Abdominal Examination

The abdominal examination is the portion of the physical exam evaluating the abdomen for signs of disease. The abdominal examination consists of inspection, auscultation, percussion, and palpation. Along with information from the history, the information gathered from the physical examination of the abdomen is used by the physician to generate a differential diagnosis and treatment plan for the patient.

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Introduction

1st steps:

  • Explain the steps to the patient and obtain consent.
  • Position the patient supine, arms at sides, with abdomen exposed.
  • Ensure good lighting, privacy, and hygiene.
  • Drape the patient with a sheet to preserve warmth.
  • Conventionally, the physical exam is performed with the provider standing on the right side of the patient.

The components of the abdominal exam:

  • Inspection
  • Auscultation
  • Percussion
  • Palpation

In a different order (auscultation before percussion), the same elements make up the other physical exam sections but carry different degrees of importance.

Pelvic, genital, and rectal exams should supplement the abdominal exam for a complete diagnostic workup of abdominal pathology.

Anatomy:

The abdomen is divided into 4 quadrants: right upper, right lower, left upper, and left lower. The quadrants correspond to specific organs and structures.

Inspection

  • Observe the distress level of the patient: 
    • Lying still: may be a sign of peritonitis 
    • Restless: may be a sign of renal colic 
  • Check surface, outline, and movements of the abdomen.
  • Findings:
    • Prior surgical scars or other skin abnormalities:
      • Jaundice in liver failure
      • Grey Turner sign: bruising of the flanks (a sign of retroperitoneal hemorrhage), or bleeding behind the peritoneum
      • Cullen sign: superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus, which is indicative of acute pancreatitis, bleeding from blunt abdominal trauma, bleeding from aortic rupture, or bleeding from ruptured ectopic pregnancy
    • Note the abdominal shape: flat, round, distended, symmetric, or asymmetric 
    • Abdominal striae, seen in:
      • Cushing syndrome  
      • Pregnancy
      • Weight gain
    • Vascular changes:
      • Caput medusae (sign of portal hypertension)
      • Cherry angiomas (senile angiomas):  
        • Harmless benign tumor
        • Contains an abnormal proliferation of blood vessels
        • Common in elderly patients 
    • Hair distribution (may be indicative of vascular supply)
    • Protrusions (masses, hernias)

Auscultation

Because mechanical manipulations of the abdomen can alter the regularity of bowel sounds, auscultation is performed prior to percussion or palpation.

Steps:

  • Listen for 2 minutes. 
  • Auscultate all 4 quadrants.

Findings:

  • Bruits: 
    • An abnormal sound generated by turbulent blood flow in an artery due to partial obstruction
    • May be indicative of atherosclerosis or aneurysmal disease
    • Listen over the aorta, renal arteries, and iliac arteries.
  • Bowel sounds:
    • Low-to-medium pitched, gurgling bowel sounds every 5–15 sec indicate normal peristalsis.
    • Borborygmi sounds: stomach gurgling (normal)
    • Hyperactive bowel sounds:
      • High pitched (tinkling): bowel obstruction
      • Gastroenteritis, irritable bowel disease, laxative use, diarrhea, and GI bleeding
    • Absent/ hypoactive bowel sounds:
      • Peritonitis
      • Late-stage bowel obstruction
      • Intestinal ischemia
      • Ileus
Auscultation of the abdomen - listening for bowel sounds

Auscultation of the abdomen: listening for bowel sounds

Image by Lecturio. License: CC BY-NC-SA 4.0
Auscultation of the abdomen - listening to the bruits over aorta, iliac and renal arteries

Auscultation of the abdomen: listening to the bruits over the aorta, iliac, and renal arteries

