ABDOMINAL EXAMINATION: THE COMPLETE GUIDE
“Listen to your patient, they are telling you the diagnosis.”-William Osler
Patient position
The patient is supine throughout the examination , sitting up or changing posture only for certain examination methods to be mentioned as we go along .
Student’s position
As usual standing on the right side of the patient ..you hardly need to change sides here .
Exposure
Consider the following points :
a. Textbook tell us to expose from the midchest to the midthigh . This is actually useful because ,
We can examine the lower chest with the upper abdomen
The genitalia should be examined as necessary and not omitted as is often done .
b.However this amount of exposure would be uncomfortable for both men and women.
c. So we usually exposure from upper abdomen from the level of the xiphisternum upto the inguinal ligament , not exposing the genitalia .
d. However ,in medicine we do examine the genitalia once , even if briefly , exposing them for as little time as is necessary .
Ideally ,
The patient should be warm and relaxed .
His / her bladder should be empty .
Examination shouldn’t ideally be just after a meal . It is possible but uncomfortable for the patient .
Examination includes
1. INSPECTION
2. PALPATION
3. PERCUSSION
4. AUSCULTATION
Clearly palpation reveals the most important findings here but we shall cover all the methods in sequence .
INSPECTION of the ABDOMEN
Consider the following points to be noted
1. Shape of the abdomen
Is it distended or scaphoid or normal
Normal : most abdomens have a normal shape .
Normal , essentially means that it is neither distended nor scaphoid .
Distended Abdomen :
The term is self explanatory .
But a distention of the abdomen could be LOCALISED or GENERALIZED .
We just look carefully before drawing a conclusion .
Scaphoid Abdomen :
It refers to a ‘concave ‘ shaped anterior abdominal wall , usually due to severe weight loss eg …in cancer ( of any type ) , tuberculosis ( inadequately treated) , diabetes ( not adequately treated ) .There is no special technique here . Just stand or sit and look carefully .
2. Flanks :
Note whether the flanks are full or not .
Fullness is suggestive of free fluid in the peritoneal cavity ie , ascites ( note suggestive ,not confirmatory)
While no fullness is not .Once again just look carefully , no special technique is required .Also remember that bulged flanks can also be caused by other pathologies , even fat .
3. Umbilicus
We note the
a. Shape
b. Position
c. Lesions around it or in it .
Once again no special techniques are required ..just look carefully .
Shape :
A normal umbilical can be a vertical slit or round sometimes a bit horizontal .
But a horizontal slit usually means that there is generalised abdominal distension ( often due to ascites ) .
Also the umbilicus is usually inverted .
If it is flushed with the abdominal wall or everted it is often due to abdominal distension .
Position
The umbilicus , in an adult is usually located midway between the xiphisternum and the symphysis pubis.
Sufficient ascites could push the umbilicus down towards the symphysis while a very large pelvic tumour ( this is rare ) might push it upwards towards the xiphisternum .
Lateral shift by a very large tumour might be possible but is rare and is better not mentioned for now .
4. Venous prominences
A venous prominence is a dilated , tortuous , superficial vein . These need to be looked for and there is special method .
a. First observe the abdomen with the patient supine
b. Then make him / her sit up and try again .
c. Finally , ask him / her to cough .
( Coughing increases Intraabdominal pressure and makes the veins ,if present , more prominent .)
Only now can you say that there are no venous prominences .
The best place to look is the epigastric area . But also look in the hypogastrium in the midline And also check the flanks carefully .
5. Look for various abdominal movements
a. Respiratory movement
As mentioned during respiration , different for men , women and children .
b. Peristaltic movements Always abnormal if found Three possible types are
1. Slow sinuous from right to left in the epigastric and left hypochondrium area In gastric outlet obstruction
2. From right to left across the upper abdomen . Seen in transverse colon obstruction .
3. Small step – ladder movements around the umbilicus Seen in small gut obstruction .
c. Visible pulsations
Best seen in the epigastric area
Probably due to
1. Abdominal aorta in a very thin person ( normal )
2. Abdominal aorta aneurysm
3. Right ventricular hypertrophy
6. Any visible skin changes
7. Any puncture marks ,bandages , drains in situ Shall continue tomorrow with palpation .
Bye for now
PALPATION
First of all
1. Palpation is the most important part of your GI examination … Nothing reveals more …
2. GI pts are the most common patients you get in your medicine examination and probably surgery and Paediatrics too , so read this first .
