction
- Frequency: Persistent (gastroenteritis), intermittent (partial obstruction)
3. Altered Bowel Habits
- Diarrhea: Acute watery (infective), chronic (>4 weeks → IBD, malabsorption)
- Constipation: Functional, hypothyroidism, obstruction (colorectal cancer)
- Alternating diarrhea/constipation: IBS, carcinoma colon
- Mucus in stools: IBS, amoebic dysentery
- Blood in stools:
- Fresh blood → Hemorrhoids, fissure, carcinoma rectum
- Mixed with stool → Colon cancer, ulcerative colitis
- Black tarry (melena) → Upper GI bleed
4. GI Bleeding
- Hematemesis:
- Bright red → Varices, gastric ulcer
- Coffee-ground → Gastritis, ulcer bleed
- Melena: Peptic ulcer, varices, small bowel tumors
- Hematochezia: Lower GI bleed, massive upper GI bleed
5. Jaundice
- Onset: Sudden (viral hepatitis), gradual (cholangiocarcinoma)
- Associated:
- Dark urine & pale stools → Obstructive jaundice
- Fever + chills → Ascending cholangitis
- Pruritus → Cholestasis
6. Abdominal Distension
- Acute: Perforation, obstruction, peritonitis
- Chronic: Ascites (cirrhosis, TB peritonitis), tumors
- Relation to position: Ascites increases on lying down
7. Dysphagia
- Solids only: Esophageal stricture, carcinoma
- Solids then liquids: Progressive carcinoma
- Liquids > solids: Achalasia cardia
- Painful swallowing (odynophagia): Esophagitis
8. Appetite & Weight Changes
- Anorexia: Hepatitis, carcinoma stomach
- Early satiety: Gastric cancer, ascites
- Unintentional weight loss: Malignancy, malabsorption
4. Associated Symptoms
- Fever → Typhoid, liver abscess, cholangitis
- Fatigue → Chronic liver disease, anemia from GI bleed
- Tenesmus → Rectal carcinoma, proctitis
- Steatorrhea → Chronic pancreatitis, celiac disease
5. Past History
- Peptic ulcer: Risk of recurrence or complications
- Jaundice: Recurrent → CBD stones, hemolysis
- Hepatitis: Viral hepatitis, autoimmune
- GI surgery: Adhesions causing obstruction
- Blood transfusions: Hepatitis B/C risk
6. Personal History
- Diet: High fat → Gallstones; low fiber → Constipation
- Alcohol: Alcoholic liver disease, pancreatitis
- Tobacco: Esophageal, gastric cancer
- Bowel habits: IBS, hemorrhoids
- Water source: Hepatitis A/E, cholera risk
7. Family History
- Colon cancer, polyposis syndromes, IBD, Wilson’s disease
8. Menstrual/Obstetric History (Females)
- Amenorrhea + abdominal distension: Pregnancy
- Menstrual irregularity: PCOS, hypothyroidism-related GI effects
9. Drug History
- NSAIDs → Peptic ulcer
- Steroids → Masked infection, ulcer
- Anti-TB drugs → Hepatitis
- Iron → Black stools (benign cause)
10. Socioeconomic & Environmental History
- Poor sanitation → Helminthic infestations
- Slum living → Hepatitis A/E, cholera
- Travel → Typhoid, traveler’s diarrhea
🍽️ Gastrointestinal (GIT) System Examination: Technical Terminology
🪞 1. Inspection (Looking)
| Term | Meaning |
|---|---|
| Scaphoid abdomen | Sunken-in appearance of the abdomen — may be seen in malnutrition or cachexia |
Distended abdomen |
Swollen abdomen — may indicate gas, fluid, mass, or obstruction |
| Peristalsis | Visible wave-like movements on the abdomen — seen in intestinal obstruction |
| Pulsations | Visible throbbing — may suggest abdominal aortic aneurysm |
| Striae | Stretch marks — seen in obesity, pregnancy, or Cushing’s syndrome |
| Surgical scars | Previous surgical sites — helpful for history and differential diagnosis |
| Umbilicus | Normally centrally placed and inverted; everted may suggest ascites or mass |
| Caput medusae | Dilated tortuous veins around the umbilicus — due to portal hypertension |
| Jaundice | Yellowish discoloration of the skin/sclera — indicates liver dysfunction |
| Clubbing | Bulbous enlargement of fingertips — seen in cirrhosis, IBD |
| Spider angioma | Small red spots with radiating vessels — seen in liver disease |
