EXAMINATION OF ABDOMEN

Dr. [Link]
Associate Professor
Deptt. Of Medicine,
VIMS, Pawapuri
Which System ?
 --
• Examination of abdomen does not mean
examination of any one body system
• It is examination of a region of the body.
• Signs & symptoms of disease of various system
may be found in Abdomen like
Hepatomegaly- May be
-Viral hepatitis
-Liver Abscess
-Malaria, kalazar
- Heart failure
-Primary or secondary malignancies
 --
-Splenomegaly-
-Malaria, Kalazar, Typhoid
-Sub acute bacterial endocarditis
-Leukemia
-Hemolytic Anemia
-Portal Hypertension
-Rheumatoid Arthritis, SLE
-Tropical Splenomegaly
 -
Ascites:-
- Infections:-
-Tuberculosis
-Pyogenic bacteria
-Malignant infiltration of peritoneum
-Acute pancreatitis
-Budd-Chiari Syndrome (Hepatic vein/
IVC obstruction)
-Portal Hypertension
-Congestive Cardiac Failure
-Nephrotic Syndrome
-Meig’s Syndrome( Ovarian Tumor)
 Examination of Abdomen
Some Basics:-
• Abdomen is a region of the body and not a
system
• Findings may be present in abdomen in many
types of diseases
• For the purpose of examination we divide the
abdomen in 4 quadrants or 9 areas by
imaginary lines
 4 Quadrants of abdomen
Abdomen is divided in 4 quadrants by 2 imaginary
lines passing through the umbilicus at right angle
 9 areas of abdomen
• Draw imaginary vertical lines from Mid
clavicular line to mid inguinal line on both side
• One horizontal line joining lower point of two
costal margin (Trans pyloric plain midway
between suprasternal notch and symphysis
pubis)
• Another horizontal line joining upper boarder
of two illiac crests.
Areas of abdomen
 Starting Examination
• Introduce yourself to the patient
• Take permission (Consent) for examination
• Ensure the patient that you will never divulge
any thing about this examination to any body
else
• If the patient is female ,examine only in
presence of female nurse or a female
attendant of the patient
• Ask if there is any pain anywhere
 Examination of abdomen
Position of patient

• Patient should lie supine on a firm mattress

• Arms should be placed loosely by his/her side
• Head & neck should be supported by pillows
• Keeping a pillow below knees relaxes the
abdominal muscle.
• Abdomen of patient should be exposed from
just above the xiphisternum to upper thigh
• Put a sheet over the genitalia
• Place of examination should not be very cold
Position of Patient
 General Examination- Must look
• Built- Cachexia:- Malignancy, Cirrhosis of liver
• Jaundice:- commonly pathology of Hepatobilliary
system
• Clubbing:- Common Billiary cirrhosis,
Inflammatory bowel disease, Polyposis coli
• Pallor:- Splenomegaly may be due to hemolytic
anemia, Leukemia, Hypersplenism etc
• Mouth:- Examine mouth for any ulcer, glossitis
etc
Cachexia:- Wasting & extreme weight loss
Clubbing
Jaundice
Pallor
Mouth, Tongue, Gum
Virchow’s Node
• Also called Troisier’s node or Signal node.
• It is enlarged hard left supraclavicular lymph
node & indicate abdominal malignancy ( Ca.
stomach – by Rudolf Virchow)
 Other points to note:-
Stigmata of Alcoholic Liver Disease:-
• Parotid enlargement
• Spider angioma
• Gynecomastia
• Decreased body hairs
• Testicular atrophy
• Palmer erythema
• Dupuytren’s contracture
--
Spider angioma:- commonly present on
upper part of chest. On pressing the center
of angioma by a pin head, the whole
angioma blanches
Gynecomastia
Palmer erythema
Dupuytren’s contracture-(Abnormal thickening
of tissue just beneath the skin of palm, creating
a thick cord which pulls one or more fingers into
bent position.
Headings of Abdominal Examination
1- Inspection
2- Auscultation
3-Palpation
4-Percussion
5-Others
 Inspection of Abdomen

• Shape
• Movement
• Umbilicus
• Skin & surface of Abdomen
• Others
Inspect the abdomen in good light. Look
tangentially for any peristaltic movement
Shape of abdomen:-

• Inspect contour of whole abdomen

• See whether the shape of abdomen is normal,
scaphoid(Sunken) or distended
• See whether the distention is generalizes of
localized
• Not for any bulge of flanks.
Shape-

