ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION

Zhu Liangru Division of Gastroenterology, Union Hospital

Range of Abdomen

Superior ： diaphragma

Inferior ： pelvis

Lateral ： lateral abdominal wall

Anterior: anterior abdominal wall

Posterior: back bone,psoas

Abdominal Mark & Area

Abdominal Mark

Costal margin

Anterior superior iliac spine

Upper abdominal angleXiphoid process

umbilicus

Lateral border of rectus muscles

Inguinal ligament

Midabdominal

line

Abdominal Mark

• Costal margin composed of 8th-10th costal cartilage; abdominal area liver measure

• Xiphoid process elongation of breast bone; measurement of liver

• Epigastric angle included angle of costal arch; judge body type measurement of liver

• Umbilicus center in abdomen;abdominal area

• Anterior superior iliac spine the outstanding place of anterior of spine iliac

• Lateral border of rectus muscles elongation of midclavicular line;operative

incision

• Midabdominal line elongation of anterior of median line; abdominal area

• Inguinal ligament mark of femoral artery,femoral vein

• Costalspinal angle included angle of 12th costal bone and back bone

Abdominal Area

Abdom

inal Area:

Nine regions

right hypochondriac

region

left hypochondriac

regionepigastric region

umbilieal region

hypogastric region

right lumber region

left lumber

region

right iliac region

left iliac region

Nine regions &

P

rojectionspleen

stomach

gallbladdertransverse colon

ascending colon

small intestine

sigmoid colon

urinary bladder

ileum

Abdom

inal Area:

Four regions

right upper quadrant

right lower quadrant

left upper quadrant

Left lower quadrant

Abdom

inal A

rea:S

even regions

Right upper abdominal region

Left upper abdominal region

Right lower abdominal region

Left lower

abdominal region

Umbilieal region

Hypogastric region

Epigastric region

Secquence of Abdominal Examination

Examination secquence inspection, auscultation, palpation , percussion

Recording secquence

inspection, palpation, percussion, auscultation

Inspection

Attention of Inspection The patient is relaxed and in a proper position.

The patient is in a supine position, the head should be elevated on a pillow, abdomen is thoroughly exposed (from nipple to symphysis pubic).

Proper time to examination.

Light is adequate and soft, and comes from one side of head.

Inspector stands on the patient’s right side, secquence is from upper to lower.

examination in tangent direction.

Method of Inspection

Abdomial Shape

Normal ： flat 、 full 、 low

umbilicus symphysis pubicxiphoid process

low

flat

full

Abdominal bulge whole abdominal bulge: ascites frog belly apical belly

pneumatosis macrosis mass part abdominal bulge: organ intumesce (liver intumesce)

tumor (stomach.liver,pancrease)

inflammatory mass (tuberculous peritonitis) distension (stomach distension)

mass in abdominal wall hernia ( umbilical hernia, indirect hernia)

Inspection in Ascites

Differential Diagnosis in mass in abdominal wall and mass in abdominal cavity

Abdominal Retraction

whole abdominal retraction

athrepsy

dehydration

cachexia (boat-belly)

part abdominal retraction :

postoperative scar

Boat shaped-abdomen

Respiratory Movement

Abdominal breathing: adult male, children Costal breathing: adult female attenuated in abdominal breathing ： acute abdomen, ascites, macrosis mass, pregnancy reinforcement in abdominal breathing ： diseases in thoracic cavity(hydrothorax), hysteria

Abdominal Vein

• Generally we can’t find distended abdominal vein in normal people.

• Prominence of distended veins indicates increased collateral circulation as a result of obstruction in the portal venous system or in the vena cava

• The normal direction of blood flow is away from umbilicus. The upper abdominal veins carry blood upward to the superior vena cava, the lower abdominal veins carry blood downtoward to the inferior vena cava.

Portal hypertension Inferior vena cava obstruction

Method to Judgement the Direction of Blood Flow

Gastrointestinal pattern & Peristalsis

Generally we couldn’t find gastrointestinal pattern

and peristalsis in normal people.

