1. ABDOMINAL EXAMINATION
Prof. Dr. Çiğdem ARIKAN
YDÜ TF Çocuk Gastroenteroloji, Hepatoloji ve Beslenme BD

2. Road map Anatomy Regions Examination Inspection Auscultation
Percussion
Palpation
Liver and spleen
4. Specific maneuvers

6. Regions

7. Physical Exam Technique
Inspection- eye only.
Palpation- tip of finger.
Percussion- use. . .
Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ).
Auscultation- stethoscope.

8. the contents of inspection 1. abdominal contour 2
the contents of inspection abdominal contour respiratory movement abdominal veins peristalsis abdominal skin
Inspect the contour of the abdomen. It
may be flat, rounded, protuberant, or
scaphoid
􀂄 Are there any visible pulsations/masses?
􀂄 Do the flanks bulge (ascites)?
􀂄 Inspect skin (scars,striae,veins,rashes)
􀂄 Inspect umbilicus

9. Inspection The skin: scar, striae, dilated vein, rashes and lesions
The umbilicus: contour, inflammation, bulges
The contour of the abdomen: flat, rounded, protuberant, scaphoid
Peristalsis
Pulsations: abdominal aorta in the epigastric region.

10. DILATED VEIN OF HEPATIC CIRRHOSIS

11. Spider Naevi are found only in the distribution of the superior vena cava, most commonly on the face and the anterior chest wall. They comprise an enlarged central arteriole from which vessels radiate in a spoke-like
manner.

13. UMBILICAL HERNIA IN NEWBORN

15. Contour of the abdomen
SCAPHOID
( diaphragmatic hernia)
PROTUBERANT

19. Budd-Chiari

21. Abdominal Physical Exam Auscultation
4 quadrants
15-20 seconds
Bowel sounds
Frequency
Pitch
Vascular Sounds
Renal
Iliac
Femoral

22. Auscultation Useful in assessing bowel motility and vascular bruits
Note frequency/character of the bowel sounds (borborygmi) with stethoscope.
Listen in one spot. Listen for bruits.
No particular bowel sound is diagnostic but rushes and high pitched tinkles suggest obstructed gut.

23. Auscultation Listen for peristalsis or bowel sounds for full minute.
Listen for bruit of the major arteries.
Listen around the umbilicus and epigastric region for venous hum (soft low pitched and con.).

24. Bowel Sounds Normal: every 10 to 30 seconds.
Listen in each quadrant long enough to hear at least one bowel sound.
Absent
Hypoactive
Normoactive
Hyperactive

25. Palpation
For the ticklish child: place her hands over your hands and have the child do the pressing down.

26. Palpation Palpate lightly then deeply in all four quadrants
Differentiate between voluntary and involuntary guarding
If a mass is detected note its location,
size, shape, consistency, tenderness,
pulsation, and mobility

27. Abdominal Physical Exam Palpation - Right Upper Quadrant
Liver: right lobe
Gallbladder – Murphy’s sign
Stomach: pylorus
Duodenum: parts 1-3
Pancreas: head
Right suprarenal gland
Right kidney
Right colic (hepatic) flexure
Ascending colon: superior part
Transverse colon: right half
Liver
Lied deep to ribs 7 through 11 and crosses midline to left nipple
Sharp inferior border follows right costal margin
More inferior when erect
Inspire deeply and may palpate
Place left hand posteriorly between right 12th rib and iliac crest then place right hand on right upper quadrant - pt takes a deep breath
Gallbladder – Murphy’s sign

28. Abdominal Physical Exam Palpation - Right Lower Quadrant
Cecum
Vermiform appendix
McBurney’s point
Rovsing’s sign
Psoas sign
Obturator sign
Most of ileum
Ascending colon: inferior part
Right ovary
Right uterine tube
Right spermatic cord
Uterus (if enlarged)
Urinary bladder (if full)

29. Abdominal Physical Exam Palpation - Left Lower Quadrant
Sigmoid colon
Descending colon: inferior part
Left ovary
Left uterine tube
Left ureter: abdominal part
Left spermatic cord: abdominal part
Uterus (if enlarged)
Urinary bladder (if full)

30. Abdominal Physical Exam Palpation - Left Upper Quadrant
Liver: left lobe
Spleen
Stomach
Jejunum and proximal ileum
Pancreas: body and tail
Left kidney
Left suprarenal gland
Left colic (splenic) flexure
Transverse colon: left half
Descending colon: superior part
Spleen
Between 9th - 11th ribs
Does not extend inferior to the left costal margin

31. Palpation Assess peritoneal irritation and rebound tenderness
Palpate liver, spleen, inguinal and femoral
lymph nodes

32. Percuss the liver in mid-clavicular line.
Assess size by percussing upper and lower
borders.
In COPD, normal sized livers are frequently palpated and lower border may be displaced downward.

34. Extras Abdominal Aorta Inguinal Lymph Nodes
Costovertebral angle (CVA) tenderness

36. Abdomen: Key Points Contour Bowel Sounds & Peristalsis
Skin: color, veins
Umbilicus
Assess for Tenderness, Ridigity, Tympany, Dullness
Hernias: umbilical, inguinal, femoral
Masses - size, shape, dullness, position, mobility
Liver, Spleen, Kidneys, Bladder

37. Abdominal Physical Exam Percussion
Notes Elicited
Tympanic
Predominant due to gas in GI tract
Hyperresonant
Dull
Organs, fluid and feces
Flat
Distension of abdomen
Fluid vs. Air
Outline Organs
Liver, spleen, and gastric bubble
Liver more than 2-3 cm below costal margin may be sign of enlargement
An enlarged spleen expands anteriorly, downward, and medially, often replacing the tympany of the stomach and colon with the dullness of a solid organ then moves below the costal margin
Tympany: musical note of higher pitch than resonance – air filled space
Hyperesonance: lies between tympany and resonance – base of left lung
Resonance: moderate pitch – lung tissue or over abdomen
Dullness: short high itch note with little resonance – solid organ

38. PERCUSSION Percuss lightly in all four quadrant
Distribution of tympany and dullness.

39. Abdominal Girth Abdominal girth should be measured over the umbilicus
Whenever possible.

40. Akut Dehidratasyon >%10 Dehidratasyon Pilisi

41. Abdominal Physical Exam Practice- 20 Minutes
Inspection
Contour
Skin
Movement
Auscultation
Bowel sounds
Vascular sounds
Percussion
Abdomen for masses or fluid
Liver span
Spleen
Gastric bubble
Palpate
General palpation
Liver
Gallbladder
Spleen
R and L kidneys
Abdominal aorta
Inguinal lymph nodes
Special:
Murphy’s sign
McBurney’s point
Rovsing’s sign
Psoas sign
Obturator sign
Rebound tenderness
CVA tenderness

44. Acute posterior fissure (arrow)
Acute posterior fissure (arrow). Anterior and posterior fissures are most common. Fissures can often be identified by merely spreading the glutei but generally require anoscopy. When fissures are found laterally, syphilis,
tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, herpes, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as causes.
Thrombosed external hemorrhoids (long arrow) and perianal tags from "old" disease (short arrow).

45. Anal tag (arrow). Anal tags should be removed or a
biopsy should be obtained to confirm the etiology.
Anoscopy may enable the physician to identify the cause
or find other lesions.
External site of perianal fistula. This patient presented
with "just a little blood when I wipe."