Understanding Abdominal Pain

Abdominal Pain

• Different patterns and mechanisms exist for abdominal pain.
• It is crucial to know which is more severe, as well as localized or diffuse.
• Visceral pain is non-specific and diffuse.
• Parietal or somatic pain is localized and more severe than visceral pain.
• Referred pain is felt at more distant sites innervated at approximately the same spinal levels as the disordered structures.
• Hollow abdominal organs elicit visceral pain when contracted forcefully, distended, or stretched.
• Solid organs such as the liver can become painful when their capsules stretch.
• Ischemia can stimulate visceral pain fibers.
• Visceral pain varies in quality, described as gnawing, cramping, or aching.
• As visceral pain progresses, systemic symptoms, like sweating, pallor, nausea, vomiting, and restlessness, may follow.
• Liver distention against its capsule, from hepatitis (alcoholic or biliary pathology) can cause visceral pain in the RUQ.
• Visceral periumbilical pain suggests early acute appendicitis from a distended inflamed appendix.
• Intestinal mesenteric ischemia must be suspected when pain lacks a correlation with the physical findings.
• Inflammation of the parietal peritoneum, called peritonitis, causes somatic or parietal pain
• Somatic pain is steady, aching, more severe than visceral pain and more precisely localized to the structure involved.
• Movement or coughing typically aggravates it.
• Patients usually prefer to lie still.
• Pain felt in more distant sites corresponds to referred pain, at approximately the same spinal levels.
• If intense, referred pain can seem to radiate from the initial site.
• Palpation at the site of referred pain often does not result in tenderness.
• Pain of duodenal or pancreatic origin may be referred to the back
• Pain from the biliary tree, to the right scapular or shoulder region or the right posterior thorax.
• Pleurisy or inferior wall myocardial infarction may be referred to the epigastric area.
• The chest, spine, or pelvis can cause pain referred to the abdomen.

Abdominal Examination

• Begin with an inspection of the abdomen.
• Auscultation occurs before performing percussion or palpation
• Palpation comes last
• Correct sequence is Inspection -> Auscultation -> Percussion -> Palpation
• Key is to carefully observe the general appearance of the patient.
• Watch for bulges or peristalsis.
• A patient who is pale, confused, or writhing in discomfort likely has higher acuity.
• Skin abnormalities, such as bruises, erythema, or jaundice, are important.
• Old silver striae or stretch marks are considered normal findings.
• Pink-purple striae are a hallmark of Cushing syndrome.
• Dilated veins suggest portal hypertension from cirrhosis or inferior vena cava obstruction.
• Observe the umbilicus for contour, location, inflammation, or bulges suggesting a hernia.
• Contour of the abdomen should be assessed
• It is it flat, rounded, protuberant (see Table 19-9), or scaphoid (markedly concave or hollowed).
• Check for visible organs or masses, and for enlarged liver or spleen possibly descending below the rib cage. Inspect for lower abdominal masses or hernias.
• Observe also for bulging flanks indicating ascites.
• The bulging flanks of ascites, the suprapubic bulge of a distended bladder, pregnant uterus, and ventral, femoral, or inguinal hernias are observed.
• Note normal aortic pulsations, but check for an increased pulsation - may denote Abdominal Aortic Aneurysm
• Listen before percussion/palpation because these maneuvers can alter bowel sounds
• Use the diaphragm of the stethoscope, gently on the abdomen, for up to 5 minutes.
• Bowel sounds consist of clicks and gurgles, occurring at a frequency of 5 to 34 per minute.
• Normoactive bowel sounds must be within the designated range
• <5 per minute are considered hypoactive

