Abdomen

There are many organs within the abdominal cavity. Those relationships are
complicated and easily affected. Palpation of the abdomen has a greater meaning and
is more important in the routine physical examination than inspection, percussion or
auscultation. A correct diagnosis of abdominal pathological lesions depends chiefly on
a complete history and positive physical signs, assisted by routine or special
laboratory tests and instrumental exploration, when necessary. Familiarity with the
topographical anatomy of the abdominal organs is the prerequisite in the processes of
abdominal examination.
Topographical landmarks and regions of abdomen
The boundaries of abdomen The abdomen is that portion of the body which
lies between the thorax and the pelvis. The abdominal boundaries are formed above
by lower costal margins down to the symphysic pubis （耻骨联合）and the inguinal
ligaments in front, the ribs, the spine, the walls of the pelvis, and the sacrum and
coccyx form the frame in the back; internally the diaphragm forms the top while the
pelvis forms the bottom. This constitutes the abdominal cavity containing the
abdominal viscera which are enclosed by a wall which is formed by the abdominal
muscles, the vertebral, the column and the iliac.
Regions of abdomen There are two kinds of topographical methods of dividing
the abdominal wall, namely the nine-region division and the four-regions division
method.
Examination of the abdomen
Inspection The chief points of abdominal inspection are as follows:
1. Contour of the abdomen: the outward appearance of the abdomen of a normal
adult is symmetrical, but the thickness of the abdominal wall depends on the state of
nutrition. The contour of abdomen is generally described as flat, round or sunken.
Unless it is significantly sunken or distended, it should not be considered
pathological.
Abdominal swelling may be generalized, but diffused abdominal enlargement,
besides obesity and late stage of pregnancy, is mostly pathological, such as
gastrointestinal gas distension, massive ascites, huge abdominal mass, artificial
pneumo-abdomen （人工气腹）, splenomegaly, hepatomegaly, gasterectasis(胃扩张),
enterectasis （肠扩张）, urinary bladder distension, etc, all can cause local abdominal
distention.
Sunken abdomen: marked emaciation, cachexia, and severe dehydration.
2. Respiratory movement: males and children have chiefly an abdominal type of
respiratory movement, while that of the females is of a thoracic type. Decreased or
absent abdominal respiratory movement may suggest abdominal pathology.
3. Varicose veins of abdominal wall: veins of abdominal wall of normal people
are not visible generally, but in the lean people or light-colored skin subjects they
may be faintly visible. In the elderly with decreased elasticity of the subcutaneous
tissue or with scanty subcutaneous fat tissue, the veins of the abdominal wall are
easily seen, sometimes even elevated above the skin. These do not, however, indicate

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 the presence of disease conditions. Disturbance of portal circulation or obstruction of
vena cava, either superior or inferior induces the formation of anastomosis （相接）;
in this case, the veins of the abdominal wall are easily seen and even may become
varicose. By examining the direction of the blood flow of the varicose vein one can
differentiate the location of the obstruction.
4. Peristaltic waves: peristaltic waves are only observed in the multiparous
women with laxed and very thin abdominal wall or in the extremely emaciated
patients. Gastric or intestinal peristaltic waves can be observed in the intestinal
obstruction, unless the abdominal wall is too thick.
5. Skin of the abdomen: contents of inspection are: skin eruptions, pigmentations,
striae, scares, hernias, condition of the umbilicus, bulgings, sinking-in or any other
abnormalities.
Palpation Palpation of the abdomen in the diagnosis of abdominal diseases such as
acute appendicitis, peritonitis, hepatomegaly, splenomegaly, or ascites, occupies a
very important position. The chief items of palpation of the abdomen are the
following.
1. Tensity of the abdominal wall. The abdominal wall is soft normally. The
abdominal wall in acute peritonitis usually becomes rigid, particularly the
abdominal rectal muscles which are very prominent, and it is called board-rigidity.
2. Tenderness and rebound-tenderness. Local tenderness may be at epigastrium,
umbilical area, hypogastrium, left or right hypochondriac, appendical point （阑尾
压痛点）, gall bladder point.
3. Abdominal mass. When a mass is found in the abdomen one should note its
location, its size, its form of surface, its consistency, its tenderness, its movability,
its pulsation, and its relationship with the neighboring organs, the skin or the
abdominal wall covering it.
4. Sensation of fluid wave. When a large amount of free fluid is present within the
abdominal cavity, taping the abdomen with the hand produces the sensation of a
fluid wave.
5. Palpation of the liver. Either using one or two hands when the liver is palpated one
should note its size, its consistency, its form, its tenderness, and its pulsation.
6. Palpation of the gall bladder. One should note the presence of Murphy’s sign or
Courvoisier’s sign.
7. Palpation of the spleen. When splenomegaly very large and superficially in
position is present, use light palpation; the splenomegaly is enlarged but deeply
seated, the bimanual method of palpation should be used. Splenomegaly is divided
into three grades or degrees.
(1) Light degree of enlargement;
(2) Moderate degree of enlargement;
(3) High degree of enlargement.
Percussion Abdominal percussion may render assistance to inspection and palpation,
both indirect and direct percussion techniques are used. However, the indirect method
generally speaking, is more reliable. The chief importance of abdominal percussion is
to determine the size and shape of solid organs. The degree of dilatation of hallow

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viscus, and abdominal distention whether is due to fluid or gas and other causes.
The chief methods of abdominal percussion are listed below:
(1) Percussion of the liver and gall bladder.
(2) Percussion of the spleen.
(3) Traube’s semilunar space.
(4) Kidney percussion: kidney percussion is used chiefly to detect whether there
is a percussion pain at the kidneys-area. Generally one percusse with his fist,
striking with rather strong force on the costovertebral angle.
(5) Percussion of the urinary bladder: a distended urinary bladder should be
differentiated from the enlarged uterus in a second trimester pregnancy, or an
enlarged ovarian cyst. Catheterization will relieve an enlarged bladder of
urine retention.
(6) Percussion of abdominal fluid: when abdominal fluid, over 1000ml, is present,
a shifting dullness can be elicited. In massive ascites, a fluid wave test may be
tried. The dullness of a large ovarian cyst does not shift as in ascites in the
postural change of the patient, like in erect or lying position.
Auscultation The main purposes of abdominal auscultation is to listen to or to detect
internal peristaltic sounds, splashing sounds, gurgling sounds, cardiovascular sounds,
friction sounds, scratching and flicking sounds, and fetal heart sound during
pregnancy.
(1) Peristaltic sounds or borborygmus (肠鸣音), a rumbling noise.
(2) Succussion sound: the splashing sound heard over the stomach caused by
splashing of water and air in the stomach when the body is shaken right and
left or by quick thrusts with the finger tips over the upper abdomen is called
succession sound.