Examinationof The Abdomen Flashcards
What are the borders of the abdomen ?
Cranial border : costal margin and xiphoid process
Caudal border : anterior superior iliac spine (ASIS), the iliac crest and the pubic bone.
What is the main center reference point of the abdomen and how is named its vertical line ?
The umbilicus / navel and the vertical line passing through is called the linea alba.
What are intra-peritoneal organs ? Who are they ?
Organs that are inside the peritoneum cavity / sac. Covered by the visceral peritoneum.
Stomach, jejunum, ileum, Cecum, transverse colon, sigmoid, liver and gallbladder, spleen, ovaries.
What are retroperitoneal organs ? Who are they ?
Organs outside the peritoneal cavity, generally backyard.
Most of the pancreas, duodenum, kidney and adrenal glands, abdominal aorta, ascending and descending colon, rectum, IVC
What are infra-peritoneal organs ? Who are they ?
Organs beneath the peritoneal cavity.
Rectum, bladder, distal ureters, uterus, Fallopian tubes.
What does the coeliac trunk supply ?
The stomach, pancreas, liver, 1/3 duodenum, spleen
What does the superior mesenteric artery supply ?
Jejunum, ileum, appendix, ascending colon, 1/3 of transverse colon
What does the inferior mesenteric artery supply ?
2/3 of transverse colon, descending colon, sigmoid, upper rectum
What does the inferior iliac artery supply ?
The lower rectum
Where is the groin ?
The inguinal region where the abdomen meet the legs, a vulnerable part where hernia can occur.
What is an hernia ?
When abdominal content bulge through the abdominal wall. If the hernia has a narrow neck its content might be entrapped, causing mechanical ileus and acute necrosis.
What is a reducible hernia ?
An hernia where the content can slide back into the abdominal cavity.
What is a non reducible hernia ?
An hernia where the content have fused with the peritoneal sac.
Where is the rectum, what is it closed by ?
It is the continuation of the sigmoid at the level of S3.
Closed on the distal side by external and internal anal sphincter.
In which order do you do the general examination of the abdomen ? Why ?
Inspection, auscultation, percussion, palpation.
Palpation is last because if could cause a patient pain thus over-tensing the muscle and making further investigation difficult.
What do you observe during inspection ?
General shape and symmetry of abdomen
Skin and navel
Any local swelling
Visible movement
What could cause diffuse swelling of the abdomen ?
Obesity : accumulation of fat
Gas accumulation : due to severe constipation
Free fluid accumulation (ascites) : common in elderly
Pregnancy : enlargement of uterus
Cyst or tumour : enlargement of ovaries
Full bladder
What abnormalities of the navel could there be ?
Bulging => intra-abdominal tension
Sunken => obesity
What abnormalities of the skin could there be ?
Exanthema = rashes
Spider naevi = spider web shaped veins
Surgery scars
What could be the cause of local swelling ?
Liver or spleen enlargement
Abdominal wall hernia : often only visible standing
What kind of movement do you observe during inspection ?
Breathing : loss of diaphragmatic breathing means a peritoneal irritation
Visible peristalsis : chance of small bowel obstruction
Pulsation of aorta : maybe sign of abdominal aortic aneurysm
What sounds do you hear during auscultation ?
Bowel sounds, vascular sounds and liver sounds.
What are bowel sounds and their clinical significance ?
Sound from the stomach that have limited clinical value, their frequency vary from 30/min to 1/4min.
Hyperactivity or absent sounds = obstruction of the bowel.
What are vascular sounds ? What are causes of their abnormalities ?
Sounds from the coeliac artery.
Abnormal bruit can be caused by renal artery aneurysm, arteriovenous fistula, compression syndrome, ischemic bowel disease.
What can you hear in the liver ?
Abnormal vascular sound linked to perihepatitis or perisplenitis.
How do you do a scratch test ?
Place the stethoscope above the liver next to the xiphoid process.
Scratch near the lower border of the liver. The sounds will be a lot louder when scratching the skin above the liver
What are the 2 types of percussion ?
Exploratory percussion : percuss in star shape or over the 9 regions
Topographic percussion : percuss specific organs
What kind of sound do you expect in percussion ? What is abnormal ?
