The Abdomen

Chapter 11
The Abdomen
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy of the Abdomen
Anatomy and Physiology of the Abdominal Wall and Pelvis

Anatomy of the Abdomen (cont.)
Dividing the Abdomen Dividing the Abdomen

into Four Quadrants into Nine Sections
Anatomy of the Abdomen (cont.)
Abdominal Cavity
History Taking of Problems of the
Abdomen: GI Tract
• How is the patient’s appetite?
• Any symptoms of the following?
– Heartburn: a burning sensation in the epigastric
area radiating into the throat; often associated
with regurgitation
– Excessive gas or flatus; needing to belch or pass
gas by the rectum; patients often state they feel
bloated
– Abdominal fullness or early satiety (‫)تخمة‬
– Anorexia: lack of an appetite
Abdomen: GI Tract (cont.)
• Regurgitation: the reflux of food and stomach acid
back into the mouth; brine-like taste
• Vomiting; retching (spasmodic movement of the
chest and diaphragm like vomiting, but no stomach
contents are passed)
– Ask about the amount of vomit
– Ask about the type of vomit: food, green- or
yellow-colored bile, mucus, blood, coffee ground
emesis (often old blood)
o Blood or coffee ground emesis is known as
hematemesis
• Qualify the patient’s pain
– Visceral pain: when hollow organs (stomach, colon)
forcefully contract or become distended. Solid organs (liver,
spleen) can also generate this type of pain when they swell
against their capsules. Visceral pain is usually gnawing,
cramping, or aching and is often difficult to localize (hepatitis)
– Parietal pain: when there is inflammation from the hollow or
solid organs that affect the parietal peritoneum. Parietal pain
is more severe and is usually easily localized (appendicitis)
– Referred pain: originates at different sites but shares
innervation from the same spinal level (gallbladder pain in the
shoulder)
Pain in Abdominal Areas
Types of Visceral Pain

• Ask patients to describe the pain in their own words
• Ask patients to point with one finger to the area of pain
• Ask about the severity of pain (scale of 0 to 10)
• Ask what brings on the pain (timing)
• Ask patients how often they have the pain (frequency)
• Ask patients how long the pain lasts (duration)
• Ask if the pain goes anywhere else (radiation)
• Ask if anything aggravates the pain or relieves the pain
• Ask about any symptoms associated with the pain
• Ask the patient about bowel movements
– Frequency of the bowel movements
– Consistency of the bowel movements
(diarrhea vs. constipation)
– Any pain with bowel movements
– Any blood (hematochezia) or black, tarry stool
(melena) with the bowel movement
– Ask about the color of the stools (white or gray stools
can indicate liver or gallbladder disease)
– Look for any associated signs such as jaundice
or icteric sclerae
• Ask about prior medical problems related to the abdomen
– Hepatitis, cirrhosis, gallbladder problems, or
pancreatitis, for example
• Ask about prior surgeries of the abdomen
• Ask about any foreign travel and occupational hazards
• Ask about use of tobacco, alcohol, illegal drugs, as well
as medication history
• Ask about hereditary disorders affecting the abdomen
in the history of the patient’s family
Abdomen: Urinary Tract
• Ask about frequency (how often one urinates) and urgency
(feeling like one needs to urinate but very little urine is
passed)
• Ask about any pain with urination (burning at the urethra or
aching in the suprapubic area of the bladder)
• Ask about the color and smell of the urine; red urine usually
means hematuria (blood in the urine)
• Ask about difficulty starting to urinate (especially in men) or
the leakage of urine (incontinence, especially in women)
• Ask about back pain at the costovertebral angle (kidney) and
in the lower back in men (referred pain from the prostate)
• In men, ask about
Copyrightsymptoms in the
© 2009 Wolters Kluwer Health penis
| Lippincott Williams &and
Wilkins scrotum
Physical Examination of the Abdomen:
Inspection
• 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:
1. 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.

Inspection
2. Take a spare bed sheet and drape it over their lower
body such that it just covers the upper edge of their
underwear
• 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

Inspection
3. 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

Inspection
• Keep the room as warm as possible and make sure that
the lighting is adequate.
• By paying attention to these small details, you create an

environment that gives you the best possible chance of
performing an accurate examination.

