EXAMINATION OF THE ABDOMEN

The major components of the abdominal exam include: observation, auscultation,

percussion, and palpation. While these are the same elements which make up the
pulmonary and cardiac exams, they are performed here in a slightly different order (i.e.
auscultation before percussion) and carry different degrees of importance. Pelvic, genital,
and rectal exams, all part of the abdominal evaluation, are discussed elsewhere.

Think Anatomically: When looking, listening, feeling and percussing imagine what
organs live in the area that you are examining. The abdomen is roughly divided into four
quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic
terms, you will remind yourself of what resides in a particular quadrant and therefore
what might be identifiable during both normal and pathologic states.

Quadrants of the Abdomen

Topical Anatomy of the Abdomen

By convention, the abdominal exam is performed with the provider standing on the
patient's right side.

Observation: Much information can be gathered from simply watching the patient and
looking at the abdomen. This requires complete exposure of the region in question, which
is accomplished as follows:

1. Ask the patient to lie on a level examination table that is at a comfortable height
for both of you. At this point, the patient should be dressed in a gown and, if they
wish, underwear.
2. Take a spare bed sheet and drape it over their lower body such that it just covers
the upper edge of their underwear (or so that it crosses the top of the pubic region
if they are completely undressed). This will allow you to fully expose the
abdomen while at the same time permitting the patient to remain somewhat
covered. The gown can then be withdrawn so that the area extending from just
below the breasts to the pelvic brim is entirely uncovered, remembering that the
superior margin of the abdomen extends beneath the rib cage.
 Draping the Abdomen

3. The patient's hands should remain at their sides with their heads resting on a
pillow. If the head is flexed, the abdominal musculature becomes tensed and the
examination made more difficult. Allowing the patient to bend their knees so that
the soles of their feet rest on the table will also relax the abdomen.
4. Keep the room as warm as possible and make sure that the lighting is adequate.
By paying attention to these seemingly small details, you create an environment
that gives you the best possible chance of performing an accurate examination.
This is particularly important early in your careers, when your skills are relatively
unrefined. However, it will also stand you in good stead when examining obese,
anxious, distressed or otherwise challenging patients.

While observing the patient, pay particular attention to:

1. Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear

symmetric or are there distinct protrusions, perhaps linked to underlying
organomegaly? The contours of the abdomen can be best appreciated by standing
at the foot of the table and looking up towards the patient's head. Global
abdominal enlargement is usually caused by air, fluid, or fat. It is frequently
impossible to distinguish between these entities on the basis of observation alone
(see below for helpful maneuvers). Areas which become more pronounced when
the patient valsalvas are often associated with ventral hernias. These are points of
weakening in the abdominal wall, frequently due to previous surgery, through
which omentum/intestines/peritoneal fluid can pass when intra-abdominal
pressure is increased.

Various Causes of Abdominal Distension

 Obese abdomen Hepatomegaly

Markedly enlarged gall bladder

Ascites
(labeled "GB")

Same umbilical hernia while patient

Umbilical Hernia
performs valsalva maneuver.

2. Presence of surgical scars or other skin abnormalities.

3. Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis)
prefer to lie very still as any motion causes further peritoneal irritation and pain.
Contrary to this, patients with kidney stones will frequently writhe on the
examination table, unable to find a comfortable position.
Auscultation: Compared to the cardiac and pulmonary exams, auscultation of the
abdomen has a relatively minor role. It is performed before percussion or palpation as
vigorously touching the abdomen may disturb the intestines, perhaps artificially altering
their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed
(accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on
the abdomen and listening for 15 or 20 seconds. There is no magic time frame. The
stethoscope can be placed over any area of the abdomen as there is no true
compartmentalization and sounds produced in one area can probably be heard
throughout. How many places should you listen in? Again, there is no magic answer. At
this stage, practice listening in each of the four quadrants and see if you can detect any
"regional variations."
Abdominal Auscultation

What exactly are you listening for and what is its significance? Three things should be
noted:

