Abdominal exam: Signs and their significance

By Rutendo Ganyani and Sarah Folkerts

Demonstration for OSCE purposes…….

Can you name these?

Spider naeviClubbing

Splinter haemorrhage

Caput medusa

KoilonychiaPalmar erythema

Leukonychia

Abdo Exam

• General Exam• Inspection• Palpation– Superficial – Deep– For specific organs

• Percussion – Specific organs

• Oedema

….some signs to look out for!Hands:• Clubbing (Cirrhosis, coeliac, IBD etc)• Palmar erythema (oestrogen excess)• Leuconychia (Hypoalbuminaemia)• Koilonychia (Iron deficient anaemia)• Liver flap (hepatic encephalopathy)

Arms:• AV fistulae Face:• Jaundice• Pallor• Xanthelasma• Corneal arcus

Mouth:• Ulcers• Hydration status• Glossitis• Angular stomatitis

Neck:• Goitre• Virchow’s node

Chest:• Spider naevi• gynaecomastia

Inspection:• Distension (bend down to eye level)• Surgical scars• Dilated veins• Visible peristalsis• Bruising

Abdo exam continued……Palpation:• Normal abdominal organs are impalpable• Technique shown tonight – flat of hand, rolling• WATCH PATIENT’S FACE• Palpate x2 – light (for tenderness and guarding),

then deep (organs and masses)

Palpation for liver and spleen:• Start – R iliac fossa• Hand flat on abdo, fingers parallel to costal

margin• From R iliac fossa diagonally across to left upper

quadrant for spleen

Kidneys:• Ballot bimanually

Percussion:• Masses and organomegaly • Liver• Can do bladder

Auscultation:• 4 quadrants – up to 30 seconds in each for

bowel sounds• Renal artery bruits – 2.5cm above and

lateral to umbilicus

Extra tests:• PR (DRE)• Hernial orifices • External genitalia

The 6 F’s of abdo distenstion

6Fs• Fat• Fluids• Flatus• Faeces• Fetus• Flipping big mass (incl. polycystic kidneys)

Contents of the 4 abdominal quadrants?

Surface anatomy

1. What is the surface anatomy of the liver?

2. At what level does the aorta bifurcate?

3. What is the surface anatomy of McBurney’s point?

DDx for LIF mass

• Renal transplant• Loaded colon• Diverticular mass• Colorectal carcinoma• Ovarian• Hernia

DDx for RIF mass

• Renal transplant• Appendix mass• Crohn’s disease (inflamed, matted small

intestine• Caecal carcinoma• Hernia• Ovarian

Causes of Hepatomegaly

2 Is, 2 Bs & 2 Cs• I- Infection (hepatitis, EBV, Malaria, hepatic abscess)• I - Infiltration (e.g.Sarcoid, Fatty liver,

Haemochromatosis)• B- Blood-related (e.g.Lymphoma, Leukaemia, Haemolytic

anaemias)• B- Biliary (PBC, PSC)• C- Cancer (Primary HCC, Metastases)• C- Congestion (RHF, Tricuspid regurgitation)

What are the causes of ascites in chronic liver disease?

• Hypoalbuminaemia• Portal hypertension• Salt & water retention due to secondary RAAS

activation

How to distinguish the kidney and the spleen on examination?

• Can’t get above spleen but kidney• Kidneys are resonant on percussion• Kidney is balottable• Spleen moves more on respiration

What are the extra-intestinal manifestations of IBD?

• Finger clubbing• Mouth ulcers (esp. Crohn’s)• Eyes:

• Episcleritis• Conjunctivitis

• Skin:• Erythema nodosum• Pyoderma gangrenosum

• Joints: Seronegative spondyloarthropathy• Primary Sclerosing Cholangitis (esp. UC)• Amyloidosis