The Abdomen - Symptoms & Signs of Surgical Disease PDF

15 The abdomen THE EXAMINATION OF THE ABDOMEN The abdomen contains the stomach, duodenum, small and large bowel, liver, gallbladder, spleen, pan- creas, kidneys, uterus, bladder, aorta and vena cava and, in women, the uterus, ovaries and Fallopian tubes. This relatively small cavi...

15 The abdomen THE EXAMINATION OF THE ABDOMEN The abdomen contains the stomach, duodenum, small and large bowel, liver, gallbladder, spleen, pan- creas, kidneys, uterus, bladder, aorta and vena cava and, in women, the uterus, ovaries and Fallopian tubes. This relatively small cavity therefore contains a number of vital organs, all of which are susceptible to disease or malfunction but many are inaccessible to palpation, being hidden behind the lower ribs or inside the bony pelvis (Fig. 15.1). Because the abdominal organs are so close together, the brain is often incapable of distin- guishing which of them is the source of a pain, but other symptoms and signs may help to distinguish the likely organ and the pathology responsible for the pain. A Preparation The environment B The examination room must be warm and private if the patient is to lie undressed and relaxed. A cold C couch placed in a draught or in the view of other patients makes proper examination impossible. A good light is essential, with, 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 asym- metry, and many neon lights falsify colours, particu- larly the yellows and blues. A B C The examination couch or bed FIG 15.1 These drawings show the extent of the abdominal cavity. The paler lavender areas indicate the parts A hard, flat couch makes the patient lie absolutely flat of the abdomen protected by the ribs and the pelvis. The and opens the gap between the pubis and the xiphis- levels of the three cross-sections are indicated on the ternum, but unfortunately stretches and tightens central diagram.  The examination of the abdomen 387 the abdominal muscles. A soft bed lets the lumbar Ask the patient to place their arms by their spine sink into a deep curve and closes the gap sides, not behind their head. between the pubis and the ribs. The best compromise Encourage the patient to sink their back into the in the office or outpatients is a hard couch with a couch and breathe regularly and slowly. backrest that can be raised by 15–20°. The hard couch Only press your hands into the abdomen during ensures that patients retain their lumbar lordosis, expiration as the abdominal muscles relax. & opening access to the abdomen and pushing the cen- If these manoeuvres do not work, ask the patient to tral contents anteriorly. The elevation of the thoracic flex their hips to 45° and their knees to 90° and place cage relaxes the anterior abdominal wall muscles. an extra pillow behind their head. Although these Exposure a inwardcase manoeuvres tilt up the pelvis and reduce access to the abdomen, they usually relax the abdominal muscles. The full extent of the abdomen must be visible and, ideally, patients should be uncovered from nipples to The position of the examiner knees. Many find this embarrassing and a comprom- The examiner’s hands should be clean and warm ise is to cover the lower abdomen with a sheet or blan- with short nails. It is impossible to palpate deeply ket while palpating the abdomen, but never forget to with long nails and it is an insult to the patient to examine the genitalia and the hernial orifices. have dirty hands. Getting the patient to relax The whole hand should rest on the abdomen by keeping the hand and forearm horizontal, in the same It is not possible to feel anything within the abdomen plane as the front of the abdomen. To achieve this if the patient is tense. There are several ways in the examiner must sit or kneel beside the bed. Do which relaxation can be encouraged. not examine the patient from a standing position by Ask the patient to rest their head on the couch leaning forwards and dorsi-flexing your wrist. or a pillow to avoid tensing the rectus Sitting or kneeling beside the patient with your abdominis muscles. forearm level with the front of the abdomen puts your (a) (c) (b) (d) FIG 15.2 EXAMINATION OF THE ABDOMEN. (a) Examine the abdomen with the patient on a firm couch or bed with just sufficient support beneath the shoulders and head to stop the anterior abdominal wall being stretched tight. (b) If the abdominal wall is tight, raise the head and flex the hips. (c) and (d) These figures show the reduction in the area of abdomen available for palpation if the patient lies on a soft bed that allows the lumbar lordosis to straighten. 388 The abdomen eyes about 50 cm above your hand, an ideal level for Palpation seeing any soft shadows caused by lumps and bumps. Palpate gently but deliberately, firmly and with pur- pose. Rapid, jerky or circular movements reminiscent Examination of kneading dough are distressing for the patient and cause them to lose confidence. Keeping your hands This should follow the standard routine of inspec- still and feeling the intra-abdominal structures mov- tion, palpation, percussion and auscultation. ing beneath them gives more information than rapid Inspection and thoughtless palpation. Finish (or begin) by feeling the areas that might Look at the whole patient. Look for any general otherwise be forgotten. abnormality indicative of intra-abdominal pathology such as cachexia, pallor or jaundice. 1. Feel the supraclavicular fossae and neck for Inspection of the abdomen from the end of the lymph glands. bed will reveal if there is any asymmetry or distension. 