Abdominal Physical Examination Joel Niznick MD FRCPC

Acknowledgements Adapted from Public Domain Web Slide-sets by: Jim Pierce, MD Luke Palmisano, MS III Kamilee Christenson, MS II H.A.Soleimani MD

The History and Physical in Perspective 70% of diagnoses can be made based on history alone. 90% of diagnoses can be made based on history and physical exam. Expensive tests often confirm what is found during the history and physical. Assess the acuity of the patient to focus your differential diagnosis

General principles of exam Stand right side of the bed Exam with right hand Head just a little elevated Ask the patient to keep the mouth partially open and breathe gently

General principles of exam If muscles remain tense, patient may be asked to rest feet on table with hips and knees flexed

Other helpful points on examination Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear

General principles of exam If the patient is ticklish or frightened Initially use the patients hand under yours as you palpate When patient calms then use your hands to palpate. Watch the patient’s face for discomfort. 1

Think Anatomically & Systemically Inspection Auscultation Palpation Percussion Special maneuvers

General Observations BMI, waist circumference, cachexia clubbing, jaundice, asterixis Eyes: Sclera (colour), conjunctiva (pallor) Head and neck: Spider nevi, dentition, fetor hepaticus, JVP, supraclavicular nodes Chest: gynecomastia, spider nevi Pheriphery: edema

Abdominal Inspection Scars Scaphoid/Distension Masses Peristalsis Movement with respiration Venous distension Echymoses

Stigmata Chronic Liver Disease Clubbing Leukonychia Palmar erythema Dupuytren’s contracture Spider nevi Gynecomastia

Liver Stigmata Testicular atrophy Loss of axillary hair Parotid enlargement Ascites Caput medusa Peripheral edema

Liver Stigmata

Signs of Hemorrhagic Pancreatitis Grey-Turner’s Sign Cullen’s Sign

The Real Inspection

Scars and Wounds

Pfannenstiel Incision

Abdominal Anatomy Key Point: The Abdomen is 3D It has a top – the diaphragm It has a front and sides – the abdominal wall It has a back – the back and retroperitoneum It has a bottom – the pelvis

The TOP of the Abdomen

Anterior Abdominal Exam

Abdominal Surface Anatomy

Abdominal Deep Anatomy Stomach Pancreas Pseudocyst Colon AAA Liver Spleen Stomach Colon Kidney Gall bladder Colon Kidney Appendix IBD mass Colon Ca Ovary Kidney Tx IBD Mass Colon Ca Stool mass Ovary Bladder Uterus

Anterior Abdomen: Auscultation Auscultate before palpation so as not to stimulate bowel sounds Auscultate for Bowel Sounds: Hyperdynamic, Normal, Occasional,Absent Bruits / Hums Rubs

Bowel Sounds

Abdominal Vasculature

Bruit Bruits confined to systole do not necessarily indicate disease.

Auscultation for vascular bruits Aortic (midline between umbilicus and xiphoid Renal (two inches superior to and two inches lateral to umbilicus) Common iliac (midway between umbilicus and midpoint of inguinal ligament)

Auscultation for vascular bruits When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures.

Rubs

Rubs –Rubs-Rubs Liver Spleen Cardiac Pulmonary Right and left upper quandrants Grating sound with respiratory movement Indicates inflammation of the capsule of the liver or spleen (infection or infarction).

Venous Hum (rare) Epigastric/umbilical area. Soft humming noises in systolic/diastolic component. Indicates collateral between portal and venous systems as in hepatic cirrhosis.

Percussion versus Palpation Light Palpation assesses: Masses and Tenderness in the Wall Deep Palpation assesses: Masses and Tenderness in the Cavity Percussion assesses: Location of organs Location of masses Deep tenderness

Tenderness

Light Palpation Inquire as to location of tenderness Start with light palpation away from tenderness Assess rigidity and guarding (voluntary/involuntary) Assess for rebound tenderness Palpate all 9 regions

Deep Palpation

Deep Palpation (alternatives)

Deep Palpation Start in non-tender area-move towards tenderness Generally start in LLQ Palpate for masses and deep tenderness Palpate for organs Liver, spleen, kidneys Palpate for AAA

Anterior Abdominal Exam: Percussion Nontender Abdomen Location of Liver, Spleen Succussion Splash of Stomach Gas in Small / Large Intestine Fluid in the Peritoneum Tender Abdomen Location and Severity of Tenderness Presence of signs of peritonitis Guarding, rigidity, rebound tenderness

Liver Palpation Start in RLQ/MCL Move hand up as patient inspires Gradually move position up towards costal margin with each inspriation Feel for liver edge as patient inspires Normal liver edge smooth and soft Describe liver edge if abnormal Hard/firm/nodular Normal liver 10-12 cm in MCL Percuss top of liver in held inspiration Scratch test

Liver palpation Hand held steady Patient inhales Patient breathes Hand lifted and moved up

Alternate Method Liver palpation Stand by the patient's chest. "Hook" your fingers just below the costal margin and press firmly.