3. There is a certain amount of overlap in examination of the GI system across Medicine , Surgery and Paediatrics .
There are considerable differences too but it is worth reading them together as a common examination and taking careful note of the differences .
This is useful because during a bedside examination , examiners often tend to cross into other subjects eg asking about Gall stone induced jaundice and Couversier’s Law in the Medicine exam , so it’s worth getting ready for .Plus such a preparation , however tedious will makes things much clearer for you all .
PALPATION OF THE GI SYSTEM
The patient remains supine as in Inspection .
Exposure remains the same initially …changes are made when necessary ( to be discussed ) . Patient must be warm and comfortable.
It is useful if the patient has emptied his / her bladder and is on an empty stomach .Before , you actually touch the patient , refer to your history and check for abdominal pain . Causing more pain by unnecessarily deep palpation over a tender area is undesirable and unethical . It doesn’t reveal much .
The abdomen must be soft and relaxed to get best findings .
Now let’s start
Palpation is of two types :
1. Superficial Palpation
2. Deep Palpation
The names are self explanatory.
A. Superficial Palpation
We note the following points :
1. Superficial Tenderness
2. Temperature
3. Any obvious lump
4. Direction of blood flow in Venous Prominences , if any
5. The feel of the abdomen in general
6. Any muscle guard or rigidity ( this is more important during Surgical patients and acute patients )
Regarding any palpation , superficial or deep , Your palpating hand :
1. Should be warm and dry
2. Should be soft and should mould with the curvature of the abdomen when touching . Stiff hands do not help at all.
3. Your wrist must be straight or flexed slightly . At most it can be very slightly extended but not more .
Too much extension at the wrist of your palpating hand causes unnecessary tension in the hand and reduces your ability to feel subtle findings .
Your hand be relaxed .
If necessary , you can lean over the patient , flex your elbow as much as you need but always relax your wrist .
4. The fingers must be together and you use the Palmar surface of the hand plus that of the fingers for best results .
1. Superficial Tenderness
a. Use your hand as described above .
b. Examine each of the 9 areas of the abdomen individually and deliberately … Don’t casually place your hand anywhere over the abdomen and start feeling .
c. After placing your hand , roll in gently in a circular motion in the horizontal plane but do not try to dig deep into the abdomen ( Remember this is Superficial Palpation , not deep !! )
d. Look at the patient’s face for any grimace or change in expression . Remember that pain is a symptom/ complaint .
Tenderness is a sign / finding .
e. If there is a complaint of localised abdominal pain , palpate there last so as to give your patient comfort and to avoid inducing any muscle guard which can spoil any palpatory examination .
2. Superficial Lump
a.Do exactly what you did for superficial tenderness .
Just look carefully for a lump.
b. If you find a lump try to describe it ( Surgery really reaches this well )
c. Do the head raising or leg raising test to understand if the lump is superficial/ parietal ( in the abdominal wall or deep ( Intraabdominal ) .
To do this test :
a. The patient remains supine and relaxed .
b. You place your palpating hand over the lump found .
c. He / she keep his/her hands over his/ her chest and elbows off the bed so as not use them while doing the test .
d.The patient is asked either to :
1. Raise his/ her head without using his / her upper limbs in any way or by any sideway movement .
2. OR he / she can flex the entire lower limbs upwards from the waist , from neutral to about 90 degrees without using his / her arms .
Either manoeuvre encourages the patient to contract his / her abdominal muscles whic would make a parietal lump more prominent and an intraabdominal lump vanish .
3. Temperature
a . Just place the dorsum of your hand over each of the nine areas of the abdomen one by one and feel for an elevated temperature , localised or generalised.
b. Always remember that the abdomen is usually covered by clothes and is therefore a bit warmer than an uncovered area eg your face .
So , you must compare the temperature with a covered part of the body .
Commonly we use the root of the neck ,under the collar .
Just touch this area once initially and then proceed to check the abdomen .
4. Direction of blood flow in Venous Prominences .
This is a bit difficult to explain without a live demonstration … do see the video . Anyway , the steps are :
a. Choose an appropriate segment of vein to examine . This segment of vein must be
a . Short ( say an inch or two )
b. Relatively straight ( perfectly straight is near impossible … Don’t look for it )
c. Devoid of any branches
d. Also try to find two such segments , one above the umbilicus ( eg . the epigastric area ) and one below ( the hypogastrium and inguinal areas ) .
b. Using the index finger of both your hands , milk the blood out of this chosen segment ( Remember condition of the Arterial wall in cardio ? Just like that ! )
c. Now release one finger and observe the presence and speed of blood flow in that direction. d. Milk the blood out again and release the other finger and observe again .
e. The direction in which blood flows faster is the direction of blood flow .
