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  2. Overview  The abdominal examination should include the following:  - General inspection from the end of the bed.  - General examination of:  o Hands / pulse  o Face  o Lymph nodes  - Examination of the abdomen.  o Inspection  o Palpation  o Percussion  o Auscultation
  3. Exam of the Abdomen Anatomy Observation Auscultation Percussion Palpation Findings Associated with Advanced Liver Disease
  4. Preparation  - Introduce yourself to the patient if you have not already done so and check the identity of the patient  - Wash your hands  - Ask the patients permission to carry out the examination  - Give a brief explanation to the patient before you start. Further explanation/instructions can be given as you proceed.
  5. Equipment   o Stethoscope
  6. Patient position  o Ideally the patient should be lying flat with the head propped on a single pillow and the arms at the sides.  o When you are ready to examine the abdomen it should be exposed from above the costal margins to the level of the symphysis pubis.
  7. Draping the Abdomen
  8. General Observations  Check visually from the end of the bed. Note:  o Obvious discomfort/pain, breathlessness, distension  o Colour
  9. Hands  - Inspect both hands; nails, back and then palms.  o You should be able to recognise, and know the significance of, the following: anaemia, dehydration, clubbing, leukonychia, koilonychia, palmar erythema, Dupuytren's contracture, spider-naevi.  - Feel the radial pulse. Note the rate, rhythm and volume  - Check for hepatic flap of liver failure (if appropriate)  o Ask patient to stretch arms out in front of them with the wrists dorsi flexed and fingers extended.  o Look for irregular, jerky flexion/extension at the wrists and MCP joints
  10. Eyes  - Gently pull down lower eyelids and ask the patient to look up. Inspect for:  o pale conjunctiva of anaemia  o yellow sclera of jaundice – ideally in natural light
  11. Mouth  - Ask patient to open their mouth. Inspect the teeth, tongue, gums and inner surface of the cheeks  o You should be able to recognise, and know the significance of, the following: ulcers, candidiasis, changes to the tongue e.g. glossitis, macroglossia,  - Note any obvious odour of the patients breath e.g. Fetor hepaticus, ketosis, uraemia
  12. Neck  - Palpate for enlarged lymph nodes, first from the front, then back/right.  o Occipital  o Post-auricular  o Pre-auricular  o Submandibular  o Submental  o Anterior and posterior cervical  o Supraclavicular (check for Virchow’s Node)
  13. Note  Virchow’s Node – An enlarged supraclavicular lymph node on the left-hand side. Suggestive of gastric malignancy
  14. The Abdomen Think Anatomically
  15. Quadrants of the Abdomen
  16. INSPECTION  With the abdomen exposed, look carefully for  - Scars, abdominal distension, focal swelling, asymmetry  - You should be able to recognise, and know the significance of, the following: dilated/prominent veins, visible peristalsis, obvious pulsation, skin discolouration.  - Note the location and nature of any surgical stomas
  17. Various Causes of Abdominal Distension
  18. Obese abdomen
  19. Hepatomegaly
  20. Ascites
  21. Markedly enlarged gall bladder (labeled "GB")
  22. Umbilical Hernia
  23. Same umbilical hernia while patient performs valsalva maneuver
  24. PALPATION  You should be at the same level as the patient to palpate the abdomen, looking at the patients face for any signs of discomfort  The abdomen should be examined by light (superficial) and deep palpation in all 9 areas before examining specific organs. The order they are examined in does not matter. Remember to examine any areas of tenderness last. Ask the patient if they have any pain before commencing.
  25. Light Palpation  - Gently palpate all nine areas  - Start away from known pain.  - Hold your hand flat, and gently press in by extending at the MCP joints to palpate  with the palmar surface of your finger - not digging in with your finger tips.  - If there is pain on light palpation, try and determine if this is rebound tenderness
  26. Deep Palpation  - Re-examine using the same technique but now using more pressure  - Note any masses or structural abnormality  - Masses should be described in terms of site, size, shape, surface, consistency, mobility, movement with respiration, tenderness and pulsatility
  27.  Rebound Tenderness – pain is worse when you release pressure on the abdomen than when you press down – this is a sign of peritoneal irritation
  28.  The Liver  - The liver is not normally palpable.  - Start palpation from the right iliac fossa using the same technique as before but angle your hand so that the index finger is aligned with the costal margin  - Ask the patient to take breaths in and out as you proceed, and feel for the descending liver edge on inspiration  - If the liver is not felt move your hand 1-2cm superiorly toward the right hypochondrium during expiration, ready to apply gentle pressure again during inspiration  - Repeat this process until the liver edge is palpated or you reach the costal margin.  - Describe your findings  o Note how far beyond the costal margin the liver extends in centimetres  o Is the surface smooth or irregular?  o Is there any tenderness?
  29. Practice Tip!  The liver edge is sometimes palpable just below the costal margin at the height of inspiration in normal healthy individuals.  Practice your technique on your colleagues
  30.  The Spleen  - Start palpation from the right iliac fossa moving diagonally toward the left hypochondrium  - Ask the patient to take breaths in and out as you proceed and use the same technique as for the liver  - Describe your findings as for the liver.  - In healthy individuals the spleen is not palpable. It enlarges along the line of the 9th rib and moves downwards and inwards on inspiration.  - The spleen has a distinctive ‘notch’ which can help to differentiate it from other structures in splenomegaly
  31.  The Kidneys  - The kidneys are not normally palpable; however, you may feel the lower pole of the right kidney in a thin person.  - Place your left hand behind the patients back just below the ribs at the right hand side  - Place your right hand on the abdomen below the right costal margin just lateral to the rectus abdominis.  - Ask the patient to breathe out and push your hands together firmly (but gently)  - Ask the patient to breathe in. You may feel the lower pole of the kidney moving down between the hands  - If this happens try to ‘Ballot’ or push the kidney back and forward between your hands  - Repeat for the left kidney by leaning over and placing the left hand under the left loin.
  32.  Ballotting the Kidney  This demonstrates the mobility of the kidney - helping to confirm what the structure is.
  33. Practice Tip!  The right kidney lies a little lower than the left. The lower pole of the right kidney may be palpable in normal, thin individuals.
  34.  Bladder  - Palpable suprapubically if full  - Start palpation from umbilicus with index finger horizontal and proceed inferiorly toward symphysis pubis
  35.  Aorta  - Palpate in the vertical midline of abdomen above the umbilicus.  - Place the fingers on either side of the outer margins, feeling for pulsation  - Normal diameter is 2-3cm  - Palpable in most healthy people.
  36. PERCUSSION  - You should percuss any lumps or masses identified on palpation to determine their size and nature  - Percuss individual organs to help determine their size (you may see some clinicians percuss the 9 regions)  - If the abdomen appears distended and you suspect the presence of ascites test for ‘shifting dullness’ and ‘fluid thrill’
  37.  Tympanitic (drum-like) sounds produced by percussing over air filled structures.  Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.
  38.  Percussion may reveal enlargement of the spleen that is not detectable on palpation. This is because the spleen would have to be 2-3 times its normal size to be palpable on abdominal examination
  39.  The Liver  - Percuss from right iliac fossa upwards  - Identify both the lower and upper borders of the liver  - Note the length in centimetres at the midclavicular line
  40.  The Spleen  - Percuss from the right iliac fossa diagonally toward the left hypochondrium  - Continue percussing over the ribs toward the midaxillary line and lower left ribs for dullness.
  41.  Bladder  - Begin percussing from just above the umbilicus with the finger positioned horizontally on the abdomen  - Percuss inferiorly toward the symphysis pubis.
  42.  Shifting Dullness  - Percuss from the centre of the abdomen laterally with the fingers positioned longitudinally until dullness is detected.  - Keep your finger pressed there (or mark the spot with a pen) as you  - Ask the patient to roll on to the opposite side to where you have marked  - Wait at least 30 seconds  - Repeat percussion moving from this point back toward centre  - If the dullness was an air/fluid level, the previously dull  area will now be resonant as fluid is moved away by gravity.
  43.  Ascites and Shifting Dullness  Ascites is free fluid within the peritoneum. With the patient lying on their back, gravity will cause the fluid to move toward the patients back and the bowel will float centrally. When the patient is rolled to onto their side, the fluid will be moved by gravity to the side they are lying on. On percussion any dullness caused by the presence of fluid will also move.
  44.  Fluid Thrill  - Place your left hand flat against the right side of the patients abdomen  - Ask the patient to place the edge of one hand longitudinally on midline of abdomen to prevent transmission of the impulse via the skin  - Tap on the left side of the abdomen with the right hand  - Feel for a ripple of fluid against the left hand
  45. AUSCULTATION  Bowel Sounds  - Listen with the diaphragm of the stethoscope just below the umbilicus  - Describe findings you should be able to recognise and understand the significance of:  o Normal, ‘tinkling’ and absent bowel sounds. You may have to listen for a while  if the sounds are quiet
  46. AUSCULTATION  Bruits  - Listen with the diaphragm of the stethoscope for turbulent blood flow  o Over the aorta, just above the umbilicus  o Over the renal arteries – just above and to either side of the umbilicus  o Over the liver
  47. Completing the Examination  - Cover patient /assist to redress if necessary  - Thank the patient  - For completion you should also consider:  o Examination of hernial orifices  o Digital Rectal Examination  o Examination of external genitalia  - Bed side tests  o Blood Pressure and Temperature  o Urine dipstick
  48. Findings Commonly Associated With Advanced Liver Disease  Chronic liver disease usually results from years of inflammation, which ultimately leads to fibrosis and decline in function. Histologically, this is referred to as Cirrhosis. This can be driven by a number of different processes, most commonly chronic alcohol use, viral hepatitis (B or C) or hemachromatosis (the complete list is much longer). It's important to realize that a cirrhotic liver can be markedly enlarged (in which case it may be palpable) or shrunken and fibrotic (non-palpable).
  49.  Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin appropriately. This can lead to  Icterus - Yellow discoloration of the sclera.  Jaundice - Yellow discoloration of the skin.  Bilirubinuria - Golden-brown coloration of the urine.
  50. Icterus
  51. Jaundice
  52.  Ascites: Portal vein hypertension results from increased resistance to blood flow through an inflamed and fibrotic liver. This can lead to ascites, accumulation of fluid in the peritoneal cavity.
  53. Ascites
  54.  Increased Systemic Estrogen Levels: The liver may become unable to process particular hormones, leading to their peripheral conversion into estrogen. High levels promote:  Breast development (gynecomastia).  Spider Angiomata - dilated arterioles most often visible on the skin of the upper chest.  Testicular atrophy.
  55. Gynecomastia
  56. Spider
  57.  Lower Extremity Edema: Impaired synthesis of the protein albumin leads to lower intravascular oncotic pressure and resultant leakage of fluid into soft tissues. This is particularly evident in the lower extremities
  58. Edema
  59.  Varices: In the setting of portal hypertension, blood "finds" alternative pathways back to the heart that do not pass through the liver. The most common is via the splenic and short gastric veins, which pass through the esophageal venous plexus enroute to the SVC. This causes esophageal varices which can bleed profoundly, though these are not apparent on physical examination. A much less common path utilizes the recanalized umbilical vein, which directs blood through dilated superficial veins in the abdominal wall. These are visible on inspection of the abdomen and are known as Caput Medusae.