بسم الله الرحمن الرحيم

Abdominal Examination by Dr. Sally Abed Lecturer Tropical Medicine

ABDOMINAL EXAMINATION INSPECTION PALPATION PERCUSSION AUSCULTATION

Anatomy Regions (Anatomical) Quadrants (Clinical)

ABDOMEN: Inspection ABDOMEN: Inspection There should be adequate exposure of the abdomen for proper inspection. The patient should be exposed from the inferior chest to the anterior iliac spines bilaterally.

INSPECTION Mid line inspection Inspection of sides 1-Subcostal angle 2-Epigastric pulsation 3-Divercation of recti 4-Umblicus 5-Suprapubic hair distribution 6-Hernial orifices 1-Contour of abdomen 2- Dilated veins 3- Skin 4-Scars 5- Movement with resp 6-Visible peristalisis

- Site - Dilated veins MID LINE INSPECTION 1-Subcostal anglecauses of  2-Epigastric pulsationcauses 3-Divercation of recti?? 4-Umblicus - Site - Dilated veins - shape - Skin - Hernia - Discharge 5-Suprapubic hair distribution 6-Hernial orifices

2- Collaterals (dilated veins) 3- Skin abdominal wall INSPECTION OF SIDES 1-Contour of abdomen 2- Collaterals (dilated veins) 3- Skin abdominal wall -Striae, scratch marks, sinus& fistula -Pigmentation, purpura 4-Scars Type, site, pigmentation, impulse on cough 5- Movement with respiration 6-Visible peristalsis

Causes of abdominal enlargement ? Generalized: Fluid (ascites) Fat (obesity) Flatus and faeces Fluid in cyst (ovarian cyst) Fetus (pregnancy) Full bladder 2)Localized: Hernias → size ↑ with cough Masses in abdominal wall ( abscess & tumors) Enlargement of intra-abdominal organs

1)Portal vein obstruction Collaterals (dilated veins) 1)Portal vein obstruction 2)IVC obstruction 1-Site -Central around the umbilicus (caput medusa) -Lateral in flanks and back 2-Direction of filling -Away from umbilicus. From below upwards 3-Oral glucose test Blood glucose in abd. wall veins = cubital vein Blood glucose in abd. wall veins > cubital vein

IVC obstruction

PALPATION

Ensure that your hands are warm Stand on the patient’s right side Help to position the patient Ask whether the patient feels any pain before you start Begin with superficial examination Move in a systematic manner through the abdominal quadrants Repeat palpation deeply. Leave the painful area for last. Move in a systematic manner through the nine regions of the abdomen in the direction of the painful area. Make sure you use the pads of your fingers and not the finger tips as this might hurt the patient.

PALPATION Superficial Deep 1- Liver Tenderness 2- Spleen Regidity Masses 1- Liver 2- Spleen 3- Kidneys 4- Gall bladder 5- Colon

Normally Palpable Structures

PALPATION OF THE LIVER Technique of palpation: 1- Upper border 2- Lower border 3- Liver span Comment on: 1- Size 4- Consistency 2- Surface 5- Tenderness 3- Edge 6- Pulsation

Liver Span

Causes of hepatomegaly? 1)Infection: -Viral: Viral hepatitis ,IMN, CMV -Bacterial: Brucellosis ,T.B -Parasitic: Bilharziasis, Malaria ,Fasciola 2)Congestion: -Rt side ht failure -Tricusbed valve disease -Constrictive pericarditis -Budd chiari syndrome -Veno-occlusive disease

3)Infiltration 6)Neoplastic: 7)Miscellaneous: - Amyloidosis - Leukemia - Lymphoma 6)Neoplastic: - HCC - Metastasis 7)Miscellaneous: -Collagen disease -Congenital cysts

Causes of tender liver : 1- Infection 2- Congestion 3- Cholestasis 4- Infiltration 5- Malignancy

PALPATION OF THE SPLEEN Technique of palpation - Usual method - Bimanual examination - Two handed method - Hooking method - Dipping method

132-133: Palpation: Spleen Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) Palpation: Spleen (if not palpable, R lateral decubitus) 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)

Right lateral decubitus PALPATION OF SPLEEN Palpation of Spleen: Right lateral decubitus. Right lateral decubitus

