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Abdominal Examination ABDOMINAL EXAMINATION VASCO DOMINIC REGIONS OF THE ABDOMEN IMPORTANT CONTENTS IN THE REGION • Right Hypochondrium; • Liver and gall bladder • Epigastrium; • Stomach • Part of the liver • Pancrease • Left hypochondrium; • Spleen • Part of the pancrease • Right lumbar region; • Right kidney • Right ureter • Umbilicus; • Intestines • Left lumbar region; • Left kidney • Left ureter • Right iliac; • Appendix • Right ovary • Hypogastrium • Uterus • Bladder • Left iliac fossa; • Ovary • Distal colon INSPECTION • Patient should be lying supine with the arms loosely by the patients side on a firm couch. • The abdomen should be exposed adequately in privacy with enough natural light. • Stand on the right side of the patient and expose the abdomen from the xiphysternum up to the upper third of the thigh. • This is important so as to reveal hernia WHAT TO INSPECT FOR • SHAPE; Is the abdomen of normal contour and fullness or distended. • Is it scaphoid (sunken) • Generalised distension is caused by; • Ascites • Foetus • Fat Abnormal distension • Can be due to; • Foetus • Formations • Fluid • Flatus • Fat • Faeces • Fibroid Abdominal assymetry • This may be caused by an enlarged; • Spleen • Liver • Ovary • Early pregnancy • Full bladder • Abdominal movements; • Normally moves with gentle rise during inspiration and falls during expiration • Visible peristalsis may indicate intestinal obstruction • The flanks can be full or free SCARS • Could be as a result of abdominal incisions which could be traditional or cosmetic. PROMINENT SUPERFICIAL VEINS • These are seen in cases of obstruction to the inferior vena cava and distended veins become visible on the abdominal wall. • Distended vessels on the umbilicus are called Capput Medusae and signifies Portal Hypertension. PIGMENTATION ON THE ABDOMINAL WALL • Linea nigra • Linea alba • Stria gravidarum PALPATION • Hands should be warm. • The patient should relax and breathe quietly. • Ask about sites where there is pain and avoid the region until later. • Start from the left iliac fossa and palpate lightly and clockwise to end in the suprapubic region ensuring that all the nine regions of the abdomen have been palpated. • After light palpation do the deep palpation for specific organs i.e. • The left kidney • Spleen • Right kidney • Liver • Urinary bladder • Aorta and para aortic glands. • Feel for the groins and the external genitalia where necessary Technique • Place the right hand on the abdomen in the right iliac fossa with the wrist and forearm in the same horizontal plane. • Superficial palpation; look for superficial tenderness, superficial masses, local temperature. • Deep palpation; deep masses, deep tenderness • Deep palpation for specific organs. LEFT KIDNEY • Place the right hand anteriorly in the lumbar region while the left hand is placed posteriorly in the lumbar region. • Ask the patient to take a deep breath then press the left hand forwards and the right one backwards. • The left kidney is not usually palpable unless its enlarged or in a lower position. • The kidney can be palpated between the palms by a method known as ballotment. Causes of enlarged Kidney •Pyelonephritis •Tumours of the kidneys •Cysts of the kidney Spleen • Its normally not palpable • It has to be enlarged two to three times its usual size before it becomes palpable. • Its felt beneath the left subcostal margin • It enlarges in the superior and posterior direction before it becomes palpable subcostally. • It then continues to enlarge downwards towards the right iliac fossa. • Ask the patient to breathe in deeply while pressing in with the fingers of the right hand at the costal margin. • The spleen will be felt as a firm swelling with smooth rounded borders. • Its dull on percussion and moves downwards on inspiration unlike the kidneys. • It is not bimanually palpable and you cant get over its upper border. The liver • Place both hands side by side flat on the abdomen in the right subcostal region lateral to the rectus muscles with the fingers pointing towards the ribs. • If resistance is encountered move hands further downwards until the resistance disappears • Ask the patient to breathe in deeply and at the height of inspiration press the fingers inwards and upwards • The liver is felt as a sharp, regular boeder which rides beneath the fingers. Repeat this maneuver working from the lateral to the medial side tracing the edge of the liver as it passes upwards and across the right hypochondrium to the epigastrium • Another method is to place the right hand below and parallel to the right subcostal margin. • The liver will be felt on the radial border of the index finger. • The liver can also be percussed and its enlargement described as so many centimetres below the subcostal margin. • This applies to the spleen as well. • Make out the character of the surface of the liver, whether its soft, smooth and tender as occurs in heart failure. • It may also be very firm and regular as occurs in Obstructive jaundice. • In liver cirrhosis the liver undergoes necrosis and