Badanie fizykalne układu pokarmowego | Digestive System Examination

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“Zespoły złego wchłaniania”, “Chronic gastrointestinal disease”: “Przewlekła choroba przewodu pokarmowego”, “Dehydration”: “Odwodnienie”, “Dry mucous membranes”: “Suche błony śluzowe”, “Sunken eyes”: “Zapadnięte oczy”, “Fluid loss”: “Utrata płynów”, “Vomiting”: “Wymioty”, “Diarrhea”: “Biegunka”, “Inadequate intake”: “Niewystarczające spożycie”, “Muscle wasting”: “Zanik mięśni”, “Temporal wasting”: “Zanik mięśni skroniowych”, “Chronic digestive diseases”: “Przewlekłe choroby układu pokarmowego”, “Skin color”: “Kolor skóry”, “Jaundice”: “Żółtaczka”, “Liver dysfunction”: “Dysfunkcja wątroby”, “Biliary obstruction”: “Zablokowanie dróg żółciowych”, “Sclerae”: “Twardówki”, “Pallor”: “Bladość”, “Anemia”: “Niedokrwistość”, “Gastrointestinal bleeding”: “Krwawienie z przewodu pokarmowego”, “Spider angiomas”: “Naczyniaki pajączkowate”, “Palmar erythema”: “Rumień dłoniowy”, “Chronic liver disease”: “Przewlekła choroba wątroby”, “Cirrhosis”: “Marskość wątroby”, “Chronic alcohol use”: “Przewlekłe spożycie alkoholu”, “Pruritus”: “Świąd”, “Bile salt accumulation”: “Nagromadzenie soli żółciowych”, “Abdominal scars”: “Blizny na brzuchu”, “Surgical scars”: “Blizny pooperacyjne”, “Appendectomy”: “Wycięcie wyrostka robaczkowego”, “Cholecystectomy”: “Cholecystektomia”, “Bowel resections”: “Resekcje jelit”, “Stomas”: “Stomie”, “Colostomy”: “Kolostomia”, “Ileostomy”: “Ileostomia”, “Inflammatory bowel disease”: “Nieswoiste zapalenia jelit”, “Diverticulitis”: “Zapalenie uchyłków”, “Colorectal cancer”: “Rak jelita grubego”, “Visible pulsations”: “Widoczne pulsacje”, “Abdominal aortic aneurysm”: “Tętniak aorty brzusznej”, “Organomegaly”: “Powiększenie narządów”, “Intra-abdominal tumors”: “Guzy wewnątrzbrzuszne”, “Hernias”: “Przepukliny”, “Reducible bulges”: “Odzyskiwalne wybrzuszenia”, “Asymmetry”: “Asymetria”, “Abdominal wall”: “Ściana brzucha”, “Oral mucosa”: “Błona śluzowa jamy ustnej”, “Lips”: “Wargi”, “Tongue”: “Język”, “Gums”: “Dziąsła”, “Buccal mucosa”: “Błona śluzowa policzków”, “Angular stomatitis”: “Zajady (kątowe zapalenie warg)”, “Glossitis”: “Zapalenie języka”, “Vitamin deficiencies”: “Niedobory witamin”, “Iron deficiency”: “Niedobór żelaza”, “Folate deficiency”: “Niedobór kwasu foliowego”, “Malabsorption”: “Złe wchłanianie”, “Ulcers”: “Owrzodzenia”, “Candidiasis”: “Kandydoza”, “Autoimmune conditions”: “Choroby autoimmunologiczne”, “Lichen planus”: “Liszaj płaski”, “Dentition”: “Uzębienie”, “Poor dentition”: “Zły stan uzębienia”, “Missing teeth”: “Brakujące zęby”, “Dental caries”: “Próchnica”, “Infective endocarditis”: “Zakaźne zapalenie wsierdzia”, “Gingivitis”: “Zapalenie dziąseł”, “Ill-fitting dentures”: “Niedopasowane protezy”, “Chewing difficulty”: “Trudności w żuciu”, “Nutritional deficiencies”: “Niedobory odżywcze”, “Halitosis”: “Nieświeży oddech”, “Poor oral hygiene”: “Zła higiena jamy ustnej”, “Gastroesophageal reflux disease (GERD)”: “Choroba refluksowa przełyku”, “Oral cavity infections”: “Infekcje jamy ustnej”, “Hepatic encephalopathy”: “Encefalopatia wątrobowa”, “Fetor hepaticus”: “Zapach mocznicowy (foetor hepaticus)”, “Abdominal examination”: “Badanie brzucha”, “Abdominal contour”: “Zarys brzucha”, “Flat abdomen”: “Płaski brzuch”, “Scaphoid abdomen”: “Zapadnięty brzuch”, “Distended abdomen”: “Wzdęty brzuch”, “Ascites”: “Wodobrzusze”, “Bowel obstruction”: “Niedrożność jelit”, “Organ enlargement”: “Powiększenie narządów”, “Bruising”: “Siniaki”, “Engorged veins”: “Poszerzone żyły”, “Portal hypertension”: “Nadciśnienie wrotne”, “Trauma”: “Uraz”, “Splenomegaly”: “Powiększenie śledziony”, “Hepatomegaly”: “Powiększenie wątroby”, “Skin striae”: “Rozstępy skóry”, “Stretch marks”: “Rozstępy”, “Caput medusae”: “Głowa Meduzy”, “Rashes”: “Wysypki”, “Dermatologic manifestations”: “Objawy dermatologiczne”, “Dermatitis herpetiformis”: “Opryszczkowate zapalenie skóry”, “Celiac disease”: “Celiakia”, “Visible peristalsis”: “Widoczna perystaltyka”, “Bowel sounds”: “Szmer jelitowy”, “Hyperactive