everything U need about Abdominal examination

1. The Abdominal Examination
By: Mohamad Fathy Zaidan (MD)
Lecturer of general and laparoscopic surgery

2. Anatomical overview

5. Organs by Quadrant
Right Upper
• Liver, gallbladder
• Pylorus, duodenum
• Head of pancreas
• Ascending/transverse colon
• Right kidney/adrenal
Right Lower
• Right kidney and ureter
• Cecum/appendix/ascending colon
• Ovary, fallopian tube
• Spermatic cord
• Uterus/bladder (if enlarged)
Left Upper
• Liver (left lobe)
• Spleen
• Stomach
• Body of pancreas
• Descending/transverse colon
• Left kidney/adrenal
Left Lower
• Left kidney and ureter
• Sigmoid/descending colon
• Ovary/fallopian tube
• Spermatic cord
• Uterus/bladder (if enlarged)

6. How to start ?
Basics

7. Abdominal Exam:
Basics
• Patient should be lying flat
• Abdomen should be fully exposed (nipple to thigh)
• Arms at side (behind head tightens abdomen) & legs
straight
• Bending knees may relax abdomen
• Sheet over the genitals
• Have the patient empty their bladder before
examination

8. Basics
• Stand to the patient right side if u are Rt.
Handed, Ur hand at the level of the Abd.
• Clean Ur hands , cut Ur nail short.
• Warm Ur hands and Ur stethoscope.
• Comfortable room & couch
• Good lightning
• Approach the patient slowly and
deliberately explaining what you will be
doing

9. Gloves should be worn when..
• Examining any
individual with
exudative lesions or
weeping dermatitis
• When handling blood-
soiled or body fluid-
soiled sheets or
clothing

10. Comment??

11. Abdominal Exam:
Order of Examination
•Inspection
•Auscultation
•Percussion
•Palpation

12. Inspection

13. General inspection

15. Local inspection

16. Static Inspection
1-Conture
2-Umbulicus
3-Skin (Scars-Dilated vines-Stria-
Hair-….)
4-Hernial orifices
5- Respiratory movement
6-Peristalsis or loops
7-Genetalia

17. contour

23. Skin

24. Hernial orifices

25. Visible peristalsis

26. Kind of respiration

27. Dynamic inspection
(ask the patient to do something)
• Ask him to cough while supine and
standing.(cough tenderness, Impulse)
• Ask him to take deep breath (type of
respiration & limitation??)
• Ask him to deflate and inflate the abdomen
(tenderness)
• Ask him to raise the head or stretched legs
(Carnett’s test)??

28. Auscultation

29. 1-intestinal sound
2-Bruits
3-venous hum
4-Rub

30. Intestinal sounds
• Need to listen before percussion or palpation since
these maneuvers may alter the frequency of bowel
sounds.
• Listen with diaphragm of stethoscope
• Normal sounds occurs every 5-10 seconds &
consist of clicks and gurgles
• Need to listen for 2 minutes to declare no bowel
sounds
• since bowel sounds are widely transmitted,
need only to listen in one spot

31. Bruits
• Bruits are high pitched sounds due to obstruction to
flow due to narrowing (stenosis) of arteries

33. Venous hum(Kenawys sign)
• Portal hypertension
• At the xiphoid process
• Loader during inspiration (compression of
the spleen).
• Possibly due to engorgement of the splenic
v

34. percussion

35. Percussion
• Helps to identify the amount and distribution of
gas and to identify possible masses that are solid
or fluid filled
• Can be used to assess size of liver and spleen
• Percuss looking for areas of tympany and dullness
• Large dull areas may indicate an underlying mass;
you will later confirm with palpation
• On the right is liver dullness; on the left, dullness
of the spleen

36. Percussion: Liver
• Upper border of the liver is percussed
in the right, midclavicular line starting
at midchest
• Resonance becomes dull as upper
border of liver is reached and becomes
resonant again as lower level of liver is
reached

39. Percussion: Liver span
The liver span is estimated by percussion.
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.
Upper border: In the midclavicular line start
percussing in the chest moving down towards the
abdomen about ½ to 1 cm at a time. Note where the
percussion notes change from resonate to dull.
Lower border: In the midclavicular
line begin percussion below the
unbillicus and proceed upward until
dullness is encounter.
The distance between the
two areas where dullness is
first encountered is the liver
span.
Liver span is normally 6 to 12 cm in
the midclavicular line.

