Abnormal Findings in Abdominal Examination

Abdominal Examination Overview

Abnormal findings in
Abdominal Examination
DR. Hamdi Al Mutori
Consultant Gastroenterologist
MRCP, FRCP (UK)Abdomin Examination:

1. Position of pt:
   - flat, at the centre of the bed ...
   - Exposure: From Symphesis pubis to Sternum
2. Inspection:
   - Any assymtry in the abdomin, shape of Abdo.
   - location of umbillicus: Inverted, flat, Everted
   formal
   -normal contor: S caphoid
   - Symmetrical
   - Capitus Medusa- above umbilicus
   5
   - obstruction of sup. vena cava
   below umbilicus
   - Portal hypertention
3. Palpation: - before touch ask for any pain ...
   - Cover all 9 regions of Abdomin
   - Start with Superficial Palpation:
   DIAPHRAGM
   Right
   Left
   hypocondriac
   region
   Epigastric
   region
   hypochondriac
   region
   ITeft
   Umbilical
   lumbar
   lumbar
   region
   region
   region
   Right
   Left
   iliac
   Hypogastric
   region
   region
   region
   - then do deep palpation with Same areas
   Superficial :
   Tenderness, Mass, Temperature
   Palpation:
   go with
   clock wise
   -umbilicus is
   the last region
   Deep:
   to be examin
   - Organomegaly
   -Palbable liver or Spleen
   - Any scars or dillated veins

Examination of Organs

Liver Examination

RightExamination of organs:
I. liver:
- Right hand flat on abdo ... wall, start from R. illiac fossa with
tip of your fingers more to the R. hypochondrium (fingers parallel to
rectus m. )
- instruct pt to take deep breath
- edge of liver:
upper border:
at 6th intercostal space
where on percasion the sound convert from Resonance
to Dullness
The normal upper level of the liver is at the level of the right nipple, whereas the lower margin of the liver is
at the right costal margin
> measure use tabe 10 cm

Spleen Examination

-Examin the spleen:
from around the umblicas, move diagonally toward left hypochondrium
Cask deep breath, move your hand superficially & Deep, 1cm at bar)
Is you have to palpate along the costal margin as enlargement of spleen could
be variable ...
L, if you can't palpate the spleen, turn the pt on Right side and palpate the Spleen again ...
- if you face any mass: Percuse 2 fingers below or above the mass
then percuss over the mass , to compare b/w
the 2 areas ...

Kidney Examination

Kidney: 2 Kidnies - R & L Side
Put your left hand behind
the back, other hand palpate
the kidney below intercostal margin
آخر
Rec
معلومة

Session Learning Objectives

• Identify abnormal signs on General Physical
  Examination
• Identify abnormal signs on abdominal inspection
• Identify abnormal signs on abdominal palpation
• Analysis of abdominal mass
• Causes of organomegaly and ascites
• Identify abnormal signs on abdominal percussion
• Identify abnormal signs on abdominal auscultation

General Examination Findings

Patient's General Appearance

General Examination
Note the patient's general appearance
In pain > Peptic ulcer disease (PUD), biliary stone
Altered mental state -> Hepatic encephalopathy
usually present with
Hyperpigmentation of the face > Hemochromatosis-> Chronic liver disease
-
--Nutritional State:
Cachectic/thin ->
GI malignancy, Malabsorption
Well nourished
Obese (truncal or generalized) > risk for gastro intestinal
----
GI

Hands Inspection

Inspect the patient's hands
Clubbing
IBD, Celiac disease, Liver cirrhosis
Iron defesciency anemia
Koilonychias (spoon-shaped nails) > IDA (PUD, Malignancy, Malabsorption)Due to hypoalbunemia
Signs of chronic liver disease > leukonychia (white nails) and palmar erythema,
clubbing, flapping tremor, Dupuytren's contracture.

Eyes Inspection

Cleus in General physical examination
Rec
Inspect the patient's eyes
Pallor -> anemia (GI malignancy, Malabsorption, GI bleeding, chronic illness)
Jaundice ->
Acute or chronic liver disease, cholestasis (Biliary stone, pancreatic tumor)
- Retecular RBCS Count: Prehepatic
KF
Kaiser Fleischer's ring
> Wilson's disease
Wilson's disease is a genetic disorder characterized by
the excess build-up of copper in the body. Symptoms are
typically related to the brain and liver. Liver-related
symptoms include vomiting, weakness, fluid build-up in
the abdomen, swelling of the legs, yellowish skin, and
itchiness.
inflammation
bile duct
Xanthomatous deposits
> Primary biliary cholangitis

Jaundice Causes

In the examination of liver-related issues, the conditions can be categorized into
prehepatic, intrahepatic, and posthepatic causes of jaundice. Here are the main
features associated with each category:

Prehepatic Causes of Jaundice

• Definition **: Conditions that occur before the liver processes bilirubin.
  ** Typical Causes **: Hemolytic anemia, sickle cell disease, thalassemia.
• ** Key Features **:
• Elevated unconjugated (indirect) bilirubin levels.
• Normal or low conjugated (direct) bilirubin levels.
• Increased urine urobilinogen.
• Anemia may be present, depending on the underlying cause.

