Division of Gastroenterology, Union Hospital Union Hosital ABDOMINAL EXAMINATION Zhu Liangru Division of Gastroenterology, Union Hospital
Range of Abdomen Superior:diaphragma Inferior: pelvis Lateral: lateral abdominal wall Anterior: anterior abdominal wall Posterior: back bone,psoas
Abdominal Mark & Area
Abdominal Mark Midabdominal line Upper abdominal angle Xiphoid process Costal margin umbilicus Lateral border of rectus muscles Anterior superior iliac spine Inguinal ligament
Abdominal Mark Costal margin composed of 8th-10th costal cartilage; abdominal area liver measure Xiphoid process elongation of breast bone; measurement of liver Epigastric angle included angle of costal arch; judge body type measurement of liver Umbilicus center in abdomen;abdominal area Anterior superior iliac spine the outstanding place of anterior of spine iliac Lateral border of rectus muscles elongation of midclavicular line;operative incision Midabdominal line elongation of anterior of median line; abdominal area Inguinal ligament mark of femoral artery,femoral vein Costalspinal angle included angle of 12th costal bone and back bone
Abdominal Area
Abdominal Area: Nine regions left hypochondriac region right hypochondriac region epigastric region left lumber region right lumber region umbilieal region right iliac region left iliac region hypogastric region
Nine regions & Projection spleen stomach transverse colon gallbladder ascending colon small intestine ileum sigmoid colon urinary bladder
Abdominal Area: Four regions left upper quadrant right upper quadrant right lower quadrant Left lower quadrant
Abdominal Area: Seven regions Epigastric region Right upper abdominal region Left upper abdominal region Umbilieal region Left lower abdominal region Right lower abdominal region Hypogastric region
Secquence of Abdominal Examination Examination secquence inspection, auscultation, palpation , percussion Recording secquence inspection, palpation, percussion, auscultation
Inspection
Attention of Inspection The patient is relaxed and in a proper position. The patient is in a supine position, the head should be elevated on a pillow, abdomen is thoroughly exposed (from nipple to symphysis pubic). Proper time to examination. Light is adequate and soft, and comes from one side of head. Inspector stands on the patient’s right side, secquence is from upper to lower. examination in tangent direction.
Method of Inspection
Normal:flat 、full、low Abdomial Shape Normal:flat 、full、low
xiphoid process umbilicus symphysis pubic low flat full
whole abdominal bulge: ascites frog belly apical belly pneumatosis macrosis mass part abdominal bulge: organ intumesce (liver intumesce) tumor (stomach.liver,pancrease) inflammatory mass (tuberculous peritonitis) distension (stomach distension) mass in abdominal wall hernia ( umbilical hernia, indirect hernia)
Inspection in Ascites
Differential Diagnosis in mass in abdominal wall and mass in abdominal cavity
Abdominal Retraction whole abdominal retraction athrepsy dehydration cachexia (boat-belly) part abdominal retraction : postoperative scar
Boat shaped-abdomen
Respiratory Movement Abdominal breathing: adult male, children Costal breathing: adult female attenuated in abdominal breathing : acute abdomen, ascites, macrosis mass, pregnancy reinforcement in abdominal breathing : diseases in thoracic cavity(hydrothorax), hysteria
Abdominal Vein
Generally we can’t find distended abdominal vein in normal people. Prominence of distended veins indicates increased collateral circulation as a result of obstruction in the portal venous system or in the vena cava The normal direction of blood flow is away from umbilicus. The upper abdominal veins carry blood upward to the superior vena cava, the lower abdominal veins carry blood downtoward to the inferior vena cava.
