1. Examination of the Abdomen
Assoc. Prof. Dr. Meltem Ergün
Yeditepe University
Department of Gastroenterology

2. Session Objectives:
Describe relevant anatomy and physiology as it pertains to the examination of the abdomen
Demonstrate the steps in examining the abdomen using illustrations
Review common abnormalities encountered on the Physical Examination of the abdomen

4. Abdominal Examination: Structure and Physiology
Abdominal cavity is divided into quadrants; two imaginary lines cross at the umbilicus
Important to known what abdominal structure is in which quadrant

6. Organs by Quadrant Right Upper Right Lower Left Upper Left Lower
Liver, gallbladder
Pylorus, duodenum
Head of pancreas
Ascending/transverse colon
Right kidney/adrenal
Right Lower
Right kidney and ureter
Cecum/appendix/ascending colon
Ovary, fallopian tube
Spermatic cord
Uterus/bladder (if enlarged)
Left Upper
Liver (left lobe)
Spleen
Stomach
Body of pancreas
Descending/transverse colon
Left kidney/adrenal
Left Lower
Left kidney and ureter
Sigmoid/descending colon
Ovary/fallopian tube
Spermatic cord
Uterus/bladder (if enlarged)

8. Retroperitoneal Structures

10. Alternative Divisions

12. Abdominal Exam: Basics
Patient should be lying flat
Abdomen should be fully exposed
Arms at side (behind head tightens abdomen) & legs straight
Bending knees may relax abdomen
Sheet over the genitals

14. Abdominal Exam: Basics
Order of Examination
Inspection
Auscultation
Percussion
Palpation

15. Inspection: General Cachexia of cirrhosis or cancer evident by temporal recession / or wasted muscles 2. Jaundice 3. Pallor 4. Vircow’s Node: left supraclavicular LN enlargement 5. Clubbing, palmar erythema, white nails, dupytren contracture, xanthelesma 6. Leg edema 7.Gynecomastia 8. Mouth ulcers of IBD, Peutz-Jaghers perioral pigmentation, talengiectasia of HHT,

20. Inspection: abdomen 1. Abdominal contour 2. Respiratory movement 3
Inspection: abdomen Abdominal contour Respiratory movement Abdominal veins Peristalsis Abdominal skin

23. Caput Meduza

28. Inspection
Skin: spider angiomas (blanching red marks mostly above nipples level), striae (purple or silver)
Contour of abdomen
Concave (scaphoid) vs convex (protuberant)
Dilated veins radiating from the umbilicus (caput medusa) & its direction of flow: from below upward or vise versa.

29. Auscultation
Provides important information about bowel motility: decreased motility suggests peritonitis; increased motility suggests obstruction
Need to listen before percussion or palpation since these maneuvers may alter the frequency of bowel sounds
Can also appreciate bruits over the aorta or other arteries, suggesting narrowing of the arteries from atherosclerosis

30. Abdominal auscultation
Bowel sounds at 4 quadrants
Listen for 2 minutes
Hyperactive bowel sounds
Postprandial physiologic
Laksatif consumption
Diare
Early mechanical obstruction
Hypoactive/Paralitik ileus
Adinamic ileus
Peritonitis

31. Auscultation For bruits
Bruits are high pitched sounds due to obstruction to flow due to narrowing (stenosis) of arteries
Listen midline (bruit in aorta)
Right / left upper quadrant (renal artery bruits)

34. Percussion
Helps to identify the amount and distribution of gas and to identify possible masses that are solid or fluid filled
Can be used to assess size of liver and spleen
Percuss looking for areas of tympany and dullness
Large dull areas may indicate an underlying mass; you will later confirm with palpation
On the right is liver dullness; on the left, dullness of the spleen

35. Percussion: Liver
Upper border of the liver is percussed in the right, midclavicular line starting at midchest
Resonance becomes dull as upper border of liver is reached and becomes resonant again as lower level of liver is reached
Total span shouldn’t be more than 10 cm

36. Physical examination Percussion
Meteorism
Liver span midclavicular line: 6-12 cm
midsternal line: 4-8 cm
Splenic dullness norm: in the midaxillary line
pathological:dullness in the ant. axillary line
during inspiration
Liver or/and splenic dullness absent: perforation

41. Percussion: The Spleen
When a spleen enlarges, it expands downward and medially, replacing the tympany of the stomach with the dullness of a solid organ
Percussion cannot confirm splenic enlargement, but it can raise your suspicion
There are two techniques to percuss splenic enlargement

42. Percussion: The Spleen
Percuss the left lower anterior chest wall between lung resonance (6 IC) above & the costal margin (an area termed Traube’s space)
As you percuss laterally, note the extent of the tympany; if tympany is prominent laterally, splenomegaly is unlikely.

