1. Division of Gastroenterology, Union Hospital
Union Hosital
ABDOMINAL EXAMINATION
Zhu Liangru
Division of Gastroenterology, Union Hospital

2. Range of Abdomen Superior：diaphragma Inferior： pelvis
Lateral： lateral abdominal wall
Anterior: anterior abdominal wall
Posterior: back bone,psoas

3. Abdominal Mark & Area

4. Abdominal Mark Midabdominal line Upper abdominal angle Xiphoid process
Costal margin
umbilicus
Lateral border of rectus muscles
Anterior superior iliac spine
Inguinal ligament

5. Abdominal Mark
Costal margin composed of 8th-10th costal cartilage; abdominal area liver measure
Xiphoid process elongation of breast bone; measurement of liver
Epigastric angle included angle of costal arch; judge body type measurement of liver
Umbilicus center in abdomen;abdominal area
Anterior superior iliac spine the outstanding place of anterior of spine iliac
Lateral border of rectus muscles elongation of midclavicular line;operative
incision
Midabdominal line elongation of anterior of median line; abdominal area
Inguinal ligament mark of femoral artery,femoral vein
Costalspinal angle included angle of 12th costal bone and back bone

6. Abdominal Area

7. Abdominal Area: Nine regions left hypochondriac region
right hypochondriac
region
epigastric region
left lumber
region
right lumber
region
umbilieal
region
right iliac region
left iliac region
hypogastric
region

8. Nine regions & Projection
spleen
stomach
transverse colon
gallbladder
ascending colon
small intestine
ileum
sigmoid colon
urinary bladder

9. Abdominal Area: Four regions left upper quadrant right upper quadrant
right lower
quadrant
Left lower
quadrant

10. Abdominal Area: Seven regions Epigastric region
Right upper abdominal region
Left upper
abdominal region
Umbilieal region
Left lower
abdominal region
Right lower
abdominal region
Hypogastric region

11. Secquence of Abdominal Examination
Examination secquence
inspection, auscultation, palpation , percussion
Recording secquence
inspection, palpation, percussion, auscultation

12. Inspection

13. Attention of Inspection
The patient is relaxed and in a proper position.
The patient is in a supine position, the head should be
elevated on a pillow, abdomen is thoroughly exposed
(from nipple to symphysis pubic).
Proper time to examination.
Light is adequate and soft, and comes from one side of head.
Inspector stands on the patient’s right side, secquence is from
upper to lower.
examination in tangent direction.

14. Method of Inspection

15. Normal：flat 、full、low
Abdomial Shape
Normal：flat 、full、low

16. xiphoid process
umbilicus
symphysis pubic
low
flat
full

17. whole abdominal bulge:
ascites frog belly apical belly
pneumatosis
macrosis mass
part abdominal bulge:
organ intumesce (liver intumesce)
tumor (stomach.liver,pancrease)
inflammatory mass (tuberculous peritonitis)
distension (stomach distension)
mass in abdominal wall
hernia ( umbilical hernia, indirect hernia)

18. Inspection in Ascites

19. Differential Diagnosis in mass in abdominal wall and mass in abdominal cavity

20. Abdominal Retraction whole abdominal retraction athrepsy dehydration
cachexia (boat-belly)
part abdominal retraction :
postoperative scar

21. Boat shaped-abdomen

22. Respiratory Movement Abdominal breathing: adult male, children
Costal breathing: adult female
attenuated in abdominal breathing ：
acute abdomen, ascites, macrosis mass, pregnancy
reinforcement in abdominal breathing ：
diseases in thoracic cavity(hydrothorax), hysteria

23. Abdominal Vein

24. Generally we can’t find distended abdominal vein in normal people.
Prominence of distended veins indicates increased collateral circulation as a result of obstruction in the portal venous system or in the vena cava
The normal direction of blood flow is away from umbilicus. The upper abdominal veins carry blood upward to the superior vena cava, the lower abdominal veins carry blood downtoward to the inferior vena cava.

