LEARNING OBJECTIVES To know the four quadrants and nine regions
of the abdomen; To be aware of some common findings on inspection,
auscultation and palpation of the abdomen, and what they may mean;
To know the reason for the sequence of abdominal examination; To
learn how some common abdominal conditions are diagnosed using
physical examination.
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EXAM Inspection Auscultation Percussion Palpation
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THE FOUR QUADRANTS Physicians locate findings in the abdomen in
one of four quadrants or one of nine regions. The four quadrants
are: right upper (RUQ), right lower (RLQ), left upper (LUQ) and
left lower (LLQ).
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THE NINE REGIONS The nine abdominal regions are: epigastric,
umbilical, hypogastric/suprapubic, right hypochondriac, left
hypochondriac, right lumbar, left lumbar, right inguinal and left
inguinal.
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LOCATIONS of ABDOMINAL ORGANS Right hypochondriac (RUQ): liver
and gall bladder eft hypochondriac (LUQ): the spleen and stomach
epigastric: the pancreas, stomach and common bile duct umbilical:
the small intestine lumbar: the kidneys iliac regions: the ovaries
left iliac/LLQ: the sigmoid colon right iliac or lumbar (RLQ): the
cecum and appendix suprapubic: the bladder and uterus
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SOME COMMON FINDINGS on ABDOMINAL INSPECTION Scars Striae
(stretch marks) Colors Jaundice Prominent veins
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SCARS Explain every scar. Each one is evidence of surgery or
injury that the patient may have forgotten to mention to you. The
injury that caused a visible scar may have also caused internal
scarring (adhesions) - which can cause intestinal obstruction
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STRIAE (Stretch Marks) On the abdomen may be a sign of past
weight changes, such as pregnancy. An endocrine disease, Cushing's
disease, may cause purple striae.
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COLORS Bluish color at the umbilicus is Cullen's sign - a sign
of bleeding in the peritoneum. Bruises on the flanks are Grey
Turner's sign (retroperitoneal bleeding - e.g. from inflamed
pancreas)
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JAUNDICE Jaundice yellow skin - is usually due to liver disease
or biliary tract obstruction
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PROMINENT VEINS Prominent veins may be due to portal vein
obstruction or inferior vena cava obstruction. The portal veins and
systemic veins connect in 3 locations; the umbilicus is one of
it.
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OTHER FINDINGS on INSPECTION: Peristalsis and Scaphoid Abdomen
Visible peristalsis is usually abnormal, unless the patient is
emaciated. Otherwise, it is a sign of intestinal obstruction. In
thin adults, the abdomen may be concave - scaphoid.
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CAUSES of ABDOMINAL DISTENSION Distension of the lower abdomen
only can be caused by pregnancy, full bladder, ovarian tumor, or
uterine fibroids (common benign growths) Diffuse abdominal
distension can be caused by any of the 6 Fs: Fat (obesity) Fluid
(ascites - peritoneal fluid - or obstructed viscera filled with
fluid) Flatus (air) - e.g. from air swallowing or intestinal
obstruction Feces (constipation Fetus (pregnancy) Fatal
cancer.
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HERNIAS Not all hernias happen in the inguinal area or scrotum.
Some abdominal hernias include: Umbilical hernias: protrude out of
the umbilicus Incisional hernias: occur at old scars Diastasis
recti: this is not a true hernia, but a separation of the rectus
abdominis muscles. You can see this best by asking the patient to
tighten the abdominal muscles (lift head when supine, or sit
up).
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Auscultation
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STOP, LOOK and LISTEN Always auscultate before touching the
abdomen. Touching the abdomen, even to percuss, may change the
bowel sounds. The order for examining the abdomen is: Inspection,
auscultation, percussion, palpation Before you proceed, consider
your patient's comfort. Is your stethoscope warm? Are your hands
warm? Are your fingernails short? Has the patient emptied his/her
bladder? Place a pillow under your patient's head. Asking your
patient to bend his/her knees may help relax the abdominal
muscles.
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GUT SOUNDS Use the diaphragm of your stethoscope to listen to
gut sounds Normal gut sounds are gurgling, 5 to 35 per minute
Borborygmi are loud, easily audible sounds. They are normal, too.