• 34 per minute are considered hyperactive

• “Stomach growling” is hyperperistalsis called borborygmi
• Listening in the RLQ is usually sufficient due to wide transmission of bowel sounds.
• Auscultation might be of limited use due to nonspecific and nondiagnostic changes.
• Auscultation of a pulsatile mass may identify turbulent flow, characterized by abnormal sounds like vascular bruits/friction rubs, within the aorta.
• Vascular bruits can be normally presents in 4-20% of healthy individuals
• Percussion of the abdomen assesses gas, viscera, masses that are solid or fluid-filled, as well as liver and spleen size.
• Lightly percuss all four quadrants; tympany should predominate due to gas within the GI tract.
• A protuberant abdomen that is tympanitic overall suggests intestinal obstruction or paralytic ileus.
• Any dull areas should be noted as this guides palpation
• Dullness can arise from an intrauterine pregnancy, ovarian tumor, distended bladder, large volume ascites, or an enlarged liver/spleen.
• In protuberant abdomens, tympany changes to dullness of solid posterior structures on each side.
• Dullness in both flanks prompts further ascites evaluation.
• Percuss lower anterior chest above the costal margins to assess liver dullness on the right, and tympany over the gastric air bubble and splenic flexure of the colon on the left.
• Palpation should start light to detect tenderness and resistance.
• Follow with deep palpation for further evaluation.
• If resistance is present, try to distinguish voluntary guarding from involuntary guarding or rigidity.
• Involuntary guarding or rigidity suggests peritonitis.
• Ask the patient to bend the lower extremities at the hip to make the abdominal muscles less tense.
• Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles.
• Deep palpation is required to delineate liver edge, kidneys, abdominal masses.
• Identify masses in all four quadrants, noting location, size, shape, consistency, tenderness, pulsations, any mobility with respiration/pressure from examining hand.
• Correlate findings with percussion exam.
• Abdominal masses may be categorized as physiologic, inflammatory, vascular, neoplastic, or obstructive.
• Peritonitis: Inflammation of the parietal peritoneum, requires urgent evaluation.
• Signs include a positive cough test, involuntary guarding, rigidity, rebound tenderness, and percussion tenderness.
• Causes include any inflammatory, infectious or ischemic intraabdominal process, such as appendicitis, diverticulitis, cholecystitis, bowel ischemia or perforation.
• Rigidity increases the likelihood of peritonitis - rigidity makes peritonitis almost four times more likely"
• Palpate gently, starting with one finger, then with your hand, to localize the area of pain. Check for peritoneal signs of guarding, rigidity, and rebound tenderness.

Abdominal Quadrants and Organs

• In the RUQ, the soft liver is challenging to palpate through the abdominal wall.
• The gallbladder and the duodenum are not normally palpable.
• The abdominal aorta is palpable in the upper abdomen (or epigastrium) of thin patients.
• Examination medially will reveal the rib cage protects the stomach
• The lower pole of the right kidney and the tip of the 12th floating rib may be palpable in children and thin adults.
• The spleen is in the LUQ, lateral to and behind the stomach, just above the left kidney and under the diaphragm.
• Pancreas in healthy people cannot be detected
• Most of the spleen is protected by the 9th, 10th, & 11th ribs
• The sigmoid colon is in the LLQ.
• The bladder,uterus and ovaries can be palpable when distended.
• Appendix and cecum are in RLQ

Performing a Liver Examination

• Limit direct assessment because the rib cage shelters most of the liver.
• Liver size and shape are estimated via palpation and percussion, while surface, consistency, and tenderness are evaluated by palpation.
• Percussion helps approximate liver size.
• An enlarged, palpable liver edge below the ribs suggests liver enlargement and cirrhosis.
• Measure the vertical span of liver dullness to estimate the liver size by percussion.
• Use light-moderate percussion and locate the midclavicular line accurately to improve measurements. Use a light to moderate percussion strike.
• Begin well below the umbilicus in the RLQ, where it is tympanitic, and percuss upward toward the liver
• Estimates of liver span by percussion correlate to actual span approximately 60-70% of the time.

Liver Exam Continued

• Next, find upper border of liver dullness by percussing downward on the midclavicular line starting at the nipple line where its lung resonance
• Outline the lower edge by percussing medially and laterally if the liver is enlarged.
• The span of liver dullness is increased when the liver is enlarged
• The span of liver dullness is decreased when the liver is small or when there is free air below the diaphragm
• Liver dullness may be displaced downward by the low diaphragm of chronic obstructive pulmonary disease, but span remains normal.
• Have patients breathe deeply to palpate the liver edge below the right costal margin
• Then, place the right hand lateral to the rectus muscle, and place the examining hand just below where lower border of the liver is expected to be
• Next, palpate the liver edge for its characteristics including contour, surface, and tenderness, and surface regularity
• Firmness, bluntness,rounding edge, and surface irregularity raise suspicion for liver disease.
• Normally, the liver is palpable 3 cm below the right costal margin and should be soft with a distinct outline.

