Gastroenterology Examination Guide

Introduce yourself and ask permission to perform the examination.

End of the Bed

  • Relate to the history
  • Inspect: from the end of the bed
    • Jaundiced
    • Central line
    • Scars
    • Fistula (dialysis)
    • Striae
    • Visible masses/hernias
    • Ascites
    • Peripheral oedema
    • Weight
    • Pallor


Signs in Chronic Liver DiseaseComments
ClubbingCirrhosis of any cause also: rarely :GI lymphoma/ coeliac disease / inflammatory bowel disease
Dupuytren’sRing& little finger. ½ are bilateral Fibrous thickening of skin and soft tissue causing contractureà Other causes: Diabetes/ Alcohol/ hereditary
JaundicePre/ Intra /Post hepatic causes
Asterixis (Liver Flap)Asymmetrical. Thought to be due to ammonia accumulation(Liver not metabolising properly) Key sign of hepatic encephalopathy
Pruritis and scratch marks 
Xanthoma/ tendon XanthomataAlso associated with Hypercholesterolemia
Spider NaeviFill from the centre, >5 in the draining of the SVC is significant
Pigmentation /palmar erythemaBronze diabetes: Haemochromatosis
Tattoo’sHep B&C risk
TremorETOH related/ withdrawal
Needle TracksHep B&C
Muscle Wasting 
Splinter Haemorrhages(think also SBE/ Vasculitis)
Leuconychiawhite nails=low protein state

Kolionychia= Iron def anaemia

Look for finger prick marks of diabetes self checking (helpful for renal)


  • Fistulae
  • Muscle bulk
  • Peripheral lines (Nutrition/ Antibiotics/ Dialysis)
  • Eyes: Jaundice/ corneal arcus
  • Mouth: hepatic foetor


  • LN (cancer/ lymphoma) esp Virchows node (gastric cancer – palpable left supraclavicular fossa)
  • JVP
  • Chest – Gynaecomastia (also marijuana/ oestrogen/ spironolactone: used to treat ascites)


  • General palpation 9 quadrants
  • Liver
  • Spleen
  • Kidneys
  • Ascites
  • Hernial orifices
  • External genitalia

Remember to always…

  1. Kneel at the bedside
  2. Always inspect first including the renal angles on both sides to check for scars
  3. Look at the patients face when you palpate
  4. Divide the abdomen into a 3×3 grid and palpate through each quadrant superficially
  5. If you find a mass attempt to describe it in terms of its
  6. Size
  7. Surface
  8. Fixed to the skin
  9. Shape
  10. Mobility
  11. Tenderness
  12. Firmness
  13. Resonant
  14. Movement with respiration
  15. Bruit

Following this in the next few pages of the guide we describe Hepatomegaly and Splenomegaly on their own or together…

Causes of ‘Just Splenomegaly’

Size of spleenCauses
MassiveCML Myelofibrosis Malaria Kala-Azar Some Lymphomas Gaucher’s Disease  
Large >6cm below costal margin (remembering it goes towards the RIF)Myeloproliferative states (As above CML/ myelofibrosis) Lymphoma& Leukaemia’s (e.g. CLL)
Smaller but palpableLoads(!) including Blood related Lymphoma Leukaemia Idiopathic thrombocytopenic purpura (ITP: bruising, treat with steroids/ rituximab/ splenectomy)   Congestive Portal Hypertension from liver disease of any sort/ hepatic vein thrombosis/CCF etc Infection EBV (glandular fever) CMV,TB, Hepatitis,HIV   Inflammatory Diseases Felty’s: [triad of Neutropaenia/ Rheumatoid arthritis& Splenomegaly] Amyloid (chronic disease) Lupus Sarcoidosis

Causes of ‘Hepatosplenomegaly’

A big liver and a big spleen usually represents either a

1) Lymphoproliferative disorder (Lymphoma/Leukaemia)

2) Cirrhosis and Portal Hypertension

Big Liver in Cirrhosis? I thought it shrank…

It does! But…there are some things that can make it large again e.g.

  • A hepatoma (advocates for screening all CLD with USS every 6 months/ Raised AFP is a common finding)
  • PBC
  • Alcoholic liver disease can still give you an enlarged (attempting to regenerate) cirrhotic liver
  • Secondary amyloidosis

Causes of ‘Just Hepatomegaly’

CancerColorectal      Only met from the liver that can be resected which can be a curative procedure: the famous Mercedes Benz scar of the 3 flap approach like the Mercedes symbol. (this scar usually signifies a liver transplant)
 Lung & others  Any Mets to LN/ other organs means the condition is inoperable
 HepatomaCheck AFP. Occurs in cirrhotic livers due to any cause of cirrhosis. In an exam think about this if a cirrhotic liver “starts to enlarge”
AutoimmunePrimary Biliary CirrhosisFemales: 25% have a big liver Anti mitochondrial Antibody 98ish % specific   Diagnosis: Liver Biopsy
InflammatorySarcoidosisGranuloma on Biopsy
 Amyloid“Congo red” stain
CongestiveCCF Portal Vein thrombosisUsually give a big spleen too…
NormalCOPD  Pushed down by hyperinflation
 Reidel’s lobePhysiological variant and this can push all the way down to the iliac crest

Other things to feel in the abdomen…

  • Colon (inflamed / normal / mass)
  • Fibroids
  • Ovarian Mass
  • Other Uterine mass
  • Pancreatic mass
  • Gallbladder
  • Renal mass / polycystic kidneys
  • Polycystic liver
  • Gastric mass
  • Hernias