ABDOMINAL EXAMINATION

All examinations must start with Introduction to the patient and consent for examination.
Failure to do so may not only prove troublesome in examination but may also prove bothersome for the
patient. Introduction and Consent are followed by proper positioning of the patient and proper
exposure for the examination

Positioning of the Patient for Abdominal Examination

For abdominal examination, the patient should lie relaxed preferably on a comfortable couch with the
hips flexed to 45 degrees and knees flexed to 90 degrees. Alternatively a pillow may be kept under the
head. These maneuvers relax the abdominal wall muscles and are crucial for the abdominal
examination.

Exposure of the Patient

Ideally, the patient should be exposed from nipples to knees.

Position of the Examiner

The examiner should be positioned in such a way that his wrist and forearm are horizontal during
palpation. This may be achieved by kneeling or sitting beside the bed with the examiner’s eyes about 50
cm above the patient.

General Physical Examination

During General Physical Examination, the findings related to abdomen usually include pallor, anemia,
cyanosis, cachexia, jaundice, dehydration, fetor and pyrexia.

Head and Chest

Head examination may reveal lymphadenopathy (as in mesenteric adenitis). Chest examination may
reveal Breast cancer or Pulmonary diseases (e.g. right sided basal pneumonia mimicking appendicitis in
children).

Cardiovascular System
Cardiovascular system should be examined for signs of cardiac failure, valvular diseases, and peripheral
vascular diseases.

Abdominal Examination
Abdominal examination is preferably carried out under proper analgesia as the pain involved in certain
abdominal conditions may cause patient to refuse to examination. The withholding of analgesia until
examination by a surgeon is now rapidly discarded from the textbooks.

Inspection
Inspection of the abdomen is preferably carried out from two points: foot end of the patient to look for
the shape and symmetry of the abdomen as well as movements of the abdomen with respiration, and a
closer view, preferably sitting beside the patient to look for any swellings in the abdominal wall. Other
findings that should be kept in mind while inspecting the abdomen are distension, scars (subsequently
examined for incisional hernias), sinuses, fistulae, dilated veins, expansile pulsations of aneurysm, skin
eruptions, visible peristalsis. The hernial orifices should also be inspected (and subsequently examined).

Palpation
Palpation is an important part of abdominal examination which has been divided into five phases for
convenience.

I – Superficial Palpation
It is done to look for any abdominal masses, pain and guarding in the abdomen. Pain in abdomen needs
further detail in order to understand abdominal examination and its findings. Therefore, it has been
explained in the text box with illustration.

Pain abdomen is the most frequently encountered symptom of abdominal problems. And
considering the variety of organs present in abdomen as well as the meshwork of nerves it may
prove to be an extremely elusive presentation of the underlying pathology. It is therefore
important to understand abdominal pain in depth.

Abdominal pain may originate from abdominal viscera or it may be caused by some pathology in
the abdominal wall. Furthermore, abdominal pain may result from referral of pulmonary or
cardiac pain downward. Other medical conditions leading to abdominal pain include Diabetic
Ketoacidosis and Porphyria. However, the localization of abdominal pain does follow certain
basic rules that, if understood, render much convenience for the examiner. Parietal peritoneum
when inflamed or irritated leads to a well localized pain which may radiate forward or backward
along the somatic nerve dermatome. Visceral peritoneum when inflamed or irritated leads to a
poorly localized pain that is associated with sweating and nausea. Pain originating in the
retroperitoneal structures like kidneys is usually felt in the back.

For example, in case of acute appendicitis early involvement of the visceral peritoneum leads to
a vague pain that is felt around the umbilicus (due to the innervation of the visceral peritoneum
by nerves originating in the corresponding nerve root). The patient becomes anorexic and
nauseated. With increasing inflammation, the overlying visceral peritoneum is also involved
which leads to a more intense pain localized in the right iliac fossa. When perforation occurs, it
leads to generalized peritonitis and a sharp pain that involves the whole abdomen.

Characteristics of Abdominal Pain

Abdominal pain is usually due to inflammation of abdominal viscera, obstruction of a hollow
viscus or perforation.

Inflammatory pain is usually very non-specific, gradually increasing over hours or days. It may be
due to acute appendicitis, cholecystitis, salpingitis, mesenteric adenitis, infarction (that initially
presents as obstruction) and hemorrhage (due to irritation of the peritoneum by blood in the
peritoneal fluid).
Pain due to obstruction of a hollow viscus (e.g. intestines) typically presents as a colicky pain,
except for the pain of obstructed gall bladder. Obstruction of the gall bladder is continuous with
acute episodic exacerbations in the pain, thus, mimicking colic with background pain.

Perforation of a viscus usually leads to acutely developed severe pain. In early perforation, site of
maximum tenderness may be determined through careful percussion. The organs usually
perforated include appendix, peptic ulcer and colon.

