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ABDOMEN EXAMINATION

REGIONS OF ABDOMEN
• ARBITRARILY DIVIDED INTO 9 REGIONS BY
• 2 IMAGINARY VERTICAL LINES
• Mid pt of clavicle on either side
• 2 IMAGINARY HORIZONTAL LINES
• At level of L1 vertebrae (i.e. Transpyloric plane)
• At level of tubercles of iliac crest
SYSTEMIC EXAMINATION OF ABDOMEN
• INSPECTION
• SHAPE
• UMBILICUS
• MOVEMENTS

• VISIBLE PULSATIONS
• VISIBLE GASTRIC/INTESTINAL PERISTALSIS (VGP/VIP)
• SKIN/SURF OF ABDOMEN
POSITIONING FOR ABDOMINAL EXAMINATION
INSPECTION
• UMBILICUS
• SHAPE
• SKIN/SURF OF ABDOMEN
• MOVEMENTS

• VISIBLE PULSATIONS
• VISIBLE GASTRIC/INTESTINAL PERISTALSIS (VGP/VIP)
PROC TO INSPECT
• UMBILICUS & SHAPE
• Look
• Tangentially across abdomen &
• From foot of bed
UMBILICUS
• NORMAL : Slightly Inverted & Retracted
• ABNORM
• EVERTED = Ascites, Umbilical hernia

• OMPHALOLITH = Inspissated desquamated epithelium

• SLIT
• VERTICAL = Pelvic/Ovarian tumor
• HORIZONTAL = Cirrhosis of liver + Ascites

• SUNKEN = Obesity
SHAPE
• NORM
• Flat/Slightly scaphoid
• Symmetrical
• ABNORM
• GENERALISED FULLNESS/DISTENSION = 5 F’s
• Fat, Fluid, Flatus, Faeces, Foetus

• LOCALISED DISTENSION
• SYMMETRICAL & CENTERED ARD UMBILICUS = Small bowel obstruction
• ASYMMETRICAL = Liver, Spleen, Ovary

• SCAPHOID/SUNKEN = Advanced starvation/Malignancy


SKIN/SURF OF ABDOMEN
• NORM
• IN OLDER PT : Haemangiomas (i.e. Campbell de Morgan spots), Seborrhoeic warts (Pink – Brown – Black)
• ABNORM
• STRIAE ATROPHICA/GRAVIDARUM
• Pink/White linear marks
• ETIO : Stretching of skin  Rupture of elastic fibres
• INDICATES : Recent change in abdomen size
• PURPLE STRIAE
• IN : Cushing’s syndrome
• PROMINENT SUPERFICIAL VEINS
• Distended veins ard umbilicus – K.A. Caput medusa = Portal HT
• ALSO IN
• IVC obstruction
• SVC obstruction
• LINEA NIGRA
• Pigmentation below umbilicus
• IN : Preg
• GREY TURNER’S SIGN
• Bluish discolouration of flanks/loins
• IN : Haemorrhagic pancreatitis
• CULLEN’S SIGN
• Bluish discolouration of periumbilical region
• IN : Haemorhagic pancreatitis
• EXAMINE HERNIAL SITES
PURPLE STRIAE
IVC OBSTRUCTION
ETIO
• Thrombosis
• Of femoral/iliac v
• Embolism

• Congenital anomalies
• Compression by
• Massive ascites
• Tumors
• Hypercoagulable states (i.e. Nephrotic syndrome)
• Idiopathic retroperitoneal fibrosis
• OC
• Trauma
• 2° to Inf
CLINICAL FEATURES
• OBSTRUCTION CAUDAL TO RENAL V
• Oedema of both lower limbs
• Dil of superficial v of legs & abdomen
• OBSTRUCTION AT LEVEL OF RENAL V
• Lumbar pain
• Renal enlargement
• Haematuria, Proteinuria
• OBSTRUCTION ABOVE RENAL V
• Budd Chiari syndrome
ANASTOMOSIS
• BETWEEN
• BELOW : Superficial epigastric & Superficial circumflex iliac v
• ABOVE : Lat thoracic v
• CONVEYING BLOOD FROM : Long saphenous v  Axillary v
• VEINS SEEN IN
• Paraspinal region
• Lat wall of abdomen

