Abdominal assessment


Abdominal Assessment


Abdominal Assessment
Slide 1 of 43
Slide 1
    Welcome to Abdominal Assessment This program will be divided into 3 parts: 1) A review of the Anatomy & Physiology of the abdomen 2) A review of history taking - Abdominal Assessment 3) The actual abdominal physical examination

Anatomy & Physiology Review
Slide 2 of 43
Slide 2
    Important landmarks of the abdomen include: Xiphoid Process (Basic Life Support BLS) Costal Margin (along ribs) Midline (center) Umbilicus Anterosuperior Iiac Spine (situated in front of, at a higher level from the iliac spine) Superior margin of os pubis (Top of pubis bone) Poupart ligament (groin) - The inguinal lig. extends from the anterior superior spine of the ilium to the pubis on each side.

Muscles of the Abdomen
Slide 3 of 43
Slide 3
    White Line (linea Alba) is a tendonous band in the abdomen that is located in the midline of the abd. between the rectus abdominus muscles.

Function of Abdominal Muscles
Slide 4 of 43
Slide 4
    Abdominal Muscles include Rectus abdominis Transversus abdominis Internal & external obliques Function of Abdominal muscles Form the abdominal cavity Protect the abdominal cavity Assist in movement

Anatomic Structures of the Abdominal Cavity
Slide 5 of 43
Slide 5
    Stomach Small intestine Large intestine Liver

Organ Structure & Function
Slide 6 of 43
Slide 6
    Organ Structure & Function STOMACH Consists of 3 lobes: fundus, body, pylorus Aids in the breakdown of food particles, very little absorption takes place in the stomach. Secretes hydrochloric acid and digestive enzymes to breakdown fats and proteins. Two digestive enzymes include: Pepsin acts to digest proteins Gastric lipase acts on emulsified fats

Small Intestine
Slide 7 of 43
Slide 7
    Small Intestine Duodenum Jejunum Ileum Approx. 21 feet long. Begins at the pyloric orific and ends at the ileocecal valve. Digestion is completed through the action of pancreatic enzymes, bile, and several small intestine enzymes. Nutrients are absorbed through the walls of the small intestine.

Large Intestine
Slide 8 of 43
Slide 8
    Large Intestine Cecum Ascending Colon Transverse Colon Descending Colon Sigmoid Colon Approx. 4.5 - 5 feet long & 2.5 in. in diameter Absorption of water takes place Lubrication of contents by secreted mucus. Neutralization of acids by an alkaline mucous secreted. Live bacteria decompose undigested food, unabsorbed amino acids, cell debris, and dead bacteria.

Liver
Slide 9 of 43
Slide 9
    Liver Heaviest organ in the body (approx. 3 lbs.) Composed of 4 lobes containing lobules Plays a role in the metabolism of carbohydrates, fats, and proteins Glucose conversion, storage & release Amino acids are converted into glucose Bile salt formation from cholesterol Storage of several minerals & iron Detoxification & release of harmful substances -“excretory organ” Other functions include: Production of antibodies Synthesis of fats from carbohydrates & proteins Proteins are broken down to amino acids Excretion of steroid hormones Production of prothrombin, fibrinogen and other substances for blood cloagulation production of proteins that circulate in the blood converts fat-soluble waste into water soluble waste for renal excretion

(Untitled)
Slide 10 of 43
Slide 10
    Removal of the stomach, small intestine, and the large intestine Gallbladder Pancrease Spleen Kidneys Ureters Bladder

Gallbladder
Slide 11 of 43
Slide 11
    Gallbladder Saclike, pear shaped organ about 4 in. Long. It concentrates & stores bile from the liver. Bile is composed of cholesterol, bile salts, & pigments. Bile acts to maintain the alkaline (basic) pH of the small intestine to permit emulsification (breakdown) of fats so that absorption can be accomplished.

Pancreas
Slide 12 of 43
Slide 12
    Pancreas Lies behind & beneath the stomach Both an exocrine & an endocrine gland Exocrine gland Digestive juices are produced by the acinar cells of the pancreas. The juices contain inactive enzymes for the breakdown of proteins, fats, and carbohydrates. Endocrine gland Islet cells within the pancreas produce both insulin & glucagon. These are secreted directly into the blood to regulate the body's level of glucose.