Alternative Palpation Techniques for Liver

• Obstructed distended gallbladder may merge with the liver, appearing as a firm oval mass below the liver that is dull to percussion.
• To feel the liver edge, adapt pressure to the abdominal wall thickness. Move your palpating hands closer to the costal margin and try again if you are having trouble
• A palpable liver edge does not reliably indicate hepatomegaly.
• Palpation of the liver through the rectus muscles is especially difficult,
• "Hooking" may be helpful, especially for obese patients.
• In order to do that, stand at the pt's right side and place both hands on their upper-right quadrant, push with the fingertips towards to costal margin, ask the pts to take deep breath

Performing the Spleen Examination

• Splenomegaly is the enlargement of the spleen
• Enlargement often replaces the tympany of the stomach and colon with the dullness of a solid organ.
• Splenomegaly expands anteriorly, downward and medially and may not be palpable below the costal margin.
• Two techniques help to detect splenomegaly: Percussion and Palpation
• Percussion is moderately accurate: sensitivity 60-80% and specificity 72-94%
• Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the sixth rib to the anterior axillary line and down to the costal margin, an area termed Traube (semilunar) space.
• Tympany in that space indicates it it is unlikely to be splenomegaly.
• Percuss for dullness rather than tympany to identify enlargement of spleen
• Check for a splenic percussion sign (Castell sign): Percuss the lowest interspace in the left anterior axillary line, from tympany to dullness on inspiration, to check for splenomegaly
• This area is usually tympanitic.
• The percussion note normally remains tympanitic, despite diaphragmatic displacement from a deep breath
• A change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign

Splenomegaly Exam Continued

• If either percussion test for the spleen are positive, palpate With the patient supine, support and press the lower left rib cage and adjacent tissues with your left hand while pressing inward towards the spleen with your right hand below the left costal margin
• The patient should keep their arms at the sides; flex the hips and legs to allow for relaxation of the abdominal wall. The examiner may miss an enlarged spleen by starting palpation too high in the abdomen.
• Palpable spleens indicate splenomegaly eight times more often, the most common causes of splenomegaly are portal hypertension.
• Ask the patient to take a deep breath and document:
  • Tenderness
  • Contour
  • The distance from the spleen’s lowest point and the left costal margin
  • Only 5% of adults have palpable spleen tips.

Examining CVAT and Special Abdominal Tests

• Assess costovertebral angle tenderness (CVAT) if concerning for kidneys.
• Kidneys are retroperitoneal and nonpalpable unless markedly enlarged.
• Percuss for percussion tenderness over each CVA to assess for inflammation or renal capsule in pts w/ suspected renal colic/pyelonephritis
• Use enough force to cause a perceptible but painless jar or thud on the area.
• Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria but may also be musculoskeletal.
• Integrate CVA assessment into the examination of the posterior thorax, lungs, or back to save repositioning the patient.
• Assess special abdominal/peritoneal signs: Murphy sign, Rovsing sign, Psoas sign, Obturator sign, McBurney point, and Shifting dullness
• Ascites, use shifting dullness, can signal congestive signs, cirrhosis
• Appendicitis is the most common cause of acute abdominal pain in the Right Lower Quadrant, test with McBurney Point, Rovsings, Psoas, and Obturator Signs

Special Points

• Check for shifting dullness for assessing Ascites
• Cirrhosis is the most common complication of ascites
• A protuberant abdomen with bulging flanks is suspicious for ascites.
• Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation
• Assessing voluntary guarding, the patient is asked to bend his/her lower extremities or breath with their mouth open/exhale which tenses musculature
• Ascitic fluid sinks with gravity whereas bowel raises
• McBurney Point test involves palpate area of local tenderness approximately 2 inches from anterior Sup Illiac Spine
• Then, palpate the tender area for guarding, rigidity, and rebound tenderness
• To palpate for Rovsing's Sign, one gently provides deep into the LLQ and then lift causing pain in the RLQ

