ABDOMINAL EXAMINATION

INSPECTION ABDOMINAL EXAMINATION

The patient must be in supine position. The doctor stands on patient’s right side and the patient should be made comfortable. Inspection must be done in good light from xiphisternum to the level of the symphysis pubis.

SHAPE:

Normal shape of the abdomen is scaphoid or boat shaped. Distention – May be Generalized or Localized.

• Generalized distension may be due to fat, fluid, flatus, faeces or pregnancy.
• Localized may be seen in small bowel obstruction, gross enlargement of the spleen, liver or ovaries.
• Groin should be examined, especially for inguinal and femoral hernia. If no swelling is seen, patient is asked to look on side and cough. The hernia may now be visible. To understand how to differentiate between inguinal and femoral hernia, please refer Palpation.

SKIN:

• Any form of pigmentation of the abdominal wall should look for. For example, linea nigra is a sign of pregnancy, below the umbilicus. Erythema ab igne a brownish pigmentation produce by constant application of heat. It suggests long standing pain, such as in chronic pancreatitis.
• Distention due to any reason may cause a smooth and glossy skin, whereas a relieved previous distention may cause wrinkled skin.
• Abdominal striae, commonly known as stretch marks represent rupture of subepidermal connective tissue, as a result of abdominal distention, present or past. They especially see after pregnancy.
• Dilated veins may see in venous obstruction of any form. On the abdominal wall, they usually see due to IVC or portal vein obstruction.
• Spider nevi see in alcoholics, cirrhosis, pregnancy, RA, Thyrotoxicosis and sometimes in normal individuals. It has a central arteriole and radiating small vessels. They are pulsatile and blanch on pressure.
• Also look for scars, old or recent. They may suggest some injury or past operations.

UMBILICUS:

• The umbilicus normally is slightly invert and retracted.
• In ascites, it acquires a smiling face (transverse stretch) or flattened or everted. In obesity, the umbilical cleft is deeper than normal.
• Normally, it is equidistant from the xiphisternum and symphysis pubis.
• In ascites, its distance from xiphisternum is greater, whereas, in ovarian tumor or full urinary bladder, its distance is greater from symphysis pubis.
• Cullen sign – Bluish discoloration of periumbilical region in acute hemorrhagic pancreatitis or ruptured ectopic pregnancy.
• Cherry red swelling suggests inflamed Meckel’s diverticulum.

MOVEMENTS OF THE ABDOMINAL WALL:

• Normally there is a gentle rise in the abdominal wall during inspiration and a fall during expiration. The movements are symmetrical.
• The abdomen bulges in diaphragmatic paralysis during expiration.
• In generalized peritonitis this movement absent or markedly diminish (the ‘still, silent abdomen’).

PULSATIONS:

• Normally, the pulsations are not visible over abdomen, but pulsation of the abdominal aorta may visible in thin and nervous patients, in the epigastrium.
• In aneurysm of abdominal aorta, this is more visible and a widened aorta felt on palpation.

PERISTALSIS:

• Peristalsis on inspection can experience only with great patience. It mark in pyloric stenosis in the epigastric region. In the same region, peristaltic wave of transverse colon can see, moving from right to left.

PALPATION ABDOMINAL EXAMINATION

This forms the most important part of abdominal examination. The patient must assure that the process will gentle. Patient should breathe deeply and should flex his legs so that the abdominal muscles are relax. If the muscles are still not relax, his attention should divert by asking him to lock fingers of both hands and pull them apart or by some other technique. The wrist and forearm should in the same horizontal plane wherever possible. The ideal method to ‘mould’ the right hand with the abdominal wall, with gentle movement and initially with light pressure (superficial palpation) followed by firm pressure (deep palpation).

