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1. Abdominal Examination By : Dr Yosef Temesgen (MD, Assistant professor of surgery)

2. Outlines Session Objectives: „ Describe relevant anatomy and physiology as it pertains to the examination of the abdomen „ Demonstrate the steps in examining the abdomen using illustrations Review common abnormalities encountered on the Physical Examination of the abdomen

3. Introduction: „ The Medical History is an account of the events in the pt’s life that have relevance to the mental/physical health of the pt. Accurate information is essential before undertaking the PE of the abdome Pain is a common symptom of diseases of the abdomen It is important to assess different aspects of a pt’s abdominal pain so that a reasonable Differential Diagnosis can be formulated

4. Abdominal Pain Important related symptoms/signs in patients with abdominal pain: „ - Fever/rigors/sweats „ - Nausea/vomiting „ - Weight loss „ - Change in bowel habits „ - Evidence of GI blood loss (hematemesis, melena,hematochezia , occult loss)

5. Dysphagia: D ifficulty of swallowing foods or liquids arising from the throats or esophagus

6. Dyspepsia, Nausea, Vomiting

7. Physical Examination: „ The PE of the abdomen must be performed in an organized, systematic fashion in order to yield accurate and consistent results.Pt should be properly prepared. Pt should be lying supine, relaxed, draped, with hands at sides or crossed on chest. Quiet room/temp. Relaxed, confident examiner. Physical Examination of the Abdomen is conducted in four parts „ Inspection/observation „ Auscultation „ Percussion „ Palpation

8. Before Examination Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Expose the patient’s chest Position patient at 45° Ask patient if they have pain anywhere before you begin!

9. General Examination Appearance : Looks Well/Ill , Consciousness , Alert Body Built : Average , Thin , Obese ( Depends On BMI ) Color : Pale , Cyanosed , jaundiced Decubitus : Patient's position in bed Distress : Difficulty In Breathing ( Dyspnoeic ), Abdominal distension .

10. Examination of head and neck

11. Lympho glandular Cervical LAP Left supraclavicular fossa( virchows node) Loss of hair gynecomastia

12. Male gynaecomastia

13. Abdominal Examination Positioning & Draping Exposure → Drape for success – expose what you need to see! Use sheet to cover lower half of body Good lighting, warm room, table flat, hands at side, head resting on table • +/- Feet flat on table

14. Surface anatomy

15. Observation Make note of : • general shape and movements • contours • symmetry • color, pigmentation • scars , striae Visible peristalsis: pyloric stenosis from left to right large bowel obstruction from left to right • ? easiest to make observations from foot of bed. • Examine from right side 1/4/2024

16. Observation of abnormal finding

17. 1. Abdominal Contour : bulge (Ascites , pregnancy , obesity, distension)or retraction(scaphoid abdomen in starvation and malignancy) 2 . Movements with respiration

18. 6 Hernias: Different types of hernias

19. Auscultation • Normal intestinal propulsion of food (peristalsis) generates noise ( Borborygmi ) • Listen (diaphragm of stethoscope) x 15-20 seconds in 4 quadrants • Pay attention to: presence, quantity (normal ~ 2-5 seconds), & quality of sounds Bowel sounds are ‘gurgles’ that are heard normally every 5-10 seconds. Listen for up to 2 minutes before concluding that bowel sounds are absent (peritonitis, paralytic ileus). In intestinal obstruction bowel sounds are sometimes described as tinkling. PS: Unlike other examinations, auscultation for bowel sounds may be carried out before percussion and palpation due to adverse effect that these procedures may have on the sound from the bowels.

20. Clinical utility: • Intestinal Obstruction: Increased frequency early (“rushes’) → declines in quantity, increase pitch (“tinkles”) → stop • After handled (surgery) → no function or noise (ileus) → w/normal recovery, noise returns • Infection of mucosa (gastroenteritis) → increased frequency • No findings pathognomonic • Auscultation not helpful in otherwise normal exam • Clinical context most important

21. Other Auscultatory findings : 1- Venous Hum: over right upper quadrant due to portosystemic collaterals in portal hypertension 2- Splenic friction rub: over the spleen (left upper quadrant ) 10th rib in inflammation of peritoneal coverage of the spleen (e.g. splenic infarction) . 3- Aortic Bruit: over abdominal aorta in case of aneurysm. 4- Renal artery bruit: over renal artery in case of renal artery stenosis. Bruits: Sounds of turbulent arterial flow → atherosclerosis Relevant if: Unexplained hypertension, kidney disease, ischemic symptoms and risk factors Listen over: - Renal arteries: several cm above umbilicus, either side rectus) - Central abdomen: celiac, SMA, IMA - Iliac arteries: below umbilicus

22. Palpation Most important structures aren’t palpable Ensure that your hands are Warm Generally right hand used (left placed on top or @ your side ) Help to position the patient Ask whether the patient feels any pain before you start Begin with superficial examination Move in a systemic manner through the abdominal quadrants Repeat palpation D eeply Palpate using pads & edges of middle 3 fingers • Gentle pressure, no sudden movements • Think about what “lives” in area you’re examining

23. Palpation Technique • First explore superficial aspect each quadrant (start R lower→ R upper→L upper→L lower) I . Superficial Palpation: 1- check if any pain and start away from that area, aim to be close to the patient's level, 2-Observe patient's face for pain during the exam 3- Start gently/softly palpating the abdomen - thinking of there being 9 regions/areas – 4- check for tenderness, guarding, masses, rebound tenderness – guarding is a sense that the abdominal muscles are tensing as you press to ‘protect’ a tender area; rebound tenderness is pain experienced by the pain when, after pressing down on part of the abdomen you release the pressure – and usually indicates intra-abdominal pathology.

