Abdomen: abnormalities

presented by:

Meet Gami
objectives
• at the end of the presentation students should be able to:
1. Discuss the parameters used to examine the abdomen for presence of
abnormalities
2. Physically diagnose abdominal abnormalities using the parameters
discussed
Concept map

Abdominal organs- P.E. Inspection:

Auscultation:
(liver, spleen, kidney, Palpation:
bladder, gall bladder, Percussion:
appendix, aorta etc)
Abdomen:
abnormalities Inspection:
Abdomen-general Auscultation:
survey & P.E. Palpation:
Percussion:
introduction
 General survey
• In emergency rooms, 40% to 45% of patients have
nonspecific pain, but 15% to 30% need surgery,
usually for appendicitis, intestinal obstruction, or
cholecystitis.
• Doubling over with cramping colicky pain signals a
renal stone. Cramping pain radiating to the right or
LLQ or groin may be a renal stone.
• Sudden knifelike epigastric pain often radiating to
the back is typical of pancreatitis
• Epigastric pain occurs with gastroesophageal reflex
disease (GERD), pancreatitis, and perforated
ulcers.
• RUQ and upper abdominal pain are common in
cholecystitis and cholangitis
• LLQ pain, especially with a palpable mass, signals
diverticulitis
inspection
striae
• Skin (temp. color, scars, rash)
• Pink–purple striae are a
hallmark of Cushing syndrome.
• Dilated veins suggest portal
hypertension from cirrhosis Caput
(caput medusae) or inferior medusae
vena cava obstruction.
• Ecchymosis of the abdominal
wall is seen in intraperitoneal
or retroperitoneal hemorrhage
• Umbilical bulge
• abdomen- contour (flat, round, protuberant, scaphoid)
• Bulges: bulging flanks of ascites, the suprapubic bulge of a
distended bladder or pregnant uterus, and ventral, femoral, or
inguinal hernias.
• Symmetry: Asymmetry suggests a hernia, an enlarged organ, or a ascites
mass.
• lower abdominal mass of an ovarian or a uterine cancer
• Peristalsis: increased peristaltic waves of intestinal obstruction
• Pulsations: increased pulsations of an abdominal aortic
aneurysm (AAA) or increased pulse pressure.

mass
auscultation
• Abdominal Bruits and Friction Rub Bruit
• Aorta, iliac and femoral arteries: A bruit in one areas
of these areas that has both systolic and
diastolic components strongly suggests renal
artery stenosis as the cause of hypertension.
• Bowel Sounds: Clicks and gurgles 5-34 per min
(normal); Altered bowel sounds (swish) are
common in diarrhea, intestinal obstruction-
hyperactive; paralytic ileus, and peritonitis-
hypoactive.
• Liver and spleen: Friction rubs are present in
hepatoma, gonococcal infection around the
liver, splenic infarction, and pancreatic
carcinoma.

Rub areas
percussion
• Tympani and dullness
• A protuberant abdomen that is tympanitic
throughout suggests intestinal obstruction
or paralytic ileus
• Dull areas characterize a pregnant uterus,
an ovarian tumor, a distended bladder, or a
large liver or spleen.
• Dullness in both flanks prompts further
assessment for ascites
• Lower costal margin: In the rare condition of
situs inversus, organs are reversed—air
bubble on the right, liver dullness on the
left.
palpation
• Light Palpation Light palpation
• Involuntary rigidity typically persists despite these
maneuvers, suggesting peritoneal inflammation.
• Deep Palpation
• Abdominal masses may be categorized in several
ways: physiologic (pregnant uterus), inflammatory
(diverticulitis), vascular (an AAA), neoplastic
(colon cancer), or obstructive (a distended bladder
or dilated loop of bowel).
• Assessing Possible Peritonitis
• Signs of peritonitis include a positive cough test,
guarding, rigidity, rebound tenderness, and Deep
percussion tenderness. When positive, these signs palpation
roughly double the likelihood of peritonitis;
rigidity makes peritonitis almost four times more
likely
Abdominal organs- PE
• LIVER
• Percussion:
• The span of liver dullness is increased when the liver is
enlarged.
• span of liver dullness is decreased when the liver is
small, in resolution of hepatitis or heart failure or, less
commonly, with progression of fulminant hepatitis, or
when there is free air below the diaphragm, as from a
perforated bowel or hollow viscus.
• Liver dullness may be displaced downward by the low
diaphragm of chronic obstructive pulmonary disease.
Span, however, remains normal.
• Dullness from a right pleural effusion or consolidated
lung, if adjacent to liver dullness, may falsely increase
estimated liver size.
• Gas in the colon may produce tympany in the RUQ,
obscure liver dullness, and falsely decrease estimated
liver size.
• In chronic liver disease, finding an enlarged palpable
liver edge roughly doubles the likelihood of cirrhosis
 • Palpation:
• Firmness or hardness of the liver, bluntness or
rounding of its edge, and surface irregularity are
suspicious for liver disease.
• Inspiration (liver 3cm below right costal
margin): An obstructed distended gallbladder
may merge with the liver, forming a firm oval
mass below the liver edge and an area that is
dull to percussion.
• Assessing Percussion Tenderness of a
Nonpalpable Liver: Tenderness over the liver
suggests inflammation, found in hepatitis,
or congestion from heart failure.
Enlarged liver

