Semester 2 Physical Exam Skills Lab Handout

Abdomen 2

Introduction
In Semester 1 Physical Examination Skills Lab: Abdomen Part I the basic abdominal exam
was introduced. In semester 2, special techniques for assessing several different
abdominal problems will be learned. Remember to introduce yourself, wash hands and
drape the patient appropriately for the exam.

Stigmata of Liver Disease

In a patient with suspected liver disease, a variety of systemic signs may be found with
hepatic decompensation progressing to chronic liver disease. Patients may develop
jaundice, ascites, spider angiomata, gynecomastia, splenomegaly, palmar erythema,
digital clubbing, asterixis, peripheral edema, or hepatic encephalopathy and other
signs. These physical examination findings are described below.
Jaundice is a yellow coloring of the skin and mucus membrane which results from
increased serum bilirubin. It is usually not detectable until the bilirubin is greater than 2
to 3 mg/dL. When jaundice affects the sclerae of the eyes, it is called scleral icterus.

Figure 1. Jaundice and scleral icterus

Fetor hepaticus refers to a sweet, pungent breath of cirrhotic patients. It is caused by

increased concentrations of dimethyl sulfide, the presence of which suggests underlying
severe portal-systemic shunting.

June 2016
Spider angiomata or spider telangiectasias are cutaneous lesions consisting of a central
arteriole surrounded by many smaller vessels. They are most frequently found on the
face, upper trunk, and upper limbs. The body of the lesion (the central arteriole) can be
seen pulsating when compressed with a glass slide. Blood fills the central arteriole first,
before traveling to the peripheral tips of each "leg" after blanching. The lesions are
usually multiple with radiating legs and surrounding erythema that may encompass the
entire lesion or only its central portion. They are believed to result from alterations in
sex hormone metabolism. Acquired spider
angiomata are not specific for cirrhosis. They
may also be seen in healthy people, pregnant
women and severe malnutrition. But, in
healthy people, they tend to be restricted in
number. As a general rule, the number and
size of spider angiomata correlate with the
severity of liver disease. Patients with
numerous, large spider angiomata can have
increased risk of variceal hemorrhage.

Figure 2. Spider angioma.

Fig 3: Gynecomastia

Gynecomastia is a benign proliferation of the glandular tissue of the male breast.

Clinically, it presents as a rubbery or firm mass extending concentrically from the
nipple(s). It is commonly seen in cirrhosis of liver, may be caused by hormonal
disturbances. Associated with other features of feminization like loss of chest or axillary
hair and inversion of the normal male pubic hair pattern are commonly seen. Apart from
cirrhosis, other causes of gynecomastia are drugs, hypogonadism and testicular tumors.

June 2016
Abdominal Findings

Ascites is the accumulation of free fluid in the peritoneal cavity. Features of ascites
include distention of the abdomen and fullness or bulging of the flanks. Clinical
detection of ascites is possible with the following examination techniques:
Shifting dullness – It is detected due to shifting of free intra -peritoneal fluid by altering
the position of the torso.

Figure 5. Demonstration of shifting dullness; the percussion note changes depending on

whether the examiner is percussing over ascites fluid or over gas filled bowel!

Figure 6. Demonstration of testing for fluid wave in ascites.

A fluid wave may be detected in a patient with ascites. Fluid is a good conducting
medium of mechanical impulse. If ascitic fluid is tapped in a part of the peritoneal cavity,
the impulse will be transmitted and felt in the other fluid filled part. A hand is placed
over the mid-abdomen to prevent transmission of the impulse through the fat.
Both of these clinical maneuvers require accumulation of significant amount of fluid, but
shifting dullness is a more sensitive indicator. At least, 1 liter collection of fluid is
required for demonstration of positive shifting dullness and about 1.5 liters for fluid
wave. Transabdominal or transvaginal ultrasound can detect much smaller
accumulations of intraperitoneal fluid.

June 2016
Figure 7. Hepatosplenomegaly.

Hepatomegaly is liver enlargement. The cirrhotic liver may be initially enlarged, then
due to fibrosis, the size gradually reduce, and finally is shrunken.
Splenomegaly, an enlarged spleen, is common, in cirrhosis especially in patients from
nonalcoholic etiologies. It is believed to be caused primarily by congestion of the red
pulp resulting from portal hypertension.

