Abdominal Examination

Being able to perform a competent examination of the abdomen is one of the most important skills to accomplish at medical school. There are a lot of things that can go wrong within the abdomen, and equally there are many ways of determining what exactly is happening. Be systematic, thorough and don’t jump to any conclusions!

As with all examinations the best way to become proficient is to practice until you find a routine that works for you. I’m strongly of the opinion that there is no one way to do an exam, rather it is a personal process that you develop over time with experience. Once you have found a way you like to do it, do it the same way every time to reinforce it effectively. This is my way of doing it, so feel free to chop and change as you wish!

Introduction

  • Wash your hands and show your name badge to the examiner
  • Introduce yourself, with name and role
  • Confirm that you have the right patient in front of you, with name and age
  • Explain why you’ve come to see them.
  • Gain consent to do the examination, and you may offer a chaperone if you feel this would make the patient more comfortable
  • Ask if they are in any pain at present, and to tell you if it becomes too uncomfortable to continue
  • Ensure your patient is sat at 45 degrees, and exposed adequately.
    • Some say ‘nipple to knee’ but in reality as long as you can see the whole abdomen down to the pubic symphysis, patient dignity should be maintained.

General Inspection

Arguably the most important part. After a while you will be able to diagnose many conditions on inspection alone.

  • Looking around the bed for things the patient has brought with them will give you a clue as to their current function, and what pathology might underly their presenting complaint
    • Medications
    • Inhalers
    • Pumps
    • Walking stick
    • Prostheses
    • Stoma bags
    • Drains
    • NG tubes
  • The patient
    • Are they comfortable at rest?
    • Are they obese/malnourished?
    • Are they short of breath?
    • What colour are they?
      • Blue – cyanotic
      • Yellow – jaundiced – liver disease
      • Grey – iron infusion, haemochromatosis
      • Pale – anaemia – liver disease, GI bleed, Malabsorption
    • Can you hear anything?
      • metallic valves
      • stridor
      • wheeze
    • Are there any obvious scars or wounds?
    • Any visible abdominal masses?
      • Transplanted organs
      • Organomegaly
      • Cysts
      • Pulsating abdominal aorta
        • normal in thin people

 

Hands

The hands will give you an idea of the chronicity of a disease as clubbing and nail changes do not occur acutely.

  • Clubbing
    • Cirrhosis
    • Inflammatory Bowel Disease
    • Malabsorption
    • Hepatopulmonary syndrome
  • Nail changes
    • Leukonychia
      • lack of protein
      • ulcerative colitis
      • trauma
      • ?zinc deficiency
    • Koilonychia
      • iron-deficiency anaemia
      • Plummer-Vinson syndrome
  • Palm colour
    • Palmar erythema
      • Portal hypertension
      • Liver disease
      • Hyperthyroidism
      • Rheumatoid arthritis
      • Pregnancy
      • Polycythaemia
  • Dupuytren’s contracture
    • Associated with:
      • manual labour
      • alcohol excess
      • familial
  • Liver flap
    • Postural failure due to encephalopathy
      • Uraemia
      • Hepatic encephalopathy

 

Arms

  • Bruising
    • suggests poor clotting
      • liver disease
  • Needle marks
    • risk of IVDU/HIV/Hepatitis
  • Excoriations
    • scratching due to pruritus
      • liver disease
  • Hair loss from axillae
    • caused by
      • malnourishment
      • iron deficiency anaemia
    • acanthosis nigricans
      • GI adenocarcinoma
      • Obesity

Eyes

  • Corneal arcus
    • normal with increasing age
      • hypercholesterolaemia
  • Xanthelasma
    • elevated lipids
      • Hypercholesterolaemia
  • Jaundice
    • yellow sclerae
      • haemolysis
      • liver disease
      • biliary obstruction
  • Kayser-fleischer rings
    • rare
      • Wilson’s disease

Mouth

  • Anaemia
    • pallor of the underside of the tongue
  • Angular Stomatitis
    • inflammation of mouth corners
      • iron/B12 deficiency
  • Glossitis
    • beefy tongue
      • iron deficiency anaemia
  • Ulcers
    • ask about these
      • Crohn’s disease
  • Parotid hypertrophy – alcohol

