Abdominal examination Introduction

LEARNING OBJECTIVES To know the four quadrants and nine regions of the abdomen; To be aware of some common findings on inspection, auscultation and palpation of the abdomen, and what they may mean; To know the reason for the sequence of abdominal examination; To learn how some common abdominal conditions are diagnosed using physical examination.

EXAM Inspection Auscultation Percussion Palpation

THE FOUR QUADRANTS Physicians locate findings in the abdomen in one of four quadrants or one of nine regions. The four quadrants are: right upper (RUQ), right lower (RLQ), left upper (LUQ) and left lower (LLQ).

THE NINE REGIONS The nine abdominal regions are: epigastric, umbilical, hypogastric/suprapubic, right hypochondriac, left hypochondriac, right lumbar, left lumbar, right inguinal and left inguinal.

LOCATIONS of ABDOMINAL ORGANS Right hypochondriac (RUQ): liver and gall bladder eft hypochondriac (LUQ): the spleen and stomach epigastric: the pancreas, stomach and common bile duct umbilical: the small intestine lumbar: the kidneys iliac regions: the ovaries left iliac/LLQ: the sigmoid colon right iliac or lumbar (RLQ): the cecum and appendix suprapubic: the bladder and uterus

SOME COMMON FINDINGS on ABDOMINAL INSPECTION Scars Striae (stretch marks) Colors Jaundice Prominent veins

SCARS Explain every scar. Each one is evidence of surgery or injury that the patient may have forgotten to mention to you. The injury that caused a visible scar may have also caused internal scarring (adhesions) - which can cause intestinal obstruction

STRIAE (Stretch Marks) On the abdomen may be a sign of past weight changes, such as pregnancy. An endocrine disease, Cushing's disease , may cause purple striae.

COLORS Bluish color at the umbilicus is Cullen's sign - a sign of bleeding in the peritoneum. Bruises on the flanks are Grey Turner's sign (retroperitoneal bleeding - e.g. from inflamed pancreas)

JAUNDICE Jaundice – yellow skin - is usually due to liver disease or biliary tract obstruction

PROMINENT VEINS Prominent veins may be due to portal vein obstruction or inferior vena cava obstruction. The portal veins and systemic veins connect in 3 locations; the umbilicus is one of it.

OTHER FINDINGS on INSPECTION: Peristalsis and Scaphoid Abdomen Visible peristalsis is usually abnormal, unless the patient is emaciated. Otherwise, it is a sign of intestinal obstruction. In thin adults, the abdomen may be concave - scaphoid.

CAUSES of ABDOMINAL DISTENSION Distension of the lower abdomen only can be caused by pregnancy, full bladder, ovarian tumor, or uterine fibroids (common benign growths) Diffuse abdominal distension can be caused by any of the 6 Fs: Fat (obesity) Fluid (ascites - peritoneal fluid - or obstructed viscera filled with fluid) Flatus (air) - e.g. from air swallowing or intestinal obstruction Feces (constipation Fetus (pregnancy) Fatal cancer.

HERNIAS Not all hernias happen in the inguinal area or scrotum. Some abdominal hernias include: Umbilical hernias: protrude out of the umbilicus Incisional hernias: occur at old scars Diastasis recti: this is not a true hernia, but a separation of the rectus abdominis muscles. You can see this best by asking the patient to tighten the abdominal muscles (lift head when supine, or sit up).

Auscultation

STOP, LOOK and LISTEN Always auscultate before touching the abdomen . Touching the abdomen, even to percuss, may change the bowel sounds. The order for examining the abdomen is: Inspection, auscultation, percussion, palpation Before you proceed, consider your patient's comfort. Is your stethoscope warm? Are your hands warm? Are your fingernails short? Has the patient emptied his/her bladder? Place a pillow under your patient's head. Asking your patient to bend his/her knees may help relax the abdominal muscles.

GUT SOUNDS Use the diaphragm of your stethoscope to listen to gut sounds Normal gut sounds are gurgling, 5 to 35 per minute Borborygmi are loud, easily audible sounds. They are normal, too. High pitched , tinkling (raindrops in a barrel) sounds are a sign of early intestinal bstruction

Decreased sounds: (none for a minute) are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury. Absent Sounds : (no sounds for 5 minutes) are a bad sign. They can be caused by longer-lasting intestinal obstruction, intestinal perforation or intestinal (mesenteric) ischemia or infarction.

