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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2853_Библиотеки_им_академика_М_И_Перельмана
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396 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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FIG. 9-3 Anatomy of the Anal Canal: Interior and Cross-Section. The anal columns (columns of Morgagni)
descen d vertically f rom the rectum and end in anal papillae that fuse to form t he pectinate or denta te line; behind ar e the anal
valves (crypts of Morgagni). The cut walls show the internal anal sphincter surrounded by the external sphincter that extends
distally. The junction between the edges of the two sphincters forms the intersphincteric line. Internal hemorrhoids arise proximal to the pectinate line, external hemorrhoids distally. Two anal fissures are shown, one distal to a resulting hypertrophied
papilla. A fistula (black and irregular) drains from an abscess in a rectal crypt (or valve) to the skin near the anus.
radiologist, and validating your picture by observing surgical procedures and
postmortem dissections.
The Anus: Figure 9-3 depicts the anal canal. It is 2.5–4 cm long surrounded by
two concentric layers of striated muscle: the involuntary internal sphincter
and the voluntary external sphincter surrounding the internal sphincter. A
band of the external sphincter extends beyond the distal end of the internal
sphincter.
The Rectum: The rectum extends from rectosigmoid junction to the anal
canal, ~12 cm. The distal end dilates to form the rectal ampulla. The rectum
contains semilunar transverse folds, the valves of Houston; they are inconstant in number and position. The upper two-thirds of the rectum is covered
by peritoneum. In men, the anterior peritoneal reection extends to within
7.5 cm of the anal orice as the rectovesical pouch; it is potentially accessible
to the examining nger. In women, the rectouterine pouch extends downward anteriorly to within 5.5 cm of the anal orice.
The Sigmoid and Descending Colon: The descending colon begins at the
splenic exure, descends retroperitoneally into left iliac fossa becoming the
sigmoid colon at the iliac exure. The sigmoid colon, suspended on its mesentery, extends from the iliac exure to the rectum. The sigmoid forms a crude S
by running transversely from the left ileum toward the right pelvis, doubling
on itself passing leftward toward the midline and then downward becoming
the rectum at about the third sacral vertebra.
PHYSICAL EXAM OF THE ABDOMEN
Examine the abdomen from the right side sequentially by inspection, auscultation, percussion, and palpation. Ensure a warm room, proper draping,
and a pillow under the head. A pillow under the knees improves comfort
while relaxing the abdominal muscles. Drape the legs and pelvis to the pubes
Physical Exam of the Abdomen 397
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FIG. 9-4 Draping for Abdominal Examination. The pat ient lies sup ine on the examin ing table wit h a sheet or blan ket
covering the lower extremities up to the pubes. For women, the breasts are covered with a folded towel or gown. A small
pillow support s the head. To further rela x the abdomina l muscles, a pillow can be place d to support the knees in slight flexion.
FIG. 9-5 Abdominal Inspection. The patient is supine with a single source of light shining across from feet to head,
or across the abdomen toward the examiner. The examiner should sit in a chair at the right of the patient with her head only
slightly higher than the abdomen so the physician can concentrate on the abdomen for several minutes, if needed.
(Fig. 9-4) with a gown covering a woman’s breasts. If the patient presents
with abdominal pain, initially avoid direct contact with the abdomen. Have
the patient point to the painful area, and then, alternately, suck the abdomen
in and push the stomach out while indicating areas of discomfort. Finally,
have the patient cough. Pain with these maneuvers implies peritoneal
inammation.
Inspection: Do not rush inspection (Fig. 9-5). Low angle light from the side or
the foot accentuates contours. Inspect for contour, distention, scars, engorged
veins, visible peristalsis, and masses. Inspecting from the foot of the table
reveals abdominal and thoracic asymmetry. Experience is necessary to learn
normal abdominal contours and identify abnormal contours and distention.