47. Palpation Several structures are palpable normally:
Sigmoid colon is frequently palpable as a firm, narrow tube in the left lower quadrant
The caecum and ascending colon form a softer, wider tube in the right lower quadrant
Normal liver distends below the costal margin but its soft consistency is difficult to feel
Pulsations of the abdominal aorta are frequently visible and usually palpable
Usually NOT palpable are: stomach, spleen, gallbladder, duodenum, pancreas, kidneys

48. Palpation: Improving the Exam
Patient should have an empty bladder
Patient supine, arms at sides or folded across chest - avoid arms above the head as this tightens the abdomen
Before you begin, ask the patient to point to areas of pain and examine last
Warm hands and stethoscope; avoid long nails; approach slowly
Distract the patient with conversation or questions

49. Light and Deep Palpation
Light palpation
Helpful in identifying tenderness, superficial organs, and masses
Palpate with a light, gentle dipping motion using the palmar surface of fingers
Deep palpation
Usually required to delineate abdominal masses
Again use palmar surface of fingers
Check for tenderness and rebound (pain induced or increased by letting go)

52. Liver Palpation
Place left hand behind patient; by pressing the left hand forward, the liver may be more easily felt
Right hand on the patient’s right abdomen with your fingers well below the lower border of liver dullness; fingers may be pointed to the patient’s head or to the left shoulder
Press gently in and up; ask the patient to take a deep breath
Try to feel the liver edge as it comes down to meet your fingertips

53. Liver Palpation
The edge should be soft, sharp and regular, with a smooth surface
The normal liver may be slightly tender
On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line
If you start too high, you may miss the liver
Can also consider the hooking technique

54. LIVER SPAN
MCL
PERCUSSION
NL < CM
2-3 CM DURING INSPIRATION AND EXPIRATION
COPD
PALPATION
PERCUSSION
SCRATCH TEST
LIVER SPAN MAY VARY BETWEEN OBSERVERS DEPENDING UPON WHERE THE MCL IS DETERMINED
JAMA 1994;271:

58. AUSCULTATION – UNCOMMON FINDINGS
FRICTION RUBS - MALIGNANCY, HEPATOMAS, LIVER ABCESS
HUMS (SYSTOLIC AND DIASTOLIC) – PORTAL HYPERTENSION
BRUITS (SYSTOLIC) – TUMORS, ETOH HEPATITIS
JAMA 1994;271:
JAMA 1979;241:495

59. Spleen Palpation
Again, with the left hand, reach over and round the patient to support and press forward the lower left rib cage
With your right hand below the left costal margin, press in toward the spleen
Again, begin palpation low so you don’t miss an enlarged spleen
Again ask the patient to take a deep breath and try to feel the tip of the spleen as it comes down to meet your fingertips

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

63. Examination of Kidney
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

65. Warn the patient Patient sit up on the exam table

66. The Aorta
Press firmly deep in the upper abdomen and try to identify the aortic pulsations
Try to assess the width by pressing deeply with one hand on each side of the aorta; normal should be not more than 3 cm
The ease of feeling varies with the thickness of the abdominal wall
Try to appreciate pulsations laterally rather than just in the anterior/posterior dimension

69. Assessing Possible Ascites
A bulging abdomen with protuberant flanks suggests the possibility of fluid in the abdominal cavity (ascites)
Because fluid sinks with gravity while gas filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen
Two additional techniques; shifting dullness and assessment for a fluid wave

70. Ascites

71. (Shifting Dullness)

73. Testing for Shifting Dullness
Map the borders of tympany and dullness
Ask the patient to turn to one side
Percuss and mark the borders again
In a person without ascites, the borders between tympany and dullness remain relatively constant

74. Other methods of Ascites examination
Ballotman Sensasyon de Flue (fluid thrill)

75. GB Signs:
Malignancy
Courvoisier’s Terrier sign – a palpable nontender gall bladder in a patient with jaundice suggesting extrahepatic obstruction of the biliary system secondary to malignancy (original description).
Acute Cholecystitis
Murphy’s sign – with the examiner’s fingers positioned along the inferior border of the liver in the right costal arch the patient is allowed to inspire. During inspiration the inflamed gallbladder touches the examiners fingers resulting in the sudden cessation of inspiration.

77. Physical examination Rectal digital examination
Perianal diseases fistulas, masses
Anal alterations hemorrhoids, fisssuras, masses
Rectal alterations polyp, neoplasm, ulcer
Prostate gland
Douglas’s space
Stool on the glove

79. Conclusions
Remember to lie the patient supine with arms and knees relaxed
Auscultate before doing anything else
Use percussion to help identify organomegaly and borders of palpation
Use light and deep palpation to help identify structures in the abdomen