1. Are bowel sounds present?

2. If present, are they frequent or sparse (i.e. quantity)?
3. What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to
as bowel sounds, is generated. These sounds occur quite frequently, on the order of every
2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves
do not carry great significance. That is, in the normal person who has no complaints and
an otherwise normal exam, the presence or absence of bowel sounds is essentially
irrelevant (i.e. whatever pattern they have will be normal for them). In fact, most
physicians will omit abdominal auscultation unless there is a symptom or finding
suggestive of abdominal pathology. However, you should still practice listening to all the
patients that you examine so that you develop a sense of what constitutes the range of
normal. Bowel sounds can, however, add important supporting information in the right
clinical setting. In general, inflammatory processes of the serosa (i.e. any of the surfaces
which cover the abdominal organs....as with peritonitis) will cause the abdomen to be
quiet (i.e. bowel sounds will be infrequent or altogether absent). Inflammation of the
intestinal mucosa (i.e. the insides of the intestine, as might occur with infections that
cause diarrhea) will cause hyperactive bowel sounds. Processes which lead to intestinal
obstruction initially cause frequent bowel sounds, referred to as "rushes." Think of this as
the intestines trying to force their contents through a tight opening. This is followed by
decreased sound, called "tinkles," and then silence. Alternatively, the reappearance of
bowel sounds heralds the return of normal gut function following an injury. After
abdominal surgery, for example, there is a period of several days when the intestines lie
dormant. The appearance of bowel sounds marks the return of intestinal activity, an
important phase of the patient's recovery. Bowel sounds, then, must be interpreted within
the context of the particular clinical situation. They lend supporting information to other
findings but are not in and of themselves pathognomonic for any particular process.

After you have finished noting bowel sounds, use the diaphragm of your stethoscope to
check for renal artery bruits, a high pitched sound (analogous to a murmur) caused by
turbulent blood flow through a vessel narrowed by atherosclerosis. The place to listen is a
few cm above the umbilicus, along the lateral edge of either rectus muscles. Most
providers will not routinely check for bruits. However, in the right clinical setting (e.g. a
patient with some combination of renal insufficiency, difficult to control hypertension
and known vascular disease), the presence of a bruit would lend supporting evidence for
the existence of renal artery stenosis. When listening for bruits, you will need to press
down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis
distal to the aorta (i.e. at the take off of the Iliac Arteries) can also generate bruits. Blood
flow through the aorta itself does not generate any appreciable sound. Thus, auscultation
over this structure is not a good screening test for the presence of aneurysmal dilatation.

Percussion: The technique for percussion is the same as that used for the lung exam.
First, remember to rub your hands together and warm them up before placing them on the
patient. Then, place your left hand firmly against the abdominal wall such that only your
middle finger is resting on the skin. Strike the distal interphalangeal joint of your left
middle finger 2 or 3 times with the tip of your right middle finger, using the previously
described floppy wrist action (see under lung exam). There are two basic sounds which
can be elicited:

1. Tympanitic (drum-like) sounds produced by percussing over air filled structures.

2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies
beneath the region being examined.

*Special note should be made if percussion produces pain, which may occur if there is
underlying inflammation, as in peritonitis. This would certainly be supported by other
historical and exam findings.
Abdominal Percussion
What can you really expect to hear when percussing the normal abdomen? The two solid
organs which are percussable in the normal patient are the liver and spleen. In most cases,
the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a
centimeter or two below the costal margin. The spleen is smaller and is entirely protected
by the ribs. To determine the size of the liver, proceed as follows:

1. Start just below the right breast in a line with the middle of the clavicle, a point
that you are reasonably certain is over the lungs. Percussion in this area should
produce a relatively resonant note.
2. Move your hand down a few centimeters and repeat. After doing this several
times, you will be over the liver, which will produce a duller sounding tone.
3. Continue your march downward until the sound changes once again. This may
occur while you are still over the ribs or perhaps just as you pass over the costal
margin. At this point, you will have reached the inferior margin of the liver. The
total span of the normal liver is quite variable, depending on the size of the patient
(between 6 and 12 cm). Don't get discouraged if you have a hard time picking up
the different sounds as the changes can be quite subtle, particularly if there is a lot
of subcutaneous fat.
4. The resonant tone produced by percussion over the anterior chest wall will be
somewhat less drum like then that generated over the intestines. While they are
both caused by tapping over air filled structures, the ribs and pectoralis muscle
tend to dampen the sound.
5. Speed percussion, as described in the pulmonary section, may also be useful.
Orient your left hand so that the fingers are pointing towards the patients head.
Percuss as you move the hand at a slow and steady rate from the region of the
right chest, down over the liver and towards the pelvis. This maneuver helps to
accentuate different percussion notes, perhaps making the identification of the
liver's borders a bit more obvious.
Percussion of the spleen is more difficult as this structure is smaller and lies quite
laterally, resting in a hollow created by the left ribs. When significantly enlarged,
percussion in the left upper quadrant will produce a dull tone. Splenomegaly suggested
by percussion should then be verified by palpation (see below). The remainder of the
normal abdomen is, for the most part, filled with the small and large intestines. Try
percussing each of the four quadrants to get a sense of the normal variations in sound that
are produced. These will be variably tympanitic, dull or some combination of the above,
depending on whether the underlying intestines are gas or liquid filled. The stomach
"bubble" should produce a very tympanitic sound upon percussion over the left lower rib
cage, close to the sternum.