CLINICAL EXAMINATION
• PROC
• Pt made to stand
• Select long segment of v w/o tributaries below umbilicus
• To detect flow
• INTERPRETATION
• Flow towards umbilicus, Cephalic direction = IVC OBSTRUCTION
• Flow away from umbilicus, Downward direction = PORTAL HT
MOVEMENTS
• NORM
• Gentle rise on inspiration
• Fall during expiration
• ABNORM
• SILENT/STILL = Peritonitis
VISIBLE PULSATIONS
• ABDOMINAL AORTIC PULSATIONS
• Thin pt
• Aortic aneurysm
VGP/VIP
• PHYSIOLOGICAL
• Thin pt
• Elderly pt w lax abdominal wall
• PATHOLOGICAL
• VGP
• Wave of gastric peristalsis
• Lt hypochondrium  Epigastric region  Rt lumbar region
• IN : Gastric outlet obstruction
• VIP
• Hypermotile small intestine  Step ladder peristatltic wave in Umbilical region
• IN : Distal small bowel obstruction

• HOW DO YOU DIFFERENTIATE VGP FROM VIP


• Region of abdomen it occurs in as underlined above
MEASUREMENTS
• ABDOMINAL GIRTH
• PROC : Measure at umbilical level
• PURPOSE OF PERIODIC MEASUREMENT
• Assess prognosis in Acute abdomen, Obstruction of bowel, Paralytic ileus, Peritonitis
• DISTANCE BETWEEN
• LOWER END OF XIPHISTERNUM  UMBILICUS &
• UMBILICUS SYMPHYSIS PUBIS
• NORM : Umbilicus at mid position
• ABNORM
• Umbilicus displaced downwards = CIRRHOSIS W ASCITES
• Umbilicus displaced upwards = OVARIAN/PELVIC TUMORS
• SPINOUMBILICAL MEASUREMENT
• DISTANCE BETWEEN UMBILICUS & ASIS
• PROC : Measure on both sides
• NORM : Equidistant
• ABNORM : Shift to 1 side = TUMOR ON OTHER SIDE
PALPATION
PROC
• Warm hands • Order of palpation of organs are
• Ask pt to • Lt kidney
• Show where any pain is
• Report tenderness during palpation • Spleen
• Ask pt to place arms by sides • Rt kidney
• To help relax abdominal wall • Liver
• Use rt hand • Urinary bladder
• Keep it flat in contact wabdominal wall • Aorta & Para-aortic glands
• Begin w light superficial palpation • Common iliac vessels
• Palpate each region in turn
• Repeat w deeper palpation
• Palpate both groins
• Start in lt iliac fossa • Examine external genitalia
• Work anti-clockwise
• End in supra pubic region
• Describe any mass
• Site, Size & Shape, Surf
• Consistency, Fixity
• Movement on respi
• Determine if mass
• Superficial in abdominal wall or
• Within abdominal cavity
• PROC : Ask pt to tense abdominal muscles by lifting head
• RESULT
• Abdominal wall mass still palpable
• Intra-abdominal mass NOT
• Decide whether mass
• Enlarged abdominal organ or
• Separate from solid organs
FINDINGS
• Palpable pulsatile mass in upper abdomen =
• Aortic aneurysm
• Aortic pulsation
• In norm thin person
• Transmitted via overlying Gastric/Pancreatic tumor
• Tenderness
• In several areas on minimal pressure = Anxiety, Generalised peritonitis
• Severe superficial pain + Pain tht disappears if pt distracted/NO tenderness =
Anxiety
PALPATION BY DIPPING
• INDICATION : Tense ascites
• AIM : To detect presence of hepatic/splenic enlargement
• PROC
• Place hand flat on abdomen
• Make quick dipping movements
• RESULT
• Sudden displacement of liquid  Tapping sensation over surf of liver/spleen
SURF MARKINGS OF ORGANS
LIVER
• UPPER BORDER
• UPPER BORDER OF RT LOBE
• At level of 5th rib
• 2.5 cm med to rt midclavicular line
• UPPER BORDER OF LT LOBE
• At level of 6th rib
• In lt midclavicular line
• MEN
• Line joining
• Point abt 1 cm below rt nipple to
• Point abt 2 cm below lt nipple
• LOWER BORDER
• Obliquely from 9th rt – 8th lt costal cartilage
• Cross midline half way btw base of xiphoid cartilage & umbilicus
• LT LOBE
• Extends to lt of sternum for abt 5 cm
SPLEEN
• Behind 9th, 10th, 11th ribs
• Separated by diaphragm
• Long axis along line of 10th rib
• ANT : Extends to mid axillary line
• POST : Sup angle 4 cm lat to 10th thoracic spine

