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Examinations in Chronic Abdominal Conditions
https://t.me/med1917
in supine position in the bed exposing the abdomen
from upper chest to knee level. Both hands should
be on the sides of the patient. It is better to ask the
patient to turn to one side (towards left as examination
is always done from right side always) breathe
comfortably and relax. It is also important to explain
the patient about what you are going to examine. Often
consent may be needed. When a male doctor examines
a female patient, it is better to have a female nursing
staff beside the doctor. Good day light is needed to
examine the patient. It is ideal to have some
conversation with the patient while examining to ease
and relax the patient. Legs may be slightly flexed at
knee joints (Fig. 20.4).
Fig. 20.4: Examination of abdomen is done
Inspection
Inspection is done from the right side, foot end side
and often from head end side of the patient with eyes
keeping at the level of the abdomen (Figs 20.5A
and B).
Movements with Respiration
Localised limitation of movement with respiration can
occur in localised inflammation. In peritonitis movement with respiration of the abdomen is absent. Patient
will have more thoracic type of respiration.
Skin Over the Abdomen
Skin over the abdomen is looked for scar, dilated veins,
redness, and oedema. Dilated veins are looked for
in standing position. Dilated veins around the umbilicus
with normal pattern of flow (away from the umbilicus)
are due to portal hypertension – caput medusae.
Normally above the umbilicus blood flow is upwards
(to SVC) and below the umbilicus downwards (to IVC).
In IVC obstruction it is upwards; in SVC obstruction
it is from above downwards. T wo fingers are kept very
close over the vein, with pressure fingers are swept
away to empty the vein, one finger is released and
flow is observed; later if it is empty other finger is
also released to see the flow. It is repeated again to
confirm the flow in opposite direction. Scar, its length,
width, margin, linear or wide scar should be checked.
Linear scar means wound has healed by primary
intention.
A
Figs 20.5A and B: Inspection of the abdomen should be done from side as well as from foot end.
B
SRB’s Clinical Surgery
https://t.me/med1917
Umbilicus
Umbilicus is situated normally in midway between
xiphoid process and pubic symphysis. It is displaced
downwards in ascites; upwards in pelvic mass –
T anyol’ s sign. It is everted in ascites, umbilical hernia;
drawn in obesity; pushed towards opposite side by
one sided mass (Normal equidistant line from anterior
superior iliac spine to umbilicus is deviated to one
side). Vertical slit in umbilicus occurs in ovarian
tumour; horizontal slit in ascites.
Shape of the Abdomen
Normally abdomen is flat or only slightly scaphoid;
neither full nor retracted. It may be scaphoid in thin
people/starvation/advanced malignancy. Fat, fluid,
flatus, faeces, and foetus cause symmetrical distension.
Distension due to obesity causes inverted umbilicus.
Umbilicus is everted in intra-abdominal causes. Localised area of fullness may be evident depending on where
the cause is upper/lower abdomen. In patient with
visceroptosis, lower abdomen becomes more prominent on standing (Fig. 20.6).
Visible Pulsation
Pulsation may be visible in thin individuals. It may
be aortic pulsation. Aortic aneurysm causes visible
pulsation. It causes expansile pulsation which is
confirmed in knee elbow position or lateral position.
Transmitted pulsation may be seen over a mass in
front of the aorta like pseudocyst of pancreas,
retroperitoneal mass, etc.
Visible Peristalsis
Visible gastric peristalsis (VGP) is located in the
epigastrium; it is from left to right towards right lumbar
region. It is a feature of pyloric stenosis. It can be
stimulated by giving the patient to drink water (500
ml) or by rubbing the abdomen. Small intestinal
peristalsis (VIP) is around the umbilicus. Peristalsis
of transverse colon is from right to left, slow and
periodic (Figs 20.7A and B).
Mass per Abdomen
Any visible mass or fullness should be inspected. Its
location, size, shape, movement with respiration should
be inspected.
Fig. 20.6: Ascites on inspection. For dilated veins
Palpation
Palpation should be done from right side of the patient.
Patient should lie down flat, breathing through mouth
in relaxed state with head turned to opposite side.
Palpation is done with flat of the hand using fingers;
forearm should be in horizontal plane. Examiner may
have to sit on a chair or lean on the patient to do a
proper palpation. Poking with the fingers placed
vertically over the abdomen should be avoided. Slight
flexion of hips and knees help in relaxing the abdominal
muscles and prevent patient from keeping it tight and
rigid. Keeping a pillow under the knees may be useful.