1. Inflammatory Pain 2. Perforation Pain

3. Colicky Pain 4. Gall bladder obstruction

For example, the pain of acute appendix is usually vaguely colicky in its early stages due to
obstruction. Being inflammatory in nature, it gradually develops. When perforation occurs, the
patient complains of a sudden intense exacerbation of the pain that has become constant. In
such patients, the pain is made worse by moving and coughing.

As can be inferred, the patient of general peritonitis will lie still in bed and will breath shallow i.e.
his abdominal breathing movements will be limited. On the other hand, a colicky pain patient will
roll around and double up with every surge in pain.

Following are two hand – sketched illustrations demonstrating the causes of pain by abdominal
region and radiation of common visceral pains.
 History questions related to pain include Time and Onset, Site, Character, Severity, Progression,
Duration, End, Radiation, Relieving factors, Exacerbating factors and Associated Symptoms e.g.
vomiting, diarrhea, painful micturition, missed or absent periods.

2 – Rebound Tenderness
Rebound tenderness represents peritonitis whether local or general. It is best examined through
coughing, percussion or by applying and suddenly releasing pressure in full inspiration.

On the other hand, guarding represents muscular spasms as the inflamed viscera touch the overlying
peritoneum. Board-like rigidity is encountered in generalized peritonitis.

Before starting superficial palpation, ask the patient if there is any tenderness in the abdomen. The site
of tenderness must be palpated at the last. Conventionally, superficial palpation is started in the left iliac
fossa and finished in the right iliac fossa after following a counter clockwise course over the abdomen.
Tender areas should be carefully defined so as to graphically represent them on paper. Rebound
tenderness may be checked by asking the patient to look to his left and cough; alternatively, percussion
may be employed over the tender area, or the patient may be asked to inhale deeply and stop his
breath then applying pressure over the area and releasing the pressure briskly.

3 – Deep Palpation
Deep palpation is done to assess any deep tenderness or abdominal mass.

Deep palpation follows the same procedure as superficial palpation.

4 – Palpation of Abdominal Masses

Masses encountered during abdominal examination may be pathological or physiological (i.e. the
viscera). Any mass felt on abdominal examination, other than the viscera, should be thoroughly
investigated through palpation and percussion.

In order to proceed with examination of abdominal masses, localization of the mass is done through
tensing the abdominal muscles (by asking the patient to raise his head or raising the legs straight). Any
mass superficial to the abdominal wall muscles will become more obvious; those attached to the deep
fascia will become less mobile, whereas those arising within the muscle layer will become fixed and less
obvious. Lumps arising deep to the abdominal wall (i.e. within the peritoneal cavity or retroperitoneum)
will usually become impalpable on tensing the anterior abdominal wall muscles.
After localization, the abdominal mass should be described in terms of its position, shape, size, surface,
edge, consistency, fluid thrill, resonance and pulsality. Tender masses can be assessed by gently pressing
on the mass during expiration and noting their surface and texture as they slide under the fingers during
breathing.

Palpation of Abdominal Viscera

Liver is the organ which is usually palpated first during abdominal examination. It is then followed by
Spleen, Kidneys, Bladder & the abdominal aorta.

Examination of liver is started from the right iliac fossa. However, in gross hepatomegaly the liver may
fill the whole abdomen which may necessitate initiating the examination from left iliac fossa. The
position of the hand is such that the fingers are kept parallel to the right costal margin. During expiration
the hand is moved upward toward the costal margin by 1cm each until it reaches the costal margin or
liver is felt sliding under the fingers during inspiration. This will determine the lower margin of liver in
hepatomegaly. In order to determine the upper border of liver, percuss downwards on the chest.
Hepatic dullness usually starts in the fifth intercostal space. Describe liver in terms of size (as distance of
edge below the costal margin or distance between upper margin of hepatic dullness and edge in
centimeters), surface (smooth or lobulated), edge (round or sharp), consistency, tenderness, pulsation
and audible bruit.

Examination of spleen is started from the right iliac fossa while positioning the hand diagonally in such a
way that palm rests in RIF while fingers point towards left costal cartilage. Move towards left costal
cartilage during each expiration until the spleen (with its characteristic notch) is felt. If the tip of spleen
is not found then palpate the whole length of left costal cartilage. If still not found, then ask the patient
to roll onto his right side while putting your left hand behind the lower ribs and pulling them forward. An
enlarged spleen will become palpable with the right hand. Percuss on the lateral ribs to exclude splenic
dullness.

Normally, kidneys are usually impalpable, except in very thin people, but both lumbar regions should
always be carefully examined. To feel the patient’s right kidney, place your left hand behind the
patient’s right loin between the twelfth rib and the iliac crest, so that you can lift the loin and kidney
forwards. Then place your right hand on the right side of the abdomen just below the level of the
anterior superior iliac spine. As the patient breathes in and out, palpate the loin between both hands.
The lower pole of a normal kidney may be felt at the height of inspiration in a very thin person. If the
kidney is very easy to feel, it is either enlarged or abnormally low. To feel the left kidney, lean across the
patient, place your left hand around the flank into the left loin to lift it forwards, then place your right
hand on the abdomen and feel any masses between the two hands. An enlarged kidney can be pushed
back and forth between the anterior and posterior hands. This is called BALLOTING.