Figure 8. Caput medusa. The direction of blood flow will be away from the umbilicus.
Venous engorgement and Caput Medusae
The veins of the lower abdominal wall normally drain inferiorly into the iliofemoral
system, while that of the upper abdominal wall into the veins of the thoracic wall and
axilla. When portal hypertension occurs as the result of cirrhosis, the umbilical vein that
normally obliterate in early life, may open. Blood from the portal venous system may be
shunted through the periumbilical veins into the umbilical vein and ultimately to the
abdominal veins of the abdominal wall, causing them to become prominent. This
appearance has been said to resemble the head (caput) of the mythical Gorgon known
as Medusa, and thus, the finding is called caput medusa (head of Medusa). Dilated

June 2016
abdominal veins can also be seen in inferior vena cava and superior vena cava
obstruction.

Genitourinary Findings
Men with cirrhosis may have testicular atrophy due to the development of
hypogonadism.

Extremity Findings
Findings on examination of the extremities of a patient with cirrhosis may include
palmar erythema, clubbing, Dupuytren's contracture, asterixis and edema.

Palmar erythema is an exaggeration of the normal speckled mottling of the palm and is
believed to be caused by altered sex hormone metabolism. It is most frequently found
on the thenar and hypothenar eminences, while sparing the central portions of the
palm. It can also be seen in pregnancy, rheumatoid arthritis, hyperthyroidism, and
hematological malignancies.

Figure 9. Palmer erythema

Figure 10. Clubbing

June 2016
Clubbing is present when the angle between the nail plate and proximal nail fold is
greater than 180 degrees. When severe, the distal finger has a "drum stick" appearance.
Clubbing is more common in biliary cirrhosis, particularly in primary biliary cirrhosis.
Presence of both clubbing and hypertrophic osteoarthropathy clinically suggests liver
diseases or lung cancer.

Figure 11. Dupuytren’s contracture.

Dupuytren's contracture may result from thickening and shortening of the palmar
fascia, which commonly causes flexion deformities of the ring and little fingers. It is
relatively common in patients with alcoholic cirrhosis, but can also be seen in several
other conditions, including in workers exposed to repetitive handling tasks or vibration,
patients with diabetes mellitus, reflex sympathetic dystrophy, cigarette smoking, alcohol
consumption, and Peyronie's disease.

Figure 12. Outstretched dorsiflexed hands to demonstrate asterixis.

Asterixis, also known as “flapping tremor” - It is commonly bilateral but asynchronous

flapping motions of outstretched, dorsiflexed hands. It is seen in patients with hepatic

June 2016
encephalopathy, a grave sign of end stage liver failure. Asterixis may also be seen in
patients with uremia, other metabolic encephalopathy and severe heart failure.

Figure 13. Two examples of bilateral pitting edema of the feet and ankles.

Edema – It is the excessive collection of extracellular fluid which generally gravitates to

the most dependent part of the body. It can be pitting or non-pitting. In gastrointestinal
diseases, it is usually pitting. Pitting edema of the lower extremities can be due to
cirrhosis, heart failure, kidney disease or a problem with pregnancy, to name a few.

Gallbladder (GB) Exam

Figure 14. Demonstrations of Murphy’s sign and radiological Murphy’s sign.

Murphy’s sign is a provocative test in a patient with suspected acute cholecystitis. This
may be performed in presence of upper right abdominal pain and tenderness. The hand
of the examiner is placed over the right upper abdomen and the patient is instructed to
breathe in. The gallbladder descends with inspiration and as it comes in contact with the
examiner’s hand, causes severe pain. This is Murphy’s sign. It can also be positive in any
tender enlargement of the liver close to the gall bladder.

June 2016
Radiological Murphy’s sign: Ultrasound is one of the most important investigations for
acute cholecystitis. Instead of using the hand, the sonographer can put the US probe
over the upper right abdomen and ask the patient to breathe in. The GB descends with
inspiration and as fundus of the inflamed GB touches the US probe, the patient will have
pain and stop breathing. The radiographer can see inflamed GB, elicit pain, and confirm
the diagnosis.

Abdominal Pain
The patient’s behavior can help reveal the cause of the pain. For example, the parietal
peritoneum is highly sensitive to pain and therefore, patients with parietal peritonitis
tend to limit any abdominal movements, even due to respiration.

In evaluating abdominal pain, it is important to consider the urgency of the situation. In

the case of an acute abdomen (a term which generally requires emergent treatment),
bowel sounds may be frequently absent; there may be rigidity on palpation as well.
Rigidity is the involuntary contraction of all parietal muscles of the abdomen and
indicates underlying peritonitis. Some causes of an acute abdomen are ruptured gastro-
intestinal perforation, ectopic pregnancy, acute cholecystitis and acute appendicitis. All
of these may lead to parietal peritonitis.

