The Abdômen

Abdominal Anatomy
Most of the abdominal organs are found within the peritoneum. These
organs can and do "move" (during pregnancy for example). Certain
structures, such as the kidneys and pancreas, are retroperitoneal.

The History and Physical in Perspective

• 70% of diagnoses can be made based on history alone.
• 90% of diagnoses can be made based on history and physical exam.
• Expensive tests often confirm what is found during the history and physical.

Key Historical Points - Abdominal Pain

• Time Course
• Location/Quality
• Radiation
• Associated Symptoms

Types of Abdominal Pain

• Pain from Hollow Viscera

o crampy/paroxismal
o often poorly localized
o related to peristalsis
o patient writhing on exam table
• Pain from Peritoneal Irritation
o steady/constant
o often localized
o patient lies still with knees up

Key Historical Points - Bowel and Bladder

• Nausea, Vomitting, Diarrhea, Constipation
• Frank Blood, "Coffee Grounds" Emesis, Black Stools
• Urinary Frequency, Urgency, Discomfort

Key Historical Points - Reproductive

• Sexual Activity, Contraception, Last Menstrual Period
• Always Consider Pregnancy in Reproductive Age Women
• Have a Low Threshold for Pregnancy Testing
Location of Abdominal Pain
• Four quadrants:
o Right Upper Quadrant

•
oLeft Upper Quadrant
oLeft Lower Quadrant
• Three central areas:
o Epigastric
o Periumbilical
o Suprapubic

Radiation of Abdominal Pain

• Perforated Ulcer
• Biliary Colic
• Renal Colic
• Dysmenorrhea/Labor
• Renal Colic (Groin)

Classic Presentations - Acute Appendicitis

• Diffuse periumbilical pain and anorexia early
• Pain localizes to RLQ as peritonitis develops
• Low grade fever, nausea and vomitting may not be present
• Xrays and other tests are often negative

Variation of Appendicitis Presentations

Caveat - Remember that the position of the appendix is highly variable. In

addition to its "normal" position it can be found against the abdominal wall
(anterior), below the pelvic brim (pelvic), behind the cecum (retrocecal), or behind the
terminal ilium (retroilial). The pain associated with appendicitis varies with the
anatomy.

Classic Presentations - Acute Cholecystitis

• Localized or diffuse RUQ pain
• Radiation to right scapula
• Vomitting and constipation
• Low grade fever

Classic Presentations - Acute Renal Colic

 • Severe flank pain
• Radiation to groin
• Vomitting and urinary symptoms
• Blood in the urine

Physical Examination of the Abdomen

Inspection

Auscultation

Percussion

Palpation

Special Tests

Inspection

Inspection is always an important first step in any physical examination.

Look at the abdominal contour and note any asymmetry. Record the location of
scars, rashes, or other lesions.

Auscultation

Unlike other regions of the body, auscultation comes before percussion and
palpation (the sounds may change after manipulation). Record bowel sounds as
being present, increased, decreased, or absent.

Bruits

In addition to bowel sounds, abdominal bruits are sometimes heard. Listen

over the aorta, renal, and iliac arteries. Bruits confined to systole do not necessarily
indicate disease. Don't be fooled by a heart murmur transmitted to the abdomen.

Percussion

Tympany is normally present over most of the abdomen in the supine

position. Unusual dullness may be a clue to an underlying abdominal mass.
Liver Span

Measure the liver span by percussing hepatic dullness from above

(lung) and below (bowel). A normal liver span is 6 to 12 cm in the midclavicular line.

Splenic Enlargement

To detect an enlarged spleen, percuss the lowest interspace in the left

anterior axillary line. Ask the patient to take a deep breath and repeat. A change from
tympany to dullness suggests splenic enlargement.

Palpation

Begin with light palpation. At this point you are mostly looking for areas of
tenderness. The most sensitive indicator of tenderness is the patient's facial
expression. Voluntary or involuntary guarding may also be present.

Deep Palpation

Proceed to deep palpation after surveying the abdomen lightly. Try to

identify abdominal masses or areas of deep tenderness.

Palpation of the Liver

To palpate the liver edge, place your fingers just below the costal margin
and press firmly. Ask the patient to take a deep breath. You may feel the edge of the
liver press against or slide under your hand. A normal liver is not tender.

Alternate Method for Liver Palpation

An alternate method for palpating the liver uses hands "hooked" around the
costal margin from above. The patient should be instructed to breath deeply to force
the liver down toward your fingers.

Palpation of the Aorta

 The aorta is easily palpable on most individuals. You should feel it pulsating
with deep palpation of the central abdomen. An enlarged aorta may be a sign of an
aortic aneurysm.

Palpation of the Spleen

Press down just below the left costal margin with your right hand while
asking the patient to take a deep breath. It may help to use your left hand to lift the
lower rib cage and flank. The spleen is not normally palpable on most individuals.

Special Tests

These tests are useful in special situations:

• Rebound Tenderness
• Costovertebral Angle Tenderness
• Shifting Dullness

Rebound Tenderness

This is a test for peritoneal irritation. Palpate deeply and then quickly
release pressure. If it hurts more when you release, the patient has rebound
tenderness.

Costovertebral Angle Tenderness

CVA tenderness is often associated with renal disease. Use the heel of your
closed fist to strike the patient firmly over the costovertebral angles.

Shifting Dullness

If dullness on percussion shifts when the patient is rolled on the side,

peritoneal fluid (ascites) may be present.

Things to Remember
• Consider inguinal/rectal examination in males.
• Consider pelvic/rectal examination in females.
• Disorders in the chest will often manifest with abdominal symptoms. It is
always wise to examine the chest when evaluating an abdominal complaint.