Session 3: Abdominal Exam

Information type

Examples

What constitutes a normal physical exam

finding

The total span of the normal liver is quite variable,

depending on the size of the patient (between 6 and 12 cm)

Where (anatomically) structures are

normally located, including helpful
external landmarks
What a normal structure looks like
(visual appearance), feels like
(palpation), or sounds like
(auscultation, percussion)

Spleen percussion should yield a tympanic sound. The

normal spleen in not palpable in adults.
When palpating the left and right lower quadrants , the
ovaries and fallopian tubes are not identifiable unless
pathologically enlarged.
Right kidney is slightly lower than left kidney
Normally kidneys are not palpable. A right kidney may be
palpable in a thin person that is well relaxed. However, you
MAY be able to palpate the kidneys in infants.
You can usually palpate liver edge in most infants/children
1-2cm below right costal margin, its sharp and soft.

What constitutes an abnormal physical

exam finding
Size limits beyond which a structure is
enlarged
Abnormal locations of structures
Abnormal appearances, textures, or
sounds associated with examination
of a structure
Basic physiologic principles that affect
how structures look, feel, or sound like on
physical exam

The correct technique (using appropriate

landmarks) for performing a physical
exam maneuver

A liver span larger than 12 cm is considered enlarged.

Abdominal Aorta greater than roughly 3 cm wide is
enlarged
When enlarged the spleen tends to grow towards the pelvis
and the umbilicus (i.e. both down and across)

n/a

Preparing/Positioning Patient:
By convention the abdominal exam is performed with
provider standing on the patients right side.
Bladder should be empty (for comfort).
Patient should be comfortable in the supine position,
with bent knees and a pillow under the head. Another
pillow for under the knees may be helpful. (NOTE: Knees
that are slightly bent help to relax the abdominal muscles.

Ask patient to point to any ares of pai and examine those

areas last.
Inspection: Assess shape/contour of abdomen (flat vs
concave, symmetric vs protrusions etc)
Note skin abnormalities ex; surgical scars, dilated veins,
rashes, lesions, striae.
Note patients movement/comfort or lack of.
For newborns and infants assess the umbilical
cord/umbilicus for redness, swelling or hernia.
Auscultation: ALWAYS DO THIS BEFORE PERCUSSION and
PALPATION so not to alter or artificially silence the bowel
sounds.

AVOID listening through clothes.

Assess for presence or absence of bowel sounds
Note the quality of the sound i.e., normal activity sounds
(NABS) vs. hypo/hyperactive sounds.
Assess for bruits; apply moderate pressure with
stethoscope over the epigastrium and all 4 quadrants.
Assessing the R/L renal arteries, R/L iliac arteries and the
R/L femoral arteries.
Use diaphragm of stethoscope to listen for renal artery
bruits a few cm above the umbilicus along the lateral edge
of either rectus muscles. Press down firmly.
Percussion Assess all quadrants noting areas of dullness vs.
tympany.
Measure the span (size) of the liver and spleen using
percussion.
By convention, the liver span is measured along the right
mid-clavicular line.
---The spleen is posterior to the left mid-axillary line.
Percuss the left lower anterior chest wall,
between lung resonance above and the costal
margin in the area known as Traubes space. Its
surface markings are the left sixth
rib
<http://www.wikidoc.org/index.php/Rib>
the left anterior axillary line, and the left costal margin.
Dullness on percussion of Traubes space is an indication of

splenic enlargement. It should normally be tympanic.

Palpation: Warm your hands first.

Assess for tenderness to palpation (TTP) and/or masses
throughout the abdomen, first using gentle (shallow)
palpation, followed by deep palpation, including:
-Epigastrium
-Right upper quadrant (RUQ), including assessing the size
and contour of the liver and the liver edge
Use two hands bimanual palpation.
Support abdomen from below (using left hand)
Place fingers of opposite hand below border of liver
dullness. Have patient exhale then inhale. As patient
breathes in, push fingers down and back,
using a kneading or wave
motion, trying to feel the livers edge
as it comes to meet the finger tips.
Hooking Technique
Helpful, especially when patient is obese.
From top right of patient, place
both hands side by side on the right upper
abdomen, below the border of liver dullness. Press
inwards and upwards with the fingers to hook
over the costal margin. Then ask the patient take a
deep breath (into belly so as to push diaphragm
down).
-Left upper quadrant (LUQ), including assessment of the
spleen
Palpate with patient on right side, knees slightly flexed
(lateral decubitus position)
Reach left hand over and around patient to support
and press forward the lower left rib cage and adjacent
soft tissue. With the right hand below the costal
margin, press inward toward the spleen.
Ask patient to take a deep breath while the examiner
tries to feel the tip or edge of the spleen
(For all pediatric patients liver & spleen exams - be sure to
start palpation very low in abdomen/pelvis, moving
upwards.

