Abdominal Examination: A Comprehensive Guide

I. Abdominal Regions:

• 2 Methods of Division:

• Method 1: Nine Regions:

• Upper Region: Epigastric, Right Hypochondriac, Left Hypochondriac

• Middle Region: Umbilical, Right Iliac, Left Iliac

• Lower Region: Hypogastric, Right Inguinal, Left Inguinal

• Method 2: Four Quadrants:

• Right Upper Quadrant: Liver, Gallbladder, Duodenum (upper portion), Right Transverse Colon, Head of Pancreas, Right Kidney, Common Bile Duct, Right Hepatic Duct

• Right Lower Quadrant: Cecum, Appendix, Ascending Colon (lower portion), Right Transverse Colon, Right Ovary

• Left Upper Quadrant: Stomach, Spleen, Tail of Pancreas, Left Transverse Colon, Left Kidney, Splenic Flexure

• Left Lower Quadrant: Descending Colon, Sigmoid Colon, Left Ovary

• Lines Used in Four Quadrant Division:

• Upper Transverse Line: Passes through the umbilicus, parallel to the line connecting the inferior costal margins.

• Lower Transverse Line: Passes through the umbilicus, parallel to the line connecting the anterior superior iliac spines.

• Right Vertical Line: Extends from the lowest point of the right costal margin to the right iliac fossa.

• Left Vertical Line: Extends from the lowest point of the left costal margin to the left iliac fossa.

II. Organ Locations and Tender Points:

• Note: Organ locations can vary depending on the patient’s build and posture.

• Errors in Organ Placement: Statement C is incorrect. The liver is located on the right side.

• Tender Points:

• Liver, Gallbladder, Pancreas:

• Epigastric Tenderness: Location: Xiphoid process of the sternum. Application: Left hepatic duct pain due to roundworm infestation.

• Gallbladder Tenderness: Location: Intersection of the right costal margin and the outer edge of the rectus abdominis muscle. Application: Gallstones, chronic cholecystitis, roundworm infestation in the gallbladder.

• Mayo Robson Point: Location: Intersection of the left latissimus dorsi muscle and the lowest point of the 12th thoracic vertebra. Application: Acute pancreatitis.

• Chauffard Rivet Triangle: Location: Connecting three points: xiphoid process, umbilicus, and the lowest point of the right costal margin. Application: Cholecystitis.

• Stomach and Duodenum:

• Epigastric Tenderness: Location: Midline between the inferior costal margins, at the level of the xiphoid process. Application: Stomach pain, peptic ulcer disease.

• Duodenal Tenderness: Location: Intersection of a horizontal line through the umbilicus and the midline of the abdomen. Application: Duodenal pain.

• Appendix:

• McBurney’s Point: Location: Intersection of a line connecting the anterior superior iliac spine and the umbilicus, dividing this line in a 2:3 ratio, with the outer portion representing 2/3. Application: Appendicitis.

• Lanz Point: Location: Intersection of a horizontal line through the umbilicus and the right vertical line. Application: Appendicitis.

• Clado Point: Location: Intersection of a line connecting the anterior superior iliac spine and the umbilicus, dividing this line in a 1:3 ratio, with the inner portion representing 1/3. Application: Appendicitis.

• Kidneys:

• Costovertebral Tenderness: Location: Intersection of the outer edge of the rectus abdominis muscle and a vertical line through the umbilicus. Application: Nephritis.

• Costoiliac Tenderness: Location: Intersection of the inferior costal margin and a vertical line through the umbilicus. Application: Nephritis.

• Ureters:

• Upper Ureteral Tenderness: Location: Intersection of the outer edge of the rectus abdominis muscle and a vertical line through the umbilicus, at the level of the inferior costal margin. Application: Ureteral calculi.

• Middle Ureteral Tenderness: Location: Intersection of a horizontal line through the umbilicus and a line connecting the two anterior superior iliac spines. Application: Ureteral calculi.

• Lower Ureteral Tenderness: Location: Bilateral to the bladder, examined via rectal or vaginal examination. Application: Ureteral calculi.

• Ovary Tenderness: Location: Intersection of the superior margin of the pubic bone and the line connecting the two anterior superior iliac spines. Application: Oophoritis.

III. Rigidity, Distention, and Abdominal Enlargement:

• Abdominal Rigidity:

• Suggestive Diseases: Peritonitis, gastric perforation, duodenal perforation.

• Mechanism: Peritoneal irritation causes abdominal muscle spasms to protect the injured organs.

• Note: Abdominal rigidity may be absent in individuals with muscle injuries (e.g., gym-goers).

• Abdominal Distention:

• Types of Distention:

• Generalized Distention: Functional bowel obstruction, mechanical bowel obstruction, flatulence due to poor diet.

