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CHAPTER

Examination of Abdomen

that are used to separate the nine segments. The vertical


I N T R O D U C T I O N

planes are known as the left and right midclavicular lines.


examination can give diagnostic
abdominal They run from the midpoint in the clavicle caudally
most strointestinal and genitourinary towards the midpoint of the inguinal ligament.
regarding
dlues also give insight regarding
pathologies and may
an The horizontal planes include the subcostal plane
abnormalities
of other organ systems. A well-performed
the transtubercular plane. The
subcostal plane runs
detailed and
Ldaminal examination decreases the need for the lower border of the tenth costal
also an important role horizontally through
the transtubercular plane
abdominal examination
adiological investigations The plays cartilage on either side. Finally,
natient management. the tubercles of the iliac crest and
the bodyY
pases through formed
consists of four basic components: inspection, palpation, of the fifth lumbar vertebra. The nine regions so
percussion, and auscultation.
are depicted in the diagram
below.

abdomen
Regions of the
There are two vertical planes and two horizontal planes

Left hypochondriac
Right hypochondriac Epigastric region
Stomach region
region - Stomach
- Liver Liver
- Liver (tip)
-Gallbladder Pancreas
- Right and left - Left kidney
- Right kidney - Spleen
and kidneys
Left lumbar region
Right Lumbar region Umbilical region -Small intestines
Liver(tip) Stomach - Descending colon
Small intestines Pancreas
- Left kidney
- Ascending colon -Small intestines
Transverse colon
Right kidney
Hypogastric region Left iliac region
Right iliac region - Small intestines
- Small intestines - Small intestines
- Sigmoid colon Descending colon
- Appendix
- Sigmoid colon
- Cecum and Bladder
ascending colon
Concepts of Clinical Examination in Surgery

Suprasternal
notch (T2/3)

Structures crossed by
transpyloricplane:
L1 vertebra
Transpyloric Pylorus
plane (L1) Pancreatic neck
Duodenojejunal flexure
Fundus of gall bladder
9th costal cartilage
Hila of kidneys
Origin of portal vein
Pubic Transverse mesocolon
symphysis 2nd part of duodenum
Superior mesenteric artery origin
Hilum of spleen
Termination of spinal cord

Transpyloric
plane
Duodenu

Transintercular
þlane

anatomical landmarks. The median plane is that which


Quadrants of the abdomen follows the linea alba and extends from the xiphoid process
150
Another method to divide the abdomen in the quadrant to the pubic symphysis and splits the abdomen vertically in
division for descriptive purposes. Learners should not half. The transumbilical plane is a horizontal line that runs
confuse quadrants and regions of the abdomen. at the level of the umbilicus. These two planes transect at
The quadrants are separated by theoretical anatomical the umbilicus in a cross-like form and divide the abdomen
lines that can be traced on the abdomen using certain into four quarters.

Right upper Left upper


Liver Stomach
Gallbladder
Spleen
Left lobe of liver
Duodenum Body of pancreas
Head of pancreas
Right kidney and Left kidney and
adrenal gland adrenal gland
Splenic flexure of colon
:Umbilicus Hepatic flexure
OT Colon Parts of transverse
Part of transverse and descending colon.
Right upper Left upper andascending colon.
Right lower| Left lower Right lower Left upper
CaecumM Part of descending
Appendix colon
Right ovary Sigmoid colon
and tube Left ovary and tube
Right ureter Left ureler

examinc
A. ETIQUETTE PRIOR TO HISTORY to their complaint and
nistory pertaining
them.
TAKING AND CLINICAL EXAMINATION
Take consent. erone
Introduce yourself to the patient have a
Ensure privacy and arrange to chapra
Inform the patient that you will ask about clinical available, if required.
Examination of Abdomen
C L I N I C A LH I S T O R Y
e) Drug history

cOMPLAINTS: PERSONAL HISTORY:


a) Dietary habits
a )
Duration-Periodicit
, Pain
b) Smoking
c)Alcohol
Site

d) Character and onset


)Radiation

d
with food e) Frequency constant in
Relation
pyloric obstruction
d)
e )C h a r a c t e r
Relation with food
1)Relievingfactors and aggravating factors g) Relief of pain after vomiting
2. F l a t u l e n tD y s p e p s i a
FAMILY HISTORY:
and Vomiting
Nausea a) Peptic Ulcer
; and onset
Character
a) b) Crohn's Disease
constan in
Frequency- pyloric obstruction
b) c)Ulcerative Colitis
c)Relation with food
d) Diverticulitis
of after vomiting
d) Relief pain e) Carcinoma
Haematemesis
and Malena
4. C.PHYSICAL EXAMINATION
5. Jaundice
Jaundice,
Build, Emaciation, Presence of anemia,
a) Due to neoplasia Examine the teeth, fauces, tonsils.
b) Calculous
Pulse, BP, Respiration, Temperature
c)Other
INSPECTION
Blood or mucus in stool- colonic diseases, 151
6. Bowel habits-
Constipation 1. Skin and subcutaneous tissue-
A. Ifsuperficial vein engorged-
7. Appetite
a) Position
8. Fever
b) Direction of flow
-
9. Loss of weight obstruction
10. Any lump or Swelling
Away from umbilicus portal
umbilicus-IVC obstruction
From below
-
a) Duration How to examine
on vein
b) Mode of Onset Two index fingers put closed together
Other Symptoms a/wlumps
d) Progression of swelling Vein emptied
e) Exact Site