• Normal Abdomen is flat or slightly scaphoid

and bilaterally symmetrical
Abnormalities of shape Of Abdomen
• Scaphoid:- Markedly scaphoid abdomen
- Starvation
- Malignant disease (Carcinoma
of Oesophagus, Stomach)
Abnormal shape-Contd .
Localized Distension
- Look for the site of distension and think about
anatomical structures in that region like Liver,
Spleen, Kidney, Ovary, U. bladder etc.
- Note whether the swelling moves with
respiration or not
- A swelling in lower abdomen arising from pelvis
may be due to- Chronic urinary retention, full
bladder, Pregnancy, ovarian cyst or tumor
- A swelling which is symmetric and centered
around the umbilicus may be due to small bowel
obstruction
Generalized distention of Abdomen
Localized distension- Incisional hernia
 Inspection of Abdomen
• Shape
• Movement
a)-Absent
b)-Paradoxical
c)-Visible peristalsis
d)-Visible pulsation
• Umbilicus
• Skin & surface of Abdomen
• Others
 Movement Of Abdomen

• Normally abdomen moves outwards during

inspiration and inwards during expiration
• The movement is symmetrical
a)Absent or markedly diminished movement of
abdominal wall– peritonitis
b)Paradoxical Movement:- Inwards during
inspiration and outward during expiration-
Paralysis of Diaphragm.
 Movement-contd

c)Visible Peristalsis:-
-Gastric outlet obstruction:-
-Congenital pyloric Stenosis of infancy
- Obstruction in distal small bowel
• In Gastric outlet obstruction, Peristalsis is seen as
slow wave passing from left hypochondrium to
right hypochondrium
• If there is gross gastric dilatation, it may pass from
Lt. Hypochondrium to suprapubic area and then
ascend to Rt. Hypochondrium.
 --

Succussion splash- By putting stethoscope

diaphragm on abdomen and shaking the patient a
splashing sound is heard due to presence of large
amount of fluid and air in the stomach in cases of
Gastric Outlet Obstruction (Suction splash may be
heard up to about 3 hours after a meal in healthy
persons also)
 .
Movement-visible peristalsis-contd

• Obstruction in distal small bowel:- ( or

coexisting large & small bowel) –Distended
coils of small bowel may be visible in centre of
abdomen in a ladder pattern & peristalsis may
be visible.
----Peristalsis may be normally seen in:-
-Very thin person
-Elderly with lax abdominal wall
-Wide necked incisional hernia
 d) Visible pulsation in abdomen
• Pulsation is usually seen in epigastrium.
Causes include
• Normal aortic pulsation in thin patient
• Aneurism of Abdominal Aorta
• Pulsation of Liver (TR)
• Right Ventricular Hypertrophy
 Inspection of Abdomen
• Shape
• Movement
• Umbilicus
• Skin & surface of Abdomen
• Others
 Umbilicus
• Normally the Umbilicus is centrally placed. It
is slightly inverted
Umbilicus

• In Obesity (a cause of distended abdomen)-

also the umbilicus is inverted
Umbilicus

Everted Umbilicus:- (flat or protruding outwards)

-Umbilical Hernia
-Causes of generalized distention
of abdomen
- Ascites
-Flatus
-Feces
-Fetus
-large ovarian cyst.
Everted Umbilicus

Umbilical Hernia
Everted Umbilicus

• Everted umbilicus with transverse slit

(Smiling Umbilicus)- In Ascites
Everted Umbilicus

• Everted Umbilicus with vertical slit:-

-Fetus
- Large Ovarian Cyst.
 Inspection of Abdomen
• Shape
• Movement
• Umbilicus
• Skin & surface of Abdomen
-Hair
-Surface of skin
-Venous prominences
• Others
 Skin & Surface of Abdomen
Hair:-
-Look for secondary sexual hairs
-They appear at Puberty
-Absence after puberty:-
-Hypopitutarism
-Hypogonadism
- Hirsutism:- male distribution of body hairs in
females-(Increased Androgen, Hyperinsulinemia
etc
-Decreased body hairs in male- may be in
Cirrhosis of liver
Hirsutism
Skin & Surface of Abdomen

• Skin:-
Seborrhoeic warts- pink ,brown or black may be
normally present in elderly
Skin

Campbell de Morgan Spots (haemangiomas):-

-Normal finding in elderly.
Skin

• Stria:-
*Stria gravidarum or Stria atropica:-
- White or pink wrinkled linear marks
on abdominal skin
Stria gravidarum Contd

-Produced due to gross stretching of

the skin with rupture of elastic fibers
-Pregnancy
-Obesity
-Chronic ascites
-Wasting disease
-Severe dieting.
Skin