bowel sounds”: “Wzmożone szmery jelitowe”, “Gastroenteritis”: “Nieżyt żołądkowo-jelitowy”, “Ileus”: “Niedrożność porażenna”, “Peritonitis”: “Zapalenie otrzewnej”, “High-pitched tinkling sounds”: “Dźwięki wysokotonowe”, “Mechanical bowel obstruction”: “Mechaniczna niedrożność jelit”, “Paralytic ileus”: “Porażenna niedrożność jelit”, “Bruits”: “Szmery”, “Aorta”: “Aorta”, “Renal arteries”: “Tętnice nerkowe”, “Iliac arteries”: “Tętnice biodrowe”, “Femoral arteries”: “Tętnice udowe”, “Vascular abnormalities”: “Nieprawidłowości naczyniowe”, “Renal artery stenosis”: “Zwężenie tętnicy nerkowej”, “Mesenteric ischemia”: “Niedokrwienie krezki”, “General percussion”: “Opukiwanie ogólne”, “Tympanic sound”: “Dźwięk bębenkowy”, “Dullness”: “Stłumienie”, “Fluid accumulation”: “Nagromadzenie płynu”, “Shifting dullness”: “Przemieszczające się stłumienie”, “Fluid thrill”: “Objaw drżenia płynu”, “Light palpation”: “Powierzchowna palpacja”, “Tenderness”: “Tkliwość”, “Muscle guarding”: “Obrona mięśniowa”, “Involuntary rigidity”: “Sztywność obronna”, “Deep palpation”: “Głębokie badanie palpacyjne”, “Rebound tenderness”: “Objaw Blumberga”, “Rectal examination”: “Badanie per rectum”, “Lower gastrointestinal symptoms”: “Objawy dolnego odcinka przewodu pokarmowego”, “Perianal region”: “Okolica okołoodbytnicza”, “Sphincter tone”: “Napięcie zwieracza”, “Bright red blood”: “Jasnoczerwona krew”, “Lower GI”: “Dolny odcinek przewodu pokarmowego”, “Excoriations”: “Przeczosy”, “Acute”: “Ostry”, “Chronic”: “Przewlekły”, “Aortic aneurysm”: “Tętniak aorty”, “Motility”: “Motoryka”, “Abdominal distension”: “Wzdęcie brzucha”, “Volvulus”: “Skręt jelita”, “Absent sounds”: “Brak szmerów”, “Secondary hypertension”: “Nadciśnienie wtórne”, “Tympanic”: “Bębenkowy”, “Hepatitis”: “Zapalenie wątroby”, “Congestive hepatopathy”: “Wątroba zastoinowa”, “Free fluid”: “Wolny płyn”, “Voluntary guarding”: “Dobrowolna obrona mięśniowa”, “Cutaneous hyperesthesia”: “Nadwrażliwość skórna”, “Mononucleosis”: “Mononukleoza”, “Hydronephrosis”: “Wodonercze”, “Polycystic kidney disease”: “Wielotorbielowatość nerek”, “Appendicitis”: “Zapalenie wyrostka robaczkowego”, “Perforated viscus”: “Perforacja trzewi”, “Guarding”: “Obrona mięśniowa”, “Murphy’s Sign”: “Objaw Murphy’ego”, “Cholecystitis”: “Zapalenie pęcherzyka żółciowego”, “Gallbladder inflammation”: “Zapalenie pęcherzyka żółciowego”, “McBurney’s Point”: “Punkt McBurneya”, “Rovsing’s sign”: “Objaw Rovsinga”, “Heart failure”: “Niewydolność serca”, “Malignancy”: “Nowotwór złośliwy”, “Fluid Wave Test”: “Objaw chebotania”, “Retrocecal appendicitis”: “Zapalenie wyrostka robaczkowego za kątnicą”, “Psoas Sign”: “Objaw mięśnia lędźwiowego”, “Psoas muscle”: “Mięsień lędźwiowy większy”, “Obturator Sign”: “Objaw mięśnia zasłaniacza wewnętrznego”, “Pelvic appendicitis”: “Zapalenie wyrostka robaczkowego w miednicy”, “Inflamed appendix”: “Zapalenie wyrostka robaczkowego”, “Hypogastric region”: “Okolica podbrzuszna”, “Rectal masses”: “Guzy odbytnicy”, “Hemorrhoids”: “Hemoroidy”, “Fissures”: “Szczeliny odbytu”, “Prostate abnormalities”: “Nieprawidłowości prostaty”, “Skin tags”: “Wyrośla skórne”, “Perianal abscesses”: “Ropnie okołoodbytnicze”, “Prolapse”: “Wypadanie”, “Induration”: “Stwardnienie”, “Nodularity”: “Guzkowatość”, “Hardness”: “Twardość”, “Occult blood”: “Krew utajona”, “Melena”: “Smoliste stolce”, “Prostatitis”: “Zapalenie prostaty”, “Prostate gland”: “Gruczoł krokowy”, “Anal fissures”: “Szczeliny odbytu” }; // Normalize keys in the dictionary const normalizedWordsToTooltip = {}; for (const [key, value] of Object.entries(wordsToTooltip)) { const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value; } function processNode(node) { if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) { let content = node.nodeValue; // Regex to match only the main words (ignores parentheses) const regex = new RegExp( `b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})b`, 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Szacowany czas lekcji: 20 minut
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General Inspection

