Inspection consists of visual examination of the abdomen with note made of the shape of the abdomen, skin abnormalities, abdominal masses, and the movement of the abdominal wall with respiration. Abnormalities detected on inspection provide clues to intra-abdominal pathology; these are further investigated with auscultation and palpation.

1. ABDOMINAL INSPECTION
By
Dr. Arun Chhajer
MD (Kayachikitsa)
CAMC, Rajnandgaon (C. G.)

2. SHAPE
Is the abdomen of normal contour and fullness, or
distended? Is it scaphoid (sunken)?
Generalized fullness or distension may be due to fat,
fluid, flatus, faeces or fetus.
Localized distension may be symmetrical and centred
around the umbilicus as in the case of small bowel
obstruction, or asymmetrical as in gross enlargement
of the spleen, liver or ovary.
chronic urinary retention may cause palpable
enlargement in the lower abdomen.
A scaphoid abdomen is seen in advanced stages of
starvation and malignant disease.

4. UMBILICUS
Normally the umbilicus is slightly retracted and
inverted.
If it is everted, then an umbilical hernia may be
present and this can be confirmed by feeling an
expansile impulse on palpation of the swelling
when the patient coughs.
Ascitis
A common finding in the umbilicus of elderly
obese people is a concentration of inspissated
desquamated epithelium and other debris
(omphalolith).

6. Movements of the abdominal wall
Normally there is a gentle rise in the abdominal
wall during inspiration and a fall during
expiration; the movement should be free and
equal on both sides.
In generalized peritonitis, this movement is
absent or markedly diminished (the ‘still, silent
abdomen’).
Visible pulsation of the abdominal aorta may be
noticed in the epigastrium and is a frequent
finding in nervous, thin patients.
It must be distinguished from an aneurysm of the
abdominal aorta, where pulsation is more
obvious and a widened aorta is felt on palpation.

7. Visible peristalsis of the stomach or small intestine may be observed in
three situations:
1. Obstruction at the pylorus.
In pyloric obstruction, a diffuse swelling may be seen in the left upper
abdomen but, where obstruction is longstanding with severe gastric
distension, this swelling may occupy the left mid and lower quadrants.
Such a stomach may contain a large amount of fluid and, on shaking the
abdomen, a splashing noise is usually heard (‘succussion splash’). This
splash is frequently heard in healthy patients for up to 3 hours after a
meal, so enquire when the patient last ate or drank.
In congenital pyloric stenosis of infancy, not only may visible peristalsis be
apparent but also the grossly hypertrophied circular muscle of the antrum
and pylorus may be felt as a ‘tumour’ to the right of the midline in the
epigastrium. Both these signs may be elicited more easily after the infant
has been given a feed. Standing behind the child’s mother with the child
held on her lap may allow the child’s abdominal musculature to relax
sufficiently to feel the walnut-sized swelling.

8. 2. Obstruction in the distal small bowel. Peristalsis
may be seen where there is intestinal obstruction in
the distal small bowel or coexisting large and small
bowel. Not only is the abdomen distended and
tympanitic (hyper-resonant) but the distended coils of
small bowel may be visible in a thin patient and tend
to stand out in the centre of the abdomen in a ‘ladder
pattern’.
3 As a normal finding in very thin, elderly patients
with lax abdominal muscles a large, wide-necked
incisional herniae seen through an abdominal scar.

9. Skin and surface of the abdomen
 In marked abdominal distension, the skin is smooth
and shiny.
 Striae atrophica or gravidarum or alba are white or
pink wrinkled linear marks on the abdominal skin. They
are produced by gross stretching of the skin with
rupture of the elastic fibres and indicate a recent
change in size of the abdomen, such as is found in
pregnancy, ascites, wasting diseases and severe
dieting.
 Wide purple striae are characteristic of Cushing’s
syndrome and excessive steroid treatment.
 Note any scars present, their site, whether they are old
(white) or recent (red or pink).

11. Look for prominent superficial veins, which may be
apparent in three situations:
 thin veins over the costal margin, usually of no
significance;
 occlusion of the inferior vena cava; and venous
anastomoses in portal hypertension. Inferior vena caval
obstruction not only causes oedema of the limbs,
buttocks and groins but, in time, distended veins on the
abdominal wall and chest wall appear.
 Distended veins around the umbilicus (caput medusae)
are uncommon but signify portal hypertension.

13. Pigmentation of the abdominal wall may be seen
in the midline below the umbilicus, where it
forms the linea nigra and is a sign of pregnancy.
Erythema ab igne is a brown mottled
pigmentation produced by constant application
of heat, usually a hot water bottle or heat pad, on
the skin of the abdominal wall. It is a sign that the
patient is experiencing severe persistent pain
such as from chronic pancreatitis.
Finally, uncover and inspect both groins and the
external genitalia. In male patients inspect and
examine the penis and scrotum for any swellings
and to ensure that both testes are in their normal
position. Then bring the sheet back up to the
level of the symphysis pubis.