The Junior Doctor's Guide to Gastroenterology

Louisa Baxter, Neel Sharma, Ian Mann

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781846193521
• eBook ISBN:
  9781315342931
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

'Becoming a first year doctor is a stressful time...you are suddenly member of a medical team. People often feel out of their comfort zone, and are commonly too embarrassed to ask for help or advice - ' Gastroenterology concerns a large number of patients and is a commonly encountered area of medicine that all doctors are exposed to, even if they are working in a different specialty. It covers disorders of the gastrointestinal tract, pancreas, gallbladder and liver. This practical, user-firendly guide to gastroenterology for the junior doctor consolidates knowledge on common gastroenterological problems. Its unique approach offers logical explanations of investigations and ways to interpret results; it also outlines complications, prognoses and management and contains vital information on running successful ward rounds. Concise and easy to read, The Junior Doctor's Guide to Gastroenterology helps you to make informed, confident decisions and gives you the assurance to optimise your time in gastroenterology.

1

Targeted gastroenterology examination

The gastrointestinal system extends from the lips to the anus, and includes the pancreas and hepatobiliary system. A complete GI examination includes a digital rectal examination (DRE) and examination of hernial orifices; it may also include pelvic examination. Vomitus, stool and urine samples should be inspected. The patient’s observation chart, as well as radiological studies and laboratory investigations, must also be considered part of the routine examination.

Introduction

It is vital to ensure patient comfort and privacy during the clinical examination. The examination room should be warm, well lit, and have adequate supplies of examination gloves, lubricant and tissues.

There is no consensus on the use of chaperones during the physical examination. We suggest that a chaperone of the same sex as the patient should always be utilised if the patient accepts this. This will usually be a member of the nursing staff or a fellow clinician. Family members should be asked to leave the examination room unless the patient requests otherwise.

Obtain verbal consent to examine the patient, and explain what the examination entails. A translator should be used for a patient whose first language is not that of the examiner if there are any concerns about understanding.

It is traditional to examine the patient from the right-hand side. Ask the patient to adopt the supine position if this is comfortable. The bed should be flat and positioned at the level of the examiner’s hip. To ensure that the abdominal wall is fully relaxed, remove the pillows behind the patient’s head. If this is uncomfortable, a thin pillow may be left in place.

Patients should undress themselves without assistance from the doctor unless for any reason they are unable to do so. It is suggested that the patient should remain draped during the general examination, and should then be exposed from nipples to knees for the targeted examination.

Inspection

Throughout the
examination it is vital to observe the patients face for signs of discomfort.

The patient and the environment around them should be inspected from the end of the bed. Look carefully for signs of muscle wasting or weight loss, such as redundant skin folds. Is there evidence of jaundice, poor mobility or use of living aids?

Approach the patient more closely. Do they appear to be in pain or distress? Are they comfortable lying flat? Is there evidence of neglect, or of alcohol misuse?

A formal examination should begin with the patients hands. Look for signs of tar staining from cigarette smoking, leukonychia from chronic illness indicating hypoalbuminaemia, and koilonychia associated with iron deficiency. Assess the warmth of the hands and the rate and rhythm of the pulse. Also assess the capillary refill time, and look for signs of haemodynamic instability. Assess for a liver flap.

Inspect the patients face for indications of their state of hydration and nutrition. Look for evidence of jaundice. Angular stomatitis may be evidence of vitamin deficiencies.

The torso should be inspected for scars, signs of visible peristalsis, redundant skin folds, abdominal masses and evidence of chronic liver disease (e.g. loss of normal hair distribution, gynaecomastia, etc.).

Palpation

Division of the abdomen into either four quadrants or nine regions is recommended. Before palpation ask the patient if they are experiencing any pain, and if so where.

Examine each quadrant in turn, starting with light palpation. Look for signs of tenderness and assess for guarding. Use deeper palpation to identify abdominal masses or areas of deep tenderness.

Palpate the liver, starting in the right iliac fossa. Time palpation with the patient’s respiratory cycle.

Palpate the spleen, again starting in the right iliac fossa. A normal healthy spleen should not be palpable.

Ballot the kidneys. An enlarged kidney should be palpable by the anterior hand.

Rebound tenderness is used to test for evidence of peritoneal irritation, and may be uncomfortable for the patient. It is advisable to warn them before proceeding. Press deeply on the abdomen with your hand, hold for a moment and then quickly release. Rebound tenderness is indicated by increased pain on release of pressure rather than on applying it.

Tenderness in the renal angle may indicate inflammation of the kidneys (e.g. pyelonephritis). Again assessment of this may be uncomfortable, so warn the patient. Ask them to sit up, and then using your hand tap firmly in both costophrenic angles.

Percussion

Liver. Percuss down from the chest in the anterior right mid-clavicular line until you detect the top border of liver dullness. Percussion should be repeated from the right iliac fossa upward until the lower border of liver dullness is detected. The distance between these two points should be measured. The normal distance in an adult is in the range 6-12 cm.

Spleen. Percuss the lowest costal space in the left anterior axillary line. This area is normally tympanitic. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement. Again, you should also percuss the spleen from the right iliac fossa towards the left upper quadrant.

Shifting dullness. This will assess for the presence of peritoneal fluid (ascites). Percuss the patients abdomen to outline areas of dullness and tympany. Percuss across the abdomen, noting the point of transition from tympany to dullness. Then roll the patient on their side away from the examiner,...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• About the authors
• List of abbreviations
• 1 Targeted gastroenterology examination
• 2 Successful ward rounds in gastroenterology
• 3 Introduction to specialist investigations and procedures
• 4 Acute abdominal pain
• 5 Acute gastrointestinal haemorrhage
• 6 Gastro-oesophageal reflux disease
• 7 Barrett’s oesophagus
• 8 Oesophageal cancer
• 9 Gastric cancer
• 10 Inflammatory bowel disease
• 11 Constipation
• 12 Colorectal cancer
• 13 Jaundice
• 14 Acute liver failure
• 15 Cirrhosis
• 16 Acute pancreatitis
• 17 Chronic pancreatitis
• 18 Pancreatic cancer
• Index