Per abdomen examination - Clinical Methods - Abdomen

1. SHORT TOPIC
EXAMINATION OF ABDOMEN
CHAIRPERSON: DR .CHANDRASHEKAR .K
STUDENT : DR .Md Anwar hussain

3. General physical examination
a.Nutritional status
b. Anaemia
c. Finger clubbing: malabsorption, chronic liver
impairment, inflammatory bowel diseases,
hepatoma
d. Leukonychia
e. Koilonychia is suggestive of chronic iron deficiency
f. Lymphadenopathy : In leukaemia or lymphoma
there may be generalised lymphadenopathy

6. Bitots spots
Dry thickened, pigmented bulbar
conjunctiva with oval or triangular glistening white spots

7. KF RING

8. Oral ulcers

9. Koilonychia

10. Palmar erythema

11. clubbing

13. Tylosis of palms in carcinoma of
oesophagus.

14. Virchows nodes

15. • Scratch marks of pruritus

17. PER ABDOMEN EXAMINATION
• INSPECTION
• PALPATION
• PERCUSSION
• AUSCULTATION

18. REGIONS OF ABDOMEN

19. Inspection

20. Inspection – shape of abdomen
• Generalised fullness or distension
• Localised distension
a. Symmetrical and centered around umbilicus?
b. Asymmetrical—liver or spleen or ovary
• Scaphoid or sunken abdomen is seen in advanced
starvation or malignancy.

21. Umbilicus
• Normal Slightly retracted and inverted
• Everted In umbilical hernia
• Omphalolith - Inspissated desquamated
epithelium & other debris.
• Slit Vertical (pelvic or ovarian tumours)
• Horizontal (cirrhosis of liver with ascites).

22. Movements with respiration
• Normally there is a gentle rise in abdominal wall in
inspiration and a fall during expiration.
• In peritonitis abdomen is still or silent.

23. Visible Pulsations
• Abdominal aortic pulsations are seen in aortic
aneurysm or in thin patients

24. Skin or Surface of Abdomen
• Striae atrophica or gravidarum: recent change in
abdominal size
• Linea nigra is a pigmentation below umbilicus seen
in pregnancy
• Purple striae: seen in Cushing’s
syndrome

25. Dilated veins

27. • Cullen’s sign:A faint blue discoloration around the
umbilicus may occur as the result of
hemoperitoneum
• Grey-Turner’s sign : a blue-red-purple or green-
brown discoloration of the flanks (Turner’s sign)
reflects tissue catabolism of hemoglobin from
severe necrotizing pancreatitis with hemorrhage.

29. Abdominal scars and stomas

30. • At the end, always inspect external genitalia
and hernial orifices.

31. Palpation
• Measurements
• Abdominal girth should be measured.
• Measure the distance between lower end of
xiphisternum to umbilicus and from umbilicus to
symphysis pubis
• Spinoumbilical measurement: Normally they are
equidistant.

32. Superficial palpation

33. Superficial palpation
Guarding = muscles contract when pressure is applied
- Ridigity = indicates peritoneal inflamation.
involuntary reflex contraction.
• The most extreme form is seen in the board-like
rigidity often associated with a perforated hollow
viscus.
- Rebound = Releasing of pressure causing pain.

34. • Guarding and rigidity, however, may be
localized, as over an acutely inflamed
appendix in the right iliac fossa or diverticulitis
in the left iliac fossa.
• Deep palpation

35. Deep palpation

36. Palpation by Dipping
• This method is used in tense ascites to detect the
presence of hepatic or splenic enlargement.
• Sudden displacement of liquid gives a tapping
sensation over the surface of liver or spleen.
• For eliciting this, place the hand flat on
abdomen and make quick dipping movements.

37. • The site of tenderness is important.
• Tenderness in the epigastrium suggests peptic ulcer;
• in the right hypochondrium, cholecystitis;
• in the left iliac fossa, diverticulitis;
• in the right iliac fossa, appendicitis or Crohn’s
ileitis.

38. Organomegaly
• When an organ is enlarged, assess the following:
a. Edge or border (sharp or rounded)
b. Surface (smooth or nodular)
c. Consistency (soft, firm or hard)
d. Presence of tenderness
e. Movement with respiration.

39. Palpation of individual organs- LIVER

43. Palpation of Gallbladder
• It is felt as a firm, smooth, rough or globular
swelling with distinct borders, just lateral to the
edge of the rectus abdominis near the tip of ninth
costal cartilage.
• It moves with respiration.

44. GALL BLADDER

46. GALL BLADDER ENLARGEMENT CAUSES
• In a jaundiced patient with CA of head of the
pancreas or other malignant causes of obstruction
of the common bile duct (below the entry of the
cystic duct), the ducts above the obstruction
become dilated, as does the gallbladder.
• In mucocele of the gallbladder
• In carcinoma of the gallbladder, the gallbladder may
be felt as a stony, hard, irregular swelling, unlike the
firm, regular swelling.

