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34 CHAPTER 2 Principles of surgery

Evaluation of the abdomen

Positioning
• Lie the patient supine with the head slightly raised with adequate
support for the head to ensure the abdominal muscles are relaxed.
• Arms should be by the sides to relax the lateral abdominal muscles.
• The patient may be rolled into left or right lateral positions during
palpation and percussion.
• Ask the patient to cough during inspection; it may reveal hernias.
• Stand the patient up to examine the groin only if necessary; most
hernias and groin pathology can be fully assessed in supine position.
Inspection
• Perform during normal and deep respiration.
• General features. Is there evidence of jaundice or signs of anaemia?
Does the patient looked underweight, malnourished, or cachectic?
• Scars. Where are they? How old do they appear? Is there evidence of
herniation on coughing?
• Is there a stoma? What type? Does it look healthy or abnormal? What
is the content in the stoma appliance?
• Overall appearance. Is the abdomen symmetrical? Is there evidence
of global distension (e.g. ascites, distended bowel)? Is there evidence
of local distortion (e.g. a local mass or organomegaly)? Does the
abdomen move well and symmetrically with deep respiration (reduced
in peritoneal irritation)? Is there any discoloration (periumbilical
bruising (Cullen’s sign) or flank bruising (Grey Turner’s sign), where
either suggests retroperitoneal haemorrhage or major inflammation)?
• Umbilicus. Is it herniated? Is there discharge or ulceration suggestive of
infection or a malignant deposit?
• Pulsation. Is there visible pulsation? (Further assessment requires
palpation.)
• Persistalsis. Is there visible peristalsis? (Identification may take several
minutes of observation.) It is rarely possible to suggest a cause or level
of obstruction related to the pattern of visible peristalsis.
Palpation
Be methodical. Use the flat of one hand (usually the right). It is usual to
examine and describe the abdomen in areas. It can be divided it into nine
regions or five ‘quadrants’ (see Fig. 2.2). Examine the areas lightly at first
in a set order. Identify any masses or areas of tenderness. Repeat the
examination with deeper palpation. Go back to any identified masses and
try to ascertain their key features.
• Signs of peritoneal irritation. Are there signs of local visceral peritoneal
irritation (tenderness and pain on palpation)? Are there signs of mild
parietal peritoneal irritation (guarding) or signs of marked parietal
peritoneal irritation (rigidity)? Rigidity may be localized or generalized.
Rebound tenderness is an unnecessary test; it merely confirms the
presence of guarding and is often excessively painful for the patient.
• Masses. Assess their surface, edge, consistency, movement with
respiration, and overall mobility.
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EVALUATION OF THE ABDOMEN 35

• Organs.
• Liver. Palpate from right lower quadrant into right upper quadrant,
feeling for the liver edge during inspiration every few cm upwards
until it is found. Assess the edge. Is it smooth/nodular/craggy?
Assess any palpable surface. Is it smooth/nodular/craggy?
• Spleen. Palpate from right lower quadrant into left upper quadrant,
feeling for the spleen edge during inspiration as for the liver. Assess
the edge and any palpable surface.
• Kidneys. Palpate bimanually in each loin. ‘Ballotting’ (bouncing the
kidneys between each hand) is of little additional value.
Percussion
Percussion identifies the presence of excessive amounts of gas or fluid. It
is also useful, when done carefully, in the confirmation of the presence of
mild to moderate parietal peritoneal irritation (‘percussion tenderness’).
• Gas (hyperresonance). Is it generalized or localized? Is there
evidence of loss of dullness over the liver (suggestive of copious free
intraperitoneal gas)?
• Fluid (ascites). Usually identified as ‘shifting dullness’; dullness in
the flanks in the supine position moves to the lower portion of the
abdomen on turning to the lateral position.
Auscultation
To fully assess bowel sounds, it is necessary to listen for at least 1min, but
they are a notoriously unreliable sign of either intra-abdominal pathology
or bowel function. If commented on, bowel sounds should broadly be
divided into: absent, normal, active, or obstructive (characterized by high-
pitched, frequent sounds often with crescendos of activity, e.g. ‘tinkling’,
‘bouncing marbles’).
Abdominal assessment should always include a rectal examination in
adults; this is very rarely useful and should usually be avoided in children.

RUQ LUQ

Central

RLQ LLQ

Fig. 2.2 The five quadrants: RUQ, right upper quadrant; LUQ, left upper
quadrant; LLQ, left lower quadrant; RLQ, right lower quadrant.