Abdomen Examination PDF

CHAPTER 18 Abdomen T he abdominal examination is performed as part of the comprehensive physical examination or when a patient presents with signs or symptoms suggestive of an abdominal disease process. It involves the core examination skills in a particular sequence: inspection, auscultation, percu...

CHAPTER 18 Abdomen T he abdominal examination is performed as part of the comprehensive physical examination or when a patient presents with signs or symptoms suggestive of an abdominal disease process. It involves the core examination skills in a particular sequence: inspection, auscultation, percussion, and palpation. Additional procedures are used to detect serious abdominal pathology. During the abdominal examination, pay careful attention to the patient’s comfort level or degree of distress. Physical Examination Components 1. Inspect the abdomen for: Skin characteristics Venous return patterns Symmetry Surface motion 2. Inspect abdominal muscles as patient raises head to detect presence of: Masses Hernia Separation of muscles 3. Auscultate with stethoscope diaphragm for bowel sounds 4. Auscultate with stethoscope bell for bruits over aorta, renal, iliac, and femoral arteries 5. Percuss the abdomen for: Tone in all four quadrants (or nine regions) Liver borders to estimate span Splenic dullness in left midaxillary line Gastric air bubble 6. Lightly palpate in all quadrants or regions for: Muscular resistance Tenderness Masses 7. Deeply palpate for: Bulges and masses around the umbilicus and umbilical ring Liver border in right costal margin Gallbladder below liver margin at lateral border of the rectus muscle Spleen in left costal margin Right and left kidneys Aortic pulsation in midline Other masses 8. With patient sitting, percuss the left and right costovertebral angles for kidney tenderness.    ANATOMY AND PHYSIOLOGY The abdominal cavity contains several of the body’s vital organs (Fig. 18.1). The peritoneum—a serous membrane—lines the cavity and forms a protective cover for many of the abdominal organs. Double folds of the peritoneum around the stomach constitute the greater and lesser omentum. The mesentery—a fan-­shaped fold of the peritoneum—covers most of the small intestine and anchors it to the posterior abdominal wall. Musculature and Connective Tissues The rectus abdominis muscles anteriorly and the internal and external oblique muscles laterally form and protect the abdominal cavity (Fig. 18.1A). The linea alba—a tendinous band—is located in the midline of the abdomen between the rectus abdominis muscles. It extends from the xiphoid process to the symphysis pubis and contains the umbilicus. The inguinal ligament (Poupart ligament) extends from the anterior superior spine of the ilium on each side to the pubis. Alimentary Tract The alimentary tract—a tube approximately 27 feet long—runs from the mouth to the anus and includes the esophagus, stomach, small intestine, and large intestine. It functions to ingest and digest food, absorb nutrients, electrolytes, and water, and excrete waste products. Food and digestive products are moved along the length of the alimentary tract by peristalsis under autonomic (involuntary) nervous system control. The esophagus—a collapsible tube about 10 inches long—connects the pharynx to the stomach. Just posterior to the trachea, the esophagus descends through the mediastinal cavity and diaphragm, entering the stomach at the cardiac orifice. The stomach lies transversely in the upper abdominal cavity, just below the diaphragm. It consists of three sections: the fundus, lying above and to the left of the cardiac orifice; the middle two-­thirds, or body; and the pylorus, the most distal portion that narrows and terminates in the pyloric orifice. The stomach secretes hydrochloric acid and digestive enzymes that break down fats and proteins. 403 Anatomy And Physiology 404 CHAPTER 18 Abdomen Pepsin acts to digest proteins, whereas gastric lipase acts on emulsified fats. Little absorption takes place in the stomach. The small intestine—about 21 feet long—begins at the pylorus. Coiled in the abdominal cavity, it joins the large intestine at the ileocecal valve. The first 12 inches of the small intestine—the duodenum—forms a C-­shaped curve around the head of the pancreas. The common bile duct and pancreatic duct open into the duodenum at the duodenal papilla, about 3 inches below the pylorus of the stomach. The next 8 feet of intestine, the jejunum, gradually becomes larger and thicker. The ileum makes up the remaining 12 feet of the small intestine. The ileocecal External oblique White line (linea alba) External oblique aponeurosis Rectus abdominis Transversus abdominis Internal oblique valve between the ileum and large intestine prevents backward flow of fecal material. The small intestine completes digestion through the action of pancreatic enzymes, bile, and several other enzymes. Nutrients are absorbed through the mucosa of the small intestine. The functional surface area of the small intestine is increased by its circular folds and villi. The large intestine begins at the cecum, a blind pouch about 2 to 3 inches long (Fig. 18.1B). The ileal contents empty into the cecum through the ileocecal valve, and the vermiform appendix extends from the base of the cecum. The ascending colon rises from the cecum along the right posterior abdominal wall to the undersurface of the liver. Rectus sheath Liver A Gallbladder Liver Hepatic Falciform Celiac duct ligament trunk Left adrenal gland Cystic duct Right kidney Common bile duct Duodenum Inferior vena cava Stomach Ascending colon Transverse colon Small intestine Descending colon Cecum Sigmoid colon Appendix Bladder B Gallbladder Spleen Spleen Pancreas Left kidney Superior mesenteric artery and vein Abdominal aorta Promontory C FIG. 18.1 Anatomic structures of the abdominal cavity. CHAPTER 18 405 Left kidney Right adrenal gland Celiac trunk Left renal artery Right kidney Abdominal aorta Right renal vein Left ureter Quadratus lumborum Psoas muscle Iliacus Common iliac artery and vein Right ureter Promontory Bladder Rectum D FIG. 18.1 cont’d The ascending colon turns toward the midline at the hepatic flexure and becomes the transverse colon. The transverse colon crosses the abdominal cavity toward the spleen and turns downward at the splenic flexure. The descending colon continues along the left abdominal wall to the rim of the pelvis, where it turns medially and inferiorly to form the S-­shaped sigmoid colon. The rectum extends from the sigmoid colon to the muscles of the pelvic floor. It continues as the anal canal and terminates at the anus. The large intestine is about 4.5 to 5 feet long, with a diameter of 2.5 inches. Its main functions are to absorb water and transport waste. Mucous glands secrete large quantities of alkaline mucus that lubricate the intestinal contents and neutralize acids formed by intestinal bacteria. Live bacteria decompose undigested food residue, unabsorbed amino acids, cell debris, and dead bacteria through a process of putrefaction. Liver The liver lies in the right upper quadrant of the abdomen (Fig. 18.1C), just below the diaphragm and above the gallbladder, right kidney, and hepatic flexure of the colon. The heaviest organ in the body, the liver weighs about 3 pounds in the adult. It is composed of four lobes containing lobules—the functional units. Each lobule is made up of liver cells radiating around a central vein. Branches of the portal vein, hepatic artery, and bile duct penetrate to the periphery of the lobules. Bile secreted by the liver cells drains from the bile ducts into the hepatic duct, which joins the cystic duct from the gallbladder to form the common bile duct. The hepatic artery transports blood to the liver directly from the aorta, and the portal vein carries blood from the digestive tract and spleen to the liver. Repeated branching of both vessels makes the liver a highly vascular organ. Three hepatic veins carry blood from the liver and empty into the inferior vena cava (Fig. 18.1D). The liver plays an important role in the metabolism of carbohydrates, fats, and proteins. Glucose is converted and stored as glycogen until—in response to varying levels of insulin and regulatory hormones—it is reconverted and released again as glucose. The liver also can convert amino acids to glucose (gluconeogenesis). Fats, arriving at the liver in the form of fatty acids, are oxidized to two-­carbon components in preparation for entry into the tricarboxylic acid cycle. Cholesterol is used by the liver to form bile salts. Synthesis of fats from carbohydrates and proteins also occurs in the liver. Proteins are broken down to amino acids through hydrolysis, and their waste products are converted to urea for excretion by the kidneys. Other functions of the liver include storage of several vitamins and iron; detoxification of potentially harmful substances; production of antibodies; conjugation and excretion of steroid hormones; and the production of prothrombin, fibrinogen, and other substances for blood coagulation. The liver is responsible for the production of the majority of proteins circulating in the plasma. It serves as an excretory organ through the synthesis of bile, the secretion of organic wastes into bile, and the conversion of fat-­soluble wastes to water-­soluble material for renal excretion. Gallbladder The gallbladder is a saclike, pear-­shaped organ about 4 inches long, lying recessed in the inferior surface of the liver. It concentrates and stores bile from the liver. In response to cholecystokinin—a hormone produced in the duodenum—the gallbladder releases bile into the cystic Anatomy And Physiology Hepatic Inferior Left adrenal vena cava veins Esophagus gland Abdomen Anatomy And Physiology 406 CHAPTER 18 Abdomen duct. The cystic duct and hepatic duct join to form the common bile duct. Contraction of the gallbladder propels bile along the common duct and into the duodenum at the duodenal papilla. Composed of cholesterol, bile salts, and pigments, bile serves to maintain the alkaline pH of the small intestine, permitting emulsification of fats so that absorption of lipids can be accomplished. Pancreas The pancreas lies behind and beneath the stomach, with its head resting in the curve of the duodenum and tip extending across the abdominal cavity to almost touch the spleen (see Fig. 18.1C). As an exocrine gland, the acinar cells of the pancreas produce digestive juices containing inactive enzymes for the breakdown of proteins, fats, and carbohydrates. Collecting ducts empty into the pancreatic duct (duct of Wirsung), which runs the length of the organ. The pancreatic duct empties into the duodenum at the duodenal papilla alongside the common bile duct. Once introduced into the duodenum, the digestive enzymes are activated. As an endocrine gland, islet cells scattered throughout the pancreas produce the hormones insulin and glucagon. Spleen The spleen is in the left upper quadrant, lying above the left kidney and just below the diaphragm. White pulp (lymphoid tissue) constitutes most of the organ and functions as part of the reticuloendothelial system to filter blood and manufacture lymphocytes and monocytes. The red pulp of the spleen contains a capillary network and venous sinus system that allow for storage and release of blood, permitting the spleen to accommodate up to several hundred milliliters at once. Kidneys, Ureters, and Bladder The two kidneys are located in the retroperitoneal space of the upper abdomen (see Fig. 18.1D). Each extends from about the vertebral level of T12 to L3. The right kidney is usually slightly lower than the left, presumably because of the large, heavy liver just above it. Both kidneys are embedded in fat and fascia, which anchor and protect these organs. Each contains more than 1 million nephrons—the structural and functional units of the kidneys. The nephrons are composed of a tuft of capillaries, the glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule. The distal tubule empties into a collecting duct. Each kidney receives about one-­eighth of the cardiac output through the renal artery. The glomerular filtration rate (GFR)—used to measure kidney function—is typically 90 mL/min/1.73 m2 or higher in healthy