Techniques to relax infants while palpating abdomen:

Use Pacifier/bottle/gloved finger to elicit suck reflex
Hold legs flexed at hips/knees)
-Right lower quadrant (RLQ)
-Left lower quadrant (LLQ)
-Suprapubic region
-Abdominal aorta, including assessing its widthPress firmly in the upper abdomen, slightly to the
left of midline.
Try to assess the width of the aorta by pressing
deeply in the upper abdomen with one hand on
either side of the aorta.
Palpating Kidneys:
Left kidney
On patients left side, place right hand behind
patient just below and parallel to 12th rib,
fingertips just reaching costovertebral angle.
Lift, trying to displace kidney anteriorly, while
placing
left hand gently in left upper quadrant,
lateral and parallel to the rectus muscle.
While patient takes a deep breath, press the
left hand firmly and deeply into left upper
quadrant, to try to capture the kidney
between the two hands.
Right kidney:
On patients right side, use left hand to lift from
the back, and the right to press into the right
upper quadrant.
Perform the exam for the right kidney using a
similar technique as with the left kidney
Physical characteristics of the structure or
appearance of body parts based on
normal, expected developmental
progression over time (i.e., age-related
changes/features)

Newborn and Young Infants:

The kidneys and spleen tip are often palpable in infants.
Toddlers typically have a very protuberant abdomen,
lordotic stance, weak abdominal musculature and relatively
large abdominal organs
Umbilical hernias are common and usually a normal finding

in young children.
Diastasis recti a midline ridge at separation of 2 rectus
abdominis muscles - is common in Newborns and Infants.
See image below.
Differences in the normal physical exam
findings in children compared to adults (if
mentioned in the assigned study
materials)

Mentioned above in other sections.

Diastasis Rectis aka abdominal separation:

Normal Findings from Power Point:

Structure

Liver

Infants

Young children

Usually palpable
on exam

Usually palpable on
exam

Soft

Soft

Edge is normally

Edge is normally 1-2

1-2 cm below
right costal
margin

Spleen

cm below right costal

margin

Can be up to 3.5
cm below costal
margin in
healthy
newborns

Usually palpable in most

premature infants

Often palpable in term newborns

(15%)

Kidneys

Normal kidneys often palpable in

flanks

Abdomina
l masses

Stool often palpable in LLQ (descending/sigmoid colon)

Spine easily palpable in thin children

Abdominal aorta easily palpable

Special Assessments from Wayne pdf:

Assessing for tenderness of the kidneys:
Place palm on posterior costal angle
Tap hand with other fist (fist percussion)
Assessing for peritoneal Inflammation:
Localize the pain as accurately as possible
Palpate gently with one finger to map the tender area

Sometimes palpable,
esp. in younger
children

10% of healthy young

children

5% of healthy
adolescents

> 2cm below costal

margin is abnormal

Sometimes, but not usually palpable

If gentle palpation (or percussion) are not sufficient, assess for rebound tenderness ; pain
induced or worsened by withdrawal of hand when palpating . If present this suggests peritoneal
inflammation.
Assessing for Ascites:
If belly is distended, this assessment helps to determine whether air, fluid or stool is in
the belly.
Shifting dullness: More on this below in additional information section.
The air in belly will rise to top no matter the position of patient. Percuss
first with patient l
ying face down, then with patient lying on side. Compare borders between tympany
and dullness. If no fluid is in belly the bowels will stay in the same place.
Fluid Wave: Tapping on one side of belly will create wave of fluid (if present), which will hit
other hand on opposite flank. Important to use a third hand (either another examiners or
patients) to stabilize body fat so that does not create a wave that might obscure the fluid.

ADDITIONAL INFORMATION and IMAGES

OBSERVATION

Global abdominal enlargement is usually caused by air, fluid, or fat.

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.
The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted
exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while
pressing out as if blowing up a balloon.- Wikipedia

Various Causes of Abdominal Distension

Obese abdomen

Hepatomegaly

Ascites

Markedly enlarged gall bladder

(labeled "GB")

Umbilical Hernia

Same umbilical hernia while patient

performs valsalva maneuver.

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
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)
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.
PERCUSSION:

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.

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 gravitydependent 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.

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
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
As the kidney lies in the retroperitoneum, pounding gently with the bottom of your fist on the costovertebral 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).

ASSESSING FOR 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.
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).

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.

Edema
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.
Info from VIDEOS:
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In a patient with hypertension a bruit in renal artery may be due to stenosis