ABDOMEN

Structure & Function

- The abdomen is a large oval cavity, extending form the diaphragm down to the brim of the pelvis.
- Bordered by:
o Back: vertebral column, paravertebral muscles
o Sides & Front: lower rib cage and abdominal muscles
 Four layers of large, flat muscles form the ventral abdominal wall.
- Solid viscera:
o Liver – RUQ, extends over to left midclavicular line, lower edge palpable
o Pancreas – soft, lobulated gland behind the stomach
o Spleen – soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, under
diaphragm; long axis behind & parallel to the 10 th rib; width extends from 9th to 11th rib;
not palpable normally
o Adrenal glands
o Kidneys – normally palpable; retroperitoneal (posterior to the abdominal contents); 11 th & 12 ribs
o Ovaries – normally palpable only on bimanual exam during pelvic exam
o Uterus
- Hollow viscera:
o Stomach – just below diaphragm, between the liver & spleen
o Gallbladder – rests under the posterior surface of the liver, just lateral to the right midclavicular
o Small intestine
o Colon
o Bladder
- Aorta – left or midline in the upper part of the abdomen
o It bifurcates into the left and right common iliac arteries opposite the fourth lumbar vertebra.
 The left and right iliac arteries become the femoral arteries in the groin area.
o Aortic pulsations easily palpated in the upper anterior abdominal wall.
- Costovertebral angle – angle formed by the 12th rib with the vertebral column
- The abdominal wall is divided into four quadrants by a vertical & horizontal line bisecting the umbilicus:
o RUQ o LUQ
- Liver - Stomach
- Gallbladder - Spleen
- Duodenum - Left lobe of liver
- Head of pancreas - Body of pancreas
- Right kidney & adrenal gland - Left kidney and adrenal gland
- Hepatic flexure of colon - Splenic flexure of colon
- Part of ascending & transverse colon - Part of transverse & descending colon
o RLQ o LLQ
- Cecum - Part of descending colon
- Appendix - Sigmoid colon
- Right ovary & tube - Left ovary & tube
- Right ureter - Left ureter
- Right spermatic cord - Left spermatic cord
o Midline
- Aorta
- Uterus (if enlarged)
- Bladder (if distended)

Aging
- Some fat accumulates in the suprapubic area in females as a result of decreased estrogen levels.
- Males show fat deposits in the abdominal area, resulting in “spare tire” or “bay window”.
 - Adipose tissue is redistributed away from the face & extremities to the abdomen & hips.
- Abdominal musculature relaxes.
- Decreased salivation  dry mouth, decreased sense of taste
- Delayed esophageal emptying  increases risk of aspiration
- Decreased gastric acid secretion  pernicious anemia, Fe deficiency anemia, Ca malabsorption
- Increased incidence of gallstones
- Decreased liver size
o Most liver function remains normal, but drug metabolism impaired
- Constipation
o Causes: decreased activity, inadequate intake of water, low fiber diet, Rx side effects, IBS, bowel
obstruction, hypothyroidism, inadequate toilet facilities

Cross Cultural Care

- Lactose intolerance
o Blacks, Am. Indians, Asians, Mediterranean groups
o Abdominal pain, bloating, flatulence when milk products are consumed

Subjective Data
- Appetite
o Anorexia – Loss of appetite from GI disease, Rx side effect, pregnancy, or with psychological disorders.
- Dysphagia – From disorders of the throat or esophagus
- Food Intolerance
o Pyrosis – heartburn, a burning sensation in esophagus & stomach from reflux of gastric acid
o Eructation – belching
- Abdominal Pain
o Visceral – from an internal organ; dull, general, poorly localized
o Parietal – inflammation of overlying peritoneum; sharp, localized, aggravated by movement
o Referred – disorder from another site
- Nausea/Vomiting
o Hematemesis – vomiting blood; occurs with stomach, duodenal ulcers, esophageal varices
- Bowel Habits
o Black stools
 Tarry – occult blood (melena) from GI bleeding
 Nontarry – iron meds
o Gray stools – hepatitis
o Red blood in stools – GI bleeding, localized bleeding around anus
- Abdominal Hx
- Medications
o Peptic ulcer dz – NSAIDS, alcohol, smoking, H. pylori infection
- Nutritional Assessment – 24hr diet recall
- Aging Adults
o Assess risk for nutritional deficit: income, store access, mobility, vision, living alone, depressed