40. Liver Span: Scratch Test
Start in the same areas
above and below the
liver as you would with
percussion. Instead of
percussing lightly,
scratch moving your
finger back and forth
while listening over the
liver. Since sound is
conducted better in
solids than in air, when
the louder sounds are
heard you are over the
liver. Mark the
superior and inferior
boarders of the liver
span in the
midclavicular line

41. Percussion: The Spleen
• When a spleen enlarges, it expands
downward and medially, replacing the
tympany of the stomach with the dullness of
a solid organ
• Percussion cannot confirm splenic
enlargement, but it can raise your suspicion

42. Percussion: The Spleen
• Percuss the left lower anterior chest wall between
lung resonance (6 IC) above & the costal margin (an
area termed Traube’s space)
• As you percuss laterally, note the extent of the
tympany; if tympany is prominent laterally,
splenomegaly is unlikely.

43. Traube’s space

46. Percussion at Castell’s Spot
• Castell’s Spot identified
Left anterior axillary line identified
Left lower costal margin identified
• Percussion at Castell’s Spot while patient
inhales and exhales deeply
Dull tone indicatesDull tone indicates
possible splenomegalypossible splenomegaly

50. Percussion of the kidney

51. Costovertebral angle tenderness (CVAT),
Murphy's punch sign or the Pasternacki's Sign
• The test is positive in people with an infection around the kidney (perinephric abscess),
pyelonephritis or renal stone.
• False positive in musculoskeletal conditions

53. Palpation

54. Palpation
Several structures are palpable normally:
– Sigmoid colon is frequently palpable as a firm, narrow
tube in the left lower quadrant
– The caecum and ascending colon form a softer, wider
tube in the right lower quadrant
– Normal liver distends below the costal margin but its
soft consistency is difficult to feel
– Pulsations of the abdominal aorta are frequently visible
and usually palpable
– Usually NOT palpable are: stomach, spleen,
gallbladder, duodenum, pancreas, kidneys

55. Palpation: Improving the Exam
• 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
• Before you begin, ask the patient to point to areas
of pain and examine last
• Warm hands and stethoscope; avoid long nails;
approach slowly
• Distract the patient with conversation or questions

56. Light and Deep Palpation
• Light palpation
– Helpful in identifying tenderness, superficial organs,
and masses
– Palpate with a light, gentle dipping motion using the
palmar surface of fingers
• Deep palpation
– Usually required to delineate abdominal masses
– Again use palmar surface of fingers
– Check for tenderness and rebound (pain induced or
increased by letting go)

59. Liver Palpation
• Place left hand behind patient; by pressing the
left hand forward, the liver may be more easily felt
• Right hand on the patient’s right abdomen with
your fingers well below the lower border of liver
dullness; fingers may be pointed to the patient’s
head or to the left shoulder
• Press gently in and up; ask the patient to take a
deep breath
• Try to feel the liver edge as it comes down to meet
your fingertips

60. Liver Palpation
• The edge should be soft, sharp and regular,
with a smooth surface
• The normal liver may be slightly tender
• On inspiration, the liver is palpable about 3
cm below the right costal margin in the
midclavicular line
• If you start too high, you may miss the
liver
• Can also consider the hooking technique

65. How to confirm liver mass??
• Intra-abdominal mass (how to confirm??)
• Related to the diaphragm(how to confirm?)
• Site
• Its dullness contentious with the hepatic
dullness
• Can not insinuate my finger below the
costal margin
• Not the Rt. Kidney (????)

66. Spleen Palpation
• Again, with the left hand, reach over and round
the patient to support and press forward the lower
left rib cage
• With your right hand below the left costal margin,
press in toward the spleen
• Again, begin palpation low so you don’t miss an
enlarged spleen
• Again ask the patient to take a deep breath and try
to feel the tip of the spleen as it comes down to
meet your fingertips

69. How to confirm splenic mass??
• Intra-abdominal mass (how to confirm??)
• Related to the diaphragm(how to confirm?)
• Site
• Notch ?
• Direction of descend?
• Its dullness contentious with the splenic
dullness
• Can not insinuate my finger below the
costal margin
• Not the Lt. Kidney (????)