Portal hypertension Inferior vena cava obstruction
Method to Judgement the Direction of Blood Flow
Gastrointestinal pattern & Peristalsis
Generally we couldn’t find gastrointestinal pattern and peristalsis in normal people. Gastrointestinal obstruction: gastral pattern intestinal pattern peristalsis
Small bowel obstruction colon obstruction
Others Information
skin rash: infection diseases, drug allergy, herpes zona pigments: Addison disease, Grey-Turner sign, Cullen sign ventral stripe: striae albicantes, purple striae (hypercortisolism) scar: operation, trauma, infection hernia: umbilical hernia, oblique inguinal hernia, direct hernia umbilicus: evection, depression, secrection hairs: disposition, increase, decrease pulsation: abdominal aneurysm, increasing in right ventricle of heart
Palpation
Method of Palpation The patient is relaxed position The patient is in a supine position, the head should be elevated on a pillow, genuflex, slowly abdominal respiration Inspector stands right beside patient Start from left iliac region, anti-clock wise, “S” shape Commence palpation at a site remote from the area of pain All areas of abdomen must be palpated systematically
Abdominal Palpation Light palpation Deep palpation
Tensity
Increase of tensity Intestinal distension, ascites, artificial pneumoperitoneum rigidity(board-like rigidity) acute diffuse peritonitis dough kneading sensation tuberculous peritonitis, carcinomatous peritonitis Decrease of tensity Chronic wasting disease, multipara, aged, dehydration
Tenderness & Rebound tenderness
tenderness rebound tenderness
1. Gastritis or gastric ulcer 2. Duodenal ulcer 3. Pancreatitis or tumor 4. Cholecystitis cholelithiaisis 5. appendicitis 6. Disease of intestine 7. Disease of urinary bladder,uterus 8. Ileocecal junction 9. sigmoid 10.spleen,splenic flexure of colon 11.liver,hepatic flexure of colon 12.pancreatitis
McBurney point ant. Sup. spine
Palpation of Organs
One hand palpation Bimanual palpation Hooking technique
Ballottement palpation
Knee-elbow Position Palpation
Attention in palpation of liver Anterior-lateral finger pulp to palpate organs Place your hand flat with fingers pointing towards the patients’s head position of palpation at exterior margin of rectus abdominis palpate deeply while asking the patient breathe in and out deeply start in the right iliac fossa when examining macrosis liver 应与肝脏鉴别的脏器: 横结肠为横行条索状物,与肝脏质地不同 腹直肌腱划左右两侧对称,不随呼吸移动 右肾下极位置较深,边缘圆顿,不能掀起下缘
Differential Diagnosis Transverse colon rectus abdominis tendon Lower lobe of right renal
Technique of Liver Palpation lung liver
Projection of Liver Perpendicula distance 4-8cm Perpendicula
Measurement
Description of liver Size :below right costal margin 1cm, below xiphoid porcess 3cm Texture:three grade---soft,moderate, hard Surface:slick, nodus Edge:thickness, regularity Tenderness:no tenderness in normal liver hepatojugular reflux Pulsation:conduct pulsation, expansile pulsation Scrape:inflammatory surrounding liver Liver thrill:ballottement ---hepatic echinococcosis
Manipulation of palpation of spleen
Measurement of spleen Line I:distance from the across point of left medioclavicular line and costal border to inferior margin of spleen Line II: distance from the across point of left medioclavicular line and costal border to ultima thule of spleen Line III: distance from right border of spleen to anterior median line
Enlarged spleen moderate cirrhosis, chronic lymphocytic leukemia, mild acute hepatitis, typhoid,acute malaria, septicemia moderate cirrhosis, chronic lymphocytic leukemia, chronic hemolytic jaundice, lymphoma severe chronic granulocytic leukemia, myelofibrosis
Description of liver Description of spleen Size Texture Surface Edge Tenderness Pulsation Scrape
Palpation of gallbladder manipulation one hand slipping palpation or hook Murphy sign Courvoisier sign
Palpation of Kidney (A) Place left hand in the right or left loin posteriorly. (B) Place the right hand on the abdomen anteriorly and press gently dowmwards. Push the left hand upwards. A palpable kidney can be balloted between the two hands.
