Abdominal Pain and Abdominal Exam

Four Examination Components of the Abdomen

1) Inspection of the Abdomen

• Ensure the patient is in a supine position.
• Look for abdominal distension, masses, or hernias.
• Check for ecchymosis, scars, striae, and vein dilation (e.g., Caput Medusa).
• Identify sinuses, fistulae, or stomas.

2) Percussion of the Abdomen

General Technique

• Ensure the patient is in a comfortable supine position.
• Use the middle finger of one hand to tap the middle finger of the other hand placed on the abdomen.
• Move systematically through all four quadrants of the abdomen.
• Recognize differences in percussion sounds:
  • Tympany: indicates air-filled structures, such as the stomach and intestines.
  • Dullness: suggests solid organs (like the liver and spleen) or masses, ascites, or fecal matter.

Assessing Specific Areas

1. Liver
   • Percuss down from the lung to the liver.
   • Note the change from resonant (lung) to dull (liver).
   • Measure the liver span: normal liver span at the midclavicular line is 6-12 cm.
   • Hepatomegaly is indicated by an increased span.
2. Spleen
   • Percuss at Castell’s point (most inferior interspace on the left anterior axillary line) while the patient takes a deep breath.
   • A change from tympany to dullness suggests splenomegaly.
   • Splenomegaly causes include hematologic malignancies, infections, and portal hypertension.
3. Shifting Dullness for Ascites
   • Percuss from the midline towards the flank until the note changes from tympanic to dull.
   • Have the patient roll to one side and repeat the percussion.
   • A change to a tympanic note where it was previously dull indicates shifting dullness, a sign of ascites.
4. Fluid Wave Test for Ascites
   • Requires two examiners.
   • One examiner places the ulnar edge of their hand firmly on the midline of the abdomen.
   • The second examiner taps one side of the abdomen and feels for the impulse on the opposite side.
   • A positive fluid wave suggests the presence of ascites.
5. Costovertebral Angle Tenderness
   • Percuss over the costovertebral angles (CVA) on the patient’s back.
   • Tenderness indicates pyelonephritis or renal pathology.
6. Stomach
   • Tympany is usually predominant in the left upper quadrant over the stomach.
   • A large area of tympany may indicate gastric distension.
7. Intestinal Gas
   • Percuss across the abdomen to assess for general tympany.
   • Generalized tympany is common but can indicate bowel obstruction if combined with other clinical signs.

Pathological Findings

• Dullness
  • Hepatomegaly (enlarged liver).
  • Splenomegaly (enlarged spleen).
  • Masses or tumors.
  • Ascites (fluid accumulation).
  • Fecal impaction.
• Tympany
  • Generalized tympany in bowel obstruction.
  • Gastric distension.
  • Large areas of tympany suggest air under the diaphragm in cases of perforated hollow viscus.

3) Auscultation of the Abdomen

General Technique

• Use the diaphragm of the stethoscope.
• Perform auscultation before percussion and palpation to avoid altering bowel sounds.
• Listen in all four quadrants but focus initially around the umbilicus.

Bowel Sounds

• Normal Bowel Sounds:
  • Low-pitched, gurgling sounds.
  • Frequency: 2-5 sounds per minute.
• Hyperactive Bowel Sounds:
  • High-pitched, rushing, or tinkling sounds.
  • Indicative of gastroenteritis or early bowel obstruction.
• Hypoactive or Absent Bowel Sounds:
  • Listen for at least 2 minutes before concluding absence.
  • Indicates ileus or late bowel obstruction.

Bruits

• Aortic Bruit:
  • Place the diaphragm above the umbilicus.
  • Indicates abdominal aortic aneurysm.
• Renal Bruit:
  • Listen 2 cm above and lateral to the umbilicus.
  • Indicates renal artery stenosis.

Other Sounds

• Venous Hum:
  • Continuous, soft, low-pitched sound.
  • Suggests increased collateral circulation between the portal and systemic venous systems.
• Friction Rub:
  • Grating sound over the liver or spleen.
  • Indicates peritoneal inflammation (e.g., perihepatitis).

Special Maneuver

• Succussion Splash:
  • Shake the patient’s abdomen while listening with the stethoscope.
  • Audible splash suggests delayed gastric emptying or gastric outlet obstruction.

4) Palpation of the Abdomen

General Technique

• Ensure the patient is in a supine position, with arms at the sides.
• Warm your hands to avoid tensing the abdominal muscles.
• Start with light palpation before proceeding to deep palpation.

Light Palpation

• Use the fingertips in a gentle, circular motion.
• Assess for:
  • Tenderness.
  • Superficial masses.
  • Muscle rigidity (guarding).
  • Crepitus.

Deep Palpation

• Use the flat portions of the fingers and apply steady, deep pressure.
• Assess for:
  • Deeper masses.
  • Organomegaly (enlarged organs).
  • Deep tenderness.

Specific Areas and Signs

1. Liver Palpation:
   • Place the right hand below the right lower rib margin.
   • Ask the patient to take a deep breath; feel for the liver edge as it descends.
   • Note any nodularity or tenderness.
2. Gallbladder Palpation:
   • Similar to liver palpation but focus on the midclavicular line.
   • Positive Murphy’s sign: sudden cessation of inspiration due to pain, indicating cholecystitis.
3. Spleen Palpation:
   • Start in the right lower quadrant and move towards the left upper quadrant.
   • Ask the patient to take a deep breath; feel for the spleen tip.
   • Enlargement suggests conditions like infections or hematologic disorders.
4. Kidney Palpation:
   • Use a two-handed technique (balloting).
   • For the right kidney, place the left hand under the back and the right hand on the abdomen.
   • Push up with the left hand and press down with the right.
   • Repeat on the left side.
   • Enlarged kidneys may indicate polycystic kidney disease or tumors.
5. Aorta Palpation:
   • Use a two-handed technique.
   • Palpate for pulsations and estimate the width.
   • Width >2.5 cm suggests an aneurysm.
6. Special Tests:
   • McBurney’s Point: Tenderness in the right lower quadrant, indicating appendicitis.
   • Rovsing’s Sign: Pain in the right lower quadrant upon palpation of the left lower quadrant.
   • Psoas Sign: Pain on flexing the right hip against resistance, indicating appendicitis.
   • Obturator Sign: Pain on internal rotation of the right thigh, indicating appendicitis.
   • Shifting Dullness: Indicates ascites.
   • Fluid Wave: Confirms ascites.