5. Feel of the abdomen .
This is automatically assessed while looking for a lump or tenderness ( all three can be noted together ) .
The normal feel is elastic .
6. Muscle guard or rigidity .
DEEP PALPATION
For deep palpation the posture of the patient changes to facilitate the palpation . Otherwise it becomes very difficult to appreciate any finding properly .
The patient remains supine but
1. Flexes his knees and hips (hips to about 60, certainly not 90 degrees : and knees a bit more ) .
2. The feet rest firmly on the bed
3. The patient must hold this posture but remain relaxed
4. He / she must look to the opposite side
5. He / she must breathe deeply with an open mouth ..very slowly but very deeply too .
This posturing relaxes the abdomen at least partially ..
The deep fascia , being thick and a bit tense is a major hindrance to deep palpation . The deep fascia of the lower limb ( ie the fascia of Camper and that of Scarpa ar attached with that of the abdomen at the inguinal ligament .. so flexing the lower limbs reduces the tension in the abdomen a bit .
Also slow deep breathing creates more relaxation , specially during exhalation .
Apart from this talking politely to your patient in attempt to distract him / her rather than to scold or scare him / her really works ..
Plus it takes quite a few respiratory cycles to achieve the desired level of relaxation .
Any impatience or extra force applied too early is usually counter productive ( it can hurt ) and you end up looking like an inexperienced fool …be patient while palpating the abdomen …it isn’t comfortable for most patients .
Fat , ascites and muscle guard make it difficult .
You hand must be positioned and used as described for superficial Palpation with one exception .. your hand must gradually go deep .. with the same rolling movement or a rocking movement …( Shall need a video to explain this exactly ) .
We aim to palpate the following by deep palpation .
1. The liver
2. The spleen
3. The kidneys
4. The colon
5. Any other mass / lump
I shall describe the liver and the spleen and a bit of the kidney
The surgeons should describe the kidney and colon plus lumps in general .
Once I am done with all 4 systems …the bare necessities that is I may come back and add more details while also going through individual types of diseases that appear in your practical examination .
1. PALPATION OF THE LIVER
This is easily one of the most important methods you need to know … It is too common to be ignored … In life and in examinations…
And so there is no excuse of not knowing it ..
There are two methods :
1. The preferred method
2. The alternative method
We commonly use the alternative method as a matter of habit but we really should be using the preferred method …it is much more scientific , as you shall realise when you actually practice .
THE PREFERRED METHOD
A. Position of the patient
Exactly as described for deep palpation .
B. The method
1. You must stand on the right side of the patient .
It may be preferable to lean over or even sit down for a better position … remember that your wrists must be relaxed and never hyperextended … That’s why ..
2. Place the four fingers of both hands right and left next to each other ( ie .eight fingers all in line , side to side ) and thumbs in their normal place between the fingers .
3. Thus put your two hands held so as a single flat palpating surface on the abdomen , the finger tips being just below the right subcostal margin .
Also your right hand which is obviously medial should not cross the margin of the rectus abdominis muscle of the right side .( Because , normally a liver is too soft to palpate through a firm structure like the rectus.)
I understand that this sounds rather vague .. please see the video or look at pictures in MacLeod’s and Hutchinson .
4. Now observe the rise and fall of the abdomen with inspiration and expiration respectively .
During expiration , press your hands down together as a single palpating unit and look for any resistance , and if found see if you can feel the margin of the liver .
If you find both you have probably found the liver and can proceed to examine various aspects of it and then to describe it formally .
If you have found a resistance but no margin then you need to move further downwards towards the iliac fossa on the right until you trace a margin .
5. Here note that this is deep palpation .. if you cannot get deep you feel nothing .
So take time to palpate . You can only actually press down during expiration when the abdomen is relaxing and soft . During inspiration the abdomen rises and putting too much pressure is akin to not letting him/ her breath freely .
Yet the liver moves down during inspiration and this timed movement is one of the features that allow us to recognise the liver .
So , to note both , we press down during expiration and try to keep our hands there during inspiration , waiting for the enlarged liver to descend to touch our palpating hands / fingertips / palms .
Getting it right requires :
1. Lots of practice
2. Taking several respiratory cycles to get deep into the abdomen .
Trying to go really fast and do it in one go simply hurts the patient , often induces muscle guard …you ultimately feel nothing .