Objective Data
Preparation:
- Strong overhead light - Keep room warm, warm stethoscope endpiece
- Expose the abdomen - Position pt supine with head on pillow
- Drape the genitalia and female breasts - Inquire about any painful areas & examine it last.
- Have pt empty bladder - Use distractions

1. Inspect
a. Contour
 - Describes the nutritional state - Abnormal:
- Flat to rounded o scaphoid, protuberant
b. Symmetry
- Symmetric bilaterally
- Abnormal:
o Asymmetric, bulges, masses, hernia (protrusion of abdominal viscera through abdominal
opening in muscle wall)
c. Umbilicus
- Midline and inverted, with no signs of discoloration, inflammation, or hernia
- Everted & pushed upward with pregnancy
- Abnormal:
o Everted with acites or underlying mass
o Deeply sunken with obesity
o Enlarged & everted with umbilical hernia
o Cullen’s sign – bluish periumbilical color with intraabdominal bleeding
d. Skin
- Smooth and even, with homogenous color
- Striae – silvery white, linear, jagged marks 1-6cm long; occurs when elastic fibers in the reticular
layer of the skin are broken after prolonged stretching; recent striae are pink/blue
- Pigmented nevi/moles, circumscribed brown macular/popular areas
- Abnormal:
o Redness with inflammation; jaundice
o Skin glistening, taut, striae with ascites
o Cushing’s Syndrome – striae looks purple-blue
o Petechiae; lesions; rashes
o Spider nevi – cutaneous angiomas with portal HTN or liver disease
o Prominent, dilated veins occur with portal HTN, cirrhosis, ascites, or vena caval
obstruction
o Poor skin turgor occurs with dehydration
e. Pulsation/Movement
- Abnormal:
o Marked pulsation or aorta occurs with HTN and aortic aneurysm
o Marked visible peristalsis indicates intestinal obstruction
f. Hair Distribution
g. Demeanor
- Abnormal:
o Stillness occurs with pain of peritonitis
o Restlessness and constant turning occur with gastroenteritis or bowel obstruction
2. Auscultate
a. Bowel Sounds
- Begin at RLQ
- Bowel sounds are high pitched, gurgling, cascading sounds
- Borborygmus – hyperperistalsis when you feel your “stomach growling”
- Listen for 5 minutes before deciding bowel sounds are completely absent
- Abnormal:
o Hyperactive sounds – loud, high-pitched, rushing, tinkling sounds
o Hypoactive sounds – follow abdominal surgery or peritoneum inflammation
b. Vascular Sounds/Bruits
- Abnormal:
o Systolic bruit – pulsatile blowing sound, occurs with stenosis or artery occlusion
3. Percuss – assess the relative density of abdominal contents, locate organs, screen for abnormal fluids/masses
a. General Tympany
 - Abnormal:
o Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass
o Hyperresonance is present with gaseous distension
b. Liver Span
- Normal liver span ranges from 6-12cm; 10.5cm for males, 7cm for females
- Chronic emphysema displaces the liver downward by hyperinflated lungs
- Scratch Test: Place stethoscope over liver. Scratch short strokes over abdomen with one
fingernail starting in the RLQ and moving up. When the scratching sound becomes magnified,
you will have crossed the border from over a hollow organ to a solid one.
- Abnormal:
o Hepatomegaly
c. Splenic Dullness
- Percuss for a dull note from 9th to 11th intercostal space just behind left midaxillary line
- Not wider than 7cm
- Tympany remains through full inspiration when percussing in the lowest interspace in the left
anterior axillary line.
- Abnormal:
o Dull note forward of the midaxillary line indicates enlargement of the spleen.
o Positive spleen percussion sign – indicates splenomegaly; the anterior axillary line
change in percussion from tympany to a dull sound with full inspiration
d. Costovertebral Angle Tenderness
- Indirect fist percussion causes the tissues to vibrate instead of producing a sound. The patient
normally feels a thud but no pain.
