Examination of The Abdomen

Dr Elias m.(MD)

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Anatomy

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 SYMPTOMS OF GASTROINTESTINAL DISEASE

Abdominal pain

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 SYMPTOMS GIS…..

• DYSPHAGIA (AND ODYNOPHAGIA)

• Dysphagia is the awareness of something sticking in
the throat or retrosternally during swallowing, and
odynophagia is pain as food or drink descends the
oesophagus
INDIGESTION (DYSPEPSIA)
• Dyspepsia is the medical term for indigestion, a
symptom that includes epigastric pain, heartburn,
distension, nausea or 'an acid feeling' occurring after
eating or drinking.
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 SYMPTOMS GIS…..
• HEARTBURN
– This is due to acid reflux from the stomach into the oesophagus.
– It causes pain in the epigastrium, retrosternally and in the neck..
– Alcohol often induces heartburn

• ANOREXIA
– This term refers to loss of appetite,
– .It often indicates important pathology, particularly in the
upper GI tract

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 SYMPTOMS GIS…..
• VOMITING

– Vomiting is a neurogenic response triggered by chemoreceptors in the brainstem or

reflexly through irritation of the stomach.
– Vomiting consists of a phase of nausea followed by hypersalivation, pallor,
sweating and hyperventilation..
– Most nausea and vomiting of gastrointestinal origin is associated with local
discomfort in the abdomen.

• It can be occur in
• GI disease or
• Non-GI disease.
.
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 SYMPTOMS GIS…..
• CONSTIPATION
– The frequency of bowel action varies greatly from
person to person.
– In a western population the statistical norm is between
three bowel actions per day and three per week.
– The term is sometimes used to describe the passage of
hard stools, irrespective of frequency.
– In clinical practice, the passage of formed stool less
often than three times per week is usually taken to
indicate an abnormality of bowel frequency,
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 SYMPTOMS GIS…..
DIARRHOEA
• Diarrhea is also subjective, but the regular passage of more
than three stools per day or the passage of a large amount of
stool (>300g/day) can certainly be called diarrhoea.
• Can be acute or chronic.

ABDOMINAL DISTENSION
• Abdominal distension has many causes, which include
flatus, fluid (e.g. ascites or ovarian cyst) and pregnancy

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 Hematemesis:
 Vomiting of blood that is the result of bleeding from the oropharynx
to the ligament of Treitz. (above the duodenojejunal flexure),
 The vomitous is look like coffee ground
 Melena:
 Passage of black and tarry stool caused by digested blood.
 50 – 100 cc of blood will render stool melenic.
 Melena without hematemesis is caused by severe bleeding distal to
the ligament of Treitz.
 Hematochezia:
 Passage of bright red blood and blood clots.
 seen in massive UGI hemorrhage
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Symmetrical in shape

slightly full but not distended in older age

group due to poor muscle tone or in subjects
who are mildly overweight
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 Striae
• Stretch marks are a light
silver hue.
• Pregnancy and obese
individuals
• Cushing’s syndrome
(more purple or pink).

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 Upward flow direction indicates IVC obstruction
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Evaluate venous return states
• Place
index
finger
side by
side over
a vein
and press
laterally,
milking
vein.
• Release
one
finger
and time
refill,
repeat
with
other
finger.
Venous
return is
in
direction
of faster
filling.

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 Visible Pulsations
• More conspicuous in the
thin than in the fat
• Greater in the old than in the
young.
• Increased in thyrotoxicosis,
hypertension, or aortic
regurgitation)
• In those with an aortic
aneurysm and tortuous aorta
• In those who have a mass
joining the aorta to the
anterior abdominal wall.
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Visible gastric Peristalsis Visible intestinal Peristalsis

• Gastric peristalsis is Intestinal peristalsis in

commonly seen in partial and chronic
neonates with intestinal obstruction
congenital hypertrophic Colonic obstruction is
pyloric stenosis usually not manifest as
visible peristalsis

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 Appearance of the abdomen Patient's
movement

• Patients with kidney

stones will frequently
writhe on the
examination table,
unable to find a
comfortable position

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 Appearance of the abdomen
Patient's movement

• Patients with peritonitis

prefer to lie very still
as any motion causes
further peritoneal
irritation and pain.

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 Auscultation

• Bowel sounds
• Vascular sounds (bruits)
• Friction Rubs
• Normal sounds consist of clicks and gurgles,
occurring at an estimated frequency of 5 to 34
per minute

It is performed before percussion

or palpation
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 Auscultation for bowel sounds
• Normal sounds are due
to peristaltic
activity.
• Peristalsis: A
progressive wavelike
movement that occurs
involuntarily in hollow
tubes of the body.

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 Auscultation

• 1.Diaphragm of
stethoscope used
• 2.Skin depressed
to approximately 1
cm

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 Three things about bowel sound
• Are bowel sounds
present?
• If present, are they
frequent or sparse
(i.e.quantity)?
• What is the nature of the
sounds (i.e.quality)?

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Bowel sound decrease
• Inflammatory processes
of the serosa
• After abdominal surgery
• In response to narcotic
analgesics or anesthesia.
Increase
• Inflammation of the
intestinal mucosa will
cause hyperactive bowel
sounds.