Spleen
Slide 13 of 43
Slide 13
    Spleen Located in the upper left quadrant Consists of white pulp (lymphoid tissue) & red pulp. White pulp (lymphoid tissue) Constitutes most of the spleen Part of the reticuloendothelial system to filter blood & manufacture lymphocytes & monocytes. Red pulp A capillary network & venous system that allows for the storage and release of blood. Allows the spleen to hold up to several hundred milliliters at 1 time.

Kidneys
Slide 14 of 43
Slide 14
    Kidneys 2 Kidneys containing more than 1 million nephrons each. Nephrone are composed of a tuft of capillaries, the glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule. The distal tubule empties into a collecting tubule. Glomeruli filter the blood of: electrolyes, glucose, water, & small proteins. Both an excretory organ & an endocrine gland. Excretory organ - responsible for the removal of water-soluble waste. Endocrine gland - produces renin, which controls aldosterone secretion. Aldosterone acts in the renal tubule to retain sodium, conserve water, and increase potassium excretion in the blood.

Ureters & Bladder
Slide 15 of 43
Slide 15
    Ureters & Bladder Ureters 2 ureters connecting the kidneys to the bladder. Peristaltic waves move the urine from the kidneys to the bladder. Bladder Serves as a urinary reservoir Capacity of approx. 400 - 500 ml in the adult

Abdominal Vasculature
Slide 16 of 43
Slide 16
    Vessels of the abdomen

Abdominal Vasculature
Slide 17 of 43
Slide 17
    Abdominal Vasculature Abdominal Aorta (descending aorta) Brances off into 2 common iliac arteries, and the splenic & renal arteries Supplies oxygenated blood to parts of the body Inferior Vena Cava Receives blood from the 2 common iliacs, the lumbar veins & the testicular veins. Returns deoxigenated blood to the heart from parts of the body. Superior Mesenteric Artery & Vein Supplies & draws blood from most of the small intestine, the cecum, and the ascending & transverse colons.

History
Slide 18 of 43
Slide 18

    Review of Related History
    Slide 19 of 43
    Slide 19
      OLD CARTS Review of Related History Present Problem Onset and duration: sudden or gradual, persostent, intermittent Character:dull, sharp, burning, stabbing, aching Location: radiates, superficial or deep, change over time Associated symptoms: n/v/d/c, change in abd. girth, belching Relationship to internal or external stressors and bodily functions: menses, time of day Recent stool characteristics: color, consistency, odor, frequency Urinary characteristics: frequency, color, odor. volume Medications: (past & current), perscription, nonperscription Present Problems: Abdominal pain, Indigestion, vomiting, diarrhea, constipation, fecal incontinence, jaundice, dysurea, urinary frequency, urinary incontinence, hematuria, chyluria (milky urine)

    (Untitled)
    Slide 20 of 43
    Slide 20
      Past Medical History Gastrointestinal disorders: ulcers, IBS, intestinal obstruction, pancreatitis Hepatitis or cirrhosis of the liver Abdominal or urinary tract surgery: For what & when, how many Urinary tract infections: number & treatment, sees a urologist? Major illnesses: cancer, kidney disease, cardiac disease, arthritis Blood transfusions: How many, when? Hepatitis vaccine: Series of 3 completed? Titers?

    (Untitled)
    Slide 21 of 43
    Slide 21
      Family History Familial Mediterranean Fever (periodic peritonitis, brucellosis) A disease caused by the gram neg. coccobacillus Brucella. Humans usually acquire it from contaminated milk or milk products. S&S: fever, chills, sweating, maliase, and weakness Gallbladder disease: cancer, cholecystitis Kidney disease: renal stone, polycystic disease, renal or bladder carcinoma Malabsorption syndrome: cystic fibrosis, celiac disease Colon Cancer

    (Untitled)
    Slide 22 of 43
    Slide 22
      Personal & Social History Nutrition: 24-hour recall intake, food likes & dislikes, food intolerences, ethnic or religious foods frequently eaten, recent weight loss or gain. First day of last menstrual period: Esp. college aged females Alcohol intake: How often, how much, what type Recent stressful life events: physical & psychologic changes Exposure to infectious diseases: hepatitis, flu, travel history Trauma: through type of work, physical activity, abuse Use of street drugs: types, frequency & usual amounts

    Examination Equipment
    Slide 23 of 43
    Slide 23
      Examination Equipment Stethoscope: for auscultation Centimeter ruler & measuring tape: to measure abdominal girth Marking pens: to mark the areas of measurment for consistency in measuring

    Examination
    Slide 24 of 43
    Slide 24
      Examination Inspection Auscultation Percussion Palpation Complete in this oder so as not to distrupt the normal abdominal sounds & movement with percussion & palpation.

