Abdominal examination

Dr.AbdulWAHID M Salih
M.D. Surgery

Right hypochondrial
liver gallbladder
right kidney
hepatic flexure of colon
right lumber
ascending colon

Epigastric
liver (left lobe) pylorus
duodenum
omentum
transverse colon
the head and body of pancreas

umbilical

Left hypochondrial
spleen
stomach
splenic flexure of colon
pancreas (tail part )
left kidney

left lumber

 The patient should have an empty

bladder.
Watch the patient's face for signs
of discomfort during
the examination.
room must be quiet
to perform adequate
auscultation and percussion.

Other areas
It is always wise to examine the chest
when evaluating an abdominal
complaint.
Consider the inguinal/rectal
examination in males.
Consider the pelvic/rectal
examination in females.

Abdomen: inspection
Pt is supine
From nipples to
pubic symphysis.
Skin:
-Herpes zoster
(abdominal pain).
-Grey-Turner's sign
(acute pancreatitis).
-Striae
-Scars.
-Lesions, or rashes.

Look for
Movement; with peristalsis or pulsations.
abdominal contour;
Flat
Scaphoid
Protuberant?

Stoma;
surgery, trauma.

PEG;
(Percutaneous
Endoscopic
Gastrostomy)

Distension;
(fat, fetus, feces, flatus,
fluid, full-sized tumors).

Local swellings;
(enlarged organs, hernia).

Pulsations;
(AAA).

Peristalsis visible;
(thin person, intestinal obstruction).

Regular striae;
ascities,
pregnancy
weight loss
Purple,
wide striae;
(Cushings).

Dilated veins location:

Normal flow is away from the umbilicus
Anterior leg (IVC block).
Caput medusae (portal HTN).
Costal margin (normal).

Dilated vein flow direction;

Test by occluding with fingers:
Flows superior (IVC block).
Flows inferior (SVC block).

Umbilicus:
Sister Joseph nodule;
(metastatic tumor).

Cullen's sign;
(acute pancreatitis,
extensive
hemoperitoneum).

Incisions
&
scars
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Laparoscopic

Choleocystectomy
Appendectomy
Colectomies

Gridiron
Appendectomy

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Midline

Laparotomy
Left Paramedian

Anterior rectal resection

Transverse suprapubic/Pfannenstiel
Hysterectomy
Other pelvic surgery

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Inguinal hernia
Hernia repair

Ask the pt to;

Cough impulse
Cough sign
----- his abdomen;

blow out
draw in
If any part tender:

Pointing sign;
examine that last.

Self examination

Palpate
Warm hands.
Abdominal muscles relaxed;
pt bends knees if necessary.

Palpate
Light palpation; Deep palpation;
All the quadrants
1. Tenderness
2. Rigidity
3. Guarding
4. Record mass characteristics

A Mass
Pt folds arms and sits halfway up;

1. Intrabdominal mass
2. Abdominal wall mass; if
Size;
same
Tenderness
same or greater.

Fothergill's sign = Carnet signs

If a mass in the abdominal wall does not;
1. cross midline
2. change with flexion of the rectus muscles,
3. this is a rectus sheath hematoma.

Palpate liver
Find edge:
Dr's R hand held still at base of RLQ,
parallel to costal margin.
Ask pt. to breathe slowly.
During inspiration;
liver edge strikes radial edge of index finger.
During expiration;
Dr's hand moves superiorly 2cm.

Alternate Method
Stand by the patient's chest.
"Hook" your fingers just below the costal
margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the
liver press against your fingers

Palpate liver surface, edge:

Hard vs. soft.

Regular vs. irregular.

Tender vs. not.
Pulsatile vs. not.

Liver span;
percussing down R midclavicular line
should be 6-12 cm in a normal adult.

Hepatomegaly DDx
Marked enlargement:

Alcoholism
RHF
Carcinoma: metastases, or 1

Moderate enlargement:

Leukemia, lymphomas, etc.

Fatty liver
Hemochromatosis
All marked causes

Minor enlargement:

Hepatitis
Cirrhosis
Metastatic dz
All marked, moderate causes

Palpate gallbladder
fingers perpendicular
to R costal margin
near midline, moved
to lateral to palpate.
Murphy's point:
costal margin in
midclavicular line.
Murphy's sign:
cessation of inspiration
upon palpation.
Courvoisier's law:
Stones= stays small since scarred.

Palpate spleen
Bimanual technique:
Dr's L hand posterolaterally,below
pt's L ribs, compressing on rib cage.
Dr's R hand below pt's umbilicus
parallel to L costal margin.
Advance R hand superiorly to L costal margin.
1.5x-2x enlarged spleen is palpable.
If miss spleen, roll pt. towards Dr.
(so pt lies on pt's R side) and repeat palpation.
Percuss the lowest costal interspace
in the Left anterior axillary line;
This area is normally tympanitic.
Dullness; splenic enlargement.

