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Year 2 MBChB

Clinical Skills Session

Gastrointestinal examination

Reviewed by:

Mr C Halloran – Consultant Pancreato-biliary Surgeon

Dr P Collins – Consultant Gastroenterologist

Dr A Clarke - GP

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Learning objectives.

To revise anatomy and physiology of the GI system

To link the anatomy and physiology to the examination

To be able to perform a GI examination including an understanding of the common abnormalities and

examination of appropriate lymph nodes

Theory and background.

The gastrointestinal system is composed of two groups of organs: the gastrointestinal tract (GI) and

the accessory digestive organs.

The gastrointestinal (GI) tract or alimentary canal is a continuum that extends from the mouth to the

anus through the ventral body cavity (comprised of thoracic and abdominopelvic cavities). Organs of

the gastrointestinal tract include the mouth, most of the pharynx, oesophagus, stomach, small and

large intestine. The accessory digestive organs are the teeth, tongue, salivary glands, liver, gallbladder

and pancreas.

The function of the gastrointestinal tract is to take a bolus of food; masticate it, swallow it, digest it,

absorb it and to expel the unwanted products.

The abdominal cavity

The abdominal cavity is bordered by the pelvis (inferiorly,) the diaphragm (superiorly) and laterally by

the walls of the torso. For the purpose of identifying abnormalities the abdomen is divided into either

4 quadrants or 9 regions (see illustrations below).

Four quadrants of the abdomen

In clinical notes

quadrants are

usually used to

describe where

pathology may

reside. Usually a

body of text is used

to describe the

location and a

simple picture or

diagram is employed

to ensure there is no

ambiguity.

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Nine regions of the abdomen

Adapted from http://cnx.org/contents/17e4eea8-a005-45af-b835f756a014cd48@3

Indications for a gastrointestinal examination.

The decision as to which examinations will be performed is always based upon the patient’s history.

There are many indications for performing the gastrointestinal examination some examples are:

o Chronic / acute vomiting

o Changes in bowel habits including constipation or diarrhoea

o Blood or mucus evident in faeces

o Unexplained weight loss which may be due to malabsorption or malignancy

o Chronic / acute abdominal or rectal pain

o Abdominal distension

o Jaundice

o Abnormal blood

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Pain associated with gastrointestinal disorders

Acute appendicitis

Nausea, vomiting, central abdominal pain that later shifts to right iliac fossa

Fever, tenderness, guarding or palpable mass in right iliac fossa, pelvic peritonitis on rectal examination

Perforated peptic ulcer with acute peritonitis

Vomiting at onset associated with severe acute-onset abdominal pain, previous history of dyspepsia, ulcer disease, non-steroidal anti-inflammatory drugs or glucocorticoid therapy

Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distension and absent bowel sounds

Acute pancreatitis

Anorexia, nausea, vomiting, constant severe epigastric pain, previous alcohol abuse/cholelithiasis

Fever, periumbilical or loin bruising, epigastric tenderness, variable guarding, reduced or absent bowel sounds

Ruptured aortic aneurysm

Sudden onset of severe, tearing back/loin/abdominal pain, hypotension and past history of vascular disease and/or high blood pressure

Shock and hypotension, pulsatile, tender, abdominal mass, asymmetrical femoral pulses

Acute mesenteric ischaemia

Anorexia, nausea, vomiting, bloody diarrhoea, constant abdominal pain, previous history of vascular disease and/or high blood pressure

Atrial fibrillation, heart failure, asymmetrical peripheral pulses, absent bowel sounds, variable tenderness and guarding

Intestinal obstruction

Colicky central abdominal pain, nausea, vomiting and constipation

Surgical scars, hernias, mass, distension, visible peristalsis, increased bowel sounds

Ruptured ectopic pregnancy

Premenopausal female, delayed or missed menstrual period, hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip pain, ‘prune juice’-like vaginal discharge

Suprapubic tenderness, periumbilical bruising, pain and tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Pelvic inflammatory disease

Sexually active young female, previous history of sexually transmitted infection, recent gynaecological procedure, pregnancy or use of intrauterine contraceptive device, irregular menstruation, dyspareunia, lower or central abdominal pain, backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis syndrome)

Fever, vaginal discharge, pelvic peritonitis causing tenderness on rectal examination, right upper quadrant tenderness (perihepatitis), pain/tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

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Timing

During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. For example, in acute appendicitis, pain is initially periumbilical (visceral pain) and moves to the right iliac fossa (somatic pain) when localised inflammation of the parietal peritoneum becomes established. If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised appendix abscess develops, with a palpable mass and localised pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the initial diagnosis was wrong or that complications have developed. In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with abdominal tenderness suggests intestinal ischaemia, as in strangulated hernia, and is an indication for urgent surgical intervention.

Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute appendicitis, cholecystitis or diverticulitis.

Exacerbating and relieving factors

Pain exacerbated by movement or coughing suggests inflammation. Patients tend to lie still to avoid exacerbating the pain. People with colic typically move around or draw their knees up towards the chest during spasms.

Severity

Excruciating pain, poorly relieved by opioid analgesia, suggests an ischaemic vascular event, such as bowel infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by potent analgesia is more typical of acute pancreatitis or peritonitis secondary to a ruptured viscus.

Equipment required to perform the examination

Hand wash

Stethoscope

Alcohol swabs to clean stethoscope

Patient safety.

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name

and date of birth, if available please check this with the name band and written documentation and

the NHS/ hospital number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination.

Ensure the procedure is explained to the patient in terms that they understand, gain informed consent

and ensure that you are supervised, with a chaperone available as appropriate. Don personal

protective equipment as required, especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018)

http://www.who.int/infection-prevention/tools/hand-hygiene/en/

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This procedure may require the presence of a chaperone. That is someone who is familiar with the

examination and can ensure that nothing inappropriate occurs by either party. The chaperone can be a

useful resource, not just being present to ensure the patient is treated appropriately, but to help and

support the patient.

General Inspection

Look at the patient and their environment at the beginning of the examination.

In the environment there may be many indicators of possible gastrointestinal conditions including:

o Vomit bowls

o Medications related to GI system

o Supplemental nutrition including tube feeding paraphernalia

o Uneaten meals

o Odours such as vomit, faeces, hepatic fetor and pear drops (associated with diabetes)

o Commode

o Alcohol containers

The patient may show some signs of possible gastrointestinal disease such as:

o Cachexia: wasting of the body due to severe chronic illness.

o Vomit or faecal soiling of bed linen or clothing.

o Signs of pain including facial expression and patient positioning

o A change in colour such as yellow (jaundice) associated with hepatobiliary conditions, pallor due to

anaemia which may be secondary to bleeding into the bowel or a flushed appearance secondary to

inflammation / infection and scars.

Specific Inspection

Moving on we will now look closely at the patient for signs of gastrointestinal disease. Adopting a

systematic approach we look at the:

Hands (see hand and nail study guide)

Look for nail signs which may develop over a period of time and indicate a chronic disease process.

These signs may include:

o Clubbing – Not specific for gastrointestinal disease but occurs with chronic disease. The tips of

the fingers take on a bulbous (swollen) appearance.

o Koilonychia – another sign of chronic disease. Koilonychia is commonly termed as spooning. It

occurs secondary to a chronic iron deficiency anaemia which may be secondary to dietary

influences or chronic bowel problems such as ulcerative colitis.

o Leukonychia – white nails due to problems associated with protein metabolism

o Nicotine tar staining – indicating chronic / heavy smoking

o Pale nail beds which may indicate acute / chronic anaemia

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We will also assess for asterixis, also known as metabolic or liver flap: ask the patient to stretch out

their arms, abduct their fingers and cock their wrists back and to hold this position for at least 15

seconds; if the patient is unable to maintain this position and the hands “flap” this is known as

asterixis. This flapping (tremor) may be due to liver or respiratory conditions so again is not specific to

gastrointestinal conditions. However, all examination findings are considered together when looking to

make your diagnosis.

You should also take this opportunity to check all the patient’s vital signs including ACVPU or Glasgow

coma scale (should hepatic encephalopathy be suspected) and capillary refill time in the case of sepsis

or shock.

Face, mouth and neck

Look at the face:

o Are the scleras of the eyes jaundiced? - jaundice will be evident in the sclera much earlier than the

skin in hepatobiliary conditions

o Are the tarsal conjunctiva (lining of the eye lids) pink or are they pale which may indicate chronic or

acute anaemia.

o Is there inflammation evident at the corners of the mouth (angular cheilitis / angular stomatitis)

which can be associated with some of the inflammatory bowel diseases, diabetes, cancer, oral

thrush and certain medications?

Look in the mouth (the start of the GI system) ensuring you look under the tongue:

o Is the mouth well hydrated? Dehydration may be a sign of poor oral intake, acute kidney injury

or chronic vomiting / diarrhoea.

