Abdominal

Examination
Wang Ailiang
Vice professor
 resume

 Vice professor
 Director of gastrointestinal
department
 12 years work of surgery
 Two years work in Musoma Hospital
of Tanzania
Introduction
Question1 :

What do you think is the better

or more appropriate sequence
of abdominal examination
compared with that in other
areas? And why?
Normal sequence:
inspection, palpation,
percussion, and
auscultation
 Abdominal examination: inspection,
auscultation, percussion, and palpation
 It’s convenient to perform the
auscultation of abdomen after the
auscultation of the heart.
 To avoid the negative impacts of a series
of palpations on auscultation of bowel
sounds due to the alteration of
Question 2:
Can we say that abdominal
examination will be outmoded
and superseded because of
remarkable advances in
supplementary examination
methods such as X-ray,
ultrasound, endoscopy, isotope,
angiography, CT, MRI, etc. ?
Definitely Not.
 Because the abdominal examination
is a fundamental method of
detecting abnormal signs of
abdomen.
 Palpation is the most difficult step of
abdominal examination, requiring
more practice.
 xiphoid
process
腹中线
midabdominal
line

costal margin Lateral border of rectus

umbilic muscle
us

Anterior 腹股沟韧带
superior iliac
inguinal
spine 耻骨上缘 ligament
superior margin of
os pubis
right upper quadrant left upper quadrant

right lower quadrant left lower quadrant

percussion
 Percussion
General percussion
 All four quadrants of the abdomen are
evaluated by percussion. Light percussion
is preferable, since it produces a clearer
tone.
 Tympany( 鼓音 ) is the most common
percussion sound in the abdomen due to
gas collection. It is appreciated over the
stomach, small intestine, and colon.
Percussion of the liver..\..\教学相关图片\
肝脏叩诊.rm
 Percussion of the upper border of
liver( 肝上界 ) is executed along the
right midclavicular line( 右锁骨中线 ), right
midaxillary line( 右腋中线 ), and right
scapular line( 右肩胛线 ).
 The level of the shift from resonance
downward into dullness is defined as the
upper border of liver. At this level, the
liver is covered by lung and hence the
border is also called the relative
dullness border of liver( 肝相对浊音界 ).
 Percussion of the liver

 Then percussing downward 1-2 intercostal space, the level of the

shift from dullness into flatness( 实音 ) is identified as the absolute
dullness border of liver( 肝绝对浊音界 ), without lung covering,
and also called the lower border of lung( 肺下界 ).
 Normally the the upper border of liver locates at the 5th
intercostal space along the right midclavicular line, the 7th
intercostal space along the right midaxillary line, and the
10th intercostal space along the right scapular line.
 Percussion of the liver

 Percussion of the lower border of

liver( 肝下界 ) is executed along the
right midclavicular line or anterior
midline.
 The level of the shift from tympany
upward into dullness is defined as the
lower border of liver.
 Percussion of liver span ( 肝上下
径)
 Percussion of liver span should be done with the
patient breathing normally.
 Percussion should occur through the right
midclavicular line from resonance over the lung
field downward to dullness and from tympany
over abdomen upward to dullness.
 Measure from upper to lower border of dullness
for liver span. It is normally about 9-11 cm in the
midclavicular line.
 Dullness extending into the normally tympanitic
right upper quadrant indicates hepatic
enlargement, a mass adjacent to the liver, or
downward displacement of the liver.

 There may be an absence of liver dullness following

perforation of a hollow viscus, which allows free air to
enter the abdominal cavity. This indication of an intra-
abdominal catastrophe must be correlated with the
clinical situation, since on occasion interposition of the
hepatic flexure of the colon between the diaphragm and
the liver ( 间位结肠 [ 结肠位于肝与横膈之间 ]) will produce the
same finding with no clinical consequences.
 Percussion of the spleen..\..\
教学相关图片\脾脏叩诊.rm

