The Umbilicus

 Lymphnodes

 Abdominal Aorta

 Gallbladder

 Pancreas

 Chronic Liver Disease

 Peritoneum and Acute Abdomen

How to Palpate for Supraclavicular Nodes Supraclavicular Nodes  The best way is to have the patient sitting up, with his head straight forward and his arms kept down (this is done to minimize the risk of  A localized node in the supraclavicular fossa (either right or left) is a misidentifying a cervical vertebra or a neck muscle for a node). very important finding. It is usually an indicator of metastatic involvement from ipsilateral breast or lung cancers (a right  Palpation from behind usually allows the examiner’s hand to best supraclavicular node, however, may also indicate cancer of the left adapt to the patient’s anatomy, and is probably preferable. lower lobe of the lung, due to bilateral crossed drainage).

 Palpation from the front, on the other hand, should be attempted in  If located in the left supraclavicular fossa, a palpable lymph node the supine patient (in this position, the change in gravity may may also represent spread from a large number of intraabdominal or mobilize the node, thus making it more accessible). intrapelvic tumors. From this standpoint, a large left supraclavicular node is often referred to as a sentinel node (signaling a deep-sited  Finally, asking the patient to perform a Valsalva maneuver, or simply to cough, may “pop out” a deeply seated node, bringing it within carcinoma), or as a Troisier’s node. reach of the examiner’s fingers.

Troisier versus Virchow’s Nodes THE UMBILICUS

 Troisier’s node (or sign) is a palpable single left supraclavicular node, frequently located behind the clavicular head of the  Purplish Discoloration of the Umbilicus: sternocleidomastoid muscle. This usually represents metastatic involvement from either an ipsilateral breast or lung carcinoma, Cullen’s sign (periumbilical ecchymosis) or from an esophageal tumor. Most commonly, however, reflects Grey-Turner’s sign (bilateral flank ecchymosis) spread from intra-abdominal or intra-pelvic malignancies, such as stomach, intestine, liver, kidneys, pancreas and even testicles and endometrium.

 When representing a metastasis from a gastric carcinoma, this node is often referred to as Virchow’s Node. THE UMBILICUS SISTER (MARY) JOSEPH NODULE

It is a periumbilical nodule, or hard mass, detectable by  Purplish Discoloration of the Umbilicus: either inspection and/or palpation of the navel. It is clinically Cullen’s sign (periumbilical ecchymosis) very valuable. Grey-Turner’s sign (bilateral flank ecchymosis) It represents metastatic involvement of the paraumbilical

 Sister (Mary) Joseph Nodule (Stomach, Ovary, Colon, Rectum, Pancreas) nodes from intra-pelvic or intra-abdominal malignancies, most commonly stomach or ovary .

This finding was first reported in article published in 1928 by W.J. Mayo. The article was based on an observation of Mayo’s first surgical assistant, Sister Joseph (born Julia Dempsey in Salamanca NY) of St. Mary’s Hospital.

THE ABDOMINAL WALL (cont.)

 Abdominal Paradox and Respiratory Alternans

Normal Respiration Abdominal Paradox

ABNORMALITIES IN THE USE OF RESPIRATORY MUSCLES (1)

Abdominal Paradox - a.k.a Paradoxical Respiratory Breathing Hemodynamic Respiratory paradox Instability

Respiratory Alternans

Acute Respiratory Distress LISTENING POINTS – BRUITS LISTENING POINTS FOR BRUITS IN THE ABDOMEN

CASE

 An overweight and pipe-smoking German physicist presents to your office c/o abdominal pain.  What is the diagnosis?

 Exam is positive for a laterally  Who was the patient? expansive and pulsatile upper abdominal (epigastric) mass,  What happened to him? 6 cm in diameter.

  You recommend surgery, but What happened to his brain? also warn about its risks.

 The patient listens to you, then says, “Doctor, let it burst…”

ABDOMINAL AORTIC ANEURYSM IDENTIFYING AORTIC PULSATIONS

Aneurysms of the infrarenal abdominal aorta are among the top ten causes of death.

They have genetic and familial predisposition.

By age 80, over 5% of white U.S. males will have one.

