In a patient with an abdominal disorder, the following points must be asked whilst taking the history and noted on examination.
History is of paramount importance in clinical examination. It enables you to narrow your examination to a region and also guides you about the likelihood of particular disorder. Following points should be asked in patient of abdominal complaints. These points cover whole abdomen in general and can be individualized depending upon the complaint.
- Anorexia, nausea, vomiting
- Dysphagia, flatulence, eructation
- Retrosternal burning, water brash
- Diarrhea, constipation, clay stools, worms in stools, mucus in stools
- Abdominal pain, abdominal lump, abdominal distension
- Hematemesis, melena, epistaxis, bleeding per rectum
- Jaundice, gynecomastia, libido, loss of hair
- Fever, weight loss
- Alcohol, smoking
- Past history of tuberculosis, malaria, kala-azar, leukemia, hemolytic crisis (sudden pallor and dyspnea) and drugs
- Built and nutrition
- Nails and conjunctiva: Pallor, clubbing, cyanosis, icterus, etc.
- Edema of feet, lymphadenopathy, JVP
- Blood pressure
- Signs of liver cell failure: Scanty hair, palmarerythema, spider nevi, parotid swelling, gynecomastia, testicular atrophy, Dupuytren’s contractures.
- Miscellaneous: Bony tenderness, petechiae, genitals
An overview of Alimentary System Examination
Teeth, Tonsils, Tongue, Oropharynx
Shape of abdomen, Umbilicus, Abdominal movements, Pulsations, Dilated veins, Peristalsis, Hernial orifices, Scars and sinuses, Skin.
1. Tenderness, guarding and rigidity
2. Liver, spleen, kidney, gall-bladder, colon, or any other lump (Its size, surface, borders, tenderness and bruit)
3. Fluid thrill
1. Horse-shoe and shifting dullness
2. Dullness over any lump, if palpable.
Peristalsis, Rub, Bruit
Abdominal girth, PR, Proctoscopy
Examination Of Abdomen-Inspection
Examination of the abdomen begins with inspection. The shape of the abdomen in most normal persons with normal musculature is boat-shaped i.e. the abdominal wall sinks slightly within the bony margins of the abdominal surface.
In a very muscular person, the lateral margin of the rectus muscle is visible in the center. Usually the medial edges of both the recti are contiguous. However they may be separated as a congenital defect, after pregnancy or with obesity and ascites. This is called divarication of recti.
Scaphoid or sunken abdomen is seen with starvation and malignancy especially of stomach and esophagus.
Normal umbilicus is usually inverted and situated centrally in the mid-abdomen. The distance between the xiphisternum and the umbilicus is equal to the distance between the umbilicus and symphysis pubis.
In ascites, the distance between xiphisternum and umbilicus is greater than that between umbilicus and symphysis pubis, whereas in ovarian tumour the distance between xiphisternum and umbilicus is less than that between umbilicus and symphysis pubis.
In ascites, te umbilicus is transversely stretched (smiling) or flattened or everted whereas in obesity, the umbilical cleft is deeper than norma.
Everted umbilicus may occur with herniation of bowel or fat into the widened umbilical ring. Sometimes, umbilicus may exude fluid e.g. ascetic fluid in massive ascites or feculent material in enteric fistulae, or clear fluid in patent urachus (crying umbilicus).
Bluish discoloration or periumbilical region (Cullen sign) occurs in acute haemorrhagic pancreatitis or ruptured ectopic pregnancy.
Cherry-red swelling of the umbilicus suggests inflamed Meckel’s diverticulum.
Normally the abdominal wall bulges during inspiration and falls during expiration. In diaphragmatic paralysis the abdomen bulges during expiration. In peritonitis, the abdominal movements are absent.
Normally pulsations are not visible over the abdomen. They may be visible in the following conditions:
- Aortic pulsations are visible in the nervous, anaemic individual.
- Aortic aneurysm produces expansile pulsations in any position.
- Transmitted pulsations from a tumour overlying the aorta disappear in knee-elbow position because the tumour falls away from the aorta in that position. This is not so if the tumour is adherent to the aorta.
- Right ventricular pulsations are seen only in the epigastrium and correspond with the apex beat.
- Congested liver, in addition, produces pulsations posteriorly.
Suggest venous obstruction. When dilated veins are present, the direction of the blood flow can be found by emptying (milking) a section of the vein and pressing each end of the emptied part with a finger. One finger is released and the filling of the vein is noted. Similarly, the other finger is released and filling of the vein is noted. Blood enters more rapidly and fills the veins from the direction of the blood flow.
