The document provides details on performing an abdominal examination, including inspection, auscultation, percussion, and palpation techniques to examine the liver, spleen, kidneys, aorta, and assess for ascites. Key steps include listening for bowel sounds, percussing and palpating the liver span and spleen, assessing aortic pulsations, and tests for shifting dullness and a fluid wave to detect ascites.

1. The Abdominal Examination Prepared by: Dr. Mohammad Shaikhani. Assistant professor, Sulaymanyiah University. Kurdistan Center for GIT/Hepatology. References: Liviu Lefter MD, PhD,Clinical Tutor, UTAS H.A.Soleimani MD, Gastroenterologist Other web-based anonymous presentations.

3. Abdominal Examination: Structure and Physiology Abdominal cavity is divided into quadrants; two imaginary lines cross at the umbilicus Important to known what abdominal structure is in which quadrant

5. Organs by Quadrant Right Upper Liver, gallbladder Pylorus, duodenum Head of pancreas Ascending/transverse colon Right kidney/adrenal Right Lower Right kidney and ureter Cecum/appendix/ascending colon Ovary, fallopian tube Spermatic cord Uterus/bladder (if enlarged) Left Upper Liver (left lobe) Spleen Stomach Body of pancreas Descending/transverse colon Left kidney/adrenal Left Lower Left kidney and ureter Sigmoid/descending colon Ovary/fallopian tube Spermatic cord Uterus/bladder (if enlarged)

7. Retroperitoneal Structures

9. Alternative Divisions

11. Abdominal Exam: Basics Patient should be lying flat Abdomen should be fully exposed Arms at side (behind head tightens abdomen) & legs straight Bending knees may relax abdomen Sheet over the genitals

12. Abdominal Exam: Basics Order of Examination Inspection Auscultation Percussion Palpation

13. I nspection: General 1. Cachexia of cirrhosis or cancer evident by temporal recession / or wasted muscles. 2. Jaundice. 3. Pallor. 4. Vircow’s Node: left supraclavicular LN enlargement. 5. Clubbing, palmar erythem, white nails, duptryn contracture. 6. Leg edema. 7.Gynecmastia. 8. Mouth ulcers of IBD, Peutz-gagher perioral pigmentation, talangiectasia of HHT, MOUTH THRUSH.

18. I nspection: abdomen 1. Abdominal contour 2. Respiratory movement 3. Abdominal veins 4. Peristalsis 5. Abdominal skin

27. Inspection Skin: spider angiomas (blanching red marks mostly above nipples level), striae (purple or silver) Contour of abdomen Concave (scaphoid) vs convex (protuberant) Dilated veins radiating from the umbilicus (caput medusa) & its direction of flow: from below upward or vise versa.

29. Respiratory movement - In men / children, manner of breathing is abdominal respiration. - In women the manner of breathing is thoracic respiration. - Respiratory movement is limited (could suggest peritonitis).

30. Gastric or intestinal pattern / peristalsis - In healthy person peristalsis is not visible - Becomes spontaneously visible or provoked by percussion in bowel obstruction

31. Auscultation Provides important information about bowel motility: decreased motility suggests peritonitis; increased motility suggests obstruction Need to listen before percussion or palpation since these maneuvers may alter the frequency of bowel sounds Can also appreciate bruits over the aorta or other arteries, suggesting narrowing of the arteries from atherosclerosis

32. Auscultation Listen with diaphragm of stethoscope Normal sounds occurs every 5-10 seconds & consist of clicks and gurgles Need to listen for 2 minutes to declare no bowel sounds; since bowel sounds are widely transmitted, need only to listen in one spot Occasionally hear borborygmi - long, prolonged gurgles of hyperperistalsis - the familiar stomach growling

33. Auscultation For bruits Bruits are high pitched sounds due to obstruction to flow due to narrowing (stenosis) of arteries Listen midline (bruit in aorta) Right / left upper quadrant (renal artery bruits)

38. Percussion Helps to identify the amount and distribution of gas and to identify possible masses that are solid or fluid filled Can be used to assess size of liver and spleen Percuss looking for areas of tympany and dullness Large dull areas may indicate an underlying mass; you will later confirm with palpation On the right is liver dullness; on the left, dullness of the spleen

