3. General rules before the abdominal examination
1. For the examiner
Examination is done in warm room with good light
The examiner must warm his hands, has short finger nails and use
warm stethoscope
2. For the patient
Patient should be lying flat (Supine)
Abdomen should be fully exposed; from above the xiphoid
process to the symphysis pubis (the groin should be visible)
Sheet over the genitalia
Arms at sides or over the chest (behind head tightens abdomen)
flexing knees may relax abdomen
The head and the neck are supported by enough pillows
7. Inspection of the Anterior Abdominal Wall
Inspection of mid-line
from above downward
Inspection of the sides
1- Subcostal angle
2- Epigastric pulsation
3- Divarication of recti
4- Umbilicus
5- Suprapubic hair distribution
6- Hernial orifices
1- Contour of the abdomen
2- Collateral (dilated veins)
3- Skin
4- Scars
5- Movement with respiration
6- Visible peristalsis
N.B. we start the inspection of the abdomen by comment on contour of
the abdomen
8. Mid-line Inspection
1- Subcostal angle
- Normal: acute to right angle (70 – 90 °)
- Abnormal: obtuse angle; occurs in:
abdominal causes: chronic ↑↑ in intra-abdominal
pressure (as in ascites, upper abdominal swelling)
Chest causes: emphysema
10. 3- Divarication of recti
Bulge of linea alba between the recti muscles with their
wide separation
Causes:
↑↑ intra-abdominal pressure (ascites, multiple
pregnancies)
11. 4- Umbilicus
I. Site
normally midway between xiphisternum and
symphysis pubis
Pushed downwards due to - masses in upper
abdomen - ascites
Pushed upwards due to masses lower abdomen
arising from the pelvis
II. Shape
Normally inverted
Abnormally everted due to increase in intra-
abdominal pressure (ascites / pregnancy)
12.
13. III. Hernia
Expansile impulse in cough
IV. Dilated veins
Caput medusa in portal hypertension
V. Skin
Pigmentation around umbilicus (T.B. peritonitis, Addison dis.)
Nodules “sister Mary-Joseph nodules” (abd. malignancy)
Ecchymosis “Cullen's sign” (hemorrhagic pancreatitis and
internal hemorrhage)
VI. Discharge:
Pus inflammation
Stool intestinal fistula
Urine patent urachus
14.
15.
16.
17.
18. 5- Suprapubic hair distribution
Normally:
In male the hair reach the umbilicus “triangular, with
the apex towards the umbilicus”
In female the hair ends in horizontal line
Abnormally feminine hair distribution in male in L.C.F.
19. 6- Hernial orifices
Weak points in the abdomen in which the abdominal contents may pass
through it with increase intra-abdominal pressure
- Detected by: the patient is examined in standing position and asked to
cough
- Sites:
Linea alba (epigastric)
Umbilical
Incisional (old scars)
Inguinal
Femoral
Scrotal
N.B. Hernia= expansile impulse on cough
20. Inspection of Sides
1- Contour of the abdomen
- Normally the abdomen is gently convex from side to side
and from front to back
- Abnormally
Retraction (scaphoid abdomen) : due to starvation,
wasting diseases or dehydration
Bulging (distension or swelling): either generalized or
localized
N.B. The flanks should be checked for any bulging.
22. • examination of abdominal contours
– Standing at the foot of the table
– Lower yourself until the anterior
abdominal wall
– ask the patient to breathe
normally while you are inspect
the abdomen.
23. Generalized abdominal
distension
Localized abdominal
distension
1- Fluid (ascites)
2- Fat (obesity)
3- Flatus and Faeces
4- Foetus (pregnancy)
5- Full urinary bladder
1- Site
2- Shape and size
3- Pulsate on cough (hernia
or not)
4- Movement with
respiration
5- Extra-abdominal or Intra-
abdominal (by asking the pt.
to sit up in bed unsupported)
Contour of the abdomen
26. 2- Collaterals (Dilated – Tortuous – Engorged
Veins): in cases of
IVC obstruction Portal vein obstruction
1- Site of
collaterals
Laterally (Sides) Around umbilicus (caput
medusa)
2- Blood
flow
From below upwards
“towards the head”
(to bypass the
obstruction the blood
bypass the IVC via
abdominal wall veins to
the thorax)
Away from the
umbilicus”towards the legs”
(the blood pass from the left
branch of portal vein to para
umbilical vein to anterior
abdominal wall veins through
the umbilicus)
3- cause in
hepatic Pt
Functional compression
on IVC by tense ascites
Intra-hepatic causes of portal
hypertension
N.B. Dilated veins can be made more visible by asking the patient to
cough or strain, while the patient is sitting or semi-setting.