Gradually descend into the abdomen over a few cycles ..it works better .
3. Warm hands and a relaxed patient .
C. What aspects to see and how to describe it
Note the following statement describing the liver as an example of what to write in the exam .
The liver is palpable , X cm below the right subcostal margin , in the right midclavicular line at the height of inspiration .
It is , soft / firm / hard in consistency. It is tender / non-tender .
The margin is rounded / sharp / nodular or irregular .
The surface is smooth / irregular / nodular .
It moves freely with respiratory .
The upper border of liver dullness is in the 5th ) 6 th / other intercostal space. The liver span is Y cm .
The left lobe of the liver is palpable / not palpable and is enlarged ) shrunken . ( Other points like surface margin should match the right lobe )
The liver is pulsatile / non-pulsatile .
A hepatic bruit is heard / not heard .
So we first feel the liver ..
Soft is soft and very difficult to actually locate at times . Firm is easy and overwhelmingly common. Hard is rare and something you won’t forget easily .
For tenderness look at the patient’s face for a grimace ) change of expression .
The margin is rounded for a soft liver and sharp or irregular for the other two .
Note the surface with your palpating hands .
Take a measurement below the right subcostal margin in the right midclavicular line at max inspiration .
To find the upper border of liver dullness ,percuss the right anterior chest wall in the midclavicular line from the second intercostal space downwards until you note a dullness , usually the 5 th or 6 th space . The distance from this space to the lower extent of the liver is the liver span .
Follow the liver towards the midline looking for the left lobe which is palpable below the xiphisternum and through the rectus margin .
It’s size ie extent below the xiphisternum is measured .
Whether it is pulsatile or not is felt while palpating .( A special method for this shall be discussed later )
We may auscultate the liver with the diaphragm of the stethoscope for a soft systolic murmur like sound , called a hepatic bruit which can be caused by a vascular tumour.
THE ALTERNATIVE METHOD .
For reasons unknown this is always used , perhaps convenience ??
The basic method and principles are the same , even the final liver description. Except for the following aspects :
1. We use one hand , not two , the right hand standing in our usual location .
2. We place in the right iliac fossa and do the same process described above but one handed .
3. The radial border of the palpating hand is held parallel to the right subcostal margin . 4. The right hand ascends until a liver is felt or until the right subcostal margin is reached . 5. The other hand is free .
THE DIPPING METHOD OF LIVER PALPATION.
The two methods described above become non- effective or less effective in the presence of a large amount of ascites .
So here we use a compromise called the dipping method which offers less information , but at least tells us whether the liver is palpable or not .
Steps .
1. Patient position is as usual
2. We start from the iliac fossa as in the alternative method .
3. However , we use two hands instead of one but not side by side as in the preferred method but one hand on the other …usually left on right if we are right-handed .
5. We start from the iliac fossa and ascend towards the subcostal margin .
6. We time with respiration as before , pressing during expiration and trying to hold it during inspiration.
7 .The difference is how we palpate ..
We press down rapidly twice in quick succession , the movement coming from the metacarpophalangeal joints , pressure being exerted by the palmar surface of the fingers.
8. The first movement is a rapid push to actually push the free fluid away from the area of interest .
The second movement follows the first immediately and the hands are held in that position, waiting for the liver to come before the displaced water flows back .
9. We just comment that the liver is palpable or not .. nothing more
Palpation of the Spleen
There are similarities and differences as compared to palpation of the liver . 1. The posture is exactly the same.
2. You always stand on the right side of the bed.
3. You place your left hand over the 9th , 10 th and 11 th ribs on the left side behind the posterior axillary line and apply traction forwards and medially .
This is essential for palpating a small spleen .
( Needs a video or picture )
4. You use the radial edge of your right hand as in the alternative method of liver palpation .
5. But you proceed in a different direction …
From the right iliac fossa towards a point formed by the intersection of the left midclavicular line with the subcostal margin .This often meets the tip of the 9 th costal cartilage anteriorly .This line thus followed is called the splenic axis and the spleen usually enlarges along this line .
6. An example of how to describe the spleen .
The spleen is enlarged , X cm along the splenic axis …It is small , moderate , huge / massive in size.
It is soft / firm / hard .
It is tender / non – tender
It moves with respiration .
Splenic notch is palpable / not palpable .
Small is 2cm
Moderate is more than 2 less than 8 cm Massive is 8 cm and above
For tenderness look at the patient’s face .
A splenic notch is an acute invagination in the splenic margin which almost confirms that the mass is a spleen .