White men over age 55 are at the greatest risk

African-Americans and women are at the lowest risk

If rupture occurs, < 20% of patients will survive Normal Upper Abdominal Mass • 3-5 cm, specific but not sensitive (1/5) 5-6 cm aneurysms are likely to rupture and should be • > 5 cm, very sensitive (4/5) repaired. • Umbilical girth > 100 cm renders the exam almost impossible Einstein had actually been diagnosed as having AAA in December 1948, after Rushed to Princeton Hospital presenting to the Brooklyn Jewish Hospital with abdominal pain and vomiting. because of severe abdominal pain on April 13, 1955. At that time, Dr. Rudolph Nissen (famous for developing a widely used operation to prevent esophageal reflux) had done an exploratory laparotomy and found a Diagnosed with a ruptured AAA. "grapefruit-sized" aneurysm, which he had then wrapped in polyethylene cellophane. On April 18 (1 AM) develops labored respiration and dies. With that Einstein managed to live six more years, during which he was offered (and declined) the presidency of Israel. Yet, he kept having bouts of “cholecystitis”. Following his wishes, remains are cremated the very same day, At re-hospitalization in 1955, he was, once again, offered heroic surgery. Yet, he and ashes put down at an turned it down by saying: “I want to go when I want. It is tasteless to prolong life unknown place. artificially. I have done my share and it is time to go. I will do it elegantly."

Brain, however, disappears. Autopsy revealed a normal gallbladder and a huge abdominal aneurysm. Gallbladder compression by the aneurysm had simulated the cholecystitis attacks*.

* JJ Chandler. The Einstein sign: the clinical picture of acute cholecystitis caused by ruptured abdominal aortic aneurysm. NEJM 1984; 310 (23):1538

Einstein’s brain disappeared after autopsy in rather mysterious circumstances.

It was only much later that it was discovered that it had been hidden away by Dr. Thomas Harvey, the Princeton pathologist who had performed the autopsy.

Forty years after Einstein’s death, 86-year old Dr. Harvey, drove Einstein's brain cross country on a rented Buick to present it to Einstein's granddaughter.

Along with Dr. Harvey also drove an Italian-American journalist/chauffer, Michael Paterniti, who later described the brain's discovery and final trip in Driving Mr. Albert: A Trip Across America With Albert Einstein's Brain. “Music helps him when he is thinking about his theories. “Life without playing music is inconceivable for me. He goes to his study, comes back, strikes a few chords I live my daydreams in music. I see my life in terms on the piano, jots something down, returns to his study." of music ...I get most joy in life out of music." (Elsa Einstein) (Albert Einstein)

“It was my intuition that led me to my [scientific insights], and I have to credit music as the driving force behind that.” (Albert Einstein) EVALUATION OF THE GALLBLADDER CASE

th  In contrast to the liver, examination of the gallbladder by physical  On his 55 birthday, an award-winning clinician-teacher develops acute epigastric pain while trying to run two Physical Diagnosis workshops after diagnosis still occupies an important role. gulping down a large Caesar’s salad.

 The gallbladder is usually not palpable, but becomes detectable in  He is able to complete the first workshop, but in the midst of the second he tells the students, “Sorry folks but I’ve got to go and throw up... I’ll be back soon…” case of pathology.  He never goes back, but gets instead escorted to the nearby Emergency Room  Two maneuvers/findings have been traditionally linked to the by a highly concerned colleague.

assessment of a diseased gallbaldder:  To a cardiology fellow who inquires about the quality of the pain, he describes it as “the pain of a distended viscus.” 1. Murphy’s sign  On exam he has no Murphy’s sign, but a distinctly palpable golf-ball-sized and tender mass in the abdominal right upper quadrant. 2. Courvoisier’s Law

MURPHY’S SIGN (cont.) MURPHY’S SIGN  Murphy’s sign has sensitivity and specificity for cholecystitis of 50 to 80%, with specificity being a little higher than sensitivity.  Painful arrest in inspiration, triggered by palpation of the edge of

an inflamed gallbladder.  Its significance increases in patients whose presentation is consistent with cholecystitis (= nausea, vomiting and right upper  To elicit this sign, the patient lies supine and takes a deep breath, quadrant pain), and decreases in those with back tenderness, while the examiner presses his/her fingers under the right lower where other conditions (like pancreatitis or renal disease) are more costal margin and along the mid-clavicular line (point of location of likely. the gallbladder), aiming towards the patient’s head.

