1) The document provides guidelines for performing an abdominal examination, including inspection, palpation, percussion, and auscultation. 2) Seven sample patient cases are described to demonstrate how findings from the abdominal exam can be used to arrive at diagnoses. Diagnoses included fatty liver, splenomegaly, sigmoid carcinoma, ascites, hydronephrosis, carcinoid tumor, and schwannoma. 3) Performing a thorough abdominal exam through inspection, palpation, percussion, and auscultation is important for identifying abnormalities and arriving at accurate diagnoses.

1. ABDOMINAL EXAMINATION
Hakan Senturk, MD
Department of Gastroenterology
Medical Faculty
Bezmi Alem University
Istanbul

2. INTRODUCTION
• GENERAL EXAMINATION
• FOCUSED EXAMINATION
Complaints
General personal history
Family History
Use and abuse of substances

3. COMPONENTS OF AE
• Inspection: The patient should be in a
comfortable position with the drapes
positioned conveniently. The light should be
adequate and, if possible, tangenital.
• Palpation: The hands should be clean and
warm as well as gentle.
• Percussion
• Ausculatation: A high quality stethoscope
should be used

4. INSPECTION
Abdominal contour:
Bulging abdomen: Obezity, bowel distension,
ascites, abdominal masses, pyloric obstruction.
Obesity: A lax abdomen. No change in umbilicus
Ascites: Effacement of umbilicus and in advanced
cases, extrovertion and even, herniation of bowel
loops.
Bowel distension due to meteorism: No change in
umbilicus intravertion. Moderate Pain. Normal
bowel sounds.

5. INSPECTION
• Bowel distension due to ileus: Hypo-
(adynamic ileus) or hyper-active bowel sounds
(visible peristalsis).
• Splenomegaly, Hepatomegaly, over-distended
stomach (succisson splash), gall-bladder
(hydrops vesicular), bladder.

6. Skin Changes
• Striae
• Venous dilation
• Rash: Infections, Allergic reactions.
• Purpura: Hematologic disturbances. Vasculitis.
• Cullen and Gray Turner signs.
• Hernias.

7. PALPATION
• Superficial and Deep Palpation:
• Superficial palpation: Tenderness,
extraabdominal masses (lipoma, myoma,
fibroma, hematoma etc.)
• Deep Palpation: Liver, spleen, kidneys, gall
bladder, appendix. Intraabdominal tumours.
Rebound tenderness.

8. PERCUSSION
• Measurement of the vertical diameter of the
liver.
• Traube space for mild splenomegaly.
• Diagnosis and evaluation of ascites.

9. Auscultation
• Evaluation of bowel sounds.
• Bruits: Renal artery stenosis.

14. PATIENT 1
• Fifty-five years old male presented with right
hypochondrial fullness of years of duration.
• The discomfort worsens in sitting position,
especially, while driving.
• His BMI is 31 kg/m2. His medical history is
insignificant. He neither smokes nor consume
alcoholic beverages.
• His father is alive and also obese, and his
mother has type II diabetes.

15. • In physical examination of abdomen, the liver
is palpable three centimeters below right
coastal margin, on midclavicular line in
inspiration. The liver edge is relatively hard
and tender that the patient stops respiration
when the examiner hand touches the liver.
• Final diagnosis: Fatty liver.

16. PATIENT 2
• 27 years old women presents with pain in
abdomen which worsens with effort.
• She had a long standing infection after
delivery two years ago. Otherwise her medical
history is negative.
• Inspection of the abdomen reveals a slightly
retracted abdomen with protuberence of left
hypochondrial and colic regions. A close look
reveals it is solis and moves with breathing.

17. PATIENT 2
• The palpation of the mass reveals that it is a
moderately smooth mass which originates
form left lower intrathoracic region. Its surface
is smooth and it is not tender.
• The liver is not palpable and there is no
ascites.
• Final diagnosis: Splenomegaly due to nğn-
cirrhotic portal hypertension.

18. PATIENT 3
• Fifty-five year old gentleman presents with
diarrheic episodes of two months of duration.
• Apetite is unimpaired and there is no weight
loss.
• Abdominal palpation reveals an almost seven
centimeters measuring mass in the left iliac
region. It is hard and relatively fixated.
• Final diagnosis: Advanced sigmoid carcinoma

19. PATIENT 4
• 29 years old lady presents with progressive
swelling of abdomen for a few months, loss of
apetite and significant weight loss. Night
sweating is reported as well.
• Abdominal inspection reveals a distended
abdomen with effacement of umbilicus. Palpation
reveals slight tenderness without rebound.
Percussion reveals a dulness in the lower part of
abdomen. However dulness is not homogenous
with intervening areas of typanism.

20. PATIENT 5
• You are before a male, 49 years old who came for
a check-up examination for insurance. He has no
complaint. His BMI is 26 Kg/m2.
• His blood pressure is 170/105 mmHg. He said, his
blood pressure is sometimes found high.
• In deep palpation of abdomen you feel the edge
of something hard in the right lumbar (or colic)
region in deep inspiration. The patient said, they
found hepatomegaly in a previous examination.

21. PATIENT 5
• However you are suspicous of this finding and
you put your left hand on the back of the
patient and you feel a ballottment of what you
noticed. Additionally, the liver edge is
distinctly palpable. The mass is not painful.
• Final diagnosis: Hydronephrosis.

22. PATIENT 6
• Fifty-eight years old man was examined for
the complaint of abdominal fullness and pain
of nearly one year duration. No change in
bowel habits, no weight loss.
• Abdominal examination revealed slight
distension with sensitivity. Spasmolytic was
prescribed.

23. PATİENT 6
• The next day, patient’s complaints increased
and was admitted to the emergency unit with
acute abdomen.
• Laparatomy was performed and revealed a
distended and inflamed appendix and
terminal ileum. Resection was performed.
• Histology showed a carcinoid tumour
originating from ileum.

24. PATIENT 7
• 31 years old male was admitted with upper GI
bleeding. He did not require blood transfusion
and endoscopy revealed, a probable resolving
hemorrhagic gastritis.
• However, a later palpation of abdomen
revelaed a mass which is not apparent in
inspection. The mass was filling all abdomen
but right inguinal region.
• Schwannoma originating form Stomach.

25. • In laparatomy a mass involving stomach and
spleen measuring 25 cm. was found and
removed alongside part of the stomach with
splenectomy.
• Histologic examination revelaed Schwannoma.
• Interestingly the patient neither reported a
previous abodminal complaint or a relief after
operation.