The abdominal examination is performed with the patient lying supine. The examiner should begin by giving his or her formal introduction and then approach the patient and perform the examination from the right side of the patient. The initial steps are described as follows:
- Wash hands thoroughly with soap and water. An alcohol-based sanitizer can also be used. It is essential for the examiner to ensure that his or her hands are dry and warm before starting the examination.
- Identify the patient.
- Briefly explain the reason for and the steps of the examination and take consent from the patient.
- Inquire if the patient has any pain.
- Position the patient. The patient is initially positioned at 45 degrees for comfort but a supine position is necessary for palpation of the abdomen. Keeping a pillow under the patient’s head or knees can be considered.
- The ideal exposure is from the nipples to the knees, but this is sometimes not practically possible. During most clinical examinations, the exposure is from the nipples to the lower abdomen.
Begin with the general inspection of the patient and then proceed to the abdominal area. This should be performed at the foot end of the bed. The general inspection can give multiple clues regarding the diagnosis of the patient, for example, yellowish discoloration of the skin (jaundice) indicates a possible hepatic abnormality. It is important to note any medical equipment for monitoring and/or treatment attached to the patient or present in the bed space. These may include catheters, pulse oximeter, oxygen mask and tubing, nasogastric tube, central lines, and total parenteral nutrition lines.
Examination of the hands and arms:
The hands should be examined for the presence of pallor and jaundice. The outstretched hands are observed for the presence of tremors. A flapping tremor (asterixis) indicates hepatic encephalopathy and may be present in cirrhosis. A non-specific tremor may also indicate alcohol withdrawal. The radial pulse should be examined and the blood pressure should be recorded. The hands and arms should be examined for evidence of intravenous drug use which may be present as injection site marks. The presence of an arteriovenous fistula indicates renal replacement therapy and should be inspected and palpated.
Examination of the face and neck:
The examination should begin by asking the patient to look straight ahead. The eyes should be examined for scleral icterus and conjunctival pallor. Additional findings may be present, for example, a Kayser-Fleischer ring, a brownish-green ring at the periphery of the cornea may be seen in patients of Wilson’s disease due to excess copper being deposited at the Descemet’s membrane. The ring can be best viewed under a slit-lamp. Peri-orbital plaques due to lipid deposition called xanthelasmas may be present in chronic cholestasis. Angular cheilitis, inflammatory lesions around the corner of the mouth indicate iron or vitamin deficiency which may be due to malabsorption. The oral cavity should be examined in detail. The presence of oral ulcers may indicate Crohn’s disease or celiac disease. A pale, smooth, and shiny tongue indicates iron deficiency and a beefy, red tongue is seen in vitamin B-12 and folate deficiency. The smell of the patient’s breath is itself indicative of different disorders, for example, fetor hepaticus, a distinctive smell indicating liver disorder or a fruity breath, pointing towards ketonemia.
The examiner should stand behind the patient to examine the neck. It is important to palpate for lymphadenopathy in the neck and the supraclavicular region. The presence of the Virchow’s node may indicate the possibility of gastric or breast cancer.
The abdominal examination itself consists of four basic components that include inspection, palpation, percussion, and auscultation.
Four Examination Components
Inspection of the abdomen:
It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Distension of the abdomen could be present due to small bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation, abdominal aortic aneurysm, and pregnancy. The presence of any abnormal masses may indicate umbilical hernia, ventral wall hernia, femoral hernia, or inguinal hernia, depending on the location. The patient may be asked to cough, which results in raised intraabdominal pressure, causing the hernia to become more prominent.
A patch of ecchymosis may be visible on any part of the abdomen on inspection and usually indicates internal hemorrhage. The ‘Grey Turner sign’, the ecchymosis of the flank and groin seen in hemorrhagic pancreatitis and the ‘Cullen's sign’, that is a periumbilical ecchymosis from retroperitoneal hemorrhage or intra-abdominal hemorrhage. The presence of scars may be due to surgical or traumatic injuries (gunshot wounds or stab wounds) and pink-purple striae may indicate Cushing's syndrome. Vein dilation may be present that indicates portal hypertension or vena cava obstruction. ‘Caput Medusa’ that are distended veins flowing away from the umbilicus, have a 90% specificity in detecting hepatic cirrhosis. Sinuses and fistulae, if present, usually occur as a result of a deep infection or an infection of a surgical tract. If a stoma is identified, various features should be noted to identify the type of stoma. These include the site and appearance of the stoma and the contents of the stoma bag.
