Abdominal Exam

9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 1

Examination of abdomen


Abdominal regions

Conventionally the abdomen

is divided into 9 regions

There are 4 dividing lines:

midclavicular (2) -

vertical

subcostal - upper

horizontal

Trans-tubicular - lower

horizontal

Alternatively they can be

divided into 4 quadrants

Anteriorsuperioriliac spine

Subcostalline

Midclavicularline

LumbarUmbilical

Epigastic

Suprapubic

Hypochondrial

IliacTrans-tubercular


Remember to always do a general

Inspection This can be undertaken with the patient upright

General appearance

Demeanour, Pallor, Jaundice, Cachexia, etc.

Hands and nails

Ask the patient to dorsiflex at the wrist (cock their hands

back) to observe for a liver flap (a flapping of the hands

back and forth associated with metabolic disorders)

Vital signs (BP, Pulse, RR, Temp)

Mouth, teeth, tongue and breath

Palpation of lymph nodes

They may enlarge for a number of reasons,

including infection, malignancy and systemic

disease.

Certain groups are assessed as part of

limited local examinations:-

Cervical and Supraclavicular in abdominal

examination.


9/19/2011 Clinical Skills Resource Centre, University of Liverpool, UK 5

Lymph nodes for abdominal examination

Deep cervical

Superficial

cervical

Supraclavicular


Abdominal examination

The patient should be relaxed in a warm environment

Lying flat on their back, with hands by their sides and a single pillow under the head

Hips and knees may be flexed to relax abdominal muscles

The abdomen should be exposed (from xiphisternum to the suprapubic area - inguinal and genital areas are covered until they are to be examined)

Examiner should have warm hands

Should position him/herself to be on level with the abdominal surface


Inspection of the torso

Should be done with the patient supine

Look for spider nivae (only on the chest)

Gynaecomastia in males

Scars

Skin

Distension

Swellings

Dilated veins

Visible peristalsis

Abdominal wall movement


Causes of abdominal distension

Flatus (gas)

Faeces

Fluid (ascites)

Fat

Foetus

F****ing big tumours


Superfical Palpation

Always start palpation

away from any site of pain.

Palpate systematically all

abdominal regions. Always

observe patients face for

signs of discomfort.

Superficial palpation

Using light pressure

assess for tone,

tenderness and any

obvious abnormalities

Use the flat of the palmar

surface of fingers to palpate

through the abdominal wall


Assessing muscle tone with superficial

palpation

Gentle pressure applied to the abdominal wall should allow the

examiner to depress the anterior wall of the abdomen as the

muscles relax

Contraction of the muscles underlying the hand as pressure is

applied is called “guarding” and may indicate some underlying

inflammation

A rigid abdominal wall, resisting any attempt to push back the

abdominal wall and usually not moving with respiration, indicates

underlying peritoneal inflammation and is called “rigidity”

A marked, acute exacerbation of pain on sudden release of pressure

applied to the abdominal wall is called “rebound”


Deep palpation

Deep Using firm pressure to

assess for deep swellings/abnormalities

Deep palpation must be done with the palmar aspect of the fingers (get on the same level as the abdomen)

Can be done using 1 or 2

hands. Making sure not to push

down on fingertips


Organ Palpation

Organ palpation Liver

Gall bladder

Spleen

Kidneys

Aorta

Use the radial margin of the index finger to move from the furthest direction enlargement can occur towards the position the organ normally lies to detect enlargement

Costal

margin

Use the edge of the index finger

to detect organ edges


Palpation

When palpating organs or masses feel for the edges

The edges provide a better contrast between

surrounding organs/tissues and the mass/organ

Palpation of masses or organs may be assisted by

assessment of mobility in relation to respiration

liver descends towards right iliac fossa on

inspiration

spleen descend inferio-medially on inspiration

towards the right iliac fossa

the kidneys descend on inspiration


Palpation of the liver

The liver lies predominantly

under the ribs on the right side,

although it does cross the mid-

line

The lowermost edge of the liver

lies approximately parallel with

the costal margin (the lower

edge of the rib cage)


How liver moves on insperation

The liver moves

inferiorly on

inspiration


How liver enlarges

Enlargement of the

liver also occurs in

an inferior direction


How liver is palpated

In view of the direction of enlargement,

palpation for the liver should

commence well away from the costal

margin in the right iliac area

The thumb is extended to expose the

lateral margin of the index finger

The hand is positioned so that the

lateral margin of the index finger is

parallel with the costal margin


How liver is palpated 2

The patient is asked to take a

deep breath in and pressure

applied to the abdominal wall by

the examining hand

If the liver is not palpated, the

examining hand is moved closer to

the costal margin by about 1 cm

The patient is asked to repeat

deep inspiration and the process is

repeated


How liver is palpated 3

The process is repeated until the

liver edge is palpated or the

costal margin reached

A normal liver may be palpated

close to the liver costal margin

An enlarged liver may be

palpated distal to the costal

margin

The distance is measured in cms

from the costal margin


Feeling the liver edge 1

The hand is placed on the

abdominal wall at the right iliac fosa

distance below the right costal

margin. The border of the index

finger is exposed by extending the

thumb.



