Abdomen_03

Exam of the Abdomen

The major components of the abdominal exam include: observation, auscultation, percussion,
and palpation. While these are the same elements which make up the pulmonary and cardiac
exams, they are performed here in a slightly different order (i.e. auscultation before percussion)
and carry different degrees of importance. Pelvic, genital, and rectal exams, all part of the
abdominal evaluation, are discussed elsewhere.

Think Anatomically: When looking, listening, feeling and percussing imagine what organs live
in the area that you are examining. The abdomen is roughly divided into four quadrants: right
upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind
yourself of what resides in a particular quadrant and therefore what might be identifiable during
both normal and pathologic states.

Quadrants of the Abdomen

Topical Anatomy of the Abdomen

By convention, the abdominal exam is performed with the provider standing on the patient's right
side.

Observation: Much information can be gathered from simply watching the patient and looking
at the abdomen. This requires complete exposure of the region in question, which is
accomplished as follows:

1. Ask the patient to lie on a level examination table that is at a comfortable height for both
of you. At this point, the patient should be dressed in a gown and, if they wish,
underwear.
2. Take a spare bed sheet and drape it over their lower body such that it just covers the
upper edge of their underwear (or so that it crosses the top of the pubic region if they are
completely undressed). This will allow you to fully expose the abdomen while at the
same time permitting the patient to remain somewhat covered. The gown can then be
withdrawn so that the area extending from just below the breasts to the pelvic brim is
entirely uncovered, remembering that the superior margin of the abdomen extends
beneath the rib cage.
 Draping the Abdomen

3. The patient's hands should remain at their sides with their heads resting on a pillow. If the
head is flexed, the abdominal musculature becomes tensed and the examination made
more difficult. Allowing the patient to bend their knees so that the soles of their feet rest
on the table will also relax the abdomen.
4. Keep the room as warm as possible and make sure that the lighting is adequate. By
paying attention to these seemingly small details, you create an environment that gives
you the best possible chance of performing an accurate examination. This is particularly
important early in your careers, when your skills are relatively unrefined. However, it
will also stand you in good stead when examining obese, anxious, distressed or otherwise
challenging patients.

While observing the patient, pay particular attention to:

1. Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear

symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly?
The contours of the abdomen can be best appreciated by standing at the foot of the table
and looking up towards the patient's head. Global abdominal enlargement is usually
caused by air, fluid, or fat. It is frequently impossible to distinguish between these entities
on the basis of observation alone (see below for helpful maneuvers). Areas which become
more pronounced when the patient valsalvas are often associated with ventral hernias.
These are points of weakening in the abdominal wall, frequently due to previous surgery,
through which omentum/intestines/peritoneal fluid can pass when intra-abdominal
pressure is increased.
 Various Causes of Abdominal Distension

Obese abdomen Hepatomegaly

Markedly enlarged gall bladder

Ascites
(labeled "GB")

Same umbilical hernia while patient

Umbilical Hernia
performs valsalva maneuver.

2. Presence of surgical scars or other skin abnormalities.

3. Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to
lie very still as any motion causes further peritoneal irritation and pain. Contrary to this,
 patients with kidney stones will frequently writhe on the examination table, unable to find
a comfortable position.

Auscultation: Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a
relatively minor role. It is performed before percussion or palpation as vigorously touching the
abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel
sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the
stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20
seconds. There is no magic time frame. The stethoscope can be placed over any area of the
abdomen as there is no true compartmentalization and sounds produced in one area can probably
be heard throughout. How many places should you listen in? Again, there is no magic answer. At
this stage, practice listening in each of the four quadrants and see if you can detect any "regional
variations."
Abdominal Auscultation

What exactly are you listening for and what is its significance? Three things should be noted:

