Peripheral Signs

Before laying hands on the abdomen it is particularly important to look for important peripheral signs of gastrointestinal disease.

In the nails important signs include leukonychia or white nails, often occurring in hypoalbuminaemic states. Beau’s lines which are thin pale lines transversely across the nail, represent periods of severe illness, or transient hypoalbuminaemia. Koilonychia or spoon shaped nails may be found in cases of chronic iron deficiency. Finger clubbing occurs rarely in gastrointestinal disease but, may occur in chronic liver disease, particularly primary biliary cirrhosis and in malabsorptive states, such as coeliac disease. The patient’s hands should be carefully examined for palmar erythema which is redness affecting the periphery of the palms of the hands, particularly the thenar and hypothenar eminences. This is found in association with alcoholic liver disease especially.But it is also found in other conditions such as rheumatoid arthritis, as well as in normal individuals. The palms should also be examined for evidence of a Dupuytren's contracture, which is thickening of the palmar fascia and is associated with alcoholic liver disease. When this is severe patients develop flexion contractures of the fingers. If the deformity is not obvious simply stroking a thumb or index finger across the palmar region of the hand will quickly demonstrate the fascial thickening.
The eyes should be examined for evidence of jaundice and inflammation in active inflammatory bowel disease with iritis. Iritis which is commonly associated with inflammatory bowel disease the affected eye is red and painful and the pupil may appear irregular in outline.

Jaundice is generally visible as a yellowish discoloration of the sclera when the bilirubin is about three times the upper limit of the normal range ie >50umol/L.As jaundice becomes more severe the skin becomes yellow and later almost green in severe cholestasis and may be accompanied by skin excoriation due to the associated pruritis.

The tongue should be examined for evidence of glossitis, with a pale atrophic tongue. An enlarged tongue with peripheral bite marks may occur where there is macroglossia in some patients with malabsorption.

Spider angiomata or naevi are a common finding in chronic liver disease. They generally but not invariably occur in the distribution of the drainage area of the superior vena on the head, upper chest and arms They may be up to a centimetre or more in diameter and are composed of a central arteriole with radiating capillaries which blanch on applying pressure to the central arteriole and then refill from the centre. One or two spider nevi can occur in normal individuals and more in pregnant females, but generally more than 2 or 3 is an abnormal sign.

The breast tissue in a male should be examined for gynaecomastia. After warning the patient the subareolar tissue should be palpated; normally this should not be more than about 2mm in diameter. Hair distribution with feminisation occurring in chronic liver disease, with generalised loss of body hair, including the male escutcheon. Bruising including ecchymoses or petechiae may also be associated with the coagulopathy of chronic liver disease.