Abdominal examination

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Abdominal examination
Abdominal examination illustration.jpg
Abdominal examination The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology
Purposeas part of a comprehensive physical exam

An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. [1] Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. [2] An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination. [3]

Contents

Positioning and environment

Abdominal examination and potential findings Abdominal Exam.pdf
Abdominal examination and potential findings

A suggested position is for the patient to be supine (on their back), with their arms to their sides. The patient should be placed in an environment with good lighting, and should be draped with towels or sheets to preserve privacy and warmth. [2] The patient's hips and knees should be flexed (in a bent position) so that their abdominal muscles remain relaxed during the examination. [4] Asking the patient to indicate areas that may be tender or painful is recommended to avoid exacerbating the pain during inspection and to increase the patient's comfort. [3]

Although physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment, separate systematic reviews by the Cochrane Collaboration [5] and the Rational Clinical Examination [6] refute this.

Inspection

The doctor will look at the movement of the abdomen checking specifically for waves or odd flexing. [7]

Auscultation

Auscultation refers to the use of a stethoscope by the examiner to listen to sounds from the abdomen. [8]

Unlike other physical exams, auscultation is performed prior to percussion or palpation, as both of these could alter the regularity of bowel sounds. [3]

Some controversy exists as to the length of time required to confirm or exclude bowel sounds, with suggested durations up to seven minutes. Bowel obstruction may present with grumbling bowel sounds or high-pitched noises. Healthy persons can have no bowel sounds for several minutes [9] and intestinal contractions can be silent. [10] Hyperactive bowel sounds may be caused by partial or complete bowel obstruction as the intestines initially try to clear the obstruction. [11] Absence of sounds may be caused by peritonitis, paralytic ileus, late-stage bowel obstruction, intestinal ischemia or other causes. [12] Some authors suggest that listening at a single location is enough as sounds can be transmitted throughout the abdomen. [13]

A prospective study published in 2014 where 41 physicians listened to the bowel sounds of 177 volunteers (19 of which had bowel obstructions and 15 with an ileus) found that "Auscultation of bowel sounds is not a useful clinical practice when differentiating patients with normal versus pathologic bowel sounds. The listener frequently arrives at an incorrect diagnosis. Agreement between raters was also low (54%).". [14] This article suggests focusing on other indicators (flatus, pain, nausea) instead. There is no research evidence that reliably corroborates the assumed association between bowel sounds and gastro-intestinal motility status. [15]

The examiner also typically listens to the two renal arteries for abnormal blood flow sounds (bruits) by listening in each upper quadrant, adjacent to and above the umbilicus. Bruits heard in the epigastrium that are confined to systole are considered normal. [3]

Palpation

Examination of the abdomen of a child. Physical examination of child, age 15 months.jpeg
Examination of the abdomen of a child.

The examiner should first talk to the patient and explain what this part of the examination will involve. [4] He or she will typically palpate all nine areas of the patient's abdomen, and being mindful of areas of discomfort, begin by palpating areas of no pain. This is typically performed twice, first with light pressure and then with deeper pressure to better exam the abdominal organs.

On light palpation, the examiner tests for any palpable mass, rigidity, or pain on the surface.

On deep palpation, the examiner is testing for any organomegaly (enlarged organs.) Typically, the clinician is looking for enlargement of the liver and spleen or abnormal masses in the intestines. Sometimes the physician looks for the kidney and uterus as well. [11]

Reactions that may indicate pathology include:

Percussion

Percussion can be performed in all four quadrants of the abdomen and may reveal a painful response by the patient. During the abdominal examination, percussion may allow the estimation of location and quantity of gas, hard or soft masses, and sizes of certain organs, such as the liver and the spleen. Abnormal findings may include splenomegaly, hepatomegaly and urinary retention.[ citation needed ]

Organomegaly of the liver and the spleen can be appreciated by percussing in a particular manner:

Examination of the spleen may reveal Castell's sign or alternatively Traube's space.