individuals. Most of the filtered material, including electrolytes, glucose, water, and small proteins, is actively reabsorbed in the proximal tubule. Some organic acids are also actively secreted in the distal tubule. Urinary volume is carefully controlled by antidiuretic hormone (ADH) to maintain a constant total body fluid volume. Urine passes into the renal pelvis via the collecting tubules and then into the ureter. Peristaltic waves move urine to the urinary bladder, which has a capacity of about 400 to 600 mL in the adult. The kidney also serves as an endocrine gland responsible for the production of renin, which controls aldosterone secretion. It is the primary source of erythropoietin production in adults, thus influencing the body’s red cell mass. In addition to synthesizing several prostaglandins, the kidney produces the biologically active form of vitamin D. Vasculature The abdominal portion of the descending aorta travels from the diaphragm through the abdominal cavity, just to the left of midline (see Fig. 18.1D). At about the level of the umbilicus, the aorta branches into the two common iliac arteries. The splenic and renal arteries, which supply their respective organs, also branch off within the abdomen. Fetal Development and Infancy The pancreatic buds, liver, and gallbladder all begin to form during week 4 of gestation, by which time the intestine already exists as a single tube. The motility of the gastrointestinal tract develops in a cephalocaudal direction, permitting amniotic fluid to be swallowed by 17 weeks of gestation. Production of meconium—an end product of fetal metabolism—begins shortly thereafter. By 36 to 38 weeks of gestation, the gastrointestinal tract is capable of adapting to extrauterine life. However, the elasticity, musculature, and control mechanisms of the gastrointestinal tract continue to develop, reaching adult function at 2 to 3 years of age. During gestation, the liver begins to form blood cells at about week 6, synthesize glycogen by week 9, and produce bile by week 12. The liver’s role as a metabolic and glycogen storage organ accounts for the large size at birth. The liver remains the heaviest organ in the body. Pancreatic islet cells are developed by 12 weeks of gestation and begin producing insulin. The spleen is active in blood formation during fetal development and the first year of life. Afterward, the spleen aids in the destruction of blood cells and functions as a lymphatic organ for immunologic response. Nephrogenesis begins during the second embryologic month. By 12 weeks, the kidney is able to produce urine, and the bladder expands as a sac. Development of new nephrons ceases by 36 weeks of gestation. After birth, the kidney increases in size because of enlargement of the existing nephrons and adjoining tubules. The GFR is approximately 0.5 mL/min before 34 weeks of gestation and gradually increases in a linear fashion to the adulthood rate. Pregnant Patients As the uterus enlarges, the muscles of the abdominal wall stretch and lose tone. During the third trimester, the rectus abdominis muscles may separate, allowing abdominal contents to protrude at the midline (diastasis recti). The umbilicus flattens or protrudes. Striae may form as the skin is stretched. A line of pigmentation at the midline (linea nigra) often develops from melanocyte-­stimulating hormone produced by the placenta (Fig. 18.2). Abdominal muscles have less tone and are less active. The abdominal contour changes when lightening, or dropping, occurs (about 2 weeks before term in a nullipara), and the fetal presenting part descends into the true pelvis. After pregnancy, the muscles gradually regain tone, though diastasis recti may persist. During the second trimester, lower esophageal sphincter pressure decreases. Peristaltic wave velocity in the distal esophagus also decreases. Gastric emptying appears to be normal; however, gastrointestinal transit time is prolonged, at times leading to constipation. Incompetence of the pyloric sphincter may result in alkaline reflux of duodenal contents into the stomach. Due to relaxation of the lower esophageal sphincter, heartburn (gastroesophageal reflux) often occurs. The gallbladder may become distended, accompanied by decreased emptying time and change in tone. The combination of gallbladder stasis and secretion of lithogenic bile increases formation of cholesterol crystals and the development of gallstones. Gallstones are more common in the second and third trimesters. The kidneys enlarge slightly (by about 1 cm in length) during pregnancy. The renal pelvis and ureters dilate from the effects of hormones and pressure from the enlarging uterus. Dilation of the ureter is greater on the right side than on the left, probably because it is affected by displacement of the uterus to the right by an enlarged right ovarian vein. The ureters also elongate and form single and double curves of varying sizes and angulation. These changes can lead to urinary stasis and pyelonephri- FIG. 18.2 Linea nigra in the third trimester of pregnancy. Abdomen 407 tis in gravid women with asymptomatic bacteriuria. Renal function is most efficient if the individual lies in the lateral recumbent position, which helps prevent compression of the vena cava and aorta. These changes can last up to 3 or 4 months postpartum. The bladder has increased sensitivity and compression during pregnancy, leading to urinary frequency and urgency during the first and third trimesters. After the fourth month, the increase in uterine size, hyperemia of all pelvic organs, and hyperplasia of muscle and connective tissue elevate the bladder trigone and cause thickening of the posterior margin. This process produces a marked deepening and widening of the trigone by the end of the pregnancy and may result in microhematuria. During the third trimester, compression may also result from the descent of the fetus into the pelvis; this, in turn, causes a sense of urgency and/or incontinence, even with a small amount of urine in the bladder. The colon is displaced laterally upward and posteriorly, peristaltic activity may decrease, and water absorption is increased. As a result, bowel sounds are diminished, and constipation and flatus are more common. The appendix is displaced upward and laterally, away from McBurney point, an anatomic landmark one-­third of the distance from the anterior superior iliac spine to the umbilicus. In the postpartum period, the uterus involutes rapidly. Immediately after delivery, the uterus is approximately the size of a 20-­week pregnancy (palpable at the level of the umbilicus). By the end of the first week, it is about the size of a 12-­week pregnancy, palpable at the symphysis pubis. The muscles of the pelvic floor and the pelvic supports gradually regain tone during the postpartum period and may require 6 to 7 weeks to recover. Stretching of the abdominal wall during pregnancy may result in persistent striae. Older Adults The process of aging results in changes in the functional abilities of the gastrointestinal tract. Motility of the intestine is the most severely affected; secretion and absorption are affected to a lesser degree. Altered motility may be caused by age-­related changes in neurons of the central nervous system and by changes in collagen properties that increase the resistance of the intestinal wall to stretching. Reduced circulation to the intestine often follows other system changes associated with hypoxia and hypovolemia. As a result of epithelial atrophy, the secretion of both digestive enzymes and protective mucus decreases in the intestinal tract. Particular elements of the mucosal cells show a lesser degree of differentiation and are associated with reduction in secretory ability. These cells are also more susceptible to both physical and chemical agents, including ingested carcinogens. Bacterial flora of the intestine can undergo both qualitative and quantitative changes and become less biologically active. These changes may impair digestive ability and thereby cause food intolerances in the older adult. Anatomy And Physiology CHAPTER 18 Review of Related History 408 CHAPTER 18 Abdomen Liver size decreases after 50 years of age, which parallels the decrease in lean body mass. Hepatic blood flow decreases as a result of a decline in cardiac output associated with aging. The liver loses some ability to metabolize certain drugs. Increasing obesity and the development of type 2 diabetes mellitus also put the liver at risk for the development of nonalcoholic fatty liver disease (NAFLD). The size of the pancreas is unaffected by aging, although the main pancreatic duct and branches widen. With aging, there is an increase in fibrous tissue and fatty deposition with acinar cell atrophy; however, the large reserve of the organ results in no significant physiologic changes. There may be an increase of biliary lipids—specifically the phospholipids and cholesterol—resulting in the formation of gallstones. REVIEW OF RELATED HISTORY For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Questions regarding these topics will help focus the physical examination and develop an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-­the-­counter) as well as complementary and alternative medicine are relevant for each area. History of Present Illness Abdominal Pain Onset and duration: sudden or gradual; persistent, recurrent, intermittent Character: dull, sharp, burning, gnawing, stabbing, cramping, aching Location: at time of onset, change over time, radiation to another area, superficial or deep Associated symptoms: vomiting, diarrhea, constipation, passage of flatus, belching, jaundice, change in abdominal girth, weight loss or weight gain Relationship to: menstrual cycle, change in menses, intercourse, urination, defecation, inspiration, change in body position, food or alcohol intake, stress, time of day, trauma Recent stool characteristics: color, consistency, odor, frequency Urinary characteristics: frequency, color, volume congruent with fluid intake, force of stream, ease of starting stream, ability to empty bladder Medications: high doses of aspirin, steroids, nonsteroidal antiinflammatory drugs (NSAIDs) Indigestion (Dyspepsia) Character: feeling of fullness, heartburn, discomfort, excessive belching, flatulence, loss of appetite, severe pain Location: localized or general, radiating to back, arms or shoulders R  elationship to: amount, type, and timing of food intake; menses Onset of symptoms: time of day or night, sudden or gradual Symptom relieved by antacids, change in diet, rest, activity Medications: antacids (calcium carbonate, H2 blockers, proton pump inhibitors) Nausea, Associated With Vomiting, Particular Stimuli (Odors, Activities, Time of Day, Food Intake), and Menses Vomiting Character: nature (color, bright red blood or coffee grounds, bilious, undigested food particles), quantity, duration, frequency, ability to keep any liquids or food in stomach Associated symptoms: constipation, diarrhea, fever, chills, headache, nausea, weight loss, abdominal pain or cramping, heartburn Relationship to: previous meal, change in appetite, medications, menses Diarrhea Character: watery, copious, explosive; color; presence of blood, mucus, undigested food, oil, or fat; odor; number of times per day, duration; change in pattern Associated symptoms: fever, chills, thirst, weight loss, abdominal pain or cramping, fecal incontinence Relationship to: amount, type and timing of food intake, stressful life events or daily stressors Travel history and/or ill contacts Medications: laxatives or stool softeners; antidiarrheals Constipation Character: presence of bright red blood, black or tarry appearance of stool; diarrhea alternating with constipation; accompanied by abdominal pain or discomfort Pattern: last bowel movement, pain with defecation, change in consistency or size of stool Diet: recent change in diet, intake of high-­fiber foods, change in fluid intake Medications: laxatives, stool softeners, iron, diuretics Fecal Incontinence Character: stool characteristics, timing in relation to meals, number of episodes per day; occurring with or without warning sensation Associated with: use of laxatives, presence of underlying disease (cancer, inflammatory bowel