Auscultation
Peristaltic sounds. Auscultate the abdomen before palpation. Learn to distinguish normal from the abnormal sounds associated with distinct types of
abdominal pathology by auscultating during every abdominal examination.
Listen with the bell in all four quadrants and the midline, listening for at least
5 minutes before concluding that bowel sounds are absent. Occasional weak
sounds are not evidence of good peristalsis. High-pitched tinkles and rushes
may denote partial obstruction.
398 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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FIG. 9-6 Fist Percussion Over the Liver. The palm of the left hand is applied anteriorly to the lower ribs of the right
hemithorax. The back of the applied hand is struck lightly with the fist of the right hand.
Abdominal murmurs. A murmur indicates turbulent blood ow in a dilated,
constricted, or tortuous artery.
Percussion: During percussion (Chapter 3, page 30) expect dullness over the
liver and tympany in the left upper quadrant (LUQ) and lower chest over
the stomach. Otherwise, the abdomen usually gives a at percussion note. An
increased area of tympany is associated with gas in the abdomen or bowel.
Routinely percuss in the LUQ over the lower ribs (Traube’s space); dullness sug-
gests an enlarged spleen. Dullness obliterating the gastric air bubble tympany
can be caused by uid in the stomach, feces in the colon, or an enlarged spleen.
Bladder distention produces suprapubic dullness. Pain with percussion, especially pain remote to the site of percussion, suggests peritoneal inammation
(rebound). Gentle st percussion performed with the heel of the hand on the
ribs overlying the liver, spleen, and kidneys (Fig. 9-6) identies pain caused by
stretching or inammation of the capsules surrounding these organs.
Percussion and palpation for costovertebral angle (CVA) tenderness. Press
with one nger or thumb into the CVA between the spine and the twelfth rib
(Fig. 9-2). Fist percussion at the same point can reveal deep tenderness.
Palpation: The anterior abdominal wall muscles resist palpation propor-
tionally to their strength and tone. Minimize resistance by being gentle and
explaining each step of the exam. If this is not effective, press rmly on the
lower sternum with the left hand while palpating with the right. Inspiration
attempted against this pressure relaxes the abdominal muscles. Examine
symptomatic areas last, watching the patient’s face for evidence of discomfort. Although usually performed supine, palpation while on either side
or in the knee–elbow position can reveal masses not otherwise discernible.
Standing is necessary to identify some hernias.
Light palpation. Start with light abdominal palpation searching for edges,
tenderness, increased resistance, and masses. Some masses cannot be felt
when pushing harder. With the palm and approximated ngers press gently
to a depth of ~1 cm (Fig. 9-7A). Sweep gently over the surface beginning at
Physical Exam of the Abdomen 399
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the pubes and working up to the costal margins. A huge liver or spleen can be
missed if the lower edge isn’t located. Ticklishness tenses muscles impairing
the exam. Patients are not ticklish to their own touch. Use this to advantage
by putting the patient’s ngers on yours as you examine (Fig. 9-7C). Use pressure on the stethoscope when auscultating to elicit tenderness. Tenderness to
palpation but not the stethoscope pressure could suggest malingering.
Deep palpation. With the palm just touching the skin press the approximated ngers ever more deeply, feeling with the ngertip pads, while slowly
FIG. 9-7 Abdominal Palpation. A. Light palpation. Take care to avoid digging into the wall with the tips of the
fingers. B. Deep palpation. C. Palpation of the ticklish abdomen. D. Rebound tenderness. T he hand is slowl y
pushed deep into the abdomen remote from the suspected tenderness, and then abruptly withdrawn. Pain in the affected
region results from rebound of the tissue, usually a sign of peritoneal irritation. E. Exploration during palpation. When
palpating the abdomen, especially deeply, the fingers remain relatively fixed to a place on the skin and the wall of the abdomen is carried with the fingers in a slow gentle to-and-fro motion to distinguish underlying masses and surfaces. The fingers
do not glide over the skin but carry the skin with them.