Palpation of the abdomen:
Ensure the following before beginning the palpation:
- The patient is in a supine position, with the head relaxed and the arms on the side of the body. This is necessary to completely relax the abdominal wall muscles.
- The patient has mentioned if he is experiencing any pain in the abdominal area and has located the point of maximal pain.
The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.
The examiner should begin with superficial or light palpation from the area furthest from the point of maximal pain and move systematically through the nine regions of the abdomen. If no pain is present, any starting point can be chosen. Several sources mention that the abdomen should first gently be examined with the fingertips. Crepitus, a crunching sensation, if present, indicates the presence of air in the subcutaneous tissue. Any irregularity in the abdominal wall may also be noted which may be due to a hernia or a lipoma.
Deep palpation should be performed in the same position of the hand and forearm relative to the patient’s abdomen but with the application of firm and steady pressure. It is important to press slowly as pressing too fast may trap a gas pocket within the intestinal lumen and distend the wall resulting in false-positive tenderness. During palpation, tenderness should be noted which may present as guarding. This may be a voluntary process, in which the patient voluntarily tightens the abdominal muscles to protect a deeper inflamed structure, or an involuntary process, where the intra-abdominal pathology has progressed to cause rigidity of the abdominal muscles. Engaging the patient in conversation may help differentiate between voluntary and involuntary guarding, as the former disappears when the attention of the patient is diverted. Tenderness in any of the nine regions of the abdomen may indicate an inflammation of the organs underneath.
Examination of the different areas of the abdomen may indicate separate disease processes. Tenderness of the epigastrium may be due to gastritis or early acute cholecystitis from visceral nerve irritation. Other signs that may be appreciated include the presence of a pulsatile mass from an abdominal aortic aneurysm or abdominal wall defects, seen in muscle diastasis. Left lower quadrant tenderness may be a presenting sign of diverticulitis in the elderly. A mass, if present may be due to a tumor of the colon, a left ovarian cyst, or ectopic pregnancy. In the elderly, constipation leading to impacted feces may also present with a mass palpated in the left lower quadrant.
In the right lower quadrant, tenderness over McBurney's point implies possible appendicitis, inflammation of the ileocolic area that may be due to Crohn's disease or an infection with bacteria that have a predilection for the ileocecal area such as Bacillus cereus and Yersinia enterocolitica.
If tenderness is appreciated at the McBurney’s point, the following maneuvers to identify possible appendicitis should be performed:
- Rovsing's sign: While standing on the patient's right side, gradually perform deep palpation of the left lower quadrant. Increased pain on the right suggests right-sided peritoneal irritation.
- Psoas sign: Place your hand just above the patient's right knee and ask the patient to push up against your hand. This results in contraction of the psoas muscle which causes pain if there is an underlying inflamed appendix.
- Obturator sign: This is performed by flexing the patient's right thigh at the hip with the knee flexed and rotating internally. Increased pain at the right lower quadrant suggests inflammation of the internal obturator muscle from overlying appendicitis or an abscess.
The examiner should palpate the periumbilical area for any defect, mass, or an umbilical hernia. The patient can be asked to cough or bear down to feel for any protruding mass. The inguinal and the suprapubic area should not be missed. If an inguinal or a femoral hernia is present, a detailed examination should be done. A mass palpated in the suprapubic area may be due to a uterine pathology such as uterine fibroids or uterine cancer in females or bladder mass or distension in both males and females.
