ABDOMINAL EXAMINATIONAll examinations must start with Introduction to the patient and consent for examination.

Failure to do so may not only prove troublesome in examination but may also prove bothersome for the patient. Introduction and Consent are followed by proper positioning of the patient and proper exposure for the examination

Positioning of the Patient for Abdominal ExaminationFor abdominal examination, the patient should lie relaxed preferably on a comfortable couch with the hips flexed to 45 degrees and knees flexed to 90 degrees. Alternatively a pillow may be kept under the head. These maneuvers relax the abdominal wall muscles and are crucial for the abdominal examination.

Exposure of the Patient Ideally, the patient should be exposed from nipples to knees.

Position of the ExaminerThe examiner should be positioned in such a way that his wrist and forearm are horizontal during palpation. This may be achieved by kneeling or sitting beside the bed with the examiner’s eyes about 50 cm above the patient.

General Physical ExaminationDuring General Physical Examination, the findings related to abdomen usually include pallor, anemia, cyanosis, cachexia, jaundice, dehydration, fetor and pyrexia.

Head and ChestHead examination may reveal lymphadenopathy (as in mesenteric adenitis). Chest examination may reveal Breast cancer or Pulmonary diseases (e.g. right sided basal pneumonia mimicking appendicitis in children).

Cardiovascular SystemCardiovascular system should be examined for signs of cardiac failure, valvular diseases, and peripheral vascular diseases.

Abdominal ExaminationAbdominal examination is preferably carried out under proper analgesia as the pain involved in certain abdominal conditions may cause patient to refuse to examination. The withholding of analgesia until examination by a surgeon is now rapidly discarded from the textbooks.

InspectionInspection of the abdomen is preferably carried out from two points: foot end of the patient to look for the shape and symmetry of the abdomen as well as movements of the abdomen with respiration, and a

closer view, preferably sitting beside the patient to look for any swellings in the abdominal wall. Other findings that should be kept in mind while inspecting the abdomen are distension, scars (subsequently examined for incisional hernias), sinuses, fistulae, dilated veins, expansile pulsations of aneurysm, skin eruptions, visible peristalsis. The hernial orifices should also be inspected (and subsequently examined).

PalpationPalpation is an important part of abdominal examination which has been divided into five phases for convenience.

I – Superficial PalpationIt is done to look for any abdominal masses, pain and guarding in the abdomen. Pain in abdomen needs further detail in order to understand abdominal examination and its findings. Therefore, it has been explained in the text box with illustration.

Pain abdomen is the most frequently encountered symptom of abdominal problems. And considering the variety of organs present in abdomen as well as the meshwork of nerves it may prove to be an extremely elusive presentation of the underlying pathology. It is therefore important to understand abdominal pain in depth.

Abdominal pain may originate from abdominal viscera or it may be caused by some pathology in the abdominal wall. Furthermore, abdominal pain may result from referral of pulmonary or cardiac pain downward. Other medical conditions leading to abdominal pain include Diabetic Ketoacidosis and Porphyria. However, the localization of abdominal pain does follow certain basic rules that, if understood, render much convenience for the examiner. Parietal peritoneum when inflamed or irritated leads to a well localized pain which may radiate forward or backward along the somatic nerve dermatome. Visceral peritoneum when inflamed or irritated leads to a poorly localized pain that is associated with sweating and nausea. Pain originating in the retroperitoneal structures like kidneys is usually felt in the back.

For example, in case of acute appendicitis early involvement of the visceral peritoneum leads to a vague pain that is felt around the umbilicus (due to the innervation of the visceral peritoneum by nerves originating in the corresponding nerve root). The patient becomes anorexic and nauseated. With increasing inflammation, the overlying visceral peritoneum is also involved which leads to a more intense pain localized in the right iliac fossa. When perforation occurs, it leads to generalized peritonitis and a sharp pain that involves the whole abdomen.

Characteristics of Abdominal PainAbdominal pain is usually due to inflammation of abdominal viscera, obstruction of a hollow viscus or perforation.

Inflammatory pain is usually very non-specific, gradually increasing over hours or days. It may be due to acute appendicitis, cholecystitis, salpingitis, mesenteric adenitis, infarction (that initially presents as obstruction) and hemorrhage (due to irritation of the peritoneum by blood in the peritoneal fluid).

Pain due to obstruction of a hollow viscus (e.g. intestines) typically presents as a colicky pain, except for the pain of obstructed gall bladder. Obstruction of the gall bladder is continuous with acute episodic exacerbations in the pain, thus, mimicking colic with background pain.

Perforation of a viscus usually leads to acutely developed severe pain. In early perforation, site of maximum tenderness may be determined through careful percussion. The organs usually perforated include appendix, peptic ulcer and colon.

