GIT

General Examination & Inspection

Pallor

Clubbing

 Primary biliary cirrhosis

LNP Virchows node – Troisier’s sign

JVP

Hepatojugular reflux

Hepatojugular reflux is the distension of the neck veins precipitated by the maneuver of firm
pressure over the liver.
The HJR maneuver may be performed as follows:

The patient is positioned supine with elevation of the head at 45 degrees. Look at jugular pulsations
during quiet respirations (baseline JVP). Apply gentle pressure (30-40 mm Hg) over the right upper
quadrant or middle abdomen for at least 10 seconds (some suggest to 1 minute). Repeat the JVP.

An increase in JVP of >3 cm is a positive HJR test.

Normal subjects will have a decrease in JVP with this maneuver since venous return to the heart will
be reduced. The jugular venous pressure may transiently rise and then return to normal or decrease
within 10 seconds.

Negative in BCS

Pedal edema

CLD, hypoprotenemia cases, IVC obstruction below renal vein origin

Icterus( will be covered in detail in jaundice session)

Skin

Vasculitic rash

HCV Cryoglobulinemic
Pruritus scratch marks – obstructive jaundice

Tylosis- CA esophagus
Nails

Koilonychia- Fe deficiency

Plummer-Vinson syndrome.

Dysphagia , esophageal web atrophic glossitis (inflammation of tongue) and/or

Platynychia

Leukonychia-

hypoprotenemia CLD
Knuckle hyperpigmentation

B12 deficiency

Arthritis- HBC HCV IBD

Eyes- KF ring ( wilsons)

Signs of liver disease

Alopecia

Parotid enlargement
Palmar erythema

Spider naevi

SVC Territory

>5 significant number

Blanching with central to peripheral arteriolar feeling

Hyperestrogen state

Campbell de Morgan spots

Cherry hemangiomas

Elderly
Venous star

Blue color

Venous insufficiency

Non blanching

Dupuytren’s contracture

Gynecomastia

Adipose and glandular tissue

Axillary hair, pubic hair loss

Testicular atrophy -orchidometer

Signs of liver cell failure

 Fetor hepaticus
 Asterixis Liver flaps -Negative Myoclonus
 Hepatic encephalopathy

GIT

Upper GIT

Oral cavity

Angular chelitis

Stomatitis
Beefy red tongue

Candidiasis

Halitosis

Per abdomen

Inspection

First horizontal line L1 vertebra Transpyloric plane by joining tips of 10 th costal cartilages

Second ---------tubercles of iliac crest

Vertical Lines

Mid inguinal to midclavicular

Femoral artery below to tip of ninth costal cartilage

Shape of abdomen
Normally globular

Distention or swelling

Generalised Vs Localised

Flanks ?? ascites early

7Fs of distension

 Fat
 Fluid
 Fetus
 Flatus
 Fatal Growth
 Fecal matter
 Full bladder

Localised Distension

HS megaly
Intestinal obstruction, intrabdominal growth
Aortic pulsatile swelling

Transmitted Vs Pulsatile sensation

Umbilicus

Normal Slightly retracted ,Inverted

Everted -Umbilical hernia, Massive ascites

Stretched vertically -Pelvic mass

Spinoumbulical distance

Xiphisternal – umbilicus – pubic symphysis (Tanyol Sign)

Scaphoid abdomen/ sunken abdomen

 Severe weight loss

Bluish discoloration of the umbilicus ( Cullen's sign) or Flanks ( Grey Turner's sign )

Haemorrhagic pancreatitis

Striae, or "stretch marks," and surgical scars

Cushings purple striae

White / pink linear coloured

Secondary to gross stretching and rupture of elastic fibres

Linea Nigra
Dilated Veins

Method

To determine the direction of blood flow in a vein, first, the vein that is free from branches for a
distance of 3 cm is identified.

Second, 2 fingers are pressed close together and placed over the middle of the venous segment.

Third, both fingers are moved in the opposite direction, “ milking” and emptying the underlying vein;
this results in complete emptying of the vein.

Finally, 1 of the fingers is released, and the speed of the filling of the vein in one direction can be
observed, and then the procedure is repeated in the other direction.

In patients with dilated abdominal wall veins due to cirrhosis, the direction of blood flow is away
from the umbilicus (radiating like a star from the umbilicus)
 In vena caval obstruction, the direction of blood flow is either completely above downward
(superior venacaval obstruction ) or completely below upward (inferior venacaval obstruction )

In IVC obstruction there is anastomosis between superficial epigastric and superficial circumflex iliac
veins below and l ateral thoracic veins above carrying blood from long saphenous vein to axillary
vein. Dilated veins are seen in paraspinal region and lateral wall of abdomen .The flow in cephalic
direction.

Caput medusae is one of the cardinal features of portal hypertension. The appearance is due to
cutanous portosystemic collateral formation between distended and engorged paraumbilical veins
that radiate from the umbilicus across the abdomen to join systemic veins. Blood from the portal
venous system is shunted through the umbilical veins into the abdominal wall veins, which manifest
as the caput medusae.

Visible Peristalsis

Intestinal obstruction

Ascultation

Normal Abdominal peristaltic sounds

Normally every 5-10 seconds

borborgymi rumbling noise due to move of air or fluid in intestine.

Cruveilhier Baumgarten syndrome is used for cases of portal hypertension due to any cause in which
a loud venous murmur can be heard over the upper abdomen.

Succussion splash

Normally over stomach just after meal upto 2 hrs

Pathologically

Pyloric stenosis, severe intestinal obstruction,

Stenosis

Renal artery stenosis ( paraumulically)

Abdominal aorta stenosis –( Takayasu Arteritis )

Liver – liver hemangioma, HCC,hepatic artery aneurysm

Rubs

Liver – hepatitis

Spleen- infarcts IE, Sickel cell