Assessing Psoas, Obturator, and Acute Cholecystitis

• To assess a psoas sign
• Place hand above patient's knee and ask the patient to raise that thigh, or turn the pts onto the left side, then extend thigh at the hip
• Increased pain indicates positive tests
• To test the obturator sign - rotate the leg internally when the hip is flexed
• Discomfort at test's positive
• When no palpitation tenderness is present in RUQ with acute cholecystitis, the Murphey's Sign test may be completed by palpating abdomen and then patient needs to take a deep breathe to determine acute cholecystitis.
• The provider has to palpate deeply in this test. The is a positive pain and pt will hold their breath

Important Info relating to Colorectal Cancer

• It is the 3rd leading cause of cancer.
• Risk factors: family history, polyps, and IBD
• Most effective prevention strategy: screen for polyps!
• Get screened starting between 45-75 y.o.
• The most useful tool: colonoscopy.

Colorectal Cancer Epidemiology

• 3rd most diagnosed cancer and 3rd leading cause of death
• Median age: 67 years of diagnosis and 73 years of death.
• Life time Risk to diagnose: 4%
• Life time risk to die: just under 2%
• Rates have been steadily declining

New Colon Cancer Guidelines

• Guidelines: low-dose aspirin for ages 50-59 and individualized choice for ages 60-69
• Screening tests that include stool detection kits or colonoscopies
• Flexible sigmoidoscopy is good too
• Colonoscopies are the most preferred/useful. But some prefer stool samples
• Higher Risk groups get tested earlier.

Abdominal Exam for New Born

• Note that the abdomen is protruberant.
• Look to see vessels and peristalsis
• Check umbilical cord for two arteries, one thick than vein, located at 12 o'clock
• A single artery suggests congenital issues.
• New born - cutaneous and amino portion - cutaneous retracts and amino dries off with in two weeks
• Look signs of infection, redness, edema, or for swelling
• Umbilical hernias are from increased abdominal pressure - often dissapear
• Can notice distasis recti
• Will her musical tinkling bowel sounds and increase and pitch with gastroenteritis
• Note increased tympany because propensity to air in intestines
• Distended tender abdomen: peritonitis
• Easily palpate
• Use a pacifier or hold flexed - to prevent any disturbances.
• Always start palpating in quadrant at the bottom. and move up
• Can feel liver
• Check the size, also check to see if other hepatites can occur
• Can feel the spleeen usually with a tongue projection
• Check aorta
• Check for kidney abnormalities or colon abnormalities
• Deep palpation will reveal olive-like mass of pyloric Stenosis
• Peristaltic waves may be present during feeding - often infants present b/n 4-6 weeks of age.

Abdominal Exam for Young Child

• For adolescents - abdomen is protuberant
• Can follow normal order
• Distract with conversation or toys/play
• Use full palm
• Pot-belly - malabsorption or constipation
• Obesity - difficult to check at first since the abdomens makes it more difficult
• Flex knees and be gentle with the abdomen (only touch the areas of interest last)
• Abdominal pain usually caused with gastroenteritis or increased bowel sounds, or tenderness with palpitation
• Mass represents stool constipation.

Brest Exam

• A female breast is located on the anterior chest from 2/2 clavicle to 6th rib/sternum to midaxillary line.
• Lobe consist of: lactiferous lobules that then converge with the ducts/sinuses
• Surface has mammary or swat glands
• Has 2 fascial layers: superficial under dermis and deep on top of pectoral
• Held by Cooper Suspensatory ligaments and skin by those
• Supernumitary may present along milk line and look like a small mole
• More glandular means greater pigmentation, swelling with menstruation, pregnancy, puberty
• Should describe what is being observed by upper, lower, lateral, etc or by a clock (like if 3, etc) or centimenter

Breast Physiology/ Axilla

• Has hormonal texture or lumpy
• Both should be soft, but increase with menses.
• Pregnancy, lactation change breast tissue along with other factors
• The neurohormone innervation is responsible lactation
• Breast contraction reflex may occur.
• Always inspect area looking breast, skin, contour changes
• Make sure to mention symmetry or scars and lesions
• Should inspect skin for thickness etc.

