Abdominal Examination

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• The abdominal examination involves,sequentially:

• inspection

• palpation

• percussion

•auscultation

Inspection of the abdomen involves firstlooking from the foot of the bed along the

length of the patient -

Points to note include:• symmetry• scars•

pulsatile masses• movements of abdominal wall with

respiration• distension - fat, faeces, flatus, foetus,

tumour, caput Medusae, umbilicus• visible peristalsis• striae

• Caput Medusae is distinguished frominferior vena cava obstruction bydetermining the direction of flow in the

veins below the umbilicus; it is towardsthe legs in the former, and towards thehead in the latter

clinical features of portal

hypertension• Presenting features may include:

• haematemesis or melaena - due to rupture ofgastro - oesophageal varices

•ascites - with low plasma albumin

• hepatic encephalopathy

• porto-systemic shunts - e.g. caput Medusae

• venous hum

• haemorrhoids

• peripheral oedema

• venous hum in the abdomen

• Uncommonly, in portal hypertension, a

venous hum can be heard between thexiphisternum and the umbilicus. It isdue to increased blood flow in theumbilical and paraumbilical veins in thefalciform ligament.

general examination

• Abdominal pathology often has asystemic effect, equally systemicdisease may present as an abdominal

disorder.

• general appearance

• mental state

skin • hands

• arms

• face • neck and chest

general appearance

• jaundice

cachexia

mental state•

The mental state of a patient may be alteredby a variety of abdominal pathologiesincluding:

• hepatic encephalopathy• uraemia encephalopathy• electrolyte disorders caused by, for example:

– diarrhoea – bowel fistulae – vomiting – pancreatitis

• hypoglycaemia: – liver failure – insulinoma

• Gastrointestinal tract and the skin havea common origin from the embryoblast.Therefore occasionally gastrointestinaldisease is sometimes reflected in skinchanges

Peutz-Jegher's syndrome

• mucocutaneous pigmentation - mainly, ofthe lips, buccal mucosa, genitalia, handsand feet

• multiple hamartogenous polyps of thegastrointestinal tract - most often in thesmall bowel but may occur affect any

portion of the GI tract

Spider naevi They contain a central large blood

vessel with tiny vessels radiating from the center,

hence the name.

Palmer Erythema

• Signs in the hands may reflect pathologyin various abdominal systems:

• chronic liver disease:

– palmar erythema

– leukonychia

– asterixis

– clubbing in cirrhosis

asterixis

• It is commonly associated with liver failurewhere it produces the flapping tremor ofhepatic encephalopathy characterised by

jerky, irregular flexion-extensionmovements at the wrist andmetacarpophalangeal joints,

Leuconychia

• Leuconychia or "white nail" is an abnormalwhiteness of the nails, either in total, partial(spot) or striate (streaks) forms. It may be

congenital or acquired.• Leuconychia may occur spontaneously or after

minor trauma.

• In association with generalised disease it isusually caused by the hypoalbuminaemia ofchronic liver disease.

palpation

• Palpation of the abdomen should always ensurethe feeling of areas that might otherwise beforgotten:

• feel the supraclavicular fossa for lymph nodes• feel the hernial orifices at rest and when the

patient coughs: external inguinal ring, femoralcanal and umbilicus

• feel for femoral pulses• examine the external genitalia• Examine the back

• general light palpation for tenderness

• palpation of the normal solid viscera(liver,spleen,kidneys)

• palpation of the liver

• Palpation aims to provide the followinginformation on the liver:

size• shape

• surface - smooth or nodular

• consistency - soft or hard

• tenderness - tender or non-tender

• pulsatility

• palpation of the spleen

• Palpation starts in the right iliac fossa withthe right hand aligned parallel to the rightcostal margin.

palpation of the kidneys

• Examination of the kidneys should be a routine part ofthe abdominal examination. A bimanual technique isused.

• With the patient supine, slide one hand underneath the

back so that the heel of the hand rests under the loin.Place the other hand over the upper quadrant on thesame side.

• First, attempt to capture the kidney between the twohands. If this is not possible, ballot the kidney; flex the

fingers of the posterior hand at the metacarpophalangeal joints in the renal angle so that the abdominal contentsare pushed anteriorly. The kidney should then floatupwards and strike the anterior hand.

percussion of the liver

• The liver is percussed to estimate its size, and therefore,to differentiate true enlargement from false.

• The liver span is estimated by percussing the width of

the liver down the thorax and abdomen. The upperborder of the liver is normally level with the sixth rib inthe mid-clavicular line. Start percussing from a pointabove this, and progress downwards until the notechanges from resonant to dull. Measure from this

position to the palpable liver edge. It should be less than12.5 cm.

ascites

• Ascites describes an abnormal collection of fluid in theperitoneal cavity.

• When ascites collects, the influence of gravity causes itfirst to accumulate in the flanks of a supine patient. Thus,

a relatively early sign of ascites - when at least two litresof fluid have accumulated - is a dull percussion note inthe flanks.

• With gross ascites, abdominal distension and umbilicalinversion may occur and dullness is detectable closer to

the middle line. However, an area of central resonancewill always persist.• Routine abdominal examination should include

percussion starting in the middle line with the fingerpointing parallel to the level of the fluid; the percussion

note is sounded out towards the flanks on each side.

• Traube's space

• Traube's (semilunar) space is an anatomicregion of some clinical importance. It's a

crescent-shaped space, encompassed by thelower edge of the left lung, the anteriorborder of the spleen, the left costal marginand the inferior margin of the left lobe of the

liver. Thus, its surface markings arerespectively the left sixth rib, the left anterioraxillary line, and the left costal margin.

Abdominal Examination

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