1. Are bowel sounds present?

2. If present, are they frequent or sparse (i.e. quantity)?
3. What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to as
bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5
seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry
great significance. That is, in the normal person who has no complaints and an otherwise normal
exam, the presence or absence of bowel sounds is essentially irrelevant (i.e. whatever pattern
they have will be normal for them). In fact, most physicians will omit abdominal auscultation
unless there is a symptom or finding suggestive of abdominal pathology. However, you should
still practice listening to all the patients that you examine so that you develop a sense of what
constitutes the range of normal. Bowel sounds can, however, add important supporting
information in the right clinical setting. In general, inflammatory processes of the serosa (i.e. any
of the surfaces which cover the abdominal organs....as with peritonitis) will cause the abdomen
to be quiet (i.e. bowel sounds will be infrequent or altogether absent). Inflammation of the
intestinal mucosa (i.e. the insides of the intestine, as might occur with infections that cause
diarrhea) will cause hyperactive bowel sounds. Processes which lead to intestinal obstruction
initially cause frequent bowel sounds, referred to as "rushes." Think of this as the intestines
trying to force their contents through a tight opening. This is followed by decreased sound, called
"tinkles," and then silence. Alternatively, the reappearance of bowel sounds heralds the return of
normal gut function following an injury. After abdominal surgery, for example, there is a period
of several days when the intestines lie dormant. The appearance of bowel sounds marks the
return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then,
must be interpreted within the context of the particular clinical situation. They lend supporting
information to other findings but are not in and of themselves pathognomonic for any particular
process.

After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for
renal artery bruits, a high pitched sound (analogous to a murmur) caused by turbulent blood flow
through a vessel narrowed by atherosclerosis. The place to listen is a few cm above the
umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely
check for bruits. However, in the right clinical setting (e.g. a patient with some combination of
renal insufficiency, difficult to control hypertension and known vascular disease), the presence of
a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening
for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal
structures. Atherosclerosis distal to the aorta (i.e. at the take off of the Iliac Arteries) can also
generate bruits. Blood flow through the aorta itself does not generate any appreciable sound.
Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal
dilatation.

Percussion: The technique for percussion is the same as that used for the lung exam. First,
remember to rub your hands together and warm them up before placing them on the patient.
Then, place your left hand firmly against the abdominal wall such that only your middle finger is
resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times
with the tip of your right middle finger, using the previously described floppy wrist action (see
under lung exam). There are two basic sounds which can be elicited:

1. Tympanitic (drum-like) sounds produced by percussing over air filled structures.

2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies
beneath the region being examined.

*Special note should be made if percussion produces pain, which may occur if there is
underlying inflammation, as in peritonitis. This would certainly be supported by other historical
and exam findings.
 Abdominal Percussion

What can you really expect to hear when percussing the normal abdomen? The two solid organs
which are percussable in the normal patient are the liver and spleen. In most cases, the liver will
be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below
the costal margin. The spleen is smaller and is entirely protected by the ribs. To determine the
size of the liver, proceed as follows:

1. Start just below the right breast in a line with the middle of the clavicle, a point that you
are reasonably certain is over the lungs. Percussion in this area should produce a
relatively resonant note.
2. Move your hand down a few centimeters and repeat. After doing this several times, you
will be over the liver, which will produce a duller sounding tone.
3. Continue your march downward until the sound changes once again. This may occur
while you are still over the ribs or perhaps just as you pass over the costal margin. At this
point, you will have reached the inferior margin of the liver. The total span of the normal
liver is quite variable, depending on the size of the patient (between 6 and 12 cm). Don't
get discouraged if you have a hard time picking up the different sounds as the changes
can be quite subtle, particularly if there is a lot of subcutaneous fat.
4. The resonant tone produced by percussion over the anterior chest wall will be somewhat
less drum like then that generated over the intestines. While they are both caused by
tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.
5. Speed percussion, as described in the pulmonary section, may also be useful. Orient your
left hand so that the fingers are pointing towards the patients head. Percuss as you move
the hand at a slow and steady rate from the region of the right chest, down over the liver
and towards the pelvis. This maneuver helps to accentuate different percussion notes,
perhaps making the identification of the liver's borders a bit more obvious.
Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally,
resting in a hollow created by the left ribs. When significantly enlarged, percussion in the left
upper quadrant will produce a dull tone. Splenomegaly suggested by percussion should then be
verified by palpation (see below). The remainder of the normal abdomen is, for the most part,
filled with the small and large intestines. Try percussing each of the four quadrants to get a sense
of the normal variations in sound that are produced. These will be variably tympanitic, dull or
some combination of the above, depending on whether the underlying intestines are gas or liquid
filled. The stomach "bubble" should produce a very tympanitic sound upon percussion over the
left lower rib cage, close to the sternum.

