1. Anatomy and Physiology of the Abdomen
Houses multiple major organs
Lined by peritoneal membrane
Greater & lesser omentum
Mesentery

2. Musculature and Connective Tissues
Linea alba
Rectus abdominis muscle
Linea alba (midline from xiphoid process to symphysis)
Inguinal ligaments (bilaterally from iliac to symphysis pubis)

3. Abdominal Variations-Pregnancy
Rectus abdominis
Umbilicus, striae, linea nigra
Striae, linea nigra
Colon
Peristalsis
Gallbladder
Renal pelvis, ureters

4. Abdominal Variations-Elderly
Motility/Peristalsis
Blood flow
Pain perception
Liver
Lean body mass, fat

5. Describing the Abdomen
Abdomen split into quadrants to help organize organs.

6. Describing the Abdomen
The abdomen can also be split into 9 sections as well.

7. Right Upper Quadrant (RUQ)
Liver & Gallbladder
Head of Pancreas
Duodenum
Right adrenal gland
Hepatic flexure of colon
Portion of right kidney

8. Right Lower Quadrant (RLQ)
Appendix
Ascending colon
Ovary
Right ureter
Bladder
Uterus

9. Left Upper Quadrant (LUQ)
Spleen
Stomach
Pancreas
Left lobe of liver
Splenic flexure of colon
Portions of transverse and descending colon

10. Left Lower Quadrant (LLQ)
Lower left kidney
Sigmoid colon
Ovary
Left ureter
Descending colon
Bladder
Uterus

11. Assessing the Abdomen Chief complaint History of present illness
Past medical history
Family history
Personal/Social history
Physical Exam
Differential
Labs

12. Importance of History Present Illness
GI versus cardiac causes
Clues to Differential
Abdominal “Review of Systems”
Seven attributes of a symptom

13. Review of Systems for the Abdomen
Abdominal pain
Indigestion
Nausea
Vomiting
Diarrhea
Constipation
Jaundice
Dysuria
Urinary frequency
Hematuria

14. Past Medical History Gastrointestinal disorders
• Review of Related History
Past Medical History
Gastrointestinal disorders
Urinary Tract Infections
Surgeries
Medications/Immunizations
Trauma/Injury
Blood transfusions
Hepatitis
Cancer

15. Family History Familial Mediterranean Fever Inflammatory bowel disease
• Review of Related History
Family History
Familial Mediterranean Fever
Inflammatory bowel disease
Familial cancer syndromes
Congenital malformations
Cystic fibrosis, Celiac’s
Kidney disease
Gallbladder disease

16. Personal and Social History
• Review of Related History
Personal and Social History
Nutrition
LMP (first day of last menstrual period)
Stressful life events
Travel /Exposure to infectious diseases
Sexual history
Use of alcohol and/or illicit drugs
Tobacco use

17. Pregnant Women Urinary symptoms Abdominal pain Contractions
• Review of Related History
Pregnant Women
Urinary symptoms
Frequency, urgency, burning, suprapubic pain
Back pain
Abdominal pain
Contractions
Onset, frequency, duration, intensity
Leakage of fluid, blood

18. Older Adults Urinary Tract Infections Constipation Indigestion
• Review of Related History
Older Adults
Urinary Tract Infections
Constipation
Indigestion
Dietary habits

19. Abdominal Exam Preparation Inspection Auscultation Percussion
Palpation

20. Preparation for the Abdominal Exam
Empty bladder
Positioning
Abdomen exposure
Visualize anatomy
Warm hands & stethoscope
Approach from the right
Remember chief complaint
Watch face

21. Inspection (1)
Skin characteristics: color, striae, rashes, lesions, scars, dilated veins
Umbilicus: location, displacement, inflammation
Contour: rounded, flat, scaphoid
Symmetry: symmetric, bulges, distension
Surface Motion: pulsations, peristalsis

22. Auscultation Bowel sounds: frequency, character
Vascular sounds: bruits, venous hums

23. Percussion (1) Assess size & density of organs
Detect presence of fluid, air, masses, tenderness
Can be done independently or concurrently with palpation

24. Percussion (2) All quadrants: tympany vs dullness
Liver span: at right MCL and at the MSL if enlarged
Spleen percussion sign: lowest left ICS before & after deep breath
Gastric bubble: left lower anterior rib cage, left epigastric area
Kidneys: costovertebral angle

25. Percussion (3)
If suspect ascites as result of percussion of abdominal wall may perform two additional tests: Shifting Dullness Test and the Fluid Wave Test

26. Palpation (1)
Evaluation of organs for: size, shape, consistency, tenderness
Evaluate umbilical ring
Palpate for pulsation of abdominal aorta
Detection of masses

27. Palpation (2)
Light Palpation: all 4 quadrants; identify muscular resistance, tenderness, masses
Deep palpation: all 4 quadrants; delineate organs and detect deeper masses
Mass: location, size, shape, consistency, tenderness, pulsation, mobility, movement with respiration, superficial or intra-abdominal

28. Palpation (3) Liver: palpate lower border of right costal margin
Aorta: for pulsation
Bladder: distension
Gallbladder, Spleen, Kidney not often done unless physician suspects abnormality

29. Additional Abdominal Tests
• Examination and Findings
Additional Abdominal Tests
Rebound tenderness
Iliopsoas muscle test
Obturator muscle test