disease, diverticulitis, colitis, proctitis, diabetic neuropathy, spinal cord injury) Relationship to: fluid and dietary intake, immobilization Medications: laxatives, stool softeners, diuretics Jaundice Onset and duration Color of stools or urine Associated with abdominal pain, chills, fever CHAPTER 18 Dysuria Character: location (suprapubic, distal urethra), pain or burning, frequency or volume changes Associated fever or other systemic signs of illness: bacterial infection, tuberculosis, fungal or viral infection, parasitic infection Increased frequency of sexual intercourse or high-­risk sexual activity Amount of daily fluid intake Urinary Frequency Change in usual pattern and/or volume Associated with dysuria or other urinary characteristics: urgency, hematuria, incontinence, nocturia; increased thirst, weight loss 409 C  hange in urinary stream; dribbling Medications: diuretics Urinary Incontinence Character: amount and frequency, constant or intermittent, dribbling versus frank incontinence Associated with: urgency, previous surgery, coughing, sneezing, walking up stairs, nocturia, menopause Medications: diuretics Hematuria Character: color (bright red, rusty brown, cola-­colored); present at beginning, end, or throughout voiding Associated symptoms: flank or costovertebral pain, passage of wormlike clots, pain on voiding A lternate possibilities: ingestion of foods containing red vegetable dyes (may cause red urinary pigment); ingestion of laxatives containing phenolphthalein Medications: aspirin, NSAIDs, anticoagulants, diuretics, antibiotics Risk Factors Persons at Risk for Viral Hepatitis RISK FACTOR HEPATITIS A People who have sex with an infected individual People experiencing homelessness √ Men who have sex with men √ People who live with an infected individual HEPATITIS C √ √ √ √ √ People traveling to countries with intermediate or high prevalence √ Household members and close contacts of children adopted from countries with intermediate or high prevalence √ People with direct contact with someone who is infected √ Infants born to infected mothers People with human immunodeficiency virus infection (HIV) People with clotting factor disorders HEPATITIS B √ √ √ √ √ √ People who received clotting factor concentrates made before 1987 √ People born between 1945 and 1965 √ People who received blood transfusions or solid organ transplants before July 1992 √ People with end-­stage renal disease including hemodialysis patients √ People with chronic liver disease √ People with substance use disorders People with substance use disorders involving injecting drugs √ √ People who use intranasal drugs √ √ Healthcare and public safety workers at risk for occupational exposure to blood or blood-­contaminated products √ People receiving immunosuppressive therapy √ People who are incarcerated √ People who received body piercing or tattoos with non-­sterile instruments    √ √ √ √ Modified from “The ABCs of Hepatitis—for Health Professionals” by the Centers for Disease Control and Prevention (2019). A useful viral hepatitis risk assessment tool can be found at https:/ /www.cdc.gov/hepatitis/riskassessment/ Review of Related History E  xposure to hepatitis, use of illicit drugs, high-­risk sexual activity Medications: high doses of acetaminophen; antipsychotics, antiepileptics, antibiotics Abdomen 410 CHAPTER 18 Abdomen Examination And Findings Past Medical History G  astrointestinal disorder: peptic ulcer, polyps, inflammatory bowel disease, irritable bowel syndrome, intestinal obstruction, pancreatitis, hyperlipidemia Hepatitis or cirrhosis of the liver Abdominal or urinary tract surgery or injury Urinary tract infection: number of episodes, treatment Major illness: cancer, arthritis (steroids, NSAIDs or aspirin use), kidney disease, cardiac disease Blood transfusions Immunization status (hepatitis A and hepatitis B) Colorectal cancer or related cancers—breast, ovarian, endometrial Sexually transmitted infections Family History C  olorectal cancer and familial colorectal cancer syndromes—familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer (Lynch syndrome) Gallbladder disease K idney disease: renal stone, polycystic disease, renal tubular acidosis, renal or bladder carcinoma Malabsorption syndrome: cystic fibrosis, celiac disease Hirschsprung disease (aganglionic megacolon) Familial Mediterranean fever (periodic peritonitis) Personal and Social History N  utrition: 24-­hour dietary recall; food preferences and dislikes; ethnic foods, religious food restrictions, food intolerances, lifestyle effects on food intake, use of probiotics or dietary supplements; voluntary and involuntary weight gain or loss First day of last menstrual period A lcohol intake: frequency, type, and usual amounts Recent major stressful life events or chronic daily stressors: physical, social, and psychological changes Exposure to infectious diseases: hepatitis, influenza; travel history; occupational or environmental exposures Trauma: through type of work, physical activity, physical or emotional abuse, intimate partner violence, community, or neighborhood violence Use of illicit drugs Tobacco use—smoking: frequency, amount, duration, pack-­years Infants G  estational age and birth weight (preterm and less than 1500 g at higher risk for necrotizing enterocolitis) Passage of first meconium stool within 24 hours, constipation Jaundice: in newborn period; exchange transfusions, prolonged use of total parenteral nutrition, phototherapy; exclusively breast-­fed infant; appearance later in first month of life Vomiting: increasing in amount or frequency, forceful or projectile (pyloric stenosis), blood in emesis, back arching (gastroesophageal reflux); associated with intermittent abdominal pain or drawing up of the legs (intussusception) Diarrhea, colic, failure to gain weight, weight loss, steatorrhea (malabsorption) Abdominal distention (with or without pain) Children C  onstipation: toilet training methods; soiling; diarrhea; abdominal distention; size, shape, consistency, typical frequency, and time of last stool; rectal bleeding; painful passage of stool Dietary habits: lack of fiber in diet, change in appetite, daily fluid intake; pica (eating non-­nutritive substances like ice or soil) Abdominal pain: splinting of abdominal movement, resists movement, keeps knees flexed Psychosocial stressors: home, school, neighborhood, and peers Pregnant Patients U  rinary symptoms: frequency, urgency, nocturia (common in early and late pregnancy); burning, dysuria, odor (signs of infection) Abdominal pain: weeks of gestation (pregnancy can alter usual location of pain) Fetal movement Contractions: onset, frequency, duration, intensity; accompanying symptoms; lower back pain; leakage of fluid, vaginal bleeding Older Adults U  rinary symptoms: nocturia, change in stream, dribbling, incontinence Change in bowel patterns, constipation, diarrhea, fecal incontinence Dietary habits: inclusion of fiber in diet, change in ability to tolerate certain foods, change in appetite, daily fluid intake EXAMINATION AND FINDINGS Equipment S  tethoscope Centimeter measuring tape Marking pen Preparation To perform the abdominal examination, you will need a good light source; full exposure of the abdomen; warm hands with short fingernails; and, ideally, a comfortable, relaxed patient. Have patients empty their bladder before the examination begins; a full bladder interferes with accurate examination of nearby organs and makes the examination uncomfortable. Place the patient in a supine position with CHAPTER 18 Abdomen 411 Colon Cancer A ge older than 50 years Family history of colorectal cancer or adenomatous polyps in one or more first-­degree relatives (higher risk if relative was diagnosed before 45 years) Family history of syndromic colon cancer, including hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome from a mutation in the MLH1 or MSH2 gene, familial adenomatous polyposis (FAP) from mutations in the APC gene, which includes Turcot syndrome (associated with brain tumors), and Gardner syndrome (associated with non-­cancer tumors of skin, soft tissue and bones) Family history of Peutz-­Jeghers syndrome caused by mutations in STK11 (LKB1) gene (affected individuals often have freckles around the mouth and hamartomas in digestive tract); and MYH-­ associated polyposis (MAP) caused by mutations in the MYH gene Personal history of colon cancer, adenomatous polyps, inflammatory bowel disease (Crohn’s disease, ulcerative colitis) African American race Jews of Eastern European descent (Ashkenazi Jews) Diet: low-­fiber, high in red meat, processed meats, and foods fired, broiled, grilled increases risk; diet high in fruits and vegetable decreases risk Overweight and obesity Diet high in red meats and processed meats Smoking cigarettes Physical inactivity Heavy alcohol use Type 2 diabetes (independent of overweight/obesity)    RUQ LUQ RLQ LLQ FIG. 18.3 Four quadrants of the abdomen. (From Wilson and Giddens, 2009.) Modified from American Cancer Society (2018). arms at the sides. Approach the patient from the right side. The patient’s abdominal musculature should be relaxed to allow access to the underlying structures. It may be helpful to place a small pillow under the patient’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Make your approach slow and gentle, avoiding sudden movements. Ask the patient to point to any tender areas and examine those last. For the purposes of examination, the abdomen is commonly divided into four quadrants, first by drawing an imaginary line from the sternum to the pubis through the umbilicus. Draw a second imaginary line perpendicular to the first, horizontally across the abdomen through the umbilicus (Fig. 18.3). Alternatively, the abdomen is divided into nine regions using the following imaginary lines: two horizontal lines, one across the lowest edge of the costal margin and the other across the edge of the iliac crest, and two vertical lines running bilaterally from the midclavicular line to the middle of the Poupart ligament, approximating the lateral borders of the rectus abdominis muscles (Fig. 18.4). Choose one of these mapping methods and use it consistently. Box 18.1 lists the contents of the abdomen in each of the quadrants and regions. Men- 4 1 5 6 2 7 8 3 9 FIG. 18.4 Nine regions of the abdomen. 1, Epigastric; 2, umbilical; 3, hypogastric; 4 and 5, right and left hypochondriac; 6 and 7, right and left lumbar; 8 and 9, right and left inguinal. (Modified from Wilson and Giddens, 2009.) tally visualize the underlying organs and structures in each of the zones as you proceed with the examination. Certain other anatomic landmarks are useful in describing the location of pain, tenderness, and other findings. These landmarks are illustrated in Fig. 18.5. Examination And Findings Risk Factors 412 CHAPTER 18 BOX 18.1 Abdomen Landmarks for Abdominal Examination Examination And Findings Anatomic Correlates of the Four Quadrants of the Abdomen RIGHT UPPER QUADRANT (RUQ) LEFT UPPER QUADRANT (LUQ) Liver and gallbladder Pylorus Duodenum Head of pancreas Right adrenal gland Portion of right kidney Hepatic flexure of colon Portions of ascending and transverse colon Left lobe of liver Spleen Stomach Body of pancreas Left adrenal gland Portion of left kidney Splenic flexure of colon Portions of transverse and descending colon RIGHT LOWER QUADRANT (RLQ) Lower pole of right kidney Cecum and appendix Portion of ascending colon Bladder (if distended) Ovary and salpinx Uterus (if enlarged) Right spermatic cord Right ureter LEFT LOWER QUADRANT (LLQ) Lower pole of left kidney Sigmoid colon Portion of descending colon Bladder (if distended) Ovary and salpinx Uterus (if enlarged) Left spermatic cord Left ureter Anatomic Correlates of the Nine Regions of the Abdomen Right Hypochondriac Right lobe of liver Gallbladder Portion of duodenum Hepatic flexure of colon Portion of right kidney Right adrenal gland Right Lumbar Ascending colon Lower half of right kidney Portion of duodenum and jejunum Right Inguinal Cecum Appendix Lower end of ileum Right ureter Right spermatic cord Right ovary Epigastric Pylorus Duodenum Pancreas Portion of liver Umbilical Omentum Mesentery Lower part of duodenum Jejunum and ileum Hypogastric (Pubic) Ileum Bladder Uterus (if