Gastrointestinal obstruction ： gastral pattern intestinal pattern peristalsis

Small bowel obstruction colon obstruction

Others Information

skin rash: infection diseases, drug allergy, herpes zona

pigments: Addison disease, Grey-Turner sign, Cullen sign

ventral stripe: striae albicantes, purple striae

(hypercortisolism)

scar: operation, trauma, infection

hernia: umbilical hernia, oblique inguinal hernia, direct hernia

umbilicus: evection, depression, secrection

hairs: disposition, increase, decrease

pulsation: abdominal aneurysm, increasing in right ventricle

of heart

Palpation

Method of Palpation

The patient is relaxed position

The patient is in a supine position, the head should be elevated on a pillow, genuflex, slowly abdominal respiration

Inspector stands right beside patient

Start from left iliac region, anti-clock wise, “S” shape

Commence palpation at a site remote from the area of pain All areas of abdomen must be palpated systematically

Abdominal Palpation

• Light palpation

• Deep palpation

Tensity

Increase of tensity Intestinal distension, ascites, artificial pneumoperitoneum

rigidity （ board-like rigidity ） acute diffuse peritonitis

dough kneading sensation tuberculous peritonitis, carcinomatous peritonitis

Decrease of tensity Chronic wasting disease, multipara, aged, dehydration

Tenderness & Rebound tenderness

tenderness rebound tenderness

1. Gastritis or gastric ulcer2. Duodenal ulcer3. Pancreatitis or tumor4. Cholecystitis cholelithiaisis5. appendicitis6. Disease of intestine7. Disease of urinary bladder,uterus8. Ileocecal junction9. sigmoid10.spleen,splenic flexure of colon11.liver,hepatic flexure of colon12.pancreatitis

ant. Sup. spine

McBurney point

Palpation of Organs

One hand palpation Bimanual palpation Hooking technique

Ballottement palpation

Knee-elbow Position Palpation

Attention in palpation of liver

• Anterior-lateral finger pulp to palpate organs

• Place your hand flat with fingers pointing towards the

patients’s head

• position of palpation at exterior margin of rectus

abdominis

• palpate deeply while asking the patient breathe in and

out deeply

• start in the right iliac fossa when examining macrosis

liver

应与肝脏鉴别的脏器： 横结肠为横行条索状物，与肝脏质地不同 腹直肌腱划左右两侧对称，不随呼吸移动 右肾下极位置较深，边缘圆顿，不能掀起下缘

Differential Diagnosis

• Transverse colon

• rectus abdominis tendon

• Lower lobe of right renal

Technique of Liver Palpation

lung

liver

Projection of Liver

Perpendicula

distance 4-8cm

Perpendicula

distance 9-11cm

Measurement

Description of liver

Size ： below right costal margin 1cm,

below xiphoid porcess 3cm

Texture ： three grade---soft,moderate, hard

Surface ： slick, nodus

Edge ： thickness, regularity

Tenderness ： no tenderness in normal liver

hepatojugular reflux

Pulsation ： conduct pulsation, expansile pulsation

Scrape ： inflammatory surrounding liver

Liver thrill ： ballottement ---hepatic echinococcosis

Manipulation of palpation of spleen

Line I ： distance from the across point of left medioclavicular line and costal border to inferior margin of spleenLine II: distance from the across point of left medioclavicular line and costal border to ultima thule of spleenLine III: distance from right border of spleen to anterior median line

Measurement of spleen

Enlarged spleen

mild

acute hepatitis, typhoid,acute malaria, septicemia

moderate

cirrhosis, chronic lymphocytic leukemia,

chronic hemolytic jaundice, lymphoma

severe

chronic granulocytic leukemia, myelofibrosis

Description of liver

Description of spleen

Size

Texture

Surface

Edge

Tenderness

Pulsation

Scrape

Palpation of gallbladder

manipulation one hand slipping palpation or hook Murphy sign Courvoisier sign

Palpation of Kidney

(A) Place left hand in the right or left loin posteriorly. (B) Place the right hand on the abdomen anteriorly and press gently dowmwards. Push the left hand upwards. A palpable kidney can be balloted between the two hands.

The kidney may be palpable in thin normal individuals.

The right kidney lies lowerlower than the left, so it is more

likely to be palpable.