27. Methods of Detection
- The 2 index fingers of both hands are used to milk the blood
away from one segment of a dilated vein then, applying
firm pressure on both ends of the segment the fingers
then can be lifted one by one, while observing the rate of
filling at which the vein fills from each direction the blood
will be seen coming more rapidly from the direction of blood
flow.
N.B. visible veins without engorgement and tortuosity may be
normal finding in thin persons, particularly when the abdominal
wall is distended, often in epigastrium
29. Caput medusae accentuated by marked ascites.
An extensive plexus of veins is seen radiating from the umbilical region
and radiating across the anterior abdominal wall. Note the large vein
coursing inferiorly along the right flank (arrows). This is the superficial
epigastric vein.
30. 3- Skin of the abdominal wall
Stretched – Smooth – Shiny in marked distended
abdomen
Striae (due to rapid stretch of the abdominal wall with
rupture of elastic fibers)
Striae alba “white”: in obesity, ascites, pregnancy
(striae gravidarum)
Striae rubra “red”: in cushing disease and prolonged
steroid therapy they are often larger and wider,
and may involve the face
31.
32. Scratch marks in obstructive jaundice
Sinus and fistula
Pigmentation – Purpura – Petichae in LCF
33. It is often difficult to understand whether tiny red spots arising on skin
surface are Petechiae or Purpura. However, Petechiae spots have a very
small diameter that is maximum 3 mm in size. Purpura rashes are larger
in size. These have a diameter that is about 5 mm. A spot that is bigger
than Purpura is known as common bruise or echymosis
Echymosis
Abdominal
petichae
34. 4- Scars
Type (operation or cautery)
Site (suggest the name of operation) e.g.
Rt. Hypochondrium: scar of cholecystectomy
Rt. Iliac fossa: scar of appendicectomy
Lt. Paramedian: Scar of splenectomy
Pigmentation
Impulse on cough (incisional hernia)
Healing cleanly by 1st intention(thin, regular) or healed
infected by 2nd intention (wide, irregular, with keloid or
not which is hypertrophic area outside the field of
normal scarring)
35.
36. 5- Movement with respiration
decrease or absent movement, occurs due to:
Rigidity (peritonitis)
Tense ascites
Diaphragmatic paralysis
37. 6- Visible peristalsis
Due to
Pyloric obstruction in the upper abdomen (from Lt. to
Rt.)
Small intestinal obstruction around the umbilicus
Large intestinal obstruction in the upper abdomen
(from RT. to Lt.)
Stimulated by
Gentle tapping
Cold stimulation of the skin (2 drops of ether)
39. General rules for palpation
For the examiner
Examination is done in warm room with good light
The examiner must warm his hands, has short
finger nails and approach slowly
use warm stethoscope
Distract the patient with conversation or
questions
40. General rules for palpation
For the patient
• Patient should have an empty bladder
• Patient supine, arms at sides or folded across chest - avoid
arms above the head as this tightens the abdomen
• The abdomen is fully exposed
• Before you begin, ask the patient to point to areas of pain and
examine last
• Observe the patient face “expression” during examination
• Flexing the knees may relax the abdomen
• The head and neck are supported by enough pillows
41.
42. Normally palpable structures
1. Contracted muscles of abdominal wall in muscular persons
2. Colon (caecum and sigmoid) is felt when it is spastic (full of gas or
fluid)
3. Vertebra (L4 – L5)
4. Pulsations of abdominal aorta (usually felt below the umbilicus) in
thin persons
5. Lower pole of Rt. Kidney (especially in female with thin lax
abdominal wall)
6. Liver edge descends 1-3 cm below the costal margin on deep
inspiration, but the consistency is soft and difficult to feel.
44. For:
- Confidence of the patient
- Superficial masses
- Tenderness
- Rigidity
- Temperature
“from the Lt. iliac fossa in anticlockwise direction
till the suprapubic area”
Superficial Palpation
45. • Technique
– Use pads of three fingers (palmar surface of fingers) of
one hand and a light, gentle, dipping maneuver to
examine abdomen
– Abdominal wall depressed approximately 1 cm
47. Deep Palpation
For :
- Organs “liver, spleen, gall bladder, kidney, colon, urinary
bladder”
- Masses
- Areas of deep tenderness and rebound (pain induced or
increased by letting go)
Deep palpation include the following methods
- Ordinary technique “classic”
- 2 handed method
- Bimanual
- Dipping
- Hooking
- Rolling
48. • Technique
– Entire palm (use palmar surface of fingers of one hand; greatest
number of fingers) and a deep, firm, gentle maneuver to examine
abdomen
– Either one- or two handed technique is acceptable (When deep
palpation is difficult, examiner may want to use left hand placed
over right hand to help exert pressure)
– Palpate tender areas last
– Palpate deeply with finger pads (do not “dig in” with finger tips)
– Abdominal wall depressed around 4 cm or Push as deeply as
patient will allow without significant discomfort.