fibrosis and reduces in size. This is common in alcoholics. • In cancer of the liver there will be nodules on the liver CAUSES OF HEPATOMEGALLY Viral hepatitis Hepatoma Malaria Hydatid cyst Congestive cardiac failure Tuberculosis Portal hypertension Kalaazar Schistosomiasis CAUSES OF SPLEENOMEGALLY Parasitic infections; Malaria, Kalaazar,Schistosomiasis, Tropical spleenomegally syndrome Infective endocarditis Leukaemia Lymphomas CAUSES OF MASSIVE SPLEENOMEGALLY Malaria Leishmaniasis Chronic myeloid leukamia Gauchers disease Myelofibrosis Tropical spleenomegally syndrome Differences between the spleen and left kidney SPLEEN LEFT KIDNEY ENLARGEMENT DOWNWARDS AND MEDIALLY DOWNWARDS BALLOTMENT NO YES GOING ABOVE NO YES PROMINENCE LEFT HYPOCHONDRIUM LUMBAR REGION MOVEMENT WITH YES NO RESPIRATION PERCUSSION DULL RESONANT EDGES SHARP SMOOTH AND ROUND NOTCH PRESENT ABSENT GALL BLADDER • Its not normally palpable but is palpated in the same way as the liver and feels smooth, cystic and globular. • Its not bimanually palpable. Its not examined routinely but jaundice prompts its palpation. • It becomes palpable in the following conditions; • Obstruction • Carcinoma • Mucocele • In cases of cancer it feels stony hard and irregular but a mucocele feels smooth and cystic. • The gall bladder is also tender in cases of inflammation i. e. Cholecystitis which may result from; • Bacterial infections • Trauma to the gall bladder • Tumours of the gall bladder. • Courvoisiers law states that when the gall bladder is palpable in a patient with jaundice then the cause of the enlarged gall bladder is likely to be a tumour other than a gall stone. • Murphys sign; demonstrated by placing the examining hand on the costal margin overlying the fundus of the gall bladder in the right hypochondrium, the patient takes a deep breath as you palpate the gall bladder. At the height of inspiration the breath is withheld hence a positive Murphy's sign • This is so because the descending diaphragm causes the inflammed gall bladder to impinge against the pressure of the examining hand and the patient experiences a lot of pain from the inflammed gall bladder. • Murphy's sign is positive only in acute cholecystitis and not chronic cholecystitis. URINARY BLADDER • Normally not palpable as urine fills upto 500 mls and creates an urge to micturate. • It enlarges when there is urine retention in a symmetrical manner and is tender. • It is smooth, oval, regular in the suprapubic region • The upper border is dome shaped and one can go over it but not below it since it disappears into the symphysis pubis. • The percussion note is dull and the patient develops an urge to micturate when pressure is applied. Before examining the abdomen it is important to let the patient empty the bladder. When a urethral catheter is passed urine is released and the bladder emptied. DIFFERENTIALS OF A FULL BLADDER Gravid uterus Ovarian tumour or cyst Fibroids • Ovarian cysts are not midline masses while the bladder is • The ovarian cyst will have a long standing history while a full bladder has a shorter history. • Ovarian cyst is found in the right or left iliac fossa. • Uterine fibroids are non tender, irregular, firm masses in the lower abdomen. They have a long standing history and are associated with menstrual cycle disturbances such as menorrhagia and dysmennorhea. BLOOD VESSELS • AORTA; can be felt on the left side of the abdomen. • Place fingers of both hands above the umbilicus on the left side. Presence of pulsations indicates abdominal aorta. Its more palpable in slender people. • FEMORAL ARTERY; palpate below the inguinal ligament at the mid point between the ASIS and the pubic symphisis. You will get pulsations indicating the femoral artery. In children it gives a clue on the location of the femoral vein and nerve so as to avoid injuring the nerve or puncturing the artery during collection of blood samples Rebound tenderness • This is ellicited by performing deep palpation and then followed by a sudden release of the palpating hand. The patient feels a lot of pain and may even attempts to get a hold of your hand. • It is positive in acute appendicitis, peritonitis and raptured ectopic pregnancy • Tenderness in the epigastrium is found in patients who have gastritis • Muscle guarding; contraction of muscles due to pain also seen in appendicitis, peritonitis and raptured ectopic pregnancy PERCUSSION • Its done to determine the liver span. The normal liver extends from the 5th to the 9th intercostal space. Its about 12cms in length. • The left kidney gives a resonant note as opposed to the spleen. • The urinary bladder gives a dull note Ascites • This refers to fluid in the peritoneum • SHIFTING DULLNESS; percuse laterally from the midline of the abdomen keeping the fingers in a longitudinal axis until dullness is detected. Maintai the fingers at the site where dullness was detected and ask the patient to roll away or turn away from you. Wait for about two minutes and percuse again in the reverse direction. Dullness shifts to the side the patient rolled over to.
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