Abdominal examination (Physical Examination for OSCE)

Property of Department of General Surgery, Faculty of Medicine, University of Zagazig, Egypt

1. ABDOMINAL EXAMINATION

2. subcostal interiliac

3. General rules before the abdominal examination 1. For the examiner Examination is done in warm room with good light The examiner must warm his hands , has short finger nails and use warm stethoscope 2. For the patient Patient should be lying flat (Supine) Abdomen should be fully exposed ; from above the xiphoid process to the symphysis pubis (the groin should be visible) Sheet over the genitalia Arms at sides or over the chest (behind head tightens abdomen) flexing knees may relax abdomen The head and the neck are supported by enough pillows

4. Anterior Back Inspection

5. Swelling Deformity Loin masses Pigmentation tuft of hair Inspection of the Back

6. Inspection of the Anterior Abdominal Wall Inspection of mid-line from above downward Inspection of the sides 1- Subcostal angle 2- Epigastric pulsation 3- Divarication of recti 4- Umbilicus 5- Suprapubic hair distribution 6- Hernial orifices 1- Contour of the abdomen 2- Collateral (dilated veins) 3- Skin 4- Scars 5- Movement with respiration 6- Visible peristalsis N.B. we start the inspection of the abdomen by comment on contour of the abdomen

7. Mid-line Inspection 1- Subcostal angle Normal: acute to right angle (70 – 90 °) Abnormal: obtuse angle; occurs in: abdominal causes: chronic ↑↑ in intra-abdominal pressure (as in ascites, upper abdominal swelling) Chest causes: emphysema

8. 2- Epigastric pulsation Aortic normal aortic incompetence aortic aneurysm Rt ventricle RVH in bilharzial corpulmonale Hepatic “pulsating” liver tricuspid regurge hemangioma

9. 3- Divarication of recti Bulge of linea alba between the recti muscles with their wide separation Causes: ↑↑ intra-abdominal pressure (ascites, multiple pregnancies)

10. 4- Umbilicus Site normally  midway between xiphisternum and symphysis pubis Pushed downwards  due to - masses in upper abdomen - ascites Pushed upwards  due to masses lower abdomen arising from the pelvis Shape Normally  inverted Abnormally  everted due to increase in intra-abdominal pressure (ascites / pregnancy)

11. Hernia Expansile impulse in cough Dilated veins Caput medusa in portal hypertension Skin Pigmentation around umbilicus (T.B. peritonitis, Addison dis.) Nodules “sister Mary-Joseph nodules” (abd. malignancy) Ecchymosis “Cullen's sign” (hemorrhagic pancreatitis and internal hemorrhage) Discharge: Pus  inflammation Stool  intestinal fistula Urine  patent urachus

12. 5- Suprapubic hair distribution Normally: In male  the hair reach the umbilicus “triangular, with the apex towards the umbilicus” In female  the hair ends in horizontal line Abnormally  feminine hair distribution in male in L.C.F.

13. 6- Hernial orifices Weak points in the abdomen in which the abdominal contents may pass through it with increase intra-abdominal pressure Detected by: the patient is examined in standing position and asked to cough Sites: Linea alba (epigastric) Umbilical Incisional (old scars) Inguinal Femoral Scrotal N.B. Hernia= expansile impulse on cough

14. Inspection of Sides 1- Contour of the abdomen Normally  the abdomen is gently convex from side to side and from front to back Abnormally  Retraction (scaphoid abdomen) : due to starvation, wasting diseases or dehydration Bulging (distension or swelling): either generalized or localized N.B. The flanks should be checked for any bulging.

15. Scaphoid abdomen slightly full abdomen but not distended

16. examination of abdominal contours Standing at the foot of the table Lower yourself until the anterior abdominal wall ask the patient to breathe normally while you are inspect the abdomen.

