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Examinations in Chronic Abdominal Conditions
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Pain present in the right hypochondriac, epigastric,
or left hypochondriac region depending on location
of the tumour. Back pain when it is present is due
to involvement of retropancreatic nerves, or pancreatic
duct obstruction or stasis.
Diarrhoea, steatorrhoea, silvery stool (due to
undigested fat mixing with metabolized blood which
is derived from the ooze of periampullary growth);
loss of appetite and weight; scratch marks on the back.
Migratory superficial thrombophlebitis—
Trousseau’s sign (10%) is due to release of platelet
aggregating factors from the tumour or its necrotic
material (Trousseau himself died of carcinoma
pancreas who had migrating thrombophlebitis).
Ascites; Left supraclavicular palpable lymph node;
secondaries in rectovesical pouch (Blumer’s shelf).
Gallbladder may be palpable which is nontender,
soft, globular, smooth, moving with respiration, mobile
horizontally, dull on percussion. Courvoisier law
favours gallbladder enlargement.
Liver is enlarged, smooth, firm, nontender , due to
dilated bile filled biliary radicles—Hydrohepatosis.
Liver can show multiple hard nodules due to
secondaries.
Cystadenocarcinoma of pancreas can present with
mass in epigastric region, which is nonmobile, not
moving with respiration, smooth, soft, nontender.
Splenic vein thrombosis with splenomegaly (10%)
can occur.
Hirschsprung’s Disease
It is a congenital, familial condition occurring in
newborn due to the absence of ganglion cells—
Auerbach’s and Meissner’s plexus in anorectum,
which may extend proximally either a part or full length
of the colon.
Types:
It has got three zones: 1. Distal immobile spastic
segment, i.e. aganglionic zone; 2. A proximal, middle
transitional zone of about 1-5 cm length with less,
sparse number of ganglions (cone); 3. A still more
proximal, hypertrophied dilated segment is actually
the normal ganglionic area.
Clinical features: It is common in males. In 90% of
cases symptoms appear in early neonatal period, i.e.
within three days of birth. Present with complaints
of failure of passage of meconium. After introducing
finger into the rectum child passes toothpaste like stool,
with evidence of straining. Distension of the abdomen
with features of intestinal obstruction is seen.
Constipation with history of passing stools once in
3-4 days with straining, is seen throughout the
childhood and also in adolescent period. Occasionally
condition can cause intestinal obstruction.
Diagnosis: History of failure of passing meconium.
Plain X-ray abdomen—shows intestinal obstruction.
Biopsy from all three zones is taken to study the
ganglions and hypertrophic nerve terminals in
spasmodic segment. Barium enema is done to look
for the extent of disease and three zones. Foley’s
catheter should not be used while doing barium enema
in case of Hirschsprung’s disease. Anorectal mano-
metry—shows the absence of rectoanal reflex in
Hirschsprung’s disease, which is diagnostic.
Complications: Colitis; intestinal obstruction; growth
retardation; constipation.
Differential diagnosis: Total neuronal dysplasia;
Acquired megacolon; anorectal malformation.
Ulcerative Colitis
An inflammatory condition of rectum and colon of
unknown aetiology perhaps related to stress, westernised diet, autoimmune factor, familial tendency , allergic
factor . Disease commonly starts in the rectum, spreads
proximally to the colon and often into the ileum as
back wash ileitis.
Pathology: To begin with, multiple minute ulcers
occurs, with proctitis and colitis → These ulcers
extends into the deeper layer → Spasm of the bowel
→ Stricture of the colon → Permanently contracted
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colon → In between ulcers, epithelial thickening occurs
which appears like polyps → Pseudopolyposis.
Clinical features: More common in females, begins
in 3rd decade. Watery diarrhoea, mucous or blood
stained discharge per rectum; colicky pain, spasms;
decreased appetite and loss of weight; relapses and
remissions at regular intervals. Two types of
presentations: (a) Fulminant type—5% common. It
is a severe form, with continuous diarrhoea with
passage of blood, mucous and pus. Patient is ill and
dehydrated; mimics fulminant amoebic colitis, severe
typhoid and dysentery. Later abdominal distension
occurs. May go for acute toxic dilatation (1.5%) of
transverse colon where in the diameter of transverse
colon > 6 cm. It has high mortality and requires
emergency sur gery , i.e. either colostomy or resection
with ileostomy and later ileoanal anastomosis.
