Abdominal Inspection

Inspection consists of visual examination of the abdomen with note made of the shape of the abdomen, skin abnormalities, abdominal masses, and the movement of the abdominal wall with respiration. Abnormalities detected on inspection provide clues to intra-abdominal pathology; these are further investigated with auscultation and palpation.

1. ABDOMINAL INSPECTION By Dr. Arun Chhajer MD ( Kayachikitsa ) CAMC, Rajnandgaon (C. G.)

2. SHAPE Is the abdomen of normal contour and fullness, or distended? Is it scaphoid (sunken)? Generalized fullness or distension may be due to fat, fluid, flatus, faeces or fetus . Localized distension may be symmetrical and centred around the umbilicus as in the case of small bowel obstruction, or asymmetrical as in gross enlargement of the spleen, liver or ovary. chronic urinary retention may cause palpable enlargement in the lower abdomen. A scaphoid abdomen is seen in advanced stages of starvation and malignant disease.

3. UMBILICUS Normally the umbilicus is slightly retracted and inverted. If it is everted , then an umbilical hernia may be present and this can be confirmed by feeling an expansile impulse on palpation of the swelling when the patient coughs. Ascitis A common finding in the umbilicus of elderly obese people is a concentration of inspissated desquamated epithelium and other debris ( omphalolith ).

4. Movements of the abdominal wall Normally there is a gentle rise in the abdominal wall during inspiration and a fall during expiration; the movement should be free and equal on both sides. In generalized peritonitis, this movement is absent or markedly diminished (the ‘still, silent abdomen’). Visible pulsation of the abdominal aorta may be noticed in the epigastrium and is a frequent finding in nervous, thin patients. It must be distinguished from an aneurysm of the abdominal aorta, where pulsation is more obvious and a widened aorta is felt on palpation.

5. Visible peristalsis of the stomach or small intestine may be observed in three situations: 1. Obstruction at the pylorus . In pyloric obstruction, a diffuse swelling may be seen in the left upper abdomen but, where obstruction is longstanding with severe gastric distension, this swelling may occupy the left mid and lower quadrants. Such a stomach may contain a large amount of fluid and, on shaking the abdomen, a splashing noise is usually heard (‘ succussion splash’). This splash is frequently heard in healthy patients for up to 3 hours after a meal, so enquire when the patient last ate or drank. In congenital pyloric stenosis of infancy, not only may visible peristalsis be apparent but also the grossly hypertrophied circular muscle of the antrum and pylorus may be felt as a ‘tumour’ to the right of the midline in the epigastrium. Both these signs may be elicited more easily after the infant has been given a feed. Standing behind the child’s mother with the child held on her lap may allow the child’s abdominal musculature to relax sufficiently to feel the walnut-sized swelling.

6. 2. Obstruction in the distal small bowel . Peristalsis may be seen where there is intestinal obstruction in the distal small bowel or coexisting large and small bowel. Not only is the abdomen distended and tympanitic (hyper-resonant) but the distended coils of small bowel may be visible in a thin patient and tend to stand out in the centre of the abdomen in a ‘ladder pattern’. 3 As a normal finding in very thin, elderly patients with lax abdominal muscles a large, wide-necked incisional herniae seen through an abdominal scar.

7. Skin and surface of the abdomen In marked abdominal distension, the skin is smooth and shiny. Striae atrophica or gravidarum or alba are white or pink wrinkled linear marks on the abdominal skin. They are produced by gross stretching of the skin with rupture of the elastic fibres and indicate a recent change in size of the abdomen, such as is found in pregnancy, ascites, wasting diseases and severe dieting. Wide purple striae are characteristic of Cushing’s syndrome and excessive steroid treatment. Note any scars present, their site, whether they are old (white) or recent (red or pink).

8. Look for prominent superficial veins, which may be apparent in three situations: thin veins over the costal margin, usually of no significance; occlusion of the inferior vena cava; and venous anastomoses in portal hypertension. Inferior vena caval obstruction not only causes oedema of the limbs, buttocks and groins but, in time, distended veins on the abdominal wall and chest wall appear. Distended veins around the umbilicus (caput medusae ) are uncommon but signify portal hypertension.

9. Pigmentation of the abdominal wall may be seen in the midline below the umbilicus, where it forms the linea nigra and is a sign of pregnancy. Erythema ab igne is a brown mottled pigmentation produced by constant application of heat, usually a hot water bottle or heat pad, on the skin of the abdominal wall. It is a sign that the patient is experiencing severe persistent pain such as from chronic pancreatitis. Finally, uncover and inspect both groins and the external genitalia. In male patients inspect and examine the penis and scrotum for any swellings and to ensure that both testes are in their normal position. Then bring the sheet back up to the level of the symphysis pubis.