VISCERA

• Liver: Start from right iliac fossa gradually moving upwards, until a firm border is feEL. The size of the liver must measure as fingerbreadths or centimeters below the right costal margin. The edge of the liver normally must be firm and regular. The surface is smooth.
• Spleen: Start from right iliac fossa moving towards left hypochondriac region, because spleen enlarges in a superior and posterior direction. It should enlarge 2-3 times its normal size to become palpable. Once the spleen has become just palpable, the direction of further enlargement is downwards and towards the right iliac fossa. In the bimanual method, the patient ask to lie in right lateral position. One hand put over left chest and spleen palpate with other hand. This done because a soft spleen may miss out in classical method.
• Kidneys: Keep the left hand in the right or left loin, depending on which kidney palpate. The right hand place in the respective lumbar region. Then, the patient ask to breathe deeply. The left hand press forwards and the right hand push inwards and upwards. Normal kidneys are usually not palpable.

TENDERNESS

• It can commonly elicit in inflammatory lesions of viscera and the peritoneum. The site of tenderness usually suggests the diagnosis. Epigastric tenderness may suggest peptic ulcer, hepatitis and cholecystitis may give rise to right hypogastric tenderness. Similarly, tenderness in right iliac fossa suggests appendicitis.
• Rebound tenderness usually seen in deep seated sub-acute conditions like appendicitis.
• Guarding is a result of muscular contraction over a tender region. The muscles can relax by diverting his attention.
• Rigidity due to muscular contraction over an inflamed area, but cannot voluntarily relax. It may occur due to perforation, peritonitis, ruptured ectopic gestation, and acute cholecystitis or pancreatitis.

HERNIA

• Two common forms – inguinal and femoral can differentiate by placing the index finger on the pubic tubercle. It can locate as a bony prominence by moving the index finger upwards behind the neck of the scrotum. It is 2 cm from the midline on the pubic crest. On coughing, if the impulse feel medial and above the index finger, it must inguinal hernia. If the impulse feel on the lateral side and below the index finger, the hernia is femoral.

PERCUSSION ABDOMINAL EXAMINATION:

The left middle finger place on the part to percuss and press firmly against it. Moreover, The right middle finger use for tapping perpendicularly on the distal interphalangeal joint of left middle finger, for a right hander examiner. The movement should at the wrist rather than at the elbow. The normal percussion note over the abdomen is tympanic except over the liver, where the note is dull. Enlarged liver, spleen or tumor may detect with a dull note over them.

• The normal liver dullness is in 5^th space in mid-clavicular line, 7^th in anterior axillary and 9th in scapular lines. This dullness may shift upward or downward depending on any liver or lung pathology.
• In ascites, dullness over the abdomen may vary according to the extent of fluid accumulated. Shifting dullness seen in moderate ascites. The upper border determine using the dull note the fluid produces. The patient ask to turn on one side and after 15-20 seconds, the upper previously dull area gives rise to tympanic note.

Horseshoe shaped

Horseshoe shaped dullness can elicit in moderate ascites by percussing from umbilicus outwards.

Fluid thrill

Fluid thrill can feel in tense ascites, with large amount of fluid accumulated. One hand place flat over the lumbar region of one side and patient’s or assistant’s hand keep firmly on the midline (to dampen the impulse felt through the visceral fat). Now, a sharp flick or tap give on the lumbar region on opposite side. A fluid thrill may then feel by the hand placed flat.

AUSCULTATION ABDOMINAL EXAMINATION:

Auscultation of the abdomen is mainly done for hearing the bowel sounds and vascular sounds.

Peristaltic sounds

Peristaltic sounds produce due to contractions of the intestines and further vibrations of the gut wall. Loud bowel sounds hear in partial intestinal obstruction due to some reason. Absence of bowel sounds for at least 5 minutes suggests intestinal atony or ileus.

Succussion splash

Succussion splash may hear even without a stethoscope in pyloric stenosis, advanced intestinal obstruction with grossly distended loops of bowel, and in paralytic ileus. Furthermore, Place the stethoscope over the epigastrium. Patient rolled briskly from side to side. If the stomach distended with fluid a splashing sound will hear.

Arterial bruit

Arterial bruit may hear over any visceral artery if there are acute angulations at branching points, tortuous arteries, aneurysms, atherosclerosis, compression/stenosis due to any reason. Also, when the blood is flowing through vascular tumors.

venous hum

A venous hum is softer, lower pitched and continuous, usually heard over liver and umbilicus in cases of portal flow obstruction.