(b) Chronic type: (95%) Lasts for months and years
with diarrhoea, blood loss, anaemia, invalidism,
abdominal discomfort and pain.
Investigations: (a) Barium enema—shows loss of
haustrations, narrow contracted colon (hose pipe
colon), mucosal changes, pseudopolyps. It is avoided
in fulminant cases. (b) Sigmoidoscopy and biopsy.
Colonoscopy also is required. Due to very high
incidence of malignant transformation in ulcerative
colitis (10-20%), multiple biopsies should be taken
from suspected ar eas of the colon. Risk increases with
age of the patient and duration of the disease (20%).
Complications: Pseudopolyposis; turning into malig-
nancy; stricture formation commonly in rectosigmoid
and anal canal; toxic megacolon in transverse colon;
massive haemorrhage; fistula in ano; liver cirrhosis
(50%); skin lesions; arthritis; iritis, ankylosing spondylitis; sclerosing cholangitis, carcinoma of gallbladder.
Familial Adenomatous Polyp (FAP)
It is inherited as an autosomal dominant neoplastic
condition (chromosome no.5). Incidence is equal in
both sex, involving commonly the large intestine but
can also occur in stomach, duodenum and small
intestine. It is familial with a high potential for malig-
nant transformation. It can be associated with duodenal
or ampullary carcinomas, Gardner’s syndrome (Des-
moid tumour in the abdomen, osteomas (75%) and
epidermoid cysts) and also Turcot’s syndrome (FAP
+ brain tumour (medulloblastoma or gliomas). It
presents in younger age group - 15-20 years; usually
multiple (over 100); presents with lower abdominal
pain, loose stools with blood and mucous, weight loss.
If there is no adenoma at the age of 30 years, then
it is not FAP of colon.
Carcinoma Colon
It is commonly adenocarcinoma. Very rarely adeno-
squamous, squamous carcinoma can occur.
Adenocarcinoma: Sigmoid colon (21%) is the
commonest site of malignancy after rectum (38%).
In caecum it is 12% common.
Aetiology: Diet: Red meat and saturated fat increases
the incidence of colonic cancer. Cholesterol increases
the bile acid concentration in the intestinal lumen
which acts as cocarcinogen. High fibre diet protects
the colon against cancer. Genetic: Carcinoma colon
is more common in individuals with adenoma colon
or with familial adenomatous polyposis—F AP or with
long standing ulcerative colitis. Alcohol and cigarette
smoking increases the risk. Aspirin and other NSAIDs
protect against colonic cancer.
Types: Patient can have de novo multiple primary
carcinomas in different parts of the colon at same time,
i.e. synchronous (5%), or can present with growth
in different parts of the colon in different periods, i.e.
metachronous (2-5%). Gross types: Annular
(stenosing)—It is more common on left side. T ubular;
Ulcerative (common on right side); Cauliflower-like.
Here the growth spreads round the internal wall and
so it often presents with intestinal obstruction.
Spread: Locally it can invade the bladder, obstruct
ureter and so cause hydronephrosis. It can perforate
and cause peritonitis/ pericolic abscess/ faecal fistula.
Growth may get adherent to psoas muscle posteriorly.
Growth through lymphatics spreads to pericolic,
epicolic, intermediate and principal group of lymph
nodes; 40% of carcinoma colon spreads to liver via
portal veins. Secondaries may be either solitary or
multiple, presents as enlarged liver with hard, umbi-
licated nodules. Rarely it spreads to bone, lung, skin.
Examinations in Chronic Abdominal Conditions
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Clinical features: It occurs usually after 50 years.
Familial type can present in younger age group.
