Palpation: Lightly, all 4 quadrants Palpate lightly in all 4 quadrants. Press down around 1 cm. Remember to look at the patient’s face during palpation to see if any tenderness is elicited.
Palpation: Deeply, all 4 quadrants One should use two hands. Press down around 4 cm
132-133: Palpation: Spleen Palpation: Spleen (attempts to do) Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) Palpation: Spleen (if not palpable, R lateral decubitus)
Palpation of Spleen: Right lateral decubitus.
127: Percussion: Liver span The liver span is estimated by percussion. Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness . Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull. Lower border: In the midclavicular line begin percussion below the unbillicus and proceed upward until dullness is encounter. The distance between the two areas where dullness is first encountered is the liver span. Liver span is normally 6 to 12 cm in the midclavicular line.
Liver Span: May Do Scratch Test If you are unable to determine liver span by percussion then the scratch test may be used. Start in the same areas above and below the liver as you would with percussion. Instead of percussing lightly scratch moving your finger back and forth while listening over the liver. Since sound is conducted better in solids than in air, when the louder sounds are heard you are over the liver. Mark the superior and inferior boarders of the liver span in the midclavicular line
Final local abdominal examination 2
Tropical medicine department• Gastroentrology and hepatology unit• Faculty of medicine• Zagazig university• Egypt
Also, The abdomen is divided into 9 regions by:2 lateral vertical planes; passing from the mid-clavicularlines, continued downwards, to the mid-point between theanterior superior iliac spine and the pubic symphysis (rightand a left lateral line drawn vertically through points halfwaybetween the anterior superior iliac spines and the middleline).2 horizontal planes; the subcostal (passing across theabdomen to connect the lowest points on the costal margin);and the interiliac (passing across the abdomen to connect thetubercles of the iliac crests)
Inspection of the Back Swelling Deformity Loin masses Pigmentation tuft of hair
Inspection of the Anterior Abdominal Wall Inspection of mid-line Inspection of the sides from above downward1- Subcostal angle 1- Contour of the abdomen2- Epigastric pulsation 2- Collateral (dilated veins)3- Divarication of recti 3- Skin4- Umbilicus 4- Scars5- Suprapubic hair distribution 5- Movement with respiration6- Hernial orifices 6- Visible peristalsis
III. Hernia Expansile impulse in coughIV. Dilated veins Caput medusa in portal hypertensionV. Skin Pigmentation around umbilicus (T.B. peritonitis, Addison dis.) Nodules “sister Mary-Joseph nodules” (abd. malignancy) Ecchymosis “Cullens sign” (hemorrhagic pancreatitis and internal hemorrhage)VI. Discharge: Pus inflammation Stool intestinal fistula Urine patent urachus
slightly full abdomen Scaphoid abdomenbut not distended
• examination of abdominal contours – Standing at the foot of the table – Lower yourself until the anterior abdominal wall – ask the patient to breathe normally while you are inspect the abdomen.
Generalized abdominal Localized abdominal distension distension1- Fluid (ascites) 1- Site2- Fat (obesity) 2- Shape and size3- Flatus and Faeces 3- Pulsate on cough (hernia4- Foetus (pregnancy) or not)5- Full urinary bladder 4- Movement with respiration 5- Extra-abdominal or Intra- abdominal (by asking the pt. to sit up in bed unsupported)
IVC obstruction Portal vein obstruction1- Site of Laterally (Sides) Around umbilicus (caputcollaterals medusa)2- Blood From below upwards Away from theflow “towards the head” umbilicus”towards the legs” (to bypass the (the blood pass from the left obstruction the blood branch of portal vein to para bypass the IVC via umbilical vein to anterior abdominal wall veins to abdominal wall veins through the thorax) the umbilicus)3- cause in Functional compression Intra-hepatic causes of portalhepatic Pt on IVC by tense ascites hypertension
Methods of Detection- The 2 index fingers of both hands are used to milk the bloodaway from one segment of a dilated vein then, applyingfirm pressure on both ends of the segment the fingersthen can be lifted one by one, while observing the rate offilling at which the vein fills from each direction the bloodwill be seen coming more rapidly from the direction of bloodflow.
