abdominal examination zhu liangru division of gastroenterology, union hospital
TRANSCRIPT
ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION
Zhu Liangru Division of Gastroenterology, Union Hospital
Range of Abdomen
Superior : diaphragma
Inferior : pelvis
Lateral : lateral abdominal wall
Anterior: anterior abdominal wall
Posterior: back bone,psoas
Abdominal Mark & Area
Abdominal Mark
Costal margin
Anterior superior iliac spine
Upper abdominal angleXiphoid process
umbilicus
Lateral border of rectus muscles
Inguinal ligament
Midabdominal
line
Abdominal Mark
• Costal margin composed of 8th-10th costal cartilage; abdominal area liver measure
• Xiphoid process elongation of breast bone; measurement of liver
• Epigastric angle included angle of costal arch; judge body type measurement of liver
• Umbilicus center in abdomen;abdominal area
• Anterior superior iliac spine the outstanding place of anterior of spine iliac
• Lateral border of rectus muscles elongation of midclavicular line;operative
incision
• Midabdominal line elongation of anterior of median line; abdominal area
• Inguinal ligament mark of femoral artery,femoral vein
• Costalspinal angle included angle of 12th costal bone and back bone
Abdominal Area
Abdom
inal Area:
Nine regions
right hypochondriac
region
left hypochondriac
regionepigastric region
umbilieal region
hypogastric region
right lumber region
left lumber
region
right iliac region
left iliac region
Nine regions &
P
rojectionspleen
stomach
gallbladdertransverse colon
ascending colon
small intestine
sigmoid colon
urinary bladder
ileum
Abdom
inal Area:
Four regions
right upper quadrant
right lower quadrant
left upper quadrant
Left lower quadrant
Abdom
inal A
rea:S
even regions
Right upper abdominal region
Left upper abdominal region
Right lower abdominal region
Left lower
abdominal region
Umbilieal region
Hypogastric region
Epigastric region
Secquence of Abdominal Examination
Examination secquence inspection, auscultation, palpation , percussion
Recording secquence
inspection, palpation, percussion, auscultation
Inspection
Attention of Inspection The patient is relaxed and in a proper position.
The patient is in a supine position, the head should be elevated on a pillow, abdomen is thoroughly exposed (from nipple to symphysis pubic).
Proper time to examination.
Light is adequate and soft, and comes from one side of head.
Inspector stands on the patient’s right side, secquence is from upper to lower.
examination in tangent direction.
Method of Inspection
Abdomial Shape
Normal : flat 、 full 、 low
umbilicus symphysis pubicxiphoid process
low
flat
full
Abdominal bulge whole abdominal bulge: ascites frog belly apical belly
pneumatosis macrosis mass part abdominal bulge: organ intumesce (liver intumesce)
tumor (stomach.liver,pancrease)
inflammatory mass (tuberculous peritonitis) distension (stomach distension)
mass in abdominal wall hernia ( umbilical hernia, indirect hernia)
Inspection in Ascites
Differential Diagnosis in mass in abdominal wall and mass in abdominal cavity
Abdominal Retraction
whole abdominal retraction
athrepsy
dehydration
cachexia (boat-belly)
part abdominal retraction :
postoperative scar
Boat shaped-abdomen
Respiratory Movement
Abdominal breathing: adult male, children Costal breathing: adult female attenuated in abdominal breathing : acute abdomen, ascites, macrosis mass, pregnancy reinforcement in abdominal breathing : diseases in thoracic cavity(hydrothorax), hysteria
Abdominal Vein
• Generally we can’t find distended abdominal vein in normal people.
• Prominence of distended veins indicates increased collateral circulation as a result of obstruction in the portal venous system or in the vena cava
• The normal direction of blood flow is away from umbilicus. The upper abdominal veins carry blood upward to the superior vena cava, the lower abdominal veins carry blood downtoward to the inferior vena cava.
Portal hypertension Inferior vena cava obstruction
Method to Judgement the Direction of Blood Flow
Gastrointestinal pattern & Peristalsis
Generally we couldn’t find gastrointestinal pattern
and peristalsis in normal people.