25. Portal hypertension Inferior vena cava obstruction

26. Method to Judgement the Direction of Blood Flow

27. Gastrointestinal pattern & Peristalsis

28. Generally we couldn’t find gastrointestinal pattern
and peristalsis in normal people.
Gastrointestinal obstruction：
gastral pattern
intestinal pattern
peristalsis

29. Small bowel obstruction colon obstruction

30. Others Information

31. skin rash: infection diseases, drug allergy, herpes zona
pigments: Addison disease, Grey-Turner sign, Cullen sign
ventral stripe: striae albicantes, purple striae
(hypercortisolism)
scar: operation, trauma, infection
hernia: umbilical hernia, oblique inguinal hernia, direct hernia
umbilicus: evection, depression, secrection
hairs: disposition, increase, decrease
pulsation: abdominal aneurysm, increasing in right ventricle
of heart

32. Palpation

33. Method of Palpation The patient is relaxed position
The patient is in a supine position, the head should be
elevated on a pillow, genuflex, slowly abdominal respiration
Inspector stands right beside patient
Start from left iliac region, anti-clock wise, “S” shape
Commence palpation at a site remote from the area of pain
All areas of abdomen must be palpated systematically

34. Abdominal Palpation
Light palpation
Deep palpation

35. Tensity

36. Increase of tensity
Intestinal distension, ascites, artificial pneumoperitoneum
rigidity（board-like rigidity）
acute diffuse peritonitis
dough kneading sensation
tuberculous peritonitis, carcinomatous peritonitis
Decrease of tensity
Chronic wasting disease, multipara, aged, dehydration

37. Tenderness & Rebound tenderness

38. tenderness rebound tenderness

39. 1. Gastritis or gastric ulcer
2. Duodenal ulcer
3. Pancreatitis or tumor
4. Cholecystitis cholelithiaisis
5. appendicitis
6. Disease of intestine
7. Disease of urinary bladder,uterus
8. Ileocecal junction
9. sigmoid
10.spleen,splenic flexure of colon
11.liver,hepatic flexure of colon
12.pancreatitis

40. McBurney point
ant. Sup. spine

41. Palpation of Organs

42. One hand palpation Bimanual palpation Hooking technique

43. Ballottement palpation

44. Knee-elbow Position Palpation

45. Attention in palpation of liver
Anterior-lateral finger pulp to palpate organs
Place your hand flat with fingers pointing towards the
patients’s head
position of palpation at exterior margin of rectus
abdominis
palpate deeply while asking the patient breathe in and
out deeply
start in the right iliac fossa when examining macrosis
liver
应与肝脏鉴别的脏器：
横结肠为横行条索状物，与肝脏质地不同
腹直肌腱划左右两侧对称，不随呼吸移动
右肾下极位置较深，边缘圆顿，不能掀起下缘

46. Differential Diagnosis
Transverse colon
rectus abdominis tendon
Lower lobe of right renal

47. Technique of Liver Palpation
lung
liver

48. Projection of Liver Perpendicula distance 4-8cm Perpendicula

49. Measurement

50. Description of liver Size ：below right costal margin 1cm,
below xiphoid porcess 3cm
Texture：three grade---soft,moderate, hard
Surface：slick, nodus
Edge：thickness, regularity
Tenderness：no tenderness in normal liver
hepatojugular reflux
Pulsation：conduct pulsation, expansile pulsation
Scrape：inflammatory surrounding liver
Liver thrill：ballottement ---hepatic echinococcosis

51. Manipulation of palpation of spleen

52. Measurement of spleen
Line I：distance from the across point of left medioclavicular line and costal border to inferior margin of spleen
Line II: distance from the across point of left medioclavicular line and costal border to ultima thule of spleen
Line III: distance from right border of spleen to anterior median line

53. Enlarged spleen moderate cirrhosis, chronic lymphocytic leukemia,
mild
acute hepatitis, typhoid,acute malaria, septicemia
moderate
cirrhosis, chronic lymphocytic leukemia,
chronic hemolytic jaundice, lymphoma
severe
chronic granulocytic leukemia, myelofibrosis

54. Description of liver Description of spleen
Size
Texture
Surface
Edge
Tenderness
Pulsation
Scrape

55. Palpation of gallbladder
manipulation one hand slipping palpation or hook
Murphy sign
Courvoisier sign

56. Palpation of Kidney
(A) Place left hand in the right or left loin posteriorly.
(B) Place the right hand on the abdomen anteriorly and press
gently dowmwards. Push the left hand upwards. A palpable
kidney can be balloted between the two hands.