    Inspection
    Slide 25 of 43
    Slide 25
      Four quadrants of the abdomen include the: Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant Imaginary line from the sternum to the pubis, through the umbilicus. Second imaginary line is perpendicular to the first, horizontally across the abdomen through the umbilicus. See page with anatomic correlations

    (Untitled)
    Slide 26 of 43
    Slide 26
      Nine regions of the abdomen 1. Epigastric 2. Umbilical 3. hypogastric (pubic) 4 & 5. Right & left hypochondriac 6 & 7 Right & left lumbar 8 & 9 Right & left inguinal See page with anatomic correlations

    Inspect for :
    Slide 27 of 43
    Slide 27
      Inspect for : Generalized skin color changes and surface characteristics: jaundice, cyanosis Ecchymosis: brusing Striae: stretch marks, indicate weight loss Lesions & nodules Scars: cause? Abnormal movements: ie-gastroenteritis Contour, symmetry, and surface motion: abd. should be symmetrical on both sides. Surface motion should be smooth and wave-like

    Abdominal profiles
    Slide 28 of 43
    Slide 28
      Abdominal profiles: 1. Flat 2. Rounded - slightly distended 3. Scaphoid - Sunken anterior wall 4. Protruberant - Distended The Fs of abdominal distention Fat Fluid Feces Fetus Flatus Fibroid Full bladder False pregnancy Fatal tumor

    Auscultation
    Slide 29 of 43
    Slide 29
      Auscultation Auscultate for: Bowel Sounds Auscultate all 4 quadrants Note frequency & character Usually 5 - 35 per minute Absence is established only after 5 minutes of continuous listening. Vascular Sounds Bruits in the aortic, renal, iliac, and femoral arteries Friction rubs over the liver & spleen Venous hum in the epigastric region - occurs with increased collateral circulation between portal & systemic venous systems. soft, low pitch & continous.

    Percussion
    Slide 30 of 43
    Slide 30
      Percussion To detect fluid, air, and an fluid-filled or solid masses. Stomach & intestines - tympany Organs & solid masses - dullness Percuss all 4 quadrants in a systematic route (May begin on the right side just below the liver, span hortizontally to the spleen & pancreas, travel down the stomach, the horizontally once again across the lower abdomen Note: Liver span (at midsternal line usually 2-3 cm) - Usual span is 6-12 cm. On right Spleen - just posterior to the midaxillary line on the left Gastric bubble - Left lower anterior rib cage and the left epigastric region The tympany produced by the gastric bubble is lower in pitch than the tympany of the intestine.

    Palpation
    Slide 31 of 43
    Slide 31
      Palpation Light, moderate, & deep palpation Palpate for masses, tenderness, organ enlargement, and ascites Palpation of specific structures: (TO BE REVIEWED IN LAB) Liver: with finger hooked over costal margin also push up from back & mead down Gallbladder (Murphy sign): two handed Spleen: push up from the left back and mead downward on the abd. Kidneys: Side of hand or fist over flank area, also pushing up from back, then down. Aorta:Slightly left of the midline. Feel for aortic pulsation. Urinary Bladder: Not palpable in the healthy pt. unless the bladder is distended. Abdominal reflexes: Stroke away from umbilicus. Should see contraction of the rectus abdominus muscles & a pulling of the umbilicus toward the stroked side.

    Areas of cutaneous hypersensitivity
    Slide 32 of 43
    Slide 32
      Common conditions producing abdominal pain: appedicitis cholecystitis pancreatitis Perforated gastric or duodenal ulcer diverticulitis intestinal obstruction volvulus leaking abd. aneurysm biliary stones, colic salpingitis ectopic pregnancy pelvic inflammatory disease ruptured ovarian cyst renal calculi spleenic rupture peritonitis

    (Untitled)
    Slide 33 of 43
    Slide 33

      Additional Procedeures in Abdominal Assessment
      Slide 34 of 43
      Slide 34
        Additional Procedeures in Abdominal Assessment Ascites Assessment - fluid wave, auscultatory percussion, puddle sign Pain Assessment - use pain scale - assess using "old carts" Rebound tenderness - fingers at 90 degree angle with abd., press deeply, remove fingers quickly. Return to position of organs causes a sharp pain. Iliopsoas muscle test - + lower quad. pain. Appendicitis. raise leg & flex at hip while examiner pushes downward Obturator muscle test - ruptured appendix or pelvic abscess. while supine, flex right leg at hip & knee to 90 degrees. Hold the leg just above the knee, grasp the ankle, & rotate the leg laterally & medially. Ballottement - floating mass. push inward on abd., while palpating flank area.