We have to discuss the difference between ‘Guarding’ and ‘Rigidity’ in semester one
hand out.

Colicky pain occurs in bouts due to ongoing proximal hyperperistalsis due to luminal
obstruction. The episodes or bouts of colic are the attempts by the body to overcome
the obstruction; sometimes these are successful such as when a patient passes a
ureteral (“kidney”) stone. Colic can be of intestinal, biliary or ureteric origin. Biliary and
ureteric colic is commonly produced by stone obstruction. In contrast to patient with
peritonitis, patients with colicky pain often cannot stop moving in an effort to find a
comfortable position.

Provocative tests for peritoneal inflammation can be performed before the abdomen
becomes rigid; these are discussed below. These provocative tests should be done in
patient with abdominal pain, especially if peritoneal irritation is suspected. The normal
abdomen is soft to palpation.

June 2016
 Acute appendicitis is the acute inflammation
of the appendix commonly precipitated by
luminal obstruction. Signs and symptoms may
differ in patients depending upon the location
of the appendix, muscle strength and medicine
intake. Clinical diagnosis of appendicitis is
often difficult. Pain and tenderness in acute
appendicitis often localize to McBurney’s
point, 1/3 of the distance (approximately 2
inches) along a line drawn from the anterior
superior iliac spine (ASIS) and the umbilicus.

Figure 15. McBurney’s point and anatomic

variations in the location of the appendix.

Provocative maneuvers for detecting acute appendicitis include Rovsing’s, psoas and
obturator signs. Psoas sign and obturator sign are clinical signs of retrocecal and pelvic
appendicitis and so, both cannot be positive in the same patient.

Rovsing’s sign is elicited by pressing firmly in the left lower

quadrant (LLQ). Pain in the right lower quadrant (RLQ) occurring
during applied pressure in the LLQ is considered a positive
Rovsing’s sign and suggests appendicitis. In Rovsing’s sign
pressure applied over the left lower abdomen will be
transmitted to the inflamed appendix either through trans-
peritoneal or intra luminal route to cause pain.
Figure 16. Rovsing’s sign.

June 2016
 Eliciting the psoas sign
assesses for a retrocecal
appendicitis. It is
performed by placing the
physician’s hand just
above the patient’s right
knee and asking the
patient to lift the thigh
against resistance. Pain in
the RLQ with this
maneuver suggests
irritation of the inflamed retrocecal appendix by the contraction of psoas muscle and
considered a positive psoas sign.

Assessing for the obturator sign is accomplished by

flexing the patient’s right thigh at the hip with the
knee bent and then internally rotating the hip. Pain in
the right pelvis with this maneuver suggests irritation
of the inflamed pelvic appendix by the obturator
internus muscle and considered a positive obturator
sign.

Figure 17. Relationship of the obturator internus muscle with the pelvic appendix.

It is also important to recognize that rectal and/or pelvic examination should be

performed in a patient with suspected pelvic appendicitis.
During digital rectal exam there may be tenderness to palpation
on the right lateral pelvic wall if the appendix is pelvic in
position.

June 2016
 For further evaluation of lower abdominal pain in a
female patient, it is important to perform a pelvic
examination. Some causes of lower abdominal pain in
females include ectopic pregnancy, pelvic
inflammatory disease, and ovarian cyst or tumor and
these can mimic acute appendicitis. Tenderness over
the right vaginal fornix can be due to pelvic
appendicitis.

The costovertebral angle (CVA) is the angle

between the lower border of the 12th rib and the
transverse process of the upper lumber vertebrae.
Positive CVA tenderness reflects tenderness of the
kidneys. CVA tenderness can be positive in
pyelonephritis of the kidneys, perirenal abscess
and other tender renal conditions and local
musculoskeletal disorders. Assessment for CVA
tenderness should be performed bilaterally. The
technique is here.

Figure 18. Location of costovertibral angle and

punch to elicite CVA tenderness.

Abdominal aortic aneurysm (AAA) is defined as a dilatation of

abdominal aorta more than 3 cm in diameter. If the diameter
of an abdominal aortic aneurysm is more than 5 cm it is more
prone to rupture, a dreaded and catastrophic complication of
the disease. It is common above the age of 50 and usually
asymptomatic.
Bruits heard during abdominal auscultation suggest vascular
occlusive disease. Both systolic and diastolic bruits are diagnostic of arterial narrowing.

June 2016
Reference: Bates pg.436 and 447-51.

June 2016