The examination starts with a general inspection of the patient, focusing on signs that may indicate underlying digestive pathology:

  • General Appearance: Assess the patient’s overall appearance, noting if they are in distress, which could indicate acute abdominal pain. Look for signs of malnutrition, such as a thin, wasted appearance, which may be indicative of malabsorption syndromes or chronic gastrointestinal disease. Also, note signs of dehydration such as dry mucous membranes or sunken eyes, which may suggest fluid loss from vomiting, diarrhea, or inadequate intake. Muscle wasting and temporal wasting are other signs of severe malnutrition often seen in chronic digestive diseases.
  • Skin Color and Changes: Inspect the skin for jaundice (yellow discoloration), which indicates liver dysfunction or biliary obstruction. Jaundice often presents first in the sclerae of the eyes and later on the skin. Also, check for pallor, which could suggest anemia due to gastrointestinal bleeding, either acute or chronic. Look for spider angiomas or palmar erythema, which are signs of chronic liver disease, typically related to cirrhosis or chronic alcohol use. Additionally, excoriations from pruritus can indicate underlying liver dysfunction with bile salt accumulation.
  • Abdominal Scars: Note any abdominal surgical scars, which may indicate prior surgeries such as appendectomycholecystectomy, or bowel resections. Surgical scars can provide important context for understanding a patient’s medical history and may explain certain clinical findings, such as adhesions or altered bowel function. Consider the presence of stomas that may be indicative of colostomy or ileostomy, which might suggest inflammatory bowel disease, diverticulitis, or colorectal cancer.
  • Visible Pulsations or Masses: Inspect the abdomen for visible pulsations, which could indicate an abdominal aortic aneurysm, or visible masses that may represent hernias, organomegaly, or large intra-abdominal tumors. Hernias should be inspected carefully while the patient is standing and straining, as this can reveal reducible bulges that may not be obvious while lying down. Assess for any asymmetry in the abdominal wall which could indicate the presence of hernias or underlying masses.

