Abdominal Examination

1. Introduction
• Introduce yourself
• Confirm patient details – name
• Explain the examination & Gain consent
• Position the patient on the bed, sat upright for the first part of the examination
• Ask if the patient currently has any pain

2. General Inspection
✓ Look around bedside for treatments or adjuncts – feeding tubes /stoma bags
/drains
✓ Patient’s appearance – pain / agitation / confusion
✓ Body habitus – obese / low BMI / cachectic
✓ Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal
(cholecystectomy)
✓ Jaundice – cirrhosis / hepatitis
✓ Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
✓ Abdominal distention – ascites / bowel distension / large masses
✓ Masses – may suggest malignancy / organomegaly
✓ Dressings – may be covering wound sites – infection / bleeding
✓ Needle track marks – Hepatitis / HIV
✓ Excoriations – pruritus – cholestasis

3. Inspection
1. Hands
❖ Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease
❖ Koilonychia – spooning of the nails – chronic iron deficiency
❖ Leukonychia – whitened nail bed – hypoalbuminemia (liver failure /
enteropathy)
❖ Palmar erythema – reddening of palms – liver disease / pregnancy
❖ Dupuytren’s contracture:
✓ Thickening of the palmar fascia
✓ Associated with alcohol excess / family history
❖ Hepatic flap:
✓ Ask patient to stretch out arms, with hands dorsiflexed and fingers
outstretched
✓ Ask them to hold their hands in that position for 15 seconds
✓ The hands will flap (flex/extend at the wrist) in an irregular fashion if
positive
✓ Causes include – hepatic encephalopathy / uraemia / CO2 retention
2. Arms
✓ Bruising – may suggest abnormal coagulation – e.g. secondary to liver failure
✓ Petechiae – low platelets – e.g. splenomegaly
✓ Excoriations – cholestasis
✓ Track marks – intravenous drug use – Hepatitis / HIV
3. Axillae
✓ Lymphadenopathy – malignancy / infection
✓ Hair loss – malnourishment / iron deficiency anaemia
✓ Acanthosis nigricans (hyperpigmentation) – GI adenocarcinomas / obesity

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 4. Eyes
✓ Xanthelasma – raised yellow deposits surrounding eyes – hyperlipidaemia Ask
patient to lower one of their eyelids with their finger. Inspect for the signs
below.
✓ Conjunctival pallor – suggests significant anaemia
✓ Jaundice – noted in the sclera – haemolysis / hepatitis / cirrhosis / biliary
obstruction

5. Mouth
✓ Angular stomatitis – inflamed red areas at the corners of the mouth –
iron/B12deficiency
✓ Oral candidiasis – white slough on oral mucous membranes – iron deficiency
/immunodeficiency
✓ Mouth ulcers – Crohn’s disease / coeliac disease
✓ Tongue (glossitis) – smooth swelling of the tongue with associated erythema –
iron/B12/folate deficiency

6. Neck
✓ Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic
malignancy
✓ Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy

7. Chest
✓ Spider naevi – central red spot with reddish extensions (>5 significant) – chronic
liver disease
✓ Gynaecomastia – overdevelopment of male mammary glands (pseudo
feminisation) – liver cirrhosis / digoxin/ spironolactone
✓ Hair loss – pseudo feminisation/ malnourishment / iron deficiency anaemia

8. Detailed abdominal inspection

Position the patient supine, with their arms by their side and legs uncrossed
✓ Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal
(cholecystectomy)
✓ Masses – assess (size/position/consistency/mobility) – organomegaly / malignancy
✓ Pulsation – a central pulsatile and expansile mass may indicate an abdominal aortic
aneurysm (AAA)
✓ Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed
(pancreatitis/ruptured AAA)
✓ Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed
(pancreatitis/ruptured AAA)
✓ Abdominal distension – fluid (ascites) / fat (obesity) / faeces (constipation) / flatus /
fetus (pregnancy)
✓ Striae – reddish/pink (new) or white/silverish (chronic) – abdominal distension
✓ Caput medusae – engorged paraumbilical veins – portal hypertension
✓ Stomas – colostomy (LIF) / ileostomy (RIF) / urostomy (RIF and contains urine)

4. Palpation
Ask about any areas of pain and examine these last.
Kneel so that you are level with the patient.
Observe the patient’s face throughout for signs of discomfort.

