THE ABDOMINAL

EXAM
ACS/ASE Medical Student Simulation-based
Surgical Skills Curriculum
CREDITS
 Author
 Ebondo Mpinga, MD,FACS
 Contributors
 Michael Hughes, MD ,FACS (expert performance video)
 Richard Damewood, MD,FACS (modified score assessment tool)
 Duane Patterson, PhD (technical support)
 Paul Schreck (videographer )
 Editors
 Keith Clancy, MD, FACS
 Amanda Beattie, MD , R5
 York Hospital Department of Surgery, York, PA
OBJECTIVES
 After the completion of this module the
student should be able to:
1. Perform a complete abdominal exam.
2. Recognize the signs of peritonitis.
3. Arrive at a differential diagnosis based upon the
findings elicited during the exam.
ABDOMINAL EXAM
 Although we will focus on the abdominal exam, it cannot
be overemphasized that a thorough physical exam
(head to toes) is important to help in arriving at a
comprehensive differential diagnosis list.
 Examples :
 presence of jaundice may add consideration of a biliary

/hepatic etiology
 Irregularly irregular heart rate atrial fibrillation->

mesenteric ischemia
 Crackle at lung bases pneumonia

 Skin lesions (pyoderma gangrenosum) -> IBD

ABDOMINAL WALL
DESCRIPTION
 The abdomen is generally
divided into four quadrants by RUQ LUQ
two artificial lines that intersect
at the umbilicus RLQ LLQ

 Other systems exist to further Right Epigastric Left

Hypochondrium Hypochondrium
subdivide these four quadrants
into nine regions/sections Right Umbilical Left
flank flank

Right Hypogastric Left

Iliac / suprapubic Iliac
ABDOMINAL EXAM
 The exam should be performed in this specific order
 General appearance
 Vital signs
 Inspection
 Auscultation
 Percussion
 Palpation
 It should include
 An examination of the inguinal area
 including the external genitalia in males (testes)
 A rectal exam (discussed in a separate module)
 A pelvic exam in women (discussed in a separate module)
 DESCRIPTION
OF TECHNIQUES
General Appearance
 Head-to-toe (skin, eyes, LOC,
position, demeanor)
  Inflammation, peritonitis
 Lies perfectly still
 Or in bed with thighs and knees
flexed
  Obstruction / colic
 Restless, writhing
 Abdominal distension?
 Shock
 Pallor/ cyanosis/ diaphoresis/
decreased mental status
Vital Signs
 Tachycardia
 ? Early shock (may present prior to hypotension)
 May be absent if on Beta blockers
 Rapid shallow breathing (splinting)
 Peritonitis
 Hypotension
 May be late finding depending on pre-existing state of health
 Fever
 Infectious etiology or perforation
Inspection
 Abdominal contour
 Distended vs. scaphoid
 Irregular -> mass /
volvulus / obstruction /
hernias
 Skin
 Ecchymosis around
umbilicus, flanks
 pancreatitis? Trauma
(seat belt sign)?
 Scars
 Prominent veins on the
abdominal wall
 Portal hypertension
Auscultation
 Bowel Sounds
 Auscultate all regions
 Listen in each region
 Listen before feeling
 Absent bowel sounds
 ileus, peritonitis, shock
 Hyperactive
 Enteritis / obstruction
(high pitched or distant)
 Bruits
 AAA / Reno-vascular Aorta
diseases
 Iliac and Femoral Renal Renal
arteries Iliac arteries

Femoral arteries
Percussion
 Hyperresonance
(tympani)
 Bowel distension with
air->obstruction
 In all quadrants but
RUQ (liver dullness)
 Loss of liver dullness in
RUQ-> Free air
 Fluid wave
 Ascites (may be hard to
elicit in the obese)
Palpation
 Palpate each region
 Work toward area of pain
Right Epigastric Left
 Warm hands Hypochondriac Hypochondriac

 Communicate with patient

Right Umbilical Left
 Let the patient know what flank flank
you are about to do Right Hypogastric Left
 Place Patient supine Iliac Iliac

 knee bent (if possible)

