ABDOMEN

I. REVIEW OF RELATED HISTORY

A. HISTORY OF PRESENT ILLNESS
1. Abdominal Pain – onset and duration, character (dull, sharp, burning,
stabbing, cramping), location,
associated symptoms, relationship to: menstrual cycle, urination,
defecation, inspiration, body
position, food or alcohol intake, stress, recent stool characteristics
(color, consistency, odor,
frequency), urinary characteristics, therapies to treat
2. Indigestion – character, location, association with: food intake, timing
of food intake, discomfort,
belching, flatulence, loss of appetite, location, onset, relief agents
3. Nausea / Vomiting – stimuli (odors, activities, time of day), date of last
menstrual period,
characteristics
4. Constipation – presence of bright blood, black or tarry appearance,
pattern
5. Jaundice – onset and duration, color of stools or urine, exposure to
hepatitis, use of club/recreational
drugs
6. Urinary frequency – change in usual pattern and/or volume, change in
urinary stream

B. PAST MEDICAL HISTORY

- gastrointestinal disorders, hepatitis or cirrhosis, abdominal or urinary
tract surgery or injury, major
illnesses (cancer, arthritis, kidney disease, cardiac disease), blood
transfusions

C. FAMILY HISTORY
- gallbladder disease, kidney disease, malabsorption syndrome (cystic
fibrosis), polyposis, colon
cancer

D. PERSONAL AND SOCIAL HISTORY

- nutrition (24-hr recall, food preferences and dislikes, ethnic foods,
religious food restrictions), first day
of last menstrual period, alcohol intake, stress, exposure to
infectious diseases, trauma, use
of club/recreational drugs

II. EXAMINATION AND FINDINGS

A. PREPARATION
- need good source of light, full exposure of abdomen
- have patient empty bladder and in supine position
 - place small pillow under patient’s head and another under slightly
flexed knees
- draw imaginary line from sternum to pubis through umbilicus then a
second imaginary line
perpendicular to first (horizontally across abdomen through
umbilicus) dividing abdomen in 4
quadrants
- anatomic landmarks are useful in describing location of pain,
tenderness, and other findings

Quadrants:
Rt. Upper (RUQ) Lt. Upper (LUQ) Rt. Lower (RLQ)
Lt. Lower (LLQ)
- liver & gall bladder - left lobe of liver - part of r. kidney
- part of l. kidney
- duodenum - spleen - cecum & appendix -
ovary
- rt. renal artery - stomach - rt. iliac artery
- lt. iliac artery
- aorta, - rt. femoral artery - lt.
femoral artery
- ovary & tube - sigmoid
colon
- ureter

B. INSPECTION
1. Surface Characteristics – observe skin color and surface
characteristics
- skin may be somewhat paler if it has not been exposed to sun
- fine venous network is often visible
- unexpected findings include generalized color changes such as
jaundice or cyanosis;
glistening, taut appearance suggesting ascites; bruises and
localized discoloration
(Cullen sign) suggesting internal bleeding; striae (originally
pink or blue, changing to
silvery white over time) resulting from pregnancy or weight
gain
- inspect for lesions, particularly nodules
- note any scars and draw their location, configuration, and relative
size on illustration of
abdomen

2. Contour – inspect for contour, symmetry, and surface motion

- contour is the abdominal profile from the rib margin to pubis
- expectations can be described as flat, rounded, or scaphoid
- should be evenly rounded with maximum height of
convexity at umbilicus
- note location and contour of umbilicus
 - may be inverted or protrude slightly, but should be free of
inflammation, swelling, or
bulges that may indicate a hernia
- distention may occur as a result of obesity, enlarged organs, and
fluid or gas
- distention from umbilicus to symphysis can be caused by
ovarian tumor, pregnancy,
uterine fibroids, or distended bladder
- ask patient to take deep breath and hold it and/or lift head from
table
- contour should remain smooth and symmetric
- this maneuver lowers diaphragm and compresses organs of
abdominal cavity
exposing previously “hidden” objects
- hernias will protrude in the area of surgical scars, navel area, and
rectus abdomens muscles
- most are reducible (contents are easily replaced)
- nonreducilble hernia is one that the blood supply to
protruded contents is obstructed
and requires immediate surgical interventions

3. Movement – smooth, even movement should occur with respiration

- males exhibit primarily abdominal movement with respiration,
whereas females show mostly
costal movement
- limited abdominal motion associated with respiration may indicate
peritonitis or disease
- marked pulsation may occur as result of increased pulse pressure
or abdominal aortic
aneurysm