enlarged) Inspection Surface Characteristics Begin by inspecting the abdomen from a seated position at the patient’s right side. This position allows a tangential view that enhances shadows and contouring. Observe the skin color and surface characteristics. The skin of the abdomen will have the same expected variations in color and surface characteristics as the rest of the body. The skin may be somewhat paler if not exposed to the sun. A fine venous network is often visible. Above the umbilicus, venous return should be toward the head; below the umbilicus, it should be toward the feet (Fig. 18.6A). When abdominal vessels appear distended or more pronounced, Left Hypochondriac Stomach Spleen Tail of pancreas Splenic flexure of colon Upper pole of left kidney Left adrenal gland Left Lumbar Descending colon Lower half of left kidney Portions of jejunum and ileum Left Inguinal Sigmoid colon Left ureter Left spermatic cord Left ovary use the following procedure to determine the direction of venous return. Place the index fingers of both hands side by side perpendicularly over a vein. Press and separate the fingers, milking to empty a section of vein. Release one finger and time the refill. Release the other finger and time the refill. The flow of venous blood is in the direction of the faster filling. Flow patterns are altered in some disease states (see Fig. 18.6B and C). Unexpected skin findings include generalized color changes such as jaundice or cyanosis. A glistening, taut appearance suggests ascites (fluid accumulation in the abdomen). Inspect for bruises and localized discoloration. Areas of redness may indicate inflammation. A bluish CHAPTER 18 Xiphoid process of sternum Costal margin Midline Anterosuperior iliac spine Umbilicus Poupart ligament Superior margin of os pubis FIG. 18.5 Landmarks of the abdomen. (From Wilson and Giddens, 2009.) A B 413 CLINICAL PEARL Scars Note any scars and draw their location, configuration, and relative size on an illustration of the abdomen. If the cause of a scar was not explained during the history, now is a good time to pursue that information. The presence of scarring should alert you to the possibility of intra-­abdominal adhesions. Contour Contour is the abdominal profile from the rib margin to the pubis, viewed on the horizontal plane. The expected contours can be described as flat, rounded, or scaphoid. A flat contour is common in well-­muscled, athletic adults. The rounded or convex contour is characteristic of young children, but in adults it is the result of subcutaneous fat or poor muscle tone. The abdomen should be evenly rounded with the maximum height of convexity at the umbilicus. The scaphoid or concave contour is seen in thin adults. Inspect the abdomen for contour, symmetry, and surface motion, using tangential lighting to illuminate contour and visible peristalsis. Note the location and contour of the umbilicus. It should be centrally located without displacement upward, downward, or laterally. The umbilicus may be inverted or protrude slightly, but it should be free of inflammation, swelling, or bulge that may indicate a hernia. Inspect for symmetry from a seated position at the patient’s side, then move to a standing position behind the patient’s head, if possible. Contralateral areas of the abdomen should be symmetric in appearance and contour. Look for any distention or bulges. Generalized symmetric distention may occur as a result of obesity, enlarged organs, and fluid or gas. Distention from the umbilicus to the symphysis can be caused by an ovarian tumor, pregnancy, uterine fibroids, or a C FIG. 18.6 Abdominal venous patterns. (A) Expected. (B) Portal hypertension. (C) Inferior vena cava obstruction. Examination And Findings periumbilical discoloration (Cullen sign) suggests intra-­ abdominal bleeding. Striae often result from pregnancy or weight gain. Striae of recent origin are pink or blue in color but turn silvery white over time. Abdominal tumors or ascites can produce striae. The striae of Cushing disease remain purplish. Inspect for any lesions, particularly nodules. Lesions are of particular importance because gastrointestinal diseases often produce secondary skin changes. A pearl-­like, enlarged and sometimes painful umbilical nodule from cancer metastasis, known as Sister Mary Joseph’s nodule, may be the first sign of an intra-­abdominal malignancy (Iavazzo et al., 2012). Skin and gastrointestinal lesions may arise from the same cause or may occur without relationship to one another. See Clinical Pearl, “Scars.” Abdomen Examination And Findings 414 CHAPTER 18 Abdomen distended bladder. Distention of the upper half, above the umbilicus, can be due to tumor, pancreatic cyst, or gastric dilation. Asymmetric distention or protrusion may indicate hernia, tumor, cysts, bowel obstruction, muscle or soft tissue hematoma, or enlargement of abdominal organs. See Clinical Pearl, “Abdominal Distention.” CLINICAL PEARL Abdominal Distention You are with a patient whose abdomen is significantly distended and whose bowel sounds are hypoactive or even absent. There is no particular pain, and you feel no masses. The deep tendon reflexes are diminished. You know that the patient is on diuretics for treatment of hypertension. Think of hypokalemia as a cause of a paralytic ileus (intestinal pseudo-­obstruction): diuretics/distention/deficiency of potassium. Narcotics and hypothyroidism are two other common causes of paralytic ileus. Ask the patient to take a deep breath and hold it. The contour should remain smooth and symmetric. This maneuver lowers the diaphragm and compresses the organs of the abdominal cavity, which may cause previously unseen bulges or masses to appear. Next, ask the patient to raise his or her head from the table. This contracts the rectus abdominis muscles, which produces muscle prominence in thin or athletic adults. Superficial abdominal wall masses may become visible. If a hernia is present, the increased abdominal pressure may cause it to protrude. An incisional hernia is caused by a defect in the abdominal musculature that develops after a surgical incision, resulting in a protrusion in the area of the surgical scar. Protrusion of the navel indicates an umbilical hernia. The adult type develops during pregnancy, in long-­ standing ascites, or when intrathoracic pressure is repeatedly increased, as occurs in chronic respiratory disease. Hernias may also occur in the midline of the epigastrium due to small fascial defects in the linea alba. This type of hernia contains a bit of fat and is felt as a small, tender nodule. Most hernias are reducible, meaning that the contents of the hernia can be pushed back into place. If not, the hernia is nonreducible or incarcerated (blood supply to the protruded contents may become obstructed and require immediate surgery). In addition to hernias, separation of the rectus abdominis muscles (i.e., diastasis recti) may become apparent when the patient raises his or her head from the table. Diastasis recti occurs more often in pregnancy and the postpartum period. The condition is of little clinical significance. Movement With the patient’s head again resting on the table, inspect the abdomen for movement. Smooth, even movement should occur with respiration. Individuals with a greater inclination of the ribs show mostly costal movement, while others exhibit abdominal movement. Limited abdominal motion associated with respiration may indicate peritonitis in an ill-­appearing patient. Surface motion from peristalsis, seen as a rippling movement across the abdomen, may be seen in thin individuals but can also be a sign of intestinal obstruction. Abdominal aortic pulsations seen in the upper midline are often visible in thin adults. Marked pulsations may occur as the result of increased pulse pressure (difference between systolic and diastolic blood pressure often seen with valve insufficiency) or abdominal aortic aneurysm. Auscultation Unlike the usual sequence, always perform auscultation of the abdomen before percussion and palpation because these maneuvers may alter the frequency and intensity of bowel sounds. Bowel Sounds Lightly place the diaphragm of a warmed stethoscope on the abdomen. Some healthcare providers say they prefer to use the bell; in reality, they tend to pull the skin taut with the bell and, in effect, make a diaphragm. A cold stethoscope, like cold hands, may initiate contraction of the abdominal muscles. Listen for bowel sounds and note frequency and character. They are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. Bowel sounds are generalized so most often they can be assessed adequately by listening in one place. Loud prolonged gurgles are called borborygmi (stomach growling). Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger. High-­ pitched tinkling sounds suggest intestinal fluid and air under pressure, as in early obstruction. Decreased bowel sounds occur with peritonitis and paralytic ileus. Auscultate in all four quadrants if you have a concern. Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 minutes of continuous listening, is typically associated with abdominal pain and rigidity and is a surgical emergency. Additional Sounds and Bruits Listen with the diaphragm for friction rubs over the liver and spleen. Friction rubs are high pitched and are heard in association with respiration. Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. A bruit is a harsh or musical intermittent auscultatory sound, which may reflect blood flow turbulence and indicate vascular disease. Listen with the bell of the stethoscope in the epigastric region and in the aortic, renal, iliac, and femoral arteries. Vascular sounds are usually well localized. Keep their specific locations in mind as you listen at those sites (Fig. 18.7). Auscultate with the bell of the stethoscope in the epigastric region and around the umbilicus for a venous hum, which is soft, low pitched, CHAPTER 18 415 Percussion Notes of the Abdomen NOTE DESCRIPTION LOCATION Tympany Musical note of higher pitch than resonance Over air-­filled viscera Aorta Hyperresonance Pitch lies between tympany and resonance Base of left lung Vena cava Left renal artery Resonance Sustained note of moderate pitch Right iliac artery Left iliac artery Over lung tissue and sometimes over the abdomen Dullness Short, high-­pitched note with little resonance Over solid organs adjacent to air-­filled structures Right renal artery Right femoral artery Left femoral artery FIG. 18.7 Sites to auscultate for bruits: renal arteries, iliac arteries, aorta, and femoral arteries. (Modified from Wilson and Giddens, 2009.) and continuous. A venous hum occurs with increased collateral circulation between the portal and systemic venous systems. Percussion Percussion is used to assess the size and density of the organs in the abdomen and to detect the presence of fluid (as with ascites), air (as with gastric distention), and fluid-­ filled or solid masses. Percussion is used either independently or concurrently with palpation of specific organs and can validate palpatory findings. For simplicity, percussion and palpation are discussed separately. First, percuss all quadrants or regions of the abdomen for a sense of overall tympany and dullness (Table 18.1). Tympany is the predominant sound because air is present in the stomach and intestines. Dullness is heard over organs and solid masses. A distended bladder produces dullness in the suprapubic area. Develop a systematic route for percussion. Liver Span Now, go back and percuss individually the liver, spleen, and stomach. Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to an area of dullness because that sound change is easiest to detect. Percuss upward along the midclavicular line, as shown in Fig. 18.8, to determine the lower border of the liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark the border with a marking pen. A lower liver border that is more than 2 to 3 cm (.75 to 1 inch) below the costal margin may indicate organ enlargement or downward displacement of the diaphragm because of emphysema or other pulmonary disease. To determine the upper border of the liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Continue downward until the percussion tone changes to one of dullness; this marks the upper border of the liver. Mark FIG. 18.8 Liver percussion routes along midclavicular and midsternal lines. (Modified from Wilson and Giddens, 2009.) the location with the pen. The upper border is usually in the fifth intercostal space. An upper border below this may indicate downward displacement or liver atrophy. Dullness extending above the fifth intercostal space suggests upward displacement from abdominal fluid or masses. Measure the distance between the marks to estimate the vertical span of the liver. The usual span is approximately 6 to 12 cm (2.5 to 4.5 inches). A span greater than this may indicate liver enlargement, whereas a lesser span suggests atrophy. Age and gender influence liver size. Liver span is usually greater in males and in tall individuals. Percussion provides a gross estimate of liver size. Errors in estimating liver span can occur when the dullness of a pleural effusion or lung consolidation obscures the upper liver border. Similarly, gas in the colon may produce tympany in the right upper quadrant and obscure the dullness of the lower liver border. If liver enlargement is suspected, additional percussion maneuvers can provide further information. Percuss upward and then downward over the right midaxillary line. Examination And Findings TABLE 18.1 Abdomen Examination And Findings 416 CHAPTER 18 Abdomen Liver dullness is usually detected around the seventh intercostal space. You can also percuss along the midsternal line to estimate the midsternal liver span (see Fig. 18.8). The usual span at the midsternal line is 4 to 8 cm (1.5 to 3 inches). Spans exceeding 8 cm suggest liver enlargement. To assess the descent of the liver, ask the patient to take a deep breath and hold it while you percuss upward again from the abdomen at the right midclavicular line. The area of lower border dullness should move downward 2 to 3 cm. This maneuver will guide subsequent palpation of the organ. See Clinical Pearl, “Assessing Liver Size.” Evidence-­Based Practice In Physical Examination Liver Size: Percussion Correlates with Ultrasound Findings In a prospective study of adults with liver disease, liver size measured by physical examination (percussion along the midclavicular line) correlated with the gold standard of ultrasound (transaxial measurement). Of the 101 patients examined, the mean liver span by percussion was 8.9 cm ± 1.13 and mean liver span by ultrasound was 14.cm ± 1.6. With a correction factor of 1.6, transaxial liver span can be accurately predicted by measurement using liver percussion. This finding can be particularly helpful in resource-­limited settings.    From Loloi (2019). CLINICAL PEARL Assessing Liver Size It is best to report the size of the liver in two ways: liver span as determined from percussing the upper and lower borders, and the extent of liver projection below the costal margin. When the size of a patient’s liver is important in assessing the clinical condition, projection below the costal margin alone will not provide enough comparative information. Be sure to specify which landmarks were used for future measurement comparison (e.g., midclavicular line). Spleen Percuss the spleen just posterior to the midaxillary line on the left side as shown in Fig. 18.9. Percuss in several directions beginning at areas of lung resonance. You may hear a small area of splenic dullness from the sixth to the ninth rib. Traube space is a semilunar region defined by the sixth rib superiorly, the midaxillary line laterally, and the FIG. 18.9 Percussion of the spleen. (From Wilson and Giddens, 2009.) left costal margin inferiorly. This area is typically tympanitic because it overlies the fundus of the stomach. With splenic enlargement, tympany changes to dullness as the spleen is brought forward and downward with inspiration (splenic percussion sign). However, a full stomach, feces-­ filled intestine, or left-­sided pleural effusion may also produce dullness. Evidence-­Based Practice In Physical Examination Detecting Splenomegaly The prevalence of palpable splenomegaly in healthy individuals is low and the physical examination is more specific than sensitive (i.e., the inability to detect the spleen with palpation and/or percussion does not rule out splenomegaly). In general, when suspicion for splenomegaly is at least 10% based on history and other physical examination findings, begin with percussion of Traube space. If dullness is appreciated, palpation should follow. For thin patients, palpation may be more useful than percussion. If clinical suspicion is high, and splenomegaly is not appreciated on examination, radiologic imaging may be necessary.    From Barkun and Grover (2009). Gastric Bubble Percuss for the gastric air bubble in the area of the left lower anterior rib cage and left epigastric region. The tympany produced by the gastric bubble is lower in pitch than the tympany of the intestine. Kidneys To assess each kidney for tenderness, ask the patient to assume a sitting position. Place the palm of your hand over the right costovertebral angle and strike your hand with the ulnar surface of the fist of your other hand (Fig. 18.10A). Repeat the maneuver over the left costovertebral angle. Direct percussion with the fist over each costovertebral angle may also be used (Fig. 18.10B). The patient should perceive the blow as a thud, but it should not cause pain. For efficiency of time and motion, this maneuver is performed while examining the back rather than the abdomen. Palpation Use palpation to assess the organs of the abdominal cavity and to detect muscle spasm, masses, fluid, and areas of tenderness. Evaluate the abdominal organs for size, shape, mobility, and consistency. Stand at the patient’s right side with the patient in the supine position. Attempt to make the patient as comfortable and relaxed as possible. Use warm hands and bend the patient’s knees to help relax the abdominal muscles. Ticklishness may be a challenge (Box 18.2). Light Palpation Begin with a light, systematic palpation of all four quadrants—or nine regions—initially avoiding any areas that the patient had identified as painful. Lay the palm of your hand lightly on the abdomen, with the fingers extended A Abdomen 417 B FIG. 18.10 Fist percussion of the costovertebral angle for kidney tenderness. (A) Indirect percussion. (B) Direct percussion. BOX 18.2 Examining the Abdomen in a Ticklish Patient The ticklishness of a patient can sometimes make it difficult to palpate the abdomen satisfactorily; however, there are ways to overcome this problem. Ask the patient to perform self-­palpation, and place your hands over the patient’s fingers, not quite touching the abdomen itself. After a time, let your fingers drift slowly onto the abdomen while still resting primarily on the patient’s fingers. You can still learn a good deal, and ticklishness might be less of a problem. You might also use the diaphragm of the stethoscope (making sure it is warm enough) as a palpating instrument. This serves as a starting point, and again your fingers can drift over the edge of the diaphragm and palpate without eliciting an excessively ticklish response. Applying a stimulus to another, less sensitive part of the body with your nonpalpating hand can also decrease a ticklish response. In some instances, a patient’s ticklishness cannot be overcome, and you just have to palpate as best you can. and held together (Fig. 18.11). With the palmar surface of your fingers, depress the abdominal wall no more than 1 cm, using a light and even pressing circular motion. Avoid short, quick jabs. The abdomen should feel smooth, with a consistent softness. The patient’s abdomen may tense if you press too deeply, your hands are cold, the patient is ticklish, or inflammation is present. Guarding—tensing of the abdominal musculature to protect inflamed organs—should alert you to move cautiously through the remainder of the examination. Light palpation is useful in identifying muscular resistance and areas of tenderness. A large mass or distended structure may be appreciated on light palpation as a sense of resistance. If resistance is present, determine whether it is voluntary or involuntary by placing a pillow under the patient’s knees and asking the patient to breathe slowly through the mouth as you feel for relaxation of the rectus abdominis muscles on expiration. If the tenseness remains, it is probably an involuntary response to localized or generalized rigidity. Rigidity is a board-­like hardness of the abdominal wall overlying areas of peritoneal irritation. Moderate Palpation Continue palpation with the same hand position and technique used for light palpation, exerting moderate FIG. 18.11 Light palpation of the abdomen.With fingers extended and approximated, press in no more than 1 cm. pressure as an intermediate step to gradually approach deep palpation. Tenderness not elicited on light palpation may become evident with deeper pressure. An additional maneuver of moderate palpation is performed with the side of your hand (Fig. 18.12). This maneuver is useful in assessing organs that move with respiration, specifically the liver and spleen. Palpate during the entire respiratory cycle. As the patient inspires, the organ is displaced downward, and you may be able to feel it as it bumps gently against your hand. Deep Palpation Deep palpation is necessary to thoroughly delineate abdominal organs and to detect less obvious masses. Use the palmar surface of your extended fingers, pressing deeply and evenly into the abdominal wall (Fig. 18.13). Palpate all four quadrants or nine regions, moving the fingers back and forth over the abdominal contents. Often, you are able to feel the borders of the rectus abdominis muscles, the aorta, and portions of the colon. Tenderness not elicited with light or moderate palpation may become evident. Deep pressure may also evoke tenderness in the healthy person over the cecum, sigmoid colon, aorta, and in the midline near the xiphoid process. If deep palpation is difficult because of obesity or muscular resistance, you can use a bimanual technique with one hand atop the other, as shown in Fig. 18.14. Exert pressure with the Examination And Findings CHAPTER 18 Examination And Findings 418 CHAPTER 18 Abdomen FIG. 18.12 Moderate palpation using the side of the hand. FIG. 18.14 Deep bimanual palpation. Kidney Fecal mass (cecum) Uterus (gravid) FIG. 18.13 Deep palpation of the abdomen. Press deeply and evenly with the palmar surface of extended fingers. top hand while concentrating on sensation with the other hand. Some examiners prefer to use the bimanual technique for all patients. Masses Identify any masses and note the following characteristics: location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To determine whether a mass is superficial (i.e., located in the abdominal wall) or intra-­abdominal, have the patient lift his or her head from the examining table, thus contracting the abdominal muscles. Masses in the abdominal wall will continue to be palpable, but those located in the abdominal cavity will be more difficult to feel because they are obscured by abdominal musculature. The presence of feces in the colon, often mistaken for an abdominal mass, can be felt as a soft, rounded, boggy mass in the cecum and in the ascending, descending, or sigmoid colon. Other structures that are sometimes mistaken for masses are the lateral borders of the rectus abdominis muscles, uterus, aorta, sacral promontory, and common iliac artery (Fig. 18.15). By mentally visualizing the placement of the abdominal structures, you can distinguish between what ought to be there and an unexpected finding. Aorta Sacral promontory Fecal mass (sigmoid) Bladder FIG. 18.15 Abdominal structures commonly felt as masses. Umbilical Ring Palpate the umbilical ring and around the umbilicus. The area should be free of bulges, nodules, and granulation. The umbilical ring should be round and free of irregularities. Note whether it is incomplete or soft in the center, which suggests the potential for herniation. The umbilicus may be either slightly inverted or everted, but it should not protrude. Palpation of Specific Organs and Structures Liver. Place your left hand under the patient at the 11th and 12th ribs, pressing upward to elevate the liver toward the abdominal wall. Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest on the right midclavicular line below the level of liver dullness, as shown in Fig. 18.16A. Alternatively, you can place your right hand parallel to the right costal margin, as shown in Fig. 18.16B. In either case, press your right hand gently but deeply, in and up. Have the patient breathe regularly a few times and then take a deep breath. Try to feel the liver edge as the diaphragm pushes it down to meet your fingertips. Ordinarily, the A Abdomen 419 B FIG. 18.16 Palpating the liver. (A) Fingers are extended, with tips on right midclavicular line below the level of liver dullness and pointing toward the head. (B) Alternative method for liver palpation with the fingers parallel to the costal margin. liver is not palpable, although it may be felt in some thin persons without pathologic conditions. If the liver edge is felt, it should be firm, smooth, even, and nontender. Feel for nodules, tenderness, and irregularity. If the liver is palpable, repeat the maneuver medially and laterally to the costal margin to assess the liver contour and surface. Liver: Alternative Techniques. An alternative technique is to hook your fingers over the right costal margin below the border of liver dullness, as shown in Fig. 18.17. Stand on the patient’s right side facing his or her feet. Press in and up toward the costal margin with your fingers and ask the patient to take a deep breath. Try to feel the liver edge as it descends to meet your fingers. If the abdomen is distended or the abdominal muscles tense, the usual techniques for determining the lower liver border may be challenging, and the scratch test may be useful (Fig. 18.18). This technique uses auscultation to detect the differences in sound transmission over solid and hollow organs. Place the diaphragm of the stethoscope over the liver and with the finger of your other hand scratch the abdominal surface lightly, moving toward the liver border. When you encounter the liver, the sound you hear intensifies. Use indirect fist percussion to check for liver tenderness when the liver is not palpable and there is clinical suspicion for hepatobiliary infection. Place the palmar surface of one hand over the lower right rib cage, and then strike your hand with the ulnar surface of the fist of your other hand. The healthy liver is not tender to percussion. Gallbladder. Palpate below the liver margin at the lateral border of the rectus abdominis muscle for the gallbladder. A healthy gallbladder will not be palpable. A palpable, tender gallbladder indicates cholecystitis, whereas nontender enlargement suggests common bile duct obstruction. If you suspect cholecystitis, have the patient take a deep breath during deep palpation. As the inflamed gallbladder comes in contact with the examining fingers, the patient will experience pain and abruptly halt inspiration (Murphy sign). FIG. 18.17 Palpating the liver with fingers hooked over the costal margin. FIG. 18.18 Scratch technique for auscultating the liver. With the stethoscope over the liver, lightly scratch the abdominal surface, moving toward the liver. The sound will be intensified over the liver. Spleen. While still standing on the patient’s right side, reach across with your left hand and place it beneath the patient over the left costovertebral angle. Press upward with that hand to lift the spleen anteriorly toward the abdominal wall. Place the palmar surface of your right hand with fingers extended on the patient’s abdomen below the left costal margin (Fig. 18.19A). Use findings from percussion as a guide. Press your fingertips Examination And Findings CHAPTER 18 Examination And Findings 420 CHAPTER 18 Abdomen A B FIG. 18.19 Palpating the spleen. (A) Press upward with the left hand at the patient’s left costovertebral angle. Feel for the spleen with the right hand below the left costal margin. (B) Palpating the spleen with the patient lying on the side. Press inward with the left hand and tips of the right fingers. inward toward the spleen as you ask the patient to take a deep breath. Try to feel the edge of the spleen moving downward toward your fingers. The spleen is not usually palpable in an adult; if you can feel it, it is probably enlarged (Box 18.3). Be sure to palpate with your fingers below the costal margin so that you will not miss the lower edge of an enlarged spleen. Be gentle in palpation. In patients with splenomegaly from infectious mononucleosis, the spleen can be three to four times its normal size and there is a small risk for splenic rupture (Bartlett et al., 2016). Repeat the palpation while the patient is lying on the right side with hips and knees flexed (Fig. 18.19B). Still standing on the right side, press inward with your left hand to assist gravity in bringing the spleen forward. Press inward with the fingertips of your right hand and feel for the edge of the spleen. Again, you will not usually feel it; if you can, it is probably enlarged. Left Kidney. Standing on the patient’s right side, reach across with your left hand as you did in spleen palpation and place your hand over the left flank. Place your right hand at the patient’s left costal margin. Have the patient take a deep breath and then elevate the left flank with your left hand and palpate deeply (because of the retroperitoneal position of the kidney) with your right hand (Fig. 18.20). Try to feel the lower pole (bottom part) of the kidney with your fingertips as the patient inhales. The left kidney is ordinarily not palpable. Another approach is to capture the kidney. Move to the patient’s left side and position your hands as before, with the left hand over the patient’s left flank and the right hand at the left costal margin. Ask the patient to take a deep breath. At the height of inspiration, press the fingers of your two hands together to capture the kidney between the fingers. Ask the patient to breathe out and hold the exhalation while you slowly release your fingers (Fig. 18.21). If you have captured the kidney, you may feel it slip beneath your fingers as it moves back into place. Although the patient may feel the capture and release, the maneuver BOX 18.3 An Enlarged Spleen or an Enlarged Left Kidney? When an organ is palpable below the left costal margin, it may be difficult to differentiate an enlarged spleen from an enlarged left kidney. Percussion should help distinguish between the organs. The percussion note over an enlarged spleen is dull because the spleen displaces the bowel. The usual area of splenic dullness will be increased downward and toward the midline. The percussion note over an enlarged kidney is resonant because the kidney is deeply situated behind the bowel. In addition, the edge of the spleen is sharper than that of the kidney. A palpable notch along the medial border suggests an enlarged spleen rather than an enlarged kidney. FIG. 18.20 Palpating the left kidney. Elevate the left flank with the left hand. Palpate deeply with the right hand. should not be painful. Again, a left kidney is seldom palpable. Right Kidney. Stand on the patient’s right side, placing one hand under the patient’s right flank and the other hand at the right costal margin. Perform the same maneuvers as you did for the left kidney. Because of the anatomic position of the right kidney (slightly lower than the left), it is more commonly palpable than the left kidney. If it is FIG. 18.21 Capture technique for palpating the kidney (left kidney palpation shown). As the patient takes a deep breath, press the fingers of both hands together. As the patient exhales, slowly release the pressure and feel for the kidney to slip between the fingers. palpable, it should be smooth, firm, and nontender. It may be difficult to distinguish the kidney from the liver edge. The liver edge tends to be sharp, whereas the kidney is more rounded. The liver also extends more medially and laterally and cannot be captured. Aorta. Palpate deeply slightly to the left of the midline and feel for the aortic pulsation. If the pulsation is prominent, try to determine the direction of pulsation. A prominent lateral pulsation suggests an aortic aneurysm. If you are unable to feel the pulse on deep palpation, an alternate technique may help. Place the palmar surface of your hands with fingers extended on the midline. Press the fingers deeply inward on each side of the aorta and feel for the pulsation. In thin individuals, you can use one hand, placing the thumb on one side of the aorta and the fingers on the other side (Fig. 18.22). Evidence-­Based Practice In Physical Examination Detecting Abdominal Aortic Aneurysms Although healthcare providers can detect asymptomatic abdominal aortic aneurysms (AAAs) by palpation, the overall sensitivity is somewhat low. A negative examination does not rule out the diagnosis, especially in obese patients and in those who are unable to relax their abdominal musculature during the examination. In general, palpation has a moderate sensitivity for detecting aneurysms large enough to be referred for surgery. The U.S. Preventive Services Task Force currently recommends a one-­time screening ultrasound for AAA in men 65–75 years of age who have ever smoked.    From U.S. Preventive Services Task Force (2019). Urinary Bladder. The urinary bladder is not palpable in a healthy patient unless the bladder is distended with urine, at which time you will feel it as a smooth, round, tense mass. You can determine the distended bladder outline with percussion; a distended bladder will elicit Abdomen 421 FIG. 18.22 Palpating the aorta. Place the thumb on one side of the aorta and the fingers on the other side. a lower percussion note than the surrounding air-­fi lled intestines. Advanced Skills Ascites Assessment Ascites—a pathologic increase in fluid in the peritoneal cavity—may be suspected in the patient with risk factors (e.g., hepatitis, congestive heart failure) who has a protuberant abdomen or bulging flank when lying supine. Percuss for areas of dullness and resonance with the patient supine. Because ascites fluid settles with gravity, expect to hear dullness in the dependent parts of the abdomen and tympany in the upper parts where the relatively lighter bowel has risen. Mark the borders between tympany and dullness. There are several physical examination maneuvers used to detect the presence of ascites. Shifting Dullness. After identifying the borders between tympany and dullness, have the patient lie on one side and again percuss for tympany and dullness and mark the borders. In the patient without ascites, the borders will remain relatively constant. With ascites, the border of dullness shifts to the dependent side (approaches the midline) as the fluid resettles with gravity (Fig. 18.23). Fluid Wave. This procedure requires assistance from the patient or another examiner (Fig. 18.24). With the patient supine, ask them or another person to press the edge of the hand and forearm firmly along the vertical midline of the abdomen. This positioning helps stop the transmission of a wave through adipose tissue. Place your hands on each side of the abdomen and strike one side sharply with your fingertips. Feel for the impulse of a fluid wave with the fingertips of your other hand. An easily detected fluid wave suggests ascites. However, a fluid wave can sometimes be felt in people without ascites and, conversely, may not occur in people with early ascites. Examination And Findings CHAPTER 18 422 CHAPTER 18 Abdomen Examination And Findings Tympany Tympany Dullness Dullness FIG. 18.23 Testing for shifting dullness. Dullness shifts to the dependent side. BOX 18.4 FIG. 18.24 Testing for fluid wave. Strike one side of the abdomen sharply with the fingertips. Feel for the impulse of a fluid wave with the other hand. (From Wilson and Giddens, 2009.) Evidence-­Based Practice In Physical Examination Detecting Ascites The most sensitive maneuvers for detecting ascites are flank dullness (84%) and the presence of bulging flanks (81%), both of which have a specificity of 59%. The most specific test is the presence of a fluid wave (90%), although its sensitivity is fair (62%). Because these maneuvers may miss smaller amounts of peritoneal fluid, radiologic studies may be necessary.    