Abdominal Exam

Article Author:
Carl Mealie
Article Editor:
David Manthey
Updated:
9/7/2018 6:31:05 PM
PubMed Link:
Abdominal Exam

Introduction

The abdominal examination can be not only diagnostic to help rule pathology in or out, for example, the cause of the patient's pain, but it can be therapeutic as in a reduction of an umbilical or ventral wall abdominal hernia.

Function

The function of the abdominal examination is two-fold. In the asymptomatic patient during a routine examination, the identification of an abnormality such as a bruit heard over the aorta or hepatomegaly can lead the examiner to make an early diagnosis of a potentially catastrophic illness.

The abdominal examination traditionally is done from the patient's right.

Issues of Concern

Four Examination Components

Inspection:

  1. Distension. Ask the patient if the abdomen is bloated or larger than normal or if their clothing is tighter than normal. The differential diagnosis for distension: Small bowel obstruction, masses, tumors, cancer, hepatomegaly or splenomegaly, constipation, AAA, and pregnancy.
  2. Mass: Umbilical and ventral wall hernias, inguinal hernias.
  3. Ecchymosis: Grey Turner sign - ecchymosis of flank and groins from hemorrhagic pancreatitis. Cullen's sign -a periumbilical ecchymotic discoloration from retroperitoneal hemorrhage or from intra-abdominal hemorrhage such as ectopic pregnancy.
  4. Scars: Surgical, traumatic injuries (GSW, stab wounds).
  5. Striae: Pink-purple striae of Cushing's syndrome.
  6. Vein dilation: Caput medusa from hepatic cirrhosis, Inferior Vena Cava obstruction, or thrombosis.

Auscultation:

  1. Bruit: Left upper quadrant (LUQ): splenic artery, left renal artery stenosis, or an aneurysm. Epigastrium transmitted heart murmur or aortic stenosis or an aneurysm. Right upper quadrant (RUQ): right renal artery stenosis or an aneurysm. Right or left lower quadrants (RLQ or LLQ): Right or Left inguinal artery stenosis or an aneurysm.  
  2. Bowel Sounds: Absent bowel sounds as in paralytic ileus or hyperactive rushes such as borborygmi in small bowel obstruction, inflammatory bowel disease.

Percussion:

Percuss while listening for (1) tympany over air filled structures such as stomach, or (2) dullness to percussion as in mass, hepatomegaly. Look for a splenic enlargement by percussing in Castell's point (the most inferior interspace on the left anterior axillary line) as the patient takes a deep inspiration. Percussion that changes from tympanitic to dull as the patient takes a deep breath suggests splenomegaly with an 82% sensitivity and an 83% specificity. Splenomegaly occurs in trauma, with hematoma, portal hypertension, hematologic malignancies, infection such as HIV and from Ebstein-Barr virus, and splenic infarct.

Percuss for the size of the liver from tympany of the lung to dullness of the liver down to tympany of the bowel below the liver. Search for shifting dullness by percussing from midline to flank to find the limit of tympany and then from having the patient roll on their side and repeating exam to find shifting dullness such as in ascites or free fluid.

Palpation:

Light palpation and then deep palpation. Note to press slowly. Pressing too fast may trap a gas pocket within the intestinal lumen and distend the wall causing a false positive pain. Feel for softness, firmness, guarding, tenderness and rebound. Attempt to find the point of maximal tenderness.

Guarding: progresses from voluntary guarding, in which the patient voluntarily tightens the abdominal muscles to protect a deeper inflamed structure, to involuntary guarding where the intra-abdominal pathology has progressed to cause rigidity of the abdominal muscles that the patient can not relax.

Epigastrium: Palpate for any tenderness such as gastritis or early acute cholecystitis from visceral nerve irritation, defects such as a muscle diastasis, or pulsatile mass from AAA. Use a two-handed technique for estimating aorta size. Place one hand longitudinally on the left along the long axis of the aorta at the lateral border of pulsation. Place the other hand longitudinally on the right side of the abdomen and move it toward the first hand until you fell the border of pulsation.

Liver: Place your palpating hand below lower rib margin and have the patient exhale and then take in a deep breath. With mild pressure, you should feel the liver margin move under your hand as a gentle wave. Feel for any nodularity or tenderness.

Gallbladder: Gently place the palpating hand below the right lower rib margin at the midclavicular line and ask the patient to exhale as much as possible. As the patient exhales, slowly push your hand deeper.  Then ask the patient to inhale deeply.  A positive Murphy sign is the sudden cessation of inspiration with pain.

Right Kidney: Use a two-handed technique with the patient supine. Use one hand on the patient's back pushing the kidney forward with the other hand palpating down below the lower rib margin between the mid-clavicular line and the anterior axillary line, looking for enlargement or tenderness.

