Abdominal Examination Techniques

• The abdomen contains the stomach, duodenum, small and large bowel, liver, gallbladder, spleen, pancreas, kidneys, uterus, bladder, aorta, vena cava and, in women, the uterus, ovaries, and fallopian tubes
• Many vital organs are in the relatively small abdominal cavity
• Abdominal organs are susceptible to disease or malfunction
• Many abdominal organs are inaccessible to palpation because they are hidden behind the lower ribs or inside the bony pelvis
• Because the abdominal organs are so close together, the brain is often incapable of distinguishing the source of a pain
• Other symptoms and signs may help to distinguish the likely organ and the pathology responsible for the pain

Preparation

• The examination room must be warm and private so the patient can lie undressed and relaxed
• A cold couch in a draught or in view of other patients makes proper examination impossible
• Good light is essential, ideally daylight coming obliquely from the side of the patient to emphasize the shadows
• Artificial light obliterates the soft shadows that often give the first indication of asymmetry
• Many neon lights falsify colors, particularly the yellows and blues
• A hard, flat couch makes the patient lie absolutely flat and opens the gap between the pubis and the xiphisternum, but unfortunately stretches and tightens the abdominal muscles
• A soft bed lets the lumbar spine sink into a deep curve and closes the gap between the pubis and the ribs
• A good compromise in the office or outpatients is a hard couch with a backrest that can be raised by 15-20°
• The hard couch ensures that patients retain their lumbar lordosis, opening access to the abdomen and pushing the central contents anteriorly
• The elevation of the thoracic cage relaxes the anterior abdominal wall muscles
• The full extent of the abdomen must be visible and, ideally, patients should be uncovered from nipples to knees
• It is important to never forget to examine the genitalia and the hernial orifices
• It isn't possible to feel anything within the abdomen if the patient is tense
• Several ways in which relaxation can be encouraged, including asking the patient to:
• Rest their head on the couch or a pillow to avoid tensing the rectus abdominis muscles
• Place their arms by their sides, not behind their head
• Sink their back into the couch and breathe regularly and slowly
• Only press your hands into the abdomen during expiration as the abdominal muscles relax
• If these maneuvers do not work, ask the patient to flex their hips to 45° and their knees to 90° and place an extra pillow behind their head
• Although these maneuvers tilt up the pelvis and reduce access to the abdomen, they usually relax the abdominal muscles
• The examiner's hands should be clean and warm with short nails
• It is impossible to palpate deeply with long nails and it is an insult to the patient to have dirty hands
• The whole hand should rest on the abdomen by keeping the hand and forearm horizontal, in the same plane as the front of the abdomen
• To achieve this the examiner must sit or kneel beside the bed
• The patient shouldn't be examined from a standing position by leaning forwards and dorsi-flexing your wrist
• Sitting or kneeling beside the patient with your forearm level with the front of the abdomen puts your eyes about 50 cm above your hand, which is an ideal level for seeing any soft shadows caused by lumps and bumps

Examination

• Should follow the standard routine of inspection, palpation, percussion, and auscultation

Inspection

• Inspect the whole patient; look for any general abnormality indicative of intra-abdominal pathology such as cachexia, pallor, or jaundice
• Inspection of the abdomen from the end of the bed will reveal if there is any asymmetry or distension
• Note the position, shape, and size of any bulge, any changes in its shape, and whether it moves with respiration or increases with coughing
• Observe the reaction of the patient to coughing or moving
• Patients with peritonitis find movement extremely painful and, consequently, tend to lie very still, whilst patients with colic roll around with each bout of pain
• Record the presence of any scars, sinuses, or fistulae Dilated surface veins may indicate the possibility of portal hypertension or inferior vena caval occlusion

Palpation

• Palpate gently but deliberately, firmly and with purpose
• Rapid, jerky, or circular movements reminiscent of kneading dough are distressing for the patient and cause them to lose confidence
• Keeping your hands still and feeling the intra-abdominal structures moving beneath them gives more information than rapid and thoughtless palpation
• Finish (or begin) by feeling the areas that might otherwise be forgotten including:
• Feel the supraclavicular fossae and neck for lymph glands
• Feel the hernial orifices at rest and when the patient coughs
• Feel the femoral pulses
• Examine the external genitalia
• Look at the hands, nails, and facies
• Light Palpation: Gently rest the hands on the patients abdomen when palpating for tenderness
• Focus on one area at a time, moving around systematically
• Start in the left iliac fossa and move round in an anti-clockwise direction to finish in the right iliac fossa, if you are right handed
• Ask patients to indicate the source of pain before beginning the palpation, for example and start on a non-tender spot
• Assess the degree of tenderness while palpating for areas of discomfort
• Palpation over an area of mild tenderness just causes pain
• Guarding, the tightening of the patient's abdominal muscles in response to pressure, indicates severe tenderness
• The sudden withdrawal of manual pressure may cause a sharp exacerbation of the pain, which is known as rebound or release tenderness
• Sometimes, release of pressure on a distant non-tender part of the abdomen may cause pain in a tender area

General Palpation for Tenderness

• If no pain is elicited by systematic light palpation, repeat the process more firmly and deeply to see if there is deep tenderness
• The whole abdomen must be carefully palpated for the presence, position, shape, size, surface, edge, consistence, fluid thrill, resonance and pulsatility of any masses
• Tender masses in the abdomen are very difficult to feel because of the protective guarding of the abdominal wall muscles
• A good idea of the surface and size of a tender mass may be obtained by resting your hand gently on the tender area and pressing a little deeper during each exploration and feeling the mass as it moves beneath your hand
• Rapid, hard pressure achieves nothing under these circumstances because the patient just tightens their abdominal muscles

Palpation of the normal solid viscera

• Begin with the liver, to feel the edge place the right hand laterally and flat on the right side of the abdomen at the level of the umbilicus, parallel with the right costal margin
• Ask the patient to take a deep breath and if the liver is grossly enlarged, its lower edge will move downwards and bump against the radial side of the index finger
• If there is any abnormality, repeat the process until the costal margin is reached
• Spleen exam: Ask the patient to take a deep breath and if nothing abnormal is felt fingertips of your right hand on the right iliac fossa just below the umbilicus
• Kidneys palpitation: The kidneys tend to be impalpable, in the exception of very thin people, where both lumbar regions should be carefully examined

Percussion

• Percussion is used to assess the abdomen as a whole and to identify any dullness caused by the presence of masses
• Abdomen percussion may be executed with careful palpation
• Percussion is also useful for identifying specific areas of tenderness

Auscultation

• Normal bowel sounds are typically low-pitched gurgles that occur every few seconds
• The absence of sounds can be indicative of a ceased peristalsis

This text explains how external factors impact effective abdominal examinations. It covers factors like room temperature, lighting, and patient positioning, and the rationale behind specific examination techniques.