this is all about abdomen

1. ABDOMINAL EXAMINATION
Rezene Berhe, MD
Gastroenterology and Hepatology unit
CHS, BLH
March 20,2014
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3. Out line
• Introduction
• Inspection
• Auscultation
• Palpation
• Percussion
• Interpretation
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4. Introduction
• Basic topography
– Nine Vs four quadrant of the abdomen
– Reminder: Please note the anatomical location of
each abdominal organs in each quadrant
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5. Anatomical areas
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6. Anatomical areas
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7. Introduction cont…
• General principle
The patient relaxed and comfortable in supine
position
Use relaxation techniques if needed
Head supported with pillow
Keep the supinated arm by patient sides,
warm hands
• Requirements:
Insure good illumination
Full exposure of the abdomen( from xipisternum to
upper thigh)
Be on the right side of the patient
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8. Proper exposure for examination
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9. INSPECTION
• Shape and contour, flank fullness,
– Scaphoid/flat /distended: reference will be the level of
the abdomen between sternum and symphysis pubis
• Symmetry
• Discoloration
– Striae:
• Whitish in pregnancy
• Pinkish in Cushing syndrome
– Localized hyper-pigmentation: Cullen’s sign, Grey-
turner’s sign
• Peristalsis, pulsations,
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10. Inspection cont…
• Distended vessels:
– Normal direction of flow: above the umbilicus upward
and below the umbilicus downward.
• Portal hypertension-veins draining away from the umbilicus
• IVC obstruction - reversal of flow in the lower abdomen – i.e
draining towards the umbilicus
• Umbilicus
– Direction of slit: normally inverted
– Horizontal slit, eversion
– Swelling
– Discoloration
– Nodule around or signs of inflammation
• Hernia sites
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11. Causes of distension
• Gross distension (5 F)
• Fluid
• Flatus
• Feces
• Fetus
• Fat
• Localized distension
–Loculated fluid
–Mass
–Hernia
–Organomegaly
–Impacted feces
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12. Gross abdominal distension
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13. Localized distension
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15. Abdominal auscultation
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16. Auscultation cont…
• Bowel sounds: four quadrant
– Normal range 4-35/min, every 2-5 sec
– Hypoactive: eg. Peritonitis
– Hyperactive: eg. Obstruction
• Bruits:
– Over enlarged organ
– Renal artery: few cm above the umbilicus lateral
at the edge of rectus abdominus.
– Aneurysmal
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17. Auscultation cont…
• Venus hum:
– Heard over collateral veins disappear by hard
pressing with stethoscope unlike bruit
– Not localized to systole only unlike bruit
– May disappear with changing position unlike bruit
• Friction rub:
– seen in infarction, sub-capsular hemorrhage and
inflammation of spleen or liver
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18. Palpating the abdomen
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19. Palpation cont….
• Step 1: ask for any pain and location.
• Step 2:
– Start superficial palpation away from the site.
– If none proceed with anticlockwise move starting from the
LLQ :
– look for tenderness, temperature, mass, rigidity, guarding,
pulsation
• Step 3:
– Deep palpation starting from the LLQ.
– Examine the Left large bowel, Spleen, Epigsatrium, Liver,
RUQ, suprapubic and periumblical,
• Step 4: Bimanual palpation for both kidneys
• Step 5: Flank fullness and fluid thrill, Succusion splash
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20. Liver topography
• Upper border:
– Rt lobe: 5th rib, 2 cm medial to
the rt MCL and 1 cm below
the rt nipple.
– Lt lobe: at 6th rib and Lt MCL,
2 cm below the lt nipple.
• Lower border:
– Rt: 9th costal margin
– Lt: 8th costal margin diagonally
– Crosses md way b/n the xyphi
and umbilicus
• Edge moves 1-3cm by
inspiration.
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21. GB surface marking
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22. Palpation of spleen
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Cephalocaudad length of 13cm and
width of 7cm

23. Techniques of spleen examination
• Bimanual palpation
• Ballottement
• Palpation from above
(Middleton maneuver)
• Percussion
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• Spleen
– Size, direction of
growth
– Notch
– Above the mass
– Bimanual palpability
– Consistency
– Tenderness
– Friction rub
– Bruit
– Ballotable

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25. Examining the kidneys
Bimanual palpation
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26. Eliciting fluid thrill
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27. PERCUSSION
• Starting from the epigastrium umbilical
suprapubic rt/lt lumbar region.
• Look for:
– Tympanicity
– Dullness-
• Direct and shifting
• Total vertical liver span(TLS= 10 ±2) . (8-12)
• Splenic percussion
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28. Percusing the abdomen
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29. Splenic percussion
Delineating the spleen by Percussion
• Traube’s semilunar space
– 6th rib superiorly, lt mid axillary line laterally and
costal margin inferiorly.
– Normal percussion note medial to lateral is
resonant.
• Nixon’s method:
– lower border of pulmonary resonance at Lt
posterior axillary percus diagonal 90 degree to
mid lt costal margin
– Normal 6-8cm. If > 8 cm= splenomegaly
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30. Shifting dullness
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31. Digital rectal examination
• Rotate finger 360 degree
• Assess-tone of sphincter and anal
musculature, irregularity and thickening of
anal canal
• Feel prostate gland (male) and cervix (females)
• Look for mucus, blood, pus on finger
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32. Characterizing a pathology
• Organomegaly
• Specific mass
• Specific pathologies
 Location, estimated size, shape, edge, surface
regularity, consistency, tenderness, Mobility,
pulsatility
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33. Distinguishing Lt. kidney from spleen
• Inspection:
– Kidney has less marked movement than spleen
with inspiration
– Direction of growth: kidney grow down and
vertically
• Palpation:
– Bimanually palpable: for kidney
– Presence/absence of notch: Kidney has no notch
– Getting above the mass: kidney, not for spleen
• Percussion:
– Kidney may have overlying colonic resonance
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34. INTERPRETATION
• Signs of acute abdomen
• Cystic lesion
• Mass
• Organomegaly
• Bowel pathologies
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35. Intra peritoneal excess fluid- Ascites:
(When exceeds 500ml)
Sensitive: (for ruling out)
• Absence of:
– Increase in abd. girth
– Flank fullness
– Flank dullness
– Shifting dullness
– fluid thrill
Specific (for ruling in)
Presence of:
– Fluid thrill (90%)
– Shifting dullness
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36. Conclusion
• Make sure that basic requirements fulfilled.
• Use the four physical examination techniques
– Inspection
– Auscultation
– Palpation
– Percussion
• Describe and/characterize abnormalities
properly.
• Interpretation of physical finding is mandatory
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