Ask about all prescribed medications, over-the-counter medicines
and herbal preparations. Many drugs affect the gastrointestinal
tract (Box 6.8) and are hepatotoxic.
Inflammatory bowel disease is more common in patients with
a family history of either Crohn’s disease or ulcerative colitis.
Colorectal cancer in a first-degree relative increases the risk of
colorectal cancer and polyps. Peptic ulcer disease is familial but
this may be due to environmental factors, such as transmission of
Helicobacter pylori infection. Gilbert’s syndrome is an autosomal
dominant condition; haemochromatosis and Wilson’s disease are
autosomal recessive disorders. Autoimmune diseases, particularly
thyroid disease, are common in relatives of those with primary
biliary cirrhosis and autoimmune hepatitis. A family history of
diabetes is frequently seen in the context of NAFLD.
• Dietary history: assess the intake of calories and sources
of essential nutrients. For guidance, there are 9 kcal per g
of fat and 4 kcal per g of carbohydrates and protein.
• Food intolerances: patients with irritable bowel syndrome
often report specific food intolerances, including wheat,
dairy products and others. Painless diarrhoea may indicate
high alcohol intake, lactose intolerance or coeliac disease.
6.7 Urine and stool analysis in jaundice
Colour Bilirubin Urobilinogen Colour
Unconjugated Normal – ++++ Normal
Hepatocellular Dark ++ ++ Normal
6.8 Examples of drug-induced gastrointestinal conditions
Weight gain Oral glucocorticoids
Non-steroidal anti-inflammatory drugs
Nausea Many drugs, including selective
Jaundice: hepatitis Paracetamol (overdose)
Jaundice: cholestatic Flucloxacillin
In haemolytic disorders, anaemic pallor combined with jaundice
may produce a pale lemon complexion. The stools and urine
are normal in colour. Gilbert’s syndrome is common and
causes unconjugated hyperbilirubinaemia. Serum liver enzyme
concentrations are normal and jaundice is mild (plasma bilirubin
<100 µmol/L (5.85 mg/dL)) but increases during prolonged fasting
or intercurrent febrile illness.
Hepatocellular disease causes hyperbilirubinaemia that is both
unconjugated and conjugated. Conjugated bilirubin leads to dark
brown urine. The stools are normal in colour.
Posthepatic/cholestatic jaundice
In biliary obstruction, conjugated bilirubin in the bile does not
reach the intestine, so the stools are pale. Obstructive jaundice
may be accompanied by pruritus (generalised itch) due to skin
deposition of bile salts. Obstructive jaundice with abdominal pain
is usually due to gallstones; if fever or rigors also occur (Charcot’s
triad), ascending cholangitis is likely. Painless obstructive jaundice
suggests malignant biliary obstruction, as in cholangiocarcinoma
or cancer of the head of the pancreas. Obstructive jaundice can
be due to intrahepatic as well as extrahepatic cholestasis, as in
primary biliary cirrhosis, certain hepatotoxic drug reactions (Box
6.8) and profound hepatocellular injury.
The physical examination • 103
• Note the patient’s demeanour and general appearance.
Are they in pain, cachectic, thin, well nourished or obese?
Record height, weight, waist circumference and body
mass index (p. 29). Note whether obesity is truncal or
generalised. Look for abdominal striae or loose skin
• Inspect the patient’s hands for clubbing, koilonychia
(spoon-shaped nails) and signs of chronic liver disease
(Fig. 6.9), including leuconychia (white nails) and palmar
• Alcohol consumption: calculate the patient’s intake in
• Smoking: this increases the risk of oesophageal cancer,
colorectal cancer, Crohn’s disease and peptic ulcer, while
patients with ulcerative colitis are less likely to smoke.
• Stress: many disorders, particularly irritable bowel
syndrome and dyspepsia, are exacerbated by stress and
• Foreign travel: this is particularly relevant in liver disease
• Risk factors for liver disease: these include intravenous
drug use, tattoos, foreign travel, blood transfusions, and
sex between men or with prostitutes and multiple sexual
partners. Hepatitis B and C may present with chronic liver
disease or cancer decades after the primary infection, so
enquire about risk factors in the distant as well as the
Fig. 6.9 Features of chronic liver disease.
104 • The gastrointestinal system
• late neurological features, which include spasticity,
extension of the arms and legs, and extensor plantar
In a jaundiced patient, spider naevi, palmar erythema and
ascites all strongly suggest chronic liver disease rather than
Examine the patient in good light and warm surroundings,
positioned comfortably supine with the head resting on only
one or two pillows to relax the abdominal wall muscles. Use extra
pillows to support a patient with kyphosis or breathlessness.
