1. ABDOMEN

2. Anatomical landmark in clinical exploration of the abdomen

3. What is normal?

4. Bony landmarks Lower ribs Spine Iliac bone Inguinal ligament
Pubic bone
Sacrum – pelvic aperture

5. Anatomic landmarks Xifoid apendix Costal margins
Spina iliaca antero-superior
Simphisis pubis
Umbilical scar

6. Topography of abdomen

7. Topography of abdominal wall
Vertical lines
Midline between pubis and antero-superior iliac spine
Horizontal lines
Through both iliac spines
Subcostal (lower most part of costal margin)

8. Antero-lateral wall. Essentials of anatomy. I
Skin
Subcutaneous tissue
Vascular and nervous structures
Umbilical scar
Inguinal arrea

9. Antero-lateral wall. Essentials of anatomy II
Muscles and corresponding fascia (internal and external oblique, transversalis and rectus abdomini)
Linea alba
Posterior aspect of the inguinal region
Umbilical region
Vessels and nerves

10. Fascial structures in the middline

11. Posterior wall. Essentials of anatomy
Diaphragm
Diaphragmatic communications
Muscles of the lumber region
Muscles of the pelvic diaphragm

12. Arteries of the abdominal wall

13. Veins of the abdominal wall

14. Nerves of the abdominal wall

15. Inguinal region Skin projection of the region (triangle)
Inguinal ligament
Lateral aspect of rectus abdomini
Perpendicular through the middle of ilio-pubic line

16. Inguinal region

17. Inguinal region

18. Examination of the abdomen The abdominal wall
Inspection
Palpation
Percussion
Auscultation

19. Inspection Shape Asymmetry Changes in decubitus and standing Scars
Cutaneous changes
Vascular pattern

20. Palpation - superficial
The structure of the abdominal wall
Sensibility
Cutaneous reflexes
Subcutaneous tissue
Weak points and areas
Muscular structures
Check muscle position within the structures

21. Clinical exploration of abdominal organs

22. Anatomic landmarks

23. Sagital and transverse sections

24. Serial tomographic section

25. Clinical examination of the abdomen
Decubitus + pillow
Arms close to the body
Ask patient for painful areas and examine them later
Warm hands
Avoid sudden movements
Distract his attention if anxious
Follow his reactions – face changes
Good light
Relaxed patient
Correct exposure. Whole abdomen to the level of symphisis and inguinal region
Protect the genital areas

26. Methods Anamnesis Inspection Palpation Percution Auscultation
Rectal and vaginal examination

27. History taking PAIN Onset and time changes Location How significant
Radiation of pain
Association with other symptoms

28. Types of abdominal pain
Hollow organs
Paroxistic crampy pain
Difficult to pinpoint
Associated with peristaltic movement
Pacient is agitated – would not find a relaxed position
Perioneal inflamation
Constant or steadily increasing pain
Well circumscribed
Patient will be reluctant to move as it increases pain

29. Radiated pain Billiary colic Duodenal ulcer Renal pain
Genital originated pain

30. Essentials of anamnesis
Nausea, vomiting, diarrhea, constipation
Stool – melena, blood,
Vomiting – blood, digested blood
Urinary symptoms : frequency, discomfort
Weight loss
Sexual history
Sexual activity, contraceptive pills, last cycle
Any fertile women may be pregnant
Pregnancy test if in doubt

31. INSPECTION Skin Venous pattern Umbilical scar Shape of abdomen
Peristaltic movement
Pulsations
Mobility during cough or respiration

32. AUSCULTATION Preferable before palpation – stimulates movements
Listen for sounds produced by bowels
Vascular abnormal sounds (stenotic vessels)

33. PERCUSSION First orientation – “in cross” in four quadrant
Map of the abdomen
Generalized/localized meteorism
Dull area localized +/- movable
Signs of peritoneal irritation

34. PALPATION Essential and the most important
One or two hands are used for deep palpation depending mostly on muscular tonus
Systematic, avoid very painful areas at the beginning
After a screening examination – characterize different organs which are accessible
Sudden decompression

35. Rectal examination Sensible area
Put yourself (only in theory…) in his/her place
He/she should trust you
A special room – respect his/her dignity

36. Rectal examination Lateral decubitus or in all fours
Explain what you do. It is not painful nor pleasant
All you need is a glove and lubricant

37. Rectal examination Inspection: Eritematous lesions
Incontinence for feaces
Scars
Fistula – puss
Tumors
Ulcerations
Fissura in ano