Causes of spenomegaly ? 1)Infection: 1-Viral: IMN, CMV 2-Bacterial: Septecemia ,Typhoid fever ,Brucellosis T.B ,Syphilis 3-Parasitic: Bilharziasis, Malaria, Leishmania 2)Congestion: (portal hypertension) 3)Infiltration -Amyloidosis -Sarcoidosis -Lipid storage disease -Leukemia- -Gaucher disease -Lymphoma

4)Blood disease: -Anemia 2-Polycythemia -Myeloproliferative disease 5)Neoplastic: -Hemangioma -Sarcoma -Metastasis 6)Miscellaneous: -Collagen disease -SLE -Rh. artheritis

Grades of splenomegaly ? - Mild: Spleen just palpable under costal margin - Moderate: Spleen is palpable between costal margin and umbilicus - Huge : Spleen is palpable below the umbilicus

Causes of huge splenomegaly ? Bilharziasis Chronic malaria Kala azar Chronic myloid leukemia Hairy cell leukemia Myelofibrosis, myelosclerosis B- thalasemia Amyloidosis Gaucher, s disease

Causes of tender spleen ? 1- Infection: - Septicemia - Infective endocardtis - Typhoid fever - Brucellosis - Acute malaria 3- Infarction: (perisplenitis, splenic rub) 4- Sickle cell anaemia 5-Causes of huge splenomealy

PALPATION OF THE KIDNEY Bimanual palpation Causes of enlargement f the kidney? 1- Hydronephrosis 2- Pyonephrosis 3- Polycystic kidney 4- Tumour

R L 135-136: Palpation of Kidneys Palpation:R kidney (take a deep breath, capture kidney, exhale, slowly release kidney) Palpation:L kidney (take a deep breath, capture kidney, exhale, slowly release kidney) L Right kidney (take a deep breath, capture kidney, exhale, slowly release kidney Left kidney (take a deep breath, capture kidney, exhale, slowly release kidney)

Splenic swelling Kidney swelling 1-Notch on anterior border (pathognomoni -No notch; reniform in shape 2-Hand cannot be insinuated ( ) swelling &costal margin -Can be insinuated ( ) swelling & costal margin 3-Does not fill renal angle -Fills the renal angle 4-Dull on percussion & continuous with splenic dullness -Percussion above swelling → band of colonic resonance anteriorly 5-Moves with respiration 6-No posterior ballotment -Posterior ballotment

Percussion

PERCUSSION Ascites Abdominal organs Minimal ascites Liver Moderate ascites Tense ascites Liver Spleen Urinary bladder Any palpable mass

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. 127: 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. 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.

PUDDLE SIGN JAMA 1992;267:2645-2648

Premature ascites: Dif: Ascites in cirrhotic patients before shrunken liver Causes: Reversible Not reversible 1-Hematemsis & melena 2-Severe vomiting & diarrhea 4-Intercurrent infection 5-Old anti-bilharzial 1-Malignant 2-T.B peritonitis 3-B. nephropathy

Ascites precox: Dif: Ascites before edema lower limb in cardiac patients Causes: 1-T.R 2-Pericardial effusion 3-Constrictive pericarditis

PERCUSSION OF THE SPLEEN 1- Percussion of traube’s area 2- Castell’s method 3- Nixon’s method

1 2 1-Nixon's Method: Place the patient in the right lateral decubitus position. Initiate percussion half-way along the costal margin and percuss cephalad in a line perpendicular to the costal margin. Dullness of >8cm suggests splenomegaly. 2-Castell's Sign (in Traube's Space): in supine percuss in the lowest intercostal space in the left-anterior axillary line in full expiration and inspiration. Splenomegaly is suggested when the percussion is dull or becomes dull on inspiration.

Nixon method

Traubs area

Traub’s area: Area of tympanetic resonance over fundus of the stomach Causes of dullness in traub’s area: 1-From above: Lt pleural eff., Pericardial eff. 2-From left : Splenomegally 3-From Right : Hepatomegally 4-From below: -Full stomach -Subpherinic abcess -Gastric tumour -Retroperitoneal neoplasm -Ascites -Complete situs inversus -Pregnancy

AUSCULTATION

Intestinal sounds Vascular sound -Arterial bruit -Venous hum Friction rub -Splenic rub -Hepatic rub Succusion splash Minimal ascites (puddle sign) Lower border of liver (scratching method)

Auscultate Bowel Sounds

Auscultate Vascular Sounds