      Common
      Slide 35 of 43
      Slide 35

        Alimentary Tract
        Slide 36 of 43
        Slide 36

          Hepatobiliary System
          Slide 37 of 43
          Slide 37

            Pancreas & Spleen
            Slide 38 of 43
            Slide 38

              Kidneys
              Slide 39 of 43
              Slide 39

                Infants
                Slide 40 of 43
                Slide 40

                  Children
                  Slide 41 of 43
                  Slide 41

                    Pregnant Women
                    Slide 42 of 43
                    Slide 42

                      Older Adults
                      Slide 43 of 43
                      Slide 43
                        Older Adults Fecal Incontinence Urinary Incontinence Stress incontinence - leakage due to increased intraabd. pressur from coughing, laughing, etc. Urge incontinence - inability to hold urine once the urge to void occurs. Overflow incontinence - mechanical dysfunction from an overdistended bladder. Functional incontinence - intact urinary tract, but cognitive abilities, immobility, or musculoskeletal impairments lead to incontinence.


                      The major components of the abdominal exam include: observation, auscultation, percussion, and palpation. While these are the same elements which make up the pulmonary and cardiac exams, they are performed here in a slightly different order (i.e. auscultation before percussion) and carry different degrees of importance. Pelvic, genital, and rectal exams, all part of the abdominal evaluation, are discussed elsewhere.
                      Think Anatomically: When looking, listening, feeling and percussing imagine what organs live in the area that you are examining. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states.

                      Quadrants of the Abdomen

                      Topical Anatomy of the Abdomen

                            
                      By convention, the abdominal exam is performed with the provider standing on the patient's right side.

                      Observation: Much information can be gathered from simply watching the patient and looking at the abdomen. This requires complete exposure of the region in question, which is accomplished as follows:

                      Ask the patient to lie on a level examination table that is at a comfortable height for both of you. At this point, the patient should be dressed in a gown and, if they wish, underwear.
                      Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered, remembering that the superior margin of the abdomen extends beneath the rib cage.
                      Draping the Abdomen

                      The patient's hands should remain at their sides with their heads resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen.
                      Keep the room as warm as possible and make sure that the lighting is adequate. By paying attention to these seemingly small details, you create an environment that gives you the best possible chance of performing an accurate examination. This is particularly important early in your careers, when your skills are relatively unrefined. However, it will also stand you in good stead when examining obese, anxious, distressed or otherwise challenging patients.
                      While observing the patient, pay particular attention to:
                      Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. Global abdominal enlargement is usually caused by air, fluid, or fat. It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). 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.
                      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.
                      Presence of surgical scars or other skin abnormalities.
                      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: Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role. It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. There is no magic time frame. The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in one area can probably be heard throughout. How many places should you listen in? Again, there is no magic answer. At this stage, practice listening in each of the four quadrants and see if you can detect any "regional variations."
                      Abdominal Auscultation

                      What exactly are you listening for and what is its significance? Three things should be noted:

                      Are bowel sounds present?
                      If present, are they frequent or sparse (i.e. quantity)?
                      What is the nature of the sounds (i.e. quality)?
                      As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry great significance. That is, 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). In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal. 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. Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process.
                      After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound (analogous to a murmur) caused by turbulent blood flow through a vessel narrowed by atherosclerosis. The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting (e.g. a patient with some combination of renal insufficiency, difficult to control hypertension and known vascular disease), the presence of a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis distal to the aorta (i.e. at the take off of the Iliac Arteries) can also generate bruits. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation.

