0

Abdominal Examination
Quadrants of abdomen
The abdomen can be divided into quadrants by a vertical median plane and a
horizontal trans umbilical plane, both passes through the umbilicus
Right upper quadrant. Contain The liver and gallbladder
Left upper quadrant. Contain The stomach and spleen
Right lower quadrant. Contain The cecum and appendix
Left lower quadrant Contain The end of the descending colon and sigmoid colon

Regions of abdomen
The abdomen can be divided into nine
regions by a midclavicular sagittal
plane on each side and by the
subcostal and intertubercular planes,
which pass through the body
transversely.
These planes separate the abdomen
into:

1
 Inspection of abdomen
 General consideration:
The patient must be exposed from the lower chest to the symphsis pubis.

The patient’s hand should remain at his sides with head resting on a
pillow
Flexion on the knees may relax the abdomen
The patient should have an empty bladder.
How to
relax Warm room and adequate light must be provided.
patient: For easy localization of any abnormalities it is useful to divide the
abdomen in 4 quadrants or 9 segments as before.
Watch the patient’s face for signs of discomfort during the
examination.

Shape of abdomen (Contour)

Stand on the person’s right side and look down on the abdomen.
Then stoop or sit to gaze across the abdomen.
Your head should be slightly higher than the abdomen
Determine the profile from the rib margin to the pubic bone.
The contour describes the nutritional state and nor ranges from flat to rounded.

2
 Shape of abdomen may be

Diffuse abdominal enlargement: Localized abdominal enlargement

Free fluid (Ascites).
Fat.
Splenomegaly in left hypochondrium.
Flatus.
Hepatomegaly in right hypochondrium.
Fetus.
Cancer stomach in epigastric region.
Fatal tumor growth.
Full urinary bladder in hypogastric area.
Full urinary bladder.
Fluid in ovarian cyst.

Subcostal angle

Normal: Acute to right (90o± 20).

Upper abdominal swelling as hepatosplenomegaly (HSM) -
Obtuse:
Ascites - barrel shaped chest.
Narrow: Flat chest, pigeon chest.

3
 Umbilicus

Normal: midway between symphysis pubis and xiphsternum.

Site
Upper abdominal swelling and ascites shift it downward.
Normal: inverted.
Everted umbilicus
Shape
means chronic increase of intraabdominal pressure (ascites, or
HSM).
Hernia: expansile impulse with cough.
Swelling
Nodules: GIT and breast cancer (Sister Mary Joseph‘s nodule)
Cullen‘s sign: intra-abdominal bleeding (as in acute pancreatitis).
Color
brown pigmentation (tuberculous peritonitis).
Urine: patent urachus.
Discharge
Feces: Colonic fistula.

Dilated veins Collateral due to portal hypertension

4
 Divarication of recti

Separation of rectus abdominis muscles.

Ask the patient to raise his head up without support (lift head).
Usually confirmed by palpating the defect between both recti.

Chronic increase of the intra-abdominal pressure (HSM - ascites)

Causes
Hypoproteinemia

5
 Suprapubic hair distribution

 Triangular in male with apex directed upward

Normal
(umbilicus) & horizontal in females.
 As in LCF: Feminine distribution.
Abnormal
 Hypogonadism: loss of hair.

Epigastric pulsation
Place your hand longitudinal in the subcostal angle and hold respiration, looking
tangential to abdomen.

At the tip of fingers , from left side: right ventricle enlargement,

Pulsation increased with deep inspiration.
classified
according From the right side: hepatic pulsation (tricuspid stenosis - TR), liver is
to the enlarged and tender during bimanual examination.
direction
From behind: aortic pulsation (thin - hyperdynamic - aneurysm),
into
pulsating down to umbilicus.

6
 Visible peristalsis
Normal In thin person or in emaciated person.
Pyloric obstruction:
Slow waves from the left rib margin to the right.
Exaggerated by massage, tapping or drinking soda +
Abnormal
confirmed by Succussion splash.
Intestinal obstruction:
Called step ladder.

Respiratory movement

Normal Rate 12 - 20 cycles per min.

Rhythm Regular.

Depth Average, deep or shallow.

Type Mainly abdominal in male and mainly thoracic in female.

Patient of tense ascites usually orthopenic and breath thoraco-abdominal.

Patient of peritonitis usually has rigid dorsal decubitus and has absolutely thoracic
breathing.