Clues in Diagnosing Abdominal Pain There are all types of rules for identifying whether pain in the abdomen has significance. The following are a few of them: Patients may give a “touch-­me-­not” warning—that is, not to touch in a particular area; however, these patients may not actually have pain if their face seems relaxed and unconcerned, even smiling. When you touch, they might recoil, but the unconcerned face persists. (This sign is helpful in other areas of the body, as well as the abdomen.) Patients with an organic cause for abdominal pain are generally not hungry. A negative response to the question, “Do you want something to eat?” is likely, particularly with appendicitis or intra-­ abdominal infection. Ask the patient to point a finger to the location of the pain. If it is not directed to the umbilicus but goes immediately to a fixed point, there is a greater likelihood that this has significant pathologic importance. The farther from the umbilicus the pain, the more likely it will be organic in origin (Apley rule). If the finger goes to the umbilicus and the patient seems otherwise well to you, you should expand your differential diagnosis to include other etiologies like stress and trauma. In general, patients with nonspecific abdominal pain from a functional disorder may keep their eyes closed during abdominal palpation, whereas patients with organic disease usually keep their eyes open. Similarly, pain that is elicited with manual palpation—but not with pressing the stethoscope during auscultation—may not have an organic disorder. From Simel (2009). Pain Assessment Abdominal pain is a common symptom but sometimes challenging to evaluate. Pain that is severe enough to make the patient unwilling to move, accompanied by nausea and vomiting, and marked by areas of localized tenderness generally suggests underlying pathology. While examining the abdomen, keep your eyes on the patient’s face. The facial response is as important in your evaluation as the patient’s verbal response to questions about the quality and degree of pain (Box 18.4). Ask the patient to cough or take a deep breath. Assess the patient’s willingness to jump or to walk. Is the pain exacerbated by movement? Common causes of abdominal pain are described in Tables 18.2 and 18.3. Careful assessment of the quality (Table 18.4) and location of pain (Box 18.5) can usually narrow the possible causes, allowing you to select additional diagnostic studies with greater efficiency. Findings associated with peritoneal irritation are summarized in Box 18.6. Appendicitis is the most common indication for emergency abdominal surgery. An accurate diagnosis based on history and physical examination can facilitate immediate surgical evaluation and defini- CHAPTER 18 423 Conditions Producing Acute Abdominal Pain CONDITION USUAL PAIN CHARACTERISTICS POSSIBLE ASSOCIATED SIGNS AND SYMPTOMS Appendicitis Initially periumbilical or epigastric; colicky; later becomes localized to RLQ, often at McBurney point Guarding, tenderness; + iliopsoas and + obturator signs, RLQ skin hyperesthesia; anorexia, nausea, or vomiting after onset of pain; low-­grade fever; + Aaron, Rovsing, Markle, and McBurney signsa Peritonitis Onset sudden or gradual; pain generalized or localized, dull or severe, and unrelenting; guarding; pain on deep inspiration Shallow respiration; + Blumberg, Markle, and Ballance signs; reduced or absent bowel sounds, nausea and vomiting; + obturator + iliopsoas signs Cholecystitis Severe, unrelenting RUQ or epigastric pain; may be referred to right subscapular area RUQ tenderness and rigidity; + Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice Pancreatitis Dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks; may be referred to left shoulder and penetrates to back Epigastric tenderness, vomiting, fever, shock; + Grey Turner sign; + Cullen sign: both signs occur 2–3 days after onset Salpingitis Lower quadrant, worse on left Nausea, vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic examination Pelvic inflammatory disease Lower quadrant, increases with activity Tender adnexa and cervix, cervical discharge, dyspareunia Diverticulitis Epigastric, radiating down left side of abdomen especially after eating; may be referred to back Flatulence, borborygmus, diarrhea, dysuria, tenderness on palpation Perforated gastric or duodenal ulcer Abrupt RUQ; may be referred to shoulders Abdominal free air and distention with increased resonance over liver; tenderness in epigastrium or RUQ; rigid abdominal wall, rebound tenderness Intestinal obstruction Abrupt, severe, colicky, spasmodic; referred to epigastrium, umbilicus Distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis; bowel sounds absent (with paralytic obstruction) or hyperactive high pitched (with mechanical obstruction) Volvulus Referred to hypogastrium and umbilicus Distention, nausea, vomiting, guarding; sigmoid loop volvulus may be palpable Leaking abdominal aneurysm Steady throbbing midline over aneurysm; may penetrate to back, flank Nausea, vomiting, abdominal mass, bruit Biliary stones, colic Episodic, severe, RUQ, or epigastrium lasting 15 min to several hours; may be lower RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature Renal calculi Intense; flank, extending to groin and genitals; may be episodic Fever, hematuria; + Kehr sign Ectopic pregnancy Lower quadrant; referred to shoulder; with rupture is agonizing Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses, soft abdominal wall, mass on bimanual pelvic examination; ruptured: shock, rigid abdominal wall, distention; + Kehr and Cullen signs Ruptured ovarian cyst Lower quadrant, steady, increases with cough or motion Vomiting, low-­grade fever, anorexia, tenderness on pelvic examination Splenic rupture Intense; LUQ, radiating to left shoulder; may worsen with foot of bed elevated Shock, pallor, lowered temperature See Table 18.5 for explanation of signs.  LUQ, Left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant. a tive treatment and prevent unnecessary use of radiologic imaging. In adults, historical symptoms that increase the likelihood of appendicitis are right lower quadrant (RLQ) pain, initial periumbilical pain with migration to the RLQ, and the presence of pain before vomiting. The presence of rigidity, a positive psoas sign (see “Iliopsoas Muscle Test”), fever, and/or rebound tenderness are physical examination findings that increase the likelihood of appendicitis. Conversely, the absence of RLQ pain, the absence of the migration of the pain, and the presence of similar pain previously are historical findings that make appendicitis less likely. On physical examination, the lack of RLQ pain, rigidity, or guarding makes appendicitis less likely. Healthcare providers rarely rely on a single symptom or sign to make a diagnosis; however, the precision and accuracy of combinations of these findings have not been reported. No single finding effectively rules out appendicitis. The Evidence-­Based Practice box describes the use of clinical prediction rules to help with diagnosing appendicitis. Examination And Findings TABLE 18.2 Abdomen 424 CHAPTER 18 Conditions Producing Chronic Abdominal Pain TABLE 18.3 Examination And Findings Abdomen CONDITION USUAL PAIN CHARACTERISTICS POSSIBLE ASSOCIATED SIGNS AND SYMPTOMS Irritable bowel syndrome Hypogastric pain; crampy, variable, infrequent; associated with bowel function Unremarkable physical examination Pain associated with gas, bloating, distention; relief with passage of flatus, feces Lactose intolerance Crampy pain after drinking milk or eating milk products Associated diarrhea; unremarkable physical examination Diverticular disease Localized pain Abdominal tenderness, fever Constipation Colicky or dull and steady pain that does not progress and worsen Fecal mass palpable, stool in rectum Uterine fibroids Pain related to menses, intercourse Palpable myoma(s) Hernia Localized pain that increases with exertion or lifting Hernia on physical examination Esophagitis/ gastroesophageal reflux disease Burning or gnawing pain in midepigastrium, worsens with recumbency and certain foods Unremarkable physical examination Peptic ulcer Burning or gnawing pain May have epigastric tenderness on palpation Gastritis Constant burning pain in epigastrium May be accompanied by nausea, vomiting, diarrhea, or fever Unremarkable physical examination Modified from Dains et al. (2007). Quality and Onset of Abdominal Pain TABLE 18.4 CHARACTERISTIC POSSIBLE RELATED CONDITIONS Burning Peptic ulcer Cramping Biliary colic, gastroenteritis Colicky Appendicitis with impacted feces; renal stone Aching Appendiceal irritation Knifelike Pancreatitis Ripping, tearing Aortic dissection Gradual onset Infection Sudden onset Duodenal ulcer, acute pancreatitis, obstruction, perforation BOX 18.5 Some Causes of Pain Perceived in Anatomic Regions RIGHT UPPER QUADRANT LEFT UPPER QUADRANT Duodenal ulcer Hepatitis Hepatomegaly Lower lobe pneumonia Cholecystitis RIGHT LOWER QUADRANT Appendicitis Salpingitis Ovarian cyst Ruptured ectopic pregnancy Tubo-­ovarian abscess Renal/ureteral stone Strangulated hernia Meckel diverticulitis Regional ileitis Perforated cecum Ruptured spleen Gastric ulcer Aortic aneurysm Perforated colon Lower lobe pneumonia PERIUMBILICAL Intestinal obstruction Acute pancreatitis Early appendicitis Mesenteric thrombosis Aortic aneurysm Diverticulitis LEFT LOWER QUADRANT Sigmoid diverticulitis Salpingitis Ovarian cyst Ruptured ectopic pregnancy Tubo-­ovarian abscess Renal/ureteral stone Strangulated hernia Perforated colon Regional ileitis Ulcerative colitis BOX 18.6 Findings in Peritoneal Irritation Involuntary rigidity of abdominal muscles Tenderness and guarding Absent bowel sounds Positive obturator test Positive iliopsoas test Rebound tenderness (Blumberg sign and McBurney sign; see Table 18.5) Abdominal pain on walking Positive heel jar test (Markle sign; see Table 18.5) Right lower quadrant pain intensified by left lower quadrant abdominal palpation (Rovsing sign; see Table 18.5) Evidence-­Based Practice In Physical Examination Diagnosing Appendicitis Several clinical prediction rules have been developed based on history, physical examination, and laboratory values. The Alvarado score (also known as the MANTRELS [Migration of pain, Anorexia, Nausea/ vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation of temperature, Leukocytosis, Shift to the left] score) has been validated in children and adults and remains the most widely accepted and simplest decision tool (Wagner, 2009). The Pediatric Appendicitis Score (PAS), which uses pain with cough, hopping, or rebound tenderness with percussion in place of right lower quadrant pain, has also been used. The Ohmann score, which uses patient age, history, physical examination, and laboratory findings, is another tool to help identify patients at low, moderate, and high risk of having appendicitis. Experts recommend observation for patients at low risk, diagnostic testing, and imaging studies (computed tomography or ultrasound) for moderate-­risk patients and urgent surgical evaluation for high-­risk patients (Ebell, 2008). In a systematic review of the literature assessing 12 studies, the most valid clinical prediction rules for diagnosing appendicitis in children are the Alvarado score and the PAS (Kulik et al., 2013).    