400 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
hand
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moving them laterally and longitudinally 4 or 5 cm gliding the abdominal
wall over the underlying structures (Fig. 9-7E). Examination can be single
handed, but when resistance is strong use reinforced palpation, the ngers of
one hand pressing on the distal phalangeal joints of the other, so the relaxed
ngers can appreciate the tactile sensations (Fig. 9-7B). Measure small masses
by grasping them between the thumb, middle, and index ngers. Bimanual
palpation is used for large masses. When ascites is present, ballottement is useful. Where a mass is suspected thrust rapidly and sequentially more deeply
into the abdomen; a tap on the ngertips indicates a mass (Fig. 9-8).
Characterizing a mass. Nearly all masses arise from previously normal tissues. Masses need to be identied by the anatomic structure involved and
the pathologic process. Useful diagnostic inferences can be drawn from a
complete description.
e.g., a LUQ mass might be spleen, left kidney, stomach, or colon. Size: This
gives insight into the pathologic process, its extent and evolution over time.
Shape: Some organs have a characteristic shape, e.g., kidney, spleen, and
liver. Consistency: The pathologic process may be inferred from the resistance of the mass to pressure: carcinomas are stony hard, lymphomas rubbery, and cysts soft and uctuant.
homogeneous process, whereas a nodular surface suggests metastases, granulomas, or irregular brosis. Tenderness: Inammation (infectious or sterile),
distention of a solid or hollow organ, and ischemia are associated with pain.
Mobility: Organs suspended on long mesenteries are mobile. Movement
Location: The location suggests the possible organs,
Surface: A smooth surface implies a diffuse
A-1. A-2. A-3.
Receiving
B-1.
hand
Pushing
FIG. 9-8 Ballottement of Abdominal Masses. The term ballottement is applied to two somewhat different maneuvers.
A. One hand ballottement. The approximated fingers abruptly plunge into the abdomen and are held there; a freely movable
mass rebounds upward and is felt with the fingers. This is most commonly employed to feel a large liver obscured by free fluid in
the abdominal cavity. B. Bimanual ballottement. B1–2: determining the size of a large mass in the abdomen.
One hand (P) pushes the posterior abdominal wall, whereas the receiving hand (R) palpates the anterior abdomen. B3: The
receiving hand is now in the flank. The pushing hand compresses the mas s to get an estimate of its thicknes s.
BR.-2.
B3.
P.
P.
R.
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FIG. 9-9 Anatomic Relations of the Normal and Enlarged Spleen. A. Position of the normal spleen,
anterior view. The area of splenic dullness is in the left posterior axilla and usually <8–9 cm. B. Normal spleen, left
lateral view. The spleen lies obliquely with its long axis along the tenth rib, its long borders coinciding with the ninth and
eleventh ribs. C. Anterior surface of the spleen. The regions touching other viscera are indicated. D. Enlarging
spleen. The directions in which the spleen enlarges are indicated by the dotted lines; the long axis of enlargement points
downward and obliquely toward the symphysis pubis.
with respiration excludes a retroperitoneal location. Pulsation: This implies
a location associated with a major artery. Aortic or major branch aneurysms
must be assumed until excluded by imaging. Solid masses and tense cysts can
simulate aneurysms by transmitting aortic pulsations.
LUQ palpation. Normal LUQ organs, including the spleen, are not palpable.
The spleen is supercial while the left kidney is deep and closer to the midline. The spleen lies posterior-lateral under the left diaphragm, the lung separating it from the chest wall during deep inspiration. Its long axis parallels the
tenth rib in the mid-axillary line (Fig. 9-9). The oblique orientation means that
the vertical extent of mid-axillary splenic dullness describes its width. Feel for
a moderately enlarged spleen or left kidney by standing on the patient’s right
side and using bimanual palpation. Lay the right hand on the abdominal wall
in the LUQ with the ngertips 4–5 cm below the rib margin at the anterior
axillary line. Place the left hand on the left mid-axillary chest wall at the eleventh and twelfth ribs with the ngers curling posteriorly. With the left hand
lifting gently from the back the right hand palpates under the costal margin
during deep inspiration (Fig. 9-10). The descending tip of an enlarged spleen
touches the palpating ngertips. Repeat the procedure with the patient lying
partially on his right side. In the Middleton method, the patient lies with his left
st beneath the left chest (Fig. 9-11). Standing on the patient’s left side facing
402 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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FIG. 9-10 Bimanual Palpation of the LUQ.