fFever One finger Released


Other Lump
8) Presence of
h) Secondary Changes
Rate of refilling of vein noted
i) Loss of Body Weight

PAST HISTORY: Repeat with other finger

a) Typhoid
b) Tuberculosis

c)Syphilis
d) Tonsillitis
in Surgery
Concepts of Clinical Examination
in a vein
How to determine blood flow direction
blood flow.
1 Place together to occlude
fingers
flow in distended abdominal wall va
Pattern of blood eins
Portal hyperlension
the other
Inferior vena caval obstruction
2 Move one finger away from
from umbilicus
away
Blood flows away from
now pYesent.
A segment Blobd flowssuperior vena cava) (toward superior venaumbilicus
of vein without blood is (toward cava

3 Lift one finger.


Ut
direction of blood
If no blood reflls, the
flow is likely in the opposite direction.
other finger.
4 Repeat steps 1,and 2, and lift the from umbilicus
N
Blood flows away
(toward inferlor vena cava)
Blood flowS away from
umbilicus
(toward superior vena cava)

blood now flows


If blood did not refill in step 3, and
direction of flow is
to fill the empty segment, the
A Confirmed

area and has located the


pain in the abdominal
B. Scars of maximal pain. point
C.Umbilicus- The ideal position for abdominal examination is
a) Upward - Swelling arising in pelvis to sit or kneel on the right side of the patient
with
-

Ascites the hand and forearm in the same horizontal plane


b) Downward as the patiene's abdomen. There are three stages of
c) Everted- Ascites palpation that include superticial or light palpation,
152 d) Tucked in - Obesity
deep palpation, and organ palpation and should be
-

D. Contour of Abdomen Retraction or Distended performed in the same order. Maneuvers specific to

E. Movements certain diseases are alsoapart ofabdominal palpation.


a) Respiration Use the flat of the palmar
b) Peristaltic- visible in pyloric stenosis, surface of fingers fo palpate
Obstruction of small and large bowel
through the abdominalwall
c)Pulsatile - Aortic aneurysm, Tumor in front of aorta

F.Swelling-
a) Condition of skin over swelling
in nine
b) Position, Size, Shape- Should be described
anatomical regions
-

c) Movement with respiration


Liver, Gall Bladder,Stomach, Spleen -Movement
present
-

Kidney and Suprarenal Little movement


G. Visible Peristalsis
The examiner should begin with superficial orlight
H. Hernia site check for cough impulse at hernial sites palpation from the area furthest from the point ot
(ventral and lateral) the
maximalpain and move systematically through
I. Scrotum nine regions of the abdomen.
in
J. Left Supraclavicular Lymph Node Deep palpation should be performed the same
position of the hand and forearm relative to nc
PALAPATION -
ot irm

Ensure the following before beginning the palpation:


patients abdomen but with the application
and steady pressure.
.The patient has mentioned if he is experiencing any noted, whicn
During palpation, tenderness should be
Examination of Abdomen
This a voluntary
guarding. may be
aS

process, i n whic
which
the patient oluntarily tightens The process is repeated until the
t h e
a b d o m i n a lm u s c l e s
to protect a deeper inflamed liver edge is palpated or the costal
minal muscles where the intra margin reached
an
involuntary process,
r
has progressed tocause rigidity A normal liver may be palpated
close to the liver costal margin
inal pathology muscles
Engaging the patient in
abdominal
abdondaminal muscles.
the fferentiate between voluntary An enlarged liver may be palpated
of sation mayhelp distal to the costal margin
as
the former disapp
guarding,
attention is diverted. Tenderness in The distance is measured in cms
patients abdomen may indicate
when from the costal margin
the nine regions ofthe
underneath.
anyof of the organs
n flammation
to proceed to palpation of the
step is
he
abdominal organs.