(NICE guidance https://www.evidence.nhs.uk/search?q=diarrhoea+and+vomiting+in+adults)

o Ulceration of the oral mucosa may be associated with chronic inflammatory bowel conditions.

o Whilst examining the face and oral cavity any odours on the breath such as a faecal odour may

indicate a bowel obstruction, hepatic fetor (sweet musty smell) indicating liver disease not to

be confused with pear drops which are associated with diabetes may be easier to identify.

Lymph nodes in the head and neck

As part of a gastrointestinal examination you should palpate the deep and superficial cervical supra

and infra clavicular, axillary and inguinal lymph nodes. An enlarged left supra clavicular lymph node

(Virchow’s node / Troiser’s sign) may be associated with metastatic spread of an abdominal

malignancy.

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Inspection of the torso

The majority of inspection of the torso may be done with the patient lying supine with hands by their

sides and a single pillow under their head. It is important that the abdominal muscles are relaxed, even

raising the head slightly can increase abdominal tone, to relax a taught abdomen you can get the

patient to flex their hips and knees (“can you bend your knees and bring your feet towards their

bottom”).

The patient’s torso should be exposed to the suprapubic region - inguinal and genital areas should

remain covered until they are to be examined.

If the patient is sat up at this point you may wish to inspect the patient’s back before laying them flat.

o Scars must be identified and the reason for the scar. If the patient has had previous abdominal

surgery this may help to rule out or indicate some possible causes of abdominal symptoms such as

“adhesions”.

o Spider naevi / telangiectasia (swollen blood vessels which appear as a red central spot with reddish

blood vessels which spread out from this central spot) may be associated with liver disease and an

increase in oestrogen levels in the blood stream. The presence of more than 5 on the torso is

abnormal.

o Gynecomastia (breast tissue in male patients) may also develop as it is associated with liver disease

and an increase in oestrogen levels.

o Abdominal distension (gross swelling) which can be remembered as the 6 F’s.

o Flatus (gas) – taut abdomen which is compressible

o Faeces – firm to hard mass take note of position as may be normal finding

o Fluid (ascites) – taut abdomen which may be non-compressible dependant on volume

o Fat – soft and compressible

o Foetus – obstetric palpation will be taught in later year

o Fairly big tumours - firm to hard mass

o Rashes - shingles may be a cause of pain and psoriasis may be associated with chronic

inflammatory bowel disorders.

o Dilated veins on the torso or around the umbilicus may be associated with increased pressure in

the vena cava due to restricted flow through the liver in liver disease.

o Abnormal abdominal movement i.e. visible peristalsis in bowel obstruction or pulsation which may

indicate an abdominal aortic aneurysm (AAA).

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Palpation of the abdominal wall

As the examiner you should position yourself to be on level with the abdominal surface, either use a

chair or stoop to achieve this. The reason you should be level with the abdomen is to ensure you DO

NOT apply too much pressure when palpating what may already be a painful / tender abdomen.

Secondary to this you will be able to look across the abdomen for swellings and it will be less

intimidating for the patient as you will not be standing over them.

If the patient has complained of abdominal pain or tenderness you should start your palpation away

from the affected area and move towards it palpating the tender area last.

Throughout abdominal palpation you should observe the patient’s face for visual signs of pain; as on

occasion patients will not verbally complain of pain but visually you can see the pain on their face as

you palpate. This observation could give you key clinical signs that may be missed had you not

observed the patients face.

There are 3 elements of abdominal palpation:

o Superficial palpation is performed to determine the tone of the abdominal wall muscles which can

become tense (contract) due to pain, infection or inflammation in order to protect the underlying

structures within the abdomen.

o Deep palpation is performed to identify possible abnormal masses within the abdominal /

peritoneal cavity.

o Specific organ palpation is used to identify potential enlargement of the liver, spleen and kidneys.

Superficial Palpation

Superficial palpation is performed by placing the flat of the hand onto the abdominal wall and lightly

pressing against the abdominal muscles to determine if they remain soft and relaxed. All regions of the

abdomen must be covered in a systematic manner and the examining hand should remain in contact

Use the flat of the palmar

surface of fingers to palpate

through the abdominal wall

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with the abdominal wall throughout. The technique is used to determine if any of the following signs

are evident;

o Pain elicited during palpation is an important finding as other signs may not be evident in the early

stages of a condition.

o Guarding is the contraction of the abdominal muscles in response to pressure being applied over

an area of infection / inflammation. The muscles tense in response to the pressure applied by the

examiner’s hand to protect the underlying structures from further insult.

o Rigidity is the contraction of the abdominal muscles in response to infection / inflammatory

changes within the abdominal / peritoneal cavity. This contraction is evident prior to any palpation

and the abdomen will be “rock” hard. Normal abdominal movement with respiration will be

absent. Rigidity is a concerning sign and should be reported to a senior upon immediately

If an abnormal finding is evident relate it to the region of the abdomen being palpated and document

its position.

