Abdominal Examination

Dr AbdulQader Said Murshed Consultant General, G.I., & Laparoscoic Surgeon FRCS Glasg, FRCSI, Jordanian Board Wednesday, 27/6/2018

Preparation

• The environment: warmth, privacy, good light. • The examination couch or bed: opens the gap between th e pubis and the xiphisternum, relaxes the anterior abdominal wall muscles. • Exposure: ideally, patients should be uncovered from nipples to knees. A compromise is to cover the lower abdomen with a sheet or blanket while the abdomen is being palpated. • Getting the patient to relax: patient’s arms by their sides, Only press your hands into the abdomen during expiration as the abdominal muscles relax. If the above do not work, ask the patient to flex their hips to 45° and their knees to 90° and place an extra pillow behind their head.

The position of the examiner

• The examiner’s hands should be clean and warm with short nails. • The whole hand should rest on the abdomen • by keeping the hand and forearm horizontal, in the same plane as the front of the abdomen. Do not dorsiflexing your wrist.

The examination

• This should follow the standard routine of inspection, palpation, percussion and auscultation. • you must never forget to examine: – Supraclavicular lymph glands – The hands, nails and facies. – Hernia orifices. – Femoral pulses. – Genitalia. – Anal canal and rectum.

Inspection

• Look for any general abnormality such as cachexia, pallor or jaundice. • Inspection of the abdomen from the end of the bed, reveals any asymmetry or distension. • position, shape and size of any bulge, any changes in its shape, and whether it moves with respiration or increases with coughing. • Observe the reaction of the patient to coughing or moving. • The presence of any scars, sinuses or fistulas. dilated surface veins. Palpation

• Palpate gently but deliberately, firmly and with purpose. • Keeping your hands still and feeling the intraabdominal structures moving beneath them.

Palpation (cont.)

• General light palpation for tenderness, guarding, rigidity, and rebound (or release) tenderness. • General deeper palpation for tenderness, when mild. • Palpation for masses. • Palpation of the normal solid viscera: The liver, The spleen, The kidneys. Palpation (cont.) liver • right hand transversely and flat on the right side of the abdomen at the level of the umbilicus. • the radial side of your index finger • deep breath. • The liver edge may be straight or irregular, thin and sharp, or thick and rounded. The surface may be smooth or knobbly. • if in doubt, begin your palpation in the left iliac fossa. Palpation (cont.) spleen • An enlarged spleen appears below the tip of the tenth rib along a line heading towards the umbilicus. • if really large, may extend into the right iliac fossa. • A normal spleen is not palpable. Palpation (cont.) spleen (cont.)

• the fingertips of your right hand on the right iliac fossa just below the umbilicus. • Ask the patient to take a deep breath. • move your hand in stages towards the tip of the left tenth rib. • When the costal margin is reached, place your left hand around the lower left rib cage, and lift the lower ribs and the spleen forwards as the patient inspires. • The spleen is recognized by its shape and site and, when present, the notch on its superomedial edge. It is dull to percussion as it lies immediately beneath the abdominal wall with no bowel in front of it, unlike a renal mass. Palpation (cont.) The kidneys • Normal kidneys are usually impalpable, except in very thin people. • place your left hand behind the patient’s right loin between the 12th rib and the iliac crest. • 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. • An enlarged kidney can be pushed back and forth between the anterior and posterior hands. This is called balloting.

Palpation (cont.)

• When a kidney is very easy to feel, it is either enlarged or abnormally low • Balloting is also used to palpate a fetus in a pregnant uterus. • Bimanual palpation • balloting

Percussion

• The whole abdomen must be percussed, particularly over any masses. • Any area of dullness should be outlined by percussion with the abdomen in two positions to see if it moves or changes shape. An enlarged liver is dull to percussion, and its upper margin should be percussed out to assess its full dimension. • A dull area may draw your attention to a mass that was missed on palpation and indicate a more detailed and careful palpation of the area of dullness. • Percussion causes pain if peritonitis is present and is a useful method for mapping out a tender area.

Percussion (cont.)

• Fluid thrill. • shifting dullness, Free fluid (ascites) changes shape and moves (shifting dullness).

• succussion splash. When a part or the whole of the abdomen appears distended, the patient should be held at the hips and the abdomen shaken from side to side Splashing sounds – a succussion splash – indicate that there is an intra-abdominal viscus, usuallythe stomach, distended with a mixture of fluid and gas. Auscultation

• Listen to the bowel sounds. • Normal bowel sounds (Peristalsis), are low-pitched gurgles that occur every few seconds. • paralytic ileus, If you can hear the heart and breath sounds but no bowel sounds over a 30-second period, the patient probably has a paralytic ileus. • Increased peristalsis. often described as ‘tinkling’. • any systolic vascular bruits. which indicate arterial stenosis or increased blood flow through, for example, a fistula.

Auscultation (cotin)

• Increased peristalsis increases the volume and frequency of the bowel sounds. Also, with a change in the character of the sounds. They become amphoric in nature with runs of high- frequency gurgles, sounding like sea water entering a large cave through a narrow entrance, often described as ‘tinkling’.

DIGITAL ANO-RECTAL EXAMINATION • This is commonly called a rectal examination but is actually an examination of the anus and lower rectum. • The patient should give clear verbal consent. • You need a plastic glove, some inert lubricating jelly and a good light. Tissues must be available for cleansing afterwards. • The patient should lie in the left lateral position with the neck and shoulders rounded so that the chin rests on the chest, with the hips flexed to 90° or more, and the knees flexed to slightly less than 90°.

Rectal exam (cont.) Inspection

• Lift the uppermost buttock with your left hand so that you can see clearly the anus, perianal skin and perineum. • Look for: • skin rashes and excoriation. • faecal soiling, blood or mucus. • scarring, or the opening of a fistula. • lumps and bumps • (e.g. polyps, papillomas, condylomas, perianal haematoma, prolapsed piles, rectal prolapse or even a visible carcinoma). • fissure, ulcers.

Rectal exam (cont.) Palpation • Place the pulp of your gloved right index finger on the centre of the anus, with the finger parallel to the skin of the perineum and in the midline. • Never thrust the tip of your finger straight in.

Rectal exam Palpation (cont.) • The anal canal. The tone of the sphincter, any pain or tenderness and any thickening or masses. • The rectum. . Feel all around the rectum as high as possible. • The mucosa of the anus and rectum. • masses or ulcers. • Note the contents of the rectum • The recto-vesico/recto-uterine pouch. • Bimanual examination. Examination of the contents of the pelvis. • The cervix and uterus. per rectum, and on bimanual. • The prostate and seminal vesicles.