 Hence, the sign is still relatively helpful if present, but not as much  The encounter between the examiner’s fingertips and the as in the original description by Dr. Murphy. inflamed edge of the gallbladder causes pain and a reflex arrest in

inspiration.  Moreover, ultrasound now provides an enticing alternative, not only for the identification of cholelithiasis, but also for eliciting a sonographic Murphy’s sign (sensitivity 87%).

 On April 12 1953 Eden undergoes elective cholecystectomy in the London Clinic OTHER SIGNS OF CHOLECYSTITIS for previous episodes of jaundice, abdominal pain and gallstones.

 Despite his own physician’s advice, Eden turns down three surgeons with special  In addition to the previous signs, patients with cholecystitis may also expertise in biliary surgery and chooses instead 60-year-old John Basil Hume, the exhibit other findings. same general surgeon who had previously removed his appendix.

 For example they may have an area of hypersensitivity over the  Surgery goes bad, and Hume even has a perioperative nervous breakdown that causes the entire operation to be put on hold for an hour while he composes his right costophrenic angle (Boas’ sign) – sensitivity only 7%. nerves.

 At times they may also exhibit an audible rub over the edge of the  In the end, the bile duct is “inadvertently” tied (causing post-op jaundice) while the ligature of the cystic duct soon breaks down necessitating re-exploration. gallbladder.

 They rarely have a palpable and tender right upper quadrant mass, (see Courvoisier’s law).  During the second operation the bile duct is “inadvertently” cut (“the knife slipped”), while the right branch of the hepatic artery is “inadvertently” ligated. “….I find it difficult to accept that Anthony’s health did not have a decisive influence on the conduct of his policy…  Eden comes close to death, but after a lengthy process slowly recovers. ….I also find it hard to believe that without his illness he would have made  In June 1953 he travels to Boston where he undergoes further repair surgery. such obvious miscalculations in both the political and military spheres.”

 In 1954 and 1955 he develops four episodes of shaking chills, fever and abdominal pain.

 In 1957 (eight days before the Suez Canal crisis) he develops one more episode of pain and rigor, plus a fever of 106o diagnosed as ascending cholangitis.

 He’s treated with antibiotics plus barbiturates for sleep, and amphetamines during daytime. (Robert Carr, Eden’s private secretary)

CASE

 You are evaluating a 72 year old Italian actor.

 He is the self-deprecating son of a Roman carpenter, who escaped from a Nazi labor camp before rising to the role of Latin Lover.

 Yet, he claims that he has always been the one being dumped rather than the dumper.

 Faye Dunaway did indeed dump him by saying: “Either you shit or you get off the pot”, but Catherine Deneuve remained instead faithful, and even sat at his bedside at the time of death.

 Still, a staunch Catholic, he remained loyally married to his Italian wife of 45 years.

October 1965

CASE COURVOISIER’S LAW

 You are evaluating a 72 year old Italian actor.  In painless jaundice, an enlarged, palpable and non-tender gallbladder is not due to cholelithiasis, but to cancer of either the  He is the self-deprecating son of a Roman carpenter, who escaped from a Nazi labor camp before rising to the role of Latin Lover. biliary tract or the pancreatic head.

 Yet, he claims that he has always been the one being dumped rather than  There are two possible explanations for why the gallbladder of the dumper. patients with cholelithiasis remains small.

 Faye Dunaway did indeed dump him by saying: “Either you shit or you get off 1. Recurrent biliary colics caused by stone migration lead to the pot”, but Catherine Deneuve remained instead faithful, and even sat at his bedside at the time of death. stiffening of the gallbaldder wall.

 Still, a staunch Catholic, he remained loyally married to his Italian wife of 45 2. Biliary colics caused by stones tend to be symptomatic and years. acted upon. They rarely produce complete ductal obstruction.  On exam he is jaundiced, and with a painless but palpable gallbladder.  The first mechanism was proposed by Courvoisier himself and is probably not as accurate as the second mechanism. COURVOUSIER’S LAW – CLINICAL SIGNIFICANCE CASE

 More recent series suggest lower sensitivity for malignant obstructions than  You are evaluating a 57-year old German musician who presented to your Courvoisier’s original data (25-50%), but still excellent specificity (80-90%). office complaining of a distended belly and dropsy.

 For example, only 50% of patients with jaundice caused by pancreatic  Interview is difficult because the patient is profoundly hard of hearing and quite carcinoma have a clinically palpable gallbladder (a value that increases to cantankerous. 80% if operative or autopsy enlargement is taken into consideration). At  In fact, he eventually tries to explain his GI symptoms through music. surgery, 42% of jaundiced patients with common duct stones have an enlarged gallbladder, as opposed to 80% of those with a pancreatic tumor.