Percussion can be quite helpful in determining the cause of abdominal distention,

particularly in distinguishing between fluid (a.k.a. ascites) and gas. Of the techniques
used to detect ascites, assessment for shifting dullness is perhaps the most reliable and
reproducible. This method depends on the fact that air filled intestines will float on top of
any fluid that is present. Proceed as follows:

1. With the patient supine, begin percussion at the level of the umbilicus and
proceed down laterally. In the presence of ascites, you will reach a point where
the sound changes from tympanitic to dull. This is the intestine-fluid interface and
should be roughly equidistant from the umbillicus on the right and left sides as the
fluid layers out in a gravity-dependent fashion, distributing evenly across the
posterior aspect of the abdomen. It should also cause a symmetric bulging of the
patient's flanks.
2. Mark this point on both the right and left sides of the abdomen and then have the
patient roll into a lateral decubitus position (i.e. onto either their right or left
sides).
3. Repeat percussion, beginning at the top of the patient's now up-turned side and
moving down towards the umbilicus. If there is ascites, fluid will flow to the most
dependent portion of the abdomen. The place at which sound changes from
tympanitic to dull will therefore have shifted upwards (towards the umbillicus)
and be above the line which you drew previously. Speed percussion (described
above) may also be used to identify the location of the air-fluid interface. If the
distention is not caused by fluid (e.g. secondary to obesity or gas alone), no
shifting will be identifiable.

The models below should help to clarify the concept of shifting dullness. With the
"patient" lying flat on their back balloons (representing the intestines)
float on the water (representing ascites). When the "patient" turns on their right
side, a new air fluid level is established.
Shifting Dullness (real patient)
Realize that there has to be a lot of ascites present for this method to be successful as the
abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on
physical exam. Also, shifting dullness is based on the assumption that fluid can flow
freely throughout the abdomen. Thus, in cases of prior surgery or infection with resultant
adhesion formation, this may not be a very useful technique. Palpation can also be used
to check for ascites (see below).

Palpation: First warm your hands by rubbing them together before placing them on the
patient. The pads and tips (the most sensitive areas) of the index, middle, and ring fingers
are the examining surfaces used to locate the edges of the liver and spleen as well as the
deeper structures. You may use either your right hand alone or both hands, with the left
resting on top of the right. Apply slow, steady pressure, avoiding any rapid/sharp
movements that are likely to startle the patient or cause discomfort. Examine each
quadrant separately, imagining what structures lie beneath your hands and what you
might expect to feel.

1. Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-
clavicular line. This should insure that you are below the liver edge. In general, it
is easier to detect abnormal if you start in an area that you're sure is normal.
Gently push down (posterior) and towards the patient's head with your hand
oriented roughly parallel to the rectus muscle, allowing the greatest number of
fingers to be involved in the exam as you try to feel the edge of the liver. Advance
your hands a few cm cephelad and repeat until ultimately you are at the bottom
margin of the ribs. Initial palpation is done lightly.

Abdominal Palpation
2. Following this, repeat the examination of the same region but push a bit more
firmly so that you are interrogating the deeper aspects of the right upper quadrant,
particularly if the patient has a lot of subcutaneous fat. Pushing up and in while
the patient takes a deep breath may make it easier to feel the liver edge as the
downward movement of the diaphragm will bring the liver towards your hand.
The tip of the xyphoid process, the bony structure at the bottom end of the
sternum, may be directed outward or inward and can be mistaken for an
abdominal mass. You should be able to distinguish it by noting its location
relative to the rib cage (i.e. in the mid-line where the right and left sides meet).

