1. ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum
THE ABDOMINAL EXAM
ACS/ASE Medical Student Simulation-based
Surgical Skills Curriculum

2. CREDITS Author Contributors Editors
Ebondo Mpinga, MD,FACS
Contributors
Michael Hughes, MD ,FACS (expert performance video)
Richard Damewood, MD,FACS (modified score assessment tool)
Duane Patterson, PhD (technical support)
Paul Schreck (videographer )
Editors
Keith Clancy, MD, FACS
Amanda Beattie, MD , R5
York Hospital Department of Surgery, York, PA

3. OBJECTIVES
After the completion of this module the student should be able to:
Perform a complete abdominal exam.
Recognize the signs of peritonitis.
Arrive at a differential diagnosis based upon the findings elicited during the exam.
Keep this slide in for the student’s to view

4. ABDOMINAL EXAM
Although we will focus on the abdominal exam, it cannot be overemphasized that a thorough physical exam (head to toes) is important to help in arriving at a comprehensive differential diagnosis list.
Examples :
presence of jaundice may add consideration of a biliary /hepatic etiology
Irregularly irregular heart rate atrial fibrillation-> mesenteric ischemia
Crackle at lung bases pneumonia
Skin lesions (pyoderma gangrenosum) -> IBD

5. ABDOMINAL WALL DESCRIPTION
The abdomen is generally divided into four quadrants by two artificial lines that intersect at the umbilicus
Other systems exist to further subdivide these four quadrants into nine regions/sections
RUQ
LUQ
RLQ
LLQ
Right
Hypochondrium
Epigastric
Left
Hypochondrium
Right
flank
Umbilical
Left
flank
Right
Iliac
Hypogastric / suprapubic
Left
Iliac

6. ABDOMINAL EXAM It should include
The exam should be performed in this specific order
General appearance
Vital signs
Inspection
Auscultation
Percussion
Palpation
It should include
An examination of the inguinal area
including the external genitalia in males (testes)
A rectal exam (discussed in a separate module)
A pelvic exam in women (discussed in a separate module)
The rectal and pelvic exam are covered in other modules.

7. DESCRIPTION OF TECHNIQUES

8. General Appearance  Obstruction / colic Shock
Head-to-toe (skin, eyes, LOC, position, demeanor)
 Inflammation, peritonitis
Lies perfectly still
Or in bed with thighs and knees flexed
 Obstruction / colic
Restless, writhing
Abdominal distension?
Shock
Pallor/ cyanosis/ diaphoresis/ decreased mental status

9. Vital Signs Tachycardia Rapid shallow breathing (splinting)
? Early shock (may present prior to hypotension)
May be absent if on Beta blockers
Rapid shallow breathing (splinting)
Peritonitis
Hypotension
May be late finding depending on pre-existing state of health
Fever
Infectious etiology or perforation

10. Inspection Abdominal contour Skin Distended vs. scaphoid
Irregular -> mass / volvulus / obstruction / hernias
Skin
Ecchymosis around umbilicus, flanks
pancreatitis? Trauma (seat belt sign)?
Scars
Prominent veins on the abdominal wall
Portal hypertension

11. Auscultation Bowel Sounds Auscultate all regions Listen in each region
Listen before feeling
Absent bowel sounds
ileus, peritonitis, shock
Hyperactive
Enteritis / obstruction (high pitched or distant)
Bruits
AAA / Reno-vascular diseases
Iliac and Femoral arteries
Aorta
Renal
Renal
Iliac arteries
Femoral arteries

12. Percussion Hyperresonance (tympani) Fluid wave
Bowel distension with air->obstruction
In all quadrants but RUQ (liver dullness)
Loss of liver dullness in RUQ-> Free air
Fluid wave
Ascites (may be hard to elicit in the obese)

13. Palpation Palpate each region Work toward area of pain Warm hands
Communicate with patient
Let the patient know what you are about to do
Place Patient supine
knee bent (if possible)
Right
Hypochondriac
Epigastric
Left
Hypochondriac
Right
flank
Umbilical
Left
flank
Right
Iliac
Hypogastric
Left
Iliac