C. AUSCULTATION
- use to assess bowel motility and discover vascular sounds
- always precedes percussion and palpation because these maneuvers
may alter frequency and
intensity of bowel sounds

1. Bowel Sounds – use diaphragm and hold in place with very light
pressure
- listen for bowel sounds and note frequency and character
- usually heard as clicks and gurgles that occur irregularly
and range from 5 to 35/min
- loud prolonged gurgles are stomach growling (borborygmi)
- high pitched tinkling sound suggest intestinal fluid and air under
pressure
- decreased bowel sounds occur with peritonitis and paralytic ileus
- absence of bowel sounds is established only after 5 minutes of
continuous listening
 2. Vascular Sounds – with bell listen to all four quadrants for bruits in
aortic, renal, iliac, and femoral
arteries
- with diaphragm listen for friction rubs over liver and spleen
- with bell in epigastric region and around umbilicus, listen for
venous hum (soft, low pitched,
continuous)
- occurs with increased collateral circulation between portal
and systemic venous
systems

D. PERCUSSION
- used to assess size and density of organs and to detect presence of fluid
(ascites), air (gastric
distention), and fluid-filled or solid masses
- percuss all quadrants for sense of overall tympany and dullness
- tympany is predominant sound because air is present in stomach
and intestines
- dullness is over organs and solid masses
- distended bladder produces dullness in suprapubic area

1. Additional Liver Assessment – if enlargement is suspected, additional

maneuvers are needed
- liver dullness is usually detected in 5th to 7th intercostal space

2. Spleen – percuss spleen just posterior to midaxillary line on left side

- may hear a small area of spenic dullness from 6th to 10th rib
- large area of dullness suggests enlargement; however, a full
stomach or feces filled intestine
may mimic dullness
- percuss lowest intercostals space in left anterior axillary line
before and after patient takes a
deep breath
- should be tympanic
- with enlargement, tympany changes to dullness

E. PALPATION
- used to assess organs of abdominal cavity and to detect muscle spasm,
masses, fluid, and areas of
tenderness
- evaluate abdominal organs for size, shape, mobility, consistency, and
tension
- have patient in supine position with abdominal muscles as relaxed as
possible
- ticklishness may be a problem
- ask patient to perform self-palpation while examiner hands are
over patient’s fingers, not
quite touching abdomen itself
- after time, let fingers drift slowly onto abdomen while still resting
primarily on patient’s fingers
 - might also use diaphragm as starting point, allowing fingers to
drift over edge of diaphragm
and palpate without eliciting an excessively ticklish response
- applying stimulus to another, less sensitive body part with non-
palpating hand can also
decrease ticklish responses

1. Light Palpation – begin with light, systematic palpation of all four

quadrants, initially avoiding any
areas that have already been identified as problem spots
- with palmar surface of fingers, depress abdominal walls no more
than 1 cm, using light even
pressing motion
- avoid short, quick jabs
- abdomen should feel smooth with consistent softness
- particularly used in identifying muscular resistance and areas of
tenderness

2. Moderate Palpation – exerting moderate pressure as intermediate step

to gradually approach deep
palpation
- tenderness not elicited on gentle palpation may become evident
with deeper pressure
- additional maneuver of moderate palpation is performed with side
of hand
- palpate during entire respiratory cycle

3. Deep Palpation – necessary to thoroughly delineate abdominal organs

and to detect less obvious
masses
- use palmar surface of extended fingers, pressing deeply and
evenly into abdominal wall
- palpate all 4 quadrants

4. Masses – identify any masses and note characteristics: location, size,

shape, consistency,
tenderness, pulsation, mobility, and movement with respiration
- determine if superficial (located in abdominal wall) or
intraabdominal - - have patient lift head
from table, contracting abdominal muscles
- in abdominal wall, masses will continue to be palpable
- in abdominal cavity, masses will be more difficult to feel
because they are obscured
by abdominal musculature

5. Umbilical Ring – area should be free of bulges, nodules, and granulation

- ring should be round and free of irregularities
- note whether incomplete or soft in center (suggests potential for
herniation)
 - umbilicus may be either slightly inverted or everted but should
not protrude

6. Kidneys – assess for tenderness

- ask patient to assume sitting position
- place palm of hand over right costoverebral angle and strike
hand with ulnar surface
of fist of opposite hand
- patient should perceive blow as thud, but should not cause
tenderness or pain
- pain is usually performed while examining back rather than
abdomen

