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- 1. ABDOMINAL EXAMINATION Rezene Berhe, MD Gastroenterology and Hepatology unit CHS, BLH March 20,2014 1
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- 3. Out line • Introduction • Inspection • Auscultation • Palpation • Percussion • Interpretation 3
- 4. Introduction • Basic topography – Nine Vs four quadrant of the abdomen – Reminder: Please note the anatomical location of each abdominal organs in each quadrant 4
- 7. Introduction cont… • General principle The patient relaxed and comfortable in supine position Use relaxation techniques if needed Head supported with pillow Keep the supinated arm by patient sides, warm hands • Requirements: Insure good illumination Full exposure of the abdomen( from xipisternum to upper thigh) Be on the right side of the patient 7
- 8. Proper exposure for examination 8
- 9. INSPECTION • Shape and contour, flank fullness, – Scaphoid/flat /distended: reference will be the level of the abdomen between sternum and symphysis pubis • Symmetry • Discoloration – Striae: • Whitish in pregnancy • Pinkish in Cushing syndrome – Localized hyper-pigmentation: Cullen’s sign, Grey- turner’s sign • Peristalsis, pulsations, 9
- 10. Inspection cont… • Distended vessels: – Normal direction of flow: above the umbilicus upward and below the umbilicus downward. • Portal hypertension-veins draining away from the umbilicus • IVC obstruction - reversal of flow in the lower abdomen – i.e draining towards the umbilicus • Umbilicus – Direction of slit: normally inverted – Horizontal slit, eversion – Swelling – Discoloration – Nodule around or signs of inflammation • Hernia sites 10
- 11. Causes of distension • Gross distension (5 F) • Fluid • Flatus • Feces • Fetus • Fat • Localized distension –Loculated fluid –Mass –Hernia –Organomegaly –Impacted feces 11
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- 16. Auscultation cont… • Bowel sounds: four quadrant – Normal range 4-35/min, every 2-5 sec – Hypoactive: eg. Peritonitis – Hyperactive: eg. Obstruction • Bruits: – Over enlarged organ – Renal artery: few cm above the umbilicus lateral at the edge of rectus abdominus. – Aneurysmal 16
- 17. Auscultation cont… • Venus hum: – Heard over collateral veins disappear by hard pressing with stethoscope unlike bruit – Not localized to systole only unlike bruit – May disappear with changing position unlike bruit • Friction rub: – seen in infarction, sub-capsular hemorrhage and inflammation of spleen or liver 17
- 19. Palpation cont…. • Step 1: ask for any pain and location. • Step 2: – Start superficial palpation away from the site. – If none proceed with anticlockwise move starting from the LLQ : – look for tenderness, temperature, mass, rigidity, guarding, pulsation • Step 3: – Deep palpation starting from the LLQ. – Examine the Left large bowel, Spleen, Epigsatrium, Liver, RUQ, suprapubic and periumblical, • Step 4: Bimanual palpation for both kidneys • Step 5: Flank fullness and fluid thrill, Succusion splash 19
- 20. Liver topography • Upper border: – Rt lobe: 5th rib, 2 cm medial to the rt MCL and 1 cm below the rt nipple. – Lt lobe: at 6th rib and Lt MCL, 2 cm below the lt nipple. • Lower border: – Rt: 9th costal margin – Lt: 8th costal margin diagonally – Crosses md way b/n the xyphi and umbilicus • Edge moves 1-3cm by inspiration. 20
- 22. Palpation of spleen 22 Cephalocaudad length of 13cm and width of 7cm
- 23. Techniques of spleen examination • Bimanual palpation • Ballottement • Palpation from above (Middleton maneuver) • Percussion 23 • Spleen – Size, direction of growth – Notch – Above the mass – Bimanual palpability – Consistency – Tenderness – Friction rub – Bruit – Ballotable
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- 25. Examining the kidneys Bimanual palpation 25
- 27. PERCUSSION • Starting from the epigastrium umbilical suprapubic rt/lt lumbar region. • Look for: – Tympanicity – Dullness- • Direct and shifting • Total vertical liver span(TLS= 10 ±2) . (8-12) • Splenic percussion 27
- 29. Splenic percussion Delineating the spleen by Percussion • Traube’s semilunar space – 6th rib superiorly, lt mid axillary line laterally and costal margin inferiorly. – Normal percussion note medial to lateral is resonant. • Nixon’s method: – lower border of pulmonary resonance at Lt posterior axillary percus diagonal 90 degree to mid lt costal margin – Normal 6-8cm. If > 8 cm= splenomegaly 29
- 31. Digital rectal examination • Rotate finger 360 degree • Assess-tone of sphincter and anal musculature, irregularity and thickening of anal canal • Feel prostate gland (male) and cervix (females) • Look for mucus, blood, pus on finger 31
- 32. Characterizing a pathology • Organomegaly • Specific mass • Specific pathologies Location, estimated size, shape, edge, surface regularity, consistency, tenderness, Mobility, pulsatility 32
- 33. Distinguishing Lt. kidney from spleen • Inspection: – Kidney has less marked movement than spleen with inspiration – Direction of growth: kidney grow down and vertically • Palpation: – Bimanually palpable: for kidney – Presence/absence of notch: Kidney has no notch – Getting above the mass: kidney, not for spleen • Percussion: – Kidney may have overlying colonic resonance 33
- 34. INTERPRETATION • Signs of acute abdomen • Cystic lesion • Mass • Organomegaly • Bowel pathologies 34
- 35. Intra peritoneal excess fluid- Ascites: (When exceeds 500ml) Sensitive: (for ruling out) • Absence of: – Increase in abd. girth – Flank fullness – Flank dullness – Shifting dullness – fluid thrill Specific (for ruling in) Presence of: – Fluid thrill (90%) – Shifting dullness 35
- 36. Conclusion • Make sure that basic requirements fulfilled. • Use the four physical examination techniques – Inspection – Auscultation – Palpation – Percussion • Describe and/characterize abnormalities properly. • Interpretation of physical finding is mandatory 36