17. Generalized abdominal distension Localized abdominal distension 1- Fluid (ascites) 2- Fat (obesity) 3- Flatus and Faeces 4- Foetus (pregnancy) 5- Full urinary bladder 1- Site 2- Shape and size 3- Pulsate on cough (hernia or not) 4- Movement with respiration 5- Extra-abdominal or Intra-abdominal (by asking the pt. to sit up in bed unsupported) Contour of the abdomen

18. Localized bulge

19. Generalized abdominal distension

20. 2- Collaterals (Dilated – Tortuous – Engorged Veins): in cases of IVC obstruction Portal vein obstruction 1- Site of collaterals Laterally (Sides) Around umbilicus (caput medusa) 2- Blood flow From below upwards “towards the head” (to bypass the obstruction  the blood bypass the IVC via abdominal wall veins to the thorax) Away from the umbilicus”towards the legs” (the blood pass from the left branch of portal vein to para umbilical vein to anterior abdominal wall veins through the umbilicus) 3- cause in hepatic Pt Functional compression on IVC by tense ascites Intra-hepatic causes of portal hypertension N.B. Dilated veins can be made more visible by asking the patient to cough or strain, while the patient is sitting or semi-setting.

21. Methods of Detection - The 2 index fingers of both hands are used to milk the blood away from one segment of a dilated vein  then, applying firm pressure on both ends of the segment  the fingers then can be lifted one by one, while observing the rate of filling at which the vein fills from each direction  the blood will be seen coming more rapidly from the direction of blood flow. N.B. visible veins without engorgement and tortuosity may be normal finding in thin persons, particularly when the abdominal wall is distended, often in epigastrium

22. Caput medusa Head of medusa

23. Caput medusae accentuated by marked ascites. An extensive plexus of veins is seen radiating from the umbilical region and radiating across the anterior abdominal wall. Note the large vein coursing inferiorly along the right flank (arrows). This is the superficial epigastric vein.

24. 3- Skin of the abdominal wall Stretched – Smooth – Shiny  in marked distended abdomen Striae (due to rapid stretch of the abdominal wall with rupture of elastic fibers) Striae alba “white”: in obesity, ascites, pregnancy (striae gravidarum) Striae rubra “red”: in cushing disease and prolonged steroid therapy  they are often larger and wider, and may involve the face

25. Scratch marks  in obstructive jaundice Sinus and fistula Pigmentation – Purpura – Petichae in LCF

26. It is often difficult to understand whether tiny red spots arising on skin surface are Petechiae or Purpura. However, Petechiae spots have a very small diameter that is maximum 3 mm in size . Purpura rashes are larger in size. These have a diameter that is about 5 mm . A spot that is bigger than Purpura is known as common bruise or echymosis Echymosis Abdominal petichae

27. 4- Scars Type (operation or cautery) Site (suggest the name of operation) e.g. Rt. Hypochondrium: scar of cholecystectomy Rt. Iliac fossa: scar of appendicectomy Lt. Paramedian: Scar of splenectomy Pigmentation Impulse on cough (incisional hernia) Healing cleanly by 1st intention(thin, regular) or healed infected by 2nd intention (wide, irregular , with keloid or not which is hypertrophic area outside the field of normal scarring)

28. 5- Movement with respiration decrease or absent movement , occurs due to: Rigidity (peritonitis) Tense ascites Diaphragmatic paralysis

29. 6- Visible peristalsis Due to Pyloric obstruction  in the upper abdomen (from Lt. to Rt.) Small intestinal obstruction  around the umbilicus Large intestinal obstruction  in the upper abdomen (from RT. to Lt.) Stimulated by Gentle tapping Cold stimulation of the skin (2 drops of ether)

30. Palpation

31. General rules for palpation For the examiner Examination is done in warm room with good light The examiner must warm his hands , has short finger nails and approach slowly use warm stethoscope Distract the patient with conversation or questions

32. General rules for palpation For the patient Patient should have an empty bladder Patient supine, arms at sides or folded across chest - avoid arms above the head as this tightens the abdomen The abdomen is fully exposed Before you begin, ask the patient to point to areas of pain and examine last Observe the patient face “expression” during examination Flexing the knees may relax the abdomen The head and neck are supported by enough pillows

33. Normally palpable structures Contracted muscles of abdominal wall in muscular persons Colon (caecum and sigmoid) is felt when it is spastic (full of gas or fluid) Vertebra (L4 – L5) Pulsations of abdominal aorta (usually felt below the umbilicus) in thin persons Lower pole of Rt. Kidney (especially in female with thin lax abdominal wall) Liver edge descends 1-3 cm below the costal margin on deep inspiration, but the consistency is soft and difficult to feel.

