Irritable bowel syndrome physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Patients with IBS usually appear normal. Physical examination of patients with IBS may elicit tenderness in the abdomen. A digital rectal examination must be performed in all patients to rule out rectal growths, blood in stool and evaluate for dyssynergic defecation (where paradoxical contraction of the rectal sphincter occurs on bearing down and abnormal perineal descent). Physical findings such as fever, abdominal mass, hepatosplenomegaly, lymph node enlargement, weight loss, peritoneal signs and ascites are absent and help rule out organic causes.
VItals Signs
· Orthostatics
Skin
· Skin examination
· Signs of dehydration
Physical examination —
volume depletion.
Skin and mucous membranes — If the skin on the thigh, calf, or forearm is pinched in normal subjects, it will immediately return to its normally flat state when the pinch is released
Although reduced skin turgor is an important clinical finding, normal turgor does not exclude the presence of hypovolemia.
This is particularly true with mild volume deficits, in young patients whose skin is very elastic, and in obese patients, since fat deposits under the skin prevent the changes in subcutaneous turgor from being appreciated.
The skin is also usually dry in hypovolemic patients, and a dry axilla is particularly suggestive of the diagnosis
The tongue and oral mucosa may also be dry since salivary secretions are decreased in this setting.
Arterial blood pressure — The arterial blood pressure changes from near normal with mild hypovolemia to low in the upright position and then, with progressive volume depletion, to persistently low regardless of posture. Postural hypotension leading to dizziness may be the patient's major complaint and is strongly suggestive of hypovolemia
Abdominal pain
Abdomen
· Back, genital and rectal examinations
· Complete abdominal examination
Acute Abdomen
In cases of ischemic acute abdomen, bowel sounds will be absent.
PHYSICAL EXAMINATION — Begin the physical examination by assessing the vital signs. Though fever increases the suspicion for infection,
Elderly patients with an intraabdominal infection are four times more likely than younger patients to present with hypothermia [2].
An oral temperature may be affected by respiratory rate, which is often elevated in those with pain [34].
If there is concern about an inaccurate reading, check a rectal temperature.
An elevated respiratory rate may itself be a compensatory reaction and should alert the clinician to the possibility of underlying metabolic acidosis.
Next, inspect The patient who is restless, curled up, and agitated may suggest renal colic, while a patient lying perfectly still in bed with knees bent raises concern for peritonitis. Inspection may reveal signs of previous surgeries (eg, midline incision scar), abdominal pulsations, or signs of systemic disease (eg, pallor in shock, spider angiomata in cirrhosis), which can be especially important in those who are unable to provide a history.
On auscultation, listen for bowel sounds for two minutes.
Bowel sounds are normally heard as two to twelve medium-pitched gurgles per minute.
The absence of bowel sounds over two minutes suggests peritonitis.
Hyperactive medium-pitched bowel sounds are associated with blood or inflammation within the gastrointestinal (GI) tract.
Periodic rushes of high-pitched "tinkling" bowel sounds or the complete absence of bowel sounds, in the presence of abdominal distention, suggests bowel obstruction [35].
A bruit may be heard in the presence of an abdominal aortic aneurysm (AAA).
Palpation of the abdomen enables the clinician to identify the location and degree of tenderness and to detect signs of peritoneal irritation, such as involuntary guarding and rigidity.
One approach is to initially perform light palpation in the area away from the site of pain. Palpation can then be extended in either a clockwise or counterclockwise rotation towards the area of maximal pain.
Once the area of maximal tenderness is localized, maneuvers to elicit somatic signs can be performed. If a specific area of tenderness is not identified with light palpation, deeper palpation can be performed to identify other abnormalities such as hepatomegaly, splenomegaly, aortic dilatation, or signs of a retrocecal appendix.
Although insensitive, the psoas, obturator, and Rovsing signs have good specificity for acute
In a patient with equivocal signs and symptoms, serial examinations can improve diagnostic accuracy [47].
Appearance of the Patient
- Patients with IBS usually appear normal/mildly distressed.
Vital Signs
- patients are usually afebrile.
- patients have regular pulse, tachycardia may be present in case of dehydration
- Blood pressure is normal in most patients, decreased in case of dehydration
- Respiratory rate normal
Skin
- skin turgor is normal in most patients
- skin turgor is reduced in IBS-diarrhea patients with dehydration as a complication
HEENT
WNL
Neck
WNL
Lungs
- Normal chest expansion
- Normal vesicular breath sounds in B/L lung fields
- Normal tactile fremitus
Heart
Abdomen
- Examination results are usually normal
- Abdominal distention may be present
- Abdominal tenderness may be elicited in different quadrants
- Absence of abdominal masses, organomegaly
- Normal bowel sounds
- To rule out organic causes, rectal exam must be done in patients to evaluate for:
- presence of stool and its consistency
- Rectal tenderness
- Strictures
- Masses
- rectal prolapse
- Fistulas
- Hemorrhoids
- Abscesses
- Fissures
- impaired sphincter function due to a neurologic disorder
- responses of the puborectalis and external anal sphincter muscles while straining to rule out dyssynergic defecation.
Genitourinary
- WNL
Neuromuscular
- Patient is usually oriented to persons, place, and time