Lecture given at Mindanao State University College of Medicine, 12 December 2022, General Santos City

1. Examination of
the Abdomen
01
Lance Catedral, MD, MCMMO, FPCP
lancecatedral@msugensan.edu.ph
bottledbrain.com

2. Key reference and image sources: Bates'
Guide to Physical Examination and
History Taking, 13th ed. Lynn S. Bickley.
Wolters Kluwer.

6. Abdomen: The
Health History
01

7. 13
Common or concerning
symptoms
GI disorders
abdominal pain
indigestion, nausea, vomiting,
hematemesis, anorexia, early satiety
dysphagia (difficulty swallowing),
odynophagia (painful swallowing)
change in bowel function
diarrhea, constipation
jaundice
Urinary and renal
disorders
suprapubic pain
dysuria, urgency,
frequency
hesitancy, decreased
stream
polyuria, nocturia
urinary incontinence
hematuria
flank pain and ureteral
colic

8. 13
Mechanisms of abdominal pain
Visceral pain
Occurs when hollow
abdominal organs such as
the intestine or biliary tree
contract unusually
forcefully or are distended
or stretched.
May be difficult to localize
Varies in quality; may be
gnawing, burning,
cramping, or aching
When severe, may be
associated with sweating,
pallor, nausea, vomiting,
restlessness.
Parietal pain
From inflammation of the
parietal peritoneum.
Steady, aching
Usually more severe
Usually more precisely
localized over the involved
structure than visceral
pain
Referred pain
Occurs in more distant
sites innervated at
approximately the same
spinal levels as the
disordered structure.
Pain from the chest, spine,
or pelvis may be referred
to the abdomen.

9. Visceral periumbilical pain in early
acute appendicitis from distention
of inflamed appendix gradually
changes to parietal pain in the
right lower quadrant (RLQ) from
inflammation of the adjacent
parietal peritoneum.
Clinical pearls
Pain of duodenal or pancreatic
origin may be referred to the back;
pain from the biliary tree—to the
right shoulder or right posterior
chest.

10. 04
GI Tract:
History
Ask patients to describe the pain in their own words, especially timing of the pain (acute or chronic);
then ask them to point to the pain.
Pursue important details:
“Where does the pain start?”
“Does it radiate or travel?”
“What is the pain like?”
“How severe is it?”
“How about on a scale of 1 to 10?”
“What makes it better or worse?”
Elicit any symptoms associated with the pain, such as fever or chills; ask about their sequence.

11. Doubling over with cramping
colicky pain signals a renal stone.
Sudden knife-like epigastric pain
often radiating to the back is
typical of pancreatitis.
Clinical pearls
Epigastric pain occurs with
gastroesophageal reflux disease
(GERD), pancreatitis, and
perforated ulcers. RUQ and upper
abdominal pain are common in
cholecystitis and cholangitis.

12. 04
Upper abdominal pain,
discomfort, or heartburn: History
Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. Related symptoms
include bloating, nausea, upper abdominal fullness, and heartburn.
Is there:
Bloating from excessive gas, especially with frequent belching, abdominal distention, or flatus,
the passage of gas by rectum
Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal
Heartburn, dysphagia, or regurgitation

13. 12
Bloating may occur with lactose
intolerance, inflammatory bowel
disease, or ovarian cancer;
belching results from aerophagia,
or swallowing air.
Early satiety:
Consider diabetic
gastroparesis, anticholinergic
drugs, gastric outlet
obstruction, gastric cancer.
Early satiety may signify
hepatitis.
Clinical pearls
Heartburn, dysphagia, or regurgitation: Suggests
GERD.
Alarm:
If patient fails empiric therapy
Age >55 years
Has “alarm symptoms” (dysphagia, pain with
swallowing or odynophagia, recurrent vomiting,
gastrointestinal bleeding, risk factors for gastric
cancer, or palpable mass), endoscopy is
warranted.

14. 04
Lower abdominal pain or
discomfort—acute and chronic
If acute, is the pain sharp and continuous or intermittent and cramping?
If chronic, is there a change in bowel habits? Alternating diarrhea and constipation?