 Still, a palpable and non-tender gallbladder in a jaundiced patients should be interpreted as a strong indication that jaundice is not due to  You examine the abdomen, then recommend fluid restriction and total hepatocellular disease, but instead to an extrahepatic obstruction of the abstinence from wine. biliary tract. Although not very sensitive, this finding is highly specific. Whether the obstruction is caused by tumor or stone, however, is difficult to say, even though the likelihood of tumor is a bit higher.

Beethoven’s Autopsy – March 27, 1827 (Vienna) ASCITES Conducted by Johnathan Wagner and Karl von Rokitansky Assistant beym pathologischen Musäum  The presence of free fluid in the abdominal cavity. • “.. The body was emaciated, especially arms and legs, and covered with petechiae”  An important clinical finding, and like pleural effusion • “.. The lower abdominal region was inflated and tense” usually the result of one of three problems: • “…The right thoracic cavity contained an abnormal accumulation of serous fluid” 1. Increased hydrostatic pressure (right-sided or • “…Four quarts of a cloudy grayish-brown liquid were found in the abdominal cavity” biventricular failure) • “… The liver was shrunk to half its volume, hard as leather, and infested with pea-sized nodules on its bumpy surface as well as 2. Decreased oncotic pressure (from either malnutrition or inside the organ itself” protein loss -- such as in cirrhosis, nephrosis, and • “… The spleen appeared twice the normal size, black and rough” enteropathy).

3. Peritoneal inflammation (neoplastic or infectious).

PRE-TEST PROBABILITY OF DISEASE PHYSICAL EXAM IN ASCITES

 Look for history of liver disease, plus any recent weight gain,  Convenient and inexpensive, but only valuable for 500-1000 cc of ascites. increased abdominal girth, and ankle swelling.  For smaller amounts the diagnostic gold standard remains ultrasonography, which can identify as little as 50-100 ml of fluid (and at a cheaper cost than CT).  The latter is a sine qua non for ascites, due to both hydraulic (compression of the leg veins by the ascitic fluid) and oncotic  There are four classic maneuvers for the bedside detection of ascites: reasons (hypoalbuminemia) 1. Inspection for bulging flanks (sensitive but not specific)

 In patients with < 20% chance of having ascites (because of 2. Percussion for flank dullness (sensitive but not specific) absent liver disease by history), lack of recent ankle swelling 3. The shifting-dullness maneuver (sensitive but not specific) further decreases the probability of ascites to less than 2.5%. 4. The fluid-wave test (specific but not sensitive) BULGING FLANKS FLANK DULLNESS TEST

 The abdominal shape of supine patients with ascites.  Percussion of the abdomen in a radiating and outward pattern from the  Due to the weight of intra-abdominal fluid (and the effect of umbilicus toward flanks and symphysis. gravity on the fluid), the flanks of a supine patient are pushed outward, almost resembling the belly of a frog.  Since gas-filled intestinal loops (resonant) float on top of ascites (dull),  This same shape, however, may be seen in obese patients. the maneuver reveals periumbilical tympany, flanked by dullness.  Hence, to separate the two conditions one might resort to the  Flank dullness (and bulging flanks) are flank-dullness test… both very sensitive (≥ 72% and ≥ 80%, respectively) but poorly specific.

SHIFTING DULLNESS MANEUVER FLUID WAVE MANEUVER

 A gravity-dependent shift in dullness of at least 1 cm (with the shifting border  With the patient supine, the remaining horizontal). examiner places one hand on one

 The maneuver is quite sensitive (≥ 83% in flank and taps gently on the two separate studies), indicating the opposite flank. To prevent a false- presence of at least 500-1000 ml of fluid. positive wave due to flickering of the abdominal wall, the patient places  Yet, it has specificity of only 50%, the the ulnar surface of one hand most common confounder being the accumulation of fluid in the colon of vertically over the umbilicus patients with diarrhea.  The test is positive when there is a

 Still, given its high sensitivity, a negative fluid wave emanating into the shifting dullness argues against the contralateral side. presence of gross ascites

FLUID WAVE MANEUVER MANEUVER SENSITIVITY (%) SPECIFICITY (%)  80–90% specific for ascites.