Caput medusae accentuated by marked ascites.An extensive plexus of veins is seen radiating from the umbilical regionand radiating across the anterior abdominal wall. Note the large veincoursing inferiorly along the right flank (arrows). This is the superficialepigastric vein.
Echymosis Abdominal petichaeIt is often difficult to understand whether tiny red spots arising on skinsurface are Petechiae or Purpura. However, Petechiae spots have a verysmall diameter that is maximum 3 mm in size. Purpura rashes are largerin size. These have a diameter that is about 5 mm. A spot that is biggerthan Purpura is known as common bruise or echymosis
Normally palpable structures 1. Contracted muscles of abdominal wall in muscular persons 2. Colon (caecum and sigmoid) is felt when it is spastic (full of gas or fluid) 3. Vertebra (L4 – L5) 4. Pulsations of abdominal aorta (usually felt below the umbilicus) in thin persons 5. Lower pole of Rt. Kidney (especially in female with thin lax abdominal wall) 6. Liver edge descends 1-3 cm below the costal margin on deep inspiration, but the consistency is soft and difficult to feel. 7. Occasionally, a tongue-like process (reidel’s lobe) is felt (which is an anatomical variation of the Rt. lobe), moves with respiration
Types of PalpationSuperficialSuperficial Deep Deep
Superficial PalpationFor:-Confidence of the patient-Superficial masses-Tenderness-Rigidity-Temperature“from the Lt. iliac fossa in anticlockwise directiontill the suprapubic area”
• Technique – Use pads of three fingers (palmar surface of fingers) of one hand and a light, gentle, dipping maneuver to examine abdomen – Abdominal wall depressed approximately 1 cm
Deep PalpationFor :-Organs “liver, spleen, gall bladder, kidney, colon, urinarybladder”- Masses (ask the patient to flexes his neck as this contracts rectus muscles)-Areas of deep tenderness and rebound (pain induced orincreased by letting go)Deep palpation include the following methods-Ordinary technique “classic”-2 handed method-Bimanual-Dipping-Hooking-Rolling
• Technique – Entire palm (use palmar surface of fingers of one hand; greatest number of fingers) and a deep, firm, gentle maneuver to examine abdomen – Either one- or two handed technique is acceptable (When deep palpation is difficult, examiner may want to use left hand placed over right hand to help exert pressure) – Palpate tender areas last – Palpate deeply with finger pads (do not “dig in” with finger tips) – Abdominal wall depressed around 4 cm or Push as deeply as patient will allow without significant discomfort.
Surface anatomy of the Spleen 9th rb Medial end 10th rb Lateral end 11th rb 10th rb
up Diaphragmatic surface pe rb or de r Lower borderVisceral surface
The spleen is not normally palpable It has to be enlarged 2-3 times its usual size to be palpable under the subcostal margin Enlargement occurs superiorly and posteriorly before it becomes palpable subcostaly Once the spleen has appeared in this situation, the direction of further enlargement is downward and towards the Rt. Iliac fossa The spleen which is not felt doesn’t exclude splenomegaly but it can be said that the spleen is not felt
Methods of Deep Palpation Classical method (single-handed method) Two handed method Bimanual examination - in the supine position - in the Rt lateral position) Dipping method Hooking method
Palpating the spleen – Bimanual palpation in supine position
Palpating the spleen – Bimanual palpation in supine position
Palpating the spleen – Bimanual palpation in Rt. Lateral positionWith the patient in the right lateral position, minimal splenicenlargement can be detected
Palpating the spleen – Bimanual palpation in Rt. Lateral position
Palpating the spleen – Bimanual palpation in Rt. Lateral position
Hooking methodExamining for the spleen from behind the patient, in the rightlateral position. In this case, the fingers are "hooked" over thecostal margin.