*Purple Stria:-
-Cushing’s Syndrome
-Excessive Steroid intake
Skin

• Scars:-
-Note site and color of any scar
-They may contain Hernia
-Old scars are white
- Recent scars are red or pink.
 Inspection-Venous prominences
• Caput medusae :- Distended veins around
umbilicus due to anastomosis between Portal
and systemic veins. Flow is outwards.
( similar anastomosis causes Esophageal
varices & piles)
Inspection-Venous prominences-Cond

Dilated veins in obstruction of SVC & IVC:-

Prominent veins on abdominal & Chest
wall, Neck, Arms may be present in
obstruction of Superior or Inferior Vena Cava
 Inspection of Abdomen
• Shape
• Movement
• Umbilicus
• Skin & surface of Abdomen
• Others
 Inspection-Others

• Inspect groin for any swelling (Hernia) and

Lymph nodes
 Abdominal Examination
1- Inspection
2- Auscultation
3-Palpation
4-Precussion
5-Others
 Auscultation of Abdomen
• Here we have slight shift in sequence of
examination
• We do auscultation before palpation &
percussion because these maneuvers may alter
the frequency of bowel sound
• Listen with diaphragm of Stethoscope
• Points to be noted:-
–Bowel sound
–Bruits(Aortic, Renal)
–Rubs (Liver, Spleen)
Auscultation of Abdomen

• Bowel Sound:-
-Normally audible every 5-10 seconds and
consists of clicks & gurgles
-Before saying that bowel sound is absent
you must listen for at least 2 minutes
-No need to auscultate at multiple sites
because bowel sounds are widely transmitted.
-Reduced or increased bowel sounds are
not reliably diagnostic but indicates for further
evaluation.
Auscultation- Bowel sound

• Borborgmi:- Prolonged gurgle of hyper

peristalsis ( Stomach growling):-
-It may be normal
-If associated with crampy abdominal
pain, it may indicate Intestinal obstruction.
• Decreased or Absent Bowel Sound:-
- Paralytic Ileus
-Peritonitis
• Increased Bowel Sound:-
- Intestinal Obstruction
Auscultation Abdomen

• Bruits:- - High pitched sound (similar to

cardiac murmurs) due to obstruction
(Stenosis) of Arteries
• Aortic bruit- midline
• Renal artery bruits- left
or right upper quadrant
of abdomen
• Illiac bruits –very
uncommon and can be heard in lower
quadrants of abdomen
Auscultation-Abdomen

• Rubs:- These are superficial leathery sound.

.
- Hepatic Rub- Heard over enlarged liver
mainly due to neoplastic disease.
-Splenic rub- Heard over enlarged spleen if
infarction of spleen occurs
 Abdominal Examination
1- Inspection
2- Auscultation
3-Palpation
4-Percussion
5-Others
 Palpation of Abdomen
Before starting Palpation:-
• Proper positioning of patient
• Empty urinary bladder
• Friendly atmosphere
• Enquire about any painful area
• Palpate the painful area last
• Insure the patient that examination will not cause
pain
• Avoid sudden poking with fingertip
• Observe the patients face for any grimace
indicating pain
• Distract the patients attention by conversation
Palpation

• Normally not palpable:-

-Stomach
-Duodenum
-Gall Bladder
-Pancreas
-Spleen
- Kidneys
-Urinary Bladder
Palpation

May be normally Palpable:-

-Liver - just below costal margin
-Pelvic colon
-Caecum
-Transverse Colon
-Faeces in colon with thin or lax abd. wall
 Palpation of Abdomen

• Superficial Palpation

• Deep Palpation
Superficial Palpation of Abdomen:--

• It is gentle palpation of each quadrant of

abdomen for :-
- Tenderness
-Temperature
- guarding
- localized swelling
- Direction of flow in distended veins
 --
• Start palpation at a area remote from ant site
of pain
• Place your hand flat on the abdomen with
wrist and forearm in same horizontal position
• Mould your hand on patients abdomen
• Palpate with light, gentle dipping motion using
the palmer surface of finger in each quadrant
of abdomen
• Note any area of guarding (rigidity),
tenderness, increased temperature, Localized
swelling etc.
Superficial palpation of Abdomen
Direction of venous flow
• Put two fingers side by side on distended vein
• Spread the fingers while keeping pressure on
the vein. This makes a segment of vein empty.
Direction of venous flow-----