Hooking
technique
spleen
• Percussion
• left lower anterior chest wall (Traube space)
• If percussion dullness is present, palpation correctly
detects splenomegaly more than 80% of the time
• Fluid or solids in the stomach or colon may also
cause dullness in Traube’ space.
• Check for a splenic percussion sign.
• A change in percussion note from tympany to Enlarged spleen
dullness on inspiration is a positive splenic
percussion sign, but this sign is only moderately
useful for detecting splenomegaly
• Palpation
• Splenomegaly is eight times more likely when
the spleen is palpable

Enlarged spleen
kidney
• Palpation
• Left kidney: A left flank mass can represent
either splenomegaly or an enlarged left
kidney. Suspect splenomegaly if there is a
palpable notch on medial border, the edge
extends beyond the midline, percussion is
dull, and your fingers can probe deep to
the medial and lateral borders but not
between the mass and the costal margin.
• Suspect an enlarged kidney if there is
normal tympany in the LUQ and you can
probe with your fingers between the mass
and the costal margin, but not deep to its
medial and lower borders.
• Right Kidney: Causes of kidney
enlargement include hydronephrosis,
cysts, and tumors. Bilateral enlargement
suggests polycystic kidney disease
• Percussion Tenderness of the
Kidneys
• Pain with pressure or fist
percussion supports
pyelonephritis if associated with
fever and dysuria, but may also
be musculoskeletal.
The Bladder
• Normally, the bladder is not palpable unless it is distended above the
symphysis pubis (dullness- 400 to 600 ml)
• Suprapubic tenderness is common in bladder infection.
The Aorta
• normal aorta >50yrs is not more than 3 cm
wide (average, 2.5 cm, excluding the
thickness of the skin and abdominal wall).
• A periumbilical or upper abdominal mass
with expansile pulsations that is ≥3 cm in
diameter suggests an AAA. Sensitivity of
palpation increases as AAAs enlarge: for
widths of 3 to 3.9 cm, 29%; 4 to 4.9 cm,
50%; ≥5 cm, 76%
• Pain may signal rupture. Rupture is 15
times more likely in AAAs >4 cm than in
smaller aneurysms, and carries an 85% to
90% mortality rate.
 • Test for shifting
dullness: dullness
Ascites shifts to the more
dependent side,
whereas tympany
shifts to the top
Test for a fluid wave: An easily Shifting
palpable impulse suggests dullness
ascites. A positive fluid wave,
shifting dullness, and
peripheral edema makes the
presence of ascites to three to
six times more likely
Appendicitis
• Appendicitis is twice as likely in the presence of RLQ
tenderness, Rovsing sign, and the psoas sign; it is
three times more likely if there is McBurney point
tenderness
• Pain with a cough: The pain of appendicitis
classically begins near the umbilicus, then migrates
to the RLQ. Older adults are less likely to report this
pattern
• Localized tenderness anywhere in the RLQ, even in
the right flank, suggests appendicitis.
• Palpate the tender area for guarding, rigidity, and
rebound tenderness: Early voluntary guarding may
be replaced by involuntary muscular rigidity and
signs of peritoneal inflammation. There may also
be RLQ pain on quick withdrawal or deferred
rebound tenderness.
• Palpate for Rovsing sign and referred
rebound tenderness: Pain in the RLQ
during left-sided pressure is a positive
Rovsing sign.
• psoas sign: Increased abdominal pain on
either maneuver is a positive psoas sign,
suggesting irritation of the psoas muscle
by an inflamed appendix.
• obturator sign: Right hypogastric pain is a
positive obturator sign, from irritation of
the obturator muscle by an inflamed
appendix. This sign has very low
sensitivity.
• Rectal and pelvic examination: Right-sided
rectal tenderness may also be caused by
an inflamed adnexa or seminal vesicle
Acute cholecystitis
• When RUQ pain and
tenderness suggest acute
cholecystitis, assess
Murphy sign
• A sharp increase in
tenderness with
inspiratory effort is a
positive Murphy sign.
• When positive, Murphy
sign triples the likelihood
of acute cholecystitis
Ventral hernia
• umbilical or incisional hernia
• The bulge of a hernia will usually appear with this action, but should not be
confused with diastasis recti, which is a benign 2- to 3-cm gap in the rectus
muscles often seen in obese and postpartum patients.

Incisional
Umbilical Diastasis recti
hernia
hernia
Mass in abdominal wall
• A mass in the abdominal
wall remains palpable; an
intra-abdominal mass is
obscured by muscular lipoma
contraction.
Clinical presentation
• A patient presents with the following PE:
• Abdomen is protuberant with active bowel sounds. It is soft and non
tender; no palpable masses or hepatosplenomegaly. Liver span is 7
cm in the right midclavicular line; edge is smooth and palpable 1 cm
below the right costal margin. Spleen and kidneys not felt. No
costovertebral angle (CVA) tenderness.”
• What is the most probable diagnosis for the patient?
references
• BATES’GUIDETOPHYSICALEXAMINATIONANDHIS
TORYTAKING
Thank you