7. Additional Procedures
Ascites Assessment – suspected in patients who have protuberant
abdomens or flanks that bulge in
supine position
- percuss for areas of dullness and resonance with patient supine
- gravity settles fluid: expect to hear dullness in dependent parts
and tympany in upper parts

Shifting Dullness – without ascites, borders will remain relatively constant

- with ascites, border of dullness shifts to dependent side
(approaches midline) as gravity
settles fluid

Fluid Wave – will need assistance

- with patient supine, press edge of hand and forearm firmly along
vertical midline of abdomen
which stops the transmission of a wave
- detected fluid wave suggests ascites, but findings are not
conclusive

Pain Assessment – rate the pain, is there an underlying physical cause?,

has there been recent
trauma?
- pain severe enough to make patient unwilling to move, is
accompanied by nausea and
vomiting and marked by areas of localized tenderness
generally with underlying
cause
- patients may give a “touch-me-not” warning - - do not touch
in particular areas
- patients with organic cause for abdominal pain are generally
not hungry
- ask patient to point finger to location
- if not directed to navel but goes to fixed point, great
likelihood of significant
physical importance
 - farther from navel, more likely it will be organic in
origin
- patients with nonspecific abdominal pain keep eyes closed,
those with organic
disease keep eyes open
- ask patient to cough or take deep breath
- asses patient’s willingness to jump or to walk
- careful assessment of quality and location of pain can usually
narrow possible causes

Common Conditions:
Appendicitis – becomes localized to RLQ
- guarding, tenderness, iliopsoas and obturator signs, RLQ skin
hyperesthesia; anorexia,
nausea, or vomiting after onset of pain; low-grade fever

Cholecystitis – severe, unrelenting RUQ or epigastric pain; may be

referred to right subscapular area
- RUQ tenderness and rigidity, palpable gallbladder, anorexia,
vomiting, fever, possible
jaundice

Pancreatitis – dramatic, sudden, excruciating LUQ, epigastric, or umbilical

pain; may be present in one
or both flanks; may be referred to left shoulder
- epigastric tenderness, vomiting, fever, shock; Cullen sign; signs
occur 2 - 3 after onset

Perforated Gastric or Duodenal Ulcer – abrupt RUQ; may be referred to

shoulders
- abdominal free air and distention with increased resonance over
liver; tenderness in
epigastrium or RUQ; rigid abdominal wall, rebound
tenderness

Diverticulitis – epigastric, radiating down left side of abdomen especially

after eating; may be referred
to back
- flatulence, borborygmius, diarrhea, dysuria, tenderness on
palpation

Intestinal Obstruction – abrupt, severe, spasmodic; referred to

epigastrium, umbilicus
- distention, minimal rebound tenderness, vomiting, localized
tenderness, visible peristalsis;
bowel sounds absent (with paralytic obstruction) or
hyperactive high pitched (with
mechanical obstruction)
III. DEVELOPMENTAL VARIATIONS
A. INFANTS AND CHILDREN
- if possible, should be examined during a time of relaxation and quiet
- sucking a bottle or pacifier may help
- parent’s lap makes best exam surface

1. Inspection – noting shape, contour, and movement with respiration

- should be rounded and dome-shaped
- note any localized fullness
- note whether abdomen protrudes above level of chest or is
scaphoid (shaped like a boat)
- pulsations are common
- superficial veins are usually visible in thin infant; however,
distended veins across abdomen
are unexpected finding
- inspect umbilical cord, counting number of vessels (2 arteries, 1
vein)
- umbilical stump should be dry and odorless
- inspect for discharge, redness, induration, and skin warmth
- note any protrusion through umbilicus or rectus abdominis
muscles when infant strains
- umbilicus is usually inverted
- umbilical hernia is common
- umbilicus often everts with increased abdominal pressure
- herniation through rectus abdominis muscles is a problem

2. Auscultation and Percussion – peristalsis is detected when metallic

tinkling is heard every 10 to 30
seconds
- bowel sounds should be present within 1 to 2 hrs after birth
- auscultate chest for bowel sounds
- no bruits or venous hums should be detected
- bruit of stenosis has high frequency and is soft
- bruit of arteriovenous fistula is continuous
- abdomen may produce more tympany on percussion than found
in adults
- tympany is usually result of gas whereas dullness may
indicate fluid or solid mass
- before 2 yrs old, females have slightly larger liver span than
males