39. Percussion: Liver Upper border of the liver is percussed in the right, midclavicular line starting at midchest Resonance becomes dull as upper border of liver is reached and becomes resonant again as lower level of liver is reached Total span shouldn’t be more than 10 cm

42. Percussion: The Spleen When a spleen enlarges, it expands downward and medially, replacing the tympany of the stomach with the dullness of a solid organ Percussion cannot confirm splenic enlargement, but it can raise your suspicion There are two techniques to percuss splenic enlargement

43. Percussion: The Spleen Percuss the left lower anterior chest wall between lung resonance (6 IC) above & the costal margin (an area termed Traube’s space) As you percuss laterally, note the extent of the tympany; if tympany is prominent laterally, splenomegaly is unlikely.

46. Percussion: The Spleen Can also check for a splenic percussion sign Percuss the lowest interspace in the left anterior axillary line; the area is usually tympanitic Then ask the patient to take a deep breath and percuss again When the spleen is normal, the space usually remains tympanitic

49. Palpation Several structures are palpable normally: Sigmoid colon is frequently palpable as a firm, narrow tube in the left lower quadrant The caecum and ascending colon form a softer, wider tube in the right lower quadrant Normal liver distends below the costal margin but its soft consistency is difficult to feel Pulsations of the abdominal aorta are frequently visible and usually palpable Usually NOT palpable are: stomach, spleen, gallbladder, duodenum, pancreas, kidneys

50. Palpation: Improving the Exam Patient should have an empty bladder Patient supine, arms at sides or folded across chest - avoid arms above the head as this tightens the abdomen Before you begin, ask the patient to point to areas of pain and examine last Warm hands and stethoscope; avoid long nails; approach slowly Distract the patient with conversation or questions

51. Light and Deep Palpation Light palpation Helpful in identifying tenderness, superficial organs, and masses Palpate with a light, gentle dipping motion using the palmar surface of fingers Deep palpation Usually required to delineate abdominal masses Again use palmar surface of fingers Check for tenderness and rebound (pain induced or increased by letting go)

54. Liver Palpation Place left hand behind patient; by pressing the left hand forward, the liver may be more easily felt Right hand on the patient’s right abdomen with your fingers well below the lower border of liver dullness; fingers may be pointed to the patient’s head or to the left shoulder Press gently in and up; ask the patient to take a deep breath Try to feel the liver edge as it comes down to meet your fingertips

55. Liver Palpation The edge should be soft, sharp and regular, with a smooth surface The normal liver may be slightly tender On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line If you start too high, you may miss the liver Can also consider the hooking technique

56. LIVER SPAN PERCUSSION PALPATION PERCUSSION SCRATCH TEST NL < 12-13 CM MCL 2-3 CM DURING INSPIRATION AND EXPIRATION COPD LIVER SPAN MAY VARY BETWEEN OBSERVERS DEPENDING UPON WHERE THE MCL IS DETERMINED JAMA 1994;271:1859-1865

57. RESONANCE LIVER SPAN - PERCUSSION CONSIDER USING MULTIPLE PLEXIMETERS AIR JAMA 1994;271:1859-1865 DULLNESS

58. 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.

63. HOOKING THE LIVER

64. SCRATCH TEST USED TO IDENTIFY THE INFERIOR BORDER OF THE LIVER STETHOSCOPE IS PLACED OVER THE LIVER IN THE MCL SCRATCHES ARE PRODUCED BEGINNING IN THE RLQ AND MOVING THE FINGER CEPHALAD IN THE MCL. A CHANGE IN THE UNDERLYING TISSUE (INFERIOR LIVER EDGE) IS IDENTIFIED BY THE CHANGE IN SOUND INTENSITY. BEGIN MOVEMENT MOSBY’S GUIDE TO PHYSICAL EXAMINATION 3 RD ED,1995