Inspection
• Inspect the abdomen
– Look at the skin: scars, striae (stretch marks), vein
pattern, hair distribution, rashes, or lesions
– Look at the umbilicus: observe contour and location
and any signs of an umbilical hernia
– Look at the contour of the abdomen: flat, rounded,
protuberant, or scaphoid
– Is the abdomen symmetric?
– Inspect for signs of peristalsis (rhythmic movement
of the intestine that can be seen in thin people) and
pulsations (within blood vessels such as the aorta)
Inspection
• 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
• Areas which become more pronounced when the patient
valsalvas are often associated with hernias (These are
points of weakening in the abdominal wall, frequently
due to previous surgery)

Various Causes of Abdominal Distension
Obese abdomen Hepatomegaly

Ascites Markedly enlarged gall bladder

• Umbilical Hernia • Same umbilical hernia while
patient performs valsalva
maneuver

Auscultation
• Always auscultate before palpating or percussing
the abdomen
• Compared to the cardiac and pulmonary exams,
auscultation of the abdomen has a relatively minor role
• Normal person who has no complaints and has 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. So are you going to do it??
Auscultation
• Place the diaphragm over the abdomen to hear bowel

sounds (borborygmi) which are long gurgles. These
sounds are transmitted across the abdomen so it is
not necessary to listen at multiple places. The normal
frequency of sound is 5-34 sounds per minute.
• Place the diaphragm over the aorta, iliac, and femoral
arteries to assess for bruits (vascular sounds, a high
pitched (analogous to a murmur) caused by turbulent
blood flow through a vessel narrowed by atherosclerosis

Auscultation
• The place to listen is a few
cm above the umbilicus,
along the lateral edge of
either rectus muscles
• When listening for bruits,
you will need to press down
quite firmly as the renal
arteries are retroperitoneal
structures

Question
What is the preferred order for examination of the
abdomen?
a. Inspection, auscultation, percussion, palpation
b. Percussion, auscultation, palpation, inspection
c. Auscultation, inspection, palpation, percussion
d. Inspection, palpation, auscultation, percussion

Answer
a. Inspection, auscultation, percussion, palpation
• When examining the abdomen, you must

always auscultate before palpating or
percussing

Percussion
• 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

Percussion

Percussion
• Percuss over all four quadrants, listening for:
– Tympanic (drum-like) sounds produced by
percussing over air filled structures versus
– Dullness: occurs 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.
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

Percussion (cont.)
• Percuss over the liver in both the midclavicular line

and at the midsternal line
– Midclavicular percussion should be 6–12 cm;
longer than this indicates an enlarged liver
– Midsternal line percussion should be 4–8 cm;
shorter than this can indicate a small, hard
cirrhotic liver

Percussion (cont.)
• 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

Percussion (cont.)
• Percuss the spleen using one of two techniques:
– Percuss the left lower anterior chest wall between

lung resonance above the costal margin (Traube’s
space). Dullness can indicate an enlarged spleen;
when tympany is prominent, splenomegaly is not
likely.

Percussion (cont.)
• Check for a splenic percussion sign.
• Percuss the lowest interspace in the left anterior axillary
line. This area is usually tympanitic. Then have the
patient take a deep breath and percuss again. If the
spleen is a normal size the percussion remains
tympanitic. Shifting from tympany to dullness with
inspiration suggests an enlarged spleen.
• This is a positive splenic percussion sign.

Percussion (cont.)
• 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

Percussion (cont.)
• Detect large amounts of pathological fluid (ascites)
• Intestines will float to surface
• Percussion can detect air-fluid interface
• Change in position shifts point of interface

Light 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.
• Avoid 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.

Light Palpation
• Start palpating the abdomen using gentle probing with
the hands; this reassures and relaxes the patient
• Identify any superficial organs or masses
• Assess for voluntary guarding (patient consciously
flinches when you touch him) versus involuntary
guarding (muscles spasm when you touch the patient,
but he cannot control the reaction)
• Use relaxation techniques to assess voluntary guarding
– Tell the patient to breathe out deeply
– Tell the patient to breathe through the mouth with
the jaw dropped open
Deep Palpation
• Palpate deeply in the periumbilical area and both lower
quadrants. Rebound tenderness occurs if pain increases when
the examiner decreases the pressure against the abdomen.
• Palpating the liver:
– Using the left hand to support the back at the level of the
11th and 12th rib, the right hand presses on the abdomen
inferior to the border of the liver and continues to palpate
superiorly until the liver border is palpated.
– Start in the right upper quadrant, 10 centimeters
below the rib margin in the mid-clavicular line parallel
to the rectus muscle

Deep Palpation
– Ask the patient to take a deep breath. This can illicit pain
in liver or gallbladder disease and also makes it easier to
find the inferior border of the liver (the diaphragm
lowering during deep inspiration forces the liver
downward).

