Complete Guide for Abdominal Examination

A. Inspection

Surface Anatomy:

• Vertical lines: From midclavicular to midinguinal points.
• Upper horizontal (subcostal) plane: Through 9th/10th costal cartilage (L3 vertebra).
• Lower horizontal (transtubercular) plane: Through iliac tubercles (L5 vertebra).

9 Abdominal Regions:

• Right hypochondriac
• Epigastric
• Left hypochondriac
• Right lumbar
• Umbilical
• Left lumbar
• Right iliac
• Hypogastric (suprapubic)
• Left iliac

1. Shape of the Abdomen

• Normal: Flat or rounded.
• Distension causes ("7 F’s"):
• Fat: Pendulous, symmetrical.
• Fluid: Shifting dullness, fluid thrill, horseshoe dullness.
• Flatus: Tympany, especially at periphery.
• Feces: Distension, fecal masses in flanks.
• Fetus: Central dullness, fetal parts palpable.
• Full bladder: Tender cystic mass above pubis.
• Fatal growth (tumors): Asymmetric dullness, e.g., ovarian tumors.
• Scaphoid abdomen: Seen in starvation or malignancy.

2. Umbilicus

• Normal: Inverted, central.
• Position change:
• Ascites:Distance between Xiphisternum–umbilicus is greater than the distance between umbilicus–pubis.
• Ovarian tumor: Distance between Xiphisternum–umbilicus is lesser than the distance between umbilicus–pubis.
• Appearance:
• Everted: Herniation, massive ascites.
• "Crying" umbilicus: Leaking fluid – ascitic, fecal, or urachal.
• Cullen’s sign: Bluish umbilicus → pancreatitis or ectopic pregnancy.
• Grey Turner’s sign: Bluish flanks → retroperitoneal hemorrhage.

3. Abdominal Movements

• Normal: Bulging on inspiration, flattening on expiration.
• Abnormal:
• Absent: Peritonitis.
• Paradoxical (bulge on expiration): Diaphragmatic paralysis.

4. Pulsations

• Visible in:
• Thin/anxious individuals: Normal aortic pulsations.
• Aortic aneurysm: Expansile pulsation in all positions.
• Tumor over aorta: Transmitted pulsation – disappears in knee-elbow position unless adherent.
• RV hypertrophy: Epigastric pulsations.
• Congested liver: May cause posterior pulsations.

5. Dilated Veins

• IVC obstruction: Veins on the sides, blood flows upward.
• Portal vein obstruction: Caput medusae (around umbilicus), blood flows radially outward.

6. Peristalsis

• How to elicit: Observe quietly; if not visible, have patient drink or tap abdomen.
• Types:
• Stomach: Left to right in epigastrium (pyloric stenosis).
• Colon: Right to left (transverse colon).
• Small intestine: Ladder-like pattern in midline.

7. Hernial Sites

• Check: Groin while standing and coughing.
• Differentiation:
• Inguinal hernia: Impulse above and medial to pubic tubercle.
• Direct: Bulges straight forward.
• Indirect: Downward oblique bulge.
• Femoral hernia: Impulse below and lateral to pubic tubercle.

8. Skin Changes

• Smooth, glossy skin: Current distension.
• Wrinkled skin: Past resolved distension.
• Striae (stretch marks): Seen in obesity, ascites, pregnancy, steroid use.
• Pink/red: Recent.
• White: Older or resolved.

B.Palpation

1. Superficial palpation

• Local temperature
• Tenderness
• Guarding or Rigidity

Patient Positioning

• Supine, with shoulders slightly raised and knees flexed (to relax abdominal muscles).
• Mouth open, breathing quietly and deeply.