Inferior vena cava obstruction
There will be dilated veins on the sides with flow of blood from below upwards. This occurs because the blood bypasses the inferior vena cava and travels from the lower limbs to the thorax via the veins of the abdominal wall. These veins are anastomotic channels between the superficial epigastric vein and circumflexiliac veins below and the lateral thoracic vein above conveying the diverted blood from the long saphenous vein to the axillary vein.
Portal vein obstruction
The engorged veins are centrally placed and may form a cluster around the umbilicus (caput medusa). The blood in these veins flows in all directions away from the umbilicus. They represent opening of anastomosis between portal and systemic veins.
Peristalsis is best elicited by patiently observing the abdomen of the patient for some time. If it is not visible, an attempt to visualize it should be made either by making the patient swallow fluids or by applying sharp tap with the finger over the abdominal wall.
Peristaltic wave of the stomach is seen in pyloric stenosis in the epigastrium and left hypochondriac region, moving from left to right. Peristaltic wave of the large intestine (transverse colon) is seen in the same region but moving from right to left. Peristaltic wave of small intestine is seen in a ladder pattern down the centre of the abdomen.
The hernial sites in the groin should be seen for any swelling. If there is no swelling, the patient should be asked to stand up, turn his head to one side and cough. If there is an impulse on coughing it suggests hernia.
Smooth and glossy skin indicates abdominal distension whereas wrinkled skin suggests old distension which has been relieved.
Abdominal striae (stretch marks) represent the rupture of subepidermal connective tissue as a result of recent or past abdominal distension. It is seen commonly following pregnancy, in obesity, in massive ascites and following corticosteroid therapy. When they first form, the striae are reddish or pink. If the state of distension stabilizes or the cause regresses, the colour fades to white.
The patient lies on back, shoulders raised slightly and legs flexed to relax the abdomen. With He should keep his mouth open and breathe quietly and deeply. The abdomen is palpated with the flat of the hand initially and the fingers are used to locate the margins of any viscera or tumour.
The patient should have an empty bladder.
Tenderness is commonly found in inflammatory lesions of the viscera and the surrounding peritoneum.
The site of tenderness often suggests the diagnosis.
- Epigastrium – Peptic ulcer
- Right hypochondrium – Hepatitis, cholecytitis
- Right iliac fossa – Appendicitis
Rebound tenderness is elicited by exerting a firm pressure with the hand and releasing it. In deep seated, subacute conditions, the patient complains of severe pain.
Abdominal guarding is due to muscular contraction which often occurs as a part of the defense mechanism over a tender region. If the patient is put in a comfortable position and his mind set at rest by explaining that no undue pain will be caused by the examination, the abdominal muscles gradually relax.
Abdominal rigidity is due to muscular contraction which occurs as a part of the defense mechanism over an inflamed organ. It cannot be voluntarily relaxed. It occurs in the following:
- Perforation of a hollow organ
- Acute pancreatitis or cholecystitis
- Intestinal strangulation
- Thrombosis of superior mesenteric artery
- Ruptured ectopic gestation
- Twisted ovarian cyst or torsion of fibroid
A board-like rigidity suggests a chemical peritonitis most commonly from perforated gastric or duodenal ulcer. Bacterial peritonitis usually causes increased resistance to compression.
Palpation of Viscera
Liver: The patient must be lying in the supine position with hip and knee flexed. The examiner moves his right hand from the right iliac fossa gradually upwards until a sense of increased resistance is noted. The liver edge is accurately located by the finger tips. It is normally sharp, firm and regular.
The surface of the liver is next palpated. Normally it is smooth.
Large nodules suggests malignancy, whereas fine irregular nodules suggest cirrhosis.
Spleen: Spleen can be palpated by the following methods:
- Classical: The patient is put in the supine position and palpated from the right iliac fossa to the left hypochondriac region. The edge of the spleen may be felt on deep inspiration.
- Bimanual: The patient is put in the right lateral position, one hand of the examiner is put over the lower chest and the spleen is palpated with the other hand. A soft spleen which may be missed by classical method may be palpated by this method.
- Hooking: The patient is put in the right lateral position and the examiner stands on the left side and feels the spleen by hooking his fingers over the left costal margin.