• Now lift one finger( say lower) and see if the vein
rapidly fills or not
-Rapidly fills– Flow from below upwards( Inferior
vena cava obstruction)
• If the vein does not fill rapidly, put the lower finger
again on the vein as before and lift the upper finger
& look for the flow
-Rapidly fills– Flow from above downwards (
Superior vena cava obstruction)
 Deep Palpation of Abdomen
• It is done to examine Organomegaly or
abdominal mass.
• Same technique as superficial palpation is
applied but the abdomen is palpated more
deeply with more pressure
 If there is organomegaly or mass
1- Location (Area, in abd. Wall / intraabdominal)
2-Size
3-Shape
4-Margin- (Sharp/ Blurred/Irregular)
5-Consistancy-(Soft/Firm/Hard)
6-Surface-(Smooth/nodular)
8-Mobility & Attachment (Yes/no)
9-Movement with Respiration (yes/No)
10-Pulsation-(Yes/No)
 Location:--Abdominal wall mass Vs
Intraabdominal mass
• If the abdominal wall become tense:-
- Mass in Muscle -- more prominent
-Intra abdominal mass– less prominent or
disappear
• How to make abdominal muscles tense:-
-Patient raises head up from the bed without
using arms.
- Patient blows against closed mouth & nostril
-Patient raises feet off the table.
Location :-

• Can get above swelling?:- In upper quadrant

swelling ,can we reach the upper boarder of
swelling? If not :- Common site of origin-
-Liver
-Spleen
-Stomach
• Can get below swelling:- In lower quadrant
swellings, can we reach the lower boarder of
swelling ? If not:-Common site of origin-
-Urinary Bladder
-Upper Rectum
-Uterus, Ovary
 Surface, Edge & Consistency

• A nodular (Surface),Irregular (edge) & Hard

(Consistency) swelling—Most likely a neoplasm
• A Smooth, round, regular, tense swelling:- Most
likely a Cyst.
• Solid, ill defined tender mass:- Most likely
Inflammatory.
 Mobility , Attachment & movement with
Respiration
• Can not be moved by hand but moves downwards
during inspiration:- Arising from:-
-Liver -Spleen
-Gall bladder -Distal Stomach
• Can be moved by hand but not with Respiration:-
-Tumors of Small Bowel & Transverse colon
-Mesenteric Cyst
-Large Secondary In Greater Omentum
-Uterine fibroid- (Side to side movement)
-Gravid Uterus ( ,, ,, )
 Mobility Attachment & movement with
Respiration
• Not Mobile (Completely Fixed):-
- Tumor of Retroperitoneal origin-(Pancreas)
-Tumor with extensive spread to anterior or
Posterior Abdominal wall.
- Severe chronic inflammation involving many
organs.
-Tumors of Ovary or Urinary Bladder
 Pulsation of Mass
• It may be transmitted pulsation from
underlying artery- --Aorta.
• It may be Aneurism of a great artery( Expansile
swelling)
• Pulsatile Liver– Tricuspid Regurgitation
• Pulsation transmitted fro RVH
Pulsatile mass(Aneurism of Aorta)
Palpation of Liver:-

• Place Right hand on right side of abdomen

well below the right costal margin
• All fingers in contact of abdominal wall with
fingers pointing towards pt. Left shoulder
• Feel by radial boarder of finger
• Press gently and ask the pt. to breath deeply
• Maintain the pressure of hand when the
patient inspires
Liver

• Try to feel the edge of liver as it comes down

to touch your finger (Soft, Sharp & regular). If
not felt gradually move upwards.

• Now put fingers over liver if it is enlarged &

feel surface for smoothness, consistency &
whether it is tender or not
Palpation-Liver
Hooking method for palpating Liver
Liver Palpation

• Measure the size of Liver below right costal

margin in MCL.
• In deep inspiration normal Liver can be
palpable up to 3 cm below costal margin in
Mid Clavicular Line(MCL). Edge is soft, sharp &
regular. The surface is smooth and consistency
is soft
• Liver Span—(Percussion)
 Palpation of Spleen
• Normally Not Palpable
• Place the flat of left hand over left lowermost rib
cage posterolaterally.
• Place flat right hand on the abdomen and start
from Right Illiac fossa.
• Press deeply with the fingers of right hand & at
the same time exert pressure medially and
downward by the left hand. Ask the patient to
inspire deeply. Gradually move your right hand
towards left costal margin with each breath.
.
Palpation-Spleen