                      Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can be elicited:

                      Tympanitic (drum-like) sounds produced by percussing over air filled structures.
                      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. This would certainly be supported by other historical and exam findings.
                      Abdominal Percussion

                      What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs. To determine the size of the liver, proceed as follows:

                      Start just below the right breast in a line with the middle of the clavicle, a point that you are reasonably certain is over the lungs. Percussion in this area should produce a relatively resonant note.
                      Move your hand down a few centimeters and repeat. After doing this several times, you will be over the liver, which will produce a duller sounding tone.
                      Continue your march downward until the sound changes once again. This may occur while you are still over the ribs or perhaps just as you pass over the costal margin. At this point, you will have reached the inferior margin of the liver. The total span of the normal liver is quite variable, depending on the size of the patient (between 6 and 12 cm). Don't get discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle, particularly if there is a lot of subcutaneous fat.
                      The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.
                      Speed percussion, as described in the pulmonary section, may also be useful. Orient your left hand so that the fingers are pointing towards the patients head. Percuss as you move the hand at a slow and steady rate from the region of the right chest, down over the liver and towards the pelvis. This maneuver helps to accentuate different percussion notes, perhaps making the identification of the liver's borders a bit more obvious.
                      Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs. When significantly enlarged, percussion in the left upper quadrant will produce a dull tone. Splenomegaly suggested by percussion should then be verified by palpation (see below). The remainder of the normal abdomen is, for the most part, filled with the small and large intestines. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced. These will be variably tympanitic, dull or some combination of the above, depending on whether the underlying intestines are gas or liquid filled. The stomach "bubble" should produce a very tympanitic sound upon percussion over the left lower rib cage, close to the sternum.
                      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:

                      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 gravity-dependent fashion, distributing evenly across the posterior aspect of the abdomen. It should also cause a symmetric bulging of the patient's flanks.
                      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).
                      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.
                      The models below should help to clarify the concept of shifting dullness. With the "patient" lying flat on their back balloons (representing the intestines)
                      float on the water (representing ascites). When the "patient" turns on their right side, a new air fluid level is established.

                       
                      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: First warm your hands by rubbing them together before placing them on the patient. The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right. Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.

                      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. Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle, allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly.
                      Abdominal Palpation

                      Following this, repeat the examination of the same region but push a bit more firmly so that you are interrogating the deeper aspects of the right upper quadrant, particularly if the patient has a lot of subcutaneous fat. Pushing up and in while the patient takes a deep breath may make it easier to feel the liver edge as the downward movement of the diaphragm will bring the liver towards your hand. The tip of the xyphoid process, the bony structure at the bottom end of the sternum, may be directed outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it by noting its location relative to the rib cage (i.e. in the mid-line where the right and left sides meet).
                      Rib Cage

                      You can also try to "hook" the edge of the liver with your fingers. To utilize this technique, flex the tips of the fingers of your right hand (claw-like). Then push down in the right upper quadrant and pull upwards (towards the patient's head) as you try to rake-up on the edge of the liver. This is a nice way of confirming the presence of a palpable liver edge felt during conventional examination.
                      Hooking Edge of the Liver

                      Place your right hand at the inferior and lateral border of the ribs, pushing down as you push up from behind with your left hand. If the right kidney is massively enlarged, you may be able to feel it between your hands.
                      Now examine the left upper quadrant. The normal spleen in not palpable. When enlarged, it tends to grow towards the pelvis and the umbilicus (i.e. both down and across). Begin palpating near the belly button and move slowly towards the ribs. Examine superficially and then more deeply. Then start 8-10 cm below the rib margin and move upwards. In this way, you will be able to feel enlargement in either direction. You can use your left hand to push in from the patient's left flank, directing an enlarged spleen towards your right hand. If the spleen is very big, you may even be able to "bounce" it back and forth between your hands. Splenomegaly is probably more difficult to appreciate then hepatomegaly. The liver is bordered by the diaphragm and can't move away from an examining hand. The spleen, on the other hand, is not so definitively bordered and thus has a tendency to float away from you as you palpate. So, examine in a slow, gentle fashion. The edge, when palpable, is soft, rounded, and rather superficial. Repeat the exam with the patient turned onto their right side, which will drop the spleen down towards your examining hand.
                      Exploration for the left kidney is performed in the same fashion as described for the right. Kidney pain, most commonly associated with infection, can be elicited on direct examination if the entire structure becomes palpable as a result of associated edema. This is generally not the case. However, as the kidney lies in the retroperitoneum, pounding gently with the bottom of your fist on the costo-vertebral 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).
                      Posterior
                      View: Location of the Kidneys