• Lower Distention: Functional bowel obstruction, mechanical bowel obstruction.

• Unilateral Distention: Volvulus of the pelvic colon.

• Distention with Upper Concavity and Lower Boat-Shaped Depression: Pyloric stenosis.

• Abdominal Enlargement:

• Suggestive Diseases: Pregnancy, obesity, cirrhosis, ovarian cyst, hepatic cyst, gastric cyst, intestinal cyst, etc.

• Note: A clinical examination is necessary to determine the cause of abdominal enlargement.

IV. Mechanical and Functional Bowel Obstruction:

• Differentiation:

• Mechanical Bowel Obstruction:

• Caused by a physical obstruction in the intestines, such as gallstones, tumors, foreign bodies, etc.

• Signs: “Rumbling” bowel sounds, visible bowel loops, severe abdominal pain, vomiting…

• Functional Bowel Obstruction:

• Caused by impaired intestinal motility, such as inflammation, infection, etc.

• Signs: Abdominal distention, pain, vomiting, constipation…

• Note: A physical examination is crucial to differentiate between mechanical and functional bowel obstruction, preventing misdiagnosis.

V. Abdominal Examination Signs:

• “Rumbling” Bowel Sounds: Bowel loops move across the abdominal wall, suggesting mechanical bowel obstruction.

• Von Wahl’s Sign: Prominent bowel loops remain stationary, tender to palpation, suggesting a double bowel obstruction.

• Soft Mass That Comes and Goes: Suggests intussusception.

• Soft Mass That Disappears Upon Palpation: Suggests a hernia.

• Soft Mass That Doesn’t Disappear Upon Palpation: Suggests an incarcerated hernia.

• Cullen’s Sign: Bruising around the umbilicus, suggesting acute hemorrhagic pancreatitis.

• Grey Turner’s Sign: Bruising in the flanks, suggesting acute hemorrhagic pancreatitis.

VI. Pre-Palpation Precautions:

• Inform the Patient: To ensure cooperation and prevent startling.

• Flexed Knees: Relaxes abdominal muscles for easier examination.

• Palpate Tender Areas First, Then Non-Tender Areas: To avoid startling the patient and facilitate comparison of pain levels.

• Use the Tips of Fingers 2-5: Increases contact area for better detection of abnormalities.

VII. Causes of Skin Swelling and Redness:

• Abscess Adherent to the Abdominal Cavity –> Rupture –> Pus Escapes from the Peritoneal Wall to the Skin Layer –> Causes Inflammation in the Affected Skin Area.

VIII. Causes of Portal Hypertension:

• Due to cirrhosis –> Portal vein obstruction –> Blood flows through collateral pathways –> Increased portal venous pressure –> Leads to portal hypertension.

IX. Abdominal Wall and Peritoneal Symptoms:

• Abdominal Wall Rigidity: Abdominal muscles become rigid like a board, serving to protect the injured organs inside. Significance: Diagnosis of peritonitis caused by perforation of the stomach, duodenum, or appendiceal abscess…

• Abdominal Wall Guarding: Palpation of the abdomen elicits increased resistance and pain as the examination deepens, significance: Indicates the location of inflammatory foci in the abdomen (without rupture), localized rigidity at the palpation site.

• Peritoneal Irritation: Probing the abdomen with one finger causes sharp pain, significance: Accurate diagnosis of peritonitis.

• Rebound Tenderness: Stimulation in one area –> pain radiates to another area, significance: Diagnosis of generalized peritonitis.

X. Describing Ten Characteristics of an Abdominal Mass:

• Location: Where it is located in the abdominal cavity.

• Size: How big or small it is.

• Shape: Round, oval, or irregularly shaped.

• Consistency: Hard or soft, firm or spongy.

• Mobility: Mobile or fixed.

• Borders: Clearly defined or indistinct.

• Surface: Smooth, bumpy, or rough.

• Pulsatile: Presence or absence of a pulsation.

• Painful or Painless: Masses are usually painless.

• Constant or Intermittent: Present consistently or only when the patient changes posture.

XI. Performing Murphy’s Sign:

• Step 1: Place the right hand under the right costal margin.

• Step 2: Apply gentle pressure initially, then gradually increase pressure with inspiration.

• Step 3: Continue to press until the patient stops breathing due to pain, then cease.

Note:

• Murphy’s sign is not a specific indicator of cholecystitis; it should be combined with other examinations for accurate diagnosis.

• Perform the steps gently to avoid causing pain to the patient.

XII. Additional Considerations:

• Combine other examination techniques such as endoscopy, ultrasound, laparoscopy, etc., for precise disease diagnosis.

• Keep up-to-date with medical knowledge to enhance the quality of your examinations.

This article aims to provide you with useful information on performing an abdominal examination.