Rib Cage
3. You can also try to "hook" the edge of the liver with your fingers. To utilize this
technique, flex the tips of the fingers of your right hand (claw-like). Then push
down in the right upper quadrant and pull upwards (towards the patient's head) as
you try to rake-up on the edge of the liver. This is a nice way of confirming the
presence of a palpable liver edge felt during conventional examination.

Hooking Edge of the Liver

4. Place your right hand at the inferior and lateral border of the ribs, pushing down
as you push up from behind with your left hand. If the right kidney is massively
enlarged, you may be able to feel it between your hands.
5. Now examine the left upper quadrant. The normal spleen in not palpable. When
enlarged, it tends to grow towards the pelvis and the umbilicus (i.e. both down
and across). Begin palpating near the belly button and move slowly towards the
ribs. Examine superficially and then more deeply. Then start 8-10 cm below the
rib margin and move upwards. In this way, you will be able to feel enlargement in
either direction. You can use your left hand to push in from the patient's left flank,
directing an enlarged spleen towards your right hand. If the spleen is very big, you
may even be able to "bounce" it back and forth between your hands.
Splenomegaly is probably more difficult to appreciate then hepatomegaly. The
liver is bordered by the diaphragm and can't move away from an examining hand.
The spleen, on the other hand, is not so definitively bordered and thus has a
tendency to float away from you as you palpate. So, examine in a slow, gentle
fashion. The edge, when palpable, is soft, rounded, and rather superficial. Repeat
the exam with the patient turned onto their right side, which will drop the spleen
down towards your examining hand.
6. Exploration for the left kidney is performed in the same fashion as described for
the right. Kidney pain, most commonly associated with infection, can be elicited
on direct examination if the entire structure becomes palpable as a result of
associated edema. This is generally not the case. However, as the kidney lies in
the retroperitoneum, pounding gently with the bottom of your fist on the costo-
vertebral angle (i.e. where the bottom-most ribs articulate with the vertebral
column) will cause pain if the underlying kidney is inflamed. Known as costo-
vertebral angle tenderness (CVAT), it should be pursued when the patient's
history is suggestive of a kidney infection (e.g. fever, back pain and urinary tract
symptoms).

Posterior

View: Location of the Kidneys

Gross Retroperitoneum Anatomy

7. Examine the left and right lower quadrants, palpating first superficially and then
deeper. A stool filled sigmoid colon or cecum are the most commonly identified
structures on the left and right side respectively. The smooth dome of the bladder
may rise above the pelvic brim and become palpable in the mid-line, though it
needs to be quite full of urine for this to occur. Other pelvic organs can also
occasionally be identified, most commonly the pregnant uterus, which is a firm
structure that grows up and towards the umbillicus. The ovaries and fallopian
tubes are not identifiable unless pathologically enlarged.
8. Finally, try to feel the abdominal aorta. First push down with a single hand in the
area just above the umbillicus. If you are able to identify this pulsating structure
with one hand, try to estimate its size. To do this, orient your hands so that the
thumbs are pointed towards the patient's head. Then push deeply and try to
position them so that they are on either side of the blood vessel. Estimate the
distance between the palms (it should be no greater then roughly 3 cm). This is,
admittedly, a crude technique. Remember also that the aorta is a retorperitoneal
structure and can be very hard to appreciate in obese patients. There have been no
reports of anyone actually causing the aorta to rupture using this maneuver, so
don't be afraid to push vigorously.

Vascular Anatomy
What can you expect to feel? In general, don't be discouraged if you are unable to
identify anything. Remember that the body is designed to protect critically important
organs (e.g. liver and spleen beneath the ribs; kidneys and pancreas deep in the
retroperitoneum; etc.). It is, for the most part, during pathologic states that these organs
become identifiable to the careful examiner. However, you will not be able to recognize
abnormal until you become comfortable identifying variants of normal, a theme common
to the examination of any part of the body. It is therefore important to practice all of these
maneuvers on every patient that you examine. It's also quite easy to miss abnormalities if
you rush or push too vigorously, so take your time and focus on the tips/pads of your
fingers.