51. The spleen has the size of cupped hand
It lies between the stomach and fundus of diaphragm
Surface anatomy
- it lies in the epigastrium and the adjoining part of the Lt.
hypochondrium
- parallel to ribs 9, 10, 11
- its long axis parallel to the posterior part of the shaft of 10th rib
- the spleen has
2 surfaces; diaphragmatic surface (convex, smooth);
visceral surface (concave, irregular, contain the hilum and
carries impression of 4 organs)
2 borders; upper border (sharp, notched); lower border
(smooth, rounded)
2 ends; medial end (broad, 4cm from the median plane);
lateral end (narrow and tappering)
52. Surface anatomy of the Spleen
11th rb
Medial end
Lateral
end
10th rb
9th rb
10th rb
54. The spleen is not normally palpable
It has to be enlarged 3 times its usual size to be palpable
under the subcostal margin
The direction of enlargement is downward and towards the
Rt. Iliac fossa
The spleen which is not felt doesn’t exclude splenomegaly
but it can be said that the spleen is not felt
55. Methods of Deep Palpation
Classical method (single-handed method)
Two handed method
Bimanual examination
- in the supine position - in the Rt lateral position)
Dipping method
Hooking method
61. With the patient in the right lateral position, minimal splenic
enlargement can be detected
Palpating the spleen – Bimanual palpation in
Rt. Lateral position
64. Examining for the spleen from behind the patient, in the right
lateral position. In this case, the fingers are "hooked" over the
costal margin.
Hooking method
65. Nature of this palpable spleen (put a comment on):
1. Size
Mild (just palpable to 5cm)
Moderate (5 – 10 cm)
Huge (more than 10 cm, below the umbilicus)
2. Border
3. Surface
4. Consistency
5. Tenderness (e.g. due to splenic infarction, septicemia,
SBE)
66. Applied anatomy and physiology of the spleen
The spleen is composed predominantly of lymphoid and R.E. tissues,
so, any condition “infectious; immunologic; metabolic; malignant or
idiopathic” that causes hyperplasia of the lymphoid/RES may cause
splenomegaly
The spleen is expansile organ containing many sinusoids, so,
interference with its venous drainage as in portal hypertension will
cause splenomegaly “congestive splenomegaly”
The spleen destroys senile and defective RBCs, so, in hemolytic
anemias, this function is increased with splenomegaly “except in
sickle cell anemia”
67. Hypersplenism
- Whenever the spleen is enlarged, hypersplenism may occur
- It is characterized by
Pancytopenia in the peripheral blood (Normocytic
normochromic anemia, neutropenia, thrombocytopenia in the
CBC) due to hyperfunction of the spleen
One element or two may be decreased only
B.M examination: hypercellular or normal
Splenectomy returns the CBC to normal
68. Characters of splenic swelling to be differentiated
from the Lt. kidney
- By inspection Moves with respiration down and medially
- By palpation it has a notch on the lower part of the anterior
(upper) border “PATHOGNOMONIC”
hand can't be insinuated between the mass and the
costal margin to get above its upper pole
negative ballottement (can’t be pushed in the renal
angle)
- By percussion dull on percussion and continuous with the splenic
dullness
71. Upper border is marked by joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point Xiphisternal joint.
3rd point Upper border of 5th rib in Rt. MCL
4th point 7th rib at RT MAL.
5th point 9th rib at RT scapular line.
Lower border is marked by curved line joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point 8th costal cartilage in the Lt. parasternal line.
3rd point midway between xiphisternal junction and the umbilicus
4th point 9th costal cartilage in the Rt. MCL.
5th point 10th rib in the Rt. MAL.