2. Feel the hernial orifices at rest and when the Note the position, shape and size of any bulge, patient coughs. any changes in its shape, and whether it moves with 3. Feel the femoral pulses. respiration or increases with coughing. 4. Examine the external genitalia. Observe the reaction of the patient to coughing 5. Look at the hands, nails and facies. or moving. Patients with peritonitis find movement General light palpation for tenderness extremely painful and, consequently, tend to lie very still, whilst patients with colic roll around with each This should be done by gently resting a hand on the paininabdomencaused n as bout of pain. ↳severe patient’s abdomen and pressing lightly. The hand Record the presence of any scars, sinuses or fistulae. should be systematically moved over the whole of ~ Dilated surface veins may indicate the possibility the abdomen. If you are right handed, start in the of portal hypertension or inferior vena caval occlu- left iliac fossa and move round in an anti-clockwise sion (see Fig. 14.24, page 384). anabnormal or direction to finish in the right iliac fossa. surgicallymadepage a b When a patient complains of pain, asked them to and a Aupulavorgana indicate its site before you begin your palpation, so that you can start over a non-tender area and move towards the tender spot. Carefully define the area of tenderness so that you can depict it as a hatched area on a drawing of the abdomen (Fig. 15.4). FIG 15.3 When you palpate the abdomen, sit or kneel so that your forearm is horizontal and level with the anterior abdominal wall, and your eyes are 50 cm above this level. If you are higher, your wrist will be extended and you will not be able to palpate comfortably and firmly. In this illustration the abdomen is inadequately exposed. The patient’s pants should have been removed or lowered down FIG 15.4 Indicate areas of tenderness by oblique lines on a to the level of the pubis. sketch like this. Masses are depicted by outlining their shape.  The examination of the abdomen 389 Assess the degree of tenderness. Palpation over General palpation for tenderness an area of mild tenderness just causes pain. Guarding, When no pain is elicited by systematic light palpa- the tightening of the patient’s abdominal muscles in tion over the whole abdomen, repeat the process, response to pressure, indicates severe tenderness. pressing more firmly and deeply to see if there is any The sudden withdrawal of manual pressure may deep tenderness. cause a sharp exacerbation of the pain, which is known as rebound or release tenderness. This test Palpation for masses may be distressing for the patient and it is preferable The whole abdomen must be carefully palpated for to assess rebound tenderness by the patient’s response the presence, position, shape, size, surface, edge, to light percussion. consistence, fluid thrill, resonance and pulsatility of Sometimes, release of pressure on a distant non- any masses. tender part of the abdomen may cause pain in a ten- Tender masses in the abdomen are very difficult der area. 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 tight- ens their abdominal muscles. Palpation of the normal solid viscera The liver To feel the liver, place your right hand transversely and flat on the right side of the abdomen at the level of the umbilicus, parallel with the right Palpate the liver by resting your fingers on the abdomen costal margin. Then ask the patient to take a deep almost parallel to the right costal margin and asking the breath. If the liver is grossly enlarged, its lower patient to breathe in. The liver edge can be made more edge will move downwards and bump against the prominent by putting your left hand under the lower ribs and lifting them forwards. Palpate the spleen with your fingers lying transversely across the abdomen so that its tip will hit the tips of your index and Palpate the kidneys by pressing firmly into the lumbar region middle fingers when the patient breathes in. You can make during inspiration while lifting the kidney forwards with your the spleen more prominent by lifting the lower ribs forwards other hand in the loin. (The exposure is inadequate for a proper with your left hand as you do when palpating the left kidney. examination of the whole abdomen in these three illustrations.). FIG 15.5 PALPATING THE ABDOMEN. 390 The abdomen radial side of your index finger. If nothing abnormal hand on the right side of the abdomen just below is felt, repeat the process after moving your hand the level of the anterior superior iliac spine. As the upwards, inch by inch, until the costal margin is patient breathes in and out, palpate the loin between reached. both hands. The lower pole of a normal kidney may The liver edge may be straight or irregular, thin be felt at the height of inspiration in a very thin per- and sharp, or thick and rounded. Palpation begin- son. If the kidney is very easy to feel, it is either ning just below the costal margin can easily miss a enlarged or abnormally low. To feel the left kidney, large liver. Gross hepatomegaly may fill the whole lean across the patient, place your left hand around abdomen so, if in doubt, begin your palpation in the the flank into the left loin to lift it forwards, then left iliac fossa. place your right hand on the abdomen and feel any masses between the two hands. The spleen An enlarged spleen appears below the tip An enlarged kidney can be pushed back and forth of the tenth rib along a line heading towards the between the anterior and posterior hands. This is umbilicus and, if really large, may extend into the called balloting. It feels like patting a ball back and right iliac fossa. A normal spleen is not