Examination of abdomen for MBBS students

1. EXAMINATION OF
ABDOMEN
Dr ANJANA MV

2. ABDOMINAL REGIONS
• Divided into 9 regions
• 4 dividing lines : 1. midclavicular – 2 lines
2. subcostal – upper horizontal
3.trans tubercular – lower horizontal

3. INSPECTION
• Pt should be relaxed ,hips and knees may be flexed to relax
abdominal muscles.
• Abdomen should be exposed [from xiphisternum to the suprapubic
area- inguinal and genital areas are covered until they are to be
examined]
• Examiner should have warm hands

4. 1. Skin and subcutaneous tissue: [a]Look for any visible swelling or erythema
[b].dilated veins[c].Subcutaneous nodules near umbilicus [d] position of
umbilicus.[e] skin discoloration eg: left flank – grey turner sign , around
umbilicus – cullens sign , both seen in acute hemorrhagic pancreatitis.
2. Hernial orifices
3. Contour of abdomen : distension of abdomen varies in each condition ,
small bowel obstruction- central , large bowel obstruction- peripheral
distension, but in biliary colic, a/c cholecystitis, a/c appendicitis,renal colic-
contour remains normal.
4. Respiratory movements- sluggish in diffuse peritonitis or hemorrhage into
peritoneal cavity.localized irritation of peritoneum causes localized limitation
of respiration.

5. 5. Peristalsis – visible peristalsis in pyloric stenosis [ left to right ] and
small and large bowel obstruction[right to left in transverse colonic
obstruction]
6. Pulsatile swelling in case of aortic aneurysm.

6. PALPATION
• Pt should lie flat on his back , relaxed and ask to breathe deeply with
mouth open.
• Always start away from the site of pain. Palpate systematically all
abdominal regions , look at the face of patient for signs of discomfort.
• Superficial palpation- using light pressure , assess for tone ,
tenderness and any obvious abnormalities.

7. Assessing muscle tone with superficial
palpation
• Gentle pressure on abdominal wall should allow the examiner to
depress the anterior abdominal wall as the muscles relax.
• Contraction of muscles underlying the hand as pressure is applied –
guarding. , indicates underlying inflammation.
• A rigid abdominal wall resisting any attempt to push back the
abdominal wall and not ,moving with respiration –rigidity , indicates
peritoneal inflammation.
• A marked , acute exacerbation of pain on sudden release of pressure
applied to abdominal wall –rebound.

8. Palpation of abdominal organs
• LIVER – lies predominantly under the ribs , on right side , although it
does cross the midline.
• Lowermost edge lies approximately parallel to costal margin.
• Liver moves inferiorly on inspiration , enlargement also occurs in an
inferior direction , hence palpation of liver should commence well
away from costal margin in the RIF.
• Hand is positioned so that the lateral margin of index finger is parallel
with costal margin.

9. • Pt asked to take deep breath in and pressure applied to abdominal
wall.
• If liver is not palpated , examiners hand is moved closer to costal
margin by about 1cm , process is repeated , until liver edge is
palpated or costal margin is reached .
• An enlarged liver may be palpated distal to the costal margin , the
distance is measured in cms from the costal margin

10. • SPLEEN – lies entirely under the ribs on the left side
• Long axis of spleen lies along the line of the 10th rib.
• Spleen moves inferomedially on inspiration , enlargement also occurs
in same direction
• Even on deep inspiration , normal spleen cannot be felt on palpation.
• To be palpable , spleen must be enlarged to atleast twice normal size.
• A massive spleen may extend into the right lower abdomen.

11. • Palpation should commence well away from the costal margin in RIF.
• Hand is positioned so that the lateral margin of index finger is parallel
with the left costal margin
• Pt is asked to take a deep breath in and pressure applied by the
examiners hand to the abdominal wall .
• If the spleen is not palpated the examining hand is moved closer to
the costal margin by about 1-2 cm
• Process is repeated until spleen is palpated or the costal margin is
reached
• Distance is measured in cm from the costal margin

12. • Palpation for spleen can be facilitated by placing the left hand under
and behind the lower left rib and applying traction in an inferomedial
direction

13. • KIDNEY- not normally palpable unless the patient is thin
• Right kidney is lower than left due to position of the liver
• They move downwards towards the end of respiration
• Retroperitoneal organ- deep bimanual palpation is required.
• To examine , position the patient close to edge of the bed, tuck the
palmar surfaces of one hand into patient’s flank , nestle the finger tips
in the renal angle.

14. • Bimanual examination of kidney- one hand under the patients flank,
fingers in the renal angle, other hand with fingers flat placed below
the costal margin later

15. • Palpate the lower pole of the kidney between the fingers of both
hands.
• Ask the pt to breath deeply and press the fingers of both hands firmly
together.
• The rounded lower pole of the kidney may be felt passing between
the opposing fingers as the patient breathes in and out.

16. PERCUSSION
• Light percussion – to elicit tenderness
• General abdomen : should be resonant
• Organs : liver –dull
spleen – dull
kidneys- resonant
bladder- dull.

17. • 1. shifting dullness : to determine presence of free fluid in the
peritoneal cavity. Pt lies on his back –fluid gravitates down to flanks,
intestine floats on the centre ,therefore resonant and flanks dull
• Start from the centre and carried down to one flank.at the point
where dullness starts the finger is kept in position and pt is asked to
turn to opp. Side .this area is again percussed after few minutes to
allow the fluid to settle down,. Now the note will be resonant—
shifting dullness positive.
• False positive shifting dullness in : abnormal retention of enema,
leading to distension of intestine

18. • 2. fluid thrill : large amount of fluid
• Gentle tap on one flank of the abdomen, thrill is felt with the other
hand placed on the other flank., asst’s hand placed vertically in the
midline, pressing deeply.
• Also obtained in case of encysted fluid like large ovarian cyst.

19. • 3 .Obliteration of liver dullness :right midaxillary line is percussed
from above downwards. At upper border of liver –dull note.
• liver dullness replaced by resonant note ---indicates free gas under
diaphragm.

20. AUSCULTATION
• BOWEL SOUNDS: produced due to normal peristaltic activity of small
bowel causing movement of its contents.
• Part of steth to be used : bell of stethoscope
• Site of auscultation : one site until the bowel sounds are heard is
sufficient –right to umbilicus , close to ileoceacal jn.

21. • Minimum amount of time to auscultate before concluding that no
bowel sounds are heard : 30secs { 2 min in macleod}
• Normal frequency : 2 -4 / minute .
• Sequence: auscultate before palpation because palpation can
stimulate peristalsis.

22. • Silent abdomen – absent bowel sounds , seen in generalized
peritonitis .
• Aortic and iliac bruits – heard in vessel stenosis.
• Succussion splash – sound like ‘shaking a half filled bottle with water’
. Heard in gastric stasis , due to gastric outlet obstruction.

24. THANK YOU