Inspection and Palpation

Inspection. The examination begins with an inspection of the perianal region. The patient should be in the left lateral position with his knees bent and pulled up. A simple inspection can detect skin changes, scars, anal skin tags, hemorrhoids, anal fissures, anal venous thromboses, fistula, injuries, or prolapse (anal or rectal prolapse). Any findings must be noted later in the examination report. Figures 5.1, 5.2 show examples of pathologies detected during inspection. The diagnostic report should include exact localization: for example, distance from the anus or a description of location as if the patient were in the dorsal recumbent position (at the 12-o'clock position ventral to the anus).

Palpation. Following inspection, a digital examination of the anal canal and distal rectum must be completed before the actual endoscopic examination begins. Attention should be paid to palpable endoluminal abnormalities (polyps, tumors, foreign objects) as well as to extraluminal appearances. Male patients can also undergo a prostate check. An assessment of sphincter tonus as well as any noticeable discomfort during the examination (inflammation, fissures) should be included in the palpation findings. Patients who have been prepared for routine endoscopy will have an empty rectal ampulla. Emergency patients are another matter, however. Especially in the event of acute gastrointestinal bleeding, in addition to endoluminal inspection, characterization of stool contents can provide important additional information (melena, fresh blood, coagulum, stool), helping to infer the source and intensity of bleeding and making the rest of the diagnostic procedure easier. Figure 5.3 provides some examples of endoscopic pathological findings that can be detected during digital palpation.

Table 5.1 provides a summary of possible findings from inspection and palpation prior to endoscopy.

Table 5.1 Inspection and palpation prior to endoscopy



Skin changes (eczema,

Intestinal contents (stool,

ulcers, condyloma)?

blood, coagulum)?

Signs of swelling (periproctic

Sphincter tonus?


Pain (inflammation, anal



Scars (surgical operations)?

Endoluminal obstruction

Anal skin tags?

(polyps, tumors, hemor-



Anal venous thrombosis?

Impressions from an

Anal fissure?

extraluminal aspect?

Fistula openings?


Anal prolapse/rectal pro-

Stenosis (passage of


finger or endoscope)?


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