Abdominal examination

A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation, percussion, and palpation. The examination begins with the patient in supine position, with the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultation, percussion, and palpation of all quadrants. Depending on the findings or patient complaints, a variety of examination techniques and special maneuvers can provide additional diagnostic information.

Positioning

• Instruct the patient to lie down and expose the patient's abdomen.
• If your hands are cold, warn the patient prior to palpating the abdomen.

Inspection of the abdomen

• Note any scars, striae, vascular changes (e.g., caput medusae), or protrusions
• Note the general contour of the abdomen

Auscultation of the abdomen

Auscultation of the abdomen should be performed prior to percussion and palpation, as physical manipulation of the abdomen may induce a change in bowel sounds.

• Purpose: to assess bowel sounds
• Auscultate over all four quadrants.
• Listen for bruits.
• Normal findings: : gurgling bowel sounds every 5–10 sec

Percussion of the abdomen

• Purpose: to determine the size and location of intra-abdominal organs
• Percuss over all four quadrants.
• Normal findings: tympanic sound over air-filled stomach/intestinal sections; muffled sounds over fluid-filled or solid organs (liver, spleen)

Palpation of the abdomen

• Purpose: to evaluate internal organs and identify any sources of pain (if present)
• Prior to palpation, ask the patient whether they have abdominal pain or tenderness. If so, begin palpation in the non-painful area.
• Observe the patient's face during abdominal palpation, as it is the main indicator of the intensity and location of pain.
• Procedure:
  1. Superficial palpation: to assess for superficial or abdominal wall processes
  2. Deep palpation in all four quadrants: to assess intraabdominal organs (potential signs of peritonitis)
     • Rebound tenderness: abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall. Caused by irritation of the receptors in parietal peritoneum
     • Abdominal guarding: patient contraction of the abdominal wall muscles during palpation
       • Involuntary guarding (also referred to as "rigidity"): involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant.
       • Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen.
  3. Palpation of the liver
     • Place the pads of your fingers over the right upper quadrant, approx. 10 cm below the costal margin at the mid-clavicular line. Palpate as you move towards the right upper quadrant and attempt to feel for the edge of the liver. Continue until you feel the liver or reach the costal margin.
     • Asking the patient to take a deep breath may facilitate palpation of the liver, as the movement of the diaphragm will move the liver toward your hand.
  4. Palpation of the spleen
     • Place the pads of your fingers lateral to the belly button and palpate as you move towards the left upper quadrant. Repeat 10 cm below the left costal margin.
     • Asking the patient to lie on their right side may facilitate palpation of an enlarged spleen.
  5. Palpation of the inguinal lymph nodes: (see examination of the lymph nodes)

Abdominal tenderness may be a sign of numerous conditions (see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain).

Liver size

• Percussion
  • Place the middle finger of your non-dominant hand against the abdominal wall. With the tip of the middle finger of your dominant hand, strike the distal interphalangeal joint 2–3 times.
  • Start below the breast at the midclavicular line. Percuss as you move your hand downward and note the sound change as you transition from lung (resonant) to liver (dull). Continue until the sound changes again after the inferior margin of the liver.
• Liver scratch test
  • The stethoscope is placed below the xiphoid and the midclavicular line is scratched with a fingernail. A scratch can only be distinctly heard over the liver.
  • The liver scratch test is generally more accurate than percussion.
• Normal findings: : The normal craniocaudal liver size is 7–11.5 cm in women and 8–12.5 cm in men. In most patients, the liver is fully covered by the ribs.
• Hepatomegaly
  • An enlargement of the liver, defined by ultrasonographic findings of liver span > 16 cm in the midclavicular line.
  • Can be caused by various conditions, including malignancy, infection, or venous congestion.
  • Often seen in conjunction with splenomegaly (hepatosplenomegaly)

Special tests

• Fluid wave test or shifting dullness for ascites
• CVA tenderness for diagnostic evaluation of the kidney and urinary tract
• Murphy sign for acute cholecystitis
• Signs of appendicitis
• Digital rectal examination: to assess for rectal bleeding, fecal impaction, colorectal cancer, and/or to evaluate the prostate
  • Positioning: The patient can stand and lean forward against the examination table or can lie down in a lateral position with their legs slightly bent.
  • Procedure: With a lubricated, gloved finger, palpate the anal canal and rectum. Assess anal sphincter tone and the size and consistency of the prostate.
  • Normal findings: There should be no palpable masses. The prostate should be rubbery and non-tender.

Common causes of abdominal pain (based on location)

Causes of diffuse or generalized abdominal pain

• Peritonitis
• Constipation
• Inflammatory bowel disease
• Bowel obstruction
• Mesenteric ischemia
• Gastroenteritis
• Ketoacidosis
• Adrenal insufficiency
• Irritable bowel syndrome

Causes of acute abdomen

• See differential diagnoses of acute abdomen