• As you move towards Lt. costal margin the tip of

enlarged spleen will touch your finger during
deep inspiration.
• If spleen is not palpable in supine position, turn
the patient to Right lateral position and palpate.
• Asses the splenic notch and consistency of spleen
• Measure the size below Lt. costal margin in MCL
• Some times hooking method is applied for
palpating spleen
• DD-Left Kidney
Palpation-Spleen
[Link]
 Palpation (Ballottement) of Kidney
• Put Right hand in lumber region of abdomen (Lt.
or Rt.) & Left hand posteriorly in the
corresponding Loin
• Ask the Pl. to take deep inspiration. Press left
hand forwards and right hand backwards,
upwards & inwards. Try to feel the kidney
between both hands.(Bimanually palpable) & and
push by one hand towards other (Ballotting)
• Some times lower pole of Right kidney may be
bimanually palpable in thin persons & can be
ballotted.
• DD- Spleen & GB
Kidney- Bimanual Palpation
 Palpation-Gallbladder
• Normally not Palpable.
• Technique- Same as liver
• If enlarged, may be palpable as firm, smooth
or rough, soft or hard globular swelling with
distinct boarders just lateral to rectus
abdominis near tip of ninth costal cartilage
• Moves with respiration & Upper boarder can
not be felt.
• DD- Right Kidney
Palpation- GB
Palpation-GB-Related signs
• Murphy’s Sigh:- In acute cholecystitis, while palpating
Gall Bladder the patient is asked to breathe deeply. As
the inflamed gall bladder touches the palpating finger
(during inspiration), the breath is suddenly arrested
with a gasp
• Courvoisier’s sign:- A palpable non tender gall bladder
in a patient with jaundice suggest extra hepatic billiary
obstruction secondary to malignancy
• Causes Palpable GB :- *CBD obstruction -Ca Head of
pancreas & other malignant disease, CBD Stone
* Mucocele of GB ---Impacted Stone in neck of GB
*Ca. Gall Bladder
 Palpation -- Urinary Bladder
• Normally not palpable
• In cases of acute or chronic retention of urine when it
is full it can be palpated
• Smooth oval shaped, firm and regular swelling is
palpable in suprapubic region symmetrically which may
extend up to umbilicus.
• Its upper and lateral boarders can be made out, but not
the lower boarder( swelling is arising out of the pelvis.
• Pressure over the lump gives the patent a desire to
micturate
• DD- In females- Gravid Uterus, Fibroid Uterus,
Ovarian Cyst
Urinary Bladder
 Palpation For Epigastric Pulsation, &
Aorta
4- Epigastric pulsation:-
Causes:- Lean thin person.(normal
pulsation of aorta)

- Aneurism of Aorta

-RVH

- Pulsatile liver (TR)

Epig. Pulsation

i)With flat hand index finger is pressed under

the rib case toward left shoulder . If it is felt
that some thing is pushing the finger
downwards with each systole the cause of
pulsation is RVH. The impact comes on tip of
finger
Epig. Pulsation

- during first examination if the impulse is felt

on the pulp of the finger & not on the tip the
pulsation is from Abdomen
- -Two fingers pressed over the aorta parallely.
If there is aneurism of abdominal aorta two
fingers will be separated during systole.
 Abdominal Examination

1- Inspection
2- Auscultation
3-Palpation
4-Percussion
5-Others
 Percussion of Abdomen

• Method:- The middle finger of left hand is

flatly and firmly applied to the area to be
percussed
• - The back of middle phalanx of this finger is
stroked by the tip of middle finger of Right
hand
• -The movement of right hand should be at
wrist
(Opposite fingers for left handed persons)
Percussion
Percussion

Points to be noted-
• Resonance:- Underlying structure contains
Gas
• Dullness:- Underlying structure is solid of
fluid filled
• Percussion should be done from resonant to
dull area.
Normal Abdomen:- Resonant note is present all
over abdomen except over liver where the
note is dull
Percussion

• Purpose of Abdominal Percussion:-

A -Defining the boundaries of abdominal
organs & mass.

B -Differentiating abdominal swelling due to

Flatus/ faeces (Intestinal Obstruction), Fluid
(Ascites) and Ovarian Cyst/ Gravid Uterus
(Cystic)
Percussion

Percussion for Liver:- Is done to measure the

Liver Span
Percussion-Liver

-Start Percussion anteriorly on the Chest from

Right 3rd ICS in Mid Clavicular Line
-Move downwards till Liver Dullness Starts
(Normally Liver Dullness starts from 5th ICS.
-Now Percuss from below in abdomen where it is
resonant and move upwards till note becomes
dull at lower boarder of Liver
-Measure the vertical distance of dullness in Mid
Clavicular Line. It is Liver Span
-Normal Liver Span in mm= (Height in Cm X 0.63)-4
(Normal Range between 6cm to 15 cm has been
reported)
Percussion-Liver