Deep Palpation (cont.)
• The “hooking technique” can be helpful when a patient is
obese.
• Place both hands, side by side, on the right abdomen below
the border of liver dullness.
• Press in with the fingers and go up toward the costal
margin. Ask the patient to take a deep breath. The liver
edge should be palpable under the finger pads of both
hands.

Hooking Edge of the Liver

• Palpate the spleen on the left side in much of the same way
as the liver, with the left hand supporting the back and the
right hand palpating the abdomen. Generally the spleen
cannot be palpated this way even with deep inspiration.
Palpating a splenic tip may indicate splenomegaly.
• When enlarged, it tends to grow towards the pelvis and
the umbilicus (i.e. both down and across).
• The spleenis not so definitively bordered and thus has a

tendency to float away from you as you palpate

• Palpating the left kidney
• move to the patient’s left side.
• Place your right hand under the 12th rib. Lift it up, trying to
displace the kidney anteriorly.
• Place your left hand in the left upper quadrant. Ask the patient
to take a deep breath.
• At the peak of inspiration, press your left hand deeply into the
left upper quadrant trying to “capture” the kidney between
your hands.

• Palpating the right kidney

• return to the patient’s right side. Use your left hand to lift the
back while your right hand feels deeply into the right upper
quadrant.
• Repeat the same steps as used for the left kidney.
• Palpate (Pounding gently with the bottom of your fist) the
costovertebral angle (where the bottom-most ribs
articulate with the vertebral column) on each side of the
back for kidney tenderness (CVAT)

costovertebral angle

Kidney Palpation


Special Techniques—Ascites
• A protuberant abdomen with bulging flanks is suspicious for
ascites (fluid in the abdomen from diseases such as cancer).
• Percuss the abdomen for areas of tympany and dullness. Due

to gravity, dullness should be located along the lateral sides of
the abdomen, while the anterior portion should be tympanitic.
• Test for shifting dullness: after mapping out the areas of

tympany and dullness, have the patient roll to one side. Remap
the areas of tympany and dullness. In ascites, there should be
a shift due to free fluid moving with gravity.

Assessment for Shifting Dullness

Special Techniques—Ascites
• Test for a fluid wave
• Have the patient or an assistant press hands firmly down the
midline.
• This pressure stops the transmission of the wave through fat

tissue.
• Now tap on one flank sharply and feel with your own hand if
the wave transmits to the other side of the flank.

Test for a fluid wave

Special Techniques—Appendicitis
• Assessing for appendicitis
– Check for involuntary guarding and rebound tenderness
in the right lower quadrant
– Check for Rovsing’s sign (rebound tenderness in the left
lower quadrant)
– Check for Psoas sign (the patient flexes his thigh against
the examiner’s hand; pain indicates a positive sign)
– Check for the Obturator sign (flex the patient’s thigh
and rotate the leg internally at the hip; pain indicates
a positive sign)

Question
A sign which confirms the presence of peritonitis is:
a. Friction rub
b. Rebound tenderness
c. Voluntary guarding
d. Borborygmus

Answer
b. Rebound tenderness
• When assessing for peritonitis, you assess for

involuntary guarding
• Place the diaphragm over the liver or spleen

to listen for friction rub
• Borborygmus is a rumbling bowel sound

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Chapter 11

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology of the Abdominal Wall and Pelvis

Dividing the Abdomen Dividing the Abdomen

Types of Visceral Pain

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• By paying attention to these small details, you create an

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Place the diaphragm over the abdomen to hear bowel

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

a. Inspection, auscultation, percussion, palpation

• When examining the abdomen, you must

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• What can you really expect to hear when percussing the

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Percuss over the liver in both the midclavicular line

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

– Percuss the left lower anterior chest wall between

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Of the techniques used to detect ascites, assessment for

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The spleenis not so definitively bordered and thus has a

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Palpating the right kidney

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Percuss the abdomen for areas of tympany and dullness. Due

• Test for shifting dullness: after mapping out the areas of

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• This pressure stops the transmission of the wave through fat

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

A sign which confirms the presence of peritonitis is:

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• When assessing for peritonitis, you assess for

• Place the diaphragm over the liver or spleen