Systemic Examination

of Gastro Intestinal
Tract – Abdomen

DR. JOSEPH MWABUSILA (MD).

 By the end of this session, students are expected to
be able to:
 Describe the techniques used to examine different
parts of the abdomen (inspection, palpation,
percussion auscultation)
 Describe the process of abdominal examination
 Demonstrate skills in examining the abdomen
Preparing for Abdominal
Examination
 Position - patient should be in supine position on the bed or
examination couch
 The patient's hands should remain at their sides, with their head
resting on a pillow.
 If the neck is flexed, the abdominal musculature becomes tense
and the examination made more difficult
 When the patient is allowed to bend their knees so that the soles of
their feet rest on the examination table, their abdomen will relax.
 The patient should be exposed only from the pubic symphysis
below to the costal margin above - in women to just below the
breasts.
 Stand back and examine the abdomen from the end of the bed

 Move to the patient’s right-hand side and kneel on a level with the
abdomen
 If you attempt to examine the abdomen while standing, you will not be able
to observe it closely and you will be forced to extend your arm so much you
will lose accuracy when palpating.
 Look at the shape of the abdomen

 Generalized distension of the abdomen is caused by one of five F’s, namely:

 Fluid (Ascites)
 Foetus
 Faeces
 Fat
 Flatus
 A localized area of distension may be a mass, a loop of bowel or an
enlarged organ
 If there is a localized bulge, try to think of what organs lay in that
position in the abdomen.
 Look for movement in the abdomen

 A central visible pulsation may be an abdominal aortic aneurysm

 Visible peristalsis is seen in very thin people and in bowel obstruction

 Look now at the abdominal wall for surgical scars, striae and distended
veins
 Look for hernia orifices

 Inspect the external genitalia (for possibility of any pathology)

Abdominal Quadrants
 Palpate the painful point at the end

 Start from non-affected area to affected area

 Usually superficial and deep palpation is carried out

 In superficial palpation note any areas of tenderness or palpable

masses
 In deep palpation feel for intra abdominal organs or any palpable
masses in detail (take in mind nine anatomical areas of abdomen )
 Start in the left iliac region palpating lightly, and working
anticlockwise to end in suprapubic region
 Repeat this using deeper palpation with both hands if necessary
Palpation of the Abdomen
 Next feel for the left kidney

 Feel for the spleen

 Feel for the right kidney

 Feel for the liver

 Feel for the urinary bladder

Palpation of the Abdomen
cont…
 If a swelling is palpable spend time eliciting its features
 Site
 Size
 Shape
 Consistence (faeces may indented by pressure)
 Smoothness
 Surroundings
 Whether you can get above it
 Movement with respiration (liver or spleen)
 Tenderness

 Examine the external genitalia

Deep Palpation of Liver,
Spleen and Kidneys
 Politely ask the patient ‘could you please breathe in and out deeply for
me as this will enable me to perform the next part of the examination’.
 Start in the right iliac fossa and work upwards by about two cm with
each breath
 Feel for the liver edge with the radial border of the index finger. If
enlarged, it will slip under the examining fingers as the patient breathes
in
 Occasionally you may be able to palpate a liver edge just beneath the
costal margin in healthy people.
 If you do feel a liver edge, note the position in fingerbreadths beneath
the costal margin and whether the surface is smooth, irregular or
tender.
Palpation of the Liver
 Smooth hepatomegaly may be due to:
 hepatitis (tender liver)
 heart failure (tender liver)

 Rough nodular hepatomegaly may be due to:

 Hepatoma
 In early cirrhosis, a firm nodular liver edge may be felt,
but as cirrhosis proceeds, the liver shrinks and
becomes impalpable.
 Ask the patient to take more deeps breaths in and
out before placing the examining hand in the right
iliac fossa again and working towards the left costal
margin with each breath
 You are feeling for the spleen moving downwards
and to the patient’s right with each breath
 It is also possible to turn the patient on to their right
hand side (the right lateral position) as this is a more
sensitive test of an enlarged spleen
 In an adult a palpable spleen is always abnormal.