30. Abdominal Signs/Associated Conditions
Blumberg (rebound tenderness)
Cullen: ecchymosis around umbilicus
Grey Turner: ecchymosis of flanks
Kehr: abdominal pain radiating to left shoulder
Markel (heel jar test): up on toes, fall back on heels
McBurney: rebound tenderness,pain over appendix
Murphy: abrupt cessation of respiration when gallbladder palpated

31. Differential by Anatomic Region-RUQ
Duodenal ulcer
Hepatomegaly
Hepatitis
Pneumonia
Cholecystitis

32. Differential by Anatomic Region-LUQ
Ruptured spleen
Gastric ulcer
Aortic aneurysm
Perforated colon
Pneumonia

33. Differential by Anatomic Region-Periumbilical Region
Intestinal obstruction
Acute pancreatitis
Early appendicitis
Mesenteric thrombosis
Aortic aneurysm
Diverticulitis

34. Differential by Anatomic Region-RLQ
Appendicitis
Ovarian cyst or mass/salpingitis
Ruptured ectopic pregnancy
Renal/ureteral stone
Strangulated hernia
Perforated cecum/regional ileitis
Diverticulitis

35. Differential by Anatomic Region-LLQ
Ovarian cyst or mass/salpingitis
Ruptured ectopic pregnancy
Diverticulitis
Renal/ureteral stone
Strangulated hernia
Ulcerative colitis
Perforated colon/regional ileitis

36. Acute Appendicitis
Pain characteristic: periumbilical or epigastric; later localized to RLQ, +McBurney
Associated findings: anorexia, nausea, possible vomiting, low grade fever, guarding, +rebound tenderness, +iliopsas, +obturator, +McBurney, +Markle
Peritonitis possible if rupture occurs: guarding, shallow respirations, hypotension or shock, reduced or absent bowel sounds; can be life-threatening

37. Acute Cholecystitis
Pain: severe pain in RUQ, epigastric or umbilical pain; lasting 2-4 hours; after meals and especially after fatty meal; may be referred to right subscapular area
Associated findings: RUQ tenderness & rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, flatulence, fever; possible jaundice

38. Acute Pancreatitis
Pain: dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks with possible ecchymosis; pain may be referred to left shoulder
Associated findings: epigastric tenderness, vomiting, fever, shock; +Grey Turner and Cullen signs which occur 2-3 days after onset

39. Ectopic Pregnancy
Pain: history of vague abdominal pain followed by sudden severe abdominal tenderness in LQ, especially on involved side
Associated findings: hypogastric tenderness, symptoms of pregnancy, spotting, missed period, mass on bimanual pelvic exam; if ruptured: shock, rigid abdominal wall, distension, + Kehr, + Cullen
Mittleschmertz: pain associated w/ovulation

40. Acute Hepatitis Pain: general abdominal discomfort; malaise
Associated findings: jaundice, clay-colored stools and dark urine which may preceed jaundice by 1 to 5 days, enlarged liver
Patients with cirrhosis: will also have ascites, prominent abdominal vasculature, cutaneous spider angiomas, generalized itching

41. Perforated Gastric or Duodenal Ulcer
Pain: abrupt RUQ; may be referred to shoulders
Associated findings: abdominal free air and distension with increased resonance over liver; tenderness in epigastrum or RUQ; rigid abdominal wall, rebound tenderness; hematemesis, melena, hypotension, increased pulse rate; “acute abdomen” is a life-threatening event

42. Abdominal Aortic Aneurysm
Pain: painless but pain may indicate imminent rupture; steady throbbing midline pain over aneurysm which may radiate to back, flank
Associated findings: nausea, vomiting, prominent aortic pulsation, bruit and or mass
Life-threatening even if occurs in hospital setting

43. Pyelonephritis Pain: flank pain, back pain
Associated findings: malaise, dysuria, nocturia, urinary frequency, possible fever, + costovertebral angle tenderness

44. Renal Calculi
Pain: intense flank pain extending to groin & genital area; may be episodic
Associated findings: fever, hematuria, + Kehr

45. Irritable Bowel Syndrome
Pain: crampy, variable hypogastric pain; associated with abdominal bloating, distension; + bowel sounds
Associated symptoms: flatus, constipation or diarrhea; may see mucous in stool; relief with passage of flatus or bowel movement

46. Diverticulitis
Pain: epigastric, radiating down left side of abdomen especially after eating; may be referred to back
Associated findings: tenderness on palpation, borborygmus, flatulence, diarrhea, possibly dysuria

47. Acute Diarrhea Pain: abrupt onset of crampy pain
Associated findings: increased bowel sounds, diarrhea, nausea, vomiting, fever, and tenesmus; consider food poisoning if develops in 2 or more following ingestion of same food

48. Hernia Pain: localized pain that increases with lifting or exertion
Associated findings: hernia on physical exam, history of abdominal trauma, surgery

49. References
Mosby’s Guide to Physical Examination, 6th Edition. Chapter 17 pp
Bates’ Guide to Physical Examination and History Taking. Chapter 9 pp
University of California, San Diego “A Practical Guide to Clinical Medicine” Accessed online 02/09/07 at medicine.ucsd.edu/clinicalmedicine/