ABDOMEN

ANATOMY & PHYSIOLOGY

Landmarks to be examine:
o Xiphoid process
o Rectus abdominis muscle
o Costal margin
o Midline, underlying linea alba
o Umbilicus
o Iliac crest
o Anterior superior iliac crest
o Linguinal ligament
o Pubic tubercle
o Symphysis pubis
Descriptive purposes:
o Divide the abdomen into 4 quadrants
o Lines from the symphysis pubis and crosses in the umbilicus
Right Upper Quadrant (RUQ)
Left Upper Quadrant (LUQ)
Right Lower Quadrant (RLQ)
Left Lower Quadrant (LLQ)
o Divide the abdomen into 9 sections
Epigastric
Umbilical
Hypogastric or suprapubic
Left & right hypochondral
Left & right lumbar
Left & right iliac
o 2 vertical lines from mid-point between anterior superior iliac crests
and Symphysis pubis
o 2 horizontal line from 2 points:
Superior: transpyloric plane lateral margin of rectus abdominis
crosses the costal margin
Inferior: intertubercular plane line joined the 2 tubercle of the
iliac crest
Surface Anatomy
o Sigmoid colon firm, narrow tube in the LLQ
o Cecum softer, wider tube in the RLQ
o Liver very soft consistency, render it hard to palpate, just below the
right costal margin
o Lower pole of kidney RUQ
o Aorta pulsation frequently visible and palpable in upper abdomen
o Iliac arteries pulsation sometimes felt in the lower quadrant
o Most of the liver and stomach impalpable, below the rib cage
o Spleen lies against diaphragm, at level of 9 th-11th rib, mostly posterior
to the left mid-axillary line. Laterally and behind the stomach, just
above the left kidney
o Gallbladder lies deeply within the liver; cannot be distinguish
 o Duodenum & Pancreas lies deep in upper abdomen; not normally
palpable
o Sacral promontory the anterior edge of the first sacral vertebra
Micturition: process by which urinary bladder empties
o Distended bladder may be palpable above the Symphysis pubis
o Bladder accommodates roughly 300 ml of urine
o Bladder expansion stimulates contraction detrusor muscle
o Contraction of the destrusor muscle is the major step for marturition
o Several things can prevent incontinence:
Increased intraurethral pressure
Internal urethral sphincter prevents micturition until the
pressure inside the main bladder rises above critical threshold
External urethral muscle skeletal voluntary muscle; preventing
by voluntary movement