Hepatomegaly More than 1cm below the costal margin An exception is a congenitally large right lobe of the liver Severe, chronic emphysema pushes liver down

Pulsation transmitted from aorta or due to severe tricuspid valve insufficiency

Hepatojugular reflux sign If you press the liver, you will find the dilated jugular vein becomes more bulged or distended, as from the enlargement of liver passive congestion resulted from right failure.

Ballotable sign

Splenic palpation Start in RLQ Move hand up with inspiration Reposition on expiration Migrate palpation towards left costal margin Feel for notched splenic surface If spleen not felt roll patient in right decubitus position Support lrfy podterior costal margin with left hand and palpate under costal margin with right hand Percuss Traube’s space for dullness

Splenic palpation Seldom palpable in normal adults. Causes include COPD, and deep inspiratory descent of the diaphragm.

Splenic palpation Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage.

Splenic palpation Palpate upwards toward spleen with finger tips of right hand, starting below left costal margin. Have the patient take a deep breath.

Splenic palpation Deep technique used Starting point is RLQ, proceeding to LUQ

Kidney palpation Place left hand posteriorly just below the right 12th rib. Lift upwards. Palpate deeply with right hand on anterior abdominal wall.

Kidney palpation Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.

Right kidney may be felt to slip between hands during exhalation

Examination of Aorta Flat palm placed over the the epigastrium to locate pulse

Examination of Aorta Press down deeply in the midline above the umbilicus. The aortic pulsation is easily felt on most individuals.

Examination of Aorta Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Examination of Aorta Lateral width of pulsation is determined by space between index fingers or finger and thumb

Abdominal Aortic Aneurysm Palpable pulsatile mass Patient feeling of pulsation On rare occasions, a lump can be visible. May rupture leading to shock and death If ruptures into IVC = continuous murmur

Abdominal examination Special maneuvers

Special exam Rebound Tenderness Murphy’s Sign McBurney’s Point Rovsing’s Sign Psoas Sign Obturator Sign Costovertebral tenderness Spinal percussion tenderness Shifting Dullness Fluid wave

Murphy’s Sign (acute cholecystitis) Examiner’s hand is at middle inferior border of liver. Patient is asked to take deep inspiration. If positive patient will experience pain and will stop short of full inspiration Hepatitis, subdiaphragmatic abscess Cholecystitis

McBurney’s Point Localized tenderness Just below midpoint of line between right anterior iliac crest and umbilicus. Heel strike, riding over bumps in road while driving, coughing, will produce pain.

McBurney’s Point (Common Causes) Appendicitis Incarcerated or strangulated hernia Ovarian torsion (twisted Fallopian tube) Pelvic inflammatory disease Abdominal abscess Hepatitis Diverticular disease Meckel''s diverticulum

Rovsing’s Sign Patient will experience right lower quadrant pain (in region of McBurney’s Point) when left lower quadrant is palpated.

Non-Classical Appendicitis Iliopsoas Sign Obturator Sign

Iliopsoas Sign Patient can lay on side and extend leg at the hip or have patient lay on back and try to flex hip against the resistance of examiner’s hand on thigh. If patient has an inflamed retrocecal appendix, this will produce pain.

Iliopsoas Sign Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

Obturator Sign Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis.

Obturator Sign Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

Rebound Tenderness (For peritoneal irritation) Warn the patient what you are about to do. Press deeply on the abdomen with your hand. After a moment, quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

Cost vertebral Tenderness (Often with renal disease) Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Compare the left and right sides.

Posterior Abdominal Exam: Percussion

Examination for Shifting Dullness Patient rolled slightly toward the examined side; movement of the dull point medially is described as “shifting dullness” and suggests ascites

Ascites / Liver Disease

Shifting Dullness

Fluid Wave

Additional Examinations Inguinal hernia Femoral hernia

Additional examinations Pelvic exam Rectal exam

Questions?