Intrahepatic Causes of Jaundice

• Definition **: Conditions that affect the liver's ability to process bilirubin.
• ** Typical Causes **: Hepatitis (viral, alcoholic), cirrhosis, liver tumors.
• ** Key Features **:
• Elevated levels of both unconjugated and conjugated bilirubin.
• Possible elevation of liver enzymes (ALT, AST).
• Possible presence of hepatomegaly or splenomegaly.
• Urine may contain bilirubin, indicating conjugated bilirubin in circulation.

Posthepatic Causes of Jaundice

• ** Definition **: Conditions that occur after bilirubin has been processed by the
  liver.
• ** Typical Causes **: Biliary obstruction (gallstones, tumors), strictures.
• ** Key Features **:
• Elevated conjugated (direct) bilirubin levels.
• Normal or low unconjugated (indirect) bilirubin levels.
• Dark urine (due to bilirubin excretion).
• Pale stools (due to lack of bilirubin reaching the intestines).

Jaundice Summary Table

### Summary Table

Oral Cavity Examination

Examine the patient's oral cavity
Fetor hepaticus -> a distinctive 'mousy' odor of dimethyl sulphide on the breath, which is
evidence of portosystemic shunting (with or without encephalopathy)
Also, Angular Stomatitis
glositis
Signs of IDA -> Angular cheilitis (painful cracks at the corners of the mouth) and atrophic
mascular
glossitis (pale, smooth tongue). The tongue has a beefy, raw appearance in folate and
vitamin B
12
deficiency> Megaloblastic Anemia, Macrocytic anemia
Mouth and throat aphthous ulcers are common in celiac disease and IBD > not specific
most common in ladies:
-bez of Stress

Neck Palpation

Palpate the patient's neck
Gastric and pancreatic cancer may spread to cause enlargement of the left supraclavicular
lymph nodes (Troisier's sign).
More widespread lymphadenopathy with hepatosplenomegaly suggests lymphoma.

Abdominal Examination: Inspection

Inspection Categories

ABDOMINAL EXAMINATION
INSPECTION
(7S)
· Symmetrical & movement with
respiration.
· Scar.
Striae.
· Stoma.
· Shape of the umbilicus (inverted,
flat, exerted).
· Shape of the flank (full, straight,
empty).
· Skin lesions.
(4P)
· Prominent veins (caput medusa,
SVC obstruction)
· Visible Pulsation (aortic
aneurysm).
· Visible Peristalsis (NL in thin,
intestinal obstruction).
· Pigmentation (Cullen's sign,
Gery-Turner's sign)Flat or slightly scaphoid.
Symmetrical => normal shape of
Abdomin ...

Abdominal Distension

Abdominal Acitis, Accumulation of fluid in
the abdominal Cavity
Abdominal distension
If the abdomen is distended, is this generalized or localized?
In obesity, the umbilicus is usually sunken;
In ascites, it is flat or everted.
Look tangentially across the abdomen and fro
bed for any asymmetry associated with a localized mass, such as
an enlarged liver or bladder.

Localized Distension

Localized distension
gall bladder
pick them
GB
on Palpation
Sagoint gall
bladdar

Scars

Scars
for cholesystomy
Kocher
Midline
Laporotomy
Nephrectomy
McBurneys
Pfannenstiel
->Sergical
scar
Mercedes
Scare
9
Liver Transplant
Hernia incision

Striae

Striae
-> diffuse distention of
Abdominal Skin
a major symptoms of
Cushing Synd.Rec
- -. Dilated tertous abdominal wall
RecRey

Surgical Stomas

Surgical stomas
an opening surgically created, which connects a portion of
the body cavity like colon of gastrointestinal tract to the
outside environment
Permenant or Temperorary
STOMa

Bruises and Signs

Bruises. >seve
>sever
1
1
bacterial
bancreatitis
Bluish color at the umbilicus is
Cullen's sign - a sign of bleeding in
the peritoneum.
Bruises on the flanks are Grey
Turner's sign (retroperitoneal
bleeding - e.g. from inflamed
pancreas).
Bruising may also indicate a
bleeding tendency.

Visible Prominent Veins

Visible prominent veins
Usually indicate
intestinal obstruction

Visible Peristalsis

Visible peristalsis
Visible peristalsis is usually
abnormal- a sign of intestinal
obstruction, unless the patient is
emaciated.

Hernias

Hernias
epigastric
umbilical
inguinal
femoral

Abdominal Palpation

Superficial Palpation Observations

Palpation
Observations on superficial palpation
▪
Tenderness : discomfort and resistance to palpation
. Rebound tenderness-when press for while on abdomin,
then remove the press,
Pt will experience sharpe Pain ....
▪
Guarding is voluntary spasm when the physician presses on to the
, take deep breath, Flex his leg
abdominal wall. It is sign of tenderness or inflammation
Rigidity is involuntary spasm (board-like rigidity) Present all the time.
▪
Guarding can often be overcome by having the patient purposely relax the
muscles; rigidity cannot be. Rigidity is thus a clear-cut sign of peritoneal
inflammation.

Gallbladder Tenderness

GALL BLