This document provides guidance on abdominal percussion techniques for evaluating various organs and conditions. It discusses how percussion can detect gas, fluid, and confirm the location of organs. Specific techniques are described for evaluating the liver, spleen, kidneys, urinary bladder, ascites, and other abdominal features. Percussion is most accurate for the lower liver border and can help identify abnormalities, detect dullness associated with various conditions, and assess organ size and borders. Proper patient positioning and techniques like shifting dullness are emphasized to accurately evaluate abdominal contents using percussion.

1. Abdominal Percussion
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Ayman Alsebaey, MD.
Lecturer of Hepatology,
National Liver Institute.

2. Key Facts
 Percussion detects:
1) Gas
2) Fluid e.g. ascites, urinary bladder
3) Organs as confirmation of palpation.
 Light or heavy percussion ??
 Light percussion should only be used
 When to do???
 After auscultation.
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3. Liver
 Why to do percussion after
palpation???
 Palpation is inaccurate for the lower
borders. 50% of normal liver by palpation
are enlarged and 50% of enlarged liver by
palpation are normal size.
 Is liver percussion accurate?
 Percussion of the upper border is not
accurate.
 Percussion of the lower border is more
accurate.
 Direct or indirect percussion should be
used?
 Both can be used.
 Artefacts:
 Upper border: effusion
 Lower border: gaseous distension
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4. Spleen
 Nixon technique: patient in the right lateral position. Percuss the
upper border in post axillary line. And the lower border obliquely from
below costal margin. [ sensitivity specificity]
 Castell technique: patient in the supine position. Percuss the lowest
intercostal space [8th or 9th] in the anterior axillary line. Ask patient to
take strong inspiration during percussion, if dull =splenomegaly. [
sensitivity specificity]
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5. Spleen
 Traube’s area:
 Examined while fasting.
 Is a triangle composed of a)left 6th rib
superiorly b) left MAL laterally c) left
costal margin inferiorly.
 If dull: a) obesity b) food c) effusion d)
splenomegaly.
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6. Kidney
 Tender costo-phrenic angle:
 Pyelonephritis.
 Abscess
 Infarction
 stones
 Technique:
 Direct
 Ulnar surface of the fist over flat left
hand
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7. Urinary bladder
 Suprapubic circular or globular dullness with
desire of micturation.
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8. Ascites
 Ascites can be detected clinically if >500ml.
 Full flanks like frogs:
 Obesity
 Ascites
 Shifting dullness:
 Dullness in dependant areas
 Peri-umblical tympany
 Flank dullness
 Map the line between both
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9.  Turn the patient to the right side,
percuss again, there is downward
movement of the dullness
 Fluid wave [thrill]:
 2 examiners
 Examiner and patient had to fix
mesentric fat transmission.
 Tap one flank sharply with your
fingertips, feel on the opposite flank
for an impulse transmitted through the
fluid.
 Dipping or ballottement:
 Turn the patient towards the organ first
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Dip: ‫؛‬ ‫غاص‬‫س‬َ‫ط‬َ‫غ‬
Ballottement: ‫نهز‬,‫كز‬‫و‬

10. Ascites
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11. Ascites
 Puddle sign for ascites
 Is ausculatory percussion for minimal
ascites.
 Of no value nowadays.
 Tap the flank while moving stethoscope
from the umbilicus towards flank.
Sudden tympanic sound is the edge of
ascites.
 Guarino variation:
 Same principle but while standing.
 Void urine firstly
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Puddle: ‫ين‬ِّ‫ط‬‫بال‬ َ‫خ‬َّ‫ط‬َ‫ل‬ ‫؛‬ َ‫ن‬َّ‫ي‬َ‫ط‬
‫كة‬‫بر‬‫ل‬ّ‫ح‬َ‫و‬ ‫ضحلة؛‬ ‫صغيرة‬

12. Thanks
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