During any examination in an OSCE it is important to understand the pathology and reasoning behind each of the signs and symptoms elicited, even if the patient being examined is ‘normal’. This article explains how to perform an abdominal (gastrointestinal) examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.
The abdominal examination follows the familiar pattern of inspection, palpation, percussion and auscultation. It begins peripherally, at the hands, arms and face, because chronic gastrointestinal and liver disease leaves clues throughout the body before the abdomen is ever touched. Work systematically from the periphery inwards.
Hands and Arms
Take the patient’s hands and inspect them carefully. Chronic liver disease in particular produces a cluster of recognisable hand signs.
Look at the nails. Koilonychia (spoon-shaped nails that are concave and brittle) is a sign of chronic iron deficiency anaemia, which may result from gastrointestinal blood loss or malabsorption. Leukonychia means white nails and has several causes. White nail-bed patterns such as Terry nails (mostly white nails with a thin pink band at the tip) may accompany chronic liver disease, but the appearance alone does not establish hypoalbuminaemia (low blood albumin) or impaired hepatic synthesis. Interpret the pattern alongside the other findings and blood tests. Clubbing (loss of the normal angle between the nail and nail fold) in a gastrointestinal context may be caused by inflammatory bowel disease (Crohn’s disease and ulcerative colitis), coeliac disease, liver cirrhosis or gastrointestinal lymphoma.
Image - Koilonychia (spoon-shaped nails). This concave nail deformity is associated with chronic iron deficiency anaemia
Creative commons source by CHeitz [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]
Image - Finger clubbing, with loss of the normal angle between the nail and nail fold. In a gastrointestinal context it points to inflammatory bowel disease, coeliac disease, cirrhosis or lymphoma
SimpleMed original
Note any tar staining of the fingers, a yellow-brown discolouration that points to smoking, which is a risk factor for several gastrointestinal cancers, peptic ulcer disease and Crohn’s disease.
Inspect the palms for palmar erythema, a reddening of the heel of the palm that is thought to be caused by the altered sex hormone metabolism and high circulating oestrogen levels of chronic liver disease (it can also be a normal finding in pregnancy). Look for Dupuytren’s contracture, a thickening of the palmar fascia (the sheet of tissue under the skin of the palm) that draws the fingers (most often the ring and little fingers) into fixed flexion. A family history is a risk factor, and it has also been linked to alcohol excess, diabetes, smoking and epilepsy, so on its own it does not prove alcohol-related liver disease.
Assess the temperature of the hands and the capillary refill time as a quick measure of peripheral perfusion. A refill time of greater than two seconds may indicate poor perfusion, such as in shock from gastrointestinal haemorrhage or sepsis.
Ask the patient to hold their arms out straight and cock their wrists back for 15–30 seconds to check for asterixis (a flapping tremor). In the context of an abdominal examination this is a sign of hepatic encephalopathy, where the failing liver cannot clear nitrogenous waste such as ammonia, which then disrupts brain function. It can also be caused by carbon dioxide retention and uraemia (a build-up of urea in the blood from kidney failure).
While at the arms, assess for bruising, excoriations (scratch marks) and needle track marks. Easy bruising may accompany liver disease and should be assessed with the platelet count and coagulation tests; impaired hepatic synthesis and vitamin K deficiency can contribute to coagulation abnormalities. Excoriations result from scratching because of pruritus (itching), which is associated with cholestasis (reduced bile flow). The scratch marks do not themselves prove that bile salts have been deposited in the skin. Track marks over the veins suggest intravenous drug use, an important risk factor for blood-borne viral hepatitis (hepatitis B and C) and its long-term complications of cirrhosis and hepatocellular carcinoma.
Face and Mouth
Move to the face and examine the eyes. Gently pull down the lower eyelid to inspect the conjunctiva (the thin membrane lining the inner eyelid), then ask the patient to look upwards while you inspect the sclera on the lower part of the eyeball, below the iris.
Look for conjunctival pallor, where the normally pink inner surface of the lower eyelid appears pale, indicating anaemia. Inspect the sclerae for jaundice (scleral icterus), a yellow discolouration that is often visible in the eyes before it is apparent in the skin. Jaundice reflects a raised serum bilirubin and may be pre-hepatic (haemolysis), hepatic (liver cell damage) or post-hepatic (biliary obstruction).