Percussion can be quite helpful in determining the cause of abdominal distention, particularly in
distinguishing between fluid (a.k.a. ascites) and gas. Of the techniques used to detect ascites,
assessment for shifting dullness is perhaps the most reliable and reproducible. This method
depends on the fact that air filled intestines will float on top of any fluid that is present. Proceed
as follows:

1. With the patient supine, begin percussion at the level of the umbilicus and proceed down
laterally. In the presence of ascites, you will reach a point where the sound changes from
tympanitic to dull. This is the intestine-fluid interface and should be roughly equidistant
from the umbillicus on the right and left sides as the fluid layers out in a gravity-
dependent fashion, distributing evenly across the posterior aspect of the abdomen. It
should also cause a symmetric bulging of the patient's flanks.
2. Mark this point on both the right and left sides of the abdomen and then have the patient
roll into a lateral decubitus position (i.e. onto either their right or left sides).
3. Repeat percussion, beginning at the top of the patient's now up-turned side and moving
down towards the umbilicus. If there is ascites, fluid will flow to the most dependent
portion of the abdomen. The place at which sound changes from tympanitic to dull will
therefore have shifted upwards (towards the umbillicus) and be above the line which you
drew previously. Speed percussion (described above) may also be used to identify the
location of the air-fluid interface. If the distention is not caused by fluid (e.g. secondary
to obesity or gas alone), no shifting will be identifiable.

The models below should help to clarify the concept of shifting dullness. With the
"patient" lying flat on their back balloons (representing the intestines)
float on the water (representing ascites). When the "patient" turns on their right side, a
new air fluid level is established.
Shifting Dullness (real patient)
Realize that there has to be a lot of ascites present for this method to be successful as the
abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on physical
exam. Also, shifting dullness is based on the assumption that fluid can flow freely throughout the
abdomen. Thus, in cases of prior surgery or infection with resultant adhesion formation, this may
not be a very useful technique. Palpation can also be used to check for ascites (see below).

Palpation: First warm your hands by rubbing them together before placing them on the patient.
The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the
examining surfaces used to locate the edges of the liver and spleen as well as the deeper
structures. You may use either your right hand alone or both hands, with the left resting on top of
the right. Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to
startle the patient or cause discomfort. Examine each quadrant separately, imagining what
structures lie beneath your hands and what you might expect to feel.

1. Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-
clavicular line. This should insure that you are below the liver edge. In general, it is easier
to detect abnormal if you start in an area that you're sure is normal. Gently push down
(posterior) and towards the patient's head with your hand oriented roughly parallel to the
rectus muscle, allowing the greatest number of fingers to be involved in the exam as you
try to feel the edge of the liver. Advance your hands a few cm cephelad and repeat until
ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly.
 Abdominal Palpation

2. Following this, repeat the examination of the same region but push a bit more firmly so
that you are interrogating the deeper aspects of the right upper quadrant, particularly if
the patient has a lot of subcutaneous fat. Pushing up and in while the patient takes a deep
breath may make it easier to feel the liver edge as the downward movement of the
diaphragm will bring the liver towards your hand. The tip of the xyphoid process, the
bony structure at the bottom end of the sternum, may be directed outward or inward and
can be mistaken for an abdominal mass. You should be able to distinguish it by noting its
location relative to the rib cage (i.e. in the mid-line where the right and left sides meet).

