Palpation in Gastric Outlet Obstruction
In patients with suspected gastric outlet obstruction (GOO), palpation should focus on detecting an epigastric mass and assessing for peritoneal signs, while recognizing that a negative abdominal examination does not exclude GOO and should prompt immediate CT imaging. 1
Key Physical Examination Findings
Essential Palpation Techniques
Palpate the epigastrium specifically for a palpable mass, which may indicate gastric malignancy as the underlying cause of GOO 1
Inspect for visible epigastric distension before palpation, which may be progressive in onset, particularly in malignancy-related GOO 1
Check for peritoneal signs including guarding, rigidity, and rebound tenderness, as their presence indicates ischemia and/or perforation requiring emergent surgical exploration 1
Critical Warning Signs on Palpation
Diffuse abdominal tenderness with guarding or rebound tenderness are signs of strangulation/ischemia requiring immediate surgical intervention 2
The absence of peritoneal signs does not exclude ischemia, as laboratory markers like elevated lactate and leukocytosis may be more sensitive indicators 1
Complete Physical Assessment Beyond Palpation
Systematic Examination Approach
Assess the patient's general appearance including facial expression, skin color and temperature, and mental status, as these may indicate critical conditions such as hypovolemic shock from prolonged vomiting 1
Examine for signs of dehydration including dry mucous membranes, poor skin turgor, and sunken eyes 1
Auscultate for high-pitched or tinkling bowel sounds, which may be present early in obstruction 1
Perform digital rectal examination to detect blood or a rectal mass that might suggest colorectal malignancy as a cause of distal obstruction 1
Vital Signs Assessment
Assess vital signs carefully for tachycardia, tachypnea, cool extremities, mottled or cyanotic skin, slow capillary refill, and oliguria, which indicate shock and require immediate intervention 1
Check for fever, which may indicate complications such as perforation or ischemia 1
Critical Clinical Pitfall
A negative abdominal examination does not rule out gastric outlet obstruction, and clinical suspicion should prompt imaging with CT abdomen and pelvis with IV contrast and neutral oral contrast 1. This is the most important caveat in GOO evaluation, as the physical examination has limited sensitivity for detecting obstruction or its complications.
Immediate Next Steps After Palpation
If peritoneal signs are present on palpation, proceed immediately to surgical consultation for emergent exploration 1
If palpation reveals an epigastric mass or distension without peritoneal signs, obtain CT abdomen and pelvis with IV contrast, which has >90% diagnostic accuracy 3, 2
If vital signs indicate shock (hypotension, cool extremities, mottled skin, oliguria), initiate immediate resuscitation while arranging urgent imaging and surgical evaluation 1