6th point 12th rib in Rt. Scapular line
74. Technique of detecting the liver
Upper border is detected by heavy percussion “hepatic
dullness”
Lower border is detected by deep palpation and light
percussion
After palpation of the lower border of the liver, you must
comment on
I. Liver span : Distance between the upper and lower
borders of the liver; which is
4 – 8 cm in the middle line “represents the Lt.
lobe”
9 – 14 cm in the Rt. MCL “represents the RT.
lobe”
75. II. Nature of this palpable liver (put a comment on):
1. Size “in finger breadth or cm”
Normally: not felt below the costal margin
Abnormally: enlarged “causes of hepatomegaly” or shrunken
“liver cirrhosis and fibrosis”
2. Surface
Normally: smooth
Abnormally:
- smooth “congestion, inflammation, infiltration”
- fine irregular “cirrhosis”
- nodular “malignancy”
2. Edge
Normally: sharp
Abnormally:
- sharp “cirrhosis, fibrosis”
- rounded “congestion, inflammation, infiltration”
77. Methods of Palpation
Classical method (single-handed palpation)
Two-handed method
Bimanual examination
Dipping method
Hooking method
- Single-handed palpation is used for lean individuals, while the
bimanual technique is best for obese or muscular individuals. Using
either technique, the liver is felt best at deep inspiration.
78. Single-handed
method
- For single-handed palpation, the examiner's right hand is initially placed on the
patient's abdomen in the right lower quadrant and parallel to the rectus muscle in
the MCL. This is done so that palpation of the rectus is not confused with palpation
of the underlying and adjacent liver
- Gently pressing in and up, ask the patient to take a deep breath.
Palpating hand is held steady while patient inhales
Palpating hand is lifted and moved while the patient breathes out
If the liver is enlarged, it will come downward to meet your fingertips and will
be recognizable.
79. Another method of palpating the liver uses the radial border of the
index finger. In this method the anterior hand is placed flat on the
anterior abdominal wall with fingers parallel to the costal margin
80. the left hand is held posteriorly,
between the 12th rib and the iliac crest.
It is lifted gently upward to elevate the
bulk of the liver into a more easily
accessible position, while the right
hand is held anterior and lateral to the
rectus musculature. The right hand
moves upward using gentle, steady
pressure until the liver edge is felt.
Bimanual palpation
of Liver
82. – Is useful when the
patient is obese or
when the examiner is
small compared to the
patient.
– Stand by the patient's
chest.
– "Hook" your fingers
just below the costal
margin and press
firmly.
Hooking method
86. Technique
- It is done with the middle finger of Rt. hand (plexor) tapping on DIP
of the middle finger of the Lt. hand (pleximeter) using a wrist action.
- The non striking finger (pleximeter) is placed firmly on the abdomen,
remainder of hand not touching the abdomen.
- Remember that it is easier to hear the change from resonance to
dullness – so proceed with percussion from areas of resonance to
areas of dullness.
pleximeter
plexor
87. Percussion of the abdomen
- The abdomen gives a resonant note which varies according to the
amount of gas present in the intestine
- Type of percussion: Light percussion
- Values:
Deleneation of borders of abdominal organs (& assessing for
organomegaly).
Detection of ascites
Detection of gaseous distension “tympanic resonant note”
Detection of acute abdomen (obliteration of normal liver
dullness) in;
- Perforated peptic ulcer and colon
- Subphrenic abscess with gas forming organisms
88. Percussion “liver”
Upper border by deep percussion
Lower border by light percussion
Upper border
Define the sternal angle “angle of Louis” (2nd rib), then start
percussing the 2nd intercostal space in the Rt. MCL (Start just
below the Rt. breast in RT. MCL). Percussion in this area should
produce a relatively resonant note
Percussing in the chest moving down towards the abdomen about
½ to 1 cm at a time (in the intercostal spaces).
Note where the percussion notes change from resonant to dull.
The normal hepatic dullness will be reached at the 5th intercostal
space in the RT. MCL
Lower border
Begin percussion below the umbilicus, in the Rt. MCL and proceed
upward until dullness is encounter.
90. Traube's area
It is a semilunar (crescent)-shaped area
It is area of tympanic resonance overlying the fundus of stomach
Boundaries
Upper border lower border of Lt. lung (convex line from the Lt.
6th rib in MCL to the Lt 9th rib in mid-axillary line)
Right border Lateral margin of left lobe of liver (from Lt. 6th rib
in MCL to the Lt. 8th costal cartilage)
Left border anterior border of the spleen (Lt. 9-11 spaces in
mid-axillary line)
Lower border Lt. costal margin (from the Lt. 8th costal cartilage
to Lt. 11th space in mid-axilary line )
91.