34. Types of Palpation Superficial Deep

35. For: Confidence of the patient Superficial masses Tenderness Rigidity Temperature “ from the Lt. iliac fossa  in anticlockwise direction  till the suprapubic area” Superficial Palpation

36. Technique Use pads of three fingers (palmar surface of fingers) of one hand and a light , gentle, dipping maneuver to examine abdomen Abdominal wall depressed approximately 1 cm

37. Palpating the abdomen – Light palpation

38. Deep Palpation For : Organs “liver, spleen, gall bladder, kidney, colon, urinary bladder” Masses Areas of deep tenderness and rebound (pain induced or increased by letting go) Deep palpation include the following methods Ordinary technique “classic” 2 handed method Bimanual Dipping Hooking Rolling

39. Technique Entire palm (use palmar surface of fingers of one hand; greatest number of fingers) and a deep, firm, gentle maneuver to examine abdomen Either one- or two handed technique is acceptable (When deep palpation is difficult, examiner may want to use left hand placed over right hand to help exert pressure) Palpate tender areas last Palpate deeply with finger pads (do not “dig in” with finger tips ) Abdominal wall depressed around 4 cm or Push as deeply as patient will allow without significant discomfort.

40. Palpating the abdomen – Deep palpation

41. Palpation of the Spleen

42. The spleen has the size of cupped hand It lies between the stomach and fundus of diaphragm Surface anatomy - it lies in the epigastrium and the adjoining part of the Lt. hypochondrium - parallel to ribs 9, 10, 11 - its long axis parallel to the posterior part of the shaft of 10th rib - the spleen has 2 surfaces ; diaphragmatic surface (convex, smooth); visceral surface (concave, irregular, contain the hilum and carries impression of 4 organs) 2 borders ; upper border (sharp, notched); lower border (smooth, rounded) 2 ends ; medial end (broad, 4cm from the median plane); lateral end (narrow and tappering)

43. Surface anatomy of the Spleen 11 th rb Medial end Lateral end 10 th rb 9 th rb 10 th rb

44. Diaphragmatic surface Visceral surface upper border Lower border

45. The spleen is not normally palpable It has to be enlarged 3 times its usual size to be palpable under the subcostal margin The direction of enlargement is downward and towards the Rt. Iliac fossa The spleen which is not felt doesn’t exclude splenomegaly but it can be said that the spleen is not felt

46. Methods of Deep Palpation Classical method (single-handed method) Two handed method Bimanual examination - in the supine position - in the Rt lateral position) Dipping method Hooking method

47. Classical method (single-handed method)

48. Two handed method

49. Bimanual examination in supine position

50. Palpating the spleen – Bimanual palpation in supine position

51. Palpating the spleen – Bimanual palpation in supine position

52. With the patient in the right lateral position, minimal splenic enlargement can be detected Palpating the spleen – Bimanual palpation in Rt. Lateral position

53. Palpating the spleen – Bimanual palpation in Rt. Lateral position

54. Palpating the spleen – Bimanual palpation in Rt. Lateral position

55. Examining for the spleen from behind the patient, in the right lateral position. In this case, the fingers are "hooked" over the costal margin. Hooking method

56. Nature of this palpable spleen (put a comment on): Size Mild (just palpable to 5cm) Moderate (5 – 10 cm) Huge (more than 10 cm, below the umbilicus) Border Surface Consistency Tenderness (e.g. due to splenic infarction, septicemia, SBE)

