CHARLES M M

PHCI

Abdominal Examination

Structure and Physiology

Abdominal cavity is divided into quadrants; two imaginary lines cross at the umbilicus

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)

Right Upper 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)

Patient should be lying flat

Abdomen should be fully exposed

Arms at side (behind head tightens abdomen) & legs straight

Bending knees may relax abdomen

Sheet over the genitals

Abdominal Exam

Basics

Order of Examination

Inspection

Auscultation

Percussion

Palpation

Cachexia of- cirrhosis or cancer evident by wasted muscles.

Jaundice. Liver disease

Pallor. Anaemia

Vircow’s Node: left supraclavicular LN enlargement. Intra abd tumour/malignancy

Palmar erythema, white nails, liver cirrhosis,hepatocellular carcinoma.

Leg edema 7.Gynecmastia.

Abdominal contour

Respiratory movement

Abdominal veins

Peristalsis

Abdominal skin

Skin: spider angiomas (blanching red marks mostly above nipples level), striae (purple or silver)

Contour of abdomen

Concave (scaphoid) vs convex (protuberant)

Dilated veins radiating from the umbilicus (caput medusa) & its direction of flow: from below upward or vise versa.

In men / children, manner of breathing is abdominal respiration.

In women the manner of breathing is thoracic respiration.

Respiratory movement is limited (could suggest peritonitis).

/ peristalsis

In healthy person peristalsis is not visible

Becomes spontaneously visible or provoked by percussion in bowel obstruction

Provides important information about bowel motility: decreased motility suggests peritonitis; increased motility suggests obstruction

Need to listen before percussion or palpation since these maneuvers may alter the frequency of bowel sounds

Can also appreciate bruits over the aorta or other arteries, suggesting narrowing of the arteries from atherosclerosis

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

For bruits

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

Listen midline (bruit in aorta)

Right / left upper quadrant (renal artery bruits)

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

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

Total span shouldn’t be more than 10 cm

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

There are two techniques to percuss splenic enlargement

Percuss the left lower anterior chest wall between lung resonance (6 IC) above & the costal margin

As you percuss laterally, note the extent of the tympany; if tympany is prominent laterally, splenomegaly is unlikely.

Can also check for a splenic percussion sign

Percuss the lowest interspace in the left anterior axillary line; the area is usually tympanitic

Then ask the patient to take a deep breath and percuss again

When the spleen is normal, the space usually remains tympanitic

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

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

Light palpation(superficial 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)

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

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

PALPATION PERCUSSION SCRATCH TEST

PERCUSSION

NL < 12-13 CM

MCL

2-3 CM DURING INSPIRATION AND EXPIRATION

COPD

LIVER SPAN MAY VARY BETWEEN OBSERVERS DEPENDING UPON WHERE THE MCL IS DETERMINED

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AIR

CONSIDER USING MULTIPLE PLEXIMETERS

JAMA 1994;271:1859-1865

RESONANCE

DULLNESS

The liver span is estimated by percussion.

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.

USED TO IDENTIFY THE INFERIOR BORDER OF THE LIVER

STETHOSCOPE IS PLACED OVER THE LIVER IN THE MCL

SCRATCHES ARE PRODUCED BEGINNING IN THE RLQ AND MOVING THE FINGER CEPHALAD IN THE MCL. A CHANGE IN THE UNDERLYING TISSUE (INFERIOR LIVER EDGE) IS IDENTIFIED BY THE CHANGE IN SOUND

INTENSITY.

MOVEMENT BEGIN

MOSBY’S GUIDE TO PHYSICAL EXAMINATION 3RD ED,1995

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

FRICTION RUBS – MALIGNANCY, HEPATOMAS, LIVER ABCESS

BRUITS (SYSTOLIC) – TUMORS,HEPATITIS

JAMA 1994;271:1859 -1865

JAMA 1979;241:495

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

Patient take a deep breath.

Feel lower pole of kidney and try to capture it between your hands.

Right kidney may be felt to slip between hands during exhalation

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

The ease of feeling varies with the thickness of the abdominal wall

Try to appreciate pulsations laterally rather than just in the anterior/posterior dimension

ANEURYSM THE EXAM

METHOD

THE PATIENT’S ABDOMEN SHOULD BE RELAXED WITH THE KNEES FLEXED.

THE EXAMINER FEELS CEPHALAD OF THE UMBILICUS FOR THE AORTIC PULSATION.

PLACE BOTH HANDS ON THE ABDOMEN WITH THE INDEX FINGER ON EITHER SIDE OF THE PULSATING AORTA. ESTIMATE THE WIDTH ( NL <2.5CM IN WIDTH).

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

Map the borders of tympany and dullness

Ask the patient to turn to one side

Percuss and mark the borders again

In a person without ascites, the borders between tympany and dullness remain relatively constant

Testing for a Fluid Wave

TRANSMITTED FLUID THRIL

Ask the patient or an assistant to press the edges of both hands firmly down the middle of the abdomen

This pressure helps to stop the transmission of a wave through fat/skin

Then tap one flank sharply with your fingers

Feel on the opposite flank for an impulse transmitted through the fluid

Unfortunately this sign is often negative until the ascites is obvious

GB Signs

MALIGNANCY

COURVOISIER’S SIGN – A PALPABLE NONTENDER GALL BLADDER IN A PATIENT WITH JAUNDICE SUGGESTING EXTRAHEPATIC

OBSTRUCTUON OF THE BILIARY SYSTEM SECONDARY TO MALIGNANCY (ORIGINAL DESCRIPTION).

CHOLECYSTITIS

MURPHY’S SIGN – WITH THE EXAMINER’S FINGERS POSITIONED ALONG THE INFERIOR BORDER OF THE LIVER IN THE RIGHT COSTAL ARCH THE PATIENT IS ALLOWED TO INSPIRE. DURING INSPIRATION THE INFLAMED GALLBLADDER TOUCHES THE EXAMINERS FINGERS RESULTING IN THE SUDDEN CESSATION OF

INSPIRATION.

A succussion splash describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body cavity.

t is usually elicited to confirm intestinal or pyloric obstruction due to pyloric stenosis or gastric carcinoma, but may also be heard with hydropneumothorax, a large hiatal hernia, or over a normal stomach

To examine for this sign, gently shake the abdomen by holding either side of the pelvis. A positive test occurs when a splashing noise is heard, either with the naked ear, or with the aid of a stethoscope. The test is not valid if the patient has eaten or drunk fluid within the last three hours.

Auscultate before doing anything else

Use percussion to help identify organomegaly and borders of palpation

Use light and deep palpation to help identify structures in the abdomen