• Absence of Liver Dullness:-

-Intestinal Perforation (Gas under Diaphragm)
-Severe Emphysema
-Large Right Pneumothorax
Percussion- Spleen
• An enlarged spleen is dull to percussion.
• Traube’s Space:- Triangular space bounded by
--Superior-Left 6th Rib
--Lateral-Left Mid [Link]
--Inferior-Left Costal margin
 --
• Traube’s Space is normally resonant to
percussion because Stomach Which contains
gas, lies beneath this space
• Dullness of Traube,s Space- Indicates
Splenomegaly
D/D- Full Stomach
-Left Pleural Effusion
Castell’s Sign:-
- Patient Lies Supine
-Percuss Left 8th or 9th ICS in Anterior Axillary
Line in full inspiration & full expiration
-If the note changes from resonant in full
expiration to dull in full inspiration, the sign is
positive & indicates Splenomegaly
 Percussion- Urinary Bladder.
• In cases of retention of urine the Suprapubic
area becomes dull to percussion due to
distended bladder
• Its superior & lateral boarders can be defined
from adjacent bowel, which is resonant
Percussion In Abdominal Distention

Causes of Abdominal Distention:-

• Ascites:- Free fluid in peritoneal cavity
• Intestinal Obstruction:- Retention of flatus &
faeces
• Cystic:- Large ovarian cyst, Gravid uterus Or
any encysted collection of fluid in abdominal
cavity
 Ascites
Signs to Diagnose Ascites:-
a) Shifting Dullness:- Requires at least 500ml
free fluid in Peritoneal cavity
b)- Fluid Thrill:- Requires 1000-1500 ml fluid (
May be elicited in any encysted fluid collection.
So will also be found in large ovarian cyst )
c)-Puddles Sign:- Can be demonstrated if 120-150
ml. free fluid is present in peritoneal cavity
(Absence of all or any of these signs do not
exclude ascites. Up to 100 ml. fluid can be
detected by USG abdomen)
Shifting Dullness
• First patient lies Supine
• Place finger in longitudinal axis and percuss
laterally from midline.
 --
• If a dullness is detected laterally during
percussion, then keep the finger there and ask
the patient to roll to other side
• Wait for about ½ minutes for any fluid to
gravitate down
• Now percuss again at the previously held
finger on the abdomen.
 --
The previous dull area
- now becomes resonant:--- Ascites
-Remains Dull- Lateral abdominal muscle
-Any solid mass
• If the dull area becomes resonant, move the
finger down wards to see whether the
previously resonant area becomes dull or not.
• If the previous resonant area now becomes
dull, it indicates that the fluid has shifted to this
part of abdomen
--
Grading Of Ascites
International Ascites Club Grading 2003
Grade-1- Mild Ascites detectable only by
Ultrasonography
Grade-2- Moderate ascites manifested by
moderate symmetrical abdominal distention
Grade-3- Large or gross ascites with marked
abdominal distention.
 ??
Q- Why normal abdomen is Resonant to
percussion ?
a) presence of Gas in abdominal cavity
b) presence of gas in peritoneal Cavity
c) presence of gas in stomach & intestine
 Fluid Thrill.
• In case of ascites if a tap is given in one flank,
the vibration is transmitted through the fluid
and is felt to the hand placed on other flank
• It can be elicited in large ascites or large
ovarian cyst. (Fluid required is 1000-1500 ml)
• Method:-
-Patient lies supine
-Ask the patient or attended to put the ulner
boarder of his/her hand firmly on midline of
abdomen
 --
• Place one of your palm in one flank of the
abdomen of the patient
• Now flick/tap the opposite flank of abdomen
 --
• Vibration is felt by the palm/hand placed on
the flank of abdomen.
Q:-Why Patients or assistants hand is placed in
midline of patients abdomen?
a) To mask the transmission of vibration
through fluid in abdomen
b) To mask transmission of vibration through
gas in the intestine & stomach
c) To mask transmission of vibration through
subcutaneous tissue & fat
 c)Puddle sign
• Ascitec fluid less than 500 ml is usually not
detectable by Shifting dullness or fluid thrill
test
• Small mount of ascitec fluid up to 120 ml can
be detected by Puddle sign test
• Puddle sine test:-
-Patient lies prone for at least 5 minutes
-After that he/she rises on elbow & Knee
(knee elbow position)
-Apply stethoscope diaphragm on most
dependent part of abdomen
 Flick repeatedly in one flank of abdomen & move the
--
stethoscope away from you.
-As the diaphragm moves away from the fluid level in
the abdomen the loudness of flick sound increases
-This type of change in flicker sound does not occur
when patient sits.
Feature Ascites
--
Ovarian cyst/ Gravid Uterus Intestinal
Obstruction

Onset Gradual Gradual Acute/Sub acute

Shape Distended with Flanks full Central swelling tilted to one Central distention
side
Umbilicus Everted with Transverse Everted with Vertical slit Everted
slit/Hernia