Deep palpation

Deep palpation is performed using a similar technique as that for superficial palpation but pressing

deeply through the abdominal (muscle) wall to palpate for any abnormal masses or swelling of the

abdominal organs. If a mass is palpated describe it by the region of the abdomen being palpated, the

underlying structures / organs and document it’s size (in cms), shape, depth (superficial or deep),

surface (smooth or irregular), consistency (hard, firm, soft or fluid), edge (defined or diffuse) or if it is

pulsating (if a pulsating mass is found ensure you inform a senior member of staff and do not continue

with the examination until the patient has been seen).

To determine if the mass is in the abdominal wall or in the abdomen itself you can ask the patient to

raise their head, this will cause the muscles to contract and allow you to differentiate whether the

mass is on the wall or within the abdomen itself.

Specific Organ Palpation

Specific organ palpation technique is used to identify any

enlargement of the liver, spleen or kidneys

(organomegaly). The patient is asked to relax and take

deep breaths at a steady rate which may be determined

by the examiner. However, care must be taken to ensure

the patient is not stressed by the rate of respiration

required as this may lead to light-headedness.

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Palpation of the liver

The liver lies under the ribs on the right side with a small portion of the liver crossing the mid-line. The

lower most edge of the liver lies just above but deep to the costal margin (the lower edge of the rib

cage). The liver descends inferiorly towards the right iliac fossa on inspiration and we use this

movement to feel for the inferior border of the liver as it moves downwards. In normal health the liver

is usually impalpable as it remains above the costal margin.

The liver may become enlarged for a number of reasons including fatty liver disease, alcohol liver

disease, cysts, infection, cirrhosis, cancer and cardiac failure.

How to palpate an enlarged liver

Palpation for the liver should commence in the right iliac fossa as this theoretically is the fullest extent

to which the liver may enlarge. The hand is positioned in the

right iliac fossa so that the lateral border of the index finger

is parallel with the costal margin. The thumb is extended to

fully expose the lateral border of the index finger.

Pressure is applied onto the abdominal wall by the

examining hand and the patient is asked to take a deep

breath in. As the diaphragm pushes the liver downwards the

edge of an enlarged liver will be felt “hitting” the lateral

border of the index finger on inspiration. If the liver edge is

not felt, the examining hand is moved closer to the right

costal margin by about 1 cm.

The process is then repeated until the liver edge is palpated

or the costal margin reached. If the liver edge is felt then the distance from the right costal margin is

measured and recorded in cm.

How to palpate an enlarged spleen

Palpation for the spleen should commence in the right

iliac fossa as this theoretically is the fullest extent to

which the spleen may enlarge. Place one hand under the

patients ribs on the left and roll them towards their

right. Your other hand is then positioned in the right iliac

fossa so that the tips point towards the normal

anatomical position of the spleen. The thumb is

extended to prevent it interfering with the positioning of

the hand.

Pressure is applied to the abdominal wall by the

examining hand and the patient is asked to take a deep

breath in. As the diaphragm pushes the spleen

downwards and medially the edge of an enlarged spleen

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will be felt “hitting” the finger tips. When very large you may also be able to palpate the distinctive

splenic notch. If the spleen is not felt, the examining hand is moved closer to the left costal margin by

about 1 cm.

The process is repeated until the spleen is palpated or the costal margin reached. If the spleen is felt

then the distance from the left costal margin is measured and recorded in cm.

Palpation of the kidneys

The kidneys are situated in the renal angle

which extends from the twelfth thoracic

vertebrae to the third lumbar vertebrae. The

right kidney is slightly lower than the left due

to the position of the liver. The kidneys

descend inferiorly on inspiration and we feel

for the kidneys as they descend. The kidneys

are retroperitoneal organs and a deep

bimanual technique of palpation is required.

Not normally palpable unless the patient is

thin.

How to palpate for enlarged kidneys

Place the palmar surface of your left hand under the patients flank and the finger tips into the renal

angle (between posterior costal margin and spine). Your right hand should be placed with fingers flat

onto the abdominal wall in opposition of your left.