Tympanic : gas in the stomach or bowel
Dull : content of the GI tract
Unusual dullness in large area : enlarged organ, full bladder, large tumor
Unusual dullness in the flanks : ascites
How do you diagnose a enlarged spleen with percussion ?
When the patient take a deep breath, the tympanic sound transform into a dull sound in the 7th-8th intercostal space
What abnormalities can you detect by percussing the liver ?
Loss of dullness : gastrointestinal perforation causing air in the abdominal cavity
Increased liver surface : right congestive heart failure, steatosis, hepatitis and tumors
Percussion tenderness below the costal arch : inflammatory gallbladder
Are abnormal liver border signs of a disorder ?
Not always, due to the large variation of the diaphragm position.
What is superficial palpation ?
Assess muscle tension, locate tender spot, detect abdominal wall abnormality (hernia, ACNES, small tumors) and local infiltrate.
What do you do do if there is superficial resistance in the abdominal wall ?
Ask the patient the raise head and shoulder. If the swelling is in the abdominal wall and not the peritoneal cavity then it will cause a lot of pain and still be palpable.
What is the difference between parietal and visceral pain ?
Parietal pain : inflammation local or diffuse of the parietal peritoneum.
- steady aching and more severe than visceral pain
- sharp and you pinpoint the part.
- aggravated by movement or coughing because it increase intra-abdominal pressure
- peritonitis
- very shallow chest breathing
Visceral pain :
- hollow abdominal organs contract unusually forcefully or are distended
- solid organ become painful when their capsule is stretched
- non specific pain, difficult to localise
- varying in quality : gnawing, cramping, aching, colic
What are the types of muscle guarding ? What is it due to ?
Voluntary muscle guarding : due to fear, pain, agitation, cold. Can be lessened by distracting the patient.
Involuntary muscle guarding : due to local or generalised irritation of the parietal peritoneum.
What are the types of deep palpation ?
Deep exploratory palpation : used to locate abnormal resistance
Deep topographic palpation : used to palpate various abdominal organ
What do you look for in deep topographic palpation of the liver ? What can you find ?
Look for : size, consistency, surface characteristics and tenderness.
You can find : cirrhosis (granular and firm swelling), tumours (coarse and firm irregularities swelling), tenderness (acute swelling or abscesses)
Why can you sometimes feel the spleen ? What are the reasons ?
The spleen can only be palpated if enlarged or hard. When it moves caudally and medially during inspiration.
Enlargement due to infection, haemolysis, thrombosis, hematological and lymphorticular malignancies and metabolic disease.
Why do you examine the kidney ?
To detect an enlarged kidney or cyst. Also to test costovertebral angle tenderness if pyelonephritis aortic renal colic is suspected.
What do you examine in the kidney ?
There is no point in auscultating and percussing the kidney. You try the palpation but it cannot be felt normally.
How do you palpate the kidney ?
Bimanual palpation : patient lie supine.
Left hand between the iliac crest and costal arch, finger parallel to the ribs.
Right hand above, lateral to the rectus abdominis muscle.
Move hand towards each other. Ask patient to breath deeply.
Contraction of the diaphragm cause the kidney to move causally, so you may feel a firm lower pool.
How do you assess tenderness of the kidney ?
Gently strike on the costovertebral angle : on the back below the costal arch.
Either, with the side of the hand or with the fist on the back of the other hand.
Clinical significance of palpable kidney ?
Only one palpable kidney : cyst, tumor, compensatory hypertrophy
Both palpable kidney : cystic kidney disease
What do you expect to hear at the percussion of bladder ?
It normally cannot be percussed but the sound expected sound be tympanic. There is no correlation between bladder enlargement and dullness.
What are the causes of an enlarged bladder ?
Caused by urinary retention due to :
Obstruction, infection, drug treatment, neurological disorder.
Where do you feel an enlarged gallbladder ?
It is difficult to distinguish an enlarged gallbladder than enlarged liver.
It is felt as a ball/pear-shaped resistance : right lateral side 9th ribs.
Why and how do you palpate the gallbladder ?
Palpation indicated if percussion tenderness in the right upper quadrant.
Palpate while following the lower boundary of costal arch from lateral to median.