Palpate spleen Alternatively:

1-palpate like liver edge with just R hand;
starting from RLQ diagonally over to LUQ.
2-combine the two methods:
start to palpate from RLQ like liver with just R hand,
reach with L hand around to pt's L ribcage and pull,
while continuing advancing with R hand.

differentiate kidney:
Shape, notch vs. no notch.
Percussion dullness vs. not.
Enlarge toward RLQ vs. LLQ.

Splenomegaly DDx
Sarcoidosis, amyloidosis
Sjogren's
Infectious:
CMV
IE, SBE
Lyme dz
Rheumatic fever
Malaria
Lymphoid:
Leukemias
Lymphoma
DIC

Hepatosplenomegaly DDx
Portal HTN
Infectious:
Hepatitis
Infectious mononucleosis

Anemias:
Sickle cell
Pernicious
Thalassemia

Marrow:
Polycythemia vera
Endocrine:
Acromegaly
Thyroid dz

SLE

Palpate kidneys
Dr's L hand under pt's R loin,
L fingers under R back.
R hand held over RUQ.
Dr flexes L MCPs in renal angle.
Dr R hand feels strike as;
kidneys float anteriorly.
Repeat for other side

Palpate pancreas
Round
Fixed
swelling above umbilicus
That doesn't move with inspiration;
1.Pseudocyst,
2.Acute pancreatitis,
3.Ca in thin pt.

Palpate aorta

Midline
superior to umbilicus
Dr's 2 fingers on outer margins of aorta;
fingers diverge (AAA).
Normally felt in thin pt.

Palpate bowel
Sigmoid usu. Palpable in;
Severe Constipation;

Indents (feces)

Doesn't indent (masses).

Sometimes can feel;
Carcinoma
Megarectum.

Palpate bladder
Ask pt when last urinated?
Was complete emptying..?
Usually palpable if full
Usually not palpable if empty.
Palpable, empty bladder;
(swelling)

Percussion

Percuss in all four quadrants

Tympany;
over most of the abd
Dullness;
Unusual
Abdominal Mass.

Percussion tenderness;
peritonitis

Abdomen: percussion
Liver border for loss of of dullness;
(necrosis, perforated bowel).
Spleen for splenomegaly.
Kidneys.
Bladder for enlarged bladder
Pelvic mass.
Percuss masses.

Ascites Shifting dullness:

The percussing finger; vertically
Starting at midline
percuss laterally to
dullness on L flank
mark site of dullness.
Roll pt towards Dr.;
so pt now laying on R side.
Pt stays on R side for 30s,
repercuss while still R side.
Ascites; dullness has moved medially
(ie the point of dullness is now resonant).
percuss laterally on both R and L flanks

Fluid thrill:
Dr. puts hands on each of pt's flanks.
If obese, pt places lateral edge of hand,
vertically on midline at umbicus.
Dr. flicks hand on right flank
Ascites;
If feels
resulting thrill
on left flank.

Rebound Tenderness

This is a test for peritoneal irritation.

Warn the patient what you are about to do.
Press deeply on the abdomen with your hand.
After a moment, quickly release pressure.
Positive; If it hurts more when you release

Auscultation

Place the stethoscope lightly.

Listen for bowel sounds;
Normal
Increased,
Decreased
Absent?; (ileus, paralysis).
No sound for 3 minutes;

Auscultate stomach
Perform on empty stomach.
Stethoscope on epigastrium.
While shaking; both iliac crests;
listen to splash from retained fluid.
Audible splash; "succussion splash
(gastric outlet obstruction;
ulcer or gastric CA).

Auscultation
Below umbilicus; bowel sounds:
Rushing sound;
"borborygmi" (diarrhea).
No sound for 3 minutes;
(ileus, paralysis).
"Tinkling" sound;
(obstructed bowel).
Above umbilicus:
AAA bruit.

Auscultation
Venus hum;
[flowing in caput medusae]
(portal HTN).
R and L above umbilicus;
Listen for bruits;
renal arteries
iliac arteries
aorta.

Auscultation
Over liver:
Friction rub [grating during breathing]
(peritonitis).
Bruit (CA, alcoholic hepatitis).
Over spleen;
splenic rub (splenic infarct).

Signs of Acute Appendicitis

a-Rebound

(tenderness)

b- Rigidity
c- Rovsings sign
d- Anteriortenderness

onrectal examination
e- Fever 37.3 38.50c
f- Psoas sign
g- obturator sign
Saleh M. Al
Salamah