Clinician should make his examining hand warm by
rubbing it with other hand. Continuous conversation
with the patient during palpation is important to console
and relax the patient.
Neville J Nicholson manoeuvre—Lower end of the
sternum is pressed progressively using base of the
palm of left hand progressively so that patient breathes
through the abdomen relaxing it; right hand is used
to palpate the abdomen (Fig. 20.8).
Examinations in Chronic Abdominal Conditions
https://t.me/med1917
Fig. 20.8: Palpation of the abdomen.
done gently and slowly with asking the patient to
undertake deep inspiration. Deep palpation is done
using fingers of the hand placed over the abdomen
A
pushing deep on each expiration. Two hands method
is better for deeper palpation (Figs 20.9A and B).
B
Figs 20.7A and B: VGP is stimulated by asking the patient
Palpation should be started away from the location
of suspected disease. Examine all other quadrants
initially then examine the needed quadrant carefully.
Often two hands placed one over the other may be
used to palpate the patient’s abdomen. Palpation should
be done first in nontender area then in tender area.
Initially palpation is done to have a clear idea where
exactly disease is suspected. Then deep palpation is
A
B
Figs 20.9A and B: Method of deep palpation of the
SRB’s Clinical Surgery
https://t.me/med1917
Fig. 20.12: Carnett’s leg raising test. Both legs are raised
palpated.
Fig. 20.10: Palpation in child/children is done using
In children child’ s hand is placed over the abdomen
and examiner’s hand is placed over the child’s hand
and is palpated. When pain is present child withdraws
the hand (due to tenderness) (Fig. 20.10).
Head raising or leg raising test (Carnett’s ) is done
to confirm any mass if present is intra-abdominal or
not. If mass becomes less prominent during these tests
it is intra-abdominal; if mass becomes more prominent
it means it is in the abdominal wall (Figs 20.11 and
20.12).
Tenderness
While palpating it is checked by looking at face of
the patient and feel of the abdomen. When tenderness
is mild patient tolerates but winces; when it is moderate
patient winces and tightens the abdomen; when it is
severe patient winces and makes abdomen rigid and
does not allow further palpation.
Deep tenderness is elicited with one finger. Point
of maximum tenderness (tender spot) should be
elicited. In duodenal ulcer it is in transpyloric plane
4 cm right of the umbilicus. In cholecystitis tender
point is below the right costal margin over the lateral
margin of the right rectus muscle. T enderness elicited
here is from the fundus of gallbladder. Murphy’s sign
for chronic cholecystitis is elicited in sitting position.
Patient lifts his right arm above the shoulder; examiner
stands on right side of the patient and right hand fingers
(or left thumb) are placed and hooked under right costal
margin lateral to the right rectus muscle. When patient
is asked to take deep breath, patient winces with pain
during Zenith of inspiration as the inflamed gallbladder
descends during inspiration and touches the examiner’s
fingers. Same tenderness if elicited in lying down
position, it is called Moynihan’ s method/sign. Cartilage
of 8th rib will be tender in cholecystitis (Figs 20.13
and 20.14).
Fig. 20.11: Head raising test.
Fluid Thrill
Fluid thrill is elicited when large amount of fluid
(> 2000 ml; fluid under tension) is present in the
peritoneal cavity (ascites). Patient’ s or assistant’s hand
is placed vertically in the midline of abdomen pressing
deeply to prevent the formation of transmitted wave
towards opposite side along the subcutaneous plane
and also to increase fluid tension inside the peritoneal
Examinations in Chronic Abdominal Conditions
https://t.me/med1917
Fig. 20.14: Moynihan’s test is done in lying down
cavity. One side abdomen is tapped with fingers; fluid
thrill is felt with the other hand on other side. Often
such fluid thrill is positive in large ovarian cyst also.
But it can be differentiated by shifting dullness and
Blaxland ruler test. Shifting dullness is done during
A
percussion. Ascites may be due to congestive cardiac
failure, portal hypertension, abdominal tuberculosis,
B
Figs 20.13A and B: Murphy’s sign is elicited in sitting position
Fig. 20.15: Demonstration of fluid thrill.
peritoneal carcinoma, advanced malignancies (Fig.
20.15).
Blaxland Ruler Test
Urinary bladder is emptied. A flat ruler is laid over
the abdomen just above the anterior superior iliac
spines. With the fingers of the both hands the ruler
is pushed firmly and steadily towards lumbar spine.