Around the eyes, look for xanthelasma (raised yellow cholesterol-laden plaques on the eyelids) and corneal arcus (a pale lipid ring in the peripheral cornea, the clear front of the eye). Xanthelasma may accompany dyslipidaemia (abnormal blood fats) or cholestatic liver disease, but often occurs with normal circulating lipid levels. Corneal arcus is commonly age-related; in a younger patient it should prompt lipid assessment. Neither sign alone establishes hyperlipidaemia. Rarely, in Wilson’s disease (an inherited disorder of copper handling), copper deposition produces brownish Kayser-Fleischer rings at the edge of the cornea.
Image - Jaundice of the sclera. The yellow discolouration reflects a raised serum bilirubin and is often visible in the eyes before the skin
Public Domain Source by unknown author [Public domain]
Ask the patient to open their mouth and inspect it. Angular stomatitis (cracked, inflamed corners of the mouth) and glossitis (a smooth, swollen, erythematous tongue) are signs of iron, vitamin B12 or folate deficiency (folate is vitamin B9), which may arise from malabsorption. Look for oral candidiasis (white plaques) and aphthous ulceration (small painful mouth ulcers), the latter being associated with inflammatory bowel disease and coeliac disease. Note the general state of hydration by inspecting the mucous membranes for dryness. As you do so, note any fetor hepaticus, a characteristic sweet or musty breath odour associated with advanced liver disease and portosystemic shunting (blood bypassing the liver through abnormal connections). Volatile sulphur compounds contribute to the odour, which should not be equated with an ammonia smell.
Neck and Chest
Examine the cervical and supraclavicular lymph nodes. A palpable, hard, enlarged left supraclavicular node (above the collarbone) is known as Virchow’s node, and the finding as Troisier’s sign. It is a classic marker of gastric malignancy (stomach cancer), because the thoracic duct (the main lymph vessel, which drains the abdomen) empties near this node.
Inspect the chest and upper abdomen for spider naevi (central red arterioles with radiating small vessels that blanch on pressure to the centre and then refill outwards). They occur in the distribution of the superior vena cava (above the nipple line) and, like palmar erythema, are thought to reflect the raised oestrogen levels of chronic liver disease, although the exact cause is still unclear. More than five spider naevi is considered abnormal in an adult. Also note gynaecomastia (breast enlargement) and loss of body hair in men, which are thought to reflect the same hormonal disturbance.
Image - A spider naevus, with a central arteriole and radiating vessels. Multiple spider naevi in the superior vena cava distribution suggest chronic liver disease
Creative commons source by Herbert L. Fred, MD and Hendrik A. van Dijk [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]
Inspection of the Abdomen
Lower the bed so the patient is lying flat and kneel or crouch beside them so that your eyes are level with the abdomen. Inspecting tangentially in this way makes subtle masses, distension and pulsation far easier to see.
Look for scars, which give away the patient’s surgical history. Examples are a midline laparotomy scar (a scar from surgical opening of the abdomen), a right iliac fossa scar (appendicectomy; the iliac fossa is the lower corner of the abdomen beside the hip bone), a small right subcostal (Kocher) scar (open cholecystectomy, removal of the gallbladder) and laparoscopic (keyhole) port scars. Identify any stoma and note its position and contents, as the site offers a clue to its type. A right iliac fossa stoma with a spout is usually an ileostomy, and a left iliac fossa flush stoma is usually a colostomy.
Note any distension, visible masses or obvious organomegaly (enlarged organs). Look for caput medusae (distended veins radiating from the umbilicus, or belly button), which forms when portal hypertension (raised pressure in the portal vein) forces blood through collateral veins in the abdominal wall. Note any striae (stretch marks): silvery-white striae are common after pregnancy, weight change or with ascitic distension, while broad purple striae point to Cushing’s syndrome (the effects of too much cortisol) or steroid use. Inspect the flanks for bruising: Grey Turner’s sign (flank bruising) and Cullen’s sign (periumbilical bruising) suggest retroperitoneal haemorrhage (bleeding behind the peritoneum), classically in severe acute pancreatitis (inflammation of the pancreas).
Ask the patient to cough and watch the hernial orifices (the common sites where hernias appear, such as the groin and umbilicus) and any scars for bulging, which may reveal a hernia. Finally, look for visible peristalsis or pulsation; a prominent central pulsation may represent an abdominal aortic aneurysm.
Image - An ileostomy. A spout and liquid to porridge-like output support an ileostomy; combine these findings with the anatomy and operative history when identifying a stoma
Photograph by Salicyna, licensed under CC BY-SA 4.0
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