High pitched, tinkling (raindrops in a barrel) sounds are a sign of
early intestinal bstruction
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Decreased sounds: (none for a minute) are a sign of decreased
gut activity. Gut sounds may be markedly decreased after abdominal
surgery; abdominal infection (peritonitis) or injury. Absent Sounds
: (no sounds for 5 minutes) are a bad sign. They can be caused by
longer-lasting intestinal obstruction, intestinal perforation or
intestinal (mesenteric) ischemia or infarction.
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BRUITS Use the bell of your stethoscope to listen for bruits:
Aortic bruits are heard in the epigastrium. They may be a sign of
abdominal aortic aneurysm; Renal artery bruits are in each upper
quadrant. They may be a sign of renal artery stenosis, which is a
potentially treatable cause of hypertension; Iliac/femoral bruits
are in the lower quadrants. They may be a sign of peripheral
atherosclerosis.
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CASE 1 A 40 year old man has nausea and vomiting for two days
and no bowel movement. His abdomen is somewhat distended. Does he
have intestinal obstruction ? Signs of intestinal obstruction are:
High-pitched tinkling bowel sounds Later: bowel sounds absent
Visible peristalsis
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PERCUSSION What it finds: liver size, spleen, fluid. Percussing
the body gives one of three notes: Tympany is found in most of the
abdomen, caused by air in the gut. It has a higher pitch than the
lung. Resonance is found in normal lung. It is lower pitched and
hollow. Dullness is a flat sound, without echoes. The liver and
spleen, and fluid in the peritoneum (ascites), give a dull
note.
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PERCUSSING THE LIVER and SPLEEN to percuss the liver. a normal
liver measures 6 to 12cm, usually 8 to 12cm. The reliability of
percussion to assess liver size is limited (Am J Gastroenterol
1995; 90:1428-32)
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To percuss the spleen : Percuss in left anterior axillary line,
just above lowest rib Ask your patient to take a deep breath and
percuss again. Dullness with full inspiration may be a sign of
enlarged spleen (splenomegaly)
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CASE 2 A 65 year old man with a distended abdomen He drinks
half a pint of bourbon daily and notes gradually increasing
abdominal girth. He has no pain. Does he have ascites (fluid)
caused by liver failure?
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Inspection: Signs of liver disease: Jaundice (yellow cast to
skin) Spider angiomas: subcutaneous vessels that look like spiders.
They fill from the center when pressed. The liver enlarges early,
later shrinks with cirrhosis Prominent veins at umbilicus
Hemorrhoids Ascites
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USING PERCUSSION to DIAGNOSE ASCITES Physical signs of ascites
include fluid wave, shifting dullness and puddle sign. Two of these
are done by percussion. Shifting dullness : Start with your patient
supine. Percuss down the lumbar area closest to you; mark the point
where note turns dull. Now turn the patient onto his/her side
facing you and percuss down again. If the dull area is now higher
(closer to the umbilicus), this suggests fluid in the peritoneum
(ascites). Puddle sign (rarely done): Patient is on all fours, on
hands and knees Percuss for a dull area around the umbilicus
(lowest point)
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PERCUSSION for renal angle TENDERNESS To look for renal causes
of pain, such as pyelonephritis (kidney infection), you may percuss
the back in the region of the costophrenic angle. Tenderness on one
side may come from that kidney.
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PALPATION Use palpation to assess: Liver, spleen and kidneys
for enlargement and consistency Masses Tenderness Spasm of
abdominal muscles Guarding=spasm when you push; sign of tenderness
or inflammation Rigidity=board-like spasm all the time; sign of bad
things like perforated intestine, dead intestine from lack of
circulation (infarction), or diffuse infection peritonitis.
Oversensitivity of skin = cutaneous hyperesthesia: a sign of
inflammation of underlying structure
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PALPATION TECHNIQUE Warm hands; use two hands and focus on what
your lower hand feels. Bend your patient's knees to relax abdominal
muscles If the patient is ticklish, include patient's hand between
your two hands - a "hand sandwich" Examine tender areas last
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PALPATION of LIVER Some hints: Push in fairly deeply, 5cm deep
or more Inch your right hand up toward the patient's lower costal
margin with each breath. The liver edge should be palpable, if at
all, at the lower costal margin. It should feel rubbery and
smooth
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PALPATION of the KIDNEYS Palpation of the kidneys : Kidneys are
usually not palpable in adults unless quite enlarged (e.g.
polycystic) The right is palpable more often than the left Kidneys
are deep in the flank and move down with inspiration. Palpation for
masses : Use deep pressure with the palmar aspect of your fingers,
with a rolling motion.