palpable. forth in a pool of water. Balloting is also used to pal- To feel the spleen, place the fingertips of your pate a fetus in a pregnant uterus. right hand on the right iliac fossa just below the umbilicus. Ask the patient to take a deep breath. If nothing abnormal is felt, move your hand in stages Percussion towards the tip of the left tenth rib. When the costal The whole abdomen must be percussed, particu- margin is reached, place your left hand around the larly over any masses. A dull area may draw your lower left rib cage and lift the lower ribs and the attention to a mass that was missed on palpation spleen forwards as the patient inspires. This man- and indicate a more detailed and careful palpation oeuvre occasionally lifts a slightly enlarged spleen of the area of dullness. When there is a circum- far enough forward to make it palpable. scribed mass, a tap on one side while feeling the The spleen is recognized by its shape and site opposite side with the other hand may reveal that it and, when present, the notch on its supero-medial conducts a fluid thrill. Any area of dullness should edge. It is dull to percussion as it lies immediately be outlined by percussion with the abdomen in two beneath the abdominal wall with no bowel in front positions to see if it moves or changes shape. Free of it, unlike a renal mass (see below). fluid (ascites) changes shape and moves (shifting dullness, see pages 433–4). The kidneys Normal kidneys are usually impalpable, Percussion causes pain if peritonitis is present except in very thin people, but both lumbar regions and is a useful method for mapping out a tender should always be carefully examined. area (see above). To feel the patient’s right kidney, place your left If a part or the whole of the abdomen is dis- hand behind the patient’s right loin between the tended, the patient should be held at the hips and twelfth rib and the iliac crest, so that you can lift the the abdomen shaken from side to side. Splashing loin and kidney forwards. Then place your right sounds, a succussion splash, indicate that there is an intra-abdominal viscus, usually the stomach, dis- tended with a mixture of fluid and gas. Revision panel 15.1 Never forget to examine Auscultation Supraclavicular lymph glands Listen to the bowel sounds. Peristalsis produces gur- Hernia orifices gling noises because the bowel contains a mixture of Femoral pulses fluid and gas. The pitch of the noise depends upon Genitalia the distension of the bowel and the proportions of Bowel sounds gas and fluid. Normal bowel sounds are low-pitched Anal canal and rectum gurgles which occur every few seconds. The absence of bowel sounds indicates that peristalsis has ceased.  Abdominal pain 391 This may be either a primary or secondary phenom- Sometimes patients are only capable of localizing enon. If you can hear the heart and breath sounds pain to the upper or lower half of the abdomen but no bowel sounds over a 30-second period, the and/or to the left or right side. patient probably has a paralytic ileus. Colicky pain is referred to the centre of the Increased peristalsis increases the volume and abdomen whatever its source, as it is a visceral sen- frequency of the bowel sounds. Distension of the sation, whereas the pain from the parietal peritoneum bowel caused by a mechanical intestinal obstruction is felt over the inflamed area (somatic sensation). is associated not only with increased bowel sounds Pain in the upper abdomen is most likely to arise but also with a change in the character of the from the biliary tree, stomach, duodenum or pan- sounds. They become amphoric in nature with runs creas. These structures produce right-sided, central of high-frequency gurgles, sounding like sea water and left-sided pain respectively. The pain from these entering a large cave through a narrow entrance, three organs radiates in different directions. often described as ‘tinkling’. Gallbladder pain may radiate through to the Having assessed the quality of the bowel sounds, it back and to the right to reach the tip of the is important to listen for any systolic vascular bruits. Epigastrium ABDOMINAL PAIN Hypochondrium Time spent taking a careful history is never wasted, as abdominal pain is the only symptom of many intra- Umbilical region abdominal diseases. The two most significant proper- ties of an abdominal pain are its site and its character. Lumbar region Iliac fossa The significance of the site of abdominal pain Hypogastrium The abdomen can be divided into three horizontal zones – upper, central and lower – by two horizon- FIG 15.6 The names of the regions of the abdomen. tal lines. These are the transpyloric plane (a line cir- cling the body mid-way between the suprasternal notch and the symphysis pubis) and the transtuber- Revision panel 15.2 cular plane (a line circling the body that passes The features of a pain that must be elicited through the two tubercles of the iliac crest) as shown in Figure 15.6. Each of these three zones can Time and nature of onset be further vertically subdivided into three regions – Site central, right and left – by the two mid-clavicular Character (burning, throbbing, stabbing, lines. constricting, colicky, aching) The anatomical names of these nine regions are: Severity Progression the epigastrium Duration the right hypochondrium End the left hypochondrium Radiation the umbilical region Relieving factors the right lumbar region Exacerbating factors the left lumbar region Associated symptoms, e.g. vomiting, the hypogastrium or suprapubic region diarrhoea, painful micturition, missed or the right iliac fossa absent periods the left iliac fossa.