• Look at the teeth, tongue and buccal mucosa; check for
• Note any smell, including alcohol, fetor hepaticus, uraemia,
• Expose the abdomen from the xiphisternum to the
symphysis pubis, leaving the chest and legs covered.
The normal abdomen is flat or slightly scaphoid and symmetrical.
At rest, respiration is principally diaphragmatic; the abdominal wall
moves out and the liver, spleen and kidneys move downwards
during inspiration. The umbilicus is usually inverted.
In older patients, seborrhoeic warts, ranging from pink to brown
or black, and haemangiomas (Campbell de Morgan spots) are
common and normal, but note any striae, bruising or scratch
Abnormally prominent veins on the abdominal wall suggest portal
hypertension or vena cava obstruction. In portal hypertension,
recanalisation of the umbilical vein along the falciform ligament
produces distended veins that drain away from the umbilicus:
the ‘caput medusae’. The umbilicus may appear bluish and
distended due to an umbilical varix. In contrast, an umbilical
hernia is a distended and everted umbilicus that does not appear
vascular and may have a palpable cough impulse. Dilated tortuous
veins with blood flow superiorly are collateral veins caused by
obstruction of the inferior vena cava. Rarely, superior vena cava
obstruction gives rise to similarly distended abdominal veins, but
Diffuse abdominal swelling could be due to ascites or intestinal
obstruction. If localised, it could be caused by urinary retention,
a mass or an enlarged organ such as the liver. In obesity, the
umbilicus is usually sunken; in ascites, it is flat or, more commonly,
everted. Look tangentially across the abdomen and from the
foot of the bed for any asymmetry suggesting a localised mass.
Note any surgical scars or stomas and clarify what operations
have been undertaken (Figs 6.10 and 6.11). A small infraumbilical
incision usually indicates a previous laparoscopy. Puncture scars
from laparoscopic surgical ports may be visible. An incisional
hernia at the site of a scar is palpable as a defect in the abdominal
• Inspect the mouth, throat and tongue.
• Ask the patient to look down and retract the upper eyelid
to expose the sclera; look to see if it is yellow in natural
• Examine the cervical, axillary and inguinal lymph
Striae indicate rapid weight gain, previous pregnancy or, rarely,
Cushing’s syndrome. Loose skin folds signify recent weight loss.
Stigmata of iron deficiency include angular cheilitis (painful
cracks at the corners of the mouth) and atrophic glossitis (pale,
smooth tongue). The tongue has a beefy, raw appearance in
folate and vitamin B12 deficiency. Mouth and throat aphthous
ulcers are common in coeliac and inflammatory bowel disease
Gastric and pancreatic cancer may spread to cause enlargement
of the left supraclavicular lymph nodes (Troisier’s sign). More
widespread lymphadenopathy with hepatosplenomegaly suggests
Do not confuse the diffuse yellow sclerae of jaundice with small,
yellowish fat pads (pingueculae) sometimes seen at the periphery
Certain signs (stigmata) suggest chronic liver disease (see
• Palmar erythema and spider naevi are caused by excess
oestrogen associated with reduced hepatic breakdown of
sex steroids. Spider naevi are isolated telangiectasias that
characteristically fill from a central vessel and are found in
the distribution of the superior vena cava (upper trunk,
arms and face). Women may have up to five spider naevi
in health; palmar erythema and numerous spider naevi are
normal during pregnancy. In men, these signs suggest
• Gynaecomastia (breast enlargement in males), with loss of
body hair and testicular atrophy, may occur due to
reduced breakdown of oestrogens.
• Leuconychia, caused by hypoalbuminaemia, may also
occur in protein calorie malnutrition (kwashiorkor),
malabsorption due to protein-losing enteropathy, as in
coeliac disease, or heavy and prolonged proteinuria
• Finger clubbing is found in liver cirrhosis, inflammatory
bowel disease and malabsorption syndromes.
Other signs that may be associated with liver disease include:
• Dupuytren’s contracture of the palmar fascia (see Fig. 3.5):
linked with alcohol-related chronic liver disease
• bilateral parotid swelling due to sialoadenosis: may be a
feature of chronic alcohol abuse.