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CASE 3: What is that lump? You feel a mass when palpating your
fellow student's abdomen. Normal "masses" include: Feces in the
sigmoid colon (often slightly tender) Air in the cecum Distended
bladder The uterus (e.g. pregnant) The aorta (it's pulsatile).
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CASE 4 A 68 year old man with hypertension is here to be
checked for anything life-threatening. Does he (or doesn't he) have
an abdominal aortic aneurysm ? Palpation of aorta : Aorta is just
to the left of the midline and is pulsatile If it seems 5 cm or
wider: evaluate for abdominal aortic aneurysm.
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HOW SENSITIVE IS PALPATION FOR DETECTING ABDOMINAL AORTIC
ANEURISM? Aneurysms require surgery if larger than 5cm. Examination
for abdominal aortic aneurysm (AAA) has sensitivity of: 82% if
patient's girth is under 100 cm (40 inches) 100% if patient's girth
is under 100 cm and aneurysm is over 5 cm 52% if patient's girth is
100 cm or more (Fink HA et al. The accuracy of physical examination
to detect abdominal aortic aneurysm. JAMA 2000;
160(6):833-836.)
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CASE 5 Does this patient have appendicitis? A 22 year old woman
with abdominal pain: She awoke with periumbilical pain; now her
pain is more in the right lower quadrant. She never had a similar
pain before. She comes to the emergency room.
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History that makes appendicitis more likely : Going to
emergency room for pain: up to 25% under age 60 have appendicitis
Right lower quadrant (RLQ) pain Pain that starts periumbilically
and migrates to RLQ No similar previous pain Pain before
vomiting.
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PHYSICAL FINDINGS Physical findings that make appendicitis more
likely : Fever (often lowgrade, around 38 degrees) 79% sensitive -
21% of patients are afebrile Abdominal rigidity Tenderness on right
side on rectal examination
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Rebound tenderness : Push gently until pain decreases, then
lift your hand suddenly. The pain is worse when you lift your hand
- a sign of peritoneal irritation. A kinder way to test for rebound
tenderness is called Rovsing's sign : you push down on the
nontender side of the abdomen and lift your hand suddenly. Patient
feels pain in the affected area (RLQ) when you lift your hand.
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MORE PHYSICAL SIGNS of APPENDICITIS Psoas sign (not sensitive,
but specificity 95%): Your patient lies supine and flexes his/her
entire leg against your hand's resistance, causing pain Or: patient
lies on his/her left side and you passively extend his/her hip;
this causes pain Not tested, but similar, is the obturator sign :
you passively flex and rotate patient's hip, stretching obturator
muscle; this causes pain.
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The area of tenderness in appendicitis should be McBurney's
point: 1/3 of the way up a diagonal line from iliac crest to the
umbilicus. Pain in RLQ near inguinal ligament in young women is
most likely pelvic (ovarian cyst, pelvic inflammatory disease,
abscess in fallopian tube) or urinary tract and NOT usually
appendicitis.
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MANTRELS Score Established in 1986 Migration of pain Anorexia
Nausea / vomiting Tenderness RLQ Rebound Elevated temp.
Leukocytosis Shift to left
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MANTRELS Score, cont'd. RLQ tenderness and leukocytosis = 2
points each ; all others 1 point Score of 5 to 6 = possible
appendicitis Score of 7 to 8 = probable appendicitis Score of 9 to
10 = very probable appendicitis
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CASE 6: Right upper quadrant pain : A 70 year old woman has
right upper quadrant (RUQ) pain for one day. Possible diagnoses:
Cholecystitis (infected gall bladder) Cancer (gall bladder,
pancreas, gastric) Pancreatitis (inflamed pancreas) Diverticulitis
(infected pocket off colon).
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USEFUL CLINICAL SIGNS of CHOLECYSTITIS Right upper quadrant
tenderness Murphy's sign : when you push toward the liver at the
right costal margin, patient has pain and stops breathing in: a
sign of gall bladder infection (cholecystitis). Palpable mass
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AN UNCOMMON CLINICAL SIGN of PANCREATITIS Bruised lateral
flanks due to bleeding: Grey Turner's sign
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SUMMARY You now know: What you can learn by inspecting the
abdomen Stop, look, and listen Sounds of intestinal obstruction
Signs of ascites Palpation for abdominal aneurysm Symptoms and
signs of appendicitis Signs of cholecystitis