Neck

  • Virchow’s node
    • left supraclavicular lymph node
      • GI malignancy
  • Lymphadenopathy
    • may suggest
      • infection
      • malignancy
  • JVP
    • may be raised in 
      • liver disease

Chest

  • Gynaecomastia
    • breast tissue develops in
      • liver disease
      • salbutamol
      • digoxin
  • Hair loss
    • seen in
      • liver disease
      • malnourishment
  • Spider Naevi
    • cherry red with wispy ‘legs’ – need more than 5 to be pathological
      • liver disease

 

Abdomen

  • Scars
  • Bruising
  • Swelling and distension
  • Prominent abdominal wall veins
    • Occlude the veins and ‘milk’ them to empty them, and see how they refill. 
      • Caput medusae refill towards the legs
      • Inferior vena cava obstruction – refill towards the head

 

NOW REPOSITION THE PATIENT SO THEY ARE LYING FLAT

People do the next bit differently depending on personal preference. I like to go organ-by-organ, palpating and percussing the liver, then the spleen etc – others like to do all of palpation, then all of percussion. Either is fine, just remember to do it all! I’ve written it here as palpation then percussion.

Palpation

  • Palpate the 9 regions of the abdomen, beginning away from painful areas
    • superficial palpation while watching patient’s face
      • guarding
      • rigidity
      • rebound tenderness
        • all signs of peritonitis
    • deep palpation for abdominal masses
      • Describe any mass by:
        • Size
        • Shape
        • Location
        • Outline
        • Consistency
        • Mobility
        • Pulsatility
        • Overlying skin (rashes/reaction)
        • Temperature
        • Auscultation – bruit?
  • Liver
    • use radial border of index finger, starting at the right iliac fossa
      • press in, and tell patient to inhale, feeling for liver edge against your hand
      • repeat, moving hand towards right costal margin each time until the costal margin is reached
  • Spleen
    • use same technique for splenic palpation, beginning in the right iliac fossa but moving towards the left costal margin
      • Features of spleen on palpation:
        • can’t get ‘above’ it (under ribs)
        • smooth edge with notch
        • moves down on inspiration
        • dull to percussion
        • if palpable, spleen is 50-100% enlarged
  • Kidneys
    • Using one hand to press into the abdomen, use the other to gently flip (ballotting) the kidney against the superior hand, and feel for an impulse. Normal kidneys aren’t ballottable except for particularly thin patients.
  • Aorta
    • gently press two thumbs above the umbilicus and feel for a pulsation
      • pulsation (moves thumbs up and down) is normal
      • expansion (moves thumbs apart) is pathological

Percussion

  • Percuss for the liver and the spleen
    • Liver
      • lower four ribs should be dull depending on level of inspiration
    • Spleen
  • Percuss for the bladder
    • ask patient if they need to urinate first!
    • begin at the umbilicus and percuss towards pubis. Dullness suggests a full or distended bladder

Test for ascites

Ascites is fluid in the peritoneal cavity that may cause distension. Remember the differential for a distended abdomen:

  • Fluid
  • Fat
  • Faeces
  • Foetus
  • Flatus
  • Fire (inflammatory mass)
  • F*** (malignancy)

 

  • Percussion
    • percuss over the umbilical region, which will be resonant in ascites as the air bubble sits at the highest point
    • percuss round towards the flank, and note the point at which the tone becomes dull – this is the fluid level
  • Shifting dullness
    • ask patient to roll onto their side (I get them to roll towards me and put their hand on my shoulder for stability)
    • The air bubble should now have moved round to the new highest point at the flank. Percussion of the flank should now be resonant and the new fluid level discovered towards the umbilicus
  • Fluid thrill
    • tapping on one side of the abdomen sends a shock wave through the abdominal fluid that is palpable on the other side. Usually only possible in massive ascites.

 

Auscultation

  • Auscultate for
    • bowel sounds
    • renal bruits
    • aortic bruits
    • venous hum (portal hypertension)

Finishing up

  • Check for leg swelling
    • pitting oedema in liver failure
  • Thank the patient
  • Sit them back up and help them get dressed
  • Wash your hands

 

Practise, Practise, Practise!

Coeliac disease in children

You’re at work in your clinic, and this pale and thin-looking boy wanders in with a half-eaten loaf of bread in his hand. He pulls down his trousers and does the single worst smelling poo all over the floor. It’s pale and very oily, and just as he’s finished his legs give way and he falls over, landing right in it. Unfortunately he lands on his front, right on top of his bread, making his tummy hurt.