92. Causes of dullness of Traube’s area:
1. Full stomach/ gastric tumours.
2. Left sided Pleural effusion / pericardial effusion “from above”.
3. Ascites/abdominal tumour “from below”
4. Splenomegaly “from left side”.
5. Enlargement of left lobe of liver “from the right side”.
93. Castell’s method “Splenic percussion sign”
Put the patient in the supine position
Left anterior axillary line identified
Left lower costal margin identified
Percuss in the lowest Left intercostal space in the anterior axillary line
(usually the 8th or 9th IC space) while patient inhales and exhales
deeply
This space should remain resonant during full inspiration
Dullness on full inspiration indicates possible splenic enlargement (a
positive Castell’s sign)
96. Nixon’s method
Place the patient in Right lateral decubitus
Begin percussion midway along the Left costal margin
Proceed in a line perpendicular to the Left costal margin
Upper limit of dullness : 8 cm
97. Detection of Ascites
Ascites is free collection of fluid within the peritoneal cavity.
The classical signs of ascites include; abdominal distension, shifting
dullness, fluid thrill.
Minimal ascites detected in the knee elbow position
Moderate ascites detected by the bilateral shifting dullness
Tense ascites detected by transmitted fluid thrill “fluid wave”
98. Bilateral shifting dullness
1.The patient is examined in the supine position.
2.Percussion is done over the abdomen, from the umbilicus to one flank.
3.The spot of the transition from tympany to dullness is detected.
4.The patient is then turned to the opposite side, while the examiner keeps his
hand unmoved.
5. Percussion of the same spot (which is top now) gives a tympanic note.
Note: The tympany over the umbilicus occurs in ascites because bowel floats
to the top of the abdominal fluid.
air
air
fluid
fluid
99. Transmitted fluid thrill
Pathognomonic for ascites when the amount of fluid is large
1.The patient is examined in the supine position.
2.The patient or an assistant places one hand in the midline and presses
firmly with the ulnar border of the hand , so cut off any vibrations
transmitted by the abdominal wall.
3. The examiner places one palm on one flank, while giving a sharp tap
with the finger tips on the opposite flank.
4. Positive test: a definite wave “impulse” will be distinctly felt by the
receiving hand.
101. Auscultaion
• Diaphragm of stethoscope used
• Skin depressed to approximately 1 cm
• Listening in one spot is usually sufficient
• Listening for 15-20 or 30-60 seconds
102. Values of auscultation
1. To hear intestinal sounds characteristic gurgling bubbling (gas
and fluid in intestine) sounds.
Increase in: acute diarrhea (↑motility) and in early intestinal
obstruction
Absent in: paralytic ileus
N.B. Bowel sounds cannot be said to be absent unless they are
not heard after listening for 3-5 minutes.
103. 2. To hear vascular sounds
Arterial bruit Venous hum
(Wind at sea shore)
Systolic murmur Systolic and diastolic sound in the
epigastrium, and Lt. hypochondrial
region “Kenawy sign”
Occurs in cases of
- Abdominal aortic
aneurysm
- Renal artery stenosis
- Over very vascular tumour
“e.g. hemangioma”
Occurs in cases of
- portal hypertension due to porto-
systemic anastomosis (collateral)
104. 3. Friction rub
a dry, grating sound heard with a stethoscope during auscultation; may
be heared over enlarged liver or spleen
Splenic rub: in Lt. hypochondrium; due to splenic infarction and
perisplenitis
Hepatic rub: in Rt. Hypochondrium; due to hepatic malignancy
with perihepatitis (inflammatory changes or infection in or
adjacent to the liver).
N.B. A hepatic rub and bruit in the same patient usually indicates
cancer in the liver. A hepatic rub, bruit, and abdominal venous hum
would suggest that a patient with cirrhosis had developed a
hepatoma.
105. 4. To detect minimal ascites (Puddle’s sign)
It is useful for detecting small amounts of ascites (as small as 120 mL;
shifting dullness and bulging flanks typically require 500 mL).
The steps are outlined as follows:
Patient lies prone for 5 minutes
Patient then rises onto elbows and knees
Apply stethoscope diaphragm to most dependent part of the abdomen
Examiner repeatedly flicks near flank with finger.
Continue to flick at same spot on abdomen
Move stethoscope across abdomen away from examiner
Sound loudness increases at farther edge of puddle
106. 5. Succusion splash in case of pyloric obstruction (distended stomach
with gas and fluid)
placing the stethoscope over the upper abdomen rocking the
patient back and forth at the hips Retained gastric material >3
hours after a meal will generate a splash sound.
6. To detect pregnancy fetal heart sounds.
Notas do Editor
45
48
Palpation: Deeply, all 4 quadrants
One should use two hands. Press down around 4 cm
132-133: Palpation: Spleen
Palpation: Spleen (attempts to do)
Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling)
Palpation: Spleen (if not palpable, R lateral decubitus)