For palpation of bladder, it must be full, because empty bladder lies in the pelvis. As it fills the fundus
moves upwards and in urinary retention the fundus of bladder may reach up to umbilicus. It is palpated
in the same way as palpating the fundus of a uterus i.e. by feeling the bladder fundus between thumb
and fingers.
Aortic pulsations are felt by placing fingers of both hands in midline above the umbilicus.
The following must also be examined during palpation.
 Supraclavicular lymph nodes
 Hernial orifices
 Femoral pulses
 Genitalia
Percussion
Percussion of abdomen is
especially useful in mapping out
a tender area and abdominal
masses. Whole abdomen must
be percussed to look for any
abdominal mass that may have
been missed on palpation. In
cases of ascites, shifting
dullness is determined through
percussion.
Ascites usually presents as dull
flanks and central resonant
notes due to the “floating
bowels”. When the patient is
asked to roll onto one side and
the flank percussed after 10 to
15 seconds, the resonance may
be noted to have “floated up”
to that flank, a phenomenon
termed as shifting dullness. The
presence of fluid in abdominal
cavity or any lump may also be
assessed by taping on one side
of the lump while feeling at the
other. If the tap is felt, an
assistant is asked to place his
palm between the examiner’s
hands. This prevents
transmission of the thrill through skin. If the thrill is still felt, this confirms the presence of a fluid thrill
(usually occurs in gross ascites).
Summary of Abdominal Examination
 Introduction
 Consent
 Positioning of the Patient
 Proper Exposure
 Inspection of the Abdomen (shape,
symmetry, visible distension or lumps,
scars, visible veins)
 Superficial Palpation (pain, mass and
tenderness)
 Deep Palpation (deep masses and
tenderness)
 Palpation of masses(site, position, size,
surface, edge, consistency, fluid thrill,
resonance, pulsatility)
 Visceral Palpation (liver, spleen,
urinary bladder, aorta)
 Supraclavicular lymph nodes
 Hernial orifices
 Femoral pulses
 Genitalia
 Percussion of Abdomen (Masses and
Areas of tenderness)
 Auscultation of Abdomen (Bowel
sounds, Aortic bruit, Renal bruit,
Splenic bruit, Hepatic bruit)
Auscultation
Auscultation of the abdomen is mainly done for two purposes: to hear the bowel sounds and to find any
audible systemic vascular bruits.

Bowel sounds are gurgling sounds of intestinal peristalsis usually heard every 5 – 10 seconds. They are
increased in frequency during increased peristalsis while absent in generalized peritonitis and paralytic
ileus. In order to listen for the bowel sounds, stetho diaphragm is placed to the right of umbilicus.
Absence of bowel sounds for 30 seconds is termed Absent Bowel Sounds. However, stetho must be kept
for 2 minutes before declaring the absence of bowel sounds.

Systolic Vascular Bruits include the aorta (heard above the umbilicus over aorta and signifying
atheromatous or aneurismal aorta or superior mesenteric artery stenosis), renal artery (2-3 cm above
and 2-3 cm lateral to umbilicus) and over the liver for bruits due to hepatoma or acute alcoholic
hepatitis, splenic bruit (left costo-phrenic angle).

Rectal Examination
Rectal examination is an important part of abdominal examination and must, therefore, be included in
the examination wherever possible. It is indicated in many conditions like suspected appendicitis, pelvic
inflammatory conditions, rectal bleeding, unexplained weight loss, prostatism and pyrexia of unknown
origin. In some patients rectal examination is used as an alternative of vaginal examination.

For examination of rectum, the patient must be explained about the procedure and asked for
permission. A chaperone should be provided wherever possible. Position the patient in the left lateral
position with the knees drawn to the chest and the heels clear of the perineum. Examine the perianal
skin for skin lesions, external hemorrhoids and fistulae. Lubricate your gloved index finger with water-
based gel. Place the pulp of the forefinger on the anal margin and with steady pressure on the sphincter
push your finger gently through the anal canal into the rectum. If anal spasm is encountered, ask the
patient to breathe in deeply and relax. Use a local anesthetic suppository before trying again. If pain
persists, examination under general anesthesia may be necessary. Ask the patient to squeeze your finger
with anal muscles and note any weakness of sphincter contraction. Palpate systematically around the
entire rectum; note any abnormality and examine any mass. Record the percentage of the rectal
circumference involved by disease and its distance from the anus. Identify the uterine cervix in women
and the prostate in men; assess the size, shape and consistency of the prostate and note any
tenderness. If the rectum contains feces and you are in doubt about palpable masses, repeat the
examination after the patient has defecated. Slowly withdraw your finger and examine it for stool color
and the presence of blood or mucus.