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 Auscultation for vascular sounds (bruits)

Aortic (midline between

umbilicus and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac (midway
between umbilicus and
midpoint of inguinal
ligament)

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 palpation
• Start in the left lower quadrant of the abdomen, palpating lightly, and
repeat for each quadrant.
• Repeat using slightly deeper palpation examining each of the nine
areas of the abdomen.
• Feel for the left kidney.
• Feel for the spleen.
• Feel for the right kidney.
• Feel for the liver.
• Feel for the urinary bladder.
• Feel for the aorta and para-aortic glands and common femoral
vessels.
• If a swelling is palpable, spend time eliciting its features.
• Palpate both groins.
• Examine the external genitalia. 42
 Palpation (superficial)
• Any areas of pain or
tenderness are reserved
for evaluation at the end
of the exam

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 Light Palpation
• Mostly looking for areas
of tenderness
• Tenderness is a physical
exam finding a reflex
occurs (muscle
splinting, wide eyes,
moaning, teeth gritting).

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 Palpation
Light palpation assesses
• Presence of superficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less prominent
if patient raises their
head

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 WHAT TO DO WHEN AN ABDOMINAL MASS IS
PALPABLE
• Site
• Size
• Shape
• Surface
• Edge
• Consistency
• Mobility , attachement
• Bimanually palpable

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 Deep Palpation

• Use palmar surface of

fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen

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 Deep Palpation

• Palpate tender areas last

• Try to identify
abdominal masses or
areas of deep tenderness

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 Normal structure that may be palpable

• Sigmoid colon • Distended bladder

• Liver • Gravid and non-gravid
• Kidney uterus
• Abdominal aorta • Xyphoid process
• Iliac artery • spleen

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 Rebound Tenderness
(For peritoneal irritation)

Warn the patient what you

are about to do.
• Press deeply on the
abdomen with your hand.
• After a moment, quickly
release pressure.
• If it hurts more when you
release, the patient has
rebound tenderness.

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 Ballotable sign

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 Kidney palpation
• Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
• Palpate deeply with
right hand on anterior
abdominal wall.

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 Cost vertebral Tenderness
(Often with renal disease)
• Use the heel of your
closed fist to strike the
patient firmly over the
costovertebral angles.
• Compare the left and
right sides.

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 Percussion
There are two basic sounds with Percussion

• Percussion the liver in

mid-clavicular line.
Asses size of liver by
percussing upper and
lower borders
1.Dull sounds that occur
when a solid structure
(e.g. liver) or fluid (e.g.
ascites) lies beneath the
region being examined.
2 tympanic sound 58
To determine the size of the liver

• Measure the liver span

by percussing hepatic
dullness from above
(lung) and below
(bowel). A normal liver
span is 6 to 12 cm in the
midclavicular line.

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 Examination for Shifting Dullness For
(peritoneal fluid)
• To demonstrate shifting dullness, lie the patient supine.
Place your fingers in the longitudinal axis on the
midline near the umbilicus and begin percussion
moving your fingers laterally towards the right flank.
• When dullness is first detected (in normal individuals
dullness is only over the lateral abdominal
musculature) keep your fingers in that position and ask
the patient to roll on their left side.
• If ascites is present the percussion note should have
become resonant
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• fluid thrill
• To elicit a fluid thrill the patient is again laid supine.
Place one hand flat over the lumbar region of one side
and ask an assistant to put the side of their hand
longitudinally and firmly in the midline of the
abdomen.
• Then flick or tap the opposite lumbar region .
• A fluid thrill or wave is felt as a definite and
unmistakable impulse by the detecting hand held flat
in the lumbar region

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 Clinical features of marked abdominal swelling

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Gross ascites Large ovarian cyst
• Dull in flanks • tympanic in flank
• Umbilicus everted and/or • Umbilicus vertical and
hernia present drawn up
• Shifting dullness positive • Large swelling felt arising
• Fluid thrill positive out of pelvis which one
cannot 'get below'

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 Rectal examination (DRE)
- Last step of the physical examination of abdomen

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 Special exam
• Murphy’s Sign • Re bound
• McBurney’s Tenderness
Point • Costovertebral
• Rovsing’s Sign tenderness
• Psoas Sign • Shifting Dullness
• Obturator Sign • Fluid wave

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 Murphy’s Sign (acute cholecystitis)

• Examiner’s hand is at
middle inferior border
of liver.
• Patient is asked to take
deep inspiration.
• If positive patient will
experience pain and will
stop short of full
inspiration
Hepatitis, subdiaphragmatic abscess
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 McBurney’s Point

• Localized tenderness
Just below midpoint of
line between right
anterior iliac crest and
umbilicus.
• Heel strike, riding over
bumps in road while
driving, coughing, will
produce pain.

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 Rovsing’s Sign

• Patient will experience

right lower quadrant
pain (in region of
McBurney’s Point)
when left lower
quadrant is palpated.
• Eg. acute appendicitis

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 Iliopsoas Sign

Patient can lay on side and extend leg at the hip or have
patient lay on back and try to flex hip against the resistance of
examiner’s hand on thigh. If patient has an inflamed retrocecal
appendix, this will produce pain.

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 Obturator Sign

Internally rotate right leg at the hip with the knee at 90 degrees of
flexion. Will produce pain if inflamed appendix is in pelvis.

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 Cullen’s sign
• Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
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 Grey-Turner’s sign
• Ecchymosis of
flanks.
(retroperitoneal
hemorrhage such
as hemorrhagic
pancreatitis)

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