BRUITS Use the bell of your stethoscope to listen for bruits: Aortic bruits are heard in the epigastrium. They may be a sign of abdominal aortic aneurysm; Renal artery bruits are in each upper quadrant. They may be a sign of renal artery stenosis, which is a potentially treatable cause of hypertension; Iliac/femoral bruits are in the lower quadrants. They may be a sign of peripheral atherosclerosis.

CASE 1 A 40 year old man has nausea and vomiting for two days and no bowel movement. His abdomen is somewhat distended. Does he have intestinal obstruction ? Signs of intestinal obstruction are: High-pitched tinkling bowel sounds Later: bowel sounds absent Visible peristalsis

PERCUSSION What it finds: liver size , spleen, fluid. Percussing the body gives one of three notes: Tympany is found in most of the abdomen, caused by air in the gut. It has a   higher pitch than the lung. Resonance is found in normal lung. It is lower pitched and hollow. Dullness is a flat sound, without echoes. The liver and spleen, and fluid in the peritoneum (ascites), give a dull note.

PERCUSSING THE LIVER and SPLEEN to percuss the liver. a normal liver measures 6 to 12cm, usually 8 to 12cm. The reliability of percussion to assess liver size is limited (Am J Gastroenterol 1995; 90:1428-32)

To percuss the spleen : Percuss in left anterior axillary line, just above lowest rib Ask your patient to take a deep breath and percuss again. Dullness with full inspiration may be a sign of enlarged spleen (splenomegaly)

CASE 2 A 65 year old man with a distended abdomen He drinks half a pint of bourbon daily and notes gradually increasing abdominal girth. He has no pain. Does he have ascites (fluid) caused by liver failure?

Inspection: Signs of liver disease: Jaundice (yellow cast to skin) Spider angiomas: subcutaneous vessels that look like spiders. They fill from the center when pressed. The liver enlarges early, later shrinks with cirrhosis Prominent veins at umbilicus Hemorrhoids Ascites

USING PERCUSSION to DIAGNOSE ASCITES Physical signs of ascites include fluid wave, shifting dullness and puddle sign. Two of these are done by percussion. Shifting dullness : Start with your patient supine. Percuss down the lumbar area closest to you; mark the point where note turns dull. Now turn the patient onto his/her side facing you and percuss down again. If the dull area is now higher (closer to the umbilicus), this suggests fluid in the peritoneum (ascites). Puddle sign (rarely done): Patient is on all fours, on hands and knees Percuss for a dull area around the umbilicus (lowest point)

PERCUSSION for renal angle TENDERNESS To look for renal causes of pain, such as pyelonephritis (kidney infection), you may percuss the back in the region of the costophrenic angle. Tenderness on one side may come from that kidney.

PALPATION Use palpation to assess: Liver, spleen and kidneys for enlargement and consistency Masses Tenderness Spasm of abdominal muscles Guarding=spasm when you push; sign of tenderness or inflammation Rigidity=board-like spasm all the time; sign of bad things like perforated intestine, dead intestine from lack of circulation (infarction), or diffuse infection peritonitis. Oversensitivity of skin = cutaneous hyperesthesia: a sign of inflammation of underlying structure

PALPATION TECHNIQUE Warm hands; use two hands and focus on what your lower hand feels. Bend your patient's knees to relax abdominal muscles If the patient is ticklish, include patient's hand between your two hands - a "hand sandwich" Examine tender areas last

PALPATION of LIVER Some hints: Push in fairly deeply, 5cm deep or more Inch your right hand up toward the patient's lower costal margin with each breath. The liver edge should be palpable, if at all, at the lower costal margin. It should feel rubbery and smooth

PALPATION of the KIDNEYS •  Kidneys are usually not palpable in adults unless quite enlarged (e.g. polycystic) •  The right is palpable more often than the left •  Kidneys are deep in the flank and move down with inspiration. Palpation for masses : Use deep pressure with the palmar aspect of your fingers, with a rolling motion.