Signs that suggest liver failure include:
• asterixis, a coarse flapping tremor when the arms are
outstretched and hands dorsiflexed, which occurs with
• fetor hepaticus, a distinctive ‘mousy’ odour of dimethyl
sulphide on the breath, which is evidence of portosystemic
shunting (with or without encephalopathy)
• altered mental state, varying from drowsiness with the
day/night pattern reversed, through confusion and
disorientation, to unresponsive coma
The physical examination • 105
• Begin with light superficial palpation away from any site of
• Palpate each region in turn, and then repeat with deeper
• Test abdominal muscle tone using light, dipping finger
• Describe any mass using the basic principles outlined in
Box 3.8. Describe its site, size, surface, shape and
consistency, and note whether it moves on respiration. Is
• To determine if a mass is superficial and in the abdominal
wall rather than within the abdominal cavity, ask the
patient to tense their abdominal muscles by lifting their
head. An abdominal wall mass will still be palpable,
whereas an intra-abdominal mass will not.
• Decide whether the mass is an enlarged abdominal organ
or separate from the solid organs.
Discomfort during palpation may vary and may be accompanied
by resistance to palpation. Consider the patient’s level of anxiety
when assessing the severity of pain and degree of tenderness
elicited. Tenderness in several areas on minimal pressure may
be due to generalised peritonitis but is more often caused by
anxiety. Severe superficial pain with no tenderness on deep
palpation or pain that disappears if the patient is distracted also
suggests anxiety. With these exceptions, tenderness usefully
indicates underlying pathology.
Voluntary guarding is the voluntary contraction of the abdominal
muscles when palpation provokes pain. Involuntary guarding is
the reflex contraction of the abdominal muscles when there is
inflammation of the parietal peritoneum. If the whole peritoneum
is inflamed (generalised peritonitis) due to a perforated viscus,
the abdominal wall no longer moves with respiration; breathing
becomes increasingly thoracic and the anterior abdominal wall
muscles are held rigid (board-like rigidity).
The site of tenderness is important. Tenderness in the
epigastrium suggests peptic ulcer; in the right hypochondrium,
cholecystitis; in the left iliac fossa, diverticulitis; and in the right
iliac fossa, appendicitis or Crohn’s ileitis (Fig. 6.12). Ask the
patient to cough or gently percuss the abdomen to elicit any
pain or tenderness ‘Rebound tenderness’, when rapidly removing
your hand after deep palpation increases the pain, is a sign of
intra-abdominal disease but not necessarily of parietal peritoneal
inflammation (peritonism). Specific abdominal signs are shown
in Box 6.9. Typical findings may be masked in patients taking
glucocorticoids, immunosuppressants or anti-inflammatory drugs,
in alcohol intoxication or in altered states of consciousness.
A pulsatile mass palpable in the upper abdomen may be normal
aortic pulsation in a thin person, a gastric or pancreatic tumour
transmitting underlying aortic pulsation, or an aortic aneurysm.
A pathological mass can usually be distinguished from normal
palpable structures by site (Fig. 6.13), and from palpable faeces
as these can be indented and may disappear following defecation.
A hard subcutaneous nodule at the umbilicus may indicate
metastatic cancer (‘Sister Mary Joseph’s nodule’).
Examine the liver, gallbladder, spleen and kidneys in turn during
deep inspiration. Keep your examining hand still and wait for
the organ to move with breathing. Do not start palpation too
wall musculature and becomes more obvious as the patient
raises their head off the bed or coughs.
• Ensure your hands are warm and clean.
• If the bed is low, kneel beside it but avoid touching the
• Ask the patient to show you where any pain is and to
report any tenderness during palpation.
• Ask the patient to place their arms by their sides to help
• Use your right hand, keeping it flat and in contact with the
• Observe the patient’s face throughout for any sign of
Fig. 6.10 Some abdominal incisions. The midline and oblique incisions
avoid damage to innervation of the abdominal musculature and later
development of incisional hernias. These incisions have been widely
superseded by laparoscopic surgery, however.
Fig. 6.11 Surgical stomas. A An ileostomy is usually in the right iliac
fossa and is formed as a spout. B A loop colostomy is created to
defunction the distal bowel temporarily. It is usually in the transverse colon
and has afferent and efferent limbs. C A colostomy may be terminal: that
is, resected distal bowel. It is usually flush and in the left iliac fossa.
106 • The gastrointestinal system
• Palpable liver not always enlarged
Moves towards right iliac fossa
9th–11th ribs mid-axillary line
Moves inferiorly on inspiration
Resonant to percussion above it
Fig. 6.12 Palpable abnormalities in the abdomen.
6.9 Specific signs in the ‘acute abdomen’
Sign Disease associations Examination
As the patient takes a deep breath in, gently palpate in the right upper
quadrant of the abdomen; the acutely inflamed gallbladder contacts the
examining fingers, evoking pain with the arrest of inspiration
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