Commonly presents with loss of appetite and weight,
anaemia, abdominal discomfort and mass per abdomen. 20% of cases presents as an acute intestinal
obstruction. Right sided growth commonly presents
with anaemia, palpable mass in the right iliac fossa,
which is not moving with respiration, mobile, nontender, hard, well localised with impaired resonant note.
Carcinoma caecum occasionally can present like acute
appendicitis or intussusception with intestinal obstruction. Left sided growth presents with colicky pain,
altered bowel habits (alternating constipation and
diarrhoea), palpable lump, and distension of abdomen
due subacute/chr onic obstruction. Later may present
like complete colonic obstruction. Tenesmus, with
passage of blood and mucous, with alternate constipation and diarrhoea, is common. Bladder symptoms
may warn colovesical fistula. Enlarged liver with
multiple umbilicated hard secondaries, ascites,
rectovesical secondaries, palpable left supraclavicular
lymph nodes are other presentations. Faecal strength
of Streptococcus bovis bacteria increases many fold
in colonic cancer patients compared to individuals
without colonic cancer.
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SRB’s Clinical Surgery
Examination of
21
In a patient presenting with abdominal mass, generally
following history should be elicited carefully.
Pain: Site, nature, aggravating or relieving factors,
duration of pain, referred pain.
Vomiting: Type, content, haematemesis, relation to
food, frequency.
Jaundice: It is an important factor in relation to liver,
gallbladder or pancreatic masses.
Bowel habits: Constipation, diarrhoea, bloody diarrhoea, furious diarrhoea, tenesmus.
Decreased appetite and weight.
Inspection of the mass: Anatomical location, mar gin,
surface, movement with respiration.
Palpation of the mass: Site, extent, surface, tenderness,
consistency, movement with respiration, mobility,
borders, plane of the swelling (by leg rising test),
presence of other masses.
Mass Abdomen
Pervaginal examination: It is done to assess pelvic
masses.
Abdomen is divided into nine regions by four lines
(Fig. 21.1).
Upper horizontal or transpyloric line is midway
between the suprasternal notch and symphysis pubis
or line between tips of ninth costal cartilages on each
side. It is often midway between xiphisternum and
umbilicus.
Lower horizontal line is transtubercular line at the
level of two tubercles (5 cm behind the anterior superior
iliac spine along the iliac crest) on the iliac crest.
Right vertical line is the line through the midpoint
of right anterior superior iliac spine and pubic
symphysis. It is usually a line joining right midclavicular and right midinguinal points.
Left vertical line is the line through the midpoint
of left anterior superior iliac spine and pubic symphysis.
It is usually a line joining left midclavicular and left
midinguinal points.
Percussion: It is an important aspect of examination
in case of an abdominal mass. Percussion over the
mass is important to determine the anatomical location
of the mass. If mass is dull, then it lies in the anterior
abdominal wall or intra-abdominally in front of the
bowel, liver, spleen, gallbladder, etc. If the mass is
with an impaired resonant note, then the mass is arising
from the bowel like stomach, colon, and small bowel.
If the mass is resonant on percussion, then the mass
is probably in the retroperitoneal region. Other than
this, liver dullness, free fluid in the abdomen should
be elicited during percussion.
Per-rectal examination: It is done to look for any
secondaries in rectovesical pouch, any primary tumour
or relation of lower abdomen masses (pelvic masses).
Fig. 21.1: Different regions in the abdomen.
Examination of Mass Abdomen
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Regions in the abdomen
Right hypochondrium
Epigastrium
Left hypochondrium
Right lumbar region
Umbilical region
Left lumbar region
Right iliac fossa
Hypogastrium
Left iliac fossa
Quadrants in the abdomen are four in number formed
by two lines—one is vertical midline through the
umbilicus; another is horizontal line passing through
the umbilicus. Quadrants are—right upper, right lower,
left upper and left lower (Fig. 21.2).
485
• Yellowish discolouration of sclera—duration
• Loss of appetite and decreased weight—weight
loss more than 10 Kg in short period/6 months is
significant
• Altered bowel habits/constipation/diarrhoea
• Fever—Its character is important to be noted in
abdominal tuberculosis, amoebic liver abscess,
cholangitis, malignancy with tumour necrosis,
infected pseudocyst of pancreas.