Nature of this palpable spleen (put a comment on): 1. Size Mild (just palpable to 5cm) Moderate (5 – 10 cm) Huge (more than 10 cm, below the umbilicus) 2. Border 3. Surface 4. Consistency 5. Tenderness (e.g. due to splenic infarction, septicemia, SBE)
Applied anatomy and physiology of the spleenThe spleen is composed predominantly of lymphoid and R.E. tissues,so, any condition “infectious; immunologic; metabolic; malignant oridiopathic” that causes hyperplasia of the lymphoid/RES may causesplenomegalyThe spleen is expansile organ containing many sinusoids, so,interference with its venous drainage as in portal hypertension willcause splenomegaly “congestive splenomegaly”The spleen is a blood forming organ in fetal life and a potential bloodforming organ throughout life, so, in myelosclerosis and myelofibrosis,extramedullary hematopoiesis may occur in the spleen withsplenomegalyThe spleen destroys senile and defective RBCs, so, in hemolyticanemias, this function is increase with splenomegaly “except in sicklecell anemia”
Causes of Huge Spleen (below the umbilicus) Bilharzial splenomegaly Kala azar “visceral leishmaniasis” Chronic malaria causing TSS “Tropical splenomegaly syndrome” CML Myelofibrosis and Myelosclerosis Polycythemia rubra vera Beta-thalassemia major Amyloidosis Gaucher’s disease
Hypersplenism- Whenever the spleen is enlarged, hypersplenism may occur-It is characterized by Pancytopenia in the peripheral blood (Normocytic normochromic anemia, neutropenia, thrombocytopenia in the CBC) due to hyperfunction of the spleen One element or two may be decreased only B.M examination: hypercellular or normal CR-51 labelled RBCs and platelets Splenectomy returns the CBC to normal
Characters of splenic swelling to be differentiatedfrom the Lt. kidney-By inspection Moves with respiration down and medially-By palpation it has a notch on the lower part of the anterior (upper) border “PATHOGNOMONIC” hand cant be insinuated between the mass and the costal margin to get above its upper pole negative ballottement (can’t be pushed in the renal angle)-By percussion dull on percussion and continuous with the splenic dullness
Upper border is marked by joining the following points: 1st point Lt. 5th intercostal space in the MCL “apex of the heart” 2nd point Xiphisternal joint. 3rd point Upper border of 5th rib in Rt. MCL 4th point 7th rib at RT MAL. 5th point 9th rib at RT scapular line.Lower border is marked by curved line joining the following points: 1st point Lt. 5th intercostal space in the MCL “apex of the heart” 2nd point 8th costal cartilage in the Lt. parasternal line. 3rd point midway between xiphisternal junction and the umbilicus 4th point 9th costal cartilage in the Rt. MCL. 5th point 10th rib in the Rt. MAL. 6th point 12th rib in Rt. Scapular line
LT. 5th space LT. 8th costal cartilage MidwayRt. 10th rib Rt. 9th costal between cartilage umbilicus umbilicus &xiphisternum
Technique of detecting the liver Upper border is detected by heavy percussion “hepatic dullness” Lower border is detected by deep palpation and light percussionAfter palpation of the lower border of the liver, you mustcomment on I. Liver span : Distance between the upper and lower borders of the liver; which is 4 – 8 cm in the middle line “represents the Lt. lobe” 9 – 14 cm in the Rt. MCL “represents the RT. lobe”
II.Nature of this palpable liver (put a comment on): 1. Size “in finger breadth or cm” Normally: not felt below the costal margin Abnormally: enlarged “causes of hepatomegaly” or shrunken “liver cirrhosis and fibrosis” 2. Surface Normally: smooth Abnormally: - smooth “congestion, inflammation, infiltration” - fine irregular “cirrhosis” - nodular “malignancy” 2. Edge Normally: sharp Abnormally: - sharp “cirrhosis, fibrosis” - rounded “congestion, inflammation, infiltration”
Methods of Palpation Classical method (single-handed palpation) Two-handed method Bimanual examination Dipping method Hooking method- Single-handed palpation is used for lean individuals, while thebimanual technique is best for obese or muscular individuals. Usingeither technique, the liver is felt best at deep inspiration.
Single-handed method- For single-handed palpation, the examiners right hand is initially placed on the patients abdomen in the right lower quadrant and parallel to the rectus muscle in the MCL. This is done so that palpation of the rectus is not confused with palpation of the underlying and adjacent liver- Gently pressing in and up, ask the patient to take a deep breath. Palpating hand is held steady while patient inhales Palpating hand is lifted and moved while the patient breathes out If the liver is enlarged, it will come downward to meet your fingertips and will be recognizable.