15. RLQ pain, or pain migrating from periumbilical region in appendicitis; in women with
RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian
follicle
Left lower quadrant (LLQ) pain in diverticulitis, diffuse abdominal pain with abdominal
distention, hyperactive bowel sounds, and tenderness on palpation in small or large
bowel obstruction; pain with absent bowel sounds, rigidity, percussion tenderness,
and guarding in peritonitis
Alternating diarrhea - constipation: colon cancer; irritable bowel syndrome
Clinical pearls

16. 04
Abdominal pain + GI symptoms:
History
Nausea, vomiting, loss of appetite (anorexia)
Regurgitation
Coffee ground emesis (hematemesis)

17. Nausea, vomiting, anorexia:
Pregnancy, diabetic ketoacidosis,
adrenal insufficiency, hypercalcemia,
uremia, liver disease. Induced
vomiting without nausea in
anorexia/bulimia.
Regurgitation: GERD, esophageal
stricture, and esophageal cancer
Clinical pearls
Coffee ground emesis
(hematemesis): Esophageal or
gastric varices, Mallory– Weiss
tears, peptic ulcer disease

18. 04
Other GI symptoms: History
Dificulty swallowing (dysphagia)
If solids and liquids, neuromuscular disorders affecting motility.
If only solids, consider structural conditions like Zenker diverticulum, Schatzki ring, stricture, neoplasm.
Painful swallowing (odynophagia)
Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV, esophageal ulceration
from aspirin or NSAIDs
Diarrhea, acute (<2 weeks) and chronic
Acute infection
Chronic in Chron disease , ulcerative colitis; oily diarrhea (steatorrhea)—in pancreatic insufficiency.
Constipation
Medications, especially anticholinergic agents and opioids; colon cancer, diabetes, hypothyroidism,
hypercalcemia, multiple sclerosis, Parkinson disease

19. 04
Other GI symptoms: History
Black tarry stools (melena)
GI bleed
Jaundice
Intrahepatic: hepatocellular or cholestatic
Extrahepatic: obstructed extrahepatic bile ducts,
commonly the cystic and common bile ducts
Ask about the color of the urine and stool.
Dark urine from increased conjugated
bilirubin excreted in urine (hepatitis)
Acholic clay-colored stool when bilirubin
excretion into intestine is obstructed

20. 04
Urinary
Tract: History
Ask about pain on urination, usually a burning sensation, sometimes termed dysuria (also refers to
difficulty voiding.
Is there:
Urgency, an unusually intense and immediate desire to void
Urinary frequency, or abnormally frequent voiding
Fever or chills; blood in the urine
Any pain in the abdomen, or back
In men, hesitancy in starting the urine stream, straining to void, reduced caliber and force of the
urine stream, or dribbling as they complete voiding.

21. 04
Urinary
Tract: History
Assess any:
Polyuria, a signifcant increase in 24-hour urine volume
Nocturia, urinary frequency at night
Urinary incontinence, involuntary loss of urine:
From coughing, sneezing, lifting →stress incontinence
From urge to void →urge incontinence
From bladder fullness with leaking but incomplete emptying →overflow incontinence

22. Abdomen: The
Physical Exam
01

23. Key
Components of
the Abdominal
Examination
01

24. Tips for examining the
abdomen
Make the patient comfortable in the supine position, with a pillow under the head and
perhaps under the knees.
Ask the patient to keep the arms at the sides. When the arms are above the head, the
abdominal wall stretches and tightens, which hinders palpation.
Drape the patient. Place the drape or sheet at the level of the symphysis pubis, then expose
the abdomen by raising the patient’s gown to just below the nipple line above the xiphoid
process.

25. Tips for examining the
abdomen
Before you begin, ask the patient to point to any areas of pain so that you can examine
these areas last.
Warm your hands by rubbing them together or placing them under lukewarm water.
Approach the patient calmly and avoid quick, unexpected movements. Avoid having long
fingernails that can scratch or scrape the patient’s skin

26. Tips for examining the
abdomen
Position yourself at the patient’s right side and proceed in a systematic fashion with
inspection, percussion, and palpation. Mentally visualize each organ in the region you are
examining. Watch the patient’s face for any signs of pain or discomfort.
If necessary, distract the patient with conversation or questions. If the patient is frightened
or ticklish, begin palpation with the patient’s hand under yours. After a few moments, slip
your hand underneath to palpate directly.

27. 04
Abdomen: general guidelines
Note the patient’s general appearance (demeanor,
distress, color, mental status).
Inspect the surface, contours, and movements of the
abdomen including skin temperature, color, and
presence of scars or striae.
Prior to palpation or percussion, place the diaphragm of
your stethoscope in one abdominal region and listen for
bowel sounds (presence, characteristics, bruits).
Percuss the abdomen lightly in all four quadrants
(tympany, dullness, area of change).
Palpate lightly with one hand in all four quadrants
(masses, tenderness, guarding).
Palpate deeply with two hands in all four quadrants
(liver edge, masses, tenderness, pulsations).
Check for signs of peritonitis (guarding, rigidity,
rebound tenderness).

28. 04
Liver
Estimate the liver size along right
midclavicular line by percussion.
Palpate and characterize the liver
edge (surface, consistency,
tenderness).
Spleen
Percuss for splenic enlargement along Traube space.
Palpate for the splenic edge with the patient supine and in
the right lateral decubitus position.