Hernia orifices
Expansible impulses with cough.
Preferred in standing patient.
Palpate hernia orifice.

Small, midline through a defect in the linea alba located

Epigastric:
between the xiphoid process and umbilicus.

Umbilical Bulging defect at umbilicus.

Defect in abdomen muscles after surgical incision.
Incisional
Must palpate the size of the defect.

7
 Abdominal Hernia through the abdominal wall.

Inguinal Direct or Indirect.

Dilated veins

 Visible or dilated?

Visible: Straight, narrow and not raised.

Dilated: Tortuous, wide and raised above the level of the skin.

 If dilated

Prominent, dilated veins may represent collateral circulation through the

abdominal wall that has developed to compensate for obstruction of either the
inferior vena cava or increase portal vein pressure.

Portal (caput medusa) Systemic (IVC obstruction)

Site Central Peripheral

Milking test Filling away from the From down to up

umbilicus

8
 Milking test:
Place both index fingers closely, then sweep to the periphery.
Allow for peripheral filling by releasing each finger. Successively, direction
of rapid filling is the direction of blood flow

Pigmentation

Bluish at Cullen’s sign (bleeding in peritoneum).

umbilicus:
Bruises on flanks: Grey Turner’s sign (retroperitoneal bleeding as pancreatitis).

Jaundice: yellow skin – usually due to liver disease or biliary obstruction.

Scratch marking

Denotes pruritus usually with obstructive jaundice

Multiple, parallel and superficial.
In accessible area.

Scars

Surgical (name - healing).

Traumatic.
Cautery.

Stria & pigmentation

9
 Palpation of abdomen
 General rules:
Warm your hands.
Ask patient if any part is tender: examine that last.
Abdominal muscles must be relaxed by patient knee flexion.
Superficial palpation not take more than 1 cm during examination.

a. Superficial palpation b. Deep palpation

To gain patient confidence.

For tenderness or rigidity. For organomegaly.

Temperature. Deep masses.

Superficial mass.

 Intra-abdominal mass vs. abdominal wall mass:

Ask the patient to raise his head.
Mass of the abdominal wall remains palpable, where the intra abdominal mass will
be obscured.

 Deep palpation: liver

Site: right hypochondrium and epigastrium.

Borders:

Upper border Lower border

Lt - MCL 5th intercostal space.
Lt - MCL 5th intercostal Lt 8th costal cartilage.
space. Midway between the xiphisternum & umbilicus
Rt - MCI 5th rib. Rh 9th costal cartilage.
Rt - MAL 7th rib. Rt – MCL 1inch below the costal margin
Rt - scapular 9th rib. Rt - MAL 11th rib.

10
 Liver palpation
 The upper border by

percussion.
 The lower border by:
Ordinary technique.
Tip of hands (Hutchinson’s method).
Bimanual. Dipping.
Hooking.
Auscultatory method (Macleod).
Right lobe at MCL beginning from right iliac region.
Left lobe at midline from umbilical region.
Ask the patient to take a deep breath.
Ordinary
technique: By radial aspect of the index or tip of fingers.
Feel the edge of the liver press against your fingers.
Or, it may slide under your hand as the patient exhales

 Comment on liver

 upper border
Size:  lower border:
• left lobe…, right lobe.

Border: Rounded or firm.

Surface: Smooth or nodular.
Consistency: Soft, or firm or h ard.
Tenderness:

Pulsation:

Rub:

11
 Palpation of spleen
left hypochondrium
Under 9th, 10th & 11th ribs (long axis on 10th rib).
Sites
Medially: scapular line.
Laterally: MAL.

 Spleen palpation:

Ordinary technique.
Tip of hands.
Bimanual.
Right lateral decubitus.
Scratch method.
Hooking.
Jumping.
Dipping

Support lower left rib cage with left hand, while patient is supine and
lift anteriorly on the rib cage.
Palpate upwards from the right iliac fossa toward the spleen with
Bimanual
spleen finger tip of right hand.
palpation: Ask the patient to take a deep breath.
Palpate for spleen as it descends.
A palpate spleen is almost always abnormal.

11
 Comment on spleen

Size:

Border: rounded or firm.

Surface: smooth or nodular.
Consistency: soft, or firm or hard.

Tenderness:

Pulsation:

Rub:

Kidney palpation
 Size:
12 X 6 X 3 cm.
 Position:
The kidney is retroperitoneal occupying the loins.
They are in the para-vertebral gutter.
The right kidney is lower than the left by
0.5 inch because of the pressure of the
liver on the right side.