Dull sounds on the abdomen could suggest pregnancy, an ovarian tumor, a distended bladder, hepatomegaly or splenomegaly. Dullness on either side of the abdomen could suggest ascites. Some other areas of the abdomen may sound dull suggesting that there may be some fluid or feces. The dullness of the liver can be appreciated by percussing at the edge of the lower chest right above the costal margins. The resonant sounds of gastric air bubbles can be appreciated at the left side. In rare cases, when organs are reversed as is the case in situs inversus, resonant (hollow) sounds would be expected on the right side and liver dullness on the left. [3]

Other tests and special maneuvers

Special maneuvers may also be performed, to elicit signs of specific diseases. [16] [17] These include

Related Research Articles

<span class="mw-page-title-main">Bowel obstruction</span> Mechanical or functional obstruction of the intestines

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Splenomegaly</span> Enlargement of the spleen

Splenomegaly is an enlargement of the spleen. The spleen usually lies in the left upper quadrant (LUQ) of the human abdomen. Splenomegaly is one of the four cardinal signs of hypersplenism which include: some reduction in number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination; a compensatory proliferative response in the bone marrow; and the potential for correction of these abnormalities by splenectomy. Splenomegaly is usually associated with increased workload, which suggests that it is a response to hyperfunction. It is therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red blood cells being destroyed in the spleen. Other common causes include congestion due to portal hypertension and infiltration by leukemias and lymphomas. Thus, the finding of an enlarged spleen, along with caput medusae, is an important sign of portal hypertension.

<span class="mw-page-title-main">Ileus</span> Disruption to the propulsive ability of the intestine

Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction. The word 'ileus' derives from Ancient Greek εἰλεός (eileós) 'intestinal obstruction'. The term 'subileus' refers to a partial obstruction.

<span class="mw-page-title-main">Rovsing's sign</span> Medical condition

Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing (1862–1927), is a sign of appendicitis. If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis. The phenomenon was first described by Swedish surgeon Emil Samuel Perman (1856–1945) writing in the journal Hygiea in 1904.

<span class="mw-page-title-main">Epigastrium</span> Upper central region of the abdomen

In anatomy, the epigastrium is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane. Pain may be referred to the epigastrium from damage to structures derived from the foregut.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

Percussion is a technique of clinical examination.

<span class="mw-page-title-main">Respiratory examination</span> Inspection conducted as part of a physical

A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination.

<span class="mw-page-title-main">Abdomen</span> Part of the body between the chest and pelvis

The abdomen is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. The area occupied by the abdomen is called the abdominal cavity. In arthropods, it is the posterior tagma of the body; it follows the thorax or cephalothorax.

In medicine, shifting dullness refers to a sign elicited on physical examination for ascites.

<span class="mw-page-title-main">Traube's space</span> Space on the left side of the human body

Traube's (semilunar) space is an anatomic space of some clinical importance. It is a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib superiorly, the left mid axillary line laterally, and the left costal margin inferiorly.

<span class="mw-page-title-main">Castell's sign</span> Medical sign assessed to evaluate splenomegaly

Castell's sign is a medical sign assessed to evaluate splenomegaly and typically part of an abdominal examination. It is an alternative physical examination maneuver to percussion over Traube's space.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

<span class="mw-page-title-main">Abdominal ultrasonography</span> Type of medical scan

Abdominal ultrasonography is a form of medical ultrasonography to visualise abdominal anatomical structures. It uses transmission and reflection of ultrasound waves to visualise internal organs through the abdominal wall. For this reason, the procedure is also called a transabdominal ultrasound, in contrast to endoscopic ultrasound, the latter combining ultrasound with endoscopy through visualize internal structures from within hollow organs.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

<span class="mw-page-title-main">Abdominal x-ray</span>

An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB.

The liver scratch test is a technique used by medical professionals during a physical exam to locate the inferior border of the liver in order to approximate the size of a patient's liver. The technique was first credited to Burton-Opitz in 1925 where it was used to identify the cardiac silhouette, however there are references of similar techniques used prior to this. The liver scratch test can be used when other exam techniques used to approximate liver size are ineffective or unavailable and is thought to be most useful if the abdomen is distended, too tender for direct palpation, the abdominal muscles are too rigid, or the patient is obese.

The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart, lungs, belly and the blood vessels.

<span class="mw-page-title-main">Spleen pain</span> Human pain from the area of the spleen

Spleen pain is a pain felt from the left upper quadrant of the abdomen or epigastrium where the human spleen is located or neighboring.