Palpation
 Note tenderness
 Localize vs. diffuse
 Rigidity
 Rebound
 Press on the abdomen and release
 Present if pain is worse upon
release
 Avoid too sudden of a release
(may startle patient -> false +)
 Involuntary & voluntary guarding
 Distract the patient while palpating
to detect involuntary guarding
 Feel for masses
Signs highly suggestive of
peritonitis
 Tenderness to percussion
 Tenderness elicited when the examiner firmly taps
on the Iliac crest
 Tenderness elicited when the examiner firmly taps
on the heel of the patient’s extended leg
 Tenderness when the bed is gently shaken or the
patient coughs
 Rebound tenderness
Abdominal exam:
findings that suggest specific etiology
 Biliary / hepatic etiology
 Courvoisier' sign
 Palpable gallbladder in the
presence of painless jaundice
  periampullary tumor
 Caput medusa (Cruveilhier sign)
 Varicose veins at umbilicus
cirrhosis with portal HTN
 Murphy’s sign
 Pain caused during inspiration
while palpating the RUQ-> acute
cholecystitis
 Ransohoff sign
 Periumbilical yellow discoloration
-> ruptured CBD
Abdominal exam:
findings that suggest specific etiology
 Appendicitis
 Rovsing’s sign
 Palpation on the LLQ produces
tenderness at McBurney’s point
 Ten Horn test
 Pain caused by gentle traction of the
right testicle
 Aaron sign
 Persistent pressure applied at
McBurney ‘s point causes pressure
in the epigatrium and upper chest
wall
Abdominal exam:
findings that suggest specific etiology
 Pelvic inflammation/abscess
 Iliopsoas sign
 Allow patient to lie on the opposite
side of the pain
 Extend the thigh on the affected side
 This should cause pain if there is
irritation of the iliopsoas muscle
(seen with appendicitis as well)
 Obturator sign
 Flexion and internal rotation of the
right thigh while supine elicits
hypogastric pain
 Indicates irritation of obturator
internus muscle (seen with
appendicitis as well)
 Chandelier sign
 Extreme lower abdominal/pelvic pain
with movement of the cervix
Abdominal exam:
findings that suggest specific etiology
 Hemoperitoneum
 Hemorrhagic pancreatitis
 Cullen’s sign
 periumbilical bruising-> hemoperitoneum
 Grey Turner’s sign
 Local area of discoloration around the flanks-> acute
hemorrhagic pancreatitis

 Danforth sign
 shoulder pain on inspiration-> hemoperitoneum
 Kehr’s sign
 Left shoulder pain when supine or pressure applied to LUQ->
splenic rupture
Inguinal exam
 Palpation of the inguinal area
with & without vasalva
maneuver
 Ask patient to cough
 Ask patient to take a deep
breath and bear down
 Pay attention to the femoral
area to rule out femoral
hernias
 In the male, the testis should
be examined
 to rule out testicular torsion
COMMON ERRORS
 Focus only on the abdomen
 Begin with palpation prior to inspection, auscultation and percussion
 Not asking the patient to localize the pain and therefore beginning
palpation of the affected area first, exacerbating the pain and thus
precluding complete examination of the abdomen
 Skipping the rectal, pelvic and groin exam
 Putting too much weight on the absence of rebound tenderness to r/o
peritonitis
 Putting to much weight on the physical exam in an immunosuppressed
patient who may not exhibit normal signs of peritonitis
 Forgetting to consider mesenteric ischemia when there is pain out of
proportion to clinical exam
GROUPING OF
SIGNS AND
SYMPTOMS
DIFFERENTIAL DIAGNOSIS
Severe central abdominal pain with
shock and no peritoneal signs
 Intra-abdominal causes
 Acute pancreatitis (pain
radiating to back)
 Severe central abdominal pain with
shock and no peritoneal signs
 Intra-abdominal causes
 Acute pancreatitis (pain
radiating to back)

 Rupture AAA (pulsatile

mass) STAT SURGERY
Severe central abdominal pain with
shock and no peritoneal signs
 Intra-abdominal causes
 Acute pancreatitis (pain
radiating to back)
 Rupture AAA (pulsatile
mass) !! STAT
SURGERY
 Hemoperitoneum
!! STAT SURGERY
 Spontaneous rupture of
spleen/Splenic artery
aneurysm (pain radiates
to left shoulder)
Severe central abdominal pain with
shock and no peritoneal signs
 Intra-abdominal causes
 Acute pancreatitis (pain
radiating to back)
 Rupture AAA (pulsatile mass)
!! STAT SURGERY
 Hemoperitoneum
!! STAT SURGERY
 Spontaneous rupture of
spleen/Splenic artery
aneurysm (pain radiates to
left shoulder)
 Ruptured ectopic pregnancy
Severe central abdominal pain with
shock and no peritoneal signs
 Intra-abdominal causes
 Acute pancreatitis (pain
radiating to back)
 Rupture AAA (pulsatile mass)
!! STAT SURGERY
 Hemoperitoneum
!! STAT SURGERY
 Spontaneous rupture of
spleen/Splenic artery
aneurysm
 Rupture ectopic pregnancy
 Late mesenteric ischemia
 Extra- abdominal causes
 Acute MI with cardiogenic
shock
Severe abdominal pain with diffuse
peritoneal signs
 Perforated viscous
 STAT SURGERY
 Gastric/duodenal ulcers
 Gallbladder
 Complication of Small and
large bowel obstruction
 Maximal distention leading
to peroration (Cecum)
 Necrotic bowel due to
mesenteric ischemia or
strangulated hernias