What are the clinical significances of the gallbladder examination ?
If pain on inspiration = positive Murphy’s sign : cholecystitis
Painless but palpable gallbladder in jaundice patient : malignancy
Palpable gallbladder without jaundice : cystic obstruction
What are ascites and how do you test for them ?
Ascites are an accumulation of free fluid in the abdomen. You can detect it using percussing or undulation.
How do you detect ascites with percussion ?
Percuss when the patient is supine : tympanic and dull sound heard with a transition in the flank
Percuss with patient on their side : the transition point between dull and tympanic change.
This is shifting dullness.
How do you detect ascites with undulation ?
Tap on the flank and feel the possible wave motion with the hand on the other side.
What is an acute abdomen ?
It’s an acute onset abdominal pain requiring an urgent diagnosis.
An acute abdominal pain : last less than 5 days.
It is mostly diagnosed based on history taking and not physical examination.
What is the meaning of absent dullness in the liver ?
Due to free gases below the diaphragm. Could be a sign of a perforation.
What is POCUS, what is it used for ?
Point of care ultrasound : scanner used as a stethoscope. It can detect very small amount of fluid.
What is very important to do before an anus or rectum examination ?
Explain clearly the procedure. Gain consent of the patient. Explain about side effect : feeling like you’re gonna poop or peep.
How do you do a rectal examination ?
Use lubricant on one finger of the glove. Rotate finger to assess the canal for abnormal resistance. Describe resistance. Withdraw finger and inspect.
Clinical significance of examination of the anus ?
Painful swelling : thrombosed external haemorrhoid
Elevated sphincter tension : anal disorder or nervous
Reduced sphincter tension : neurological disorder or age
Soft painful swelling : high perianal abscesses
What abnormalities can you find in the rectum ?
A painful or fixed mucosa, a polys (soft and smooth but not painful).
Beware to differentiate feces and resistance.
What is the result of an enlarged spleen ?
It can trap and store blood cells causing anemia.
What are possible causes of an acute abdomen ?
Gastrointestinal :
- acute : appendicitis, cholecyctitis, pancreatitis
- complicated diverticulitis
- inflammatory bowel disease
- perforated gastric ulcer
- trauma : perforation and ruptures
Gynaecological tract :
- Acute salpingitis : STD, deep infection could leak in the peritoneal cavity
- ectopic pregnancy
Urological tract :
- pyelonephritis
Vascular :
- dissected AAA
- myocardial infraction
Neurological tract :
- Abdominal wall pain
What is referred pain ?
It is pain felt more distant site innervated at the same spinal level as the disturbed structures.
Occurs when the initial pain becomes more intense and radiate.
No palpation tenderness.
ABCDE of acute abdomen ?
Airway : unusual
- lateral position preferred to avoid patient choking on their vomit
Breathing : unusual
- depth can be limited by the pain
Circulation :
- check BP and pulse => check for shock
- beware of internal bleeding
Disability :
- measure glucose in diabetics : vomiting and diarrhea can cause fast dysregulation
Exposure :
- temperature : fever indicate inflammation
- skin
- intoxication
Physical examination for peritoneal irritation ?
Inspection
- no movement due to pain
Coughing test :
- positive : pain
Percussion :
- tenderness may be present even gently
Palpation :
- superficial : voluntary / unvoluntary guarding
- wall test
- rebound tenderness
- McBurney sign
- Psoas sign
Technique of wall test ?
Check whether or not a painful resistance i located in the abdominal wall.
Raise head and shoulder. If the pain increase the problem is in the abdominal wall.
Technique of rebound tenderness ?
If there’s local pain.
Slowly and deeply depress the abdomen, then release the pressure suddenly. You can do the ipsilateral or contralateral side.
If the abrupt movement cause more sharp pain => peritoneal irritation
Technique of McBurney sign ?
Local pain in the right lower abdomen with local tenderness.
Maximum tenderness at 1/3 of ASIS from the umbilicus.
Psoas sign technique ?
Seen in retrocaecal appendicitis or abscess in the psoas region.
Patient lies on their left side : hyperextending the right leg causes more pain in the right lower abdomen.
Patient supine : flex right leg at the hip against resistance causes more pain in the right lower abdomen