  • caucasian
  • failure to grow
  • foul smelling faeces
  • steatorrhoea
  • muscle wasting
  • abdominal pain

As he attempts to get back up, he continues to slip and slide, gliding around the room like an ice rink. After a little while he gets tired, and you’re worried because you start to see some blood on your new poo-ice-rink floor, and you think he may have broken his arm in the process of trying to stand up.

  • gliadin protein sensitivity
  • fatigue
  • anaemia
  • osteoporosis/osteopenia 

To try and cheer him up a little, you hand him some toys from Star Wars, and after deb8-ing for a little while he chooses a plastic R2-D(Q)2. While he’s playing you notice a nasty rash over his legs, and so you ask him what his name is in order to call his parents. He says his name is Marsh and his parents can’t come to help him because his mother is pregnant.

  • HLA-B8
  • HLA-DQ2
  • Dermatitis herpetiformis
  • Marsh classification
  • pregnancy complications

Finally you ask why he’s come in today, and he says he thinks his spleen is too small, and he’s broken his toy dIgA (digger).

  • Hyposplenism
  • IgA deficiency

Hopefully this particularly ridiculous scenario will help link some of the features and associations of coeliac disease in your mind. Feel free to change what you will, and the details are summarised below.

The Background

Coeliac disease is a condition in which the small intestine undergoes villous atrophy as the result of a T cell mediated autoimmune sensitivity response to gliadin and other gluten proteins found in wheat. These proteins set off an inflammatory cascade that causes the villi of the intestine to be burned away, reducing the ability of the intestine to absorb the necessary nutrients, and the characteristic features of foul-smelling diarrhoea and failure to gain weight result.

Symptoms

  • Those related to the villous atrophy
    • pale, loose, fatty stools that smell foul
    • abdominal pain and cramping
      • sometimes with distension, though to be due to fermentation in the gut
  • Those related to the malabsorption
    • weight loss
    • fatigue
    • anaemia
      • iron deficiency
      • B12 deficiency
      • Folate deficiency
    • Calcium and vitamin D deficiency
      • osteoporosis
      • osteopenia
    • Rarely – coagulopathy
      • vitamin K deficiency

Genetics

  • Incidence 1/1000-2000
  • very common in caucasians, rare in black/asian populations
  • HLA-DQ2 (95%)
  • HLA-B8 (80%)

Diagnosis

  • History
  • Examination
  • Jejunal biopsy
  • Antibody tests are useful for screening
    • anti-endomysial 
    • anti-gliadin

Pathology

The pathology of coeliac disease is categorised by the Marsh Classification.

  • Marsh stage 0
    • normal mucosa
  • Marsh stage 1
    • Increased number of intra-epithelial lymphocytes (IEL)
  • Marsh stage 2
    • proliferation of the crypts of Lieberkuhn
  • Marsh stage 3
    • partial or complete villous atrophy and crypt hypertrophy
  • Marsh stage 4
    • hypoplasia of the small intestine architecture

Associations

Coeliac disease is linked with a number of other conditions, although it is not clear as to the causal nature of the relationship.

  • IgA deficiency
  • Dermatitis Herpetiformis
  • Growth failure
  • Pregnancy complications
  • Hyposplenism
  • Abnormal liver function tests

Risks

Coeliac disease confers greater risk of:

  • adenocarcinoma
  • lymphoma
    • enteropathy-associated T cell Lymphoma (EATL)
  • ulcerative jejunitis
  • stricturing

Treatment

At the moment, the only known successful therapy for coeliac disease is a gluten-free diet for the rest of the individual’s life.

but…cake

Santa’s AAA

Santa has an abdominal aortic aneurysm. Sad I know, but what with his lifestyle of inactivity and indulgence he has brought it upon himself, and after all, he does have all the risk factors.

He’s a fat, old man who does very little all year and then has one night of unbelievable stress that puts his already high blood pressure through the roof. You don’t see them often but he has insanely long fingers, it’s how he reaches down the chimney to deliver the presents. These long fingers are due to his diagnosis of Marfan’s, and he always wears his big black boots to keep his feet warm because his peripheral artery disease makes his feet very chilly when he’s flying over the Baltic States. You probably also didn’t realise but his mum and dad both died of abdominal aortic aneurysms and he is now destined to the same fate.