| Gynecomastia | Male breast enlargement — can be seen in cirrhosis |
✋ 2. Palpation (Feeling)
| Term | Meaning |
|---|---|
| Superficial palpation | Gentle pressing to detect tenderness or rigidity |
Deep palpation |
Firm pressing to feel deep organs like liver, spleen, kidney |
Rebound tenderness |
Pain when pressure is suddenly released — indicates peritonitis |
| Guarding | Involuntary tightening of abdominal muscles — protective reflex in peritonitis |
| Rigidity | Board-like hardness of abdominal wall — suggests severe peritonitis |
| Murphy’s sign | Pain on pressing under right costal margin during deep inspiration — indicates cholecystitis |
McBurney’s point |
One-third from ASIS to umbilicus — tenderness here indicates appendicitis |
| Rovsing’s sign | Pain in right lower abdomen when pressing on the left — suggests appendicitis |
| Palpable liver | Normally not felt below costal margin; if palpable — could indicate hepatomegaly |
| Palpable spleen | Felt below the left costal margin — suggests splenomegaly |
| Ballotable kidney | Kidney felt between two hands (anterior-posterior) — usually indicates enlargement |
| Fluid thrill | Wave-like impulse felt — suggests massive ascites |
| Shifting dullness | Percussion note changes when patient changes position — confirms free fluid (ascites) |
🥁 3. Percussion (Tapping)
| Term | Meaning |
|---|---|
| Tympanic note | Drum-like sound — normal over air-filled intestines |
| Dull note | Flat sound — over solid organs like liver or fluid-filled area (ascites) |
| Liver span | Measured in midclavicular line — normal: 6–12 cm |
| Splenic dullness | Normally not percussible; dullness suggests splenomegaly |
| Shifting dullness | As above; suggests free peritoneal fluid |
Fluid thrill |
Confirms presence of large volume of ascitic fluid |
🎧 4. Auscultation (Listening)
| Term | Meaning |
|---|---|
| Bowel sounds | Normal gurgling sounds every 5–15 seconds |
| Hyperactive bowel sounds | Loud and frequent — seen in early obstruction or gastroenteritis |
| Absent bowel sounds | No sound for over 2 minutes — suggests paralytic ileus or late obstruction |
| Bruits | Whooshing sounds over arteries — suggests turbulent blood flow (e.g., renal artery stenosis) |
| Succussion splash | Splashing sound heard over the stomach — seen in gastric outlet obstruction |
🧠 Other Important Terms
| Term | Meaning |
|---|---|
| Hepatomegaly | Enlarged liver |
| Splenomegaly | Enlarged spleen |
| Ascites | Fluid accumulation in the peritoneal cavity |
| Peritonitis | Inflammation of the peritoneum — often with guarding, rigidity, rebound tenderness |
| Portal hypertension | Increased pressure in portal vein system — leads to ascites, caput medusae, varices |
| Hernia | Protrusion of organ/tissue through abdominal wall — seen as bulge |
| Rectal examination | Digital exam of rectum to check for masses, bleeding, tenderness |
| Digital rectal exam (DRE) | Using finger to assess rectum and prostate (in males) |
🔁 GIT Surface Anatomy Landmarks
| Structure | Surface Landmark |
|---|---|
| Liver | Right hypochondrium, below costal margin |
| Gallbladder | Intersection of right costal margin and lateral border of rectus muscle |
| Appendix | McBurney’s point (RLQ) |
| Spleen | Left hypochondrium, under ribs 9–11 |
| Kidneys | Posterior abdomen, T12–L3 vertebrae area |
| Stomach | Epigastrium and left upper quadrant |
GASTROINTESTINAL EXAMINATION — STEP BY STEP
A. Preparation & basic checks (before you touch the patient)
- Explain the exam; obtain consent; ensure privacy and a chaperone if needed.
- Ask patient to empty bladder if possible.
- Position: supine, arms at sides, knees slightly flexed (relaxes abdominal wall). Also have patient sit/stand when requested (hernia/veins).
- Inspect lighting and expose abdomen from nipples to mid-thigh.