3. Palpation - palpate with infant’s feet slightly elevated and knees flexed
to promote relaxation
- begin with superficial palpation

a. Deep Palpation – perform in all quadrants

- note location, size, shape, tenderness, and consistency of
any masses
- use transillumination to distinguish cystic masses from solid
masses
 - if any suspicion of neoplasm exists, limit palpation of mass
because manipulation
may cause injury or spread of malignancy
- distended bladder, felt as firm, central dome-shaped
structure in lower abdomen,
may indicate urethral obstruction or central nervous
system defects
- tenderness or pain on palpation may be difficult to detect
- pain and tenderness are assessed by change in pitch
of crying, facial
grimacing, rejection of opportunity to suck, and
drawing the knees to
the abdomen with palpation
- after age 5, contour, when supine, may become convex and
will not extend above
imaginary line drawn from xiphoid process to
symphysis pubis
- respirations continue to be abdominal until 6 or 7 yrs
old

B. ADOLESCENTS
- techniques are the same as those for adults

C. PREGNANT WOMEN
- bowel sounds will be diminished as a result of decreased peristaltic
activity
- striae and midline band of pigmentation (linea nigra) may be present
- constipation is common and hemorrhoids often develop later

D. OLDER ADULTS
- abdominal wall becomes thinner and less firm as result of loss of
connective tissue and muscle mass
- palpation may be relatively easier and yield more accurate findings
- pulsating abdominal aortic aneurysm may be more readily palpable
- abdominal contour is often rounded as result of loss of muscle tone
- use judgment in determining whether a patient is able to assume a
particular position
- be aware that respiratory changes can produce corresponding findings
in exam
- intestinal disorders are common, particularly sensitive to patient
complaints and related findings
- constipation is common
- fecal impaction is common
- gastrointestinal cancer increases with age
- various symptoms depend on site of tumor
- symptoms range from dysphagia to nausea, vomiting, anorexia,
and meatemesis; can
include changes in stool frequency, size, consistency, or color
IV. COMMON ABNORMALITIES
GASTROESOPHAGEAL REFLUX DISEASE – relaxation of incompetence of lower esophagus
produces gastroesophgeal
reflux
- backward flow of acid from stomach up into esophagus
- patients experience heartburn (acid indigestion)
- common among elderly and pregnant women
- symptoms in infants and children include regurgitation and vomiting

IRRITABLE BOWEL SYNDROME – functional disorder of intestine that produces cluster of

symptoms, consisting most
commonly of abdominal pain, bloating, constipation, and diarrhea
- no sign of disease that can be seen or measured, but intestine is not
functioning normally
- more common in women

HIATAL HERNIA WITH ESOPHAGITIS – occurs when a part of stomach has passed through
esophageal hiatus in
diaphragm into chest cavity
- very common and occurs more in women and older adults
- associated with obesity, pregnancy, ascites, and use of tight-fitting belts and
clothes
- clinically significant when accompanied by acid reflux, producing esophagitis

DUODENAL ULCER (DUODENAL PEPTIC ULCER DISEASE) – most common form of peptic ulcer
disease, duodenal ulcer is a
chronic circumscribed break in duodenal mucosa that scars with healing
- occurs twice as often in men as in women
- occurs on both anterior and posterior walls
- perforation of duodenum is life-threatening, requires immediate surgical
intervention
- posterior ulcers are more likely to bleed

CROHN DISEASE – chronic inflammatory disorder of gastrointestinal tract that produces

ulceration, fibrosis, and
malabsorption
- terminal ileum and colon are most common sites
- mucosa has characteristic cobblestone appearance
- patient exhibits chronic diarrhea, compromised nutritional status and often
other systemic manifestations
such as arthritis, iritis, and erythema nodosum

ULCERATIVE COLITIS – chronic inflammatory disorder of colon and rectum that produces
mucosal friability and areas of
ulceration; fibrosis is minimal
- characterized by bloody, frequent, watery diarrhea (as many as 20 or 30/day)
- patients exhibit weight loss, fatigue, and general debilitation

STOMACH CANCER – most commonly found in lower half of stomach

 - metastases, local and distant are common
- symptoms may be vague and nonspecific, and include loss of appetite, feeling
of fullness, weight loss,
dysphagia, and persistent epigastric pain
- physical exam may reveal tenderness, enlarged liver, positive supraclavicular
nodes, and ascites

DIVERTICULOSIS – inflammation of existing diverticula produces left quadrant pain,

anorexia, nausea, vomiting, and
altered bowel habits (usually constipation)
- abdomen may be distened and tympanic with decreased bowel sounds and
localized tenderness

COLON CANCER (COLORECTAL CANCER) – carcinoma of colon usually occurs in rectum,

sigmoid, and lower descending
colon; may appear in proximal colon
- earliest sign is occult blood in stool detectable by fecal occult blood testing
- history of frequency and character of stools