The risk factors for an abdominal aortic aneurysm are important when you see a patient with abdominal pain, especially if the pain was sudden in onset.

male
– age over 60
– family history of AAA
– Marfans disease
– artery disease
– hypertension
– obesity
– diabetes



poor guy

Intussusception

Here’s a story to help remember some of the details of intussusception. Remember to try and really picture this event, in your garden. If you can use children that you’ve seen or know, it will help make the story stick better. If you can make it even more ridiculous than I have, then go for it – the weirder the better!

Two boys and a girl are playing in the garden at a family barbecue. The boys are 6 months and 18 months old, and the girl is 12 months old.

  • Typically affects children between 6 and 18 months
  • Boys are twice as affected as girls

They’re all dancing, and doing a special dance where they have to jump as high as they can, and bring their knees up to their chest. As they’re doing this, they all turn completely white and start rolling around on the floor complaining of pain in their abdomen.

  • Child complains of abdominal pain
  • Often characteristically draws knees up to chest
  • Pale
  • Characteristic ‘Dance’s Sign’ (retraction of right iliac fossa)

One of the boys then does a poo. Unfortunately all he’s been eating is jelly, so he blasts jelly all over the other two. They both vomit, but since they’ve just been eating sausages from the barbecue, there’s now jelly and sausages all over the garden.

  • Vomiting
  • Blood-stained faeces (like jelly)
  • Sausage like mass palpable in the lower right quadrant

The children then all start screaming, but they’re screaming at such a high pitch that it’s causing all the windows to smash, so you then have to go on a trip to Target to buy replacements.

  • Ultrasound is the primary imaging modality
  • Characteristic ‘target’ sign seen

The Background

Intussusception is a medical emergency in which part of the bowel collapses into the adjacent part like a telescope (or extendable selfie-stick for those born after 1994). It can lead to obstruction and perforation, and then sepsis and shock.

The reason it’s dangerous is because the segment of bowel that is drawn in can have its blood supply cut off, and become necrotic and then perforate. The ischaemic bowel loses its mucosa into the bowel lumen, and this forms the characteristic ‘red jelly’. In reality, any type of blood in the stool should have intussusception on the differential diagnosis, especially if the child is between 6 and 18 months.

Causes

A variety of things can cause intussusception, although how it is that they do it isn’t well understood. It is thought that enlarged lymphoid tissue after an infection may play a role, and this would also explain why intussusception is relatively rare in the first three months of life, while the infant is still protected by passive immunity.

The different types include:

  • ileocolic (90%)
  • ileoileocolic (less common)
  • ileoileal (rare)
  • colocolic (rare)

Diagnosis

The diagnosis is made based on:

  • clinical examination
    • PR exam can be very helpful in children
  • history
  • Dance’s sign
    • emptiness in the lower right quadrant
    • sausage shape in right upper quadrant
  • Ultra-sound Scan
    • diagnostic imaging modality of choice
    • gives a characteristic target shape

If you google intussusception you get some awesome radiographs

I can’t put any on here because I don’t own them

sad face

Right iliac fossa mass

What on earth is that lump?

You have a young patient screaming in pain “my appendix!“, but her mother is much more worried that it might be cancer. You ask her why she thinks he has cancer, and she says

  • appendix mass
  • caecal carcinoma

“He’s had diarrhoea that floats!” to which you reply “Sounds more like Crohn’s…”

  • Crohn’s

You’re interrupted by the patient, who is now convinced her ovaries are exploding and her intestine is eating itself.

  • Ovarian mass
  • Intussusception

Do you think it could be her transplant?” asks the mother quietly – this surprises you so you look at the patient’s abdomen for scars, but instead you see a huge pulsating lump that looks like an aneurysm of some sort.

  • Pelvic kidney
  • Common iliac aneurysm

Have you had a fever?”  you ask? You’re thinking it could be an infection, either TB or an abscess.

  • Iliocaecal TB
  • Iliac lymphadenitis
  • Actinomycosis
  • Psoas abscess

The patient shakes her head, you then ask “can you push it back in?

  • Spigelian hernia

Both mother and daughter look at you like you’re an idiot, before daughter wets herself all over the bed. “What’s wrong with my bladder?” Which makes you think of her other bladder.

