PERCUSSION OF THE ABDOMEN

Prof. R. Sukumar MD

Institute of Internal Medicine

MMC & GGH

A MUSICAL INTERLUDE Dr. Leopold Auenbrugger was the

inventor of percussion He got the idea by observing a wine

merchant percussing out a half-full barrel Later, he began to practice this

technique on his patients History tells us that he percussed

immediately with one hand, using all four fingertips

PERCUSSION OF THE ABDOMEN

Liver Spleen Kidneys Urinary bladder Free fluid

PERCUSSION OF LIVER Percuss downwards from the right 5th

intercostal space in the midclavicular line to locate the upper border of the liver

Patient's breath held in full expiration Measure the distance from the upper

border of dullness to the palpable liver edge in the midclavicular , midaxillary and midscapular line

LIVER SPAN

Normal span is 12-15 cm at midclavicular line

Loss of normal Liver Dullness Emphysema Large right pneumothorax Hollow viscus perforation Post Laparotomy/ Laparoscopy Massive hepatic necrosis. Interposition of the transverse

colon between the liver and the diaphragm (Chilaiditi's sign)

PERCUSSION OF SPLEEN

Nixon’s method

Castell’s method

Traube’s space percussion

NIXON’S METHOD The patient is placed on the right side so that

the spleen lies above the colon and stomach Percussion begins at the lower level of

pulmonary resonance in the posterior axillary line

Proceeds diagonally along a perpendicular line toward the lower midanterior costal margin

The upper border of dullness is normally 6–8 cm above the costal margin

Dullness >8 cm in an adult is presumed to indicate splenic enlargement

CASTELL’S METHOD Patient is poitioned supine Percuss in the lowest intercostal space

in the anterior axillary line (8th or 9th) Resonant note is produced if the spleen

is normal in size This is true during expiration or full

inspiration Dull percussion note on full inspiration

suggests splenomegaly

CASTELL’S METHOD

TRAUBE’S SPACE

TRAUBE’S SPACE Described by Ludwig Traube It is a semilunar space over the fundus of

stomach Bounded medially by the left lobe of the liver,

laterally by the spleen, superiorly by the left lung resonance and inferiorly by left costal margin

On the surface, it can be mapped by dropping perpendicular lines from the sixth rib at the costochondral junction and the ninth rib at the anterior axillary line to the costal margin

Tympanic on percussion Percussed in sitting or supine posture

Obliteration of Traube’s Space

Left sided Pleural Effusion Massive Splenomegaly Enlarged Left lobe of Liver Full Stomach Fundal Growth Massive Pericardial effusion

KIDNEYS Percussion over a right or left

subcostal mass To distinguish hepatic or splenic

from renal masses Resonant area is percussed over

renal mass because of overlying bowel

Sometimes a very large renal mass may displace overlying bowel

URINARY BLADDER

Percussion in the suprapubic region

Helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant)

ABDOMINAL DISTENTION

DEMONSTRATION OF FREE-FLUID

Fluid thrill

Shifting dullness

Puddle’s sign

FLUID THRILL An assistant (or the patient) to place the

medial edge of palm firmly on the centre of the abdomen

The examiner flicks the side of the abdominal wall

Pulsation (thrill) is felt by the hand placed on the other abdominal wall

Positive in massive ascites (>2L), massive ovarian cyst or a pregnancy with hydramnios.

FLUID THRILL

SHIFTING DULLNESS The percussion note over most of the

abdomen is resonant, due to air in the intestines

When ascites collects, the influence of gravity causes this to accumulate first in the flanks in a supine patient

When at least 1 litre of fluid have accumulated, a dull percussion note in the flanks

Even with gross ascites an area of central resonance will always persist

SHIFTING DULLNESS Percuss centrally and laterally until dullness is

detected Keep your finger pressed there Ask the patient to roll onto the opposite side Ask the patient to hold the new position for

about half a minute. Repeat percussion moving laterally to central

over your mark The fluid(dull note) will now be moved by

gravity away from the marked spot and the previously dull area will be resonant

SHIFTING DULLNESS

PUDDLE’S SIGN Ausculto percussion method Have the patient lie prone for 5 minutes and

then raise himself up to a knee elbow position Place the diaphragm of the stethoscope over

the most dependent portion of the abdomen. Flick with your finger, gradually moving it from

the periphery toward the stethoscope A positive sign consists of an abrupt perceived

increase in the intensity and clarity of the note just as the flicking finger moves beyond the edge of the pool of fluid

Detects as little as 120 mL of ascites

PUDDLE’S SIGN

THANK YOU

Medicine is learned by the bedside and not in the classroom.Sir William Osler (1849-1919)