HEPATITIS – inflammatory process of liver characterized by diffuse or patchy

hepatocellular necrosis
- most commonly caused by viral infection, alcohol, drugs, or toxins
- symptoms include jaundice, hepatomegaly, anorexia, abdominal and gastric
discomfort, clay-colored stools,
and tea-colored urine

CIRRHOSIS – characterized by destruction of liver parenchyma

- liver is initially enlarged with firm, nontender border on palpation; but as
scarring progresses, liver mass is
reduced, and generally cannot be palpated
- associated symptoms include ascites, jaundice, prominent abdominal
vasculature, cutaneous spider
angiomas, dark urine, light-colored stools, and spleen enlargement
- patient complains of fatigue, and in late stages muscle wasting may be
evident

CHOLELITHIASIS – stone formation in gallbladder

- symptoms of indigestion, colic, and mild transient jaundice are common
- commonly produces episodes of acute cholecystitis and pancreatitis

GALLBLADDER CANCER – invasion of gallbladder by malignant cells results in abdominal

pain, jaundice, and weight loss
- mass may be palpable in upper abdomen

CHOLECYSTITIS – inflammatory process of gallbladder that may be either acute or

chronic
acute = associated stone formation in 90% of all cases, causing obstruction
and inflammation
- symptoms include pain in right upper quadrant with radiation around
midtorso to right scapular region
 - pain is abrupt and severe, lasting from 2 to 4 hours
chronic = repeated attacks of acute in gallbladder that is scarred and
contracted
- patients exhibit fat intolerance, flatulence, nausea, anorexia, and
nonspecific abdominal pain and
tenderness of right hypochondriac region

CHRONIC PANCREATITIS – chronic inflammation of pancreas produces constant,

unremitting abdominal pain, epigastric
tenderness, weight loss, steatorrhea, and glucose intolerance

PANCREATIC CANCER – malignant degeneration results in abdominal pain that radiates

from epigastrium to upper
quadrants or back, weight loss, anorexia, and jaundice

SPLEEN RUPTURE – most commonly injured in abdominal trauma because of its anatomic
location
- mechanism of injury can be either blunt (most common) or penetrating
- symptoms are pain in left upper quadrant with radiation to left shoulder,
hypovolemia, and peritoneal irritation
- diagnosis is made by positive paracentesis or splenic scan
- surgical intervention may be required

GLOMERULONEPHRITIS – inflammation of capillary loops of renal glomeruli usually

producing nonspecific symptoms
- patient complains of nausea, malaise, and arthralgias
- hematuria may occur and pulmonary infiltrates may be present

PYELONEPHRITIS – infection of kidney and renal pelvis characterized by flank pain,

bacteriuria, pyuria, dysuria, nocturia,
and frequency
- costovertebral angle tenderness may be evident

ACUTE RENAL FAILURE – sudden, severe impairment of renal function causing acute
uremic episode
- urine output may be normal, decreased, or absent
- patient may show signs of either fluid overload or deficit

CHRONIC RENAL FAILURE – slow, insidious, and irreversible impairment of renal function
- uremia develops gradually
- patient may experience oliguria (slight or infrequent urination) or anuria
(absence of urine formation) and
have signs of fluid overload

Intussusception – prolapse of one segment of intestine into another causing intestinal

obstruction
- commonly occurs between 3 and 12 mos. old
- cause is unknown
- symptoms include acute intermittent abdominal pain, abdominal distention,
vomiting, and passage at first of
 normal brown stool
- subsequent stools may be mixed with blood and mucus with a red
currant jelly appearance
- mass may be palpated in right or left upper quadrant, whereas lower quadrant
feels empty
- child is inconsolable, sometimes doubling up with pain

Urinary Incontinence – most common types are

stress – leakage of urine due to increased intraabdominal pressure that can
occur from coughing, laughing,
exercise, or lifting heavy things
- causes include weakness of bladder neck supports and anatomic
damage to urethral sphincter

urge – inability to hold urine once the urge to void occurs

- causes can be local genitourinary (genital organ functions) conditions,
or central nervous system
disorders (stroke)

overflow – mechanical dysfunction resulting from overdistended bladder

- causes include anatomic obstruction by prostatic hypertrophy and
strictures; neurologic abnormalities
that impair detrusor contractility (multiple sclerosis); or spinal
lesions

functional – intact urinary tract, but other factors such as cognitive abilities,
immobility, or musculoskeletal
impairments lead to incontinence