Lecture #114: DPR: History and Physical Exam of the Gastroenterology I

What are common definitions of constipation by physicians vs. patients?

Physicians define constipation as fewer than 3 bowel movements per week; patients describe it as hard stools, straining, feeling of incomplete evacuation, or need for manual assistance

What are common causes of constipation?

Reduced activity, low-fiber diet, dehydration, endocrine/metabolic disorders, medication side effects (opiates, anticholinergics), electrolyte imbalance, obstruction, or fecal impaction

Which anatomic landmark defines the costovertebral angle (CVA)?

The angle formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae—used to assess kidney tenderness

How should a patient be prepared for an abdominal exam?

Ensure a warm, well-lit room; patient supine with knees slightly flexed, bladder emptied, abdomen fully exposed, arms at sides, and painful areas examined last

What are the steps of the abdominal exam?

1) Inspection 2) Auscultation 3) Percussion 4) Palpation – in this order to avoid altering bowel sounds

What are key points during inspection of the abdomen?

Observe contour, symmetry, scars, striae, dilated veins, rashes, lesions, umbilicus, and visible motion or pulsations; always observe from the right side

What are normal abdominal wall contours?

Flat, scaphoid, rounded (protuberant), or distended; symmetry and smooth contour are typical in a healthy abdomen

What conditions cause abdominal distention?

Obesity, ascites, pregnancy, intestinal obstruction, or organomegaly

What are abdominal striae and when are they seen?

Reddish or silvery stretch marks from dermal rupture during rapid skin stretching; seen in pregnancy, obesity, Cushing’s syndrome, ascites, or puberty

What skin discolorations may appear on the abdomen?

Cullen’s sign (periumbilical ecchymosis) suggests hemoperitoneum; Grey-Turner’s sign (flank ecchymosis) suggests retroperitoneal bleeding

What are the causes of jaundice and how are they classified?

Pre-hepatic (RBC hemolysis), hepatic (liver failure to conjugate bilirubin), and post-hepatic (biliary obstruction)

What does absence of abdominal respiratory motion indicate?

Peritoneal irritation or acute abdomen; paradoxical motion suggests diaphragmatic fatigue or COPD

What may visible pulsations or peristalsis suggest?

Pulsations—abdominal aortic aneurysm; visible peristalsis—intestinal obstruction

Why is auscultation performed before palpation or percussion?

Because palpation or percussion may alter the frequency or intensity of bowel sounds

What are normal bowel sounds?

Normoactive bowel sounds occur 5–34 times per minute, heard as low-pitched gurgles or clicks produced by intestinal peristalsis

What are hypoactive bowel sounds and their causes?

Reduced frequency and tone, normal after surgery or with opioids; pathological in ileus, peritonitis, or obstruction

What are hyperactive bowel sounds and their causes?

Increased frequency and pitch, common with diarrhea, Crohn’s disease, GI bleeding, enteritis, or early obstruction

When are bowel sounds considered absent?

No sounds heard after 2–3 minutes of auscultation, indicating ileus, bowel necrosis, or peritonitis

What special bowel sounds may be heard?

Borborygmi—loud rumbling; high-pitched tinkling—dilated bowel with fluid and air; rushing sounds—intestinal obstruction

What do vascular bruits in the abdomen indicate?

Bruit suggests turbulent blood flow from renal artery stenosis, arterial occlusion, or aneurysm; check over aorta, renal, iliac, and femoral arteries

What do friction rubs over the liver or spleen suggest?

Rare finding; indicates peritoneal inflammation or tumor, abscess, or infarction of the organ

What percussion sounds are expected over the abdomen?

Tympany (air-filled intestines) predominates; dullness suggests organ enlargement or mass

How is the liver percussed and measured?

Percuss downward from lung resonance and upward from tympany in the mid-clavicular line; normal liver span ≈ 6–12 cm

How is splenic enlargement assessed by percussion?

Percuss lowest interspace in left anterior axillary line—normally tympanic; if dull on inspiration, suspect splenomegaly

What are key causes of abdominal tenderness by quadrant?

RUQ—cholecystitis, hepatitis; LUQ—splenic or gastric pathology; RLQ—appendicitis; LLQ—diverticulitis; suprapubic—UTI or uterine pathology

What are the osteopathic considerations for lower bowel disorders?

Sympathetics: T10–T11 (right colon), T12–L2 (left colon); Parasympathetics: vagus (right colon) and pelvic splanchnic nerves (left colon); Chapman’s points—anterior iliotibial bands

What preventive screening is recommended for colon cancer?

Begin at age 45, continue until 75. Options: stool tests yearly, sigmoidoscopy q5 yrs, colonoscopy q10 yrs, CT colonography q5 yrs

What lifestyle factors influence colon cancer risk?

↑ Risk—alcohol, smoking, obesity; ↓ Risk—regular exercise, aspirin use