 Patients will rapidly progress to septic

shock if surgery is delayed
Severe central abdominal pain
without associated signs
 Intra-abdominal
causes
 Intestinal colic
 Early appendicitis
 Early/ mild pancreatitis
 Early mesenteric
thrombosis
Severe central abdominal pain
without associated signs
 Intra-abdominal causes
 Intestinal colic
 Early appendicitis
 Early/ mild pancreatitis
 Early mesenteric
thrombosis
 Extra- abdominal causes
 Herpes Zoster (rash in
dermatome distribution)
 CAD (ECG/Enzymes)
 Glaucoma
 Tabes dorsalis (rare)
Severe central abdominal pain with
distension, no vomiting & peritoneal
signs
 Intra-abdominal causes
 Large bowel obstruction
while ileocecal valve is
competent
 Sigmoid diverticular
stricture/ inflammation/
cancer
 Volvulus
 Hernias
 Adhesions
Severe central abdominal pain with
distension, no vomiting & peritoneal
signs
 Intra-abdominal causes
 Large bowel obstruction
while ileocecal valve is
competent
 Sigmoid diverticular
stricture/ inflammation/
cancer
 Volvulus
 Hernias
 Adhesions
 Extra- abdominal causes
 Uremia
Severe central abdominal pain with
vomiting, distension & no peritoneal
signs

 Small obstruction
 Bilious vomiting in proximal
obstruction
 Feculent vomiting in distal
SB obstruction
 Gastric outlet obstruction
 Non-bilious vomiting
 Undigested food particles
Severe abdominal pain with
localized peritoneal signs
 RUQ
 Acute cholecystitis (pain
referred to back)
Severe abdominal pain with
localized peritoneal signs
 RUQ
 Acute cholecystitis
 Hepatic etiology: abscess/
hydatid cyst / Hepatitis
 Retrocecal appendicitis
Severe abdominal pain with
localized peritoneal signs
 RUQ
 Acute cholecystitis
 Hepatic etiology: abscess/
hydatid cyst/ Hepatitis
 Retrocecal appendicitis
 Leaking duodenal ulcer
Severe abdominal pain with
localized peritoneal signs
 RUQ
 Acute cholecystitis
 Hepatic etiology: abscess/
hydatid cyst/ Hepatitis
 Retrocecal appendicitis
 Leaking duodenal ulcer
 Pyelonephritis/stones
Severe abdominal pain with
localized peritoneal signs
 RUQ
 Acute cholecystitis
 Leaking duodenal ulcer
 Hepatic etiology: abscess/
hydatid cyst/ Hepatitis
 Retrocecal appendicitis
 Pyelonephritis/stones
 Extra- abdominal causes
 Lobar pneumonia
Severe abdominal pain with
localized peritoneal signs
 RLQ
 Appendicitis
 Periumbilical at onset
 Shifts to RLQ
Severe abdominal pain with
localized peritoneal signs
 RLQ
 Appendicitis
 Cholecystitis (low lying GB)
 Leaking duodenal ulcer
 Terminal ileitis
 Meckel’s diverticulitis
 Right sided diverticulitis
(cecal)
 Mesenteric adenitis (children)
 Retained testis/ right testicular
torsion
 Urinary system (urteral
stones, pyelonephritis)
 Psoas abscess
Severe abdominal pain with
localized peritoneal signs
 LUQ
 Pancreatitis (most
common cause)
 Perforated gastric ulcer
localized by adhesions
 Splenic infarct/ injury
 Subphrenic abscess
 Jejunal diverticulitis
 Pyelonephritis
Severe abdominal pain with
localized peritoneal signs
 LLQ
 Diverticulitis of sigmoid
and left colon
 Colon cancer with
surrounding
inflammation
 Upper extension of
pelvic abscess
 IBD
 Pyelonephritis
Severe abdominal pain with
localized peritoneal signs
 Hypogastric / Suprapubic area
 Perforated diverticulitis
or appendicitis
 Appendicitis
 Pelvic appendix
 Urinary tract
 Ureteral stones
 lower ureter
 Bladder distention
 Cystitis
Severe abdominal pain with
localized peritoneal signs
 Hypogastric / Suprapubic area
 Perforated diverticulitis
or appendicitis
 Appendicitis (pelvic appendix)
 Urinary tract
 Ureteral stones (lower ureter)/
Bladder distention / cystitis
 Gynecologic / obstetric
conditions
 Uterine colic (Dysmenorrhea)
 Torsion/ ruptured ovarian cyst
 Ectopic pregnancy/ Threatened abortion
 PID