 In fact, it is probably the only truly History specific bedside test for ascites. Increased abdominal girth 90 60  Hence, a positive fluid wave can help Recent weight gain 60 70 rule in ascites. Ankle swelling 100 60  Yet, it still detects only very large amounts of ascites (sensitivity 50%). Physical examination  Hence, a negative test should not rule out ascites. Bulging flanks 70 60 Flank dullness 80 60  Note that the wave must be moderate- Shifting dullness 90 60 to-strong in intensity (slight fluid waves Fluid wave 60 90 have high interobserver variability and should not be relied upon). ACCURACY OF PHYSICAL EXAM FOR ASCITES ACCURACY OF PHYSICAL EXAM FOR ASCITES (Cont.)  No single sign or maneuver is both sensitive and specific. Many, however, are quite sensitive or quite specific.

 There is little interobserver variability in the elicitation of these signs, suggesting  In summary, patients with a history of liver disease, prolonged PT that physicians tend to agree on whether a sign is present or absent. (Bayes Theorem…), and positive fluid wave are likely to have

 Overall, in patients with abdominal distention, the most useful signs to rule out ascites and do not need an ultrasound for confirmation. gross ascites is absence of shifting dullness (especially in the absence of ankle edema or recent increase in abdominal girth).  On the other hand, patients with normal PT and no shifting dullness are unlikely to have ascites, even if they have a history of  The most useful signs to rule in ascites are: liver disease; therefore, they probably do not need an ultrasound.

 A positive fluid wave maneuver, and  Still, exam only detects large volume ascites.  A history of ankle edema (or liver disease or prolonged PT).

 Diagnostic accuracy can be improved by combining these maneuvers

SPIDER TELEANGIECTASIAS (NEVI) SPIDER TELEANGIECTASIAS (NEVI)

 Dilated blood vessels that are primarily localized to skin areas where  Spider nevi can be present in normal individuals, but in this case tend to be blushing is most intense (face and neck, but also shoulders, arms, hands fewer in number (average 3) and smaller in size. Hence, when not and torso). otherwise congenital, spider nevi are typically seen in only three conditions:  Conversely, they are very rare on palms, scalp and below the umbilicus,  Liver disease – In these patients the angiomas tend to correlate probably reflecting regional differences in neuro-hormonal control of the with an abnormally increased serum ratio of estradiol to microcirculation. testosterone, and possibly with increased levels of nitric oxide too.  They are compared to spiders insofar as they appear to have both a body “Spiders” also wax and wane according to disease severity. (the central arteriole) and legs (the various radiating branches of the  Pregnancy – In pregnant women spiders appear between the arteriole). They also have an area of erythema, which usually surrounds the second and fifth month of gestation, and quickly disappear after teleangiectasia. delivery.  When the “body’ of the lesion is compressed with a cover glass slide, it  Malnutrition appears to pulsate, and eventually blanches. Upon release of the compression, first the body and then the branches refill.

CASE PALMAR ERYTHEMA

 You are respectively the U.S. President’s secretary and a former  Like in the case of spider nevi, this is another vascular Lieutenant in the U.S. army. anomaly often associated with liver disease.  After traveling thousands of miles across unknown and unfriendly territory, you return to Washington having lost only one man.  It is characterized by a symmetric reddening of the palms, mostly over the thenar and hypothenar eminences.  You report to the President that Sergeant Charles Floyd died of acute belly pain and fever.  Erythema occurs in the same clinical conditions as vascular

spiders, and the two lesions tend to come and go together.  He was buried in 1804 at Floyd's Bluff, near modern Sioux City, Iowa.  Probably due to hepatic inability to inactivate vasodilators, such as nitric oxide. THE ACUTE ABDOMEN (PERITONEAL EXAM)

 Physical examination in patients with peritonitis is crucial for the identification of a surgical “abdomen”.

 A set of bedside maneuvers has been developed over the years to help reach a diagnosis, and remains valuable even in our times of MRIs and CT scans.

 Still, individual capabilities play an important role in determining the success (or failure) of these techniques.