1. Inflammatory Pain 2. Perforation Pain

3. Colicky Pain 4. Gall bladder obstruction

For example, the pain of acute appendix is usually vaguely colicky in its early stages due to obstruction. Being inflammatory in nature, it gradually develops. When perforation occurs, the patient complains of a sudden intense exacerbation of the pain that has become constant. In such patients, the pain is made worse by moving and coughing.

As can be inferred, the patient of general peritonitis will lie still in bed and will breath shallow i.e. his abdominal breathing movements will be limited. On the other hand, a colicky pain patient will roll around and double up with every surge in pain.

Following are two hand – sketched illustrations demonstrating the causes of pain by abdominal region and radiation of common visceral pains.

2 – Rebound TendernessRebound tenderness represents peritonitis whether local or general. It is best examined through coughing, percussion or by applying and suddenly releasing pressure in full inspiration.

On the other hand, guarding represents muscular spasms as the inflamed viscera touch the overlying peritoneum. Board-like rigidity is encountered in generalized peritonitis.

Before starting superficial palpation, ask the patient if there is any tenderness in the abdomen. The site of tenderness must be palpated at the last. Conventionally, superficial palpation is started in the left iliac fossa and finished in the right iliac fossa after following a counter clockwise course over the abdomen. Tender areas should be carefully defined so as to graphically represent them on paper. Rebound tenderness may be checked by asking the patient to look to his left and cough; alternatively, percussion may be employed over the tender area, or the patient may be asked to inhale deeply and stop his breath then applying pressure over the area and releasing the pressure briskly.

3 – Deep PalpationDeep palpation is done to assess any deep tenderness or abdominal mass.

Deep palpation follows the same procedure as superficial palpation.

4 – Palpation of Abdominal MassesMasses encountered during abdominal examination may be pathological or physiological (i.e. the viscera). Any mass felt on abdominal examination, other than the viscera, should be thoroughly investigated through palpation and percussion.

In order to proceed with examination of abdominal masses, localization of the mass is done through tensing the abdominal muscles (by asking the patient to raise his head or raising the legs straight). Any mass superficial to the abdominal wall muscles will become more obvious; those attached to the deep fascia will become less mobile, whereas those arising within the muscle layer will become fixed and less obvious. Lumps arising deep to the abdominal wall (i.e. within the peritoneal cavity or retroperitoneum) will usually become impalpable on tensing the anterior abdominal wall muscles.

History questions related to pain include Time and Onset, Site, Character, Severity, Progression, Duration, End, Radiation, Relieving factors, Exacerbating factors and Associated Symptoms e.g. vomiting, diarrhea, painful micturition, missed or absent periods.

After localization, the abdominal mass should be described in terms of its position, shape, size, surface, edge, consistency, fluid thrill, resonance and pulsality. Tender masses can be assessed by gently pressing on the mass during expiration and noting their surface and texture as they slide under the fingers during breathing.

Palpation of Abdominal VisceraLiver is the organ which is usually palpated first during abdominal examination. It is then followed by Spleen, Kidneys, Bladder & the abdominal aorta.

Examination of liver is started from the right iliac fossa. However, in gross hepatomegaly the liver may fill the whole abdomen which may necessitate initiating the examination from left iliac fossa. The position of the hand is such that the fingers are kept parallel to the right costal margin. During expiration the hand is moved upward toward the costal margin by 1cm each until it reaches the costal margin or liver is felt sliding under the fingers during inspiration. This will determine the lower margin of liver in hepatomegaly. In order to determine the upper border of liver, percuss downwards on the chest. Hepatic dullness usually starts in the fifth intercostal space. Describe liver in terms of size (as distance of edge below the costal margin or distance between upper margin of hepatic dullness and edge in centimeters), surface (smooth or lobulated), edge (round or sharp), consistency, tenderness, pulsation and audible bruit.

Examination of spleen is started from the right iliac fossa while positioning the hand diagonally in such a way that palm rests in RIF while fingers point towards left costal cartilage. Move towards left costal cartilage during each expiration until the spleen (with its characteristic notch) is felt. If the tip of spleen is not found then palpate the whole length of left costal cartilage. If still not found, then ask the patient to roll onto his right side while putting your left hand behind the lower ribs and pulling them forward. An enlarged spleen will become palpable with the right hand. Percuss on the lateral ribs to exclude splenic dullness.

Normally, kidneys are usually impalpable, except in very thin people, but both lumbar regions should always be carefully examined. To feel the patient’s right kidney, place your left hand behind the patient’s right loin between the twelfth rib and the iliac crest, so that you can lift the loin and kidney forwards. Then place your right hand on the right side of the abdomen just below the level of the anterior superior iliac spine. As the patient breathes in and out, palpate the loin between both hands. The lower pole of a normal kidney may be felt at the height of inspiration in a very thin person. If the kidney is very easy to feel, it is either enlarged or abnormally low. To feel the left kidney, lean across the patient, place your left hand around the flank into the left loin to lift it forwards, then place your right hand on the abdomen and feel any masses between the two hands. An enlarged kidney can be pushed back and forth between the anterior and posterior hands. This is called BALLOTING.

