Osteopathy Practical Technique Bridging Course

Session 11: Viscera of the Thorax and Abdomen

Part A:

Surface Anatomy and Palpation of the Viscera of the

Thorax and Abdomen

References:
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th Ed. Philadelphia:Wolters
Kluwer/Lippincott Williams & Wilkins. 2010. Ch 2
Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4th Ed.
Edinburgh:Churchill Livingstone. 2008. Ch 5
Chila AG. Editor. Foundations of Osteopathic Medicine. 3rd Ed. Philadelphia: Lippincott
Williams & Wilkins. 2011. Ch 44

Structures of the abdomen and thoracic and abdominal viscera that need to be known
The following list contains the structures to be covered in this lecture and associated
practical class. You will need to use the above references, or other suitable texts, to outline
the details required. For muscles and ligaments you will need to know their origin*, insertion*
and action.
Some of these structures will have been covered in previous lectures.
*Note the origin and insertion may be known as proximal, distal, superior or inferior
attachment in some texts.
Viscera:

Thoracic: heart and lungs

Abdominal: stomach, liver, gallbladder, duodenum, colon, cecum, sigmoid
colon, small intestine, pancreas, kidney, umbilicus, uterus, bladder

Bones:

REVIEW: Thoracic vertebrae, ribs, sternum and manubrium, scapula, lumbar

vertebrae, sacrum, innominates

Landmarks:

Abdominal regions:
9 quadrant regions: right hypochondriac, left hypochondriac, epigastric, right
lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac.
4 quandrant regions: right upper quadrant, left upper quadrant, right lower
quadrant, left lower quadrant
Lines: midclavicular line, mid axillary line, anterior and posterior axillary line,
transpyloric line, intertubercular line

Muscles:

Rectus abdominus, diaphragm

Ligaments:

Inguinal ligament

Pulse:

Abdominal aorta

Palpation and Surface Markings of the Lungs

The apex of the lung is the only part of the lung that can be palpated directly. On deep
inspiration the apex of the lung rises behind the middle third of the clavicle.
To outline the position of the lungs, proceed as follows:
a.
with the patient supine: for each lung, draw a line from posterior to the middle of the
clavicle to the sternoclavicular joint. Continue the line to a point just lateral of midline of the
manubriosternal angle.
b.

continue the line in a caudad direction until the level of the 4th costal cartilage

c.
for the left lung: at the inferior border of the 4th costal cartilage, mark a line laterally
and stop at the mid clavicular line.
d.
from this point take the line down to the 6th costal cartilage so that it stops medial to
the mid clavicular line. The line from the 4th costal cartilage to the 6th is curved rather than
two straight lines. (See figure 1.31 of Moores Clinically Oriented Anatomy.) This shows the
space for the heart and represents the cardiac notch of the left lung.
e.
from the 6th costal cartilage draw the line laterally so that it reaches the 8th rib in the
mid axillary line. You will note that this line is not straight across, but angles down.
f.
draw a line from the 9th rib, mid axillary line, to the 4th costal cartilage at the sternum.
This line does not completely follow the same line previously drawn, as it does not deviate to
allow for the cardiac notch as the previous line does.
g.
for the right lung: at the inferior border of the 4th costal cartilage, continue the line in
a caudad direction to the inferior aspect of the 6th costal cartilage where it joins the sternum
h.
draw a line laterally to where the 8th rib is located in the mid axillary line. This line is
also angled inferiorly.
i.
draw a line from the 9th rib, mid axillary line, to the inferior border of the 7th costal
cartilage where it joins the sternum. This represents the costodiaphragmatic recess of the
pleura of the lungs.
j.
draw a line from the 6th costal cartilage (on both sides) up to where the 4th rib lies mid
axillary line. This line represents the oblique fissure that separates the lobes of the lung
k.
on the right lung: draw a line from the 4th costal cartilage to the 4th rib, mid axillary
line. This represents the transverse fissure between the superior and middle lobe of the right
lung. Note the left lung only has two lobes, while the right lung has three.
l.
with the patient prone: for both sides draw a line from the 8th rib, mid axillary line, to
the 10th rib, approximately 2 cm either side of the spinous process.

m.
from this point continue drawing the line in a cephalad direction until you reach the
spinous process of T1. These lines should be 2 cm lateral to the spinous processes of the
thoracic spine.
n.
draw a line from the 12th rib, 2 cm lateral to the spinous process, laterally until it
meets up with the line at the 9th rib, mid axillary line. This line represents the inferior border
of the posterior costodiaphragmatic recess.
o.
draw a line from the from the space between the spinous processes of T3 and T4 to
th
the 4 rib, mid axillary line. This represents the posterior fissure between the upper and
lower lobe of the both lungs.