Breast - Exam Techniques

• Retractions occur when cancer.
• Note the relationship w/ the muscle too if contracted
• Note, must make have pt be arms at side -> arms pressed -> arms overhead -> leaning over
• To examine or palpate -> patient must be supine.
• Should flatten breast and palpate rectangular area of the breast up in the axilla
• 3 minutes per head
• Use finger pads of 234
• Always be systematic
• One can be mistaken for rib when palpating deeply.
• Flatten area, and when palpate one side, ask to bring are upper head.
• Consistency of test: from firmness to fat is always different
• Note at margin of inframammy in lage breast - might cause tenderness if there is already prior to menses.
• And assess anything by location - measure center to clocks. Look at skin/chest wall. Assess shape/ tenderness

What indicates concerns w/ breast exam?

• Check where nipple is located and see if the elasticity as well
• Should always report anything with milky related discharge
• A nipple pulled inward signals nipple retraction from underlying cancer.

Four Important Tests of the Axillae

• The nerves are: thoracodorsal, medial, intercostobrachial
• Skin should be inspected noting evidence of:
  • sweat glands, rash, lesion
• Should examine skin
• To test and perform palpitation - first left side - use your right hand.
• Axillae can be sitting lying but it should be preferrable where pt is sitting
• Then support with right arm down
• Use right hand to cup fingers to push and reach apex of the axilla. Press against chest wall and go down
• All the axillary will be present.

• 1cm, tender - not a good sign of lymph node involvement - should be smooth.

• Other areas should then palpated.
• Enlarged axillary nodes require inspection and lymph node analysis of the other groups

Newborn breast findings

• It last month's with maternal estrogent causing engorgement
• Witch milk can occur.
• Premature thelarche (thelarche) can occur without hormonal abnormalities
• Tanner staging is also to occur

Key gynecomastia points

• Always inspect/palpitation nipple
• Benign fatty - is pseudo gynecomasti
• Tender-gynecomastia
• Hormone imbalance - gynecomastia or drugs
• Hard irregular mass - probably breast cancer - a hard mass - always requires referral

Key Male Genitalia Exam Points

• For many male tests - the student may feel uneasy
• Ask the test so it's collaborative
• Explain each stage or test and what's happening and reassure pts
• Wear gloves - always!
• Remember and understand maturation levels
• Scrotums or testes must be examined as well!

Key steps of Pennis Examination

• Must inspect and examine for inflammation or excoriation on dorsal surface
• Retract back it and check, because cannot be done with carcinogens or chancers
• Cheesy or whitish called smegma may stay and accumulate under foreskin
• Paraphimosis one can not extend as tightness can develop, Phimosis cannot be extended
• Inspect - ulcer/inflammation
• Inflammation of glans: balanitis
• hypospadias, epispadias can occur - must be examined for
• Compress and if you can see, that will reveal what may be present

Examination Details Male part 2

• Should look to expel if there is some sort of discharge.
• Must be stained ofr Gram and cultures to definitively diagnose
• Palpate for tenderness and induration of the shact.
• Peyronie disease - palpated and can be done with the skin to reveal
• Replace back the skin when done and then move to next section
• Scrotal contents - do they have normal epidermoid cysts
• Also the vas deterens, etc, epidymis, the testes, must be felt for
• Lift to visualize
• Check pubic hair distribution, etc
• Can see or palp nodules too but if you're not, than not
• If 1 hand is used - go bitwenm thum and fingers, or use two

Evaluating Groin Hernias: Men

• 25% risk during lifetime vs women
• Men - inguinal v females -femoral or a little less in women
• femoral means high chance emergency or incarceration
• Have test pt both standing and suprine to test
• Inspect genital to inguinal
• And test with inguinal ring for bulge
• If a bulge with cough - the canal is inguinal, if bulges anterior, than directionals

Important Points and Testing Techniques

• To Test Spermatic cord: if chronically infect, there is a nodule and suggest hydrocele if test it

Abnormal Findings

• Testicular tumor most likely.
• Testes for size and consistency
• Palate each for tenderness/ nodule (producing deep visceral pain)
• Any nodule raises cancer possibiltiy
• Assess scrotol size and lymph
• After test - assess epidydmiss

Assess for Groin Area

• Should note for: standing seated
• Should check to: indirect, direct etc
• Assess with coughing and then do
• Make then do in position