Palpation Uniform distention/ No Upper level/ Fundal height -----

boundary can be mapped and lateral boundaries can be
out mapped out
Fetal parts may be palpable.
Percussion Central Resonance with Central Dullness with Resonant Through
Dull flanks resonant flanks out
Shifting dullness present No Shifting dullness
Fluid Thrill May be present May be present No
Auscultation Normal/Decreased Bowel Fetal Heart sound may be Increased/ Noisy
sound heard bowel sound
---
 Splenomegaly VS enlarged Kidney
Feature Spleen Kidney
Direction of enlargement & Superficial Deeply &
Movement with Respiration towards Right Vertically
Iliac Fossa downwards
Able to insinuate finger between No Yes
mass and costal margin?
Able to feel deep to the mass? Yes No

Palpable notch? Yes, on medial No

boarder
Percussion over mass? Dull Resonant
(Colonic)
Ballottement? No Yes
 Abdominal Examination

1- Inspection
2- Auscultation
3-Palpation
4-Percussion
5-Others
 Abdominal Examination-Others
a)- Hernial orifices & male genitalia

b)-Per Rectal Examination

C-Per Vaginal Examination

 Hernial orifices & male genitalia
• Groin and male genitalia should be examined
for:-
- Any swelling (Lymph node, inguinal
hernia, Femoral hernia, Scrotal swelling)
- If there is swelling in groin and scrotum,
palpate the neck of scrotum between thumb
& finger to see whether you can reach over
swelling or not
 --
If Yes (Can reach over the swelling):- The
swelling is from scrotum and may be:-
-Vaginal hydrocele
-Epidedimitis
-Epididymo-orchitis
-Tumors of Testes
If NO:-
- Inguinal Hernia
- Femoral Hernia
 Per Rectal Examination
For:-
- Perianal Pathology:- Fistula, mass
-Anal Pathology- Hemorrhoid, Fistula, Mass
-Rectal Pathology:- Polyp, Ulcer, Mass
-Prostate Pathology
Per Vaginal Examination- Not Routinely done
Only is specific situation like- Surveillance
for cervical cancer, Vaginal discharge, Post
menopausal bleeding, Uterine prolaps etc
 End of Exam-Discussion

Spleen & Liver

Q- What is meant by Mild, Moderate
& Massive enlargement of Spleen
 Spleen

• Mild :- 1-2 cm below costal margin in left MCL

• Moderate:-3-7 cm below costal margin in left MCL
• Massive:- Moe than 7cm below costal margin in
left MCL or crosses midline.
 --
What are causes of Splenomegaly?
-Normal spleen is not palpable
-it becomes palpable only when its
size increases more than 2 times
- If spleen is not palpable, it can’t be
said that spleen is not enlarged
-So we use the term ‘Spleen not
palpable’
Causes of Splenomegaly:-
A-Massive Splenomegaly:- 7cm+
- Chronic Kalazar -Chronic Malaria
- CML -CLL
- Lymphoma -Myelofibrosis with
myeloid metaplacia
B-Moderate Splenomegaly:-3-7cm
-Viral hepatitis -Hemolytic anemia
-Polycythemia -Portal Hypertension
-All causes of Massive Splenomegaly at some
stage
Splenomegaly

C-Mild Splenomegaly:- 1-2 cm

-Acute Malaria -Typhoid
-Infective Endocarditis -Septicemia
-Milliary Tuberculosis -Thalassemea
-All causes of Moderate & Massive
Splenomegaly at early stage
 What are Common causes of
Splenomegaly ?
-Malaria
-Kalazar
-Typhoid
-CML (Chronic Myeloid Leukemia)
Myelofibrosis
Cirrhosis of Liver (Portal Hypertension)
 Causes of Hepatomegaly

-Viral Hepatitis - Liver Abscess

-Malaria -Kalazar
-Leptospirosis -Hydatid Cyst
…………………………………………………………………
-Hepatocellular Ca -Metastasis
-Leukemia -Lymphoma
-Primary Billiary Cirrh. -Polycystic Liver
-Non alcoholic Fatty Liver Disease
 Hepatomegaly

What are causes of enlarged, soft, Tender Liver?

