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.