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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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin abnormalities:
      • Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice in liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver failure
      • Grey Turner sign: bruising of the flanks (a sign of retroperitoneal hemorrhage), or bleeding behind the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum
      • Cullen sign: superficial edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and bruising in the subcutaneous fatty tissue around the umbilicus, which is indicative of acute pancreatitis Acute pancreatitis Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Acute Pancreatitis, bleeding from blunt abdominal trauma, bleeding from aortic rupture, or bleeding from ruptured ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. 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 Portal hypertension Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. 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 Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis or aneurysmal disease
    • Listen over the aorta, renal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries, and iliac arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.
  • Bowel sounds:
    • Low-to-medium pitched, gurgling bowel sounds every 5–15 sec indicate normal peristalsis.
    • Borborygmi sounds: stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach gurgling (normal)
    • Hyperactive bowel sounds:
      • High pitched (tinkling): bowel obstruction
      • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis, irritable bowel disease, laxative use, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, and GI bleeding
    • Absent/ hypoactive bowel sounds:
      • Peritonitis
      • Late-stage bowel obstruction
      • Intestinal ischemia Intestinal ischemia Intestinal ischemia occurs when perfusion fails to meet the demands of the intestines, resulting in ischemic tissue injury that can be life-threatening if bowel necrosis and/or perforation occurs. Symptoms can range from mild indigestion or diarrhea to severe abdominal pain. 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 Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. 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 Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand firmly against the abdominal wall with only the middle finger resting on the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of 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 Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach and intestines
    • Muffled, dull sounds over fluid-filled or solid organs ( liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver, spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen)
  • Determining liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver size:
    • Start just below the right breast in the midclavicular line to produce a resonant sound.
    • Move the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand down a few centimeters and repeat. 
    • After several times, the location is now over the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. 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 Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver is reached → mark the spot
    • Use a ruler to measure between the points. 
    • The total span of the normal liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver is 6–12 cm.
  • Assess for ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain hurts the most; start away from the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain initially. 
  • Maintain eye contact during palpation (main indicator of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology 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 Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms (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 Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver.
    • Spleen:
      • Palpate from the LLQ toward the LUQ.
      • Ask the patient to take a deep breath to facilitate palpation of the spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen
    • Kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys:
      • Place 1 hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand under the patient’s flank; press the fingertips of the other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand into the same flank from above.
      • Feel for an enlarged kidney between your fingers.
  • Normal palpable structures:
    • Edge of the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. 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 Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix
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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain occurs on inspiration, Murphy sign is positive.
    • Indicates gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation ( cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis)
  • Costovertebral angle tenderness: Gently tap over the costovertebral angle to evaluate for kidney pathology.
  • Signs of appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the RLQ with palpation of the LLQ
    • Psoas sign: RLQ pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with passive hip extension (characteristic of retrocecal appendix)
    • Obturator sign: RLQ pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands.

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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