o Neuroregulatory mechanism: consist of 3 innervations

Pelvic nerve
Principal nerve supply
Connected to sacral plexus S2& S3
Give rise to :
o Sensory nerve fibers
Action: detect the degree of stretch in the
bladder wall
o Motor nerve fibers
Parasympathetic fibers
Action: innervate the detrusor muscle
Pudendal nerve
Skeletal nerve fibers
Action: control the voluntary skeletal muscle of the
external urethral sphincter
Hypogastric nerve
Sympathetic fibers/innervations
Connected to lumbar plexus L2
Action: stimulate mainly the blood vessels and have a
little to do with the bladder contraction
Sensation of fullness and pain
Kidneys
o Located posteriorly
o Upper part is protected by the ribs
o Costovertebral angle: angle created by the inferior border of 12 th rib
and the transverse process of the lumbar vertebra
o Costovertebral angle is use to locate tenderness in kidney
Changes with Aging
o Pain maybe less severe
o Fever is often less pronounce
o Sign of peritoneal inflammation may be diminish or absent
HEALTH HISTORY
GASTROINTESTINAL DISORDER
Hows your appetite?
Anorexia, nausea, vomiting in many gastrointestinal disorders; also in
pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia,
uremia, liver disease, emotional states, adverse drug reactions
Heartburn, or a sense of burning or warmth that is retrosternal and may
radiate from the epigastrium to the neck
o If chronic, consider reflux esophagitis
Excessive gas, especially with frequent belching, abdominal bloating or
distention
Flatus, the passage of gas by rectum
Early satiety usually associated with hepatitis
Anorexia is a loss or lack of appetite
Retching is the spasmodic movements of the chest and diaphragm
Vomiting is the forceful expulsion of gastric contents out through the mouth
Regurgitation is raise esophageal or gastric contents in the absence of
nausea or retching
In vomiting and regurgitation case, ask:
o Color, odor, volume, presence of blood and frequency
Coffee-grounds emesis or red blood are termed hematemesis
3 Broad category of Abdominal pain:
o Visceral pain occurs when hollow abdominal organs such as the
intestine or biliary tree contract unusually forcefully or when they are
distended or stretched
o Parietal pain originates in the parietal peritoneum and is caused by
inflammation
o Referred pain is felt in more distant sites, which are innervated at
approximately the same spinal levels as the disordered structure
o Always ask the OPQRST of abdominal pain
Dysphagia, the sense that food or liquid is sticking, hesitating, or wont go
down right.
Odynophagia, or pain on swallowing
o Burning sensation inflammation
o Squeezing or cramping pain muscular cause
Bowel movement. Frequency and changes
o Constipation passage of hard and perhaps painful stool
o Obstipation complete constipation with no passage of either feces or
gas
o Diarrhea - excessive frequency in the passage of stools that are usually
unformed or watery
Color of the stool:
o Melena black tarry stool
o Hematochezia presence of red blood in the stool
o Steatorrhea - Large yellowish or gray greasy foul smelling, sometimes
frothy or floating stools; fatty stool
Tenesmus - intense urge with straining but little or no result
 Jaundice yellowish discoloration of skin and sclera; cause by:
o Increase production of bilirubin hemolytic anemia
o Decrease uptake of bilirubin by the hepatocytes
o Decrease ability of liver to conjugate bilirubin Gilberts syndrome
o Decrease excretion of bilirubin through bile causing reabsorption to the
blood obstructive liver disease
Intrahepatic jaundice can be hepatocelullar, damage to the hepatocyte, and
cholestatic.
Extrahepatic jaundice arises from obstructive of the extrahepatic bile duct or
increase turn-over of RBC
For Jaundice, ask:
o Color of the stool
o Color of the urine
o Level of bilirubin (TBil, Bu, Bc)
o Presence of diseases such as:
Hepatitis
Alcoholic hepatitis or cirrhosis
Toxic liver damage
Gallbladder disease or surgery
Hereditary disorder

GENITOURINARY DISORDER
Frequency, Nocturia, and Polyuria
Involuntary voiding suggest cognitive or neurosensory deficit
Color of the urine:
o Hematuria blood in the urine
Pain of the urine:
o Suprapubic pain bladder disorder
o Painful urination burning sensation; indicate inflammation
o Prostatic pain acute prostatitis
Urinary urgency is an unusually intense and immediate desire to void
Urinary frequency, or abnormally frequent voiding with low volume of urine
Polyuria refers to a significant increase in 24-hour urine volume roughly
defined as exceeding 3 liters
Nocturia refers to urinary frequency at night, sometimes defined as
awakening the patient more than once; urine volume may be large or small
Urinary incontinence, an involuntary loss of urine that may become socially
embarrassing or cause problems with hygiene
o Stress incontinence with increased intra-abdominal pressure from
decreased contractility of urethral sphincter or poor support of bladder
neck
o Urge incontinence if unable to hold the urine, from detrusor
overactivity
o Overflow incontinence when the bladder cannot be emptied until
bladder pressure exceeds urethral pressure, from anatomic obstruction
by prostatic hypertrophy or stricture, also neurogenic abnormalities
 o Functional incontinence from impaired cognition, musculoskeletal
problems, immobility
Kidney pain is a visceral pain usually produced by distention of the renal
capsule and typically dull, aching, and steady; flank pain
Urethral pain is usually severe and colicky, originating at the costovertebral
angle and radiating around the trunk into the lower quadrant of the
abdomen, or possibly into the upper thigh and testicle or labium

HEALTH PROMOTION
TECHNIQUE OF EXAMINATION
For good examination:
1. Good light
2. Relaxed patient
3. Full exposure of the abdomen from above the Xiphoid process to the
Symphysis pubis
Steps for Enhancing Examination of the Abdomen
The patient should have an empty bladder.
Make the patient comfortable in a supine position
Have the patient keep arms at the sides or folded across the chest.
Before you begin palpation, ask the patient to point to any areas of
pain and examine these areas last.
Warm your hands and stethoscope, and avoid long fingernails.
Approach slowly and avoid quick unexpected movements. Watch the
patients face closely for any signs of pain or discomfort.
Distract the patient if necessary with conversation or questions.