References

  1. ↑ "UCSD's Practical Guide to Clinical Medicine". meded.ucsd.edu. Retrieved 2019-09-01.
  2. 1 2 Seidel, Henry M.; Ball, Jane W.; Dains, Joyce E.; Flynn, John A.; Solomon, Barry S.; Stewart, Rosalyn W. (2011). Mosby's Guide to Physical Examination (7th ed.). St. Louis, MO: Elsevier. pp. 492–513. ISBN   978-0-323-05570-3.
  3. 1 2 3 4 5 MD, Lynn B. Bates' Guide to Physical Examination and History-Taking, 11th Edition. Lippincott Williams & Wilkins, 11/2012.
  4. 1 2 3 4 5 Greenberger, NJ (2016). "Part IV - Approach to the Patient at the Bedside: Acute Abdominal Pain". Principles and Practice of Hospital Medicine. AccessMedicine: McGraw-Hill.
  5. ↑ Manterola C, Vial M, Moraga J, Astudillo P (2011). Manterola C (ed.). "Analgesia in patients with acute abdominal pain". Cochrane Database of Systematic Reviews (1): CD005660. doi:10.1002/14651858.CD005660.pub3. PMID   21249672.
  6. ↑ Ranji SR, Goldman LE, Simel DL, Shojania KG (2006). "Do opiates affect the clinical evaluation of patients with acute abdominal pain?". JAMA. 296 (14): 1764–74. doi:10.1001/jama.296.14.1764. PMID   17032990.
  7. ↑ Bates, Barbara (1982), A Visual guide to physical examination., Lippincott, OCLC   16319335
  8. ↑ Cleveland Clinic medical professional (2022-05-20). "Auscultation: Definition, Purpose & Procedure". Cleveland Clinic. Retrieved 2024-07-27.
  9. ↑ McGee, S, Evidence-Based Physical Diagnosis, 3rd Edition. Philadelphia, PA: Elsevier-Saunders; 2012
  10. ↑ "Listening to Bowel Sounds: An Outdated Practice?". March 2017.
  11. 1 2 Mendiratta, Vicki; Lentz, Gretchen M. (2017). "History, Physical Examination, and Preventative Health Care - Abdominal Exam". Comprehensive Gynecology. ClinicalKey: Elsevier, Inc.
  12. ↑ Jarvis, C.(2008). Physical Examination and Health Assessment. 5th edn. Saunders Elsevier, St Louis
  13. ↑ Reuben, A. (2016). Examination of the abdomen. Clinical Liver Disease, 7(6), 143–150. doi:10.1002/cld.556
  14. ↑ Felder, S., Margel, D., Murrell, Z., & Fleshner, P. (2014). Usefulness of Bowel Sound Auscultation: A Prospective Evaluation. Journal of Surgical Education, 71(5), 768–773. doi:10.1016/j.jsurg.2014.02.003
  15. ↑ Massey RL. Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition? Medsurg Nurs . 2012;21(3):146–150
  16. ↑ Rastogi, Vaibhav; Singh, Devina; Tekiner, Halil; Ye, Fan; Kirchenko, Nataliya; Mazza, Joseph J.; Yale, Steven H. (December 2018). "Abdominal Physical Signs and Medical Eponyms: Physical Examination of Palpation Part 1, 1876–1907". Clinical Medicine & Research. 16 (3–4): 83–91. doi: 10.3121/cmr.2018.1423 . ISSN   1539-4182. PMC   6306141 . PMID   30166497.
  17. ↑ Rastogi, Vaibhav; Singh, Devina; Tekiner, Halil; Ye, Fan; Mazza, Joseph J.; Yale, Steven H. (1 June 2019). "Abdominal Physical Signs and Medical Eponyms: Part II. Physical Examination of Palpation, 1907–1926". Clinical Medicine & Research. 17 (1–2): 47–54. doi: 10.3121/cmr.2018.1426 . ISSN   1539-4182. PMC   6546280 . PMID   31160480 . Retrieved 27 February 2021.
  18. 1 2 3 4 Fasen, Geoffrey; Schirmer, Bruce; Hedrick, Traci L. "Appendix: Abdominal Exam". Shackelford's Surgery of the Alimentary Tract. ClinicalKey: Elsevier, Inc. pp. 1951–1958.
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