Palpation ofliver
Palpation of spleen
The spleen lies entirely
The liver lies predominantly under the ribs on the left side
under the ribs on the right side
although it does cross the midline.
The normal spleen is
approximately fst sized

The lowermost edge of the liver The long axis of the spleen
lies approximately parallel with lies aiong the line of the
the costal margin (the lower edge
10th rib
of the rib cage

The spleen moves inferic- 153


medially on inspiration

of Even on deep inspiration


In view of the direction cannot
for the liver the normal spieen
enlargement, palpation be felt on palpation
from
should c o m m e n c e well away
margin in the
the costal
right iliac area
To be palpable the spleen
must enlarge to at least
extended to
The thumb is twice normal size
lateral margin
expose the
of the index finger
that
the
The hand is positioned so In view of the direction of
index finger lis
lateral margin of the for the
the costal margin enlargement, paipation
parallel with spleen should commence well
costai margin in
away from the
the right liac area

The thumb is extended to expose


a the lateral margin of the index finger
asked to take
The patient is
in pressure
and
deep breath abdominal wall by
appliedto the The hand is positioned so thatthe
the examining hand
lateral margin of the index finger
is parallel with the left costal margin

liver is palpated, the


If the not moved closer to
examinin9 hand is cm
the costal margin
by about 1

asked to repeat
The patient is
and the
deep inspiration
process is repeated
Examination in Surgery under the patients The other
Concepts of Clinical One hand
in a.
hand with fingere
flank, fingers the renal angle placedbelow the s lat
(between posterlor lateral to the rectuscosta
and spine) musclemargin
costal margin
is asked to
The patientbreath in and
take a
deep the
pressure applied by
examiners hand to the
abdominal wall

not palpated,
If the spleen ishand is moved
the examlning
the costal margin by
closer to
about 1-2 cm Hands should be opposite one another

Ifany swelling/ lump in noted - deep palpation reas

details about abdominal swelling


to know

a) Local temperature
untl b) Tenderness
The process is repeated
or the and surface
the spleen is palpated c) Position, size, shape
costal margin reached

not be d) Margins
normal spleen will
A
palpated e) Consistency
An enlarged spleen my be f) Movement-
costal
palpated distal to the Movement with respiration
margin
.Movement ofswelling in all direction
The distance is measured in
cms from the costal margin Ballotability
g) Parietal or Intra-abdominal swelling - Rising test, Leg
raise test, Blow out from nose with mouth shut
Parietal Swelling are Prominent if muscles are taut
154 h) Swelling pulsatile or not- with two index fingers
Palpation of the kidneys
transmitted or expansile
The kidneys should not be palpated in every abdominal
examination, when indicated based on the clinical
only i) Any swelling at hernia site
history.
They are retroperitoneal PERCUSSION
organs and deep bimanual Percussion technique
palpation is required Take note of the technique
Use the tip of the finger
The blow is deliveredby
a sharp wrist movement
To examine position the
patient close to the
Strike the middle phalanx
edge of the bed 12th rrib firmly. Two-three taps only
Remove striking finger
11th rib immediately
Tuck the palmar surfaces
of one hand into the Kldney-
patients flank Liver dullness/span
Costovertebral
Nestle the finger tips in angle LIver span
the renal angle
Upper liver border is defined by
Posterlor view percussing down at Rt. 2nd IC space
in MCI., untl dullness is encountered.
Lower liver borderis defined by
percussing up at Rt. lliac fossa in
MCl., until dullness is encountered.

Measure the distance between the


two dull areas.

Normalliverspan is 10+/-2
Examination of Abdomen

Spleenpercussion
AUSCULTATION
last Lt. IC space & Lt.
ell'smethod percuss on
hod, pe resonant and dull if
Place the diaphragm anywhere around umbilicus.
normally

mally is Normal bowel sounds are intermittent, low pitched


ine.
axilary bordered by 6th rib gurgles. Describe bowel sounds as present or absent
splenomegaly
ant. triable bordered
Bowel sounds are described as absent when not present for
a u b e s s p a c e , and Lt.
midaxillary line laterally
periorly LT is resonant and 3 minutes.
costa
Imargin inferior
iorly. Nornmally more
Bowel sounds are described as exaggerated when
dull
ifsplenomegaly
on Rt. Lateral than 3 are present in one minute.
ethod,
place the patient be heard.
at point of Lt. Abdominal bruits and venous hums may also
Nixona
d e c u b i t u s p o s i t i o r
ion, percuss unless present.
procedd perpendicularly These sounds should not be mentioned
cOstal margin and
Sltes abdominal bruits
axi
line. Splenomegaly if
posterior
llary
Lt.
cm.
tOward > 8
ness

dull be dull oon


will
is solid organ
there from
Swelling arise
arise
Renal
percussion
Shifting dullness

Aortic
h i t i n gd u l n eSsS
s.
out to Lt.
midline

the
r e a c h e d .
from

Percussd u l n e s s is

unti
patient liac
hank
ask the
and
thispoint
Mark you.
t o w a r d

rol
O
o repeat
Femoral
then
Sec.

for30
Wait
per uss again. 155
resonant
is
become

dull a r e a
Hthe
indication ofascites

detect
mild to
is
maneuver
is used
This
moderate ascites.

and
o v e r swelling
3 fingers thrill will be
thrill- place and after
Hydatid middle one
over
the
percussing
finger
felt by other2

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