47. Murphy’s sign
• In acute inflammation of the gallbladder (acute
cholecystitis), severe pain is present.
• Not seen in chronic cholecystitis

48. Courvoisier’s law
• In a jaundiced patient, a palpable gallbladder is
likely to be due to extrahepatic obstruction, e.g.
from pancreatic cancer.
• In cholelithiasis, the gallbladder wall is diseased,
thickened, contracted and not palpable due to
repeated cholecystitis.

49. PALPATION OF SPLEEN
• To become palpable, spleen should have enlarged
2-3 times. Direction of enlargement is towards right
iliac fossa.
• Enlargement takes place in a superior and posterior
direction before it becomes palpable subcostally.

50. Palpation of spleen
• Palpate from right iliac fossa to left
hypochondrium
• Wait for one full phase of respiration
• At the height of inspiration, release the pressure
on the examining hand so that the finger tips slip
over the lower pole of spleen, confirming its
presence and surface characteristics.

51. Methods of palpation

52. Middletons method

53. Palpation of Kidneys
• Use bimanual technique to palpate the kidneys.
• Place one hand posteriorly below lower rib cage
and other over upper quadrant.
• Push the two hands together firmly, but gently as
the patient breathes out.
• Try to trap the palpable kidney between the two
hands by delaying application pressure until the end
of inspiration.

54. • Confirm the structure of the kidney, by pushing
the kidney between the two hands (ballotting)
and by assessing its degree of movement
during respiration.
• Assess the size, surface and consistency of a
palpable kidney.
• Examine the left kidney from either side.

55. Bimanual palpation of kidney

57. Palpation of Urinary Bladder
• Normally it is not palpable.It is palpable as a
smooth, firm, regular, oval shaped swelling in
suprapubic region and its dome may reach as far
as the umbilicus.
• Its lower border cannot be felt. It is
symmetrically placed in suprapubic region
beneath the umbilicus, which is dull on
percussion.

58. Percussion
• Defining Boundaries
• Liver
• In normal liver, upper border is at 5th inter costal
space where note is dull;
• This extends down to the lower border found at or
just below right subcostal margin.
• Percussion below the right costal margin is useful in
hepatomegaly. Ask the patient to breathe in deeply
as you percuss, lightly keeping the fingers parallel to
the rib margin.

59. • Liver span: Direct measure of liver size is 12-15
cm in height extending from 5th rib or (below
right nipple in men) to the palpable border or
right costal margin.

60. Spleen percussion

61. Percussion by Nixon’s method
• Right lateral decubitus , begin percussion
midway along the Left costal margin ,
• proceed in a line perpendicular to the Left
costal margin .
• if the upper limit of dullness extends >8 cm
above the Left costal margin, this indicates
possible splenomegaly

64. Percussion can also be Used for Detecting Fluid in
the Abdomen by the Following Methods
About 1000 ml of fluid should be present to elicit
this sign.

66. Fluid thrill
This is felt when there is a large amount of fluid
under tension, i.e. > 2000 ml.

67. It can detect as little as 120 ml of ascitic
fluid

68. • Chronic ascites is associated with
• 1. Umbilical hernia
• 2. Puncture marks
• 3. Striae
• 4. Divarication of recti.

69. Auscultation
• Bowel Sounds
• Normal motility of the gut creates a characteristic
gurgling sounds every 5-10 seconds.
Bowel sounds are increased in:
1. Simple, acute, mechanical, small bowel obstruction.
Increased bowel sounds with colicky pain is
pathognomonic of small bowel obstruction.
2. Malabsorption
3. Severe GI bleeding
4. Carcinoid syndrome.

70. • Bowel sounds are absent in
a. Paralytic ileus
b. Peritonitis.

71. Succussion Splash
• It is a sound resembling shaking a half filled bottle.
It is heard in:
• 1. Pyloric stenosis
• 2. Advanced intestinal obstruction
• 3. Paralytic ileus (with grossly distended loops of
bowel)
• 4. Normal stomach within 2 hours after a meal.

72. Bruit
• Bruit over aorta can be heard above and to the left of
umbilicus in cases of aortic aneurysm.
• Bruit over mid abdomen is heard in renal artery
stenosis.
• Bruit over common iliac artery can be heard in stenosis
or aneurysm.
Bruit over liver may be heard in:
a. Haemangioma
b. Hepatocellular carcinoma
c. Acute alcoholic hepatitis
d. Hepatic artery aneurysm.

73. Venous Hum
• It is heard between xiphisternum and umbilicus
due to turbulence of blood flow in well-
developed collaterals as a result of portal
hypertension (Cruveilhier- Baumgarten
syndrome).
• It signifies a congenital patent umbilical vein
draining into the portal vein.

74. Friction Rub
• It is heard in perisplenitis or perihepatitis due to
microinfarction and inflammation.
• Splenic rub is heard in the following conditions:
• a. Chronic myeloid leukaemia
• b. Infective endocarditis
• c. Sickle cell anaemia
• d. After biopsy

75. References
• Hutchisons clinical methods
• Mcleods clinical examinations
• S.DAS clinical manual of surgery
• Harrisons principles of internal medicine ,19th
edition

76. •Thank you