- Dipping: This method is used when there is severe ascites which may mask an enlarged spleen. The patient is put in the supine position and examiner palpates as in the classical method except that he dips his fingers into the abdomen with each palpation, so that the fluid is displaced temporarily to the side facilitating palpation of the spleen.
Gall Bladder: The gall bladder is normally not palpable. When distended, it is palpated as a firm, smooth, rounded or globular swelling with distinct borders just lateral to the rectus abdominis muscle. Its upper border merges with the lower border of liver or disappears beneath the costal cartilage and hence is not usually felt.
Causes of enlarged gall-bladder
- Carcinoma of the head of the pancreas and malignant obstruction of the common bile duct.
- Mucocele of the gall-bladder due to impaction of a stone at the neck of the gall-bladder.
- Carcinoma of the gall-bladder
Kidneys: The left kidney is palpated by keeping the left hand posteriorly in the loin and the right hand anteriorly in the left lumbar region. Then the patient takes a breath, the left hand is pressed forward and the right hand backwards, upwards and inwards.
The right kidney is likewise are not palpable because of ovrlying liver , unless placed low in position or enlarged. Its lower pole is felt as a rounded firm swelling between both the hands and can be pushed from one hand to the other ballotable.
Examination Of Abdomen-Percussion
Uniform enlargement of the abdomen may be because of gas or fluid in the abdomen. In the former there is tympanic note on percussion while in the latter there is dullness.
Because the fluid accumulates in the flanks, the areas of dullness on both sides resembles a horse-shoe shape.If fluid is suspected-
- Perform percussion with the patient lying on his back
- Then change patien to lateral position and percuss on each side.
In these maneuvers , the upper flank will be resonant as the fluid is pushed down by gravity to the lower flank, a phenomenon called shifting dullness.
Percussion also helps to delineate the outline of an enlarged viscera or abdominal tumour.
An enlarged spleen is dull note on percussion whereas from an enlarged left kidneyis resonant note because of the intervening colon.
The upper border of the liver can be accurately determined by percussion. Percussion is started anteriorly in the right midclavicular line from second intercostals space downwards and repeated in the anterior mid and posterior axillary lines and the scapular line posteriorly.
The normal liver dullness is in the fifth space in the midclavicular, seventh space in the anterior axillary and ninth space in the scapular lines.
The upper border of the liver may be percussed in the fourth or third space in the midclavicular line in patients with amebic abscess of liver or any abscess on the superior surface of the liver.
The liver dullness is lower in the sixth or seventh right intercostals space in emphysema, right sided pneumothorax, when there is air in the peritoneal cavity, acute yellow atrophy of the liver and in terminal cirrhosis.
Auscultation of Abdomen
The patient is positioned comfortably in the supine position.
The stethoscope is used to listen over several areas of the abdomen for several minutes for the presence of bowel sounds. The diaphragm of the stethoscope should be applied to the abdominal wall with firm but gentle pressure.
It is often helpful to warm the diaphragm in the examiner’s hands before application, particularly in ticklish patients. When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent.
Auscultation for abdominal bruits is the next phase of abdominal examination. Bruits are “swishing” sounds heard over major arteries during systole or, less commonly, systole and diastole. The area over the aorta, both renal arteries. and the iliac arteries should be examined carefully for bruits.
Rubs are infrequently found on abdominal examination but can occur over the liver, spleen, or an abdominal mass.
These are intestinal sounds generated by contractions of the muscular walls of the gut and resultant vibration of the gut wall produced by movement of a gas-fluid mixture through the gut. These bowel sounds (peristalsis) persist in the fasting state due to the presence of intestinal secretions and swallowed air.
Loud bowel sounds (hyperperistalsis) accompanied by abdominal distension and crampy abdominal pain suggests partial bowel obstruction.
These may occur by unusually acute angulations at arterial branch points arteriosclerotic plaques, extreme tortuousity of an artery, or massive blood flow through very vascular tumours like hemangiomas or hepatoma.
Bruits over the liver suggests very vascular tumour like hepatoma or angioma, Similarly, over the spleen it suggests hemangioma or vascular tumour. Bruit over the aorta, if soft, has no significance. A loud bruit suggests aortic aneurysm, atherosclerosis or extreme tortuousity of the aorta.
Bruit over the kidneys in the flanks suggests renal artery stenosis.
Venous hum is continuous, softer and lower pitched than bruit. It signifies portal systemic shunting of venous flow when portal flow is obstructed. It is usually heard over the liver area and umbilicus.