7. A splenic mass must be differentiated from a left-sided renal mass . The differences are
a. Incase of a spleen it is not possible to insinuate your fingers between the subcostal margin and the mass .In case of a renal mass ,the kidney being retroperitoneal , the fingers slide easily between the renal mass and the subcostal margin .
b. The spleen has a splenic notch while the kidney does not .
c. The kidney is bimanually palpable , ie can be felt between both hands , one in the left renal angle and one over the mass. The spleen is not .
d. The renal mass is ballotable ie if you push it up with your fingers placed in the renal angle it floats up to touch your other hand placed a ove the mass and vice versa .
e. If you percuss above a renal mass you get a band of resonance because of the presence of the colon ( not always ) . Percussion over the spleen is always dull .
Percussion of the spleen .
There are several methods.
The first is Percussion of Traube’s Space .
Traube’s space is bound by the left midaxillary line laterally , the xiphisternum medially , the 6 th intercostal space above and the left subcostal margin below .
Placing your pleximeter parallel to the midaxillary line we percuss the area from medial to lateral .
There are several causes of a dull Traube’s space , but an enlarged spleen is one of them .
PERCUSSION
There are just two important methods in percussion of the abdomen , both of which are very important to learn …
A. Eliciting shifting dullness B. Fluid Thrill
Shifting dullness .
If this is present …it is CLINICAL CONFIRMATION OF THE PRESENCE OF FREE FLUID IN THE PERITONEAL CAVITY
Method :
1. Patient remains supine but as for superficial palpation with lower limbs outstretched. 2. His / her bladder must be emptied before the examination for optimum findings.
3. First you percuss , lightly ( so as not to hurt the patient , remember this is the soft abdomen not the firm chest )
From the xiphisternum to the symphysis pubis , in the midline . Your pleximeter finger is kept parallel to the upper border of the pelvic bone ,ie horizontally .
4. As you percuss , the intensity of the note ( which is normally tympanitic , a kind of hollow sound elicited over the abdomen ) increases towards the umbilicus and then decreases lower down .
Percuss the full distance and then note the point of maximum tympanicity .
5. From this point , you percuss towards the sides / flanks lalmost upto the bed in a horizontal line ,once to the left side and once to the right .
6. If fluid is present , you may find dullness appearing as you move laterally towards the flank . If found mark this point of appearance of dullness and then proceed downwards towards the flank .It is usually dull all the way down now .
Repeat this process on the other side .
7. Before percussion ,always check for a very large hepatomegaly or splenomegaly . Either can cause enough dullness to confuse the examiner and so the percussion is not done on that side .
8. Now place your pleximeter finger over any one of the marks you have made and turn the patient over so that that mark is now the highest point above the ground .
9. Wait for about 20 seconds .
10. Now percuss over that mark .
It should be tympanitic and not dull like before because the fluid causing dullness should have gravitated down instantly while the air – filled gut , whose presence causes tympanicity should have slowly floated up to take its place .
11. Percuss towards that flank to demonstrate that the entire dullness has become tympanitic .
12. Now proceed percussiing towards the midline and then beyond the midline , until a new mark of dullness appears earlier than the previous mark because of the free fluid which accumulated there when the patient turned over .
13. Note this new mark and repeat the process on the opposite side to get a similar mark . 14 .This is called shifting dullness .
Fluid Thrill
This finding is present only when the ascites is really tense .
Some books say that fluid Thrill and shifting dullness cannot coexist in the same patient .
That is if the fluid is so tense that it elicits a fluid thrill,it will hardly shift enough to cause shifting dullness and if the fluid can move enough to allow elicitation of a shifting dullness , it is not tense enough to create a fluid thrill .
However , many books differ .
Method
1. The patient remains supine as above.
2. You place the palm of one hand flat over one side of the abdomen , say a little above the flank .
3. You flick the diametrically opposite side of the abdomen gently with the other hand . 4. If positive ,the flick should felt very distinctly by the other palm of the hand .
5. The patient’s radial border of one hand is placed in the midline of his / her abdomen during this procedure to avoid transmission via the skin , creating confusion .
AUSCULTATION
Auscultation of IPS – Intestinal Peristaltic Sounds
1 . Place the diaphragm of your stethoscope very firmly over four imaginary quadrants of the abdomen (divide the abdomen into four parts for this purpose ) and listen for the intermittent gurgling sound called IPS .
Normally , we hear 2-6 gurgles every minute .
That’s all for GI examination .
Bye for now