Surface anatomy of the kidney

 Posterior surface marking of the kidney:
Bounded by 4 lines (Morris’ parallelogram):

2 vertical
lines:
3 & 9 cm from median plane.
2 horizontal
lines:
at level of T11 and L3 .

12
 Anterior surface marking of the kidney:

Rt. Kidney Lt. Kidney

Upper end 11th space 11th rib

Lower end 5 cm above iliac crest 6,5 cm above iliac crest

Right kidney (stand on the right side of the patient).

Put your finger tips of the left hand below 12th rib
Bimanual (costovertebral angle), then lift up.
technique: On
Press the right hand below costal margin and try to capture the
supine
position: kidney, then ask patient to breath.
Left kidney (do the reverse) stand on left, left hand up and right below.
bimanual technique

Keep your anterior hand steady in the deep palpation position in the
right upper quadrant lateral and parallel to rectus muscle.
Ballottement
Attempt to ballot the kidney with the other hand in renal angle.
method:
An enlarged kidney should be palpated by the anterior hand.
Repeat the same maneuver for the other kidney.

 Comment on kidney
Abnormal finding: If mass is identifiable, note:

Unilateral enlargement: (hydronephrosis, tumor, cyst).

Size: Bilateral enlargement: (polycystic kidney, lower urinary
obstruction).
1. Acute pyelonephritis.
Tenderness
2. Acute glomerulonephritis

13
 Palpation of gall bladder (GB):
The fundus of the GB approaches the surface behind
the anterior end of the ninth right costal cartilage
close to the lateral margin of the Rectus abdominis.

 Palpation of gall bladder:

Murphy’s sign (Benjamin Murphy 1857 - 1916)
 Technique:
Firstly, ask the patient to breath out.
Then gently place the left hand below the costal margin on the right MCL.
Lastly, ask the patient inspire (breath in).
Positive test: the patient suddenly holds breathing

14
 Percussion of abdomen
Simple roles

The percussing finger: middle finger of the right hand.

The movement: from the wrist joint.
The percussed finger: middle finger of the left hand

Abdominal percussion:

Ascites. Kidneys.

Liver borders: liver span. Bladder: for enlarged bladder or

pelvic mass.
Spleen: for splenomegaly.
Masses.

Shifting dullness
Percuss from the midline to the flanks on both sides:

Place the finger parallel to the expected edge.

Percuss from resonance in the mid-abdomen to dullness in the flanks.
The patient rolled to the opposite side.
Waiting for 30 seconds.
The previous area of dullness should now be resonant. It does not
matter which side one chooses to start with.

15
Transmitted thrill (fluid thrill)
Place one hand on the patient flanks.
With the other hand briskly tap the other flank.
A third hand is placed in the mid-abdomen with
sufficient pressure applied to dampen any wave
that may pass through the anterior abdominal wall.
Positive test: a shock wave be felt with palpating hand.

Auscultation of abdomen.
Auscultation of the abdomen has a relatively minor role For:

Intestinal sounds. Succession splash.

Vascular sounds. Buddle sign.
Scratch test. Friction rubs.

Case scenario
A male patient, 55 years presented by diffuse abdominal enlargement, and
jaundice. He was diagnosed as chronic liver disease caused by hepatitis C virus.

16
Inspection of abdomen

Diffuse abdominal enlargement with full flanks.

Wide subcostal angle.
Positive divarication of recti.
Umbilicus shifted downward, flat shape, with no dilated veins, nodules,
discharge or pigmentation around.
Visible dilated vein.
Scratches markers all over the abdomen.
Respiratory movement is mainly abdominal, and restricted.
No visible peristalsis movement.
No epigastric pulsations.
No apparent hernia orifices.
Famine hair distribution.

Palpation of abdomen:

Superficial palpation: No superficial mass, tenderness, areas of hotness.

Deep palpation

Liver Spleen
Upper border in 6th intercostal space. Moderate enlargement
Lower border of left lobe: two hand‘s Rounded border
breadth below xiphisternum. Firm consistency
Lower border of right lobe was not Smooth surface.
palpable. Can’t insinuate my hands below costal
Sharp border, nodular surface, firm margin
consistency, no pulsations or tenderness. Palpable notch.

Kidney: was not palpable. Colon: was not palpable.

17