ACUTE ABDOMEN GUARDING

 Indicates a diffuse or localized tension of the abdominal wall.  Guarding (localized/Induced)  This muscular stiffness can be:  Carnett’s sign and AWT  Involuntary (commonly referred to as rigidity)

 Rebound Tenderness (Blumberg’s Sign)  Voluntary, and in this case is usually elicited by a gentle (or deep) pressure by the examiner’s fingertips.  Referred Rebound Tenderness

 Voluntary guarding does not necessarily indicate peritoneal  Stethoscope sign inflammation, since can be also the result of patient’s anxiety or  Closed eye sign examiner’s cold hands. As a sign of peritonitis it is therefore more sensitive than rigidity, but less specific.

CARNETT’S SIGN IMPORTANT SEMANTICS  This maneuver utilizes induced guarding to differentiate abdominal  Localized Rigidity is a specific indicator of a focal area of tenderness caused by an inflamed intra-abdominal viscus from peritonitis. In this case the stiffness of the abdominal wall is abdominal tenderness caused by an inflamed abdominal wall. localized to the area overlaying the inflamed viscus. A good example of localized rigidity is the absence of respiratory motion  The examiner first localizes by palpation the area of tenderness in selective parts of the abdominal wall. and then asks the patient to contract the abdominal muscles by raising the head from the pillow.  Induced Guarding is triggered by having the patient raise the head from the pillow until he can touch the chest with the chin.  During this maneuver, the pressure on the examining fingers is This maneuver tenses the abdominal musculature, thus forming maintained and the patient is asked whether there is any change in a sort of cuirass that protects any inflamed intra-abdominal tenderness. organ from the examiner’s hand or other offending palpation.  Pain originating from the abdominal wall increases (positive This maneuver can be used to elicit Carnett’s sign. Carnett’s sign), whereas pain originating from an intra-abdominal viscus decreases (negative Carnett’s sign). ABDOMINAL WALL TENDERNESS (AWT) ABDOMINAL WALL TENDERNESS (AWT)

 This maneuver, also known as modified induced guarding technique, SIGNIFICANCE is a variation of Carnett’s sign.  A positive abdominal wall tenderness (AWT) has very much the same  As for Carnett’s, the examiner first identifies the site of maximal significance as a positive Carnett’s sign. abdominal tenderness while the patient is lying flat and relaxed.  Since pain on abdominal palpation may arise from either the  At that point, with the examining hand still in place, the patient is asked abdominal wall, the parietal peritoneum, or an underlying viscus, to cross arms and sit forward. tensing of the abdominal muscles allows the physician to differentiate the first from the other two.  With the patient midway between a sitting and recumbent position (and while the anterior abdominal wall muscles are tensed), the  If tenderness on palpation is increased by the tension of the abdominal examiner then renews pressure on the previously tender spot. muscles (positive abdominal wall tenderness), the pain originates from the abdominal wall itself. This is because the tension of the abdominal  If tenderness at midway is increased, the test is recorded as positive muscles protects parietal peritoneum and intra-abdominal viscera (positive Abdominal Wall Tenderness); if it is made better, the test is against the pressure of the examiner’s hand. recorded as negative (negative AWT)

ABDOMINAL WALL TENDERNESS (AWT) ABDOMINAL WALL TENDERNESS (AWT) SIGNIFICANCE SIGNIFICANCE

 Gray et al. studied 158 patients admitted to the hospital for acute  The maneuver was studied by several authors and found to be abdominal pain. They found AWT to be less accurate; it was present in clinically helpful in differentiating peritonitis or intra-abdominal only 28% of patients without intra-abdominal pathology (true positive) pathology from inflammation of the abdominal wall. and 5% of patients with intra-abdominal pathology (false positive). The authors found a predominance of young females among patients with  Thomson and Francis used it in 120 patients admitted as no intra-abdominal pathology and a positive AWT. surgical emergencies for acute localized abdominal pain. Only 1 of the 24 patients with a positive AWT had an intra-abdominal  Finally, Thomson et al. revisited this sign for the evaluation of patients inflammatory process (acute appendicitis). All 96 patients with a with chronic abdominal pain. Over time patients with positive AWT underwent a great deal of studies (including surgical procedures) but negative test, however, had intra-abdominal pathology. only a small minority had serious pathology.

 Hence, the AWT sign is quite useful for the assessment of patients with either acute or chronic abdominal pain.

REBOUND TENDERNESS (BLUMBERG’S SIGN) REFERRED REBOUND TENDERNESS

 This is a severe pain of the abdominal wall indirectly elicited by a sudden  This is a more humane variation of Blumberg’s sign, and also a more release of hand pressure. correct application of the original technique.

