For localization and communication purposes, the abdomen is divided into six regions
These regions are
- Right and left Hypochondrium
- Right and left lumbar
- Right and left iliac
A better classification, however, is that divides the abdomen into four quadrants namely
- Right Upper
- Left upper
- Right lower quadrant
- Left lower quadrant
However, the old terms are still used and swellings or mass of the abdomen could be communicated either way.
- Globular swelling in the hypogastrium which may extend from symphysis pubis to the umbilicus
- The lump is tender and dull on percussion
- Pressure induces a desire for micturition
Uterus and its Appendages
Spherical midline swelling above symphysis pubis harder than the urinary bladder. It should be a rule to exclude swelling of the bladder by passing a catheter before concluding that it is uterine swelling).
Fallopian Tube and Ovary
- Features of pelvic peritonitis: Pain, fever and bladder disturbances
- Mass in the midline or on one or other side of the midline
- Vaginal examination confirms the diagnosis
Ovarian Cyst or Tumor
- Mass arising from one side of the pelvis but later on may become central
- Menstruation normal or scanty
- Vaginal examination confirms attachment to the uterine appendages
- Swelling has dullness over the front of the abdomen with resonance in the flanks (In ascites resonance is in the center and dullness is in the flanks)
Ruptured Tubal Gestation
- History of missed periods
- A lump few days after the leakage
It may follow acute appendicitis, salpingo-oophoritis, and puerperal sepsis.
- Constitutional symptoms
- Copious discharge of mucus per rectum and frequency of micturition.
- Rectal examination reveals bulging of the anterior wall of the rectum.
- It moves with respiration but is not mobile sideways
- The swelling is continuous with the liver dullness without a band of colonic resonance
- Oval smooth swelling, the size of an egg
- Moves with respiration can be moved sideways but cannot be pushed down into the loin (like kidney swelling)
Chronic Cholecystitis and Cholelithiasis
- Pain over the right rectus muscle radiating to the inferior angle of scapula, aggravated after fatty meals. Often the patient makes an attempt to get relief from frequent belching or vomiting but relief is seldom complete.
- Gallbladder may be palpable.
- Murphy’s sign is positive: i.e. Tenderness under the right costal margin at the lateral border of the rectus muscle when the patient takes a deep breath. This occurs due to the descent of the inflamed gallbladder which touches the examiner’s fingers. If a stone is present in the common bile duct there is a triad of intermittent colic, intermittent jaundice, and fever with chills and rigors. By Courvoisier’s law, gallbladder is not palpable.
- Pain in the right hypochondriac region referred to the shoulders
- Diffuse tender swelling in the right hypochondriac region
- Signs of septicemia: High fever with rigors, sweating and marked tachycardia
- Screening: Raised and fixed diaphragm with gas under it
- Features of the causative condition e.g. perforated peptic ulcer, liver abscess
Stomach and Duodenum
Carcinoma of Pylorus:
- There is irregular firm lump which moves on respiration
- The patient is usually elderly and has anorexia and weight loss
- Barium meal would show filling defect
Sub-Acute Perforation of a Peptic Ulcer
- Localized, tender, inflammatory mass may be present with a central abscess
- History of peptic ulcer
- Barium meal would reveal the ulcer
This usually causes a lump in the right iliac fossa which may be drawn towards the right hypochondriac region by fibrosis.
Carcinoma of Colon
- This commonly occurs in men above the age of 40 years
- There is alternate diarrhea and constipation.
- The lump is irregular, firm and moves poorly on respiration
- Occult blood may be present in stools
- The filling defect may be seen on barium enema.
- There is sudden intermittent abdominal pain with vomiting.
- Absolute constipation may be replaced later by passage of blood and mucus (red currant jelly) per anum without fecal odor.
- There may be curved, sausage-shaped lump in the line of the colon with its concavity towards the umbilicus.
- The lump may harden under examining fingers synchronously with an attack of screaming.
- Barium enema would show typical pincer-shaped ending of the radio-opaque material.