                      Gross Retroperitoneum Anatomy


                      Examine the left and right lower quadrants, palpating first superficially and then deeper. A stool filled sigmoid colon or cecum are the most commonly identified structures on the left and right side respectively. The smooth dome of the bladder may rise above the pelvic brim and become palpable in the mid-line, though it needs to be quite full of urine for this to occur. Other pelvic organs can also occasionally be identified, most commonly the pregnant uterus, which is a firm structure that grows up and towards the umbillicus. The ovaries and fallopian tubes are not identifiable unless pathologically enlarged.
                      Finally, try to feel the abdominal aorta. First push down with a single hand in the area just above the umbillicus. If you are able to identify this pulsating structure with one hand, try to estimate its size. To do this, orient your hands so that the thumbs are pointed towards the patient's head. Then push deeply and try to position them so that they are on either side of the blood vessel. Estimate the distance between the palms (it should be no greater then roughly 3 cm). This is, admittedly, a crude technique. Remember also that the aorta is a retorperitoneal structure and can be very hard to appreciate in obese patients. There have been no reports of anyone actually causing the aorta to rupture using this maneuver, so don't be afraid to push vigorously.
                      Vascular Anatomy

                      What can you expect to feel? In general, don't be discouraged if you are unable to identify anything. Remember that the body is designed to protect critically important organs (e.g. liver and spleen beneath the ribs; kidneys and pancreas deep in the retroperitoneum; etc.). It is, for the most part, during pathologic states that these organs become identifiable to the careful examiner. However, you will not be able to recognize abnormal until you become comfortable identifying variants of normal, a theme common to the examination of any part of the body. It is therefore important to practice all of these maneuvers on every patient that you examine. It's also quite easy to miss abnormalities if you rush or push too vigorously, so take your time and focus on the tips/pads of your fingers.
                      Examining for a 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.

                      Assessing for a fluid wave

                      The abdominal examination, like all other aspects of the physical, is not done randomly. Every maneuver has a purpose. Think about what you're expecting to see, hear, or feel. Use information that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest of your evaluation. If, for example, a certain area of the abdomen was tympanitic during percussion, feel the same region and assure yourself that there is nothing solid in this location. Go back and repeat maneuvers to either confirm or refute your suspicions. In the event that a patient presents complaining of pain in any region of the abdomen, have them first localize the affected area, if possible with a single finger, pointing you towards the cause of the problem. Then, examine each of the other abdominal quadrants first before turning your attention to the area in question. This should help to keep the patient as relaxed as possible and limit voluntary and involuntary guarding (i.e. superficial muscle tightening which protects intra-abdominal organs from being poked), allowing you to gather the greatest amount of clinical data. Make sure you glance at the patient's face while examining a suspected tender area. This can be particularly revealing when evaluating otherwise stoic individuals (i.e. even these patients will grimace if the area is painful to the touch). The goal, of course, is to obtain relevant information while generating a minimal amount of discomfort.

                      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).

                      After many years (generally greater then 20) of chronic insult, the liver may become unable to perform some or all of its normal functions. There are several clinical manifestations of this dysfunction. While none are pathonomonic for liver disease, in the right historical context they are very suggestive of underlying pathology. Some of the most common findings are described and/or pictured below.

                      Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin appropriately. This can lead to
                      Icterus - Yellow discoloration of the sclera.
                      Jaundice - Yellow discoloration of the skin.
                      Bilirubinuria - Golden-brown coloration of the urine.
                      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.
                      Increased Systemic Estrogen Levels: The liver may become unable to process particular hormones, leading to their peripheral conversion into estrogen. High levels promote:
                      Breast development (gynecomastia).
                      Spider Angiomata - dilated arterioles most often visible on the skin of the upper chest.
                      Testicular atrophy.
                      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.
                      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.

                      Icterus



                      Ascites


                      Jaundice


                      Gynecomastia


                      Spider


                      Edema




                      Skip Navigation Links

                      Making sense of abdominal assessment

                      O'Laughlen, Mary C. RN, FNP-BC, PhD


                      Author Information

                      Assistant Professor • University of Virginia School of Nursing • Charlottesville, Va.

                      With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. This order is different from the rest of the body systems, for which you inspect, then percuss, palpate, and auscultate. The difference is based on the fact that physical handling of peritoneal contents may alter the frequency of bowel sounds.

                      What do you need to know about inspection, auscultation, percussion, and palpation of the abdomen? In this article, I'll help you make sense of abdominal assessment.


                      Inspection

                      First, take a look at the abdomen. You do most of the exam standing to the right of your supine patient. The abdomen is divided into four quadrants by drawing an imaginary vertical line down the middle of the sternum and a horizontal line through the umbilicus (see Abdominal quadrants and their structures).

