GI Examination - Part 2 - Kofi's Learning Hub

Clinical Skills

Mastering the physical examination of the gastrointestinal system requires systematic approach and attention to subtle signs. This guide covers the essential examination setup and general inspection findings that reveal critical diagnostic information.

🛏️ EXAMINATION SETUP

🛏️ Optimal Examination Conditions

Patient Positioning:

🎯 Ideal Position

Supine, flat, arms by sides
Ideally no pillows (one if breathless)
Expose from xiphoid to pubis (cover genitalia for modesty)
Bad positioning = missed signs!

🎯 Room Conditions

Warm room, good lighting
Warm hands (cold = can't relax = missed signs)

👐 GENERAL INSPECTION: Hands Assessment

👐 Hand Findings in GI Disease

Clubbing - GI Causes:

Malabsorption syndromes
Liver disease (cirrhosis, hepatoma)
IBD (Inflammatory Bowel Disease): Ulcerative colitis, Crohn's
Abdominal TB, GI lymphomas, celiac disease

Chronic Liver Disease Stigmata:

🎯 Palmar Changes

Palmar erythema (red palms—thenar and hypothenar eminences)
Leukonychia (white nails—hypoalbuminemia from liver failure)
Dupuytren's contracture (thickened palmar fascia)

Asterixis (Flapping Tremor):

Extend arms, cock hands up ("stop traffic")
Brief downward flapping = liver failure (hepatic encephalopathy)
Also renal/respiratory failure

👁️ FACE & EYES: Systemic Clues

👁️ Facial Findings in GI Disease

Facial Signs:

🎯 Vascular Changes

Spider nevi: Small, red, spider-like vessels with central feeding vessel
Facial telangiectasia: Dilated small vessels on face

🎯 Eyelid & Parotid Signs

Xanthelasma: Yellow plaques around eyelids
Parotid swelling: Alcohol-related liver disease

Endocrine Changes (Chronic Liver Disease):

🎯 Male Feminization

Gynecomastia (40% of cirrhotic men)
Loss of body/facial hair
Testicular atrophy

🎯 Female Masculinization

Occurs in females with chronic liver disease

💛 JAUNDICE (Icterus) Assessment

💛 Jaundice Evaluation

Detection & Progression:

🎯 Where to Look

Sclera (bilirubin stains elastic tissue)
Visible when bilirubin >50 μmol/L (>3 mg/dL) = 3× normal

🎯 Color Progression

Lemon tinge → deep yellow → greenish-brown (as it deepens)
Hemolysis + anemia = pale lemon-yellow tinge

Three Types of Jaundice:

🎯 Pre-hepatic

Problem: Too much bilirubin production
Causes: Hemolysis, Gilbert's syndrome

🎯 Hepatocellular

Problem: Liver can't process bilirubin
Causes: Hepatitis (A, B, C), drugs, alcohol, cirrhosis

🎯 Obstructive (Cholestatic)

Problem: Bile duct blockage
Causes: Gallstones, pancreatic cancer, PBC

👁️ EYE SPECIFICS

👁️ Ocular Findings

Critical Eye Signs:

🎯 Kayser-Fleischer Rings

Light brown rings at cornea periphery
Copper deposits = Wilson's disease
May need slit lamp to see

🎯 Pallor Assessment

Check conjunctiva, tongue, palms
GI bleeding → anemia

👄 THE MOUTH: A Goldmine of Information

👄 Oral Cavity Examination

Why Examine the Mouth?

Assess hydration (tongue, mucous membranes)
Look for specific lesions (ulcers, lumps, patches)
Find systemic disease clues

Lips Assessment:

🎯 Common Lip Conditions

Cheilitis: Painful fissuring, scaling, crusts
Angular stomatitis: Cracks at corners of mouth
Herpes simplex: Clusters of vesicles on lips

🎯 Lip Carcinoma

Chronic ulcer/thickened plaque/warty growth
Lower lip common site (especially pipe smokers)
Check submental nodes

Lip Syndromes:

🎯 Hereditary Hemorrhagic Telangiectasia

Bluish spots on lips, tongue, buccal mucosa
Bleed → chronic iron deficiency anemia

🎯 Peutz-Jeghers Syndrome

Brown pigmented flecks around lips
Associated with small intestinal polyps

🦷 GUMS AND TEETH

🦷 Dental & Gingival Findings

Gum Pathology:

🎯 Swollen Gums Causes

Normal: Puberty, pregnancy
Phenytoin therapy (anticonvulsant)
Acute leukemia (gross hypertrophy, bleeding, necrosis)
Vitamin C deficiency (scurvy—rare)

🎯 Acute Necrotizing Ulcerative Gingivitis

Painful, sloughy ulcers at gum margins
Unpleasant halitosis (bad breath)

Pigmentation & Tooth Abnormalities:

🎯 Gum Pigmentation

Addison's disease: Brown pigmentation of gums/buccal mucosa
Lead/bismuth poisoning: Dark line 1mm from gum margin

🎯 Tooth Abnormalities

Hutchinson's teeth: Domed, notched, widely spaced—congenital syphilis
Acromegaly: Enlarged mandible, underbite, widely spaced lower teeth

👅 TONGUE EXAMINATION

👅 Tongue Findings

Normal Variants (Don't Panic!):

Scrotal tongue (deeply furrowed)
Geographic tongue (patchy loss and regrowth of papillae)
Black hairy tongue (can follow antibiotics)

Pathological Tongue Findings:

🎯 Dry Tongue

Severe DKA, mouth breathing, no saliva
Drugs (atropine, tricyclics, antidepressants)

🎯 Raw Red Beefy Tongue

Deficiency: Iron, B12 (pernicious anemia), folate, niacin (pellagra)
Also: Radiotherapy, chemotherapy

Oral Lesions & Masses:

🎯 White Lesions

Leukoplakia: White streaks/patches with sharp edges (premalignant)
Candidiasis (thrush): Creamy-white curdy patches
Lichen planus: White plaque on side of tongue OR chronic ulcer

🎯 Carcinoma of Tongue

Edges or base of tongue
Malignant ulcer: indurated, everted edges, sloughy base
Metastasizes to submental → cervical nodes

🎯 Macroglossia (Enlarged Tongue)

Myxedema (hypothyroidism), acromegaly, amyloidosis, tumor infiltration

👃 ORAL FOETOR (Breath Smells)

👃 Diagnostic Breath Odors

Characteristic Breath Smells:

🎯 Anaerobic Infection Stench

Lung abscess, Vincent's infection

🎯 Sickly Sweet Aroma

Hepatic coma

🎯 Fishy, Uriniferous

Uremia

🎯 Ketones (Fruity/Sweet)

Diabetic ketoacidosis

📋 Summary Checklist for Exams

📋 High-Yield Exam Points

Key Physical Exam Pearls:

Warm hands + warm room = essential for good exam
Clubbing in liver disease, IBD, malabsorption
Asterixis = hepatic encephalopathy
Spider nevi + palmar erythema = chronic liver disease
Kayser-Fleischer rings = Wilson's disease
Healthy young man with thrush = think AIDS
Breath odors can diagnose systemic conditions

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