38. Rectal examination Palpation: Bimanual examination
Sphyncter tonus
Fissura in ano
Prostate
Tumors
Rectal content
Cervix and uterus
Peritoneal “Coul de sac” or Douglas pouch
Bimanual examination
Look for faces aspect on you glove

39. Exploration of the liver

40. Inspection Volume Venous collateral circulation
Uniform distension in ascites
Asymmetric distension in tumors
Venous collateral circulation

41. Inspection
Umbilical hernia
Spider hemangioma
Gynecomastia
Rinofima

42. Auscultation More often unhelpful
Before ascites there is a period with paretic distension with dimished intestinal sounds
Large tumors with lare tributaries – arterial murmurs
Acoustic finding of liver edge

43. Percussion Evaluate the area of liver dullness
If significantly increased you need to find both edges
In general the liver is underestimated

44. Percussion Meteorism before ascites Movable dullness
Iceberg sign
Wave sign
Prehepatic tympanism
Sdr. Chilaiditi
Pneumoperitoneum
Situs inversus

45. Palpation Inferior limit of the liver Tumors Limits Morphologic aspect
Sensibility
Tumors
charcaterize

46. Palpation

47. Rectal examination Faeces with melena aspects
Fresh
Old
Large volume internal hemorrhoids (portal hypertension)
Metastasis in the Douglas pouch

48. Clinical exploration of the spleen

49. Inspection Changes determined by anemia or hematological diseases
Abdominal deformities
Peritoneal irritation in trauma with blood in peritoneum

50. Percussion. – dull area of the spleen
Percussion – dull area of the spleen - movable dullness – liquid in peritoneum

51. Palpation

52. Auscultation
Murmurs projected on the area of the splenic artery in stenosis, arterio-venous fistula, aneurism

53. Rectal examination Douglas shout Hemoperitoneum due to splenic rupture
Douglas pouch is full and painful

54. Clinical exploration of the kidney

55. Inspection Situated deep in the back structures
Deformity is unusual, only in very large tumors
Peripheric signs of chronic renal failure
Exteriorization of retroperitoneal hematoma

56. Palpation Bimanual Forced inspiration – the kidney descends
Costo-vertebral angle
Anterior
Forced inspiration – the kidney descends
Ectopic kidney
Sensibility
Ureteral points:
Superior
Middle
Inferior

57. Percussion Auscultation Pain induced by vibration Giordano maneuver
-Murmurs generated by stenotic arteries in patients with arterial hypertension

58. Exploration of the aorta
Bimanual palpation to evaluate the lateral margins and the transverse diameter
Fat tissue may produce error in measurements
Auscultation for murmurs
Palpate iliac arteries for puls

59. Exploration of the digestive tract – hollow organs

60. Anamnesis Might be completely non-characteristic Pain
Location and character may help in orientation for organ
Topographic delimitation helps
Abnormalities in bowel movements
Changes in aspect of stool
Other symptoms
Weight loss

61. Inspection Changes in abdominal volume Peristaltic movements
In intestinal obstruction the volume increases significantly
Changes in symmetry of the abdomen
You may even see intestinal tumors
Marked asymmetric distention of the abdomen in intestinal volvulus
Peristaltic movements
Spontaneous
Induced: Kussmaul’s sign
Significant or sugestive cutaneous signs
Anemia
Tumors frequently associated with digestive lesions
Rendu-Osler

62. Auscultation Absence of intestinal sounds
Paralytic ileus due to diverse medical problems
Accentuate peristaltic sounds
Mechanic obstruction
Might help to appreciate the area with the obstruction

63. Percussion Meteorism Tympanism
Aeric distension of bowell loops above obstruction
In dynamic ileus the aspect of a chase table
Tympanism
In aeric distension of the stomach
Acute gastric dilation
Pyloric stenosis
Combination of liquid and air in stomach produces a specific sound

64. Palpation Screening for a large palpable tumor Locate in quadrants
Suggest a possible organ as a source of the tumor
Superficial and deep mobility
Dimensions
Shape

65. Rectal examination Lesions in the perineum Tumors of the rectum
E.g. in Crohns disease – fistula in ano
Inferior rectal cancer may appear on inspection
Tumors of the rectum
Malignant – limits are important
Benign – some are every soft – might be missed
Tumors in the Douglas pouch
Tumors from organs outside rectum
Content – blood or mucus on the glove