Spleen: If percussion was positive for splenomegaly or equivocal, place your palpating hand below the left lower rib margin and have the patient exhale and then take a deep breath in. With mild pressure, you should feel the spleen move under your hand as a firm mass. If you suspect a very enlarged spleen, start palpation in right lower quadrant and work toward the splenic flexure.

Left kidney: Standing on the right side,  use a two-handed technique with the patient lying in a right lateral decubitus position. Use one hand on the patient's back pushing the kidney toward you while the other hand is palpating down below the lower rib margin between the mid-clavicular line and the anterior axillary line as the patient takes a deep breath looking for enlargement or tenderness. Alternatively, walk to the patient's left side and palpate the left kidney as the right kidney. 

Umbilicus: Palpate the periumbilical area and place the finger in the umbilicus to feel for any defect, mass or an umbilical hernia. Have a patient cough or bear down to feel for any protruding mass.

Left lower quadrant: Palpate for tenderness or mass such as colon mass or tumor, constipation, left ovarian cyst, or ectopic pregnancy.

Right lower quadrant: Palpate over McBurney's point which is located two-thirds down an imaginary line from the umbilicus to the anterior superior iliac spine. Tenderness implies possible appendicitis, inflammation of the ileocolic area such as Crohn disease or infectious etiology with bacteria that have a predilection for the ileocecal area such as Bacillus cereus and Yersinia enterocolitica.

Other helpful signs and maneuvers to identify possible appendicitis are:

  • Rovsing's sign: While standing on the patient's right side, gradually do a slow deep palpation of the left lower quadrant.  Increased pain on the right suggests right sided peritoneal irritation.
  • Psoas sign: Place your hand just above the patient's right knee and ask the patient to push up against your hand causing contraction of the psoas muscle which causes pain if the psoas muscle is inflamed, which could be due to appendicitis, or another source of inflammation.
  • Obturator sign: Flex the patient's right thigh at the hip with the knee flexed and rotate internally.  Increased pain at the right lower quadrant suggests inflammation of the internal obturator muscle from an overlying appendicitis or abscess.

Suprapubic area: Palpate for mass such as a fibroid, gravid uterus, or uterine cancer in the female or bladder mass or distension.

Back: With the patient sitting up, perform percussion at the right and left costal-vertebral angle first to determine if there is any renal tenderness as in pyelonephritis.

Inguinal area: Since testicular torsion can radiate to the abdomen and present as abdominal pain, and since a hernia is the second most common cause of abdominal pain from small bowel obstruction, an examination of the genitalia is mandatory. For torsion, look for Bell Clapper deformity or a horizontal line of the testis with tenderness. For an inguinal hernia, place your gloved finger into the inguinal canal and ask the patient to bear down or cough to feel a pulsation on the tip of your finger.

The abdominal examination ends with the rectal examination. Feel for rectal tone and saddle anesthesia looking for neurologic pathology. Gradually placed your lubricated, gloved finger against the back rectal sphincter muscle to dilate the sphincter and slowly slide your finger into the rectum feeling for hemorrhoids, fissures, or foreign bodies.  Feel the prostate for size and firmness. Tenderness or bogginess suggest prostatitis. Nodules may suggest cancer. Remove your finger and inspect it for signs of active bleeding or melena. Perform a Guaiac test if bleeding is suspected.

The ultrasound examination is becoming a useful tool to assist the identification of abdominal pathology.

RUQ: Examine liver for mass or dilation of common bile duct. Examine gallbladder for stones, gallbladder wall thickening or pericholecystic fluid, Morison's pouch for free fluid, inferior vena cava for distension or hypovolemia. Examine right kidney for mass or hydronephrosis.

LUQ: Examine spleen for enlargement from hematoma or hematologic malignancy. Examine left kidney for mass or hydronephrosis. Look in the splenorenal recess for free fluid.

Epigastrium: Examine size of the aorta for suspicion of AAA.

RLQ: Look for mass, abscess, appendix wall thickening in thin individuals, intussusception, free fluid, ovarian mass or cysts.

LLQ: Look for mass, abscess from diverticular disease, free fluid, ovarian mass, or cysts.

Suprapubic area: Look for urinary retention, uterine masses or pregnancy, and free fluid in the pouch of Douglas.

Clinical Significance

In a time of increased technology with CT scans, ultrasounds, and MRIs, it is easy for the clinician to become a technician and rely solely on technology. It is an excellent clinician who develops the hypotheses for the cause of the patient's symptoms. These are based on the chief complaint, the patient's history, and a physical examination such as the abdominal examination. It is the intelligent clinician who then judiciously orders the appropriate test to knowingly search for specific findings that will either support the hypothesis or force the clinician to reconsider new theories for the cause of the patient's symptoms.