T1

Posterior fissure T3/4 to

4th rib mid axillary line

T10 to 8th rib mid axillary line

12th rib to 9th rib mid axillary line

Posterior Lung

4th costal cartilage

Cardiac notch
4th rib mid axillary line

6th costal cartilage

8th rib mid axillary line

Costal recess
10th rib mid axillary line

Anterior Lung

Surface Markings of the Heart

The position of the heart on the anterior aspect of the chest can be determined using the
following guide. Use curved lines to join the following marker points, outlining a shape
approximately the size of the subjects clenched fist.
a.

make a mark at a point 9 cm from the midline at the left 5th intercostal space. This
represents that apex of the heart, which points downwards and to the left and
represents the lower left border of the heart. The heart beat can be palpated at this
point. The heart beat is enhanced if the subject is seated and leaning slightly
forward.

b.

make a mark at the inferior edge of the 2nd costal cartilage, 3 cm to the left of midline.
This represents the upper limit of the heart on the left side.

c.

make a mark at the upper border of the 3rd costal cartilage, 3 cm to the right of the
midline. This represents the upper limit of the heart on the rights side.

d.

make a mark at the inferior border of the 6th costal cartilage on the right, 3 cm from
midline. This represents the lower right border of the heart.

3rd costal cartilage,

3cm from midline

6th costal cartilage,

3cm from midline

2nd costal cartilage,

3 cm from midline

5th intercostal space,

9 cm from midline

The Heart

Surface Markings of the Nine Abdominal Regions

The abdomen can be divided into nine regions by two vertical lines and two horizontal lines.
The two vertical lines run from the mid point of the inguinal ligament, inferiorly, to the mid
point of the clavicle, superiorly; one line on each side. They are known as the midclavicular
lines.
The superior horizontal line is drawn level with the tip of the 9th costal cartilage. It is known
as the transpyloric line, and the pylorus of the stomach lies posterior to this line. Posteriorly,
this line crosses the tip of the 12th rib and the spinous process of L1.
The inferior horizontal line is drawn across the abdomen between the tubercles of the iliac
crest and is known as the intertubercular line. The tubercles of the iliac crest are located 5
cm posterior to the anterior superior iliac spine (ASIS) of the ilium. They are on the lateral
aspect of the iliac crest. Posteriorly this line runs through the body of L5.
The nine abdominal regions are then named as follows:

Right
hypochondriac

Epigastric

Left
hypochondriac

Right lumbar

Umbilical

Left lumbar

Right iliac

Hypogastric

Left iliac

Transpyloric line

Intertubercular line

Surface Markings of the Four Abdominal Quadrants

The four quadrants of the adomen are formed by drawing:
a.
b.

a line along the midline of the abdomen

a line that crosses at the level of the umbilicus (belly button)

See the separate document that lists the organs that lie within each quadrant.

Right upper

Right lower

Left upper

Left lower

Surface Markings of the Liver

With the patient supine:
a.
draw a line at the level of the 6th intercostal space, from the left nipple, just lateral to
the mid-clavicular line at the left, to the right mid-axillary line. This represents the upper
border of the liver. The liver may lie just superior, or just inferior to this line depending on the
phase of respiration.
b.
draw a line from the left, so that it crosses the left at the 8th costal cartilage and
continues diagonally down to where the 9th costal cartilage lies on the right. Continue along
the right costal margin to the mid axillary line.

6th intercostal space

In line with left nipple

Crosses 8th costal cartilage

Crosses 9th costal cartilage and
then follows costal margin

Surface markings of the liver

Surface markings of the Gall Bladder

The gall bladder lies at the junction of the transpyloric and right midclavicular lines. It is
approximately 3 cm in diameter, and 8 cm in length. It lies posterior to the liver.

Surface Markings of the Stomach

The stomach varies enormously in shape and size according to its contents but is normally
in the left hypochondriac and umbilical regions. It is basically J-shaped, with the upper
section being thicker and more expanded. A full stomach may be palpated as it extends
below the rib cage on the left side and can be felt contracting and moving during early
digestion. An empty stomach is hidden beneath the rib cage.

Despite the mobility of the stomach, its two openings, the cardiac and pyloric orifices, remain
relatively fixed.
a.
make a mark 2.5cm left of midline along the 7th costal cartilage. This represents the
position of the cardiac orifice, which is just distal to the cardiac sphincter. It is approximately
2 cm across about and is represented by a 2cm oblique line, running from the 7th costal
cartilage to the right (the oblique angle is not great).
b.
make a mark 1.5 cm to the right of the midline on the transpyloric line. This
represents the pyloric orifice of the stomach.