History
History of Present Illness
Pain
Site of origin of pain; onset (sudden/insidious);
duration; radiation of pain/referred pain; type of pain—
intermittent/persistent; dull, severe pricking, colicky;
periodicity with an interval of free period—ulcer pain
has often got periodicity unless it is complicated;
relation to food intake—more/less/not related to meals;
relation to vomiting/induced vomiting; aggravating/
relieving factors; pain in relation to bowel habits/
urinary habits.
Fig. 21.2: Different quadrants in the abdomen. They are
four in number formed by two lines—one is vertical midline
through the umbilicus; another is horizontal line passing
through the umbilicus. Quadrants are—right upper, right
lower, left upper and left lower.
Chief Complaints
• Mass per abdomen—ask for duration, progress,
site, mass appearing/disappearing (like in intussusception, Dietl’s crisis of hydronephrosis kidney,
and choledochal cyst)
• Pain in the abdomen—region of pain; duration of
pain to be mentioned
• Vomiting—duration
• Haematemesis, malaena—duration
• Satiety—sensation of fullness after taking food
(early satiety signifies gastrointestinal pathology
like carcinomas
Vomiting
• Duration, frequency, relation to food, type
(projectile/effortless)
• Vomitus—content (food/blood/bile), quantity,
smell, colour—coffee ground/bloody/yellow , taste
• Relation to pain, details of haematemesis if present
• It is better to ask the patient to collect and keep
the vomitus and clinician should personally
observe it.
Jaundice
• Duration, colour (greenish yellow suggests
obstruction), severity, progress (progressive/
intermittent/static/reducing)
• Presence of fever with jaundice—cholangitis
• Association with pruritus, clay coloured stool/
silvery stool.
Altered Bowel Habits
• Duration, type, malaena, with distension of
abdomen
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Altered Urinary Symptoms
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History of frequency/urgency/haematuria/pyuria/
oliguria/painful urination/burning urine/difficulty in
passing urine/hesitancy/hiccough/oedema feet or face;
relation of urinary symptoms to pain, mass in abdomen
should be asked for.
Other Relevant History
Cough and haemoptysis, bone pain, etc.—suggestive
of metastases.
Past History
Earlier history of abdominal surgery—reason for
surgery, how long ago it was done, whether earlier
symptoms are relieved or not, whether the symptoms
are now similar or different, whether it was an emergency or an elective surgery, whether it was earlier
properly investigated or not, whether drain was placed
or not—if placed when it was removed; what content
was coming through the drain, whether blood transfusion was done during surgery or in postoperative
period.
A
Personal History
History of alcohol intake, diet, smoking, etc. has to
be noted.
T reatment history—any relevant history of surgery
in the past, chemotherapy for malignancies, abdominal
tuberculosis treated, and so on.
Family history—any relevant history in the family
should be taken as some GI malignancies run in
families.
General Examination
Pallor/jaundice/clubbing/oedema feet /cachexia is
noted. Pulse/blood pressure is recorded. Genitalia/
respiratory and cardiovascular system should be
examined (Figs 21.3A and B).
Local Abdominal Examination
Inspection
Inspection of the abdomen is done in supine position
exposed from midchest to midthigh region with arms
extended. Inspection is done from side of the bed as
B
Figs 21.3A and B: Obstructive jaundice in a patient with
carcinoma head of pancreas. Note the sclera for discoloration.
Severe itching is common in these patients.
well as from foot end with eye level at the level of
the patient (Figs 21.4A to 21.5B).
Shape of the abdomen—contour—normal/scap-
hoid/distended.
Skin over the abdomen whether stretched/pigmen-
ted; presence of scar whether healed primarily or
secondarily; site of scar; length and width of scar;
whether there is any incisional hernia or not.