e. Ascites OR Gaseous Distention
- Ascites occurs with HF, portal HTN, cirrhosis, hepatitis, pancreatitis, and cancer.
- Fluid Wave: (+) indicates large amounts of ascitic fluid.
- Shifting Dullness: (+) with large volume of ascitic fluid (must be >500ml).
4. Palpate
a. Light and Deep Palpation
- Begin with light palpation (1cm) and then deep palpation (5-8cm).
- Voluntary guarding – when a person is cold, tense, or ticklish; bilateral
- To overcome the resistance of an obese abdomen, use a bimanual technique.
- Palpable structures: xiphoid process, liver edge, right lower kidney, pulsatile aorta, rectus
muscles, sacral promontory, cecum, sigmoid colon, uterus, full bladder
- Sigmoid colon may have mild tenderness
- Abnormal:
o Muscle guarding, rigidity, large masses, tenderness
o Involuntary rigidity: constant boardlike hardness of the muscles; occurs with acute
inflammation of the peritoneum; unilateral
o Tenderness occurs with local inflammation
o Identifying a mass must include: location, size, shape, consistency, surface, mobility,
pulsatility, tenderness
b. Liver
- Place left hand under back parallel to 11 th and 12th ribs and lift up abdominal contents. Place
right hand on RUQ with fingers parallel to midline. Push deeply down under the right costal
margin. Ask patient to take a deep breath.
- The edge of the liver bumps your fingertips as the diaphragm pushes it down during inhalation.
- Hooking Technique
- Abnormal: Palpated more than 1-2cm below right costal margin.
c. Spleen
- Place left hand over abdomen and behind the left side at the 11 th and 12th ribs. Lift up for
support. Place right hand obliquely on the LUQ with fingers pointing toward left axilla and just
 inferior to the rib margin. Push hand deeply down and under the left costal margin. Ask patient
to take a deep breath.
- Normally not palpable
- Abnormal:
o Spleen enlarges with mononucleosis and trauma.
o Must be enlarged 3x before it can be felt
d. Kidneys
- Place hands together in a “duck-bill” position at the person’s right flank. Press hands together
firmly and ask the patient to take a deep breath.
- May feel the lower pole of the right kidney as a round, smooth mass sliding between fingers.
e. Aorta
- Use opposing thumb and fingers to palpate the aortic pulsation in the upper abdomen slightly to
the left of the midline.
- Normally 2.5-4cm and pulsates in the anterior direction.
f. Special Procedures
i. Blumberg’s Sign – Rebound Tenderness
- Choose site away from painful area. Hold hand perpendicular to abdomen. Push down
slowly and deeply. Life up quickly.
- (-) no pain on release of pressure.
- (+) sign of peritoneal inflammation that occurs with appendicitis
ii. Murphy’s Sign – Inspiratory Arrest
- Hold fingers under the liver border. Ask patient to take deep breath.
- (-) No pain
- (+) Sharp pain with inflammation of gallbladder
iii. Iliopsoas Muscle test
- Suspecting appendicitis.
- With the patient supine, lift right leg straight up. Push down over the lower part of the right
thigh as the person tries to hold the leg up.
- Abnormal: Pain in the RLQ.
iv. Obturator Test
- Suspecting appendicitis.
- With the patient supine, lift the right leg, flex at the knee. Hold the ankle and rotate the leg
internally and externally.
- Abnormal: Perforated appendix irritates the obturator muscle, producing pain.

Abnormal Findings
- Abdominal Distention o Diastasis Recti
o Obesity
o Air/Gas - Abnormal Bowel Sounds
o Ascites o Succussion Splash
o Ovarian Cyst o Hypoactive bowel sounds
o Pregnancy o Hyperactive bowel sounds
o Feces - Abnormalities on Palpation of Enlarged Organs
o Tumor o Enlarged Liver
- Abnormalities on Inspection o Enlarged Nodular Liver
o Umbilical Hernia o Enlarged Gallbladder
o Epigastric Hernia o Enlarged Spleen
o Incisional Hernia o Enlarged Kidney
o Aortic Aneurysm