29. 04
Kidneys
Check for costovertebral angle (CVA) tenderness using fist percussion.
Urinary bladder
Percuss the urinary bladder (distention, tenderness).
Special techniques
Perform special techniques if indicated (ascites, appendicitis, cholecystitis, ventral
hernia, abdominal wall mass).

30. Abdomen

31. 05
Inspection
contours
surface
movements
skin: temperature, color, scars,
striae, dilated veins, ecchymoses,
umbilicus
contour of the abdomen:
flat, rounded, or protuberant
bulging flanks, local bulges
asymmetric?
pulsations?

32. 07
Image adapted from Rachel S. Natividad, https://slideplayer.com/slide/14176545/ and Roshan Lall Gupta’s: Recent Advances in Surgery (Volume 14) (pp.33-52)

33. Image source: https://www.healthline.com/health/ecchymosis#prevention
Striae
Ecchymosis

34. 05
Auscultation
Auscultate the abdomen before performing percussion or
palpation
maximum: 5 mins
normoactive bowel sounds: 5 to 34 per minute
hypoactive bowel sounds: <5 / min
hyperactive bowerl sounds: > 34 / min
typically non-specific and non-diagnostic

35. abdominal pulsatile mass
→auscultation may
identify bruits
14

36. Friction rubs
Friction rubs are infrequently found on abdominal
examination but can occur over the liver, spleen, or
an abdominal mass
hepatoma, gonococcal infection around the liver,
splenic infarction, and pancreatic carcinoma
15

37. 05
Percussion
Percuss the abdomen lightly in all
four quadrants to determine the
distribution of tympany and
dullness.
Note tympanitic areas
gas
Note dull areas
underlying mass / enlarged
organ
Note where tympany changes to
dullness
Image: https://pressbooks.library.torontomu.ca/assessmentnursing/chapter/abdomen-
percussion/#:~:text=Percussion%20of%20the%20abdomen%20involves,some%20of%20the%20underl
ying%20structures.

38. 05
Light
palpation
aids detection of abdominal tenderness,
muscular resistance, and some
superficial organs and masses.
voluntary vs involuntary guarding
(rigidity)
voluntary guarding DECREASES
with:
bending lower extremities at the
hip
mouth-breathing with jaws wide
open
exhaling

39. 05
Deep
palpation
required to delineate the liver edge, the kidneys, and
abdominal masses
use the palmar surfaces of your fingers, press down in all
four quadrants
Abdominal masses may be categorized in several ways:
physiologic (pregnant uterus)
inflammatory (diverticulitis), vascular (an AAA)
neoplastic (colon cancer), or
obstructive (a distended bladder or dilated loop of
bowel)

40. 21
Assessing
peritonitis
CLINICAL PEARL
positive cough test
involuntary guarding
voluntary contraction of the abdominal wall, often accompanied by a grimace that may
diminish when the patient is distracted.
rigidity
involuntary reflex contraction of the abdominal wall from peritoneal inflammation that
persists over several examinations.
rebound tenderness
refers to pain expressed by the patient after the examiner presses down on an area of
tenderness and suddenly removes the hand.
percussion tenderness.

41. Direct assessment is limited
Percussion — estimate liver size
Liver
06

42. Starting at the nipple line, percuss
downward in the midclavicular line until
lung resonance shifts to liver dullness
Gently displace a woman’s breast as
necessary to be sure that you start in a
resonant area.
Now, measure the distance between your
two points in centimeters—this is the
vertical span of liver dullness.
Percussion
06

43. Palpate for the liver edge below the right costal margin.
Place your right hand on the patient’s right abdomen lateral
to the rectus muscle, with your fingertips
done to prevent mistaking the rectus muscle for the
underlying and adjacent liver.
Also place your hand well below where you would expect the
lower border of the liver. Press gently in and up.
Ask the patient to take a deep breath.
On inspiration, the liver is palpable about 3 cm below the
right costal margin in the midclavicular line.
Note: A palpable liver edge does not reliably indicate
hepatomegaly.
Palpation
06

44. Stand to the right of the patient’s chest.
Place both hands, side by side, on the
right abdomen below the border of liver
dullness.
Press in with your fingers and up toward
the costal margin.
Ask the patient to take a deep breath.
Palpation:
Hooking
technique
06

45. Spleen
06
When a spleen enlarges, it expands
anteriorly, downward, and medially,
often replacing the tympany of stomach
and colon with the dullness of a solid
organ. It then becomes palpable below
the costal margin

46. 11
Percussion
First, percuss the left lower anterior
chest wall roughly from the border
of cardiac dullness at the sixth rib to
the anterior axillary line and down
to the costal margin, an area
termed Traube (semilunar) space

47. Percussion
Second, check for a splenic percussion sign (Castell sign).
Percuss the lowest interspace in the left anterior axillary line (tympanitic).
Then ask the patient to take a deep breath to let the air-filled lungs and
diaphragm push the spleen and percuss again. When spleen size is
normal, the percussion note usually remains tympanitic despite this
downward displacement by the diaphragm.