ABDOMEN
Inspection
The skin, including:
Scars. Describe or diagram their location.
Striae. Old silver striae or stretch marks, as illustrated above,
are normal.
Pinkpurple striae of Cushings syndrome
Dilated veins. A few small veins may be visible normally.
Rashes and lesions
The umbilicus
The contour of the abdomen
Peristalsis
Pulsation
Auscultation
Listen to the abdomen before performing percussion or palpation,
since these maneuvers may alter the frequency of bowel sounds
Bruits, vascular sounds resembling heart murmurs, over the aorta or
other arteries in the abdomen, which suggest vascular occlusive
disease
Patient has high blood pressure, listen in the epigastrium and in
each upper quadrant
 Costovertebral angles suggest renal artery stenosis
Over the aorta, the iliac arteries, and the femoral arteries
arterial insuffieciency in the legs
Borborygmi long prolonged gurgles of hyperperistalsisthe familiar
stomach growling.
friction rubs: listen over the liver and spleen- suspect a liver tumor,
gonococcal infection around the liver, or splenic infarction
Percussion
Function:
assess the amount and distribution of gas in the abdomen
identify possible masses that are solid or fluid filled
estimating the size of the liver and spleen
Tympany usually predominates because of gas in the gastrointestinal
tract, but scattered areas of dullness due to fluid and feces there are
also typical
Palpation
Light palpation using one hand; keep hand and fingers horizontally
positioned against the stomach
Palpate with light, gentle and dipping motion
Moving smoothly, feel all quadrant
Identify any superficial organs or masses and any area of
tenderness or increased resistance to your hand
if any present, do these:
Try the relaxing method
Feel for relaxation of abdominal muscle that accompanies
exhalation
Ask patient to mouth-breath with jaw dropped open
Deep palpitation require to delineate abdominal masses; usually
using 2 hands
Using the palmar surfaces of your fingers, feel in all four
quadrants
Identify any masses and note their location, size, shape,
consistency, tenderness, pulsations, and any mobility with
respiration or with the examining hand.
Correlate your palpable findings with their percussion notes
Abdominal masses may be categorized in several ways:
Physiologic (pregnant uterus),
Inflammatory (diverticulitis of the colon),
Vascular (an aneurysm of the abdominal aorta),
Neoplastic (carcinoma of the colon), or
Obstructive (a distended bladder or dilated loop of bowel).
Assessment for Peritoneal Inflammation:
Ask the patient to cough abdominal pain on coughing suggest
peritoneal inflammation
Palpate gently with one finger to map the tender area
Look for rebound tenderness rebound tenderness suggest peritoneal
inflammation
 Press fingers slowly and quickly retract them
Ask patient if:
Compare which hurt more, upon pressing or withdrawing
Show you exactly where it hurts

LIVER
Percussion
Use to determine the lower and upper border of the liver in right mid-
clavicular line
Lower border: palpate from the tymphanic area of the abdomen, going
up to the dullness area
Upper border: palpate from the areola (men) or infra-mammary line
(women) to the dullness area
Use measurement to determine the distance between the 2 points
liver spans
N : 6-12 cm right mid-clavicular line; 4-8 cm midsternal line
Palpation
Place the left hand parallel and behind the 11 th and 12th ribs and
adjacent the soft tissue
Palpate using right fingers just below the right costal margin; press up
and gently
Ask the patient to breath with diaphragm inhalation usually cause 3
cm descends of liver
Note for tenderness
Determine the liver edge laterally and medially
Hooking technique maybe useful for obese patient
Stand right of the patient
Place both hands, side by side, on the right abdomen below the
border of liver dullness
Press in with your fingers and up toward the costal margin
Ask the patient to inhale

Determination of tenderness for nonpalpable liver:

Place your left hand flat on the lower right rib cage and then
gently strike your hand with the ulnar surface of your right fist.
Ask the patient to compare the sensation with that produced by
a similar strike on the left side