FIG. 9-11 Palpation of the Spleen, Middleton Method.
his feet, curl your ngers under the ribs feeling for the spleen tip during deep
inspiration. Greatly enlarged spleens may be felt without bimanual palpation. Tympany over Traube’s space, however, makes splenomegaly unlikely
and obviates the need for extensive palpation maneuvers.
RUQ palpation. The RUQ contains the liver, gallbladder, hepatic exure of the
colon, and right kidney. Bimanual palpation is used for palpating the liver. The
right hand is placed on the abdominal wall below the costal margin. The left
hand is placed under the lower right chest lifting as the patient inspires deeply
the right hand moving up and in (Fig. 9-12). As full inspiration is approached
lift the ngertips toward the costal margin to catch the liver edge from below.
Again, light ngertip pressure improves detection of the liver edge. To avoid
missing an enlarged liver start well below the costa margin and move cephalad. An enlarged right kidney is felt as a xed mass deep to the liver.
Palpation of the lower quadrants. RLQ and LLQ palpation are straightforward as there are normally no palpable organs, except for stool in the colon.
The spine and sacral prominence are easily palpable in thin individuals and
must not be confused with masses. Psoas and obturator signs should be performed in patients with abdominal pain (Fig. 9-13). With the patient at or
on their side, fully ex and extend both hips. Pain suggests inammation of
the psoas muscle or the overlying peritoneum. The obturator sign is elicited
with the patient supine, and the hip and knee exed to 90 degrees. Move the
Physical Exam of the Abdomen 403
A. Iliopsoas test B. Obturator test
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FIG. 9-12 Bimanual Palpation of the RUQ.
FIG. 9-13 Testing for Irritated Iliopsoas and Obturator Muscles. Abscesses in the pelvis may be localized
by demonstrating irritation of the more lateral iliopsoas or the medial obturator internus muscles. A. Iliopsoas test. The
supine patient keeps his knee extended and is asked to flex the thigh against the resistance of the examiner’s hand. Pain in
the pelvis indicates irritation of the iliopsoas. B. Obturator test. The supine patient flexes the thigh to 90 degrees. The
examiner moves the hip in internal and external rotation. Pelvic pain indicates an inflamed muscle.
hip fully through internal and external rotation; deep pelvic pain suggests
inammation of the obturator muscle or pelvic peritoneum.
Examining the abdomen and pelvis per rectum and vagina. (See the rectal
examination below, the female pelvic examination in Chapter 11, page 486, and
the male rectal examination in Chapter 12, page 511) A chaperone must be present during these examinations. Palpation via the rectum and vagina detects
intrinsic disease of the rectum and vagina, allows examination of other structures
of the male and female genitourinary tracts and the lower peritoneal cavity in
the pelvis (Figs. 9-14 and 9-15). Errors in the diagnosis of abdominal conditions are
notoriously common when these examinations have been omitted. Post-void vaginal
exam is part of the abdominal exam of symptomatic women, even when speculum examination cannot be performed. Vaginal and rectal exams in the lithotomy
position are preferred because masses will tend to fall on the examining nger.
Wear lubricated gloves and use the index nger for rectal examination and the
index and long ngers for the vaginal exam. Palpate the vagina rst, then the rectum. For bimanual palpation bring the ngers of one hand pressing into the suprapubic abdominal wall toward the examining nger(s) in the rectum or vagina.