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1. Light palpation:
Palpate each of the 9 abdominal regions, assessing for any of the below.
✓ Tenderness – note the areas involved and the severity of the pain
✓ Rebound tenderness – pain is worsened on releasing the pressure – peritonitis
✓ Guarding – involuntary tension in the abdominal muscles – localised or
generalised?
✓ Masses – large/superficial masses may be noted on light palpation
2. Deep palpation
Assess each 9 regions again, but with greater pressure applied during palpation
If any masses are identified then assess
✓ Location – which region?
✓ Size
✓ Shape
✓ Consistency – smooth / soft / hard / irregular
✓ Mobility – is it attached to superficial/underlying tissues?
✓ Pulsatility – a pulsatile mass suggests vascular aetiology

1. Liver
✓ Begin palpation in the right iliac fossa using the flat edge of your hand (radial
side of your right index finger)
✓ Press your hand into the abdomen as you ask the patient to take a deep
breath
✓ Feel for a step, as the liver edge passes below your hand
✓ If you don’t feel anything, repeat the process with your hand 1-2 cm higher
✓ If you feel the liver edge, note the following:

2. Gallbladder
1. The gallbladder is not usually palpable.
2. An enlarged gallbladder suggests obstruction to biliary flow/infection
(cholecystitis).
3. Perform palpation at the right costal margin, mid-clavicular line (9th rib tip).
4. If enlarged, a rounded mass moving with respiration may be palpated (note any
tenderness)
5. Murphy’s sign:
• Place your hand in the area noted above (right costal margin, mid-clavicular
line)
• Ask the patient to take a deep breath
• As the gallbladder is pushed down into your hand the patient may suddenly
develop pain and stop inspiring.
• If this occurs and there is no discomfort in the same location on the left side
of the
3. Spleen
The spleen only becomes palpable when it’s at least three times its normal size!
1. Start in right iliac fossa – massive splenomegaly can extend this far!
2. Align your fingers in the same direction as the left costal margin
3. Press your right hand into the abdomen as you ask the patient to take a deep
breath
4. Feel for a step, as the splenic edge passes under your hand (a notch may be
noted)
5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the
left hypochondrium

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 4. Kidneys
1. Place your left hand behind the patient’s back, at the right flank
2. Place your right hand just below the right costal margin in the right flank
3. Press your right hand’s fingers deep into the abdomen
4. At the same time press upwards with your left hand
5. Ask the patient to take a deep breath
6. You may feel the lower pole of the kidney moving inferiorly during inspiration
7. Repeat this process on the opposite side to assess the left kidney
5. Aorta
1. Palpate using fingers from both hands
2. just above umbilicus at the border of the aortic pulsation
3. Note the movement of your fingers:
• Upward movement = pulsatile
• Outward movement = expansile (suggestive of AAA)
6. Bladder
An empty bladder will not be palpable (pelvic). However, an enlarged full
bladder can be felt arising from behind the pubic symphysis. This may suggest a
diagnosisof urinary retention.

5. Percussion
Abdominal organs
1. Liver –percuss up from RIF then down from right side of chest to determine the
size of the liver
2. Spleen – percuss up from RIF moving towards the left hypochondrium to assess
for splenomegaly
3. Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder
(dull) / bowel (resonant))

Shifting dullness
1. Percuss from the centre of the abdomen to the flank until dullness is noted
2. Keep your finger on the spot at which the percussion note became dull
3. Ask patient to roll onto the opposite side to which you have detected the dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites) then the area that was previously dull should now be
resonant
7. If the flank is now resonant, percuss back to the midline, which if ascites is
present, will now be dull (i.e. the dullness has shifted)

6. Auscultation
Bowel sounds
✓ Normal – gurgling
✓ Abnormal – e.g. “tinkling” (bowel obstruction)
✓ Absent – ileus / peritonitis
Bruits
✓ Aortic bruits – auscultate just above the umbilicus – AAA
✓ Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline

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