SPLEEN
Percussion To raise suspicion of splenomegaly. 2 Techniques:
Percuss the left lower anterior chest wall between lung resonance
above and the costal margin (an area termed Traubes space)
Check for a splenic percussion sign lowest interspace of the left
anterior axillary line
Palpation
Left hand: reach over & around the patient support and press forward
the lower left rib cage and adjacent soft tissue
 Right hand: below the left costal margin, press in toward the spleen
Start low enough that youre below a possible enlarge spleen
Ask the patient to breath
Note any tenderness, assess the splenic contour, and measure the
distance between the spleens lowest point and the left costal margin
Repeat with patient lying on the right side

KIDNEY
Palpation
Left kidney:
Move to the left side of the patient
Right hand: behind, below and parallel to the 12 th rib in the
costovertebral angle
Left hand: left upper quadrant, lateral and parallel to the rectus
muscle
Ask the patient to take a deep breath
Try to catch the kidney by pressing your left hand firmly and
deeply into the left upper quadrant, just below the costal margin
Slowly release the pressure of your left hand, feeling at the
same time for the kidney to slide back into its expiratory
position
Alternatively, try to feel for the left kidney by a method similar
to feeling for the spleen
Right kidney:
Move to the right side of the patient
Left hand to support the back of the patient
Right hand to palpate
Proceed as for the left kidney
In both: If the kidney is palpable, describe its size, contour, and any
tenderness
Assessing kidney tenderness:
Search it in each costovertebral angle
Fist percussion: Place the ball of one hand in the costovertebral
angle and strike it with the ulnar surface of your fist

BLADDER
Palpation
Dome of the distended bladder feels smooth and round
Check for tenderness
Percussion
Determine how high the bladder rises above the symphysis pubis
Check for dullness

AORTA
 Press firmly deep in the upper abdomen, slightly to the left of the midline,
and identify the aortic pulsations
>50 y/o N: 3 cm palpate at the upper abdomen
Periumbilical/ upper abdomen mass with expansile pulsation aortic
aneurysm

SPECIAL TECHNIQUES
POSSIBLE ASCITES
A protuberant abdomen with bulging flanks suggests the possibility of ascitic
fluid
Percussion: percussing outward in several direction from central area of
tympany
Map the border between the tympany and dullness
2 Further techniques:
Test for shifting dullness
Ask the patient to turn onto one side.
Percuss and mark the borders again.
In a person without ascites, the borders between tympany and
dullness usually stay relatively constant.
In ascites, dullness shift following the gravity
Test for a fluid wave
Press the edges of both hands firmly down the midline of the
abdomen
While you tap one flank sharply with your fingertips, feel on the
opposite flank for an impulse transmitted through the fluid
Identifying organ or mass in ascitic abdomen:
Try to ballotte the organ or mass
Straighten and stiffen the fingers
Make a brief jabbing movement directly toward the anticipated
structure

POSSIBLE APPENDICITIS
The pain of appendicitis classically begins near the umbilicus, then shifts to
the right lower quadrant, where coughing increases it.
Determine whether and where the pain results
Any local tenderness
Localized tenderness anywhere in the right lower quadrant
Muscular rigidity
Perform a rectal examination and, in women, a pelvic examination
Check for following signs:
Rovsings sign pain in the RLQ during left sided pressure suggest
appendicitis
Psoas sign -Flexion of the leg at the hip makes the psoas muscle
contract; extension stretches it
Obturator sign - Flex the patients right thigh at the hip, with the knee
bent, and rotate the leg internally at the hip
 Cutaneous hyperesthesia - gently pick up a fold of skin between your thumb
and index finger, without pinching it

POSSIBLE ACUTE CHOLECYSTITIS

Right upper quadrant pain and tenderness suggest acute cholecystitis
Murphys sign - Hook your left thumb or the fingers of your right hand under
the costal margin at the point where the lateral border of the rectus muscle
intersects with the costal margin
A sharp increase in tenderness with a sudden stop in inspiratory effort

VENTRAL HERNIAS
Hernias in the abdominal wall exclusive of groin hernias
Ask the patient to raise both head and shoulders off the table
Bulge of hernia will usually appear after this action

MASS
Ask the patient either to raise the head and shoulders or to strain down, thus
tightening the abdominal muscles
A mass in the abdominal wall remains palpable
Intra-abdominal mass is obscured by muscular contraction