Rib Cage
3. You can also try to "hook" the edge of the liver with your fingers. To utilize this
technique, flex the tips of the fingers of your right hand (claw-like). Then push down in
the right upper quadrant and pull upwards (towards the patient's head) as you try to rake-
up on the edge of the liver. This is a nice way of confirming the presence of a palpable
liver edge felt during conventional examination.

Hooking Edge of the Liver

4. Place your right hand at the inferior and lateral border of the ribs, pushing down as you
push up from behind with your left hand. If the right kidney is massively enlarged, you
may be able to feel it between your hands.
5. Now examine the left upper quadrant. The normal spleen in not palpable. When enlarged,
it tends to grow towards the pelvis and the umbilicus (i.e. both down and across). Begin
palpating near the belly button and move slowly towards the ribs. Examine superficially
and then more deeply. Then start 8-10 cm below the rib margin and move upwards. In
this way, you will be able to feel enlargement in either direction. You can use your left
hand to push in from the patient's left flank, directing an enlarged spleen towards your
right hand. If the spleen is very big, you may even be able to "bounce" it back and forth
between your hands. Splenomegaly is probably more difficult to appreciate then
hepatomegaly. The liver is bordered by the diaphragm and can't move away from an
examining hand. The spleen, on the other hand, is not so definitively bordered and thus
has a tendency to float away from you as you palpate. So, examine in a slow, gentle
fashion. The edge, when palpable, is soft, rounded, and rather superficial. Repeat the
exam with the patient turned onto their right side, which will drop the spleen down
towards your examining hand.
6. Exploration for the left kidney is performed in the same fashion as described for the right.
Kidney pain, most commonly associated with infection, can be elicited on direct
examination if the entire structure becomes palpable as a result of associated edema. This
is generally not the case. However, as the kidney lies in the retroperitoneum, pounding
gently with the bottom of your fist on the costo-vertebral angle (i.e. where the bottom-
most ribs articulate with the vertebral column) will cause pain if the underlying kidney is
inflamed. Known as costo-vertebral angle tenderness (CVAT), it should be pursued when
the patient's history is suggestive of a kidney infection (e.g. fever, back pain and urinary
tract symptoms).

Posterior

View: Location of the Kidneys

Gross Retroperitoneum Anatomy

7. Examine the left and right lower quadrants, palpating first superficially and then deeper.
A stool filled sigmoid colon or cecum are the most commonly identified structures on the
left and right side respectively. The smooth dome of the bladder may rise above the
pelvic brim and become palpable in the mid-line, though it needs to be quite full of urine
for this to occur. Other pelvic organs can also occasionally be identified, most commonly
the pregnant uterus, which is a firm structure that grows up and towards the umbillicus.
The ovaries and fallopian tubes are not identifiable unless pathologically enlarged.
8. Finally, try to feel the abdominal aorta. First push down with a single hand in the area just
above the umbillicus. If you are able to identify this pulsating structure with one hand, try
to estimate its size. To do this, orient your hands so that the thumbs are pointed towards
the patient's head. Then push deeply and try to position them so that they are on either
side of the blood vessel. Estimate the distance between the palms (it should be no greater
then roughly 3 cm). This is, admittedly, a crude technique. Remember also that the aorta
is a retorperitoneal structure and can be very hard to appreciate in obese patients. There
have been no reports of anyone actually causing the aorta to rupture using this maneuver,
so don't be afraid to push vigorously.

Vascular Anatomy
What can you expect to feel? In general, don't be discouraged if you are unable to identify
anything. Remember that the body is designed to protect critically important organs (e.g. liver
and spleen beneath the ribs; kidneys and pancreas deep in the retroperitoneum; etc.). It is, for the
most part, during pathologic states that these organs become identifiable to the careful examiner.
However, you will not be able to recognize abnormal until you become comfortable identifying
variants of normal, a theme common to the examination of any part of the body. It is therefore
important to practice all of these maneuvers on every patient that you examine. It's also quite
easy to miss abnormalities if you rush or push too vigorously, so take your time and focus on the
tips/pads of your fingers.