Examination of the Mouth

  • Oral Mucosa: Inspect the oral cavity, including the lips, tongue, gums, and buccal mucosa. Look for pallor of the mucous membranes, which is suggestive of anemia. Angular stomatitis (cracks at the corners of the mouth) or glossitis (smooth, swollen tongue) could indicate vitamin deficiencies (e.g., vitamin B12, iron, or folate) or malabsorption. Look for ulcers or white patches that could suggest infection (e.g., candidiasis) or autoimmune conditions, such as lichen planus.
  • Dentition: Poor dentition or missing teeth may affect nutrition and indicate neglect or underlying socioeconomic issues. Dental caries may also be a source of infection that can seed other organs, particularly the heart, leading to infective endocarditis. Inspect for gingivitis (inflamed gums), which can also be a sign of vitamin deficiencies or poor oral hygiene. Consider the implications of ill-fitting dentures in older patients, which could contribute to difficulty in chewing and subsequent nutritional deficiencies.
  • Halitosis: Assess for halitosis (bad breath), which may indicate poor oral hygiene, gastroesophageal reflux disease (GERD), or infections in the oral cavity. Halitosis can also be a sign of more serious gastrointestinal issues, such as hepatic encephalopathy, where a characteristic “musty” odor is observed due to liver dysfunction. Fetor hepaticus, another specific type of halitosis, is often indicative of severe liver disease.

Abdominal Examination

Inspection

  • Contour and Symmetry: Inspect the contour of the abdomen, noting whether it is flat, scaphoid, or distended. A distended abdomen may indicate ascites, bowel obstruction, or organomegaly. Inspect for asymmetry, which may be caused by masses, organ enlargement, or hernias. Note any visible surgical scars, bruising, or engorged veins that could indicate underlying pathology such as trauma or cirrhosis. Additionally, visible masses or areas of bulging may suggest underlying tumors or large organ enlargement, such as splenomegaly or hepatomegaly.
  • Skin Changes: Look for striae (stretch marks), which can occur due to rapid changes in abdominal size, such as in pregnancy or ascites. Caput medusae (dilated abdominal veins) may indicate portal hypertension, commonly due to chronic liver disease. Observe for rashes or discoloration that may indicate systemic disease or dermatologic manifestations of gastrointestinal pathology, such as dermatitis herpetiformis, which is associated with celiac disease.
  • Visible Peristalsis: Visible peristalsis may indicate bowel obstruction, particularly in thin patients, and can provide important clues regarding gastrointestinal motility. Visible pulsations in the epigastric region may suggest an aortic aneurysm and warrant further investigation. Additionally, abdominal distension and visible movement of bowel loops may suggest severe bowel obstruction or even volvulus.

Auscultation

  • Bowel Sounds: Using the diaphragm of the stethoscope, auscultate all four quadrants of the abdomen to assess bowel sounds. Normal bowel sounds occur every 5-10 seconds and are characterized by a gurgling or rumbling sound. Hyperactive bowel sounds may indicate gastroenteritisearly bowel obstruction, or increased gastrointestinal motility, while hypoactive or absent sounds may suggest ileusperitonitis, or late-stage bowel obstruction. Auscultate for at least two minutes if bowel sounds are not initially heard. Additionally, high-pitched tinkling sounds may be heard in mechanical bowel obstruction, whereas absent sounds may indicate paralytic ileus.
  • Bruits: Auscultate over the aortarenal arteriesiliac arteries, and femoral arteries for bruits, which may suggest vascular abnormalities such as renal artery stenosisabdominal aortic aneurysm, or mesenteric ischemia. A bruit is a whooshing sound indicating turbulent blood flow, often due to narrowing of the vessel. Detection of bruits over the renal arteries is particularly important when evaluating for secondary hypertension.

Percussion

  • General Percussion: Percuss all four quadrants of the abdomen to determine the presence of gas or fluid. A tympanic sound generally indicates gas in the intestines, which is typical in a healthy individual. Dullness may indicate fluid (ascites), a mass, or enlarged organs such as the liver or spleen. Dullness over the flanks may indicate fluid accumulation, whereas dullness in localized areas may suggest a mass.
  • Liver Span: Percuss the right upper quadrant to determine the size of the liver. Start at the level of the nipple and move downward to identify the upper and lower borders of the liver, noting any hepatomegaly. The normal liver span is typically between 6-12 cm at the midclavicular line. Hepatomegaly can be a sign of liver disease, congestive heart failure, or malignancy. Pay attention to any tenderness elicited during percussion, which may indicate underlying hepatitis or congestive hepatopathy.
  • Shifting Dullness: In cases of suspected ascites, percuss the abdomen while the patient is supine, then ask the patient to roll to one side and repeat. A change in the location of dullness suggests the presence of free fluid in the abdomen. Shifting dullness is one of the more sensitive tests for detecting moderate amounts of ascites. Additional percussion for fluid thrill can also be helpful in confirming large volume ascites.