Soft, Tender Hepatomegaly

• Congestive Cardiac Failure (CCF)

• Viral Hepatitis
 Causes of Tender Hepatomegaly

• CCF
• Viral Hepatitis
• Liver Abscess (Amoebic/ Pyogenic)
• Bud- chiari Syndrome
 Causes of Hepatosplenomegaly
• Malaria
• Kala azar
• Leukemia
• Lymphoma
• Myelofibrosis
• Myloproliferative disease
• Thalassaemea
• Sickle cell anemia
 Distended Abdomen
CAUSES
F- Fat
F- Flatus
F- Faeces
F- Fluid (Ascites)
F- Fetus, Ovarian Cyst.
Feature Ascites
--
Ovarian cyst/ Gravid Uterus Intestinal
Obstruction

Onset Gradual Gradual Acute/Sub acute

Shape Distended with Flanks full Central swelling tilted to one Central distention
side
Umbilicus Everted with Transverse Everted with Vertical slit Everted
slit/Hernia

Palpation Uniform distention/ No Upper level/ Fundal height -----

boundary can be mapped and lateral boundaries can be
out mapped out
Fetal parts may be palpable.
Percussion Central Resonance with Central Dullness with Resonant Through
Dull flanks resonant flanks out
Shifting dullness present No Shifting dullness
Fluid Thrill May be present May be present No
Auscultation Normal/Decreased Bowel Fetal Heart sound may be Increased/ Noisy
sound heard bowel sound
 Ascites
It is accumulation of free fluid in peritoneal
Cavity
Causes of Ascites:-
A- Peritoneal Causes:-
a)Infections:-
-Tuberculosis
- Pyogenic
-Fungal
 .
Ascites- Causes-contd

b) Malignant:-
-Primary Peritoneal Mesothelioma
-Secondary Peritoneal carcinomatosis
c) Vasculitis:-
-SLE
-Henoc-schonleic purpura
d) Misc.:-
-Whipple disease
-Endometriosis
Causes of Ascites-Cond.

B)- Non Peritoneal Causes:-

a) Portal Hypertension
-Cirrhosis of Liver
-Bud- Chiari Syndrome
b)- Congestive Cardiac Failure
c)- Hypoalbuminimea:-
-Nephrotic Syndrome
-Protein loosing enteropathy
d) Chylus:- -Secondary to Malignancy
-Trauma
e)- Pancreatitis, Billiary ascites, Ovarian Tumor,
Myxedema, Complicated dengue
 --
1)What is non invasive Investigation to confirm
Ascites ?
Ans- Ultrasonography of Abdomen
2)How USG differentiate between Ascites &
Large Ovarian Cyst?
Ans –Fluid in pouch of Douglas
If Present- Ascites
If not- No Ascites
 Paracentesis abdominis
• Aspiration of ascitec fluid.
Indication:-
-Diagnostic
-Therapeutic- in tense ascites causing
cardio- pulmonary embarrassment
Site:- Left lower quadrant of abdomen 2 finger
breadth cephalic and medial to Anterior
Superior Illiac Spine (The area should be dull
to percussion)
Complication of Paracentesis
• Abdominal wall hematoma
• Oozing of fluid from puncture site
• Hemoperitoneum
• Bowel perforation
• Shock- If large amount of fluid is rapidly taken
out ( It leads to sudden release of pressure on
splanchnic vessels leading to splanchnic
vasodilatation and pooling of blood)
Necked Eye Examination of Ascitec Fluid:-
• Straw Colored- Tuberculosis
• Brown:- Hyperbilirubinemea/ GB or billiary
perforation
• Cloudy/Turbid- Infection
• Hemorrhagic:- Malignancy/ Trauma
• Milky (Chylus)- Cirrhosis, Thoracic duct injury,
Lymphoma
Analysis Of Ascitic Fluid:-
• Total & Differential cell count in fluid
• Total protein- (Albumin & Globulins)In Fluid
• Sugar in fluid
• LDH in Fluid
• If Turbid- Culture & sensitivity
• If hemorrhagic– malignant Cells
• Blood test- Serum albumin.
 SAAG (Serum- Ascitic albumin gradient

• SAAG= Serum Albumin- Ascitic fluid Albumin

-SAAG ≥ 1.1 gm/dl-- Cause Portal hypertension

-SAAG ≤ 1.1gm/dl- Not due to portal hypertension

(About 97% accuracy)
 --
SAAG ≥1.1gm/dl SAAG ≤1.1 gm/dl
Cirrhosis of Liver Peritonea Tuberculosis

Alcoholic Hepatitis Peritoneal carcinomatosis

CCF Pancreatitis

Hepatic metastasis Serositis

Constrictive pericarditis Nephrotic Syndrome

Budd-Chiari Syndrome
--
Nixon’s Sign (for splenomegaly)
• Patient lies in Right lateral decubitus position
• Start percussion from mid point of Left costal
margin and go upwards perpendicular to the
costal margin
• If the dullness extends more than 8cm above
the costal margin, Splenomegaly is diagnosed.