Examining for a fluid wave: When observation and/or percussion are suggestive of ascites,
palpation can be used as a confirmatory test. Ask the patient or an observer to place their hand so
that it is oriented longitudinally over the center of the abdomen. They should press firmly so that
the subcutaneous tissue and fat do not jiggle. Place your right hand on the left side of the
abdomen and your left hand opposite, so that both are equidistant from the umbillicus. Now,
firmly tap on the abdomen with your right hand while your left remains against the abdominal
wall. If there is a lot of ascites present, you may be able to feel a fluid wave (generated in the
ascites by the tapping maneuver) strike against the abdominal wall under your left hand. This test
is quite subjective and it can be difficult to say with assurance whether you have truly felt a
wave-like impulse.

Assessing for a fluid wave

The abdominal examination, like all other aspects of the physical, is not done randomly. Every
maneuver has a purpose. Think about what you're expecting to see, hear, or feel. Use information
that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest
of your evaluation. If, for example, a certain area of the abdomen was tympanitic during
percussion, feel the same region and assure yourself that there is nothing solid in this location.
Go back and repeat maneuvers to either confirm or refute your suspicions. In the event that a
patient presents complaining of pain in any region of the abdomen, have them first localize the
affected area, if possible with a single finger, pointing you towards the cause of the problem.
Then, examine each of the other abdominal quadrants first before turning your attention to the
area in question. This should help to keep the patient as relaxed as possible and limit voluntary
and involuntary guarding (i.e. superficial muscle tightening which protects intra-abdominal
organs from being poked), allowing you to gather the greatest amount of clinical data. Make sure
you glance at the patient's face while examining a suspected tender area. This can be particularly
revealing when evaluating otherwise stoic individuals (i.e. even these patients will grimace if the
area is painful to the touch). The goal, of course, is to obtain relevant information while
generating a minimal amount of discomfort.

Findings Commonly Associated With Advanced Liver Disease: Chronic liver disease usually
results from years of inflamation, which ultimately leads to fibrosis and decline in function.
Histologically, this is referred to as Cirrhosis. This can be driven by a number of different
processes, most commonly chronic alcohol use, viral hepatitis (B or C) or hemachromatosis (the
complete list is much longer). It's important to realize that a cirrhotic liver can be markedly
enlarged (in which case it may be palpable) or shrunken and fibrotic (non-palpable).
After many years (generally greater then 20) of chronic insult, the liver may become unable to
perform some or all of its normal functions. There are several clinical manifestations of this
dysfunction. While none are pathonomonic for liver disease, in the right historical context they
are very suggestive of underlying pathology. Some of the most common findings are described
and/or pictured below.

1. Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin

appropriately. This can lead to
a. Icterus - Yellow discoloration of the sclera.
b. Jaundice - Yellow discoloration of the skin.
c. Bilirubinuria - Golden-brown coloration of the urine.
2. Ascites: Portal vein hypertension results from increased resistance to blood flow through
an inflamed and fibrotic liver. This can lead to ascites, accumulation of fluid in the
peritoneal cavity.
3. Increased Systemic Estrogen Levels: The liver may become unable to process particular
hormones, leading to their peripheral conversion into estrogen. High levels promote:
a. Breast development (gynecomastia).
b. Spider Angiomata - dilated arterioles most often visible on the skin of the upper
chest.
c. Testicular atrophy.
4. Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to lower
intravascular oncotic pressure and resultant leakage of fluid into soft tissues. This is
particularly evident in the lower extremities.
5. Varices: In the setting of portal hypertension, blood "finds" alternative pathways back to
the heart that do not pass through the liver. The most common is via the splenic and short
gastric veins, which pass through the esophageal venous plexus enroute to the SVC. This
causes esophageal varices which can bleed profoundly, though these are not apparent on
physical examination. A much less common path utilizes the recanalized umbilical vein,
which directs blood through dilated superficial veins in the abdominal wall. These are
visible on inspection of the abdomen and are known as Caput Medusae.

Icterus
 Ascites Jaundice

Gynecomastia Spider