48. 19
Palpation
With your left hand, reach over and around
the patient to support and press forward the
lower left rib cage and adjacent soft tissue.
With your right hand below the left costal
margin, press in toward the spleen.
Begin palpation low enough so that you can
detect an enlarged spleen

49. 05
Kidney
The kidneys are retroperitoneal
and usually not palpable unless
markedly enlarged.
Assessing costovertebral angle
(CVA) tenderness

50. 05
Urinary
bladder
Normally, the urinary bladder is not
palpable unless it is distended
above the symphysis pubis.
Percussion.
Percuss for dullness and the
height of the urinary bladder
above the symphysis pubis.
Bladder volume must be 400 to
600 mL before dullness appears.

51. 05
Aorta
Palpation. Identify aortic pulsations.
Press firmly deep in the epigastrium, slightly to
the left of the midline, and identify the aortic
pulsations.

53. Special
techniques
Ascites
Appendicitis
Acute cholecystitis
Ventral hernias
Abdominal wall mass
01

54. common complication of cirrhosis
ascitic fluid — sinks with gravity →
dullness
bowel loops (with gas) — rise →
tympanitic
two techniques
Percuss from area of central
tympany to area of dullness on
supine patient.
Test for shifting dullness
Ascites
06

55. 05
Start with the patient supine then
percuss for dullness outward in several
directions from the central area of
tympany in the abdomen. Map the border
between tympany and dullness

56. 04
Shifting
dullness
Percuss the border of tympany and dullness
with the patient supine, then ask the patient to
roll onto one side.
Percuss and mark the borders again. In a
person without ascites, the border between
tympany and dullness usually stays relatively
constant

57. How to
identify an
organ / mass
in ascites?
ballotte
01

58. McBurney point tenderness
Rovsing sign (indirect tenderness)
psoas sign, and
obturator sign
Appendicitis
06

59. 18
McBurney
point
tenderness
APPENDICITIS
Classically, McBurney
point lies 2 in from the
anterior superior iliac
spine on a line drawn
from that process to the
umbilicus

60. 18
Rovsing
sign
(indirect
tenderness)
APPENDICITIS
referred rebound tenderness. With the patient supine,
press deeply and evenly in the LLQ. Then quickly withdraw
your fingers.
Pain in the RLQ during left-sided pressure is a positive
Rovsing sign.

61. 18
Psoas sign
APPENDICITIS
With the patient supine, place your hand just
above the patient’s right knee and ask the
patient to raise that thigh against your hand.
Alternatively, ask the patient to turn onto the
left side. Then extend the patient’s right
thigh at the hip.
Flexion of the thigh at the hip makes the
psoas muscle contract; extension stretches
it.
Increased abdominal pain on either
technique is a positive psoas sign,
suggesting irritation of the right psoas
muscle by an inflamed retrocecal appendix.

62. 18
Obturator
sign
APPENDICITIS
Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the
hip. This maneuver stretches the internal obturator muscle.
Right hypogastric pain is a positive obturator sign, from irritation of the right obturator internus
muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity.

63. When a patient present with RUQ pain
suspicious for acute cholecystitis but
does not have any tenderness on
palpation in the RUQ → Murphy's sign
Deeply palpate the RUQ at the location
of the patient’s pain.
Ask the patient to take a deep breath,
which forces the liver and gallbladder
down toward the examining fingers.
Positive Murphy sign: sharp halting in
inspiratory effort due to pain from
palpation of the gallbladder on
examination
this finding is only useful in a patient
who does not have tenderness in the
RUQ with regular palpation.
Acute
Cholecystitis
06

64. hernias in the abdominal wall exclusive
of groin hernias
ask the patient to raise both legs off the
table or perform a Valsalva maneuver
to increase intraabdominal pressure
Ventral hernia
06
Image: https://abdominalkey.com/incisional-and-ventral-hernia-repair/

65. “Abdomen is protuberant, soft and nontender;
no palpable masses or hepatosplenomegaly.
Liver span is 7 cm in the right midclavicular line;
edge is smooth and palpable 1 cm below the
right costal margin. Spleen and kidneys not felt.
No costovertebral angle (CVA) tenderness.”
Recording findings
“Abdomen is protuberant, soft and nontender;
no palpable masses or hepatosplenomegaly.
Liver span is 7 cm in the right midclavicular line;
edge is smooth and palpable 1 cm below the
right costal margin. Spleen and kidneys not felt.
No costovertebral angle (CVA) tenderness.”

66. Examination of
the Abdomen
01
Lance Catedral, MD, MCMMO, FPCP
lancecatedral@msugensan.edu.ph
bottledbrain.com