Gastrointestinal obstruction : gastral pattern intestinal pattern peristalsis
Small bowel obstruction colon obstruction
Others Information
skin rash: infection diseases, drug allergy, herpes zona
pigments: Addison disease, Grey-Turner sign, Cullen sign
ventral stripe: striae albicantes, purple striae
(hypercortisolism)
scar: operation, trauma, infection
hernia: umbilical hernia, oblique inguinal hernia, direct hernia
umbilicus: evection, depression, secrection
hairs: disposition, increase, decrease
pulsation: abdominal aneurysm, increasing in right ventricle
of heart
Palpation
Method of Palpation
The patient is relaxed position
The patient is in a supine position, the head should be elevated on a pillow, genuflex, slowly abdominal respiration
Inspector stands right beside patient
Start from left iliac region, anti-clock wise, “S” shape
Commence palpation at a site remote from the area of pain All areas of abdomen must be palpated systematically
Abdominal Palpation
• Light palpation
• Deep palpation
Tensity
Increase of tensity Intestinal distension, ascites, artificial pneumoperitoneum
rigidity ( board-like rigidity ) acute diffuse peritonitis
dough kneading sensation tuberculous peritonitis, carcinomatous peritonitis
Decrease of tensity Chronic wasting disease, multipara, aged, dehydration
Tenderness & Rebound tenderness
tenderness rebound tenderness
1. Gastritis or gastric ulcer2. Duodenal ulcer3. Pancreatitis or tumor4. Cholecystitis cholelithiaisis5. appendicitis6. Disease of intestine7. Disease of urinary bladder,uterus8. Ileocecal junction9. sigmoid10.spleen,splenic flexure of colon11.liver,hepatic flexure of colon12.pancreatitis
ant. Sup. spine
McBurney point
Palpation of Organs
One hand palpation Bimanual palpation Hooking technique
Ballottement palpation
Knee-elbow Position Palpation
Attention in palpation of liver
• Anterior-lateral finger pulp to palpate organs
• Place your hand flat with fingers pointing towards the
patients’s head
• position of palpation at exterior margin of rectus
abdominis
• palpate deeply while asking the patient breathe in and
out deeply
• start in the right iliac fossa when examining macrosis
liver
应与肝脏鉴别的脏器: 横结肠为横行条索状物,与肝脏质地不同 腹直肌腱划左右两侧对称,不随呼吸移动 右肾下极位置较深,边缘圆顿,不能掀起下缘
Differential Diagnosis
• Transverse colon
• rectus abdominis tendon
• Lower lobe of right renal
Technique of Liver Palpation
lung
liver
Projection of Liver
Perpendicula
distance 4-8cm
Perpendicula
distance 9-11cm
Measurement
Description of liver
Size : below right costal margin 1cm,
below xiphoid porcess 3cm
Texture : three grade---soft,moderate, hard
Surface : slick, nodus
Edge : thickness, regularity
Tenderness : no tenderness in normal liver
hepatojugular reflux
Pulsation : conduct pulsation, expansile pulsation
Scrape : inflammatory surrounding liver
Liver thrill : ballottement ---hepatic echinococcosis
Manipulation of palpation of spleen
Line I : distance from the across point of left medioclavicular line and costal border to inferior margin of spleenLine II: distance from the across point of left medioclavicular line and costal border to ultima thule of spleenLine III: distance from right border of spleen to anterior median line
Measurement of spleen
Enlarged spleen
mild
acute hepatitis, typhoid,acute malaria, septicemia
moderate
cirrhosis, chronic lymphocytic leukemia,
chronic hemolytic jaundice, lymphoma
severe
chronic granulocytic leukemia, myelofibrosis
Description of liver
Description of spleen
Size
Texture
Surface
Edge
Tenderness
Pulsation
Scrape
Palpation of gallbladder
manipulation one hand slipping palpation or hook Murphy sign Courvoisier sign
Palpation of Kidney
(A) Place left hand in the right or left loin posteriorly. (B) Place the right hand on the abdomen anteriorly and press gently dowmwards. Push the left hand upwards. A palpable kidney can be balloted between the two hands.
The kidney may be palpable in thin normal individuals.
The right kidney lies lowerlower than the left, so it is more
likely to be palpable.