Pressure is applied to the

abdominal wall so that the hand

presses slightly depresses the

superficial surface



The patient is asked to

breath in deeply through

their mouth. This flattens the

diaphragm and the liver

moves inferiorly.



An enlarged liver will

move towards the lateral

border of the index finger

as inspiration reaches

maximum



As the enlarged liver continues

to move downwards it lifts the

the finger and the edge can be

appreciated. The point at which

the edge is palpated at

maximum inspiration can be

measured from the right costal

margin


Palpation of the spleen

The spleen lies entirely under the ribs on the left side

The normal spleen is approximately fist sized

The long axis of the spleen lies along the the line of the 10th rib


Position of spleen in health

The spleen moves inferio-medially on inspiration

Even on deep inspiration the normal spleen cannot be felt on palpation

To be palpable the spleen must enlarge to at least twice normal size


Position of an enlarged spleen

Enlargement of the spleen also

occurs in an inferio-medial

direction

Indeed, a massive spleen may

extend into the right lower

abdomen

When very large you may be able

to palpate the distinctive splenic

notch


Palpation of the spleen 1

In view of the direction of

enlargement, palpation for the

spleen should commence well

away from the costal margin in

the right iliac area

The thumb is extended to expose

the lateral margin of the index

finger

The hand is positioned so that the

lateral margin of the index finger

is parallel with the left costal

margin



The patient is asked to take a deep breath in and pressure applied by the examiners hand to the abdominal wall

If the spleen is not palpated, the examining hand is moved closer to the costal margin by about 1-2 cm



If the spleen is not

palpated

The patient is asked to

repeat deep inspiration

and the process is

repeated



The process is repeated until

the spleen is palpated or the

costal margin reached

A normal spleen will not be

palpated

An enlarged spleen may be

palpated distal to the costal

margin

The distance is measured in

cms from the costal margin


If palpation is difficult

Palpation for the spleen can be facilitated by placing the left hand under and behind the lower left rib and applying traction in the direction shown

This may encourage an enlarged spleen, otherwise not palpable, to appear beyond the costal margin on inspiration

Some clinicians prefer the patient to roll onto their right side to achieve the same effect


Palpation of the kidneys

Extend from the twelfth thoracic vertebrae to the third lumbar vertebrae.

Not normally palpable unless the patient is thin

The right kidney is lower than the left due to the position of the liver

They have a firm consistency and smooth surface

They move downwards towards the end of inspiration

Posterior view

L R


Renal angle

They are retroperitoneal organs and deep bimanual palpation is required.

To examine position the patient close to the edge of the bed

Tuck the palmar surfaces of one hand into the patients flank

Nestle the finger tips in the renal angle

Posterior View

L R


Bimanual examination of the kidneys 1

One hand under the patients

flank, fingers in the renal angle

(between posterior costal

margin and spine

The other hand with fingers flat

placed below the costal margin,

lateral to the rectus muscle

Hands should be opposite one another


Bimanual examination of the kidneys 2

Palpate the lower pole of the kidney between the fingers of both hands

Asks the patient to breathe in deeply and press the fingers of both hands firmly together

The rounded lower pole of the kidney may be felt passing between the opposing fingers as the patient breaths in and out


Percussion

Assess the need to perform percussion depending on your clinical findings.

It is important to distinguish kidney enlargement from splenomegaly on the left and hepatomegaly on the right

Percussion of an enlarged liver or spleen will be dull whereas over the kidney it should be resonant due to the overlying bowel

The kidneys can be “balloted” this a technique where by a structure that is not fixed can be patted between the examining hands


Percussion technique

Take note of the technique

Use the tip of the finger

The blow is delivered by a

sharp wrist movement

Strike the middle phalanx

firmly. Two – three taps

only.

Remove striking finger

immediately

PRACTISE!

Please see basics of examination


Percussion

General abdomen - should be resonant

Organs

Liver - dull

Spleen - dull

Kidneys - resonant

Bladder - dull

Ascites

Shifting dullness

Dullness peripheral

Ovary

Dullness central


Detecting shifting dullness

Determines cause of abdominal distension, distinguishes

between fluid and gas.

There has to be a lot of fluid (ascites) present which can flow

freely for the method to work

With the patient lying on their back the highest point of fluid is

detected by percussion and marked

The patient rolls to an angle and is allowed to rest in this

position for a short time to allow the free fluid to flow and

establish a new upper level

Percussion is repeated and fluid confirmed by detecting

dullness “above” the previous level


Auscultation

Bowel sounds – Listen in

one area, bowel sounds

should be heard within 2-3

minutes.

Bruits

Liver

NB A full abdominal

examination should

normally include

examination of the groins,

external genitalia and

rectum

Renal

Aortic

Iliac

Femoral

Sites of abdominal bruits


Recording your findings

Don’t forget when recording your findings

Patient identifier, date (and time), signature and name

When documenting the size, position and shape of

a swelling, a diagram may often be useful. Where

possible remember to comment on the consistency,

surface and mobility of the swelling also.

Remember examination techniques will vary

depending on the patient and clinician

Abdominal Exam

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