                      Inspect for symmetry while standing at the side of your patient, then move to a position behind his head. Note the contour of the abdomen: Is it flat, scaphoid (concave), or protuberant (convex)? A flat contour is expected in well-muscled, athletic adults; thin adults may have a scaphoid abdomen. A rounded abdomen is commonly seen in young children, but in adults it's the result of poor muscle tone from inadequate exercise or being overweight. A localized enlargement may indicate a hernia, tumor, cysts, bowel obstruction, or enlargement of abdominal organs. Ask your patient to take a deep breath and hold it because this lowers the diaphragm and compresses the organs of the abdominal cavity, which may make previously unseen bulges or masses appear.

                      To assess the abdomen for herniation or diastasis recti (the separation of the rectus abdominis muscles often caused by pregnancy or obesity), or to differentiate a mass in the abdominal wall from one below it, ask your patient to raise his head. A bulge seen in the abdomen is a common symptom of a hernia. Abdominal hernias are caused by a combination of muscle weakness and strain that produces an opening in the abdominal musculature through which the abdominal contents move.

                      Next, inspect the abdomen for changes in pigmentation and color of the skin. Cullen's sign, a bluish color at the umbilicus, is a sign of bleeding in the peritoneum. Grey Turner's sign is bruising on the flanks indicating retroperitoneal bleeding, such as in pancreatitis. Jaundice is usually caused by liver disease or biliary tract obstruction.

                      Scars should be correlated with the patient's recollection of previous operations or injuries. An injury that caused a visible scar may have also caused adhesions (internal scarring) that may cause intestinal obstruction. Striae (stretch marks) on the abdomen may be a sign of past weight changes or pregnancy. Cushing's disease may cause purple striae. Also inspect for any lesions or nodules. They may or may not be related to gastrointestinal diseases. For example, an enlarged umbilical node may signal metastatic cancer. Liver disease may cause spider angiomas (spiderlike blood vessels that develop on the skin) or caput medusae (dilated superficial veins radiating from the umbilicus).

                      Peristalsis is the rhythmic contraction of smooth muscles to propel contents through the digestive tract that may be seen as a rippling movement across a section of the abdomen. However, peristaltic movement isn't normally seen on the surface of the abdomen. Visible peristalsis is usually abnormal and may be a sign of an intestinal obstruction. Pulsation in the upper midline is often visible in thin adults. Marked pulsations may be the result of increased pulse pressure or an abdominal aortic aneurysm.


                      Auscultation

                      Normal gut sounds are gurgling sounds (usually occurring 5 to 35 per minute) that can be heard with the diaphragm of a stethoscope. Decreased sounds, such as no sounds for 1 minute, are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery, abdominal infection, or injury. Absent sounds (no sounds for 5 minutes) are an ominous sign. They can be caused by intestinal obstruction, intestinal perforation, or intestinal ischemia or infarction. See What's that sound? for other sounds you may hear.


                      Percussion

                      Figure. Abdominal qu...
                      Figure. Abdominal qu...

                      Percussing the body gives one of three results:

                      Tympany is usually present in most of the abdomen caused by air in the gut (a higher pitch than the lungs).

                      Resonance is a lower-pitched and hollow sound (found in normal lungs).

                      Dullness is a flat sound without echoes; the liver, spleen, and fluid in the peritoneum (ascites) give a dull note, but an unusual dullness may be a clue to an underlying abdominal mass.

                      With your patient supine, percuss all four quadrants of the abdomen using proper technique. Hyperextend the middle finger of your nondominant hand and place this finger firmly against your patient's abdomen. With the end (not the pad) of your dominant middle finger, use a quick flick of your wrist to strike the finger on the abdomen. Categorize what you hear as tympanitic or dull.

                      You shouldn't be able to percuss the bladder unless it's distended above the symphysis pubis. Use percussion to check for dullness and to determine how high the bladder rises above the symphysis pubis.



                      span suggests atrophy. The liver is proportionate to the height and weight of your patient.

                      Percuss the spleen at the lowest costal interspace in the left anterior axillary line. This area is normally tympanitic. Ask your patient to take a deep breath and percuss again. Dullness with full inspiration may be a sign of an enlarged spleen or splenomegaly.



                      To percuss the kidneys, have your patient sit up on the exam table, place the palm of your nondominant hand over the right costovertebral angle, make a fist with your dominant hand, and use the ulnar surface to strike your nondominant hand. Repeat the maneuver over the left costovertebral angle. Compare the left and right sides. Costovertebral angle tenderness is often associated with renal disease, but could be muscular in origin. You may want to percuss the kidneys later in the exam so as not to tire your patient.