I. Tenderness

• Definition: Pain on pressure.
• Associated with: Inflammatory lesions of viscera/peritoneum.
• Key Sites & Diagnoses:
  • Epigastric – Peptic ulcer
  • Right hypochondrium – Hepatitis, cholecystitis
  • Right iliac fossa – Appendicitis (McBurney’s point)
• Rebound tenderness: Pain when pressure is released → Suggests peritonitis/appendicitis

II. Guarding

• Voluntary muscular contraction over a tender area.
• Reduces with patient relaxation and reassurance.
• Seen in early or localized peritoneal irritation.

III. Rigidity

• Involuntary, persistent muscle contraction.
• Indicates serious intra-abdominal pathology, e.g.:
  • Perforated hollow organ
  • Peritonitis
  • Acute pancreatitis or cholecystitis
  • Intestinal strangulation
  • Mesenteric artery thrombosis
  • Ruptured ectopic pregnancy
  • Torsion of ovarian mass
• Board-like rigidity: Chemical peritonitis (e.g. gastric/duodenal ulcer perforation)

Palpation of Viscera or Deep palpation

• General Positioning:
  • Supine position
  • Head slightly raised, knees flexed
  • Arms by the side, abdomen relaxed
  • Ask the patient to breathe quietly and deeply through an open mouth
  • Examine from the right side of the patient

A. Liver Palpation

• Method:
  • Place right hand flat on the right iliac fossa, parallel to the costal margin.
  • Gently press inward and upward, moving step-by-step toward the right costal margin.
  • Ask the patient to take a deep breath with each step.
  • Feel the liver edge (if enlarged) descending with inspiration.
  • Use fingertips to define the liver edge.
• Normal Findings: Not palpable or felt just at costal margin. Edge is sharp, firm, regular, and smooth.
• Abnormal Findings:
  • Nodular surface → Cirrhosis
  • Tender liver → Hepatitis, hepatic congestion
  • Firm, enlarged, non-tender → Malignancy
  • Pulsatile liver → Tricuspid regurgitation
• Measurement: Liver span is recorded in cm or fingerbreadths below the right costal margin in mid-clavicular line.

B. Spleen Palpation

• Classical Method (Supine):
  • Stand on the right side.
  • Start from right iliac fossa and move diagonally toward the left costal margin.
  • Ask the patient to take a deep breath at each step.
  • Feel for spleen tip descending during inspiration.
• Bimanual Method (Right Lateral):
  • Left hand on posterior lower left rib cage.
  • Right hand below the left costal margin anteriorly.
  • Press inward and upward during deep inspiration.
• Hooking Method: In right lateral position, hook fingers under left costal margin (useful in obese patients).
• Dipping Method: Used in ascites; press deeply to displace fluid and feel spleen.
• Findings:
  • Enlarged spleen: Notched edge, moves with respiration, firm, may be tender/non-tender
• Hackett's Classification of Splenomegaly:
  • 0 – Not palpable
  • 1 – Just palpable
  • 2 – Palpable halfway between costal margin and umbilicus
  • 3 – Palpable up to umbilicus
  • 4 – Palpable between umbilicus and pubic symphysis
  • 5 – Reaching up to pubic symphysis

C. Gallbladder Palpation

• Method: Same as liver; palpate just lateral to rectus abdominis, below right costal margin.
• Findings:
  • Palpable, non-tender gallbladder with jaundice → Carcinoma head of pancreas (Courvoisier's law)
  • Tender, palpable gallbladder → Acute cholecystitis
  • Mucocele → Obstructed by gallstone, non-tender, non-jaundiced

D. Kidneys Palpation

• Method (Bimanual Ballotment):
  • Stand on right side.
  • Right kidney: Left hand posterior in loin; right hand anterior in right upper quadrant.
  • Patient takes deep breath.
  • Push posterior hand forward and anterior hand backward.
  • Feel lower pole between hands.
  • Repeat on the left side.
• Ballotable Kidney: Mobile kidney felt between hands.
• Abnormal Findings:
  • Enlarged → Hydronephrosis, renal tumors, polycystic kidney
  • Tender → Pyelonephritis
  • Mobile → Ptotic kidney (nephroptosis)