The kidney may be palpable in thin normal individuals. The right kidney lies lower than the left, so it is more likely to be palpable. Nephroptosis enlarged kidney is found in nephrydrosis, empyema, tumor of kidney, polycystic renal disease
Tenderness Point of nephric duct and Kidney Upper nephric duct point hypochondrium Costa-carinal point 肋腰点 Costa-lumbar point Upper nephric duct point middle nephric duct point ventral aspect Back side
Mass in Abdomen
“Mass” in normal abdomen rectus muscle belly & tendinea body of lumbar vertebra cochlear of sacral bone stoolmass in sigmoid colon transverse colon caecum
Abnormal Mass Location Size length,broad,deep Shape skeleton,edge,surface Texture Tenderness Pulsation Degree of excursion
Fluid thrill (Fluctuation)
Manipulation of fluid thrill patient assistant inspector fluctuation Assistant places his hand vertically at the anterior median line, Examiner places hand flat at both side of lateral abdominal wall, One hand percuss one side abdominal wall, fluctuation can be sensed in another hand
Succussion Splash Succussion splash can exist in people after meal or drinking Succussion splash exists in fast or 6-8 hours after meals suggests pyloric obstruction or gastric dilatation
Percussion Percussion is used to demonstrate the presence of gaseous distension and fluid or solid masses. Light percession is preferable, since it produced a clearer tone.
Abdomen Percussion Sound All four quadrant of abdomen are evaluated by percussion Tympany is the most commom percussion note in abdomen presence of gas within the stomach,small bowel,colon. Dullness exists in liver (right hypochondrium region) spleen (left hypochondrium region) distended urinary bladder (suprapubic area) enlarged uterus (suprapubic area) psoas (back side)
Increasing in Dullness region organ swell tumor ascites Increasing in tympany gaseous distension perforation
Percussion of Liver upper border of liver right midclavicular line right anterior axillary line right scapular line relative dullness area resonance dullness absolute dullness area dullness flatness
right midclavicular line Anterior median line lower border of liver right midclavicular line Anterior median line tympany dullness
Normal Liver Border upper border right midclavicular line the fifth interspace right axillary line the senenth interspace right scapular line the tenth interspace lower border right midclavicular line right costal margin
Measurement Size right midclavicular line 9-11cm anterior median line 4-8cm
Change of Liver Border Increasing in liver dullness area liver carcinoma, liver abscess, hepatitis, polycystic Decreasing in liver dullness area acute hepatic necrosis, cirrhosis, gaseous distension Absence of liver dullness area acute perforation of hollow viscus
Percussion Tenderness of Liver and Gallbladder
Traube Area Traube area 9.5cm×6.0cm
Percussion of Spleen left midaxillary line normal spleen border route left midaxillary line normal spleen border left midaxillary line the ninth-eleventh interspace longitude 4-7cm Change of spleen border increasing enlarged spleen decreasing gastric dialation, distension
Shifting Dullness The quantity of ascites is more than 1000ml
Percussion of ascites tympany dullness
Shifting Dullness supine tympany dullness tympany dullness lateral position
Manipulation supine lateral position Place left hand on the umbilicus region, right hand percuss. note central tympany. Move left hand to one side of abdominal wall,then rotate patient onto another side. Notice that dullness has shifted toward the umbilicus on the dependent side. Tympany area has shifted toward the superior flank.
Differential diagnosis between Ovarian cyst and ascites
Differential diagnosis between Ovarian cyst and ascites tympany tympany dullness dullness ovarian cyst ascites
Ruler Pressing test
Sensitive to percussion in Ridge costal angle
Projection of ridge costal angle right kidney ridge costal angle
Sensitive to percussion in ridge costal angle
Bladder Percussion Location:suprapubic area Empty bladder tympany Filling with urinary dullness
Auscultation
Area of Abdominal Auscultation pancrease liver spleen abdominal aorta gurgling sound arteria renalis
Bowel Sound Normal 4-5/min Active >10/min Auscultation of bowel sounds can provide information about the motion of air and liquid in the gastrointestinal tract. Normal 4-5/min Active >10/min Hyperactive mechanic intestine obstruction Hypoactive Absent paralytic intestine obstruction
Vascular Murmur Arterial murmur center of abdomen: abdominal aneurysm abdominal aorta stenosis left or right upper quadrant: renal arterial stenosis bilateral of inferior belly:arteria iliaca stenosis left lobe of liver:left lobe carcinoma Venous murmur portal hypertension:umbilicus or epigastrium continious buzz
Friction Sound Splenic infarction Perisplenitis Zuckergussleber Cholecystitis Peritonitis
Scratch Sound
Identify lower edge of liver
Small amounts of ascites:puddle sign
Thank you!