                      To percuss the liver, begin at the right midclavicular line over an area of tympany, moving to an area of dullness. Percuss upward along the midclavicular line from the level of the umbilicus to determine the lower border of the liver; the area of liver dullness is usually heard at the costal margin or slightly below it. A lower liver border that's greater than 3 cm below the costal margin may indicate organ enlargement. To determine the upper border of the liver, begin percussion on the right midclavicular line at an area of lung resonance and continue downward until the percussion tone changes to one of dullness; this marks the upper border of the liver. The usual span of the liver is approximately 6 to 12 cm. A vertical span greater than this may indicate liver enlargement; a lesser 

                      Palpation

                      With your patient in the supine position, begin light palpation by depressing the abdominal wall no more than 1 cm. At this point, you're mostly looking for areas of tenderness. The most sensitive indicators of tenderness are your patient's facial expression. Also note any abdominal guarding that's present. Next, proceed to deep palpation, depressing 3.8 to 5 cm in an effort to identify abdominal masses or areas of deep tenderness. If your patient is ticklish, place your hand over his hand while palpating.


                      Figure. No caption a...

                      Palpate the liver by placing your left hand under your patient and your right hand lateral to the rectus muscle, with your fingertips below the liver border. Because the liver moves down on inspiration, press gently in and up as your patient takes a deep breath. The liver is considered enlarged if the edge extends more than 2 cm below the right costal margin. If your patient is obese, use the hooking technique. Stand by his chest, hook your fingers just below the costal margin, and press firmly. Ask him to take a deep breath. You may feel the edge of the liver press against your fingers as it descends on inspiration.



                      When palpating the spleen, stand on your patient's right side and reach over, using your left hand to lift his left lower rib cage and flank. Press down just below the left costal margin with your right hand and ask him to take a deep breath. If enlarged, the spleen will come down on inspiration and you'll feel the tip. The spleen isn't normally palpable on most individuals.

                      Figure. No caption a...



                      To palpate the left kidney, stand on your patient's right side and reach across with your left hand. Place that hand over the left flank and your right hand at your patient's left costal margin. Have him take a deep breath, elevate the left flank with your left hand, and palpate deeply (because of the retroperitoneal position of the kidney) with your right hand. Kidneys move down with inspiration, so try to feel the lower edge of the kidney when your patient inhales. The left kidney is ordinarily not palpable unless enlarged.



                      To palpate the right kidney, place one hand under your patient's right flank and the other hand at the right costal margin. Because of the anatomic position of the right kidney (lower because of being pushed down by the liver), it's more easily palpable than the left kidney. If it's palpable, it should be smooth, firm, and nontender.


                      The importance of assessment

                      Performing an abdominal assessment will help you detect health problems in your patients earlier and prevent further complications from developing with existing disease. And now you've learned how to do a thorough physical assessment of the abdomen and the importance of systematically documenting your findings.


                      What's that sound?

                      Use the diaphragm of your stethoscope to listen for these sounds.

                      Borborygmi (BOR-boh-RIG-mee) are normal, loud, and easily audible sounds.

                      High-pitched, tinkling sounds are a sign of early intestinal obstruction.

                      * A friction rub is a high-pitched sound heard in association with respiration. Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. Listen for them over the liver and spleen.

                      Use the bell of your stethoscope to listen for these sounds.

                      Aortic bruits are heard in the epigastrium. They may be a sign of abdominal aortic aneurysm.

                      Renal artery bruits are heard in each upper quadrant. They may be a sign of renal artery stenosis, which is a potentially treatable cause of hypertension.

                      Iliac/femoral bruits are in the lower quadrants. They may be a sign of peripheral atherosclerosis.

                      * A venous hum is a soft, low-pitched, continuous sound heard in the epigastric region and around the umbilicus. It occurs with increased collateral circulation between the portal and systemic venous systems.



                      Learn more about it
                      Bickeley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, Pa., Lippincott Williams & Wilkins; 2008: 434-451.

                      Health Assessment Made Incredibly Visual! Philadelphia, PA, Lippincott Williams & Wilkins; 2007:132-139.

                      University of Washington. Techniques: Liver and ascites.http://depts.washington.edu/physdx/liver/tech.html.


                      © 2009 Lippincott Williams & Wilkins, Inc.
                      Source: Nursing made easy


                      Abdominal Assessment


                      Comments