14. Palpation Note tenderness Rigidity Rebound
Localize vs. diffuse
Rigidity
Rebound
Press on the abdomen and release
Present if pain is worse upon release
Avoid too sudden of a release (may startle patient -> false +)
Involuntary & voluntary guarding
Distract the patient while palpating to detect involuntary guarding
Feel for masses

15. Signs highly suggestive of peritonitis
Tenderness to percussion
Tenderness elicited when the examiner firmly taps on the Iliac crest
Tenderness elicited when the examiner firmly taps on the heel of the patient’s extended leg
Tenderness when the bed is gently shaken or the patient coughs
Rebound tenderness

16. Abdominal exam: findings that suggest specific etiology
Biliary / hepatic etiology
Courvoisier' sign
Palpable gallbladder in the presence of painless jaundice
 periampullary tumor
Caput medusa (Cruveilhier sign)
Varicose veins at umbilicus cirrhosis with portal HTN
Murphy’s sign
Pain caused during inspiration while palpating the RUQ-> acute cholecystitis
Ransohoff sign
Periumbilical yellow discoloration -> ruptured CBD

17. Abdominal exam: findings that suggest specific etiology
Appendicitis
Rovsing’s sign
Palpation on the LLQ produces tenderness at McBurney’s point
Ten Horn test
Pain caused by gentle traction of the right testicle
Aaron sign
Persistent pressure applied at McBurney ‘s point causes pressure in the epigatrium and upper chest wall

18. Abdominal exam: findings that suggest specific etiology
Pelvic inflammation/abscess
Iliopsoas sign
Allow patient to lie on the opposite side of the pain
Extend the thigh on the affected side
This should cause pain if there is irritation of the iliopsoas muscle (seen with appendicitis as well)
Obturator sign
Flexion and internal rotation of the right thigh while supine elicits hypogastric pain
Indicates irritation of obturator internus muscle (seen with appendicitis as well)
Chandelier sign
Extreme lower abdominal/pelvic pain with movement of the cervix

19. Abdominal exam: findings that suggest specific etiology
Hemoperitoneum
Hemorrhagic pancreatitis
Cullen’s sign
periumbilical bruising-> hemoperitoneum
Grey Turner’s sign
Local area of discoloration around the flanks-> acute hemorrhagic pancreatitis
Danforth sign
shoulder pain on inspiration-> hemoperitoneum
Kehr’s sign
Left shoulder pain when supine or pressure applied to LUQ-> splenic rupture

20. Inguinal exam
Palpation of the inguinal area with & without vasalva maneuver
Ask patient to cough
Ask patient to take a deep breath and bear down
Pay attention to the femoral area to rule out femoral hernias
In the male, the testis should be examined
to rule out testicular torsion

21. COMMON ERRORS Focus only on the abdomen
Begin with palpation prior to inspection, auscultation and percussion
Not asking the patient to localize the pain and therefore beginning palpation of the affected area first, exacerbating the pain and thus precluding complete examination of the abdomen
Skipping the rectal, pelvic and groin exam
Putting too much weight on the absence of rebound tenderness to r/o peritonitis
Putting to much weight on the physical exam in an immunosuppressed patient who may not exhibit normal signs of peritonitis
Forgetting to consider mesenteric ischemia when there is pain out of proportion to clinical exam

22. GROUPING OF SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS

23. Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes
Acute pancreatitis (pain radiating to back)

24. Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass) STAT SURGERY

25. Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass) !! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY
Spontaneous rupture of spleen/Splenic artery aneurysm (pain radiates to left shoulder)

26. Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass) !! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY
Spontaneous rupture of spleen/Splenic artery aneurysm (pain radiates to left shoulder)
Ruptured ectopic pregnancy

27. Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass) !! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY
Spontaneous rupture of spleen/Splenic artery aneurysm
Rupture ectopic pregnancy
Late mesenteric ischemia
Extra- abdominal causes
Acute MI with cardiogenic shock

28. Severe abdominal pain with diffuse peritoneal signs
Perforated viscous
STAT SURGERY
Gastric/duodenal ulcers
Gallbladder
Complication of Small and large bowel obstruction
Maximal distention leading to peroration (Cecum)
Necrotic bowel due to mesenteric ischemia or strangulated hernias
Patients will rapidly progress to septic shock if surgery is delayed