Pressure is applied to the abdominal wall by the right hand and the left lifted to meet it. The patient is

asked to take a deep breath in. As the diaphragm pushes the kidneys downwards the rounded lower

pole of an enlarged kidney may be felt passing between the opposing fingers as the patient breaths in

and out.

The kidneys are then “balloted”. The kidney is moved by pressure from behind, allowing it to be

palpated between the hands so that its size, shape, and mobility may be determined

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Percussion

Before palpating the abdomen you should percuss for the size and position of the liver. You can either

percuss down from the right clavicle until you find the superior border when dullness is noted, then up

from the right inguinal region until the lower border is found. Alternately you may percuss up from the

right inguinal region identify the lower border of the liver and continue upwards until the note changes

indicating the superior border.

If a mass is palpated percussion allows us to determine the boundaries of a mass and also to

determine the consistency i.e. gas, fluid or solid tissue. The overall percussion note found over the

abdomen is resonance as in the supine position any fluid in the bowel settles to the patients back and

gases rise to the anterior surfaces of the bowel.

Routine percussion is performed for the purposes of identifying the superior border of the liver and

the inferior border. Starting in the midclavicular line percuss down from the right clavicle until the note

becomes dull (this should identify the superior border of the liver). Once the superior border is

identified percuss up from the right iliac fossa until the lower border is identified (the normal abdomen

is resonant when the patient is lying supine).

If a mass or organomegaly was detected during the examination of the abdomen, then percussion is

performed to determine the borders.

There may be an area of dullness evident on the left side where the descending colon lies due to the

presence of faecal matter.

Percussion Tenderness (when pain is elicited during percussion) indicates an inflammatory process

within the abdominal / peritoneal cavity i.e. peritonitis or appendicitis.

Shifting dullness is a sign elicited when the patient has ascites (fluid in the peritoneal cavity). With the

patient supine percuss the whole abdomen. Note the distribution of dullness and resonance. Then

place the patient on their side and wait for 30-60 seconds. Percuss the abdomen again this time

systematically starting from the lower side (in contact with the couch) and move towards the upper

side. If 500ml or more of ascitic fluid is present in the peritoneal cavity you should pick up consistently

dull sounds from the lower side and resonance from the upper side. The level of dull sounds

represents the amount of ascetic fluid present.

In a positive shifting dullness test there will be consistently dull percussion sounds from the lower side

and resonant sounds from the top side. The level of dullness represents the level of ascetic fluid

present. In a negative shifting dullness tests there would be little difference noted in the percussion

sounds compared with the supine position.

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Auscultation

Auscultation for bowel sounds may be considered if organomegaly is present or signs / symptoms

suggest disruption of normal bowel activity has occurred. Not all clinicians will routinely auscultate the

abdomen.

To auscultate for bowel sounds; place the head of the stethoscope onto the abdominal wall in the right

lower quadrant and listen. The right lower quadrant is where sounds are more frequently and therefore

more likely to be heard. Do not move the position of the stethoscope for 2 minutes or until bowel

sounds are heard. After this time if NO bowel sounds are heard the stethoscope may be moved to

another position and listen again for a further 2 minutes.

o Normal bowel sounds are termed as borborygmi, these are low to medium pitched grumbles

associated with the passage of fluid and gases through the bowel as peristalsis occurs. Sounds

should occur at least every 2 – 4 minutes in health, but the frequency will increase after a meal or

in the case of an acute bowel obstruction as the peristaltic action of the bowel tries to clear the

obstruction.

o Increased bowel sounds may be an indication of inflammation, infection, recent intake of food,

partial obstruction or the initial stages of acute obstruction –the sounds increase in frequency and

become higher in pitch as the peristaltic action of the bowel increases to try to move the

obstruction along.

o Tinkling bowel sounds may be an indication of acute obstruction. They are increased in frequency

and higher in pitch due to the increased peristaltic action of the bowel trying to move the

obstruction along.

o “Absent” bowel sounds occur if an obstruction is complete. Complete obstruction may lead to

necrosis and as a result peristaltic action may cease (ileus). If after 4 minutes of listening in a

variety of places on the abdomen you have not heard bowel sounds contact a senior member of

the health care team. You may hear referred heart and breath sounds if bowel sounds are absent.

o Whilst auscultating the abdomen you should take the opportunity to listen for abdominal bruits as

detailed within your cardiovascular examination study guide.