Abdominal aortic pulsation is felt in ovarian cyst. It
is not felt in ascites (Figs 20.16A and B).
SRB’s Clinical Surgery
https://t.me/med1917
A
B
Figs 20.16A and B: Blaxland ruler test. First ascertain
Dipping Method
When there is large quantity of fluid in the abdominal
cavity palpation of different organs is done by dipping
the fingers by which fluid is displaced away from the
place.
Palpation of Different Organs
Stomach
Normally stomach is not felt on palpation. It is felt
as dilated in pyloric stenosis due to chronic duodenal
ulcer (cicatrised), pyloric growth. Visible gastric
peristalsis (VGP), positive succussion splash, positive
auscultopercussion test is significant. Dilated stomach
will be below the level of umbilicus (greater curvature).
VGP may be absent if gastric paresis occurs due to
atony of stomach wall. Stomach mass is usually due
to carcinoma, occasionally leiomyoma or sarcoma.
Mass moves with respiration, freely mobile, all borders
well made out, irregular surface, hard in consistency,
resonant or impaired resonant on percussion. It
becomes immobile once it gets fixed posteriorly.
Absence of stomach mass will not exclude carcinoma
of stomach.
Liver
In infants it is palpable upto 3 years. In adult it is
usually not palpable. Any palpable liver is considered
as pathological. Liver is palpated using right hand.
Palpation should begin well below from right iliac
fossa otherwise it may be missed. Right fingers are
laid flat with outer margin of the index finger held
facing upwards and inwards. Fingers are pointed
towards left axilla parallel to right costal margin.
During deep inspiration fingers are pressed firmly to
feel; during expiration fingers are moved upwards
towards right costal margin. During full inspiration
as fingers are moving upwards, lower margin of
descended liver will come and touch the outer edge
of the index finger. The fingers are kept there for further
confirmation of the liver and also other features of
the liver like—presence of tenderness or not; extent
in cms or fingerbreadth below right costal margin;
edge type—sharp or rounded; surface—smooth,
irregular, granular , nodular, umbilications; consistency
– soft, firm, hard. Smooth tender liver may be in
amoebic liver abscess or viral hepatitis. Nodular hard
liver is a feature of secondaries in liver. Umbilication
is seen in liver secondaries due to central necrosis.
Hepatocellular carcinoma may be smooth/nodular;
soft/firm or hard. Soft, smooth liver is felt in congestive
conditions. In obstructive jaundice, liver may be
enlarged due to obstruction causing dilated intrabiliary
radicals – hydrohepatosis where liver is soft and
smooth; or it may be due to secondaries (nodular, hard)
from carcinoma of head or periampullary region.
Spleen
Spleen is only occasionally palpable in normal person
(1-3% of normal people – in New Guinea commonly).
Normal spleen is 12 × 7 cm in size. It is enlarged
if it is more than 14 cm. Spleen should get enlarged
three times to become palpable. Method 1: Right hand
fingers are used to palpate the spleen from right iliac
fossa. Index finger is placed like palpation for liver.
Fingers are moved towards left hypochondrium and
Examinations in Chronic Abdominal Conditions
https://t.me/med1917
upwards in each phase of respiration. Spleen is palpated
under the tip of 10th rib. Method 2: Left hand may
be kept under the left lower chest wall and skin is
moved downwards so that more lax skin is available
to insinuate the right hand fingers under left costal
margin. Method 3: While right hand is palpating, left
hand is placed under the left rib cage to lift it upwards
so that spleen comes forward to facilitate the palpation
by right hand. Method 4: Spleen can be palpated from
above – left side of the patient with two hands arching
below the left costal margin, and during phases of
respiration spleen will come down and touch the
examiner’s fingers. Often tilting the patient with left
side up during palpation makes spleen to be palpated
in easier way . Method 5: Hook sign: Hooking the left
costal margin with fingers is not possible in splenic
enlargement. Method 6: Middleton’s manoeuvre:
Examiner stands on left side of the patient facing
towards foot end, keeps his left hand fingers hooked
under left costal margin and exerts pressure over the
posterolateral aspect of the lower thorax using his right
hand and spleen is felt at the end of deep inspiration
(Figs 20.17A and B).
A
Causes of splenomegaly – Congestive cardiac failure,
malaria, portal hypertension, haemolytic anaemias,
idiopathic thrombocytopenic purpura, ka lazar, lymphomas, chronic myeloid leukaemia (massive spleen),
polycythaemia rubra vera, sarcoidosis, myelofibrosis,
typhoid fever, autoimmune diseases, splenic abscess,
splenic cyst, tuberculosis.
