Steve Goodyear MRCS(Ed)

Abdominal Examination
Patient must be:
Exposed nipple to knee (to underwear is most appropriate).
Laid flat with one pillow behind head (although this is not always possible, e.g. if the patient has
orthopnoea).
Arms by side.
If the patient cannot relax the abdomen fully, they should flex their hips to 450 and their knees to 900.

General Inspection (foot of the bed)

Is the patient comfortable or distressed at rest?
Is there any obvious pain?
Is there any cachexia, pallor, jaundice or abnormal skin pigmentation?
A rapid, but systematic survey of the patient should ensue.

Hands:
Note the presence of:
Metabolic flap (asterixis). This may indicate hepatic encephalopathy (-coarse flap), carbon dioxide
retention (-fine tremor) or uraemia (-fine tremor).
Signs of chronic liver disease. Inspect ad palpate both hands for evidence of Dupytrens Contracture,
palmar erythema, leuconychia (white nails) and clubbing.
Anaemia: if the patient is profoundly anaemic, palmar skin creases may be pale. Koilonychia (spoon
shaped nails) suggests iron-deficiency anaemia.

Eyes:
Inspect the lower lid for anaemia.
Inspect the sclera for jaundice.
Corneal arcus and xanthelasma may be present in hypercholesterolaemia.

Face:
Note abnormal pigmentation around the lips (e.g. in Peutz-Jeghers syndrome).
Angular stomatitis occurs in many medical conditions, especially in iron deficiency anaemia,
malabsorption and oral infections.

Oral Cavity:
Ulceration e.g. due to inflammatory bowel disease, chemotherapy, Behcets syndrome.
Inflammation.
Oral candidiasis e.g. secondary to antibiotic therapy, immunodeficiency, diabetes mellitus or use of
oral steroids.
Halitosis e.g. due to infection, poor hygiene, hepatic foetor, uraemia, diabetes mellitus.

Chest Wall:
Spider naevi.
Gynaecomastia.

Supraclavicular Lymphadenopathy:
Pay particular attention to the left side and look for Virchows node. If present in a patient with intra-
abdominal malignancy, this is referred to as Trosiers sign.
 Steve Goodyear MRCS(Ed)

Exposure of the Abdomen

Examination of the abdomen follows the typical procedure of inspection, palpation, percussion and
auscultation.

Inspection:
Stand at the end of the bed and inspect the abdomen for:
Symmetry (e.g. massive splenomegaly produces a bulge on the left side).
Abnormal pulsation e.g. due to AAA.
Shape e.g. distension.
Return to the right hand side of the patient and actively inspect for the presence of:
Scars.
Sinuses e.g. due to retained suture material.
Fistulas e.g. due to Crohns disease or surgical colostomy.
Visible peristalsis e.g. due to intestinal obstruction.
Distended veins/Caput medusae.
Flank haemorrhages e.g. Grey-Turners Sign in pancreatitis. Also NB Peri-umbilical bruising (Cullens
Sign) in pancreatitis.

Ask the patient whether they have noticed any abnormal lumps or areas of tenderness. This may give a
clue as to the area of pathology. Ask the patient to cough, observing pain (peritoneal irritation) and the
hernial orifices.

Palpation:
Tell the patient what you are about to do, and ensure to ask about areas of tenderness before palpating. The
three stages of abdominal palpation are:
Light palpation.
Deep palpation.
Specific palpation of the intra-abdominal organs.

Light Palpation:
Start at an area away from the pain.
Palpate the nine areas of the abdomen systematically.
Light palpation is to elicit any tenderness or guarding.
Watch the patients face at all times.
Examiner should be on the same level as the patients abdomen.
It is essential to be as gentle as possible in order to gain the patients confidence, and prevent voluntary
guarding (which will mask pathological signs).

Deep Palpation:
Warn the patient that you will be pressing more firmly.
Feel for any obvious masses or tenderness in the nine regions.
If a mass is identified, determine its characteristics systematically.

Specific Palpation of the Intra-Abdominal Organs:

Liver:
Always begin in the right iliac fossa.
Patient is to take deep breaths while the appropriate palpation is performed.
The liver may be palpated in normal subjects, especially if they are thin or there is chest hyperinflation.
If the liver edge is palpable, describe:
The size of the liver.
Its contour.
Its texture.
 Steve Goodyear MRCS(Ed)

Any tenderness.
 Steve Goodyear MRCS(Ed)

Spleen:
Similar palpation technique to the liver. Again, start in the RIF, and move to LUQ in a J-Shape.
If there is no palpable spleen, ask the patient to roll onto their right hand side. Place your hand around
the lower left costal margin, and when the patient inspires, lift forwards while palpating with your right
hand.
A normal spleen is impalpable.

Kidneys:
Examined bimanually, by ballottment.
NB: the right kidney lies lower down than the left and is therefore more likely to be ballotted.

Abdominal Aorta:
Is palpated with the flat of the hand. Fingers point upwards towards the xiphisternum and should be
located approximately 1 inch below this landmark.
An AAA is both pulsatile and expansile.
A non-aneurysmal aorta is pulsatile only. (Fingertips pushed upwards but not outwards)

Percussion:
Percuss over the whole abdomen and particularly over masses.
This is also a sensitive method for eliciting peritonitis (elicits rebound tenderness).
Specifically percuss for ascites by testing for shifting dullness.

Auscultation:
Listen specifically for bowel sounds.
The presence or absence of bowel sounds is important. You must wait 30 seconds before you conclude
that bowel sounds are absent
Listen specifically for bruits over the aorta and the renal arteries.
Auscultate any masses detected for bruits (vascular mass or not?).

A complete abdominal examination includes assessment of:

Hernial orifices.
External genitalia.
A digital rectal examination.

Digital Rectal Examination:

The rectal examination is usually performed with the patient in the left lateral position, with both hips and
knees fully flexed. It is essential to explain the procedure fully to the patient and be gentle! Wear gloves,
and lubricate the finger. It is usually possible to palpate lesions up to 6-8cm from the anal verge. Before
performing the digital rectal examination:
Inspect the anus, its margins and the surrounding skin.
Look for skin tags, excoriations, prolapsed or thrombosed haemorrhoids, fistulas, fissures or ulceration
due to an anal carcinoma.
Ask the patient to bear down, or strain. This may reveal the presence of a rectal prolapse or
occasionally a polyp.

While performing a digital rectal examination, the sphincter tone should be assessed and any tenderness
elicited.
 Steve Goodyear MRCS(Ed)

Structures palpable during a normal rectal examination:

Palpate anteriorly, laterally and posteriorly. Note the following:
Posteriorly: the tip of the coccyx and sacrum are palpable.
Laterally: ischial spines and the ischio-rectal fossa.
Anteriorly in males: prostate gland (smooth lateral lobes separated by the median sulcus); a prostatic
carcinoma may be differentiated from BPH by the loss of the median sulcus, and possibly the presence
of a craggy, hard, irregular mass.
Anteriorly in females: cervix through the vaginal wall and occasionally the body of the uterus.

The normal rectum may contain some faeces. Always look at the glove afterwards for blood and mucus.
Melaena stool has the appearance of sticky tar and an offensive characteristic smell. A rectal Ca may be
palpable as a shelf-like lesion associated with blood on the glove.
Always wipe the patient after examination and offer further tissues.

Urinalysis:
Is particularly important in the context of abdominal pain (the urinary tract may be a source of pain),
anaemia (haematuria) and jaundice (bilirubin).