57. The kidney may be palpable in thin normal individuals.
The right kidney lies lower than the left, so it is more
likely to be palpable.
Nephroptosis enlarged kidney is found in nephrydrosis, empyema, tumor of kidney, polycystic renal disease

58. Tenderness Point of nephric duct and Kidney Upper nephric duct point
hypochondrium
Costa-carinal point
肋腰点
Costa-lumbar
point
Upper nephric duct point
middle nephric
duct point
ventral aspect
Back side

59. Mass in Abdomen

60. “Mass” in normal abdomen
rectus muscle belly & tendinea
body of lumbar vertebra
cochlear of sacral bone
stoolmass in sigmoid colon
transverse colon
caecum

61. Abnormal Mass Location Size length,broad,deep
Shape skeleton,edge,surface
Texture
Tenderness
Pulsation
Degree of excursion

62. Fluid thrill (Fluctuation)

63. Manipulation of fluid thrill
patient
assistant
inspector
fluctuation
Assistant places his hand vertically at the anterior median line,
Examiner places hand flat at both side of lateral abdominal wall,
One hand percuss one side abdominal wall, fluctuation can be sensed in another hand

64. Succussion Splash
Succussion splash can exist in people after meal or drinking
Succussion splash exists in fast or 6-8 hours after meals suggests pyloric obstruction or gastric dilatation

65. Percussion
Percussion is used to demonstrate the presence of gaseous distension and fluid or solid masses.
Light percession is preferable, since it produced a clearer tone.

66. Abdomen Percussion Sound
All four quadrant of abdomen are evaluated by percussion
Tympany is the most commom percussion note in abdomen
presence of gas within the stomach,small bowel,colon.
Dullness exists in liver (right hypochondrium region)
spleen (left hypochondrium region)
distended urinary bladder (suprapubic area)
enlarged uterus (suprapubic area)
psoas (back side)

67. Increasing in Dullness region
organ swell
tumor
ascites
Increasing in tympany
gaseous distension
perforation

68. Percussion of Liver upper border of liver right midclavicular line
right anterior axillary line
right scapular line
relative dullness area resonance dullness
absolute dullness area dullness flatness

69. right midclavicular line Anterior median line
lower border of liver
right midclavicular line
Anterior median line
tympany dullness

70. Normal Liver Border upper border
right midclavicular line the fifth interspace
right axillary line the senenth interspace
right scapular line the tenth interspace lower border
right midclavicular line right costal margin

71. Measurement Size right midclavicular line 9-11cm
anterior median line 4－8cm

72. Change of Liver Border Increasing in liver dullness area
liver carcinoma, liver abscess, hepatitis, polycystic
Decreasing in liver dullness area
acute hepatic necrosis, cirrhosis, gaseous distension
Absence of liver dullness area
acute perforation of hollow viscus

73. Percussion Tenderness of Liver and Gallbladder

74. Traube Area
Traube area
9.5cm×6.0cm

75. Percussion of Spleen left midaxillary line normal spleen border
route
left midaxillary line
normal spleen border
left midaxillary line the ninth-eleventh interspace
longitude 4－7cm
Change of spleen border
increasing enlarged spleen
decreasing gastric dialation, distension

76. Shifting Dullness
The quantity of ascites is more than 1000ml

77. Percussion of ascites
tympany
dullness

78. Shifting Dullness supine tympany dullness tympany dullness
lateral position

79. Manipulation
supine
lateral position
Place left hand on the umbilicus region, right hand percuss. note central tympany. Move left hand to one side of abdominal wall，then rotate patient onto another side. Notice that dullness has shifted toward the umbilicus on the dependent side. Tympany area has shifted toward the superior flank.

80. Differential diagnosis between Ovarian cyst and ascites

81. Differential diagnosis between Ovarian cyst and ascites
tympany
tympany
dullness
dullness
ovarian cyst
ascites

82. Ruler Pressing test

83. Sensitive to percussion in Ridge costal angle

84. Projection of ridge costal angle
right kidney
ridge costal angle

85. Sensitive to percussion in ridge costal angle

86. Bladder Percussion Location：suprapubic area Empty bladder tympany
Filling with urinary dullness

87. Auscultation

88. Area of Abdominal Auscultation
pancrease
liver
spleen
abdominal aorta
gurgling sound
arteria renalis

89. Bowel Sound Normal 4-5/min Active >10/min
Auscultation of bowel sounds can provide information about the motion of air and liquid in the gastrointestinal tract.
Normal /min
Active >10/min
Hyperactive mechanic intestine obstruction
Hypoactive
Absent paralytic intestine obstruction

90. Vascular Murmur Arterial murmur center of abdomen: abdominal aneurysm
abdominal aorta stenosis
left or right upper quadrant： renal arterial stenosis
bilateral of inferior belly：arteria iliaca stenosis
left lobe of liver：left lobe carcinoma
Venous murmur
portal hypertension：umbilicus or epigastrium
continious buzz

91. Friction Sound Splenic infarction Perisplenitis Zuckergussleber
Cholecystitis
Peritonitis

92. Scratch Sound

93. Identify lower edge of liver

94. Small amounts of ascites：puddle sign

95. Thank you!