Examining for a fluid wave: When observation and/or percussion are suggestive of
ascites, palpation can be used as a confirmatory test. Ask the patient or an observer to
place their hand so that it is oriented longitudinally over the center of the abdomen. They
should press firmly so that the subcutaneous tissue and fat do not jiggle. Place your right
hand on the left side of the abdomen and your left hand opposite, so that both are
equidistant from the umbillicus. Now, firmly tap on the abdomen with your right hand
while your left remains against the abdominal wall. If there is a lot of ascites present, you
may be able to feel a fluid wave (generated in the ascites by the tapping maneuver) strike
against the abdominal wall under your left hand. This test is quite subjective and it can be
difficult to say with assurance whether you have truly felt a wave-like impulse.

Assessing for a fluid wave

The abdominal examination, like all other aspects of the physical, is not done randomly.
Every maneuver has a purpose. Think about what you're expecting to see, hear, or feel.
Use information that you've gathered during earlier parts of the exam and apply it in a
rational fashion to the rest of your evaluation. If, for example, a certain area of the
abdomen was tympanitic during percussion, feel the same region and assure yourself that
there is nothing solid in this location. Go back and repeat maneuvers to either confirm or
refute your suspicions. In the event that a patient presents complaining of pain in any
region of the abdomen, have them first localize the affected area, if possible with a single
finger, pointing you towards the cause of the problem. Then, examine each of the other
abdominal quadrants first before turning your attention to the area in question. This
should help to keep the patient as relaxed as possible and limit voluntary and involuntary
guarding (i.e. superficial muscle tightening which protects intra-abdominal organs from
being poked), allowing you to gather the greatest amount of clinical data. Make sure you
glance at the patient's face while examining a suspected tender area. This can be
particularly revealing when evaluating otherwise stoic individuals (i.e. even these patients
will grimace if the area is painful to the touch). The goal, of course, is to obtain relevant
information while generating a minimal amount of discomfort.

Findings Commonly Associated With Advanced Liver Disease: Chronic liver disease
usually results from years of inflamation, which ultimately leads to fibrosis and decline in
function. Histologically, this is referred to as Cirrhosis. This can be driven by a number
of different processes, most commonly chronic alcohol use, viral hepatitis (B or C) or
hemachromatosis (the complete list is much longer). It's important to realize that a
cirrhotic liver can be markedly enlarged (in which case it may be palpable) or shrunken
and fibrotic (non-palpable).
After many years (generally greater then 20) of chronic insult, the liver may become
unable to perform some or all of its normal functions. There are several clinical
manifestations of this dysfunction. While none are pathonomonic for liver disease, in the
right historical context they are very suggestive of underlying pathology. Some of the
most common findings are described and/or pictured below.

1. Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete

bilirubin appropriately. This can lead to
a. Icterus - Yellow discoloration of the sclera.
b. Jaundice - Yellow discoloration of the skin.
c. Bilirubinuria - Golden-brown coloration of the urine.
2. Ascites: Portal vein hypertension results from increased resistance to blood flow
through an inflamed and fibrotic liver. This can lead to ascites, accumulation of
fluid in the peritoneal cavity.
3. Increased Systemic Estrogen Levels: The liver may become unable to process
particular hormones, leading to their peripheral conversion into estrogen. High
levels promote:
a. Breast development (gynecomastia).
b. Spider Angiomata - dilated arterioles most often visible on the skin of the
upper chest.
c. Testicular atrophy.
4. Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to
lower intravascular oncotic pressure and resultant leakage of fluid into soft
tissues. This is particularly evident in the lower extremities.
5. Varices: In the setting of portal hypertension, blood "finds" alternative pathways
back to the heart that do not pass through the liver. The most common is via the
splenic and short gastric veins, which pass through the esophageal venous plexus
enroute to the SVC. This causes esophageal varices which can bleed profoundly,
though these are not apparent on physical examination. A much less common path
utilizes the recanalized umbilical vein, which directs blood through dilated
superficial veins in the abdominal wall. These are visible on inspection of the
abdomen and are known as Caput Medusae.

Icterus
 Ascites Jaundice

Gynecomastia Spider
Edema