Dilated veins over the abdomen should be looked
for—caput medusae is dilated veins radiating from the
umbilicus—seen in portal hypertension. In inferior
vena caval obstruction (lateral abdominal wall)
dilated veins are visible with their flow of blood from
below upwards towards superior vena cava. In superior
vena caval obstruction dilated veins are visible with
blood flow from above downwards. Dilated veins
should be inspected in standing position and also
Examination of Mass Abdomen
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A
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B
Figs 21.4A and B: Proper exposure of the abdomen is
important from midchest to midthigh and position of the patient
for proper abdominal examination.
A
B
Figs 21.5A and B:Inspection of the abdomen should be
done at the level of the patient’s abdomen both from right
side as well as from foot end.
direction of flow should be checked by placing two
fingers apart over the vein and the fingers are released
one by one to see the direction of blood flow . Normally
abdominal wall drains to superior vena cava above the
umbilicus and to inferior vena cava below the umbilicus—water shed area (Figs 21.6 and 21.7A and B).
Movements of regions with respiration should be
noted.
Fig. 21.6: Superior vena caval obstruction causing dilated
veins in the neck chest wall and shoulder. Note the neck
swelling extending into the mediastinum.
A
Figs 21.7A and B: Inferior vena caval obstruction causing
dilated veins over the lateral aspect of the flank with flow
of blood upwards.
B
Pulsations over the mass or any region should be
noted. Patient should hold the breath after full
expiration to see for pulsations.
Any visible peristalsis should be looked for—
V isible gastric peristalsis (VGP) is seen in upper middle
region with waves beginning from left upper abdomen
directed downwards and towards right to umbilical
region. It is stimulated by drinking glass of water or
by massaging the epigastrium. It signifies gastric outlet
obstruction. But may be absent in gastric outlet
obstruction where gastric paresis develops and stomach
becomes dilated and silent without any motility . Visible
intestinal peristalsis (VIP) occurs in step ladder pattern
in central abdomen from left to right or vice versa
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in umbilical region. Visible colonic peristalsis may
be obvious from right to left along the line of colon
Inspection of the mass—Its location (exact location
should be mentioned as in which region it is located
and then its extension into the other region should
be mentioned later); extent; approximate size; well
defined or ill defined (often mass is not clearly seen
but fullness is visible); margins whether clear or not
or which part is clear and which part is not; presence
of movement of mass with respiration or not (upper
abdomen mass like liver, stomach, spleen, gallbladder ,
omental mass, kidney mass moves with respiration).
Mass which was initially mobile may not be mobile
later once it gets fixed to retroperitoneum or deeper
plane. But occasionally mass which was initially not
mobile, may start moving with respiration once gets
attached to structures like omentum. Lower abdominal
mass, retroperitoneal mass will not usually move with
respiration. Mass which comes in close contact with
diaphragm will move with respiration. Composite mass
may move with respiration because of its component
like omentum, lymph nodes, bowel, etc (Figs 21.8
to 21.10).
Fig. 21.9: Large secondaries in liver. Patient has undergone
enucleation of left eye (with artificial eye) for primary
melanoma choroids—15 years ago. Now he has presented
with late large liver secondaries.
Umbilicus—Position is noted. It may be everted/
inverted. Tanyol sign: Umbilicus is shifted upwards
in pelvic/ovarian mass and downwards in ascites. Sister
Joseph nodules can occur in the umbilicus as
secondaries from abdominal GI malignancies through
ligamentum teres. Umbilical black eye is Cullen’ s sign
of discolouration of umbilicus seen in acute pancreatitis. Umbilical concretions, umbilical discharge
Fig. 21.8: Visible large upper abdomen mass—could be
enlarged liver/pseudocyst of pancreas/retroperitoneal mass.
Fig. 21.10: Head raising test should be done to find out
whether mass is intra-abdominal or in the abdominal wall.
(sinus/fistula), bluish tinge in ruptured ectopic gestation
(Cullen’s), yellow tinge around umbilicus in acute
pancreatitis in women (Johnston)—should be observed
(Fig. 21.11).
Hernial orifices and genitalia inspection—is a must.
Scrotum should be examined for testicular tumour/
Examination of Mass Abdomen
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Fig. 21.11: Sister Joseph secondary nodule in the
umbilicus.