57. Applied anatomy and physiology of the spleen The spleen is composed predominantly of lymphoid and R.E. tissues , so, any condition “infectious; immunologic; metabolic; malignant or idiopathic” that causes hyperplasia of the lymphoid/RES may cause splenomegaly The spleen is expansile organ containing many sinusoids, so, interference with its venous drainage as in portal hypertension will cause splenomegaly “congestive splenomegaly” The spleen destroys senile and defective RBCs , so, in hemolytic anemias, this function is increased with splenomegaly “except in sickle cell anemia”

58. Hypersplenism - Whenever the spleen is enlarged, hypersplenism may occur It is characterized by Pancytopenia in the peripheral blood (Normocytic normochromic anemia, neutropenia, thrombocytopenia in the CBC) due to hyperfunction of the spleen One element or two may be decreased only B.M examination: hypercellular or normal Splenectomy returns the CBC to normal

59. Characters of splenic swelling to be differentiated from the Lt. kidney By inspection  Moves with respiration down and medially By palpation  it has a notch on the lower part of the anterior (upper) border “PATHOGNOMONIC”  hand can't be insinuated between the mass and the costal margin to get above its upper pole  negative ballottement (can’t be pushed in the renal angle) By percussion  dull on percussion and continuous with the splenic dullness

60. Palpation of the Liver

61. Surface anatomy of the Liver

62. Upper border is marked by joining the following points: 1 st point  Lt. 5 th intercostal space in the MCL “apex of the heart” 2 nd point  Xiphisternal joint. 3 rd point  Upper border of 5 th rib in Rt. MCL 4 th point  7 th rib at RT MAL. 5 th point  9 th rib at RT scapular line. Lower border is marked by curved line joining the following points: 1 st point  Lt. 5 th intercostal space in the MCL “apex of the heart” 2 nd point  8 th costal cartilage in the Lt. parasternal line. 3 rd point  midway between xiphisternal junction and the umbilicus 4 th point  9th costal cartilage in the Rt. MCL. 5 th point  10 th rib in the Rt. MAL. 6 th point  12 th rib in Rt. Scapular line

63. Xiphisternal junction Rt. 5 th rib Rt. 7 th rib Rt. 9 th rib LT. 5 th space 1 1 2 2 3 3 4 4 5 5 6 7 7 6 9 8 10 8 9 10 umbilicus

64. Rt. 9 th costal cartilage LT. 5 th space 1 1 2 2 3 3 4 4 5 5 6 7 7 6 9 8 10 8 9 10 LT. 8 th costal cartilage Midway between umbilicus &xiphisternum umbilicus Rt. 10 th rib

65. Technique of detecting the liver Upper border is detected by heavy percussion “hepatic dullness” Lower border is detected by deep palpation and light percussion After palpation of the lower border of the liver, you must comment on Liver span : Distance between the upper and lower borders of the liver; which is 4 – 8 cm in the middle line “represents the Lt. lobe” 9 – 14 cm in the Rt. MCL “represents the RT. lobe”

66. Nature of this palpable liver (put a comment on): Size “in finger breadth or cm” Normally: not felt below the costal margin Abnormally: enlarged “causes of hepatomegaly” or shrunken “liver cirrhosis and fibrosis” Surface Normally: smooth Abnormally: - smooth “congestion, inflammation, infiltration” - fine irregular “cirrhosis” - nodular “malignancy” Edge Normally: sharp Abnormally: - sharp “cirrhosis, fibrosis” - rounded “congestion, inflammation, infiltration”

67. Consistency Normally: soft Abnormally: - soft “congestion, inflammation, infiltration” - firm “cirrhosis, fibrosis” - hard “malignancy” Tenderness: congestion, inflammation, infiltration, malignancy Pulsation: TI, TS, hemangioma

68. Methods of Palpation Classical method (single-handed palpation) Two-handed method Bimanual examination Dipping method Hooking method - Single-handed palpation is used for lean individuals , while the bimanual technique is best for obese or muscular individuals . Using either technique, the liver is felt best at deep inspiration .

69. Single-handed method For single-handed palpation, the examiner's right hand is initially placed on the patient's abdomen in the right lower quadrant and parallel to the rectus muscle in the MCL. This is done so that palpation of the rectus is not confused with palpation of the underlying and adjacent liver Gently pressing in and up , ask the patient to take a deep breath .  Palpating hand is held steady while patient inhales Palpating hand is lifted and moved while the patient breathes out If the liver is enlarged, it will come downward to meet your fingertips and will be recognizable.

70. Another method of palpating the liver uses the radial border of the index finger. In this method the anterior hand is placed flat on the anterior abdominal wall with fingers parallel to the costal margin

71. the left hand is held posteriorly, between the 12 th rib and the iliac crest . It is lifted gently upward to elevate the bulk of the liver into a more easily accessible position, while the right hand is held anterior and lateral to the rectus musculature. The right hand moves upward using gentle, steady pressure until the liver edge is felt. Bimanual palpation of Liver

72. Bimanual palpation of Liver

73. Is useful when the patient is obese or when the examiner is small compared to the patient. Stand by the patient's chest. "Hook" your fingers just below the costal margin and press firmly. Hooking method

74. Hooking method

75. Causes of ptosed liver Emphysema Pneumothorax Pleural effusion Subphrenic abscess Causes of upward displacement of the liver Lung fibrosis/collapse Diaphragmatic paralysis Ascites / abdominal tumours

76. Percussion Percussion is a method of tapping on a surface to determine the underlying structure

77. Technique It is done with the middle finger of Rt. hand (plexor) tapping on DIP of the middle finger of the Lt. hand (pleximeter) using a wrist action . The non striking finger (pleximeter) is placed firmly on the abdomen , remainder of hand not touching the abdomen . Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness . pleximeter plexor

78. Percussion of the abdomen The abdomen gives a resonant note which varies according to the amount of gas present in the intestine Type of percussion: Light percussion Values: Deleneation of borders of abdominal organs (& assessing for organomegaly). Detection of ascites Detection of gaseous distension “tympanic resonant note” Detection of acute abdomen (obliteration of normal liver dullness) in; Perforated peptic ulcer and colon Subphrenic abscess with gas forming organisms

79. Percussion “liver” Upper border  by deep percussion Lower border  by light percussion Upper border Define the sternal angle “angle of Louis” (2 nd rib), then start percussing the 2 nd intercostal space in the Rt. MCL (Start just below the Rt. breast in RT. MCL). Percussion in this area should produce a relatively resonant note Percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time (in the intercostal spaces). Note where the percussion notes change from resonant to dull. The normal hepatic dullness will be reached at the 5 th intercostal space in the RT. MCL Lower border Begin percussion below the umbilicus, in the Rt. MCL and proceed upward until dullness is encounter.

80. Percussion “spleen” Percussion of Traube’s area Splenic percussion sign “Castell’s method” Nixon’s method

81. Traube's area It is a semilunar (crescent)-shaped area It is area of tympanic resonance overlying the fundus of stomach Boundaries Upper border  lower border of Lt. lung (convex line from the Lt. 6 th rib in MCL to the Lt 9 th rib in mid-axillary line) Right border  Lateral margin of left lobe of liver (from Lt. 6 th rib in MCL to the Lt. 8 th costal cartilage) Left border  anterior border of the spleen (Lt. 9-11 spaces in mid-axillary line) Lower border  Lt. costal margin (from the Lt. 8 th costal cartilage to Lt. 11 th space in mid-axilary line )

82. Causes of dullness of Traube’s area: Full stomach/ gastric tumours. Left sided Pleural effusion / pericardial effusion “from above”. Ascites/abdominal tumour “from below” Splenomegaly “from left side”. Enlargement of left lobe of liver “from the right side”.

83. Castell’s method “Splenic percussion sign” Put the patient in the supine position Left anterior axillary line identified Left lower costal margin identified Percuss in the lowest Left intercostal space in the anterior axillary line (usually the 8th or 9th IC space) while patient inhales and exhales deeply This space should remain resonant during full inspiration Dullness on full inspiration indicates possible splenic enlargement (a positive Castell’s sign)

84. Castell’s point

85. Nixon’s method Place the patient in Right lateral decubitus Begin percussion midway along the Left costal margin Proceed in a line perpendicular to the Left costal margin Upper limit of dullness : 8 cm

86. Detection of Ascites Ascites is free collection of fluid within the peritoneal cavity. The classical signs of ascites include; abdominal distension, shifting dullness, fluid thrill. Minimal ascites  detected in the knee elbow position Moderate ascites  detected by the bilateral shifting dullness Tense ascites  detected by transmitted fluid thrill “fluid wave”

87. Bilateral shifting dullness The patient is examined in the supine position . Percussion is done over the abdomen , from the umbilicus to one flank . The spot of the transition from tympany to dullness is detected . The patient is then turned to the opposite side , while the examiner keeps his hand unmoved. Percussion of the same spot (which is top now) gives a tympanic note . Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid. air air fluid fluid

88. Transmitted fluid thrill Pathognomonic for ascites when the amount of fluid is large The patient is examined in the supine position . The patient or an assistant places one hand in the midline and presses firmly with the ulnar border of the hand , so cut off any vibrations transmitted by the abdominal wall. The examiner places one palm on one flank , while giving a sharp tap with the finger tips on the opposite flank . Positive test: a definite wave “impulse” will be distinctly felt by the receiving hand.

89. Transmitted fluid thrill

90. Auscultaion Diaphragm of stethoscope used Skin depressed to approximately 1 cm Listening in one spot is usually sufficient Listening for 15-20 or 30-60 seconds

91. Values of auscultation To hear intestinal sounds  characteristic gurgling bubbling (gas and fluid in intestine) sounds. Increase in: acute diarrhea (↑motility) and in early intestinal obstruction Absent in: paralytic ileus N.B. Bowel sounds cannot be said to be absent unless they are not heard after listening for 3-5 minutes.

92. To hear vascular sounds Arterial bruit Venous hum (Wind at sea shore) Systolic murmur Systolic and diastolic sound in the epigastrium, and Lt. hypochondrial region “Kenawy sign” Occurs in cases of Abdominal aortic aneurysm Renal artery stenosis Over very vascular tumour “e.g. hemangioma” Occurs in cases of - portal hypertension due to porto-systemic anastomosis (collateral)

93. Friction rub  a dry, grating sound heard with a stethoscope during auscultation ; may be heared over enlarged liver or spleen Splenic rub : in Lt. hypochondrium; due to splenic infarction and perisplenitis Hepatic rub : in Rt. Hypochondrium; due to hepatic malignancy with perihepatitis (inflammatory changes or infection in or adjacent to the liver). N.B. A hepatic rub and bruit in the same patient usually indicates cancer in the liver. A hepatic rub, bruit, and abdominal venous hum would suggest that a patient with cirrhosis had developed a hepatoma.

94. 4. To detect minimal ascites (Puddle’s sign) It is useful for detecting small amounts of ascites (as small as 120 mL; shifting dullness and bulging flanks typically require 500 mL). The steps are outlined as follows: Patient lies prone for 5 minutes Patient then rises onto elbows and knees Apply stethoscope diaphragm to most dependent part of the abdomen Examiner repeatedly flicks near flank with finger. Continue to flick at same spot on abdomen Move stethoscope across abdomen away from examiner Sound loudness increases at farther edge of puddle

95. 5. Succusion splash  in case of pyloric obstruction (distended stomach with gas and fluid) placing the stethoscope over the upper abdomen  rocking the patient back and forth at the hips  Retained gastric material >3 hours after a meal will generate a splash sound. 6. To detect pregnancy  fetal heart sounds.