KIDNEYS
• INDICATED BY : Morris quadrilateral on either side
• Draw 2 parallel horizontal lines
• On back
• At levels of 11th dorsal & 3rd lumbar spine
• Draw 2 vertical lines
• 3.75 cm & 8.75 cm from midline respectively
GALLBLADDER
• At junc of
• 9th costal cartilage &
• Outer border of rt rectus abdominis
• GREY-TURNER’S METHOD
• Draw line from lt ASIS through umbilicus
• Gallbladder at junc of this line & costal margin
• NOTE
• Gallbladder better seen than felt when enlarged
PALPATION OF LIVER
• PROC 1
• Place hand flat on abdomen
• Finger pointing upwards
• Position sensing fingers (i.e. index & middle) lat to rectus muscle
• Press hand firmly inwards & upwards
• Keep steady while pt takes deep breath through mouth
• Wait 1 full phase of respiration
• Continue up
• PROC 2
• Keep rt hand below & parallel to rt subcostal margin
• RESULT
• Liver edge felt against radial border of index finger
• Confirm w percussion
• PRECAUTION
• Avoid placing hand over rectus abdominis
• Do NOT begin palpation too close to costal margin
CHARACTERISTIC OF LIVER COND/DISEASE
FIRM Chronic congestive cardiac failure (i.e. Nutmeg liver
REGULAR Cirrhosis of liver
Obstructive jaundice
NODULAR LIVER Advanced 2° carcinoma
Hepatoma
PULSATILE LIVER Systolic pulsations – TR
Diastolic pulsations – TS
SOFT Acute viral hepatitis
TENDER

• j
PALPATION OF SPLEEN
• PROC 1
• Palpate from Rt Iliac fossa to Lt Hypochondrium
• Wait 1 full phase of respiration
• Release P on examining hand at height of INSPIRATION
•  Finger tips slip over lower pole of spleen
• Confirm Presence & Surf characteristics

• PROC 2 : IF SPLEEN NOT PALPABLE


• Move hand upwards after each INSPIRATION
• Till finger tips under costal margin
• Repeat process along entire rib margin
• As position of enlarging splenic tip variable
• PROC 3 : IF SPLEEN STILL NOT PALPABLE
• PT POSITION
• Rt lat position
• Flex lt hip & knee
• Place lt hand posteriorly
• AIM : To support lower rib cage
• Palpate w rt hand from Rt Iliac fossa to Lt hypochondrium
• PROC 4
• Stand on lt side of pt
• Curl fingers of lt hand beneath costal margin
• MIDDLETON’S MANOEUVRE
• Stand on lt side of pt
• Face foot of bed
• Curl fingers of lt hand under costal margin
• Exert P over posterolat aspect of lower thorax w rt hand
• Ask pt to take deep breath
• Feel spleen at end of deep INSPIRATION
• NORM SPLEEN = NOT PALPABLE
• As lies beneath 9th-11th ribs in lt mid-axillary line
• SPLEEN PALPABLE WHEN ENLARGED 2-3×
• DIRECTION OF ENLARGEMENT : Towards rt iliac fossa
• PALPATE : Characteristic Notch
CAUSES OF SPLENOMEGALY
HAEMATOLOGICAL DISORDERS • Congenital spherocytosis
• Haemolytic anaemia
• Leukemias, Lymphomas
• Myeloproliferative diseases
• Polycythaemia rubra vera
INFECTIONS • Bacterial endocarditis
• Brucellosis, Salmonellosis, Tuberculosis
• Glandular fever
• Leishmaniasis
• Malaria
PORTAL HYPERTENSION
RHEUMATOLOGICAL CONDITIONS • RA
• SLE
RARITIES • Amyloidosis
• Glycogen storage disorders
• Sarcoidosis
PALPABLE ABNORMALITIES/PATHOLOGIES IN ABDOMEN
PHYSIOLOGICAL PALPABLE MASSES