Midclavicular line
Cardiac orifice of stomach 2.5 cm left of
midline. 2 cm long

Transpyloric line
Pyloric orifice 1.5 cm right of midline
Gallbladder 3cm diameter,
8 cm in length

Stomach and gallbladder

Surface markings for the Duodenum (First Section of the Small Intestine)
The duodenum is the continuation of the digestive tract beyond the pylorus of the stomach.
It lies in umbilical and epigastric areas and is approximately 25 cm long.
a.
make a mark at the pyloric orifice.
b.
make a mark 5 cm to the right of the pyloric orifice. This represents the right superior
aspect of the duodenum
c.
make a mark 7.5 cm below the superior aspect of the duonem.This represents the
inferior aspect of the duodenum.
d.
make a mark 2 cm to the left of midline approximately 2 cm superior to the inferior
aspect indicated on the right side. This point is level with the body of L2.
Join the marks up with slightly curved lines, to form the traditional C shape of the
duodenum.
Note: the duodenum crosses, inferiorly, from left to right at the level of the body of L3.
Surface markings for the Small Intestine
a.
make a mark at the left inferior aspect of the duodenum. This is the duodenum and
the jejunum (second section of the small intestine).
b.
make a mark lateral to the mid-clavicular line on the right at the level of the
intertubercular line. This represents the junction of the ileum (third section of the small
intestine) and the cecum of the large intestine.
Note that the positions of these structures can vary from person to person, and vary within
the same person. These represent an ideal position of these structures.
The caecum is the first section of the large intestine and lies in the right iliac region. It lies
above the lateral half of the right inguinal ligament, with the appendix lying in the
midclavicular line, 1.5 cm medial to the ASIS.

5cm to right of pyloric orifice

Duodenum
2 cm left of midline; level with body of L2

7.5 cm inferior
Junction of ileum and cecum
Lateral to mid clavicular line and
Level with intertubercular line

Also represents the duodenum

and jejunum junction

The Pancreas
The pancreas lies along the transpyloric line between the epigastric and umbilical areas. It
has a head to the right with a body and tail which narrows as it passes to the left. It is 10 cm
long and 4 cm broad at its head. It is situated anterior to the vertebral column, level with the
body of L1. The head is surrounded by the four parts of the duodenum. The tail lies near the
spleen.
The pancreas is not palpable in the normal subject.

Pancrease

Surface markings of the Kidneys

With the patient prone.
a.
On the right side locate the inferior border of the right 11th rib. Draw a mark
approximately 2.5 cm lateral to the spinous processes. This represents the medial and
superior aspect of the right kidney
b.
Draw a mark 9.5 cm lateral of the spinous process at the same level as the above
mark. This represents the lateral and superior aspect of the right kidney.
c.
Draw a mark 2.5 cm lateral of the spinous process of L3. This represents the medial
and inferior aspect of the right kidney.
d.
Draw a mark 9.5 cm lateral to the spinous process of L3. This represents the lateral
aspect of the right kidney
Connect the marks to draw a rectangle. The kidney lies within this rectangle.
e.
On the left side, locate the superior border of the 11th rib. . Draw a mark
approximately 2.5 cm lateral to the spinous processes. This represents the medial and
superior aspect of the left kidney
f.
Draw a mark 9.5 cm lateral of the spinous process at the same level as the above
mark. This represents the lateral and superior aspect of the left kidney.
g.
Draw a mark 2.5 cm lateral of the spinous process of L2. This represents the medial
and inferior aspect of the left kidney.
h.
Draw a mark 9.5 cm lateral to the spinous process of L2. This represents the lateral
aspect of the left kidney
Connect the marks to draw a rectangle. The kidney lies within this rectangle.
The right kidney generally lies 1 cm lower than the left. This is likely to be due to the position
of the liver on the right side. The kidney may move superiorly and inferiorly 2-3 cm in
response to the diaphragmatic motion.

Surface markings of the Spleen

Patient Posterior
a.
draw a line at the level of the tip of the ninth thoracic spinous process and mark a
point 4cm from the spinous process toward the left. This point represents the highest point of
the spleen
b.
draw a line at the level of the first lumbar spinous process and make a mark at the
left mid axillary line. This represents the lowest point of the spleen.
c.
the spleen lies behind the 9th to 11th rib on the left, lateral to the left kidney.

Kidneys

2.5 cm from midline

Superior aspect of rib 11

Inferior aspect of rib 11

L2
L3

9.5 cm from midline

4cm left of 9th spinous process

Spleen

Level with L1 spinous process

at mid axillary line
Kidneys