70. HACKETT CLASSIFICATION
0 – Spleen not palpable
1 – spleen just palpable below LCM, on deep
inspiration
2 – spleen palpable< halfway between CM and
umblicus
3 – spleen palpable> halfway to umblicus but not
beyond it
4 – Spleen palpable below umblicus but not below
horizontal line midway between umblicus and pubic
symphysis
5 – lower than 4 1,2- mild spleen 3- moderate spleen
4,5 – massive spleen

71. Hackett's classification of
splenomegaly

72. Palpation of Kidney
• Left hand on the renal
angle.
• Rt. one anteriorly at the
hypoconderial region
facing the left hand
• Feel lower pole of
kidney and try to
capture it between your
hands.

73. How to confirm kidney mass??
• Intra-abdominal mass (how to confirm??)
• Related to the diaphragm(how to confirm?)
• Rentiform shaped , smooth or lobulated surface, rounded
edge
• Band of resonance
• Fills the renal angle, with dullness in percussion
• Balloted except if very large
• If grasped between the 2 hands causes sickness
sensation.
• Projects vertically downwards and never cross the
midline
• Hand can be insinuated below the costal margin

74. The Aorta
• Press firmly deep in the upper
abdomen and try to identify the aortic
pulsations
• Try to assess the width by pressing
deeply with one hand on each side of
the aorta; normal should be not more
than 3 cm

77. Assessing Possible Ascites
• A bulging abdomen with protuberant flanks
suggests the possibility of fluid in the abdominal
cavity (ascites)
• Because fluid sinks with gravity while gas filled
loops of bowel float to the top, percussion gives a
dull note in dependent areas of the abdomen
• Two additional techniques; shifting dullness and
assessment for a fluid wave

78. Testing for Shifting Dullness
• 1-Map the borders of tympany and dullness
• 2-Ask the patient to turn to one side
• 3-Percuss and mark the borders again
• 4-In a person without ascites, the borders
between tympany and dullness remain
relatively constant

80. Testing for a Fluid Wave:
TRANSMITTED FLUID THRIL
• 1-Ask the patient or an assistant to press the edges
of both hands firmly down the middle of the
abdomen
• 2-This pressure helps to stop the transmission of
a wave through fat/skin
• 3-Then tap one flank sharply with your fingers
• 4-Feel on the opposite flank for an impulse
transmitted through the fluid
• 5-Unfortunately this sign is often negative until
the ascites is obvious

82. Think on other swellings
• 1-Pelvi-abdominal mass (Can not reach the lower border)
• 2-G.B. mass (Tender, site, continuous with hepatic dullness.)
• 3-Mesintric mass (Tillaux triad)
• 4-Extra-parital mass (not related to the diaphragm, relation to
muscles)
• 5-Masses according to the anatomical
region (slide No. 5)
• 6-Retro-peritoneal mass painless ill-defined masses ,
restricted mobility , doesn’t fall on knee-elbow position

83. Pelvi-abdominal mass

84. Mesenteric mass

85. Acute abdomen

86. Causes

87. Acute abdomen
• History:
1-Pain :site , duration , kind , shift , referred.
2-Diaphragmatic irritation (shoulder pain,
hiccough)
3-Bleeding : site, color , amount…
4-N&V.
5- Constipation
6--Drugs (NSIDS, Pills…)
7-Renal H.
8-Mensterual H.

88. Acute abdomen
• Examination
• 1-Vital signs ….
• 2-Gait & Posture….
• 3-Respiratory movement….
• 4-Distention & visible loops or visible peristalsis.
• 5-Pallor and or jaundice….
• 6-Tenderness & rebound T., Cough T.
• 7-Rigidity….
• 8-Skin signs (CULLENS)
• 9-PR….
• 10-Auscultation….

89. Acute pancreatitis

90. Thank you