 The maneuver is carried out by palpating an area of abdominal tenderness as  It is carried out by compressing and then releasing the abdominal gently but as deeply as allowed, and then by suddenly releasing the pressure. wall of the contralateral quadrant to that where the patient has pain.  The elastic abdominal wall springs back quickly into its baseline position, thus eliciting an exquisite (and localized) pain in patients who have localized  The maneuver is positive only when it elicits pain in the original site peritonitis (with the pain being caused by the sudden tension of the inflamed where the patient first felt it. peritoneum.)  Pain at the site of palpation represents a negative test.  A less painful alternative to rebound tenderness may be a light indirect percussion over the area of pain.  A negative test, however, should not exclude a diagnosis of localized peritonitis, and should therefore be followed with a test of rebound  Overall, rebound tenderness has a modest sensitivity and specificity, is painful and totally unnecessary in patients who already have either guarding or rigidity. tenderness over the painful area. REBOUND TENDERNESS - VARIANTS (1) REBOUND TENDERNESS - VARIANTS (2)

 Jar Tenderness can also be used for detecting (and localizing)  A cough test is the sudden increase in abdominal pain peritoneal irritation. caused by a brisk rise in intra-abdominal pressure, such as the one elicited by coughing.  Its mechanism is very similar to the cough test.

 In the ambulatory setting ask the patient to first stand on outstretched  The test is indicative of peritonitis, but since it has toes and then let his entire body weight fall on the heels. greater sensitivity than specificity, is more valuable when absent than present.  The maneuver sets the abdominal wall into motion and allows the patient to localize any area of pain.

 It is obviously of limited value in patients too ill to stand up.

 In the bed-ridden patients one can shake the bed.

REBOUND TENDERNESS - VARIANTS (3) ACUTE ABDOMEN

 Valsalva’s can also be used to heighten peritoneal pain.  Guarding (localized/Induced)  This maneuver causes a sudden distention of the abdominal wall, thus helping patients better identify a particular area of tenderness.  Carnett’s sign and AWT

 After a 20-second Valsalva a patient with acute appendicitis may be  Rebound Tenderness (Blumberg’s Sign) able to pinpoint with one finger the area of abdominal pain.  Referred Rebound Tenderness  Hence, Valsalva may be used as a screening method – very much like the cough test and the jar tenderness -- to guide (and possibly  Stethoscope sign avoid) more painful maneuvers, such as rebound tenderness.  Closed eye sign

THE CLOSED EYE SIGN GENERAL GUIDELINES FOR

THE EXAM OF AN ACUTE ABDOMEN  This refers to the particular face of patients with nonspecific abdominal pain (i.e., pain without a clear-cut intra-abdominal pathology), who often keep their eyes closed during  While testing for guarding or rebound tenderness,always abdominal palpation, and maintain an embalmed and almost observe the patient’s face and not the abdomen. beatific smile.

 Pay special attention to the patient’s expression.  This behavior is quite different from that of patients with true intra-abdominal pathology, who keep eyes wide open and  Any grimacing or reaction to even a light touch is monitor very carefully what the examiner’s hands are doing. sometimes the only clue to an acute abdomen.

 Hence, the closed-eyes sign is an accurate test for the recognition of nonspecific abdominal pain. STETHOSCOPE SIGN THE CLOSED-EYES SIGN - SIGNIFICANCE  This is a technique for patients who are fidgety and resistant to palpation.

 Gray et al. studied this sign in 158 consecutive patients  It consists in palpating the abdomen twice, first with your hands and then admitted for acute abdominal pain. with your stethoscope.

 Before doing the latter, inform the patient that you are only going to listento  The eyes were closed in 6 of 91 patients with true pathology the abdomen. (6.5%), and 22 of the 67 patients with no pathology (33%).

 This seems to have a distracting effect, and in patients whose pain is either  Twenty-two of 28 patients with a positive closed-eyes sign exaggerated or unreal, may allow compression of the anterior abdominal were women (p < 0.01), usually young. wall all the way against the back (while before a simple light touch had elicited flinching, grimacing, complaining, and quick abdominal tension).  Hence, the predictive value of a positive closed-eyes sign is  As always, evaluate the sign in the context of serial observations and the 79% and that of a negative closed-eyes test is 65%. overall picture.There are, in fact, rare case reports of false-positive stethoscope signs in patients with acute appendicitis.