CLINICAL EVALUATION OF GIT DISEASE

Evaluation of GIT disease depends on presenting symptoms though general aspects are as follows:

I. History in GIT disease should include onset, duration and progression of presenting complaints, apart from review of general GIT functions, e.g.

II. General examination specially relates to anthro­pometric parameters, local examination of oral cavity and signs of dehydration, micronutrient deficiencies or hepatic dysfunction. Search for extra-intestinal septic focus as well as cardiovascular and respiratory examination is equally important to assess the cause/ effect of GIT disorders.

III. Abdominal examination is the most important and specific component of GIT evaluation, which includes: inspection, palpation, percussion and auscultation of abdomen as well as examination for genitals, hernia sites and spine.

• Inspection involves visual examination for—(a) abdo­minal shape and appearance of skin, (b) movement

with respiration, (c) umbilical site, (d) superficial abnormalities, e.g. scars, sinuses and dilated veins, (e) hernia sites, (f) genitals, and (g) perineum.

Abnormal shapes include scaphoid (diaphragmatic hernia) or distended abdomen. Asymmetrical abdomen may be either due to phantom hernia or underlying mass.

Restriction of abdominal movements during breathing indicates peritonitis, while visible peristalsis may be due to underlying dynamic intestinal obstruction. Paradoxical abdominal movements suggest dia­phragmatic paralysis.

Umbilicus is transversely stretched (smiling umbi­licus) in abdominal distension. Cherry-red swelling of umbilicus in para-neonates indicates umbilical granuloma, while bluish periumbilical pigmentation suggests intra-peritoneal bleeding (Cullen sign).

Abdominal veins are normally visible in early infancy or in thin, fair-complexion children. Dilated veins indicate portal hypertension or inferior vena cava (IVC) obstruction, further differentiated by their location and direction of blood flow on milking­refilling method—(a) dilated flank and back veins with upward flow indicate IVC obstruction, e.g. Budd- Chiari syndrome, while (b) dilated and radiating periumbilical veins, flowing away from umbilicus (Caput medusae) indicate portal hypertension.

Genitals should be examined for descent of testes and urethral opening in males vaginal discharge in females and abnormal fecal passage for anorectal malformations. Inguinal hernia must be specially looked for, in cases of undescended testis.

Perineal inspection for anal patency, fissures or excoriation is essential in all, though per-rectal examination should be avoided and advised only in select cases, e.g. suspected Hirschsprung disease.

• Palpation should be done in supine position with semi-flexed lower limbs, to confirm inspection findings and assess for: (a) abdominal tenderness, guarding or rigidity, and (b) organomegaly.

Abdominal tenderness, voluntary guarding or involuntary rigidity may be local or generalized and suggests underlying peritoneal or visceral inflammation. Persistent generalized abdominal rigidity also indicates muscle spasms, e.g. in tetanus. Abdominal girth should always be recorded in cases with distended abdomen, for monitoring.

Liver must be palpated from right iliac fossa upwards, to record its—(i) size, (ii) span, (iii) surface, (iv) margins, (v) consistency, (vi) tenderness and (vii) pulsations (Ch 15.2). Liver is normally palpable till two years of age.

Spleen is palpated from right iliac fossa by moving obliquely towards left costal margin. It may be normally palpable in first 3 months. Enlarged spleen must be assessed for size and need to be differentiated from renal mass (Ch 19.16).

Kidneys are palpated bimanually in supine and standing position. Lower pole of the left kidney may be normally palpable in infants.

• Percussion mainly aims to detect presence of fluid in peritoneum by—(a) fluid thrill for large ascites, (b) Horse-shoe dullness for moderate ascites, (c) shifting dullness for mild fluid collection, and (d) Puddle sign in knee-chest position for minimal fluid collection of lt;50 ml. Percussion is also used to determine liver span and bladder fullness.

• Auscultation includes search for abnormal peristaltic activity, renal arterial bruit in renal artery stenosis and periumbilical venous hum suggestive of portal hypertension. Intestinal peristalsis are best heard in left lumbar region with a rate of ~ 1-3/minute; increased in intestinal obstruction and decreased in paralytic ileus or peritonitis.

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