To percuss for splenic dullness

√This should be done when splenic
enlargement is suspected.
√ Normally splenic dullness can be
percussed between 9 intercostal space to
11 intercostal space along left midaxillary
line, the scope that is 4-7cm, without
passing over left anterior axillary line.
spleen
 presence or absence of free fluid
in the abdominal cavity (ascites)
 Thismay be detected by
several maneuvers(1) shifting
dullness, (2) fluid wave, and
(3) elbow-knee position.
 Percussion for shifting
dullness( 移动性浊音 )..\..\教学相关图片\
移动性浊音.rm
 The examiner should first tell the
patient to lie on his back (in the supine
position).
 tympany at midabdomen could be
found because of the underlying bowel.
 At the same time, dullness at the
bilateral flanks could be found during
percussion due to the accumulation of
ascites. The reason is that when the
patient with ascites lies on his back,
the fluid will migrate into the flanks,
producing dullness laterally.
 Percussion for shifting
dullness( 移动性浊音 )
 When dullness is found in the flanks, The line of
demarcation between the dullness and tympany is
marked.
 The examiner percusses the patient’s abdomen at the
umbilicus level from the midabdomen toward the patient’s
left side. If the examiner finds the point where percussion
sound of tympany changes into dullness, the examiner
should hold his pleximeter on that point, simultaneously,
ask the patient to turn on his right side and then continue
to percuss the same point again.
 If the sound changes from dullness to tympany, it means
that the dullness has been shifted to a more dependent
position. This implies that ascites is present.
 Percussion for shifting
dullness( 移动性浊音 )
 Similarly, the examiner percusses the
patient’s abdomen toward the patient’s
right side. If the examiner finds the point
where percussion sound of tympany
changes into dullness, the examiner should
hold his pleximeter on that point,
simultaneously, ask the patient to turn on
his left side and then continue to percuss
the same point again to confirm the shift of
dullness.
 A volume of free fluid in the peritoneal
cavity greater than 1000ml can be detected
with this method.
 If the amount is too little, shifting
dullness could not be found, the
examiner could ask the patient to
take elbow-knee position, letting the
umbilicus at the lowest level, and
then percusses the patient from
flanks toward the umbilicus. If
percussion sound could change from
tympany to dullness, it indicates
ascites.
Palpation
 This procedure is usually
the most important and
often the most difficult to
perform accurately.
1. the principle of
palpation

a) To relax the patient

√ During palpation the patient should
continue to lie supine with arms
relaxed on the chest or at the sides.
√ The examiner should make certain
that his hands are warm.
√ He should assure the patient that he
will make an effort not to cause
discomfort and follow up this
assurance by avoiding at the outset an
area already described as painful.
√ If the patient exhibits ticklishness,
the examiner should disregard it and
try to continue.
√ If this proves unsuccessful, it is
useful to have the patient place his
own hand on his abdomen, since this
exert pressure on the abdomen
through the patient’s own hand,
and gradually increase the
pressure, while assuring the
patient that the examination will
cause no discomfort.
√ When the patient has relaxed,
the examiner again places his
own hand on the abdomen and
allows the patient to maintain
contact with his hand. This
usually completes the relaxation
of the ticklish patient, and the
examination proceeds as usual.
gentle exploration of the
abdominal wall and with no effort
made to palpate deeply.
√ The patient may be further
relaxed by instructing him to
breathe slowly and deeply.
√ As with inspection, the initial
step in palpation may be
facilitated by distracting
conversation or questions
regarding the history.
√ If the patient remains tense or
if the abdominal wall is very
muscular, better results may be
√ It should be emphasized
again that during the
preliminary stages muscle
relaxation is the goal. At this
time no attempt should be
made either to elicit
discomfort or to palpate for
a mass or enlarged viscus.
b) To palpate four quadrants
superficially from LLQ
counterclockwise
√ To palpate all areas of the
abdomen counterclockwise
and superficially from left
lower quadrant screening for
tenseness( 紧张度 ),
tenderness( 压痛 ), masses,
etc.
√ Examination begins with
gentle maneuvers and then
palpation occurs more
deeply.
√ Examiner uses the palms of
his hands with fingers
together and arm relaxed
and forearm on a horizontal
plane.
√ The examiner presses with
his fingers.
c) To palpate four quadrants
deeply
√Using the palmer surface
of the fingers, examiner
palpates in four quadrants to
identify masses, tenderness,
pulsations, etc. √ The
abdominal wall should be
depressed more than 2 cm.
√ When deep palpation is
difficult, examiner may want
to use left hand placed over
right hand to help exert
pressure.
ight palpation of the abdome
Deep palpation of the
abdomen
Bimanual palpation of the
abdomen
palpation of the abdomen
Middleton method
 触诊基本方法
浅部触诊 (light  palpation)
深部触诊 (deep  palpation)
深部滑行触诊 (deep slipping palpation) ：
腹腔包块、器官
双手触诊 (bimanual palpation) ：
肝、脾、肾、腹腔肿物。
深压触诊 (deep press palpation):
确定腹腔压痛点与反跳痛
冲击触诊 (ballottement):
适用于腹部大量积液时肝脾及腹腔包块难以触
及者。
√ If a mass is suspected,
determine its size, contour,
mobility, tenderness,
smoothness, irregularity, the
hardness or softness and
listen with stethoscope for a
bruit over the mass.
√ If there is tenderness,
determine the point of
maximum tenderness and
distribution.
√ To check for rebound
tenderness, palpate deeply at
the point of tenderness,
pause briefly, then remove
the fingers quickly. Watch the
patient’s face to see whether
it hurts. Then check other
areas in the same manner for
comparison.
a) abdominal tenseness 腹壁
紧张度