  • Gall bladder enlargement

The differential diagnosis for a right iliac fossa mass includes the following:

  • Appendix mass
  • Caecal carcinoma
  • Crohn’s disease
  • Ovarian mass
  • Intussusception
  • Pelvic kidney
  • Enlarged gall bladder
  • Iliocaecal TB
  • Iliac lymphadenitis
  • Psoas abscess
  • Retroperitoneal tumour
  • Actinomycosis
  • Common iliac artery aneurysm
  • Spigelian hernia

Clearly the likelihood of each is going to depend on the patient, the history, and the presentation. Caecal carcinoma is much more common in an elderly person than a teenager, while appendicitis is less likely if the patient has already had an appendicectomy…

Abdominal X-ray

Chest radiographs are phenomenal in terms of how much information they can provide given how simple and easy they are to perform. Abdominal films are also useful, but less commonly used as there are fewer indications for ordering them, and they don’t give the same wealth of information that a chest film can. Nevertheless, it’s essential that you can look at one without panicking, and get a rough idea about what’s going on inside that patient of yours.

Indications: “Gasses, masses, bones and stones”

  • Obstructed bowel
  • Perforated bowel
  • Bowel Ischaemia
  • Blunt or perforating abdominal injury
  • Intussusception
  • Foreign bodies
  • Suspected abdominal mass
  • Acute and chronic pancreatitis
  • Toxic megacolon

Views:

  • AP Supine
  • AP erect
  • Lateral decubitus
  • Supine lateral
  • KUB

Step 1: The basics

  • Patient Identity
    • right patient
      • name
      • date of birth
      • hospital number
        • always always always check all three – statistically the probability of two patients in the hospital having the same name and date of birth is scarily high…
    • right time
      • are you looking at a previous scan or the most recent
    • right view
      • is it the same as the one you ordered?
      • is it adequately exposed?
      • can you see the whole abdomen

 

Step 2: Gasses 3,6,9

  • Small bowel
    • Look for valvulae conniventes – or rings that distinguish small bowel from large
    • Small bowel shouldn’t be more than about 3 cm in diameter
  • Large bowel
    • Look for haustra – lines only go part way across the large bowel
    • The retroperitoneal parts are easier to find as they’re relatively constant in their location:
      • ascending
      • descending
      • rectum
    • Large bowel shouldn’t be more than 6 cm in diameter
    • The caecum shouldn’t exceed 9 cm
  • Walls
    • gas in the wall of bowel suggests ischaemic colitis
  • Air-Fluid levels
    • more than four or five visible fluid levels, great than 2.5 cm long is abnormal and may suggest:
      • gastroenteritis
      • ischaemia
      • obstruction
      • ileus
  • Peritoneum
    • Rigler’s sign (double wall) is a sign of intraperitoneal gas, and may reflect perforation or penetrating trauma
    • air may be seen under the diaphragm
  • Soft tissues
    • surgical emphysema may be visible especially after trauma

Step 3: Masses

  • Solid organs
    • Liver
      • Right upper quadrant
      • Grey
      • Breast tissue may overlie the upper aspect
      • May have cholescystectomy clips present
    • Spleen
      • Left upper quadrant
    • Kidneys
      • T12-L3
      • Right lower than left due to liver
    • Bladder
  • Psoas muscles
    • bulging may indicate a retroperitoneal pathology
  • Vessels
    • Calcifications may indicate an aortic aneurysm

Step 4: Bones

  • Ribs
  • Spine
  • Sacrum
  • Pelvis
    • Check all of these for:
      • fractures
      • degeneration
      • metastasis
      • cysts

 

Step 5: Stones

  • Stones should be looked for in the:
    • Kidneys
    • Ureters
      • follow the tips of the lumbar transverse processes down to the sacroiliac joint
      • The ischial spines mark where the ureters enter the bladder
    • Bladder
    • Gallbladder
    • Pancreas (calcification)

 

Remember:

  • Piercings may look like foreign bodies
  • Not all calcification of soft tissues is clinically important

 

Hope this helps!

 

 

 

References:

https://www.rcr.ac.uk/audit/indications-plain-abdominal-films-emergency-department

https://radiopaedia.org/articles/abdominal-radiography

http://lifeinthefastlane.com/investigations/axr-interpretation/

http://www.radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray/anatomy_system_bowel_gas