The next step is to proceed to palpation of the abdominal organs. To palpate the liver, the examiner must place the palpating hand below the right lower rib margin and have the patient exhale and then inhale. With mild pressure, the liver margin may be felt under the hand as a gentle wave. It is important to feel for any nodularity or tenderness. For palpation of the gallbladder, it is recommended that the examiner gently place the palpating hand below the right lower rib margin at the midclavicular line and ask the patient to exhale as much as possible. As the patient exhales, the palpating hand should slowly be pushed in deeper and the patient should then be asked to inhale. The sudden cessation of inspiration due to pain characterizes a positive ‘Murphy sign’ seen in acute cholecystitis. To start palpation of the spleen, the hand should be placed in the right lower quadrant and moved toward the splenic flexure. When the hand reaches the left lower rib margin and the patient should be asked to exhale and then take a deep breath in. With mild pressure, the spleen may be felt under the hand as a firm mass if splenomegaly is present. There are multiple causes of splenomegaly and must be correlated with the patient’s history and other physical findings.
A two-handed technique with the patient in the supine position is used to palpate the kidneys. To palpate the right kidney, place the left hand underneath the patient's back pushing the kidney forward and the right hand below the right lower rib margin between the mid-clavicular line and the anterior axillary line, gently pushing down. This technique is called ‘balloting’. To palpate the left kidney, the examiner should lean onto the pateint with the left hand placed around the flank into the patient's loin and place the right hand on the abdomen below the left lower rib margin between the mid-clavicular line and the anterior axillary line. Enlarged or cystic kidneys may be appreciated using this technique.
To estimate the size of the aorta, the patient should be asked to lie down supine and completely relax the muscles of the abdominal wall. A two-handed technique is preferred, with the left and right hands placed along the lower borders of the left and right costal margins, respectively, and the fingers pointing toward the umbilicus. A generous amount of skin should be left between the two index fingers. The aorta can be palpated as a pulsatile mass, and its width can be recorded. A width greater than 2.5 cm indicates an aneurysm and an abdominal ultrasound should be performed to further investigate it. However, an enlarged aneurysm may still not be appreciated by palpation due to body habitus.
Percussion of the abdomen:
A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly). To appreciate splenic enlargement, the percussion of the Castell's point (the most inferior interspace on the left anterior axillary line) as the patient takes a deep inspiration, may be helpful. A percussion note that changes from tympanitic to dull as the patient takes a deep breath suggests splenomegaly, with an 82% sensitivity and an 83% specificity. Splenomegaly occurs in trauma with hematoma formation, portal hypertension, hematologic malignancies, infection such as HIV and Ebstein-Barr virus, and splenic infarct.
Percussion is necessary to assess the size of the liver, percussion downward from the lung to the liver and then the bowel, the examiner may be able to demonstrate the change in percussion note from resonant to dull and then tympanitic. Shifting dullness, present in ascites, should be demonstrated by percussing from the midline to the flank till the note changes from dull to resonant and then having the patient roll over on their side towards the examiner and wait for ten seconds. This allows any fluid, if present, to move downwards. The percussion should then be repeated, moving in the same direction. If the percussion note changes to resonant, shifting dullness is positive. With the patient sitting up, the right and left costal-vertebral angles can be percussed to determine if there is any renal tenderness as in pyelonephritis.
Auscultation of the abdomen:
The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance.
The diaphragm should be placed above the umbilicus to listen for an aortic bruit and then moved 2 cm above and lateral to the umbilicus to listen for a renal bruit. The presence of the former indicates an abdominal aortic aneurysm and the latter indicates renal artery atherosclerosis. These clinical findings must be correlated with the remaining physical examination and history to formulate a preliminary diagnosis. If there is a clinical suspicion of delayed gastric emptying, a maneuver, that is sometimes uncomfortable for the patient, may be performed. The examiner should place the stethoscope on the abdomen and hold the patient at the hips and shake him from side to side. If splashing sounds, called the ‘succussion splash’ are audible, the test is positive.
Digital rectal examination:
The abdominal examination ends with the digital rectal examination. After explaining the procedure, taking the patient’s consent, and maintaining the patient’s privacy, the rectal examination should be performed with the proper technique. The examiner should place his or her lubricated, gloved finger against the patient’s rectal sphincter muscle to dilate the sphincter and slowly slide it into the rectum palpating for hemorrhoids, fissures, or foreign bodies. The prostate for size and firmness should be assessed. Tenderness or bogginess suggests prostatitis and nodules may suggest cancer. After the finger is removed it should be inspected for signs of active bleeding or melena. Perform a Guaiac test if bleeding is suspected. Examination of the external genitalia should also be performed.