History taking and stool assessment
Patient interrogation is of paramount importance because many visual changes in feces are transient. By the time laboratory tests are performed, they may already be gone, so the physician must find out all the details from the patient's words.
Special attention is paid to the following pathological impurities and changes:
- Melena (melena): the stool becomes black, sticky, and tarry. This is an absolutely reliable sign of gastrointestinal bleeding, usually originating from the upper tracts. This symptom requires mandatory exclusion in every gastroenterological patient.
- Native blood: visualized as red streaks directly on the surface of the feces. A similar picture is typical for pathologies of the terminal section, for example, with anal fissures.
- Steatorrhea: excessive excretion of fat in the stool. Serves as an important clinical sign of exocrine pancreatic insufficiency.
- Mucus: determined in the form of strands or lumps on the surface of the stool, which directly indicates the presence of an inflammatory lesion of the colonic mucosa.
- Pus: its presence indicates severe ulcerative processes in the colon (tumor breakdown, tuberculosis, dysentery) or the breakthrough of a perirectal abscess into the intestinal lumen.
General abdominal inspection and peristalsis assessment
During visual inspection of the abdominal cavity, the physician evaluates the correct shape of the abdomen, its symmetry, and size. Attention is also paid to the condition of the skin and the severity of subcutaneous adipose tissue. In some cases, both normally and with pathological enhancement, intestinal peristalsis can be visualized through the abdominal wall.
The most frequent symptom upon inspection is abdominal distension (meteorism). It is subdivided into two types:
- General (diffuse) distension: occurs as a result of total increased gas production or with a systemic decrease in the tone of the intestinal muscular wall.
- Local distension: is a formidable sign of impaired patency of the intestinal tube. Foreign bodies, fecal stones, kinks, or strictures can be the cause. An important pathogenetic mechanism: during obstruction, it is the section of the intestine preceding the obstacle (the proximal segment) that distends.
Palpation, percussion, and auscultation
Physical examination of the abdomen requires a strict sequence for accurate topical diagnosis.
Palpation is traditionally divided into two stages, each of which pursues its own goals:
- Superficial palpation: performed to identify local pain zones, determine pathological tension of the muscles of the anterior abdominal wall (défense musculaire), as well as to detect muscle diastasis, hernia defects, and superficially located masses.
- Deep gliding palpation: used for a detailed study of the topography and condition of various sections of the colon according to generally accepted rules.
Percussion is indispensable in the differential diagnosis of the causes of abdominal enlargement. With its help, the physician distinguishes the accumulation of free fluid (ascites) from meteorism. When gas accumulates in the intestinal loops over the entire surface of the abdomen, a characteristic loud tympanic sound is determined.
Auscultation makes it possible to evaluate the functional (motor) activity of the intestines. Normally, only moderate sounds associated with natural peristalsis are heard. In acute inflammatory processes (e.g., enteritis), peristalsis increases, which is accompanied by loud "rumbling". On the contrary, the complete disappearance of sounds, the so-called "grave silence", is a sign of intestinal paresis, which accompanies diffuse peritonitis and paralytic ileus.
As a clarifying diagnostic stage, additional instrumental methods are used, primarily endoscopic examinations, which allow visual inspection of the mucosa from the inside and taking a biopsy.
Briefly: answers to topical questions
In what sequence is deep gliding palpation of various parts of the colon performed?
Deep gliding palpation of various parts of the intestine is performed in a strict order from the most accessible areas to the more complex ones. The examination sequence includes the following stages:
- Sigmoid colon (colon sigmoideum) — palpated first.
- Caecum (caecum) — palpated second.
- Ileum (ileum) — examined after the cecum.
- Ascending colon and descending colon — palpated at the fourth stage.
- Transverse colon — completes the examination of the intestinal sections.
How to properly position the patient for abdominal palpation?
For high-quality abdominal palpation, it is necessary to give the patient a position that ensures maximum relaxation of the abdominal wall muscles. The patient should lie on their back without a pillow or with a very low pillow, and their arms should be extended along the torso. If the muscles of the anterior abdominal wall remain tense, a special technique is used to relax them: the patient is asked to bend their legs at the knees and rest their feet on the bed.
What specific symptoms exist for diagnosing acute appendicitis during palpation?
When diagnosing acute appendicitis, the sources indicate the following positive appendicular symptoms:
- Voskresensky's sign.
- Sitkovsky's sign.
- Rovsing's sign.
Symptoms of peritoneal irritation include a positive Blumberg's sign; it is noted in a number of cases.
For a quick assessment of impurities in the stool, use the floor rule: black tar (melena) — bleeding "from above", red streaks — a problem at the very "exit" (fissures), and mucus and ulcers — inflammation and ulcers in the colon itself.
Class and exam questions
Why is it so important to question the patient in detail about the nature of the stool during history-taking?
Many stool changes, such as impurities of blood, pus, or mucus, can be transient. By the time the laboratory stool test is prescribed, they may have already disappeared, so anamnestic data remain a crucial key to the diagnosis.
How to determine the location of intestinal obstruction by the localization of abdominal distension?
With local abdominal distension, the section of the intestine that is located more proximally (i.e., precedes) the obstruction area expands. This happens due to the accumulation of contents and gases in front of the stricture, fecal stone, or kink.
What does a tympanic sound indicate during abdominal percussion?
The tympanic sound over the entire surface of the abdomen is caused by the accumulation of a large amount of gas in the intestinal loops. This percussion sign helps to distinguish meteorism from ascites (accumulation of free fluid).
What else to study on this topic
- Technique of deep gliding palpation of the intestines
- Differential diagnosis of the causes of blood in the stool
- Mechanisms of development of muscle tension (défense musculaire)
- Endoscopic methods of GI examination and indications for biopsy
- Pathogenesis of paralytic ileus
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