- Record vital signs: pulse, BP, temperature, respiratory rate, oxygen saturation. (Abnormal vitals = urgent).
B. General inspection & systemic signs (head-to-toe glance)
Inspect the whole patient for systemic signs that point to GI disease:
- General appearance — cachexia/wasting → chronic disease, malignancy, IBD.
- Skin: jaundice (hepatitis/obstructive jaundice), bruising/spider nevi/palmar erythema (chronic liver disease), xanthelasma (cholestasis/hyperlipidemia), excoriations (pruritus of cholestasis).
- Hands: asterixis (flapping) → hepatic encephalopathy; leukonychia/koilonychia → chronic disease/iron deficiency.
- Eyes & mouth: conjunctival pallor → anemia from GI bleed; angular stomatitis, glossitis → malabsorption. Fetor hepaticus (distinctive breath) → severe liver failure.
- Chest & breasts: gynaecomastia (chronic liver disease), chest wall scars (previous surgery).
- Abdomen (quick look): distension, visible peristalsis (obstruction), surgical scars (adhesions), dilated veins (caput medusae → portal hypertension), visible pulsation (AAA).
Why: These signs help triage: e.g., jaundice + pruritus → obstructive cholestasis; weight loss + mass → malignancy.
C. Abdominal examination — correct sequence: INSPECT → AUSCULTATE → PERCUSS → PALPATE
1. Inspect (stand at foot and right side)
- Contour: flat, scaphoid, distended (ascites; obstruction).
- Scars / stomas / fistulae — note location & type (past surgery, ileostomy).
- Striae / pigmentation / bruising (Cushing’s, chronic disease).
- Veins: caput medusae (portal hypertension), dilated abdominal wall veins.
- Pulsation: epigastric pulsation (AAA if strong & expansile).
- Visible peristalsis: suggests small-bowel obstruction.
- Masses: visible lumps or hernias on coughing/standing.
Clinical connections: Distension + fluid thrill/shifting dullness → ascites (cirrhosis, malignancy, TB). Visible peristalsis + vomiting → obstruction.
2. Auscultation
- Use diaphragm; listen before palpation:
- Bowel sounds: normal (5–35/min).
- Hyperactive, high-pitched, tinkling → small-bowel obstruction.
- Hypoactive or absent → ileus or peritonitis (if absent in all quadrants).
- Borborygmi (loud rumbling) → gastroenteritis, hunger.
- Bruits: listen over aorta, epigastrium, renal arteries, iliac arteries.
- Systolic bruit → renal artery stenosis, mesenteric ischemia, AAA.
- Friction rubs over liver/spleen → rare but suggest tumour/abscess/inflammation of capsule.
- Bowel sounds: normal (5–35/min).
Tip: Succussion splash (rocking patient) audible if gastric outlet obstruction.
3. Percussion
- General percussion to map tympany (gas) vs dullness (mass, organ, fluid).
- Liver span (midclavicular line): percuss from lung resonance down to liver dullness and from abdomen tympany up — normal ~6–12 cm (adult) — indicates hepatomegaly if increased.
- Splenic percussion: Percuss Traube’s space / use Castell’s sign — change from tympany to dullness on inspiration suggests splenomegaly (splenic enlargement = malaria, kala-azar, portal hypertension, haematological disease).
- Shifting dullness: test for ascites: percuss center to flank -> mark; patient rolls to side -> dullness shifts = ascites.
- Fluid thrill / fluid wave: positive in moderate-large ascites (check with helper).
- Percussion for gastric bubble: tympany under left costal margin.
Clinical connections: Increased liver span → hepatomegaly (congestive hepatopathy, hepatitis, fatty liver, malignancy). Fixed dull mass → tumour. Shifting dullness/fluid thrill → ascites.
4. Palpation
Start with light (superficial) then deep palpation in all quadrants. Ask about tenderness early.
- Light palpation: detect guarding, superficial masses, tenderness.
- Guarding (voluntary) vs rigidity (involuntary): rigidity = peritonitis (surgical abdomen).
- Deep palpation: feel for masses, organomegaly, aortic pulsation. Note size, location, consistency, mobility, tenderness.
- Liver palpation: place right hand flat on RUQ, fingers parallel to costal margin, ask patient to take a deep breath. Hooking technique or traditional palpation. Characteristics:
- Smooth, firm, tender → hepatitis, congestive hepatopathy, acute hepatitis (tender).