 There are several causes of splenomegaly, the commonest

are malaria, typhoid fever, myelofibrosis, chronic myeloid
leukaemia and tropical splenomegaly syndrome.
 There are a number of ways in which the enlarged spleen
can be distinguished from the left kidney: In an enlarged
spleen:
 You cannot get above it (fingers bellow the ribs)
 The overlying percussion note is dull
 It moves downwards and forwards with inspiration
 It can have a palpable notch on its medial side
 Examine the kidneys by placing your left hand under
the kidney in the renal angle and the right hand over it.
 Push upwards with the left hand and try to feel the
kidney as it bounces up towards the right hand. This is
called balloting the kidney.
 The right kidney lies slightly lower than the left (it is
pushed down by the liver) and so is easier to feel.
 The lower pole of a normal right kidney may thus be
felt in thin people
 This is done by pressing a hand against the
abdominal wall.
 There are three reactions that indicate pathology:
 Guarding (muscles contract as pressure is applied)
 Rigidity (rigid abdominal wall indicates peritoneal
inflammation)
 Rebound tenderness (release of pressure causes pain)
 In the abdomen only superficial percussion is necessary.

 A tympanic note is heard throughout except over the liver

where the note is dull
 Percussion is particularly useful for confirming the presence
of enlarged liver or spleen suspected on palpation.
 Percuss for the shifting dullness of ascites.

 Start in the midline and percuss towards the patient’s left

flank keeping the percussed finger parallel to the patient.
 If ascites is present, a point of dullness will be reached.
Percussion of the
Abdomen cont…
 Ask the patient to roll towards you to lie on his right hand side for a
minute keeping your finger at the point of dullness. Thank the
patient when they do so.
 Wait 30 seconds and then percuss again towards the midline. The
initial point of dullness will become tympanic and the dullness shifts
to the other point as you percuss towards the midline.
 Demonstrate for fluid thrill
 The patient is laid supine; place one hand flat over the lumbar region of
one side and get an assistant to put the side of the hand 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.
 Auscultation is sometimes done before percussion and palpation, unlike
in other examinations.
 It may be performed first because vigorously touching the abdomen may
disturb the intestines, perhaps artificially altering their activity and thus
the bowel sounds
 Additionally, it is the least likely to be painful/invasive; if the person has
peritonitis and you check for rebound tenderness and then want to
auscultate, you may no longer have a cooperative patient.
 Pre-warm the diaphragm of the stethoscope by rubbing it on the front of
your shirt before beginning auscultation.
 Auscultation is useful way of listening for bowel sounds and deciding
whether they are normal, increased or absent and of detecting bruits in
the aorta and main abdominal vessels.
Auscultation of the
Abdomen cont…
 Normal bowel sounds are heard as intermittent low
or medium pitched gurgles interspersed with an
occasional high pitched noise or tinkle.
 Growling sounds may be heard with obstruction.

 Absence of sounds may be caused by peritonitis.

 Stethoscope should be placed on one site on the

abdominal wall (just to the right of the umbilicus is
best) and kept there until sounds are heard. It
should not be moved from one site to another
Auscultation of the
Abdomen cont…
 To conclude that bowel sounds are absent one has
to listen for five minutes.
 Abdominal examination is not complete without a
digital rectal exam
 Perform a pelvic examination only if clinically
indicated
 Finish off abdominal examination

 It is very important at this stage to tell the patient

‘thank-you, you may sit back now’ and to cover them
up with the blanket.
 Reflection
 What are the common symptoms of the common
gastrointestinal conditions?
 What do you report on inspection of the abdomen?

 During palpation of the abdomen, what do you

palpate for?
 What are the possible causes of abdominal
distension?
 In abdominal examination the patient is examined in privacy,
calmness and confidentiality are usually observed.
 The patient should be on supine position.

 The examiner should stand on the right side of the patient

except if one is left handed.
 In some conditions for patient with acute/severe abdominal
pain auscultation may be performed prior to palpation.
 Examination proceeds in a systemic way by performing
inspection, palpation, percussion and auscultation.
 References
 Bickley, L.S. (2008) Bates’ Guide to Physical
Examination and History Taking. (10th ed.)
Philadelphia, USA: Lippincott Williams & Wilkins.
 Swash. M. & Glynn, M. (2007). Hutchison’s Clinical
Methods. (22nd ed.) London: Saunders.
 Swash, M. (2002). Hutchison’s Clinical Methods (21st
ed.) London: Saunders.