Fig. 21.12: Impulse on coughing should be seen and
also felt to confirm associated hernia.
loss of testicular sensation as testicular tumour may
present as epigastric mass due to enlarged para-aortic
lymph nodes (Figs 21.12 and 21.13).
Palpation
While palpating the abdomen patient should take deep
breath with mouth open to relax the abdomen otherwise
it is difficult to get proper finding. Hands should be
warm and forearm should be horizontal at the same
level as patient’s abdomen. Palpation is done with
ventral aspect of the fingers. Legs should be partially
flexed at hips and knees.
Fig. 21.13: Loin should be inspected from behind for
fullness and oedema.
Local rise of temperature is checked using back
of hand. It suggests inflammatory pathology.
T enderness over the abdomen or over the mass must
be noted. It may be due to inflammatory pathology.
Often malignant condition may cause tenderness either
due to secondary infection or due to tumour necrosis.
Position, size, shape, and surface of the mass:
Nodular surface may be neoplastic; smooth surface
may be of benign or inflammatory pathology.
Margin: Well-defined margin which is distinct may
be a feature of neoplasm. Ill-defined margin may be
seen in inflammatory or traumatic pathology. Mar gin
which is indistinct whether upper or lower should be
confirmed. In the upper abdomen feeling the upper
margin is important. In liver mass upper margin is
not felt but it is felt in stomach mass. Upper margin
of the mass may be difficult to feel in mass from fundus
of stomach. Feeling the lower margin is important in
the lower abdomen mass . If lower margin is not clear
one has to find out whether mass is extending to pelvis
or not. Rectal or per vaginal examination confirms
the pelvic mass. Often full bladder may interfere or
mimic the mass and so mass should be palpated again
after emptying the bladder, if needed after passing
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a urinary catheter. Margin may be better felt with
change in position either sitting, standing, or lateral
position.
Mobility of the mass: Mass is held between thumb
and fingers and moved in vertical and horizontal
directions. If there is restriction in movement, which
movement is restricted should be checked. T otally fixed
mass will not be mobile at all.
During inspiration (on deep breathing) mass moves
down to touch the hand of the examiner kept on the
lower margin of the mass. During expiration it moves
back to its original position (Figs 21.14 to 21.16).
Fig. 21.14: Checking the temperature of the abdomen
using dorsum of the hand.
Fig. 21.16: Lower abdominal mass—retroperitoneal
tumour/ovarian tumour/uterine mass.
taut. Raising both legs straight above the bed (Carnett’s
test) can also be used for the same. Air is tried to
be blow out by holding the nose tightly with fingers
and mouth shut—V alsalva manoeuvre. Abdominal wall
mass will become prominent and immobile during
these manoeuvre.
Fig. 21.15: Palpation of abdominal mass using fingers.
Head raising test or leg raising test (Carnett’ s test):
It is done to confirm whether mass is in the abdominal
wall or intra-abdominal. Mass is seen initially and
palpated and patient is asked to raise his head along
with shoulders with arms folded over the chest. If mass
disappears or becomes smaller, it is intra-abdominal
mass; if becomes more prominent it is in the abdominal
wall. Manoeuvre is done to make the abdominal muscle
Palpation of Liver
Liver is palpated by placing flat of the hand parallel
to the right costal margin—initially near right iliac
fossa with fingers directed upwards up to the margin
of the right rectus. Slowly with each phase of respiration
fingers should be moved upwards towards right
hypochondrium to feel the lower margin of the liver.
The surface of the liver is then felt for tenderness,
nodularity , round/sharp margin. Level of lower margin
should be measured in centimeters from right costal
margin. In children below 3 years, liver is palpable
3 cm below the right costal margin. Liver is not palpable
or just palpable in normal adult. Whenever there is
ascites liver is palpated by ‘dip method’ - (dipping
fingers quickly so as to displace the fluid). Liver may
be enlarged upwards in hydatid cyst, and liver abscess
(Figs 21.17A to C).
Normal liver span in adult is (vertical height) 1215 cm. Liver span in infant is 2.4-2.8 cm. At the age
of 14 years it is 5.5-7.5 cm.
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