[...]... mouth should be noted for anaemia, pigmentation, aphthous ulceration and Candida; the tongue for glossitis and telangectasia; the teeth for damage and lips for angular stomatitis CHEST WALL This should be inspected for spider naevi and (in men) the presence of gynaecomastia ABDOMEN Inspect for distension and previous surgical scars, and note distended veins - if emanating and filling from the umbilicus... Ovarian tumour Abdominal wall mass Amoebiasis Intussusception fossa Gastric tumour Pancreatic tumour or cyst Abdominal aortic aneurysm Transverse colon tumour Abdominal wall mass Table 2 Causes of hepatomegaly Fatty liver - smooth and firm Hepatic tumour (primary or secondaries) - hard and irregular Right ventricular failure - firm and smooth, possibly pulsatile Hepatic vein thrombosis (Budd-Chiari) -. .. for the quantity and characteristics of the bowel sounds Anal examination for haemorrhoids, mucosal prolapse, tumours and fistulae should precede rectal examination which examines both the mucosa and faeces - these should be inspected for colour and consistency on the glove NECK AND HEAD The neck should be examined for jugular venous engorgement, a goitre and lymphadenopathy Mucous membranes in the... palpation for masses (Table 1) and then specific examination for enlarged liver, spleen and kidneys If the liver is enlarged (Fig 3) its size and consistency should be determined and particularly careful examination for the spleen performed (Table 2) Percussion of the upper Table 1 Differential diagnosis of masses in the right iliac fossa and the epigastrium Right iliac Caecal mass - tumour or faeces Terminal... breathing or speech and concentration should be obvious, and abnormal posture, such as that due to a hemiparesis, should be noted Skin should be inspected for rashes, such as erythema nodosum, pyoderma gangrenosum (Fig 1) and dermatitis herpetiformis, and joints should be examined for arthropathy HANDS Look for finger clubbing (Fig 2), leuconychia, koilonychia, and Dupuytren's contracture and palmar erythema... xanthelasma and skin excoriation • Eating disorders are suggested by wasting, lanugo, abnormal dentition associated with repeated vomiting and thickened skin on the dorsum of the fingers caused by repeated selfinduced vomiting syndrome - an impacted stone in the cystic duct causing partial obstruction of the common hepatic duct - is one exception) INVESTIGATION Each section in this book features an. .. palliation of malignant strictures, injection therapy for bleeding lesions and placement of gastrostomy tubes Technique All endoscopes are essentially similar with a flexible distal tip which is controlled by two wheels allowing right, left, up and down movements There is an operating or biopsy channel, and a separate channel which passes air to distend the organ under examination Water can also be passed... under examination Water can also be passed down this channel to wash the lens Suction can be applied via the operating channel Air/water and suction are controlled by blue and red buttons on the control head (Fig 2) Following a period of fasting ( 4-6 hours), patients are placed on their left side and the oropharynx is anaesthetised by topical anaesthetic The patient may or may not be sedated, depending... midazolam, which has both sedating and amnesic effects The principal risk of sedation is suppression of breathing, and training is essential to allow the clinician to correctly titrate doses - for midazolam doses range from 2 mg for an elderly frail women or child to 10 mg or occasionally more in a large man who may be currently using a benzodiazepine The benzodiazepine receptor antagonist flumazenil allows... smooth and tender Myeloproliferative disorders - smooth and firm Infective (viral, abscesses, hydatid cyst) Storage disorders (amyloidosts, Gaucher's, haemochromatosis) With splenomegaly Infective - infectious mononucleosis Myeloproliferative - myelofibrosis, chronic myeloid leukaemia Portal hypertension - when associated with hepatomegaly Storage disorders (Gaucher's, amyloidosis) Anaemia (pernicious anaemia) . hepatitis 98 Drugs and the liver 10 0 Chronic viral hepatitis 10 2 Autoimmune hepatitis and liver transplantation Pregnancy and liver disease 10 6 10 4 Normal nutrition 10 8 Index 11 1 ACUTE UPPER. clinical approach 10 Cancer of the oesphagus 12 Disorders of the distal oesophagus 14 Neurological and infective causes of dysphagia 16 The clinical approach 18 Gastro-oesophageal . accordance with the Copyright, Designs and Patents Act 19 88. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,