CLINICAL PEARL Ectopic Pregnancy Unfortunately, ectopic pregnancy is often not diagnosed before rupture because symptoms are mild. In a pregnant patient, a dramatic change from mild, even vague abdominal pain that is not particularly distressing to a sudden onset of severe abdominal tenderness in the hypogastric area— particularly on the involved side—is very worrisome. Rigidity and rebound may come on early or late. If a patient of childbearing age presents with vague abdominal symptoms, be sure to inquire about the patient’s sexual activity and menstrual history and strongly consider performing a urine pregnancy test. Do not disregard the mild tenderness that might be evoked. Try, at least, to anticipate the emergency of a rupture. Abdominal Signs “Classic” abdominal pain signs have often been given the name of the person who first described them. Some of the most common and historic signs are included in Table 18.5. Rebound Tenderness Several maneuvers can be used to assess for peritoneal inflammation (see Box 18.6). Rebound tenderness is identified in the following manner. Holding your hand at a 90-­degree angle to the abdomen with the fingers extended, press gently and deeply into a region remote from the area of abdominal discomfort. Rapidly withdraw your hand and fingers (Fig. 18.25). The return to position—or “rebound” of the structures that were compressed by your fingers— causes a sharp stabbing pain at the site of peritoneal inflammation (positive Blumberg sign). Rebound tenderness over McBurney point in the lower right quadrant TABLE 18.5 Abdomen 425 suggests appendicitis (positive McBurney sign). The maneuver for rebound tenderness should be performed at the end of the examination because a positive response produces pain and muscle spasm that can interfere with any subsequent examination. Because light percussion produces a mild localized response in the presence of peritoneal inflammation, assessing for rebound tenderness is considered unnecessary by many examiners. See Clinical Pearl, “Ectopic Pregnancy.” Iliopsoas Muscle Test This test is performed when you suspect appendicitis because an inflamed appendix may cause irritation of the lateral iliopsoas muscle. Ask the patient to lie supine and then place your hand over the lower right thigh. Ask the patient to raise the right leg, flexing at the hip, while you push downward (Fig. 18.26A). An alternative technique is to position the patient on the left side and ask that the right leg be raised from the hip while you press downward against it. A third technique is to hyperextend the right leg by drawing it backward while the patient is lying on the left side (see Fig. 18.26B). Pain with any of these techniques is considered a positive psoas sign, indicating irritation of the iliopsoas muscle. Obturator Muscle Test This test can be performed when you suspect a ruptured appendix or a pelvic abscess due to irritation of the obturator muscle. While in the supine position, ask the patient to flex the right leg at the hip and knee to 90 degrees. Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially (Fig. 18.27). Pain in the right hypogastric region is a positive sign, indicating irritation of the obturator muscle. Abdominal Signs Associated With Common Abdominal Conditions SIGN DESCRIPTION ASSOCIATED CONDITIONS Aaron Pain or distress occurs in area of patient’s heart or stomach on palpation of McBurney point Appendicitis Ballance Fixed dullness to percussion in left flank and dullness in right flank that disappears on change of position Peritoneal irritation Blumberg Rebound tenderness Peritoneal irritation; appendicitis Cullen Ecchymosis around umbilicus Hemoperitoneum; pancreatitis; ectopic pregnancy Dance Absence of bowel sounds in right lower quadrant Intussusception Gray Turner Ecchymosis of flanks Hemoperitoneum; pancreatitis Kehr Abdominal pain radiating to left shoulder Spleen rupture; renal calculi; ectopic pregnancy Markle (heel jar) Patient stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body; action will cause abdominal pain if positive Peritoneal irritation; appendicitis McBurney Rebound tenderness and sharp pain when McBurney point is palpated Appendicitis Murphy Abrupt cessation of inspiration on palpation of gallbladder Cholecystitis Romberg-­Howship Pain down the medial aspect of the thigh to the knees Strangulated obturator hernia Rovsing Right lower quadrant pain intensified by left lower quadrant abdominal palpation Peritoneal irritation; appendicitis Examination And Findings CHAPTER 18 CHAPTER 18 Examination And Findings 426 Abdomen A B FIG. 18.25 Testing for rebound tenderness. (A) Press deeply and gently into the abdomen. (B) Then rapidly withdraw the hands and fingers. A FIG. 18.27 Obturator muscle test. With the right leg flexed at the hip and knee, rotate the leg laterally and medially. (From Swartz, 2006.) B FIG. 18.26 Iliopsoas muscle test. (A) The patient raises the leg from the hip while the examiner pushes downward against it. (B) Alternate technique. The examiner hyperextends the right leg by drawing it backward while the patient lies on the left side. (B, From Swartz, 2006.) Ballottement Ballottement is a palpation technique used to assess an organ or a mass. To perform abdominal ballottement with one hand, place your extended fingers, hand, and forearm at a 90-­degree angle to the abdomen. Push in toward the organ or mass with the fingertips (Fig. 18.28A). If the mass is freely movable, it will float upward and touch the fingertips as fluid and other structures are displaced by the maneuver. To perform bimanual ballottement, place one hand on the anterior abdominal wall and one hand against the flank. Push inward on the abdominal wall while palpating with the flank hand to determine the presence and size of the mass (Fig. 18.28B). Infants and Children If possible, the infant’s abdomen should be examined during a time of relaxation and quiet. It is often best to do this at the start of the overall examination, especially before initiating any procedure that might cause distress (Fig. 18.29). Sucking on a pacifier may help relax the infant. The parent’s lap often makes the best examining surface as the infant or toddler will feel most secure. Sit facing the parent and conduct the abdominal examination entirely on the parent’s lap. This works well during the first several months—and often the first 2 to 3 years—of life (Fig. 18.30). Inspection Inspect the abdomen, noting its shape, contour, and movement with respiration. It should be rounded and dome-­ shaped because the abdominal musculature has not fully developed. Note any localized fullness. Abdominal and chest movements should be synchronous, with a slight bulge of the abdomen at the beginning of respiration. Note whether the abdomen protrudes above the level of the chest or is scaphoid. A distended or protruding abdomen can result from feces, a mass, or organ enlargement. A scaphoid abdomen in a patient in respiratory distress suggests that the abdominal contents are displaced into Abdomen 427 Examination And Findings CHAPTER 18 A P B R FIG. 18.28 Ballottement technique. (A) Single-­handed ballottement. Push inward at a 90-­degree angle. If the object is freely movable, it will float upward to touch the fingertips. (B) Bimanual ballottement. P, Pushing; R, receiving hand. FIG. 18.29 Positioning for examination of the infant’s abdomen. the thorax due to a congenital diaphragmatic hernia or diaphragm rupture from blunt trauma. Note any pulsations over the abdomen. Pulsations in the epigastric area are common in newborns and infants. Superficial veins are usually visible in the thin infant; however, distended veins across the abdomen are an unexpected finding suggestive of vascular obstruction or abdominal distention or obstruction. Spider nevi may indicate liver disease. Inspect the umbilical cord of the newborn, counting the number of vessels. Two arteries and one vein should be present. A single umbilical artery should alert you to the possibility of congenital anomalies. Any intestinal structure present in the umbilical cord or protruding into the umbilical area and visible through a thick transparent membrane suggests an omphalocele (see Clinical Pearl, “Umbilical Cord”). The umbilical stump area should be dry and odorless. Inspect it for discharge, redness, induration, and skin warmth. Once the stump has separated, typically by 2 FIG. 18.30 Positioning for examination of a toddler in a parent’s lap. weeks of age, serous or serosanguineous discharge may indicate a granuloma when no other signs of infection are present. Inspect all folds of skin in the umbilicus for a nodule of granulomatous tissue. If drainage persists after cord separation, consider the possibility of a patent urachal cyst or remnant. Note any protrusion through the umbilicus or rectus abdominis muscles when the infant strains. The umbilicus is usually inverted. A small umbilical hernia (i.e., the protrusion of omentum and intestine through the umbilical opening, forming a visible and palpable bulge) is a common finding in infants. Umbilical hernias can be very large and impressive (Fig. 18.31). It is ordinarily easy to reduce them temporarily by pushing the contents back into the intra-­abdominal position. Measure the diameter of the umbilical opening rather than the protruding contents to determine the size. The maximum size is general- Examination And Findings 428 CHAPTER 18 Abdomen FIG. 18.31 Umbilical hernia in an infant. (From Zitelli and Davis, 2012.) ly reached by 1 month of age, and most umbilical hernias will close spontaneously by 1 to 2 years of age. Diastasis rectus abdominis, a separation 1 to 4 cm wide in the midline, usually between the xiphoid and the umbilicus, is a common finding when the rectus abdominis muscles do not approximate each other. Ordinarily, there is no need to repair this. Although rare, herniation through the rectus abdominis muscles can be a problem. If the infant is vomiting frequently, use tangential lighting and observe the abdomen at eye level for peristaltic waves. Peristalsis is not usually visible. Peristaltic waves may sometimes be seen in thin, malnourished infants, but their presence usually suggests an intestinal obstruction such as pyloric stenosis. The abdomen of the young child protrudes slightly, giving a potbellied appearance when the child is standing, sitting, and supine (Fig. 18.32). After age 5 years, the contour of the child’s abdomen, when supine, may become convex and will not extend above an imaginary line drawn from the xiphoid process to the symphysis pubis. Respirations will continue to be abdominal until the child is 6 to 7 years old. Restricted abdominal respiration in young children can be caused by peritoneal irritation or an acute abdomen. CLINICAL PEARL Umbilical Cord A thick umbilical cord suggests a well-­nourished fetus; a thin cord suggests otherwise. FIG. 18.32 Potbellied stance of a toddler. may be appreciated in the chest. Bruits and venous hums should not be heard on abdominal auscultation. Renal bruits are associated with renal artery stenosis and rarely with a renal arteriovenous fistula. The bruit of stenosis has a high frequency and is soft; the bruit of an arteriovenous fistula is continuous. Both are difficult to hear. When suspicious (because of hypertension), try first with the patient held upright or sitting, listening at the posterior flank; then try with the patient supine, listening over the abdomen. The abdomen may produce more tympany on percussion than is found in adults because infants swallow air when feeding or crying. As with adults, tympany in a distended abdomen is usually the result of gas, whereas dullness may indicate fluid or a solid mass. Palpation Palpate the abdomen with the infant’s feet slightly elevated and knees flexed to promote relaxation of the abdominal musculature (see Clinical Pearl, “Palpating an Infant’s Abdomen”). Begin with superficial palpation to detect the spleen, liver, and masses close to the surface. The spleen is usually palpable 1 to 2 cm below the left costal margin during the first few weeks after birth. A detectable spleen tip at the left costal margin is a common finding in well infants and young children. An enlarged spleen may indicate congenital hemolytic disease or sepsis in an ill-­appearing infant. Auscultation and Percussion CLINICAL PEARL The procedures of auscultation and percussion of the abdomen do not differ from those used for adults. Bowel sounds should be present within 1 to 2 hours after birth and peristalsis is detected when a metallic tinkling sound is heard every 10 to 30 seconds. A scaphoid abdomen in a newborn with respiratory distress suggests a congenital diaphragmatic hernia. In this instance, bowel sounds Palpating an Infant’s Abdomen The abdomen of an infant can seem very tiny in relation to the size of your hand. One technique for palpating a very small abdomen is as follows. Place your right hand gently on the abdomen with the thumb at the right upper quadrant and the index finger at the left upper quadrant. Press very gently at first, only gradually increasing pressure (never too vigorously) as you palpate over the entire ab