Abdominal exam: Signs and their significance By Rutendo Ganyani and Sarah Folkerts
Demonstration for OSCE purposes…….
Can you name these? Spider naevi Clubbing Splinter haemorrhage Caput medusa Koilonychia Palmar erythema Leukonychia
Abdo Exam General Exam Inspection Palpation – Superficial – Deep – For specific organs Percussion – Specific organs Oedema
….some signs to look out for! Hands: Clubbing (Cirrhosis, coeliac, IBD etc) Palmar erythema (oestrogen excess) Leuconychia (Hypoalbuminaemia) Koilonychia (Iron deficient anaemia) Liver flap (hepatic encephalopathy) Arms: AV fistulae Face: Jaundice Pallor Xanthelasma Corneal arcus Mouth: Ulcers Hydration status Glossitis Angular stomatitis Neck: Goitre Virchow’s node Chest: Spider naevi gynaecomastia Inspection: Distension (bend down to eye level) Surgical scars Dilated veins Visible peristalsis Bruising
Abdo exam continued…… Palpation: Normal abdominal organs are impalpable Technique shown tonight – flat of hand, rolling WATCH PATIENT’S FACE Palpate x2 – light (for tenderness and guarding), then deep (organs and masses) Palpation for liver and spleen: Start – R iliac fossa Hand flat on abdo, fingers parallel to costal margin From R iliac fossa diagonally across to left upper quadrant for spleen Kidneys: Ballot bimanually Percussion: Masses and organomegaly Liver Can do bladder Auscultation: 4 quadrants – up to 30 seconds in each for bowel sounds Renal artery bruits – 2.5cm above and lateral to umbilicus Extra tests: PR (DRE) Hernial orifices External genitalia
The 6 F’s of abdo distenstion 6Fs Fat Fluids Flatus Faeces Fetus Flipping big mass (incl. polycystic kidneys)
Contents of the 4 abdominal quadrants?
What can be found in the RUQ? Liver: right lobe Gallbladder Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half
What can be found in the RLQ? Cecum Vermiform appendix – McBurney’s point – Rovsing’s sign – Psoas sign – Obturator sign Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right spermatic cord Uterus (if enlarged) Urinary bladder (if full)
Which organs can be found in the LLQ? Sigmoid colon Descending colon: inferior part Left ovary Left uterine tube Left ureter: abdominal part Left spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if full)
What can be found in the LUQ? Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left kidney Left suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior part
Surface anatomy 1.What is the surface anatomy of the liver? 2.At what level does the aorta bifurcate? 3.What is the surface anatomy of McBurney’s point? 1.What is the surface anatomy of the liver? 2.At what level does the aorta bifurcate? 3.What is the surface anatomy of McBurney’s point?
DDx for LIF mass Renal transplant Loaded colon Diverticular mass Colorectal carcinoma Ovarian Hernia
DDx for RIF mass Renal transplant Appendix mass Crohn’s disease (inflamed, matted small intestine Caecal carcinoma Hernia Ovarian
Causes of Hepatomegaly 2 Is, 2 Bs & 2 Cs I-Infection (hepatitis, EBV, Malaria, hepatic abscess) I-Infiltration (e.g.Sarcoid, Fatty liver, Haemochromatosis) B-Blood-related (e.g.Lymphoma, Leukaemia, Haemolytic anaemias) B- Biliary (PBC, PSC) C-Cancer (Primary HCC, Metastases) C-Congestion (RHF, Tricuspid regurgitation)
What are the causes of ascites in chronic liver disease? Hypoalbuminaemia Portal hypertension Salt & water retention due to secondary RAAS activation
How to distinguish the kidney and the spleen on examination? Can’t get above spleen but kidney Kidneys are resonant on percussion Kidney is balottable Spleen moves more on respiration
What are the extra-intestinal manifestations of IBD? Finger clubbing Mouth ulcers (esp. Crohn’s) Eyes: Episcleritis Conjunctivitis Skin: Erythema nodosum Pyoderma gangrenosum Joints: Seronegative spondyloarthropathy Primary Sclerosing Cholangitis (esp. UC) Amyloidosis