For palpation of bladder, it must be full, because empty bladder lies in the pelvis. As it fills the fundus moves upwards and in urinary retention the fundus of bladder may reach up to umbilicus. It is palpated in the same way as palpating the fundus of a uterus i.e. by feeling the bladder fundus between thumb and fingers.

Aortic pulsations are felt by placing fingers of both hands in midline above the umbilicus.

The following must also be examined during palpation.

Supraclavicular lymph nodes Hernial orifices Femoral pulses Genitalia

PercussionPercussion of abdomen is especially useful in mapping out a tender area and abdominal masses. Whole abdomen must be percussed to look for any abdominal mass that may have been missed on palpation. In cases of ascites, shifting dullness is determined through percussion.

Ascites usually presents as dull flanks and central resonant notes due to the “floating bowels”. When the patient is asked to roll onto one side and the flank percussed after 10 to 15 seconds, the resonance may be noted to have “floated up” to that flank, a phenomenon termed as shifting dullness. The presence of fluid in abdominal cavity or any lump may also be assessed by taping on one side of the lump while feeling at the other. If the tap is felt, an assistant is asked to place his palm between the examiner’s hands. This prevents transmission of the thrill through skin. If the thrill is still felt, this confirms the presence of a fluid thrill (usually occurs in gross ascites).

Summary of Abdominal Examination

Introduction Consent Positioning of the Patient Proper Exposure Inspection of the Abdomen (shape,

symmetry, visible distension or lumps, scars, visible veins)

Superficial Palpation (pain, mass and tenderness)

Deep Palpation (deep masses and tenderness)

Palpation of masses(site, position, size, surface, edge, consistency, fluid thrill, resonance, pulsatility)

Visceral Palpation (liver, spleen, urinary bladder, aorta)

Supraclavicular lymph nodes Hernial orifices Femoral pulses Genitalia Percussion of Abdomen (Masses and

Areas of tenderness) Auscultation of Abdomen (Bowel

sounds, Aortic bruit, Renal bruit, Splenic bruit, Hepatic bruit)

AuscultationAuscultation of the abdomen is mainly done for two purposes: to hear the bowel sounds and to find any audible systemic vascular bruits.

Bowel sounds are gurgling sounds of intestinal peristalsis usually heard every 5 – 10 seconds. They are increased in frequency during increased peristalsis while absent in generalized peritonitis and paralytic ileus. In order to listen for the bowel sounds, stetho diaphragm is placed to the right of umbilicus. Absence of bowel sounds for 30 seconds is termed Absent Bowel Sounds. However, stetho must be kept for 2 minutes before declaring the absence of bowel sounds.

Systolic Vascular Bruits include the aorta (heard above the umbilicus over aorta and signifying atheromatous or aneurismal aorta or superior mesenteric artery stenosis), renal artery (2-3 cm above and 2-3 cm lateral to umbilicus) and over the liver for bruits due to hepatoma or acute alcoholic hepatitis, splenic bruit (left costo-phrenic angle).

Rectal ExaminationRectal examination is an important part of abdominal examination and must, therefore, be included in the examination wherever possible. It is indicated in many conditions like suspected appendicitis, pelvic inflammatory conditions, rectal bleeding, unexplained weight loss, prostatism and pyrexia of unknown origin. In some patients rectal examination is used as an alternative of vaginal examination.

For examination of rectum, the patient must be explained about the procedure and asked for permission. A chaperone should be provided wherever possible. Position the patient in the left lateral position with the knees drawn to the chest and the heels clear of the perineum. Examine the perianal skin for skin lesions, external hemorrhoids and fistulae. Lubricate your gloved index finger with water-based gel. Place the pulp of the forefinger on the anal margin and with steady pressure on the sphincter push your finger gently through the anal canal into the rectum. If anal spasm is encountered, ask the patient to breathe in deeply and relax. Use a local anesthetic suppository before trying again. If pain persists, examination under general anesthesia may be necessary. Ask the patient to squeeze your finger with anal muscles and note any weakness of sphincter contraction. Palpate systematically around the entire rectum; note any abnormality and examine any mass. Record the percentage of the rectal circumference involved by disease and its distance from the anus. Identify the uterine cervix in women and the prostate in men; assess the size, shape and consistency of the prostate and note any tenderness. If the rectum contains feces and you are in doubt about palpable masses, repeat the examination after the patient has defecated. Slowly withdraw your finger and examine it for stool color and the presence of blood or mucus.