Nephroptosis

enlarged kidney is found in nephrydrosis, nephrydrosis, empyema, tumoempyema, tumo

r of kidney, polycystic renal diseaser of kidney, polycystic renal disease

Tenderness Point of nephric duct and Kidney

hypochondrium

middle nephric duct point

Costa-carinal point

肋腰点Upper nephric d

uct point

ventral aspect Back side

Costa-lumbar

point

Mass in Abdomen

“Mass” in normal abdomen

rectus muscle belly & tendinea

body of lumbar vertebra

cochlear of sacral bone

stoolmass in sigmoid colon

transverse colon

caecum

Abnormal Mass

• Location • Size length,broad,deep• Shape skeleton,edge,surface• Texture • Tenderness• Pulsation• Degree of excursion

Fluid thrill (Fluctuation)

Manipulation of fluid thrill

assistant

patient

inspector fluctuation

Assistant places his hand vertically at the anterior median line,Examiner places hand flat at both side of lateral abdominal wall, One hand percuss one side abdominal wall, fluctuation can be sensed in another hand

Succussion Splash

Succussion splash can exist in people after meal or drinking

Succussion splash exists in fast or 6-8 hours after meals suggest

s pyloric obstructionpyloric obstruction or gastric dilatationgastric dilatation

Percussion

Percussion is used to demonstrate the presence of gaseous distension and fluid or solid masses.

Light percession is preferable, since it produced a clearer tone.

Abdomen Percussion Sound

All four quadrant of abdomen are evaluated by percussion

Tympany is the most commom percussion note in abdomen presence of gas within the stomach,small bowel,colon.

Dullness exists in liver (right hypochondrium region)

spleen (left hypochondrium region)

distended urinary bladder (suprapubic area)

enlarged uterus (suprapubic area)

psoas (back side)

IncreasingIncreasing inin Dullness regionDullness region

organ swell

tumor

ascites

IncreasingIncreasing in tympanyin tympany

gaseous distension

perforation

Percussion of Liver

upper border of liverupper border of liver right midclavicular line right anterior axillary line right scapular line relative dullness area resonance dullness

absolute dullness area dullness flatness

lower border of liverlower border of liver

right midclavicular line

Anterior median line

tympany dullness

Normal Liver Border

upper border

right midclavicular line the fifth interspace

right axillary line the senenth interspace

right scapular line the tenth interspace lower border right midclavicular line right costal margin

Measurement

SizeSize

right midclavicular line 9-11cm

anterior median line 4 － 8cm

Change of Liver Border Increasing in liver dullness area liver carcinoma, liver abscess, hepatitis, polycystic

Decreasing in liver dullness area acute hepatic necrosis, cirrhosis, gaseous distension

Absence of liver dullness area acute perforation of hollow viscus

Percussion Tenderness of Liver and Gallbladder

Traube Area

9.5cm×6.0cmTraube area

Percussion of Spleen

route left midaxillary line

normal spleen border left midaxillary line the ninth-eleventh interspace longitude 4 － 7cm

Change of spleen border increasing enlarged spleen decreasing gastric dialation, distension

Shifting Dullness

The quantity of ascites is more than 1000ml

Percussion of ascites

dullnesstympany

Shifting Dullness

tympany

tympany

dullness

dullness

supine

lateral position

Manipulation

supine lateral position

Place left hand on the umbilicus region, right hand percuss. note central tympany. Move left hand to one side of abdominal wall ， then rotate patient onto another side. Notice that dullness has shifted toward the umbilicus on the dependent side. Tympany area has shifted toward the superior flank.

Differential diagnosis between Ovarian cyst and ascites

ovarian cystascites

Differential diagnosis between Ovarian cyst and ascites

tympanytympany

dullness dullness

ascitesovarian cyst

Ruler Pressing test

Sensitive to percussion in Ridge costal angle

Projection of ridge costal angle

right kidney

ridge costal angle

Sensitive to percussion in ridge costal angle

Bladder Percussion

Location ： suprapubic area

Empty bladder tympany

Filling with urinary dullness

Auscultation

Area of Abdominal Auscultation

liver

pancrease

spleen

gurgling sound

abdominal aorta

arteria renalis

Bowel Sound

Auscultation of bowel sounds can provide information about the motion of air and liquid in the gastrointestinal tract.

Normal 4-5/min

Active >10/min Hyperactive mechanic intestine obstruction

Hypoactive Absent paralytic intestine obstruction

Vascular Murmur

Arterial murmur

center of abdomen: abdominal aneurysm

abdominal aorta stenosis

left or right upper quadrant ： renal arterial stenosis

bilateral of inferior belly ： arteria iliaca stenosis

left lobe of liver ： left lobe carcinoma

Venous murmur

portal hypertension ： umbilicus or epigastrium

continious buzz

Friction Sound

Splenic infarction

Perisplenitis

Zuckergussleber

Cholecystitis

Peritonitis

Scratch Sound

Identify lower edge of liver

Small amounts of ascites ： puddle sign

Thank you!