- Hard, nodular → cirrhosis or tumour.
- Spleen palpation: start in right lateral decubitus or supine with patient on right side; palpate from right iliac fossa toward left costal margin during inspiration. Large spleen is palpable below costal margin in splenomegaly.
- Kidney palpation: ballottement for renal masses; palpate costovertebral angle for tenderness (pyelonephritis, renal stone).
- Aortic pulse: palpate for expansile/pulsatile mass >3 cm in elderly → suspect AAA.
- Palpable mass assessment: location, relation to breathing, pulsatility, mobility (respiratory movement suggests organ origin).
Special tenderness tests:
- Murphy’s sign: RUQ palpation with inspiration — sudden stop in inspiration = positive → acute cholecystitis.
- McBurney’s point tenderness / rebound tenderness → appendicitis / peritonitis.
- Rovsing’s sign: left lower quadrant pressure causes right lower quadrant pain → appendicitis.
- Psoas sign: pain on passive extension (or active flexion) of right hip → retrocecal appendicitis.
- Obturator sign: pain on internal rotation of flexed right hip → pelvic appendix.
- Carnett’s sign: increase in pain when patient tenses abdominal muscles (raise head) → abdominal wall source (e.g., rectus sheath hematoma) rather than intra-abdominal.
- Heel-jar (Markle) / cough test: pain on heel striking or cough suggests peritonitis (appendicitis/peritonitis).
Interpretation: Localized peritonism → surgical abdomen. Diffuse tenderness + rigidity → generalized peritonitis (urgent).
D. Examination of hernia & inguinoscrotal region
- Inspect standing and ask to cough / strain (Valsalva).
- Palpate superficial inguinal ring and deep ring; reduce hernia to assess reducibility.
- Note scrotal swelling: transillumination, expansile cough impulse, tenderness (strangulation).
- Distinguish direct (bulge on cough at Hesselbach’s triangle) vs indirect (through deep inguinal ring) clinically if required.
Why: Hernias can cause obstruction/strangulation — surgical referral if tender and irreducible.
E. Per-rectal (PR) and female pelvic examination (if indicated)
- PR exam (on indicated cases; get consent & chaperone):
- Sphincter tone (neuro), palpable masses, tenderness, impacted stool, prostate (in men): size, consistency, nodules (prostate cancer), boggy/tender prostate (prostatitis).
- Check glove for stool color (melena = black/tarry), frank blood.
- Do FOBT (fecal occult blood) if indicated.
- Female pelvic exam when pain/bleeding suggests gynae cause — may include speculum and bimanual exam (do with consent/indication).
Connections: PR mass or blood → colorectal cancer, fissure, haemorrhoids, IBD.
F. Quick neurologic/mental check related to GI
- Asterixis, confusion → hepatic encephalopathy.
- Peripheral neuropathy → malabsorption (e.g., B12 deficiency in celiac disease).
G. Wrap-up tests and bedside adjuncts
- Dressing & safety: keep patient warm, allow rest.
- Bedside tests you can do: urine dipstick (bilirubin), stool for occult blood, bedside ultrasound (if available) for ascites/hepatosplenomegaly, abdominal X-ray in suspected obstruction/perforation.
- Document: location of tenderness, organ measurements (liver span in cm), presence of ascites, type of bowel sounds, positive signs (Murphy, Rovsing, etc.), vital signs.
H. Red flags — immediate action needed
- Peritonitis (rigidity, rebound, severe pain) → urgent surgical review.
- Hypotension + severe GI bleed (hematemesis/hematochezia) → resuscitate; urgent GI/surgical input.
- Signs of sepsis (fever, tachycardia, hypotension) with abdominal source → urgent management.
- Suspected obstructed/strangulated hernia → urgent surgery.
I. Practical OSCE / bedside checklist (short)
- Consent, chaperone, exposure.
- Vitals.
- Inspect (patient supine & standing).
- Auscultate 4 quadrants + bruits.
- Percuss all quadrants + liver & spleen span.
- Palpate superficial → deep, check for guarding/rigidity.
- Special signs (Murphy, Rovsing, Psoas, Obturator, Carnett).
- Hernia exam standing + cough.
- PR exam if indicated.
- Record findings, provisional differential, red-flag plan.
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