Palpation

  • Light Palpation: Begin with light palpation in all quadrants to assess for tendernessmuscle guarding, or superficial masses. This helps to identify areas of pain before proceeding to deeper palpation. Voluntary guardingmay indicate tenderness or anxiety, whereas involuntary rigidity is suggestive of peritoneal irritation. Note any cutaneous hyperesthesia, which can be a sign of underlying peritoneal inflammation.
  • Deep Palpation: Use deep palpation to assess for organomegaly and deep masses. Palpate the liver and spleen to assess for enlargement. The liver edge should be smooth, firm, and non-tender. Splenomegaly may indicate hematologic disorders, portal hypertension, or infections like mononucleosis. When palpating, also assess for any masses, noting their size, consistency, mobility, and tenderness. Be sure to also palpate for the kidneys, noting if they are ballotable, as this can indicate hydronephrosis or polycystic kidney disease.
  • Rebound Tenderness: Assess for rebound tenderness by pressing deeply and then quickly releasing. Pain upon release suggests peritonitis and is a critical sign of acute abdominal pathology, such as appendicitis or perforated viscus. Rebound tenderness is often accompanied by guarding and rigidity in peritoneal irritation, indicating an acute surgical abdomen.
  • Murphy’s Sign: To assess for cholecystitis, palpate the right upper quadrant while asking the patient to take a deep breath. A sharp increase in pain and an involuntary halt in inspiration indicates a positive Murphy’s sign, suggestive of gallbladder inflammation. This sign is particularly important in patients with right upper quadrant pain and fever.
  • McBurney’s Point Tenderness: Palpate McBurney’s point (one-third of the distance from the anterior superior iliac spine to the umbilicus) to assess for appendicitis. Tenderness in this area suggests acute appendicitis. Look for associated signs such as guardingrigidity, or Rovsing’s sign in the right lower quadrant.

Special Tests

  • Fluid Wave Test: To confirm ascites, place one hand on either side of the abdomen and tap one side while feeling for a transmitted wave on the opposite side. A positive fluid wave indicates free fluid in the abdomen, usually due to cirrhosisheart failure, or malignancy. This test is most reliable in patients with significant ascites and can be corroborated with ultrasound for confirmation.
  • Rovsing’s Sign: Palpation of the left lower quadrant that results in pain in the right lower quadrant is suggestive of appendicitis. This referred pain is a sign of peritoneal irritation and supports the diagnosis of acute appendicitis. Rovsing’s sign is an important finding in the context of suspected right lower quadrant pathology.
  • Psoas Sign: To assess for retrocecal appendicitis, have the patient lift their right leg against resistance or extend the right hip while lying on their left side. Pain elicited in the right lower quadrant suggests irritation of the psoas muscle, often due to appendicitis. This sign helps localize the appendix, especially when it lies in a retrocecal position.
  • Obturator Sign: To assess for pelvic appendicitis, flex the patient’s right hip and knee, then internally rotate the hip. Pain in the hypogastric region suggests irritation of the obturator muscle by an inflamed appendix. This sign is particularly useful when the appendix is located in the pelvic cavity.

Rectal Examination

rectal examination is essential for assessing certain gastrointestinal complaints, especially in patients presenting with lower gastrointestinal symptoms, such as changes in bowel habits, rectal bleeding, or unexplained abdominal pain. This examination is particularly important for evaluating the distal rectum, anal canal, and surrounding structures. It provides valuable insights into potential causes of symptoms such as rectal masseshemorrhoidsfissures, or prostate abnormalities in male patients.

  • Inspection: Before inserting a gloved, lubricated finger, visually inspect the perianal region for abnormalities such as hemorrhoidsfissuresskin tags, or perianal abscesses. Check for prolapse of the rectal mucosa or other lesions that might suggest external pathology. Skin irritation or excoriation may also indicate pruritus ani or other skin conditions.
  • Palpation: Gently insert a lubricated, gloved finger into the anal canal, assessing for sphincter tone and anal tenderness. Reduced sphincter tone may indicate neurological issues, whereas increased tone can be due to anal fissures or anxiety. Palpate the entire circumference of the rectum for massesinduration, or tenderness. In male patients, palpate the prostate gland for size, consistency, and tenderness. A normal prostate should feel firm, smooth, and non-tender, while nodularity or hardness may suggest malignancy. Tenderness could indicate prostatitis.
  • Stool Examination: After the rectal examination, inspect the gloved finger for stool. Note the color and consistency, and check for the presence of blood or mucusOccult blood may suggest gastrointestinal bleeding, which requires further investigation. Melena (black, tarry stool) could indicate upper GI bleeding, whereas bright red blood is more suggestive of lower GI sources, such as hemorrhoids or fissures.