Examination of hernias

Hernias are common and typically occur at openings of the abdominal wall, such as the inguinal,

femoral and obturator canals, the umbilicus and the oesophageal hiatus. They may also occur at sites

of weakness of the abdominal wall, as in previous surgical incisions. An external abdominal hernia is an

abnormal protrusion of bowel and/or omentum from the abdominal cavity. External hernias are more

obvious when the pressure within the abdomen rises, such as when the patient is standing, coughing

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or straining at stool. Internal hernias occur through defects of the mesentery or into the

retroperitoneal space and are not visible. An impulse can often be felt in a hernia during coughing

(cough impulse). Identify a hernia from its anatomical site and characteristics, and attempt to

differentiate between direct and indirect inguinal hernias.

Examine the groin with the patient standing upright. Inspect the inguinal and femoral canals and the

scrotum for any lumps or bulges. Ask the patient to cough; look for an impulse over the femoral or

inguinal canal and scrotum. Identify the anatomical relationships between the bulge, the pubic

tubercle and the inguinal ligament to distinguish a femoral from an inguinal hernia. Palpate the

external inguinal ring and along the inguinal canal for possible muscle defects. Ask the patient to cough

and feel for a cough impulse. Now ask the patient to lie down and establish whether the hernia

reduces spontaneously. If so, press two fingers over the internal inguinal ring at the mid-inguinal point

and ask the patient to cough or stand up while you maintain pressure over the internal inguinal ring. If

the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is an indirect

inguinal hernia. Examine the opposite side to exclude the possibility of asymptomatic hernias.

An indirect inguinal hernia bulges through the internal ring and follows the course of the inguinal

canal. It may extend beyond the external ring and enter the scrotum. Indirect hernias comprise 85% of

all hernias and are more common in younger men.

A direct inguinal hernia forms at a site of muscle weakness in the posterior wall of the inguinal canal

and rarely extends into the scrotum. It is more common in older men and women

A femoral hernia projects through the

femoral ring and into the femoral canal.

Inguinal hernias are palpable above and

medial to the pubic tubercle. Femoral

hernias are palpable below the inguinal

ligament and lateral to the pubic

tubercle.

Macleod's Clinical Examination 14th Ed 2018

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In a reducible hernia the contents can be returned to the abdominal cavity, spontaneously or by

manipulation; if they cannot, the hernia is irreducible (incarcerated). An abdominal hernia has a

covering sac of peritoneum and the neck of the hernia is a common site of compression of the

contents. If the hernia contains bowel, obstruction may occur. If the blood supply to the contents of

the hernia (bowel or omentum) is restricted, the hernia is strangulated. It is tense, tender and has no

cough impulse, there may be bowel obstruction and, later, signs of sepsis and shock. A strangulated

hernia is a surgical emergency and, if left untreated, will lead to bowel infarction and peritonitis.

Recording your findings

Don’t forget when recording your findings to include the patient identifiers, date (and time), your

signature and print your name at the end.

When documenting or describing your findings remember to comment on inspection describing the

position of any abnormalities seen, the tone of the abdominal wall and any sign such as guarding or

rigidity, any masses found, findings of percussion and auscultation.

Remember to describe your findings as fully as possible: e.g. size, position (relative to the regions or

quadrants as previously described) and the shape of a swelling etc.

A diagram may often be useful in written notes (see below)

Palpable mass

Umbilicus Appendicectomy scar

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Special examination techniques for self-directed study

McBurney's sign

Deep tenderness at a point approx’ 2 inches from the anterior superior iliac spine on a line between

the umbilicus and the anterior superior iliac spine (McBurney’s point) is indicative of late stage acute

appendicitis with an increase in the risk of rupture.

Aaron's sign

Referred pain felt in the epigastrium upon continuous firm pressure over McBurney's point. It is

indicative of appendicitis.

Obturator sign

Flexing the right hip and knee, then internally rotation the right hip will cause an increase in abdominal

pain in appendicitis.

Murphy’s sign

Placing fingers or thumb under right costal cartilage and asking the patient to breathe in. If there is an

increase in pain +/- catching breath then this is indicative of cholecystitis.

Rosving’s Sign

Pressure over the patient's left lower quadrant causes pain in the right lower quadrant in appendicitis. However

this test is unreliable with a sensitivity of 30.1%.

https://www.bmj.com/rapid-response/2011/11/03/rovsings-sign-0

Further Reading

Innes, J Alastair, BSc PhD FRCP(Ed); Dover, Anna R, PhD FRCP(Ed); Fairhurst, Karen, PhD FRCGP.

Macleod's Clinical Examination, Fourteenth Edition