E. Abdominal Masses & Special Signs

• Doughy abdomen: Suggests tuberculous peritonitis
• Firm, irregular mass: Possible tumor
• Mobile mass: Cyst or benign lesion
• Always assess: Consistency, mobility, tenderness, pulsation

C. Percussion

1. General Observations

• Uniform abdominal enlargement may be due to:
  • Gas: Tympanic note on percussion
  • Fluid (ascites): Dull note on percussion

2. Signs of Ascites

• a. Shifting Dullness (Moderate Ascites):
  • Percuss from midline to flanks to detect dullness
  • Turn patient to one side and re-percuss same spot
  • Positive sign: Dullness shifts to dependent side, tympany appears above → Indicates free fluid
• b. Horseshoe-Shaped Dullness (Moderate Ascites):
  • Percuss radiating outwards from umbilicus
  • Findings: Dullness forms a horseshoe pattern with concave upper border (intestines float on fluid)
• c. Fluid Thrill (Tense Ascites):
  • Place one hand on one flank
  • Sharply tap the opposite flank
  • Feel transmitted impulse in first hand
  • Patient's hand in midline to prevent wall transmission
• d. Puddle’s Sign (Minimal Ascites – ~150 ml):
  • Patient kneels on all fours (fluid collects centrally)
  • Flick one flank while auscultating dependent part
  • Change in sound intensity on opposite side indicates fluid

3. Percussion to Distinguish Enlarged Organs

• Spleen vs. Left Kidney:
  • Spleen: Dull on percussion
  • Left Kidney: May be resonant due to overlying colon
  • Percussion aids differentiation

4. Tidal Percussion (Liver)

• Purpose: Determine upper border of liver dullness
• Percussion Lines:
  • Midclavicular line
  • Anterior axillary line
  • Scapular line
• Normal Liver Dullness Levels:
  • 5th intercostal space (midclavicular)
  • 7th space (anterior axillary)
  • 9th space (scapular line)
• Liver Span:
  • Men: 10–12 cm
  • Women: 8–11 cm
• Abnormal Findings:
  • Higher liver border (3rd/4th ICS): Suggests amebic abscess or superior liver abscess
  • Lower liver dullness (6th/7th ICS or below): Seen in:
    • Emphysema
    • Right-sided pneumothorax
    • Pneumoperitoneum (air in peritoneum)
    • Acute yellow atrophy
    • Terminal cirrhosis

D. Auscultation

Auscultation of the abdomen is done for the following:

1. Peristalsis (Bowel Sounds)

• Origin: Intestinal muscular contractions and movement of gas-fluid mixtures.
• Normal: Present even during fasting due to ongoing secretions and air swallowing.
• Abnormal Findings:
• Hyperperistalsis: Loud, frequent sounds → Suggests partial bowel obstruction, especially with abdominal distension and crampy pain.
• Absent bowel sounds (≥5 minutes): Suggests bowel atony or paralytic ileus.
• Borborygmi: Loud, gurgling sounds audible without a stethoscope; can be normal or related to hunger or hypermotility.

2. Arterial Bruit

• Definition: Harsh, pulsatile sounds caused by turbulent arterial flow.
• Possible Causes:
• Structural issues: Acute angulations, atherosclerotic plaques, tortuosity.
• External factors: Arterial compression or highly vascular tumors (e.g., hepatoma, hemangioma).
• Clinical Significance by Location:
• Liver: Likely vascular tumor.
• Spleen: Suggests vascular lesion.
• Aorta:
  • Soft bruit → Often benign.
  • Loud bruit → May indicate aortic aneurysm, atherosclerosis, or tortuosity.
• Kidneys (flanks): Suggests renal artery stenosis (important in renovascular hypertension).

3. Venous Hum

• Characteristics: Continuous, soft, low-pitched sound (not pulsatile like bruit).
• Cause: Portal-systemic shunting, due to obstructed portal venous flow.
• Location: Typically heard over the epigastric region, liver, or umbilicus.