CASE 3: What is that lump? You feel a mass when palpating your fellow student's abdomen. Normal "masses" include: Feces in the sigmoid colon (often slightly tender) Air in the cecum Distended bladder The uterus (e.g. pregnant) The aorta (it's pulsatile).

CASE 4 A 68 year old man with hypertension is here to be checked for anything life-threatening. Does he (or doesn't he) have an abdominal aortic aneurysm ? Palpation of aorta : Aorta is just to the left of the midline and is pulsatile If it seems 5 cm or wider: evaluate for abdominal aortic aneurysm .

HOW SENSITIVE IS PALPATION FOR DETECTING ABDOMINAL AORTIC ANEURISM? Aneurysms require surgery if larger than 5cm. Examination for abdominal aortic aneurysm (AAA) has sensitivity of: 82% if patient's girth is under 100 cm (40 inches) 100% if patient's girth is under 100 cm and aneurysm is over 5 cm             52% if patient's girth is 100 cm or more (Fink HA et al. The accuracy of physical examination to detect abdominal aortic aneurysm. JAMA 2000; 160(6):833-836.)

CASE 5 Does this patient have appendicitis? A 22 year old woman with abdominal pain: She awoke with periumbilical pain; now her pain is more in the right lower quadrant. She never had a similar pain before. She comes to the emergency room.

History that makes appendicitis more likely : Going to emergency room for pain: up to 25% under age 60 have appendicitis Right lower quadrant (RLQ) pain Pain that starts periumbilically and migrates to RLQ No similar previous pain Pain before vomiting .    

PHYSICAL FINDINGS Physical findings that make appendicitis more likely : Fever (often lowgrade, around 38 degrees) 79% sensitive - 21% of patients are afebrile Abdominal rigidity Tenderness on right side on rectal examination

Rebound tenderness : Push gently until pain decreases, then lift your hand suddenly. The pain is worse when you lift your hand - a sign of peritoneal irritation. A kinder way to test for rebound tenderness is called Rovsing's sign : you push down on the nontender side of the abdomen and lift your hand suddenly. Patient feels pain in the affected area (RLQ) when you lift your hand.

MORE PHYSICAL SIGNS of APPENDICITIS Psoas sign (not sensitive, but specificity 95%): Your patient lies supine and flexes his/her entire leg against your hand's resistance, causing pain Or: patient lies on his/her left side and you passively extend his/her hip; this causes pain Not tested, but similar, is the obturator sign : you passively flex and rotate patient's hip, stretching obturator muscle; this causes pain.

The area of tenderness in appendicitis should be McBurney's point: 1/3 of the way up a diagonal line from iliac crest to the umbilicus. Pain in RLQ near inguinal ligament in young women is most likely pelvic (ovarian cyst, pelvic inflammatory disease, abscess in fallopian tube) or urinary tract and NOT usually appendicitis.

MANTRELS Score Established in 1986 Migration of pain Anorexia Nausea / vomiting Tenderness RLQ Rebound Elevated temp. Leukocytosis Shift to left

MANTRELS Score, cont'd. RLQ tenderness and leukocytosis = 2 points each ; all others 1 point Score of 5 to 6 = possible appendicitis Score of 7 to 8 = probable appendicitis Score of 9 to 10 = very probable appendicitis

CASE 6: Right upper quadrant pain : A 70 year old woman has right upper quadrant (RUQ) pain for one day. Possible diagnoses: Cholecystitis (infected gall bladder) Cancer (gall bladder, pancreas, gastric) Pancreatitis (inflamed pancreas) Diverticulitis (infected pocket off colon).

USEFUL CLINICAL SIGNS of CHOLECYSTITIS Right upper quadrant tenderness Murphy's sign :   when you push toward the liver at the right costal margin, patient has pain and stops breathing in: a sign of gall bladder infection (cholecystitis). Palpable mass

AN UNCOMMON CLINICAL SIGN of PANCREATITIS Bruised lateral flanks due to bleeding: Grey Turner's sign

SUMMARY You now know: What you can learn by inspecting the abdomen Stop, look, and listen Sounds of intestinal obstruction Signs of ascites Palpation for abdominal aneurysm Symptoms and signs of appendicitis Signs of cholecystitis

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