When the exam is complete, provide tissues for the patient to clean themselves.
Examining for abdominal hernias. (See page 460.) Hernias are protrusions
of abdominal contents through a weak point in the abdominal wall. Most
404 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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FIG. 9-14 Palpation of the Male Abdomen per Rectum. The examining hand is supinated. Anteriorly, the finger
pad feels the prostate gland and seminal vesicles. Superiorly on the anterior rectal surface, the fingertip reaches the location
of the rectovesical pouch of the peritoneum. Normally, this pouch is not palpable; in the presence of pus or a tender mass it
may be perceived. Cancer cells may settle in this pouch from the abdominal cavity, producing a hard, nontender, transverse
ridge, called a rectal shelf or Blumer shelf.
FIG. 9-15 Palpation of the Female Abdomen per Rectum. The finger pad feels the cervix uteri and the fundus uteri
through the anterior rectal wall. Passing the finger inward, superior to the cervix, the fingertip reaches the location of the rectouterine pouc h (Douglas po uch). Normally, this i s not palpabl e; a tender mass i s evidence of pu s. See legend o f Fig. 9-14 for Blumer shelf.
hernias have a peritoneal sac which may contain bowel, stomach, omentum,
urinary bladder, colon, or even liver. Start with inspection. If the patient suspects a problem, have him demonstrate his observation. Many hernias are
encountered unexpectedly, a bulge being seen at rest or appearing during
maneuvers that increase intraabdominal pressure, e.g., cough or Valsalva.
Palpate the abdominal wall defect and its contents. Omentum feels soft and
nodular, whereas bowel is smooth and uctuant. Gas in herniated bowel may
cause peristaltic sounds or crepitation. If the hernia can be pushed back into
the abdomen, it is reducible; if not, it is irreducible or incarcerated.
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A. B.
C. D.
FIG. 9-16 Positions of the Patient for Rectal Examination. A. Modified lithotomy position. B. Left
lateral prone position (Sims position). C. The knee–chest position. D. Bent over the table.
Zieman inguinal examination. See page 461.
Examining the Perineum, Anus, Rectum, and Distal Colon: The patient is
examined in one of several positions (Fig. 9-16). The left lateral prone (Sims)
and bent-over-table positions permit inspection of the perineum, palpation of the anal canal and rectum, and inspection of the anal canal and rectum with an anoscope. Raising the buttocks raised on a pillow facilitates
exam in the lithotomy position. The anal canal cannot be examined in this
position. The knee–chest and knee–elbow positions are uncomfortable for the
patient and are reserved for special conditions such as evacuating colonic gas.
Inspecting the perineum. Whatever position is selected for the patient, the
buttocks should be spread wide apart. Inspect the skin of the perineum and
perianal region for signs of inammation, sinuses, stulas, excoriations, hemorrhoids, masses, and cutaneous lesions.
Examining the Anus.
Anal palpation. Ask the patient to breathe normally and explain the procedure as you go along. After gloving both hands, gently palpate for warmth,
tenderness, and consistency around the orices for sinuses and stulas feeling
for subcutaneous cords indicating tracks. Palpate between the anus and the ischial tuberosities, the site of ischiorectal abscesses. Inspect the mucocutaneous
junction by everting the anal mucosa. Next, place the lubricated nger pad on
the anal sphincter applying gentle pressure inward and somewhat anteriorly
slants anteriorly, so the axis of entry is toward the umbilicus. Slowly advance
while estimating sphincter tone, palpating the walls, and estimating the length
of the anal canal. The exam is not painful unless a ssure in ano or thrombosed
hemorrhoid is present. Palpation between the index nger in the canal and the
thumb on the perineum can identify a soft tissue abscess or mass. Without ex-
plicit indication do not perform a rectal exam on a neutropenic patient.
Anoscopy. When anal pathology is suspected, view the anal canal using an
anoscope. A good light must be available. The patient is placed in position
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