Hypersplenism is overactivity of the splenic function
which has nothing to do with splenic size with typical
features of – splenomegaly; pancytopenia; hypercellular or normal bone marrow; reversible by splenectomy.
Causes for hypersplenism are – lymphoma, cirrhosis,
myeloproliferative diseases, and connective tissue
diseases.
Gallbladder: Gallbladder when enlarged is visible on
inspection in the right hypochondrium as globular mass
directed downwards and forwards below right costal
margin or below the lower margin of the palpable liver
just lateral to the lateral border of the right rectus muscle
along the tip of the 9th rib. Mass moves with respiration;
mobile horizontally, dull on percussion, soft, smooth.
It may be tender if it is empyema gallbladder otherwise
B
Figs 20.17A and B: Palpation of spleen—different methods.
it is nontender. It is enlarged in mucocele of gallbladder ,
in carcinoma head of pancreas or periampullary
carcinoma. It is hard in carcinoma of gallbladder.
Pancreas: It is being a retroperitoneal organ is felt
if at all on deep palpation only. It is felt if there is
pseudocyst of pancreas or cystadenocarcinoma or
cystadenoma of pancreas. Carcinoma of head of
pancreas is usually not palpable (gallbladder is palpable
SRB’s Clinical Surgery
https://t.me/med1917
here with obstructive jaundice). Pancreas in chronic
pancreatitis or pancreatic cyst is better felt in lateral
position from left side with patient turned towards
right side with hip and knees flexed. Left subcostal
and epigastric regions are deeply palpated. In this
position bowel in front will be displaced making
pancreas better palpable. Tenderness elicited in this
position in chronic pancreatitis is called as Mallet –
Guy’s sign (Fig. 20.18).
Fig. 20.18: Eliciting Mallet – Guy sign in chronic pancreatitis.
Colon
Faecal mass may be felt like a colonic mass. Faecal
mass yields/moulds (indents) on pressure. It subsides
or reduces in size after giving enema. Distended
caecum is better seen than felt as fullness in the right
iliac fossa. Colonic mass is located along the anatomical line of the colon depending on the site of pathology . It is mobile but does not move with respiration,
nodular, hard well localised mass. Anaemia, diarrhoea,
constipation, distension are other features.
Kidney
Kidney is palpated by—bimanual palpation; ballottability. In sitting position renal angle tenderness should
be checked (Figs 20.19 and 20.20A to C).
Abdominal girth measurement is done at umbilical
level. Periodic measurement is done to assess the
progress of the disease.
Percussion
Liver dullness is elicited in the 5th intercostal space
in midclavicular line on right side. Liver span is
assessed. It is 12-15 cm in adult. Percussion is started
Fig. 20.19: Renal angle tenderness is elicited in sitting
from right 4th space downwards until dullness is
reached and continued upto the lower margin of the
dullness. Liver dullness is reduced in severe
emphysema, right sided pneumothorax. It is obliterated
in perforation of viscus causing gas under diaphragm.
Percussion over the mass is important to locate
the anatomical plane. Abdominal wall masses, masses
in front of the bowel like liver, spleen, gallbladder
are dull on percussion. Mass arising from bowel is
impaired resonant. Retroperitoneal mass is resonant
(as bowel is present in front) on percussion like
pancreatic mass, renal mass, aortic aneurysm, paraaortic lymph node mass, retroperitoneal tumours or
cyst. Mass in the upper abdomen when is dull during
percussion should confirm whether it is continuous
with liver dullness or not.
Shifting dullness for free fluid should be checked
(1000 ml of fluid should be present). Puddle sign is
assessing small quantity of free fluid in the abdominal
cavity in knee elbow position (120 ml). It is checked
in same position often by auscultopercussion also.
Examinations in Chronic Abdominal Conditions
https://t.me/med1917
Note: Proper US may detect 30 ml of fluid. Grading
of ascites: Grade 1–Detectable only by careful
examination; Grade 2–Easily detectable small volume;
Grade 3–Obvious ascites but not tense; Grade 4 –
Tense ascites.
In ascites, it is dull in the flanks but resonant on
the summit–centre whereas in ovarian cyst it is resonant
in periphery but dull in the centre.