65. Liver Span: 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

67. Pulsation transmitted from aorta Tricuspid valve insufficiency

69. AUSCULTATION – UNCOMMON FINDINGS FRICTION RUBS - MALIGNANCY, HEPATOMAS, LIVER ABCESS HUMS (SYSTOLIC AND DIASTOLIC) – PORTAL HYPERTENSION BRUITS (SYSTOLIC) – TUMORS, ETOH HEPATITIS JAMA 1994;271:1859 -1865 JAMA 1979;241:495

70. Spleen Palpation Again, with the left hand, reach over and round the patient to support and press forward the lower left rib cage With your right hand below the left costal margin, press in toward the spleen Again, begin palpation low so you don’t miss an enlarged spleen Again ask the patient to take a deep breath and try to feel the tip of the spleen as it comes down to meet your fingertips

75. Examination of Spleen (Percussion) Percussion at Castell’s Spot Castell’s Spot identified Left anterior axillary line identified Left lower costal margin identified Percussion at Castell’s Spot while patient inhales and exhales deeply Dull tone indicates possible splenomegaly

80. Examination of Kidney Patient take a deep breath. Feel lower pole of kidney and try to capture it between your hands.

81. Examination of Kidney Right kidney may be felt to slip between hands during exhalation

83. Warn the patient Patient sit up on the exam table

84. The Aorta Press firmly deep in the upper abdomen and try to identify the aortic pulsations Try to assess the width by pressing deeply with one hand on each side of the aorta; normal should be not more than 3 cm The ease of feeling varies with the thickness of the abdominal wall Try to appreciate pulsations laterally rather than just in the anterior/posterior dimension

85. ABDOMINAL AORTIC ANEURYSM THE EXAM METHOD THE PATIENT’S ABDOMEN SHOULD BE RELAXED WITH THE KNEES FLEXED. THE EXAMINER FEELS CEPHALAD OF THE UMBILICUS FOR THE AORTIC PULSATION. PLACE BOTH HANDS ON THE ABDOMEN WITH THE INDEX FINGER ON EITHER SIDE OF THE PULSATING AORTA. ESTIMATE THE WIDTH ( NL <2.5CM IN WIDTH).

88. Assessing Possible Ascites A bulging abdomen with protuberant flanks suggests the possibility of fluid in the abdominal cavity (ascites) Because fluid sinks with gravity while gas filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen Two additional techniques; shifting dullness and assessment for a fluid wave

89. Testing for Shifting Dullness Map the borders of tympany and dullness Ask the patient to turn to one side Percuss and mark the borders again In a person without ascites, the borders between tympany and dullness remain relatively constant

91. Testing for a Fluid Wave: TRANSMITTED FLUID THRIL Ask the patient or an assistant to press the edges of both hands firmly down the middle of the abdomen This pressure helps to stop the transmission of a wave through fat/skin Then tap one flank sharply with your fingers Feel on the opposite flank for an impulse transmitted through the fluid Unfortunately this sign is often negative until the ascites is obvious

93. GB Signs: MALIGNANCY COURVOISIER’S SIGN – A PALPABLE NONTENDER GALL BLADDER IN A PATIENT WITH JAUNDICE SUGGESTING EXTRAHEPATIC OBSTRUCTUON OF THE BILIARY SYSTEM SECONDARY TO MALIGNANCY (ORIGINAL DESCRIPTION). CHOLECYSTITIS MURPHY’S SIGN – WITH THE EXAMINER’S FINGERS POSITIONED ALONG THE INFERIOR BORDER OF THE LIVER IN THE RIGHT COSTAL ARCH THE PATIENT IS ALLOWED TO INSPIRE. DURING INSPIRATION THE INFLAMED GALLBLADDER TOUCHES THE EXAMINERS FINGERS RESULTING IN THE SUDDEN CESSATION OF INSPIRATION. BOAS’ SIGN – HYPERESTHESIA & REFERRED PAIN TO THE RIGHT COSTOPHRENIC ANGLE IN PATIENT’S WITH ACUTE CHOLECYSTITIS.

95. Conclusions Remember to lie the patient supine with arms and knees relaxed Auscultate before doing anything else Use percussion to help identify organomegaly and borders of palpation Use light and deep palpation to help identify structures in the abdomen