24. 1)Abdominal Mass

25. Deeper palpation 2 ) Liver • Start R lower, moving up towards R ribs • Move hands a few cm up w/each palpation • Push down (posterior) & then towards head • As approach ribs, palpate while patient inspires deeply (diaphragm brings liver down towards hand) • Might feel liver edge in normals (usually not)

26. 3 ) Spleen The normal spleen is not palpable since it is underneath the left costal margin. When it is enlarged the spleen enlarges towards the umbilicus and – in gross enlargement – towards the right iliac fossa. The spleen also moves down with breathing in. So – start from the right iliac fossa/umbilicus with moderately deep palpation. Ask the patient to breath in – an enlarged spleen will push against your fingers. Ove your hand progressively (1 cm at a time) towards the left costal margin. • Palpate towards left upper quadrant from midline & below - can use L hand to “pull” spleen towards you Aorta (if RFs for aneurysm: Age > 60, smoking) • Above umbillicus , left of midline • Push down (deep) w/palpating hand Remainder of abdomen • Uterus, bladder, other (rarely palpable) • Evaluate painful areas last!

27. Palpating to Detect fluid Wave (ascites) • Examiner’s right hand on patient’s right • Push quickly→ initiate a “wave” w/in ascites • Receiving hand on Left identifies the wave • A third hand dampens passage of wave through sub-cu fat Sensitivity : 62% Specificity : 90%

28. 4 ) Palpation/Percussion Of The Kidneys • Kidneys are retroperitoneal structures, deep & protected by the ribs → rarely palpable • If markedly enlarged, may appreciate in lateral aspects abdomen (rare) • Assess for tenderness via posterior approach, tapping on back at CostoVertebral Angle – if kidney infected (pyelonephritis), patient will have Tenderness (CVAT) • Not done routinely: only in right clinical context

29. 5) Palpating Bladder

30. 6) palpating Aorta

31. Percussion Same principle as Lung Tapping over solid or liquid filled structure→ dull tone; air filled → tympanitic (resonant) Percussion → what’s beneath skin & bones – e.g : liver → dull; air filled stomach → tympanitic Abdomen not designed w/1st yr students in mind! - Key solid structures protected: liver & spleen by ribs; pancreas & kidneys deep in retro-peritoneum; bladder & uterus in pelvis - Central abdomen filled w/intestines: freely moving→ promotes peristalsis, tolerates direct trauma

32. Percussion Technique • Stand on Right • Middle finger of non-percussing hand firmly against abdomen • Using floppy wrist action, hammer middle finger of other hand down, aiming for last joint • Percuss all 4 quadrants – normal =‘s mix of dull and tympanitic

33. 1- Percussion of the liver 1- Lower border of the liver: Start percussion from right iliac fossa and go upwards in mid calavicular line till you reach the area of lower border hepatic dullness . 2- Upper Border of the liver: Start from the second right intercostal space till you reach the hepatic dullness which is normally in 5th right intercostal space Percuss downwards from the fifth intercostal space below nipple (mid- clavicular line) & move down –tone changes from resonant (lung) to dull (liver) to resonant (intestines ) as a check of the size of the liver AND localize the right lobe lower edge by palpation (liver span). Normal liver span is 6-12 cm at the right MCL and 4-8 cm at midaternal line. Measurements by means of percussion typically underestimates liver size.

34. 2- Percussion of the spleen Spleen – small, located in hollow of ribs – percussion over last intercostal space, anterior axillary line should normally be resonant – dullness suggests splenomegaly Stomach – tympanitic

35. 3- Percussion of Bladder : An enlarged bladder may be felt and percussed rising up centrally from the pelvis.

36. Percussion To Detect Ascites: 4- Shifting Dullness If there is free fluid in the abdomen – ascites – it may be appropriate to test for ‘shifting dullness’. With the patient flat on their back, percuss from the umbilicus out to the flanks on each side and note where the tone becomes dull. Then ask the patient to lie on one side for about 15 secs and repeat the exercise. If there is free fluid the dullness on the flank which is now upper most should have shifted (as the fluid moves down) and this area should now be resonant. Used to detect large amounts of pathological fluid (ascites ) • Intestines will float to surface • Percussion can detect air-fluid interface • Flank Dullness alone : • Sensitivity: 84% • Specificity: 59% • Shifting Dullness : • Sensitivity: 77% • Specificity: 72%

37. 5-Fluid Thrill If there is gross ascites, it may be possible to feel for a ‘thrill’ – vibration sensation. Ask the patient to place their hand on the midline of the abdomen. Flick one side of the abdomen and place your other hand on the other side of the abdomen to feel if this creates a vibration.

38. DRE

39. THANKS !!!!