Traube’ s ar ea: It is bounded above by lung resonance;
below by left costal margin; on the right side by left
border of the liver and on the left side normal splenic
dullness. It lies in left lower chest behind 9th, 10th
and 11th ribs. Normally it is resonant as it is occupied
by stomach. It becomes dull in left sided pleural
effusion, splenomegaly, and stomach (fundus) with
solid tumour or fluid, enlarged left lobe of the liver,
massive pericardial effusion. It is shifted upwards in
left lower lobe collapse/left lung fibrosis/left side
diaphragm paralysis.
Percussion for splenic dullness: Method 1: (Nixon’s)—
Patient is turned towards right side (left up) and
percussion is started at posterior axillary line
proceeding perpendicularly towards anterior costal
margin. Upper border of dullness is 8 cm above the
costal margin in normal people. Dullness more than 8
cm signifies splenic enlargement. Method 2 (Castell’ s):
– Resonant note normally felt while percussing in
supine position along the lowest intercostal space in
anterior axillary line (left) becomes dull on full
inspiration in case of splenomegaly.
Figs 20.20A and C: Different methods of kidney palpation.
Percussion over the r enal angle: Normally renal angle
(angle of erector spinae and 12th rib) is resonant due
to colon underneath. In kidney enlargement angle is
occupied by enlarged kidney in deeper plane reflecting
the colon in front and medially making it dull on
percussion (Fig. 20.21).
Auscultation
Bowel sounds: Normal bowel sounds (Borborygmi)
are 2-4 in number per minute. If it is more than 5
it is hyperperistaltic—feature of early obstruction,
enteritis, carcinoid syndrome. Absence bowel sounds
is called as silent abdomen. It is observed in paralytic
ileus, late intestinal obstruction, acute peritonitis, acute
pancreatitis, acute mesenteric ischaemia. In late
SRB’s Clinical Surgery
https://t.me/med1917
Fig. 20.21: Percussion over the renal angle in sitting
paralytic ileus, high pitched tinkling sound is heard
due to spill over of contents from one loop to another
– ‘bells at evening pealing’. Bowel sounds are checked
with bell of the stethoscope in umbilical region. It
is small bowel peristalsis which is heard.
Bruit around umbilicus may be due to renal artery
stenosis. Bruit above the umbilicus may be due to
aortic aneurysm.
Bruit over liver may be due to increased vascularity
– haemangioma, HCC, hepatic artery aneurysm.
Hepatic rub suggests perihepatitis.
Kenawy’s sign: By placing stethoscope beneath the
xiphoid process, a venous hum is heard in portal
hypertension which is louder during inspiration. It is
due to engorgement of the splenic vein and during
inspiration spleen is compressed making it louder.
adjacent to stethoscope, placed outwards towards left
side. It is done repeatedly from above downwards left
side. Change in the sound at the margin of greater
curvature will be obvious. All points from above
downwards are joined to mark the greater curvature
of the stomach. It is above the level of the umbilicus
in normal individual. It shifts below in gastric outlet
obstruction like pyloric stenosis, carcinoma pylorus.
Only greater curvature is assessed as dilatation takes
place at greater curvature.
Succussion splash: Stethoscope is placed over the
epigastrium. Using thumb and fingers of both hands,
which are placed on each side of lower chest wall,
patient is held firmly and shaken to hear splashing
sounds of fluid in the stomach. Patient should not take
any fluid for at least 4 hours as succussion splash
is heard even in normal person giving false positive
result. Positive succussion splash suggests gastric
outlet obstruction.
Examination of Left Supraclavicular
Lymph Nodes
It is enlarged when there is spread from gastrointestinal
malignancies through thoracic duct. It is located deep
to deep fascia between two heads of the sternocleidomastoid muscle. This Virchow’ s node enlargement is
called as Troisier’s sign. It suggests advanced
malignancy. FNAC of this node will give the histological diagnosis of adenocarcinoma. It is felt using finger
dipping deep between two heads of sternomastoid
muscle (Fig. 20.22).
Cruveilhier-Baumgarten syndrome is venous hum
heard between xiphisternum and umbilicus in portal
hypertension due to patent congenital umbilical vein
draining portal vein.
Splenic rub suggests splenic infarction, chronic
myeloid leukaemia, endocarditis, sickle cell disease.
Bruit in this region may be due to splenic artery
aneurysm.
Auscultopercussion test for stomach dilatation:
Stethoscope is placed over the xiphisternum. W ith the
finger, gentle strokings are done from epigastrium,
Fig. 20.22: Palpation of left supraclavicular
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