Abdomen examination -

palpation

PRIYA

ABDOMEN EXAMINATION

Palpation • Palpation is one of the assessment

techniques which health providers use during physical examination to determine certain characteristics of the body

Types of palpation:• Light palpation • Deep palpation• Specific palpation of intra –

abdominal organs

Light palpation• It is used to feel the abnormalities that

are on the surface.• Use the front of fingers, gently press down

into the area of the body about 1-2 cms.• Then lift your fingers off the body and

move to the next nearby area.• It helps to identify the texture, tenderness

,temperature ,moisture, elasticity ,pulsations and masses.

• All areas must be palpated systemically• Use nine quadrants as a guide

Deep palpation • Deep palpation is used to feel internal organs and

masses .• Use the front of fingers to firmly press down into the

area of the body about 4-5cms ,then lift your fingers off the body and move to next area nearby .

• It helps to identify the size ,shape ,tenderness, symmetry and motility .

• Deep palpation can be painful and uncomfortable for patients while examining abdomen .

• Another way to palpate is to put one hand on top of another when pressing down it is called bimanual technique .

Basic steps

• Inform the child or the attender .• Ask where the pain is .• Painful areas to be palpated last.• Warm approach and warm hands are

prerequisties for successful abdomen examination.

In a Crying childIn a crying child, palpate when the

child pauses to take a breath.

In an older child • Patient position.• Good lighting.• Empty the bladder• Undressed nipple to

knees.• Flat on couch with

single pillow on head.• Arms by their sides.• Ask the patient to

relax .• If not, flex hips to 45

degrees, knees to 90 degrees.

Rebound tenderness• If the area which is said to have pain

is painless on examination, press firmly and release suddenly for rebound tenderness indicates peritoneal irritation like appendicitis

• Pain due to spastic bowel is relieved by pressure or squeeze

• Other causes like peritonitis , pain is aggravated

Abdomen as a whole :• Feel of the

abdomen • Soft ( normal)• Firm• Doughy• Rigid

very soft …..prune belly syndrome

localised firmness…. swellings

Doughy ….abdominal tuberculosis

Localised rigidity …acute appendicitis

Palpation of individual organs

LIVER• Start with hand at right iliac fossa, fingers pointed to

head.• Palpate deeply whilst patient breathes in and out deeply.• If nothing is felt repeat the process moving the hand up

slightly. • If edge is palpable describe size shape consistency border tenderness pulsations

Causes of palpable liver• Visceroptosis : here the upper border of

liver is displaced downwards and thus the liver span remains normal .

• Pushed down liver: liver span remains normal eg :emphysema, pneumothorax ,pleural effusion .

• True hepatomegaly.• Upward enlargement of liver eg :

amoebic liver abscess.

Normal values of palpable liver

• Upto 6 months – 3cms or less.• 6months to 4 years - 2-3 cms.• >4years – 1-2 cms.

Spleen • Spleen becomes palpable when it is enlarged

at least 2-3 times its normal size. • Palpate either in supine or right lateral

position .• In right lateral position ,palpate spleen with

right hand with the left hand encircling the left lower ribs and pushing forwards .

• To avoid missing large spleen it is recommended to start palpating from right iliac fossa ,the direction of enlargement of spleen being that way .

Bimanual palpation of Spleen

• Patient should be supine and relaxed.• Relaxation is improved if legs and neck

are slightly flexed.• Start palpating from lower left quadrant

in infants as the spleen tends to enlarge inferiorly toward the left iliac fossa.

• Palpation should be started from the right lower quadrant in older children.

Characters to be noted in splenic swelling

• Size .• Shape.• Consistency(eg :soft in typhoid , firm in

portal hypertension).• Surface (look for splenic notch on medial

border ).• Tenderness.• Fingers cannot be insinuated between

costal margin and the mass.

Grading of splenomegaly• Mild :spleen is of few cms -<3

cms(eg :typhoid ,endocarditis).• Moderate :spleen measures several

cms but does not cross midline 4-7cms (eg :portal hypertension).

• Massive :spleen is hugely enlarged ,crosses midline in the direction of right iliac fossa >7cms (eg :CML, gaucher’s disease).

Kidney Bimanual palpation :• palpate with one hand placed

anteriorly while the other hand which is placed posteriorly pushes the kidney upwards (ballonate swelling).

• Try to approximate both hands and see if kidney can be felt in between .

• It is felt best moving down between examining hands in deep inspiration .

Palpation of kidney contd….• Right kidney being placed lower than the

left,is more likely to be palpable in the normal .

• Though its conventional for all examinations to be done from right side<it is more rewarding to plapate the left kidney from left side.

• The bimanual examination of a newborn can be done with single hand,by placing the thumb anteriorly and the fingers posteriorly.

Difference between kidney and splenic swellings

SPLEEN KIDNEY

Finger insinuation between swelling and costal margin not possible

Possible to push fingers between kidney swelling and costal margin

Splenic notch may be palpated

No notch

Moves freely with respiration ,direction of movement is down and to right

Moves with respiration but much less readily ,direction of movement is vertically down

Renal angle resonant Renal angle(angle between 12th rib and lateral margin of erector spinae muscle)may become dull

Dipping palpation• In presence of ascites if ordinary

palpation fails to reveal the organ , one may resort to dipping palpation

• The hand is placed on the abdomen and the fingers are suddenly dipped into the abdomen ,which displaces fluid quickly for a short while giving time for the examining fingers to have a feel of organs.

Demonstration of direction of flow in distended veins

• Patient is best examined standing .• Empty a segment of vein that does not have

any branching point ,then release one finger .• If it is not filling try releasing the other

finger and see if it is filling from the other side (this methods fails to give right info on direction of flow in long standing cases due to incompetence in valves of veins) .

• In a normal child and in intrahepatic portal hypertension direction of flow is away from umbilicus .

Contd….• In extrahepatic portal

obstruction ,the flow is towards the umbilicus as the blood is passed via paraumbilical veins to liver.

• In inferior venacava obstruction the distended veins are seen in flanks with direction of flow upwards .

• In superior venacava obstruction distended veins have flow downwards .

Other palpable masses• If any other mass is palpated, define its • size,• consistency (soft firm ,hard ,cystic or varying

consistency)• surface (smooth or irregular ),• tenderness ,• location and • movement with respiration• To differentiate intra abdominal from

parietal mass• ask the patient to try get up from supine

position ,if mass disappears it is abdominal ;if it becomes more prominent ,it is parietal.