Nephroptosis
enlarged kidney is found in nephrydrosis, nephrydrosis, empyema, tumoempyema, tumo
r of kidney, polycystic renal diseaser of kidney, polycystic renal disease
Tenderness Point of nephric duct and Kidney
hypochondrium
middle nephric duct point
Costa-carinal point
肋腰点Upper nephric d
uct point
ventral aspect Back side
Costa-lumbar
point
Mass in Abdomen
“Mass” in normal abdomen
rectus muscle belly & tendinea
body of lumbar vertebra
cochlear of sacral bone
stoolmass in sigmoid colon
transverse colon
caecum
Abnormal Mass
• Location • Size length,broad,deep• Shape skeleton,edge,surface• Texture • Tenderness• Pulsation• Degree of excursion
Fluid thrill (Fluctuation)
Manipulation of fluid thrill
assistant
patient
inspector fluctuation
Assistant places his hand vertically at the anterior median line,Examiner places hand flat at both side of lateral abdominal wall, One hand percuss one side abdominal wall, fluctuation can be sensed in another hand
Succussion Splash
Succussion splash can exist in people after meal or drinking
Succussion splash exists in fast or 6-8 hours after meals suggest
s pyloric obstructionpyloric obstruction or gastric dilatationgastric dilatation
Percussion
Percussion is used to demonstrate the presence of gaseous distension and fluid or solid masses.
Light percession is preferable, since it produced a clearer tone.
Abdomen Percussion Sound
All four quadrant of abdomen are evaluated by percussion
Tympany is the most commom percussion note in abdomen presence of gas within the stomach,small bowel,colon.
Dullness exists in liver (right hypochondrium region)
spleen (left hypochondrium region)
distended urinary bladder (suprapubic area)
enlarged uterus (suprapubic area)
psoas (back side)
IncreasingIncreasing inin Dullness regionDullness region
organ swell
tumor
ascites
IncreasingIncreasing in tympanyin tympany
gaseous distension
perforation
Percussion of Liver
upper border of liverupper border of liver right midclavicular line right anterior axillary line right scapular line relative dullness area resonance dullness
absolute dullness area dullness flatness
lower border of liverlower border of liver
right midclavicular line
Anterior median line
tympany dullness
Normal Liver Border
upper border
right midclavicular line the fifth interspace
right axillary line the senenth interspace
right scapular line the tenth interspace lower border right midclavicular line right costal margin
Measurement
SizeSize
right midclavicular line 9-11cm
anterior median line 4 - 8cm
Change of Liver Border Increasing in liver dullness area liver carcinoma, liver abscess, hepatitis, polycystic
Decreasing in liver dullness area acute hepatic necrosis, cirrhosis, gaseous distension
Absence of liver dullness area acute perforation of hollow viscus
Percussion Tenderness of Liver and Gallbladder
Traube Area
9.5cm×6.0cmTraube area
Percussion of Spleen
route left midaxillary line
normal spleen border left midaxillary line the ninth-eleventh interspace longitude 4 - 7cm
Change of spleen border increasing enlarged spleen decreasing gastric dialation, distension
Shifting Dullness
The quantity of ascites is more than 1000ml
Percussion of ascites
dullnesstympany
Shifting Dullness
tympany
tympany
dullness
dullness
supine
lateral position
Manipulation
supine lateral position
Place left hand on the umbilicus region, right hand percuss. note central tympany. Move left hand to one side of abdominal wall , then rotate patient onto another side. Notice that dullness has shifted toward the umbilicus on the dependent side. Tympany area has shifted toward the superior flank.
Differential diagnosis between Ovarian cyst and ascites
ovarian cystascites
Differential diagnosis between Ovarian cyst and ascites
tympanytympany
dullness dullness
ascitesovarian cyst
Ruler Pressing test
Sensitive to percussion in Ridge costal angle
Projection of ridge costal angle
right kidney
ridge costal angle
Sensitive to percussion in ridge costal angle
Bladder Percussion
Location : suprapubic area
Empty bladder tympany
Filling with urinary dullness
Auscultation
Area of Abdominal Auscultation
liver
pancrease
spleen
gurgling sound
abdominal aorta
arteria renalis
Bowel Sound
Auscultation of bowel sounds can provide information about the motion of air and liquid in the gastrointestinal tract.
Normal 4-5/min
Active >10/min Hyperactive mechanic intestine obstruction
Hypoactive Absent paralytic intestine obstruction
Vascular Murmur
Arterial murmur
center of abdomen: abdominal aneurysm
abdominal aorta stenosis
left or right upper quadrant : renal arterial stenosis
bilateral of inferior belly : arteria iliaca stenosis
left lobe of liver : left lobe carcinoma
Venous murmur
portal hypertension : umbilicus or epigastrium
continious buzz
Friction Sound
Splenic infarction
Perisplenitis
Zuckergussleber
Cholecystitis
Peritonitis
Scratch Sound
Identify lower edge of liver
Small amounts of ascites : puddle sign
Thank you!