In normal persons,
abdominal wall is somewhat
tense, but usually soft when
palpated and easily
depressed , and is called
abdominal softness( 腹壁柔软 ).
 While some pathological
conditions can lead to an
abnormal increase or
decrease of abdominal
tenseness.
1) The increase of
abdominal
tenseness
√ Abdominal tenseness
increases, not accompanyed
by muscle spasm, is due to
the increase of abdominal
contents, as gastrointestinal
flatulence( 肠胃胀气 ),
artificial
pneumoperitoneum( 人工气
腹 ), ascites, etc.
        Board-like rigidity 板状腹

√ If abdominal wall is
palpated as obviously tense,
even as rigid as a board,
board-like rigidity is so
called.
√ This sign is caused by the
spasm of abdominal muscle
due to peritoneal irritation,
as the perforation of the
gastrointestinal diseases or
 揉面感；柔韧感

√ If abdominal wall is
palpated as pliable and
tough, and if it has
resistance and is not easily
depressed, then the
examiner feels the sensation
of dough kneading.
√ This sign is usually seen in
tuberculose peritonitis or
cancerous
  The decrease of abdominal
tenseness
√ caused by the decrease or
disappearance of abdominal
muscle’s tension( 张力 ), the
sign usually found in
chronic deeline( 消耗性疾病 ) or
drainage of large amount of
ascites
tenderness
压痛和反跳痛
√ After relaxation is obtained,
the examining hand is first
moved gently over the entire
abdomen, and an estimate of
the muscle tone in the various
quadrants is made. √ Following
general palpation an attempt
should be made to detect and
localize any painful area (i. e.
tenderness) within the
abdomen.
1. Visceral( 内脏的 )
√ arises from an organic
lesion or functional
disturbance within an
abdominal viscus
√ For example, it is the type
seen in an obstructive lesion
of the intestine in which
there is a buildup of pressure
and distention of the gut.
√ sveral characteristics: dull,
poorly localized, and difficult for
the patient to characterize
√ similar to the distress noted in
painful lesions of the skin
√ sharp, bright, and well localized.
√ not caused primarily by
involvement of the viscera
√ indicates involvement of one of
the somatic structures, such as the
parietal peritoneum or the
abdominal wall itself
√ an inflammatory process
originating in a viscus will
produce visceral pain that may
extend to involve the
√ Inflammation of the peritoneum
would then result in somatic
pain.
√ best illustuated by
appendicitis( 阑尾炎 ) in which the
pain is at first poorly localized,
dull, ill defined, and primarily
midiline (when it is entriely
visceral in origin). Later, as the
inflammation spreads to the
peritoneum, the pain becomes
sharp, bright, and well localized
in the right lower quadrant over
the involved region.
the examiner should determine
whether the pain is constant
under the pressure of the
examing hand or if it is
transient, tending to disappear
even though pressure is
continued over the area.
√ Pain caused by inflammation
usually remains unchanged or
increases as pressure is applied.
Visceral pain as the result of
distention or contraction of a
viscus tends to become less
severe while pressure is
may have difficulty in
distinguishing visceral pain from
that arising in somatic
structures, such as the spine
and abdominal wall.
An example of abdominal wall
discomfort is seen in patients
with fibrositis( 纤维组织炎 ).
These types of pain may be
differentiated by having the
patient tense his abdominal
muscles, which may be
accomplished by forcefully
elevating his head while keeping
√ Under these conditions
increased tension of the
abdominal wall will accentuate
the pain if it originates in
somatic structures.
√ On the other hand, discomfort
from intra-abdominal sources
will be less severe with the
abdomen tense than when
relaxed.
the examiner should test for the
phenomenon of rebound
tenderness.
√ This is found only when the
peritoneum( 壁层腹膜 ) overlying a
diseased viscus becomes
inflamed.
√ Although it may be produced in
different ways, the most common
is to press firmly over a region
distant from the tender area and
then suddenly release the
pressure. The patient will feel a
sharp stab of pain in the area of
right lower quadrant and
then suddenly released will
cause a marked increase in
pain over an area of
diverticulitis( 憩室炎 ) in the
left quadrant
√ Rebound tenderness may
also be elicited by having
pressure over the tender
area and having the patient
cough or strain. √ Marked
tenderness to percussion in
the area is usually seen in
√ At times, if the area
involved is small, rebound
tenderness may be elicited
only over the most tender
area of the abdomen.
The end肠 梗 阻
（ intestinal
obstruction
十胃 ）
一肠
楼外
科