29. Severe central abdominal pain without associated signs
Intra-abdominal causes
Intestinal colic
Early appendicitis
Early/ mild pancreatitis
Early mesenteric thrombosis

30. Severe central abdominal pain without associated signs
Intra-abdominal causes
Intestinal colic
Early appendicitis
Early/ mild pancreatitis
Early mesenteric thrombosis
Extra- abdominal causes
Herpes Zoster (rash in dermatome distribution)
CAD (ECG/Enzymes)
Glaucoma
Tabes dorsalis (rare)

31. Severe central abdominal pain with distension, no vomiting & peritoneal signs
Intra-abdominal causes
Large bowel obstruction while ileocecal valve is competent
Sigmoid diverticular stricture/ inflammation/ cancer
Volvulus
Hernias
Adhesions

32. Severe central abdominal pain with distension, no vomiting & peritoneal signs
Intra-abdominal causes
Large bowel obstruction while ileocecal valve is competent
Sigmoid diverticular stricture/ inflammation/ cancer
Volvulus
Hernias
Adhesions
Extra- abdominal causes
Uremia

33. Severe central abdominal pain with vomiting, distension & no peritoneal signs
Small obstruction
Bilious vomiting in proximal obstruction
Feculent vomiting in distal SB obstruction
Gastric outlet obstruction
Non-bilious vomiting
Undigested food particles

34. Severe abdominal pain with localized peritoneal signs
RUQ
Acute cholecystitis (pain referred to back)

35. Severe abdominal pain with localized peritoneal signs
RUQ
Acute cholecystitis
Hepatic etiology: abscess/ hydatid cyst / Hepatitis
Retrocecal appendicitis

36. Severe abdominal pain with localized peritoneal signs
RUQ
Acute cholecystitis
Hepatic etiology: abscess/ hydatid cyst/ Hepatitis
Retrocecal appendicitis
Leaking duodenal ulcer

37. Severe abdominal pain with localized peritoneal signs
RUQ
Acute cholecystitis
Hepatic etiology: abscess/ hydatid cyst/ Hepatitis
Retrocecal appendicitis
Leaking duodenal ulcer
Pyelonephritis/stones

38. Severe abdominal pain with localized peritoneal signs
RUQ
Acute cholecystitis
Leaking duodenal ulcer
Hepatic etiology: abscess/ hydatid cyst/ Hepatitis
Retrocecal appendicitis
Pyelonephritis/stones
Extra- abdominal causes
Lobar pneumonia

39. Severe abdominal pain with localized peritoneal signs
RLQ
Appendicitis
Periumbilical at onset
Shifts to RLQ

40. Severe abdominal pain with localized peritoneal signs
RLQ
Appendicitis
Cholecystitis (low lying GB)
Leaking duodenal ulcer
Terminal ileitis
Meckel’s diverticulitis
Right sided diverticulitis (cecal)
Mesenteric adenitis (children)
Retained testis/ right testicular torsion
Urinary system (urteral stones, pyelonephritis)
Psoas abscess

41. Severe abdominal pain with localized peritoneal signs
LUQ
Pancreatitis (most common cause)
Perforated gastric ulcer localized by adhesions
Splenic infarct/ injury
Subphrenic abscess
Jejunal diverticulitis
Pyelonephritis

42. Severe abdominal pain with localized peritoneal signs
LLQ
Diverticulitis of sigmoid and left colon
Colon cancer with surrounding inflammation
Upper extension of pelvic abscess
IBD
Pyelonephritis

43. Severe abdominal pain with localized peritoneal signs
Hypogastric / Suprapubic area
Perforated diverticulitis or appendicitis
Appendicitis
Pelvic appendix
Urinary tract
Ureteral stones
lower ureter
Bladder distention
Cystitis

44. Severe abdominal pain with localized peritoneal signs
Hypogastric / Suprapubic area
Perforated diverticulitis or appendicitis
Appendicitis (pelvic appendix)
Urinary tract
Ureteral stones (lower ureter)/ Bladder distention / cystitis
Gynecologic / obstetric conditions
Uterine colic (Dysmenorrhea)
Torsion/ ruptured ovarian cyst
Ectopic pregnancy/ Threatened abortion
PID