Image by Lecturio. License: CC BY-NC-SA 4.0

Percussion

  • Percuss all 4 quadrants.
  • The technique for abdominal percussion is the same as the lung exam: 
    • Place the left hand firmly against the abdominal wall with only the middle finger resting on the skin. 
    • Strike the distal interphalangeal joint of the left middle finger 2–3x with the tip of the right middle finger.
  • Normal findings: 
    • Tympanic sound over air-filled stomach and intestines
    • Muffled, dull sounds over fluid-filled or solid organs (liver, spleen)
  • Determining liver size:
    • Start just below the right breast in the midclavicular line to produce a resonant sound.
    • Move the hand down a few centimeters and repeat. 
    • After several times, the location is now over the liver and producing a dull sound → remember the spot (consider marking the patient)
    • Continue downward until the sound changes again when the inferior margin of the liver is reached → mark the spot
    • Use a ruler to measure between the points. 
    • The total span of the normal liver is 6–12 cm.
  • Assess for ascites:
    • Transmitted thrill test (fluid wave):
      • Instruct the patient to push the hands down on the midline of the abdomen.
      • The result is positive if the tap can be felt on the other side.
    • Shifting dullness test: 
      • Percuss the midline of the abdomen to elicit an area of high resonant note.
      • Percuss laterally (away from the examiner).
      • Instruct the patient to lean on the right lateral side.
      • Wait 30 sec for any fluid to shift.
      • The test is positive if the dull position becomes resonant.
Assessing for shifting dullness

Assessing for shifting dullness

Image by Lecturio. License: CC BY-NC-SA 4.0

Palpation

  • Ask the patient where the pain hurts the most; start away from the pain initially. 
  • Maintain eye contact during palpation (main indicator of pain or discomfort).
  • Start with superficial palpation to assess for: 
    • Muscle tone
    • Superficial tenderness
  • Deep palpation to assess for: 
    • Deep tenderness
    • Abdominal masses including an aortic aneurysm (pulsating)
    • Voluntary or involuntary guarding (muscle contraction as pressure is applied)
    • Rigidity (involuntary spasms, sign of peritonitis) 
    • Rebound tenderness: 
      • Pain occurs when the examiner suddenly releases compression of the abdominal wall.
      • Sign of peritonitis 
  • Organ palpation:
    • Liver:
      • Palpate from the RLQ toward the RUQ.
      • Ask the patient to take a deep breath to facilitate palpation of the liver.
    • Spleen:
      • Palpate from the LLQ toward the LUQ.
      • Ask the patient to take a deep breath to facilitate palpation of the spleen. 
    • Kidneys:
      • Place 1 hand under the patient’s flank; press the fingertips of the other hand into the same flank from above.
      • Feel for an enlarged kidney between your fingers.
  • Normal palpable structures:
    • Edge of the liver (especially in thin patients and the pediatric age group)
    • Lower lobe of the right kidney
    • Aorta (in thin people)
    • Bladder
    • Inguinal lymph nodes
    • Feces in the descending colon
Palpation for abdominal tenderness in 4 quadrants

Palpation for abdominal tenderness in the 4 quadrants

Image by Lecturio. License: CC BY-NC-SA 4.0

Special Tests

  • Murphy sign:
    • Elicited by asking the patient to take in and hold a deep breath while palpating the RUQ
    • If pain occurs on inspiration, Murphy sign is positive.
    • Indicates gallbladder inflammation (cholecystitis)
  • Costovertebral angle tenderness: Gently tap over the costovertebral angle to evaluate for kidney pathology.
  • Signs of appendicitis: 
    • McBurney point tenderness: maximal tenderness at 3–4 cm from the anterior iliac spine on a straight line to the umbilicus 
    • Rovsing sign: pain in the RLQ with palpation of the LLQ
    • Psoas sign: RLQ pain with passive hip extension (characteristic of retrocecal appendix)
    • Obturator sign: RLQ pain with internal hip rotation and a flexed knee (pelvic appendix)
  • Complete the abdominal examination by performing the following:
    • Genitourinary examination:
      • Testicular exam 
      • Pelvic exam
    • Digital rectal examination: 
      • Assess for rectal bleeding.
      • Assess for rectal masses.
      • Evaluate the prostate.

References

  1. Rabinowitz, S. (2020). Abdominal Examination. Emedicine. Retrieved April 16, 2021, from https://emedicine.medscape.com/article/1909183-overview
  2. Kiev J, Eckhardt A, Kerstein MD. (1993). Reliability and accuracy of physical examination in detection of abdominal aortic aneurysms. Vascular Surgery 31: 143–46.
  3. McClouglin MJ, Colapinto RF, Hobbs BB. Abdominal bruits: Clinical and angiographic correlation. JAMA 1975; 232: 1238–42.
  4. Naylor CD. (1994). Physical examination of the liver. JAMA. 271: 1859–65.
  5. Sapira JD. (1990). The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins. 371–90.

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