The abdominal examination involves, sequentially: inspection palpation percussion auscultation
Inspection of the abdomen involves first looking from the foot of the bed along the length of the patient Points to note include: symmetry scars pulsatile masses movements of abdominal wall with respiration distension - fat, faeces, flatus, foetus, tumour, caput Medusae, umbilicus visible peristalsis striae
Caput Medusae is distinguished from inferior vena cava obstruction by determining the direction of flow in the veins below the umbilicus; it is towards the legs in the former, and towards the head in the latter
clinical features of portal hypertension
Presenting features may include: haematemesis or melaena - due to rupture of gastro - oesophageal varices ascites - with low plasma albumin hepatic encephalopathy porto-systemic shunts - e.g. caput Medusae venous hum haemorrhoids peripheral oedema
venous hum in the abdomen
Uncommonly, in portal hypertension, a venous hum can be heard between the xiphisternum and the umbilicus. It is due to increased blood flow in the umbilical and paraumbilical veins in the falciform ligament.
general examination
Abdominal pathology often has a systemic effect, equally systemic disease may present as an abdominal disorder.
general appearance mental state skin hands arms face neck and chest
general appearance
jaundice cachexia
mental state
The mental state of a patient may be altered by a variety of abdominal pathologies including: hepatic encephalopathy uraemia encephalopathy electrolyte disorders caused by, for example:
diarrhoea bowel fistulae vomiting pancreatitis
hypoglycaemia:
liver failure insulinoma
skin
Gastrointestinal tract and the skin have a common origin from the embryoblast. Therefore occasionally gastrointestinal disease is sometimes reflected in skin changes
Peutz-Jegher's syndrome
mucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia, hands and feet multiple hamartogenous polyps of the gastrointestinal tract - most often in the small bowel but may occur affect any portion of the GI tract
Spider naevi They contain a central large blood
vessel with tiny vessels radiating from the center, hence the name.
Palmer Erythema
Hands
Signs in the hands may reflect pathology in various abdominal systems: chronic liver disease:
palmar erythema leukonychia asterixis clubbing in cirrhosis
asterixis
It is commonly associated with liver failure where it produces the flapping tremor of hepatic encephalopathy characterised by jerky, irregular flexion-extension movements at the wrist and metacarpophalangeal joints,
Leuconychia
Leuconychia or "white nail" is an abnormal whiteness of the nails, either in total, partial (spot) or striate (streaks) forms. It may be congenital or acquired. Leuconychia may occur spontaneously or after minor trauma. In association with generalised disease it is usually caused by the hypoalbuminaemia of chronic liver disease.
palpation
Palpation of the abdomen should always ensure the feeling of areas that might otherwise be forgotten: feel the supraclavicular fossa for lymph nodes feel the hernial orifices at rest and when the patient coughs: external inguinal ring, femoral canal and umbilicus feel for femoral pulses examine the external genitalia Examine the back
general light palpation for tenderness palpation of the normal solid viscera (liver,spleen,kidneys)
palpation of the liver Palpation aims to provide the following information on the liver: size shape surface - smooth or nodular consistency - soft or hard tenderness - tender or non-tender pulsatility
palpation of the spleen Palpation starts in the right iliac fossa with the right hand aligned parallel to the right costal margin.
palpation of the kidneys
Examination of the kidneys should be a routine part of the abdominal examination. A bimanual technique is used. With the patient supine, slide one hand underneath the back so that the heel of the hand rests under the loin. Place the other hand over the upper quadrant on the same side. First, attempt to capture the kidney between the two hands. If this is not possible, ballot the kidney; flex the fingers of the posterior hand at the metacarpophalangeal joints in the renal angle so that the abdominal contents are pushed anteriorly. The kidney should then float upwards and strike the anterior hand.
percussion of the liver
The liver is percussed to estimate its size, and therefore, to differentiate true enlargement from false. The liver span is estimated by percussing the width of the liver down the thorax and abdomen. The upper border of the liver is normally level with the sixth rib in the mid-clavicular line. Start percussing from a point above this, and progress downwards until the note changes from resonant to dull. Measure from this position to the palpable liver edge. It should be less than 12.5 cm.
ascites
Ascites describes an abnormal collection of fluid in the peritoneal cavity. When ascites collects, the influence of gravity causes it first to accumulate in the flanks of a supine patient. Thus, a relatively early sign of ascites - when at least two litres of fluid have accumulated - is a dull percussion note in the flanks. With gross ascites, abdominal distension and umbilical inversion may occur and dullness is detectable closer to the middle line. However, an area of central resonance will always persist. Routine abdominal examination should include percussion starting in the middle line with the finger pointing parallel to the level of the fluid; the percussion note is sounded out towards the flanks on each side.
Traube's space Traube's (semilunar) space is an anatomic region of some clinical importance. It's a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin.