Another method of palpating the liver uses the radial border of the index finger. In this method the anterior hand is placed flat on the anterior abdominal wall with fingers parallel to the costal margin
Bimanual palpation of Liverthe left hand is held posteriorly,between the 12th rib and the iliac crest.It is lifted gently upward to elevate thebulk of the liver into a more easilyaccessible position, while the righthand is held anterior and lateral to therectus musculature. The right handmoves upward using gentle, steadypressure until the liver edge is felt.
Hooking method– Is useful when the patient is obese or when the examiner is small compared to the patient.– Stand by the patients chest.– "Hook" your fingers just below the costal margin and press firmly.
Causes of ptosed liver Emphysema Pneumothorax Pleural effusion Subphrenic abscessCauses of upward displacement of the liver Lung fibrosis/collapse Diaphragmatic paralysis Ascites / abdominal tumours
Percussion is a method of tapping on a surface to determine theunderlying structure
plexor pleximeterTechnique-It is done with the middle finger of Rt. hand (plexor) tapping on DIP ofthe middle finger of the Lt. hand (pleximeter) using a wrist action.-The non striking finger (pleximeter) is placed firmly on the abdomen,remainder of hand not touching the abdomen.-Remember that it is easier to hear the change from resonance todullness – so proceed with percussion from areas of resonance to areasof dullness.
There are two basic sounds – Resonant sounds indicates hollow, air-filled structures. The abdomen gives resonant note which varies according to the amount of gas present in the intestine. – Dull sounds indicates the presence of a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined
Percussion of the abdomen-The abdomen gives a resonant note which varies according to theamount of gas present in the intestine-Type of percussion: Light percussion-Values: Deleneation of borders of abdominal organs (& assessing for organomegaly). Decetction of ascites Detection of gaseous distension “tympanic resonant note” Detection of acute abdomen (obliteration of normal liver dullness) in; - Perforated peptic ulcer and colon - Subphrenic abscess with gas forming organisms
• The two solid organs which are percussable in the normal patient – Liver: will be entirely covered by the ribs. – Spleen: The spleen is smaller and is entirely protected by the ribs.
Percussion “liver”Upper border by deep percussionLower border by light percussionUpper border Define the sternal angle “angle of Louis” (2nd rib), then start percussing the 2nd intercostal space in the Rt. MCL (Start just below the Rt. breast in RT. MCL). Percussion in this area should produce a relatively resonant note Percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time (in the intercostal spaces). Note where the percussion notes change from resonant to dull. The normal hepatic dullness will be reached at the 5th intercostal space in the RT. MCLLower border Begin percussion below the umbilicus, in the Rt. MCL and proceed upward until dullness is encounter.
The liver span is estimated by percussionThe distance between the two areas where dullness is first encountered is the liver span.
Traubes areaIt is a semilunar (crescent)-shaped areaIt is area of tympanic resonance overlying the fundus of stomachBoundaries Upper border lower border of Lt. lung (convex line from the Lt. 6th rib in MCL to the Lt 9th rib in mid-axillary line) Right border Lateral margin of left lobe of liver (from Lt. 6th rib in MCL to the Lt. 8th costal cartilage) Left border anterior border of the spleen (Lt. 9-11 spaces in mid-axillary line) Lower border Lt. costal margin (from the Lt. 8th costal cartilage to Lt. 11th space in mid-axilary line )
Causes of dullness of Traube’s area: 1. Full stomach/ gastric tumours. 2. Left sided Pleural effusion / pericardial effusion “from above”. 3. Ascites/abdominal tumour “from below” 4. Splenomegaly “from left side”. 5. Enlargement of left lobe of liver “from the right side”.
Castell’s method “Splenic percussion sign”Put the patient in the supine positionLeft anterior axillary line identifiedLeft lower costal margin identified Percuss in the lowest Left intercostal space in the anterior axillary line (usually the 8th or 9th IC space) while patient inhales and exhales deeplyThis space should remain resonant during full inspirationDullness on full inspiration indicates possible splenic enlargement (apositive Castell’s sign)
Nixon’s methodPlace the patient in Right lateral decubitusBegin percussion midway along the Left costal marginProceed in a line perpendicular to the Left costal marginIf the upper limit of dullness extends >8 cm above the Left costalmargin, this indicates possible splenomegaly
Ascites is free collection of fluid within the peritoneal cavity.The classical signs of ascites include; abdominal distension, shiftingdullness, fluid thrill.Minimal ascites detected in the knee elbow positionModerate ascites detected by the bilateral shifting dullnessTense ascites detected by transmitted fluid thrill “fluid wave”
Bilateral shifting dullness1.The patient is examined in the supine position.2.Percussion is done over the abdomen, from the umbilicus to one flank.3.The spot of the transition from tympany to dullness is detected.4.The patient is then turned to the opposite side, while the examiner keeps hishand unmoved.5. Percussion of the same spot (which is top now) gives a tympanic note.Note: The tympany over the umbilicus occurs in ascites because bowel floatsto the top of the abdominal fluid. air air fluid fluid
Transmitted fluid thrillPathognomonic foe ascites when the amount of fluid is large1.The patient is examined in the supine position.2.The patient or an assistant places one hand in the midline andpresses firmly with the ulnar border of the hand , so cut off anyvibrations transmitted by the abdominal wall.3.The examiner places one palm on one flank, while giving a sharp tapwith the finger tips on the opposite flank.4.Positive test: a definite wave “impulse” will be distinctly felt by thereceiving hand.
• Diaphragm of stethoscope used• Skin depressed to approximately 1 cm• Listening in one spot is usually sufficient• Listening for 15-20 or 30-60 seconds
Values of auscultation1.To hear intestinal sounds characteristic gurgling bubbling (gas andfluid in intestine) sounds. Increase in: acute diarrhea (↑motility) and in early intestinal obstruction Absent in: paralytic ileus N.B. Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes.
2. To hear vascular sounds Arterial bruit Venous hum (Wind at sea shore) Systolic murmur Systolic and diastolic sound in the epigastrium, and Lt. hypochondrial region “Kenawy sign” Occurs in cases of Occurs in cases of -Abdominal aortic aneurysm - portal hypertension due to porto- -Renal artery stenosis systemic anastomosis (collateral) -Over very vascular tumour “e.g. hemangioma”
3. Friction rub a dry, grating sound heard with a stethoscope during auscultation; may be heared over enlarged liver or spleen Splenic rub: in Lt. hypochondrium; due to splenic infarction and perisplenitis Hepatic rub: in Rt. Hypochondrium; due to hepatic malignancy with perihepatitis (inflammatory changes or infection in or adjacent to the liver). If detected in a young woman, the examiner should consider gonococcal peritonitis of the upper abdomen (Fitz–Hugh–Curtis syndrome). N.B. A hepatic rub and bruit in the same patient usually indicates cancer in the liver. A hepatic rub, bruit, and abdominal venous hum would suggest that a patient with cirrhosis had developed a hepatoma.
4. To detect lower border of the liver (scratch method) Place the diaphragm over the area of the liver scratch parallel to the costal margin in MCLWhen the liver is encountered, the scratching sound heard in the stethoscope will increase significantly5. To detect minimal ascites (Puddle’s sign)It is useful for detecting small amounts of ascites (as small as 120 mL; shifting dullness and bulging flanks typically require 500 mL).The steps are outlined as follows: Patient lies prone for 5 minutes Patient then rises onto elbows and knees Apply stethoscope diaphragm to most dependent part of the abdomen Examiner repeatedly flicks near flank with finger. Continue to flick at same spot on abdomen Move stethoscope across abdomen away from examiner Sound loudness increases at farther edge of puddle
Scratch Test Start in the same areas above and below the liver as you would with percussion. Instead of percussing lightly, scratch moving your finger back and forth while listening over the liver. Since sound is conducted better in solids than in air, when the louder sounds are heard you are over the liver. Mark the superior and inferior boarders of the liver span in the midclavicular line
6. Succusion splash in case of pyloric obstruction (distended stomach with gas and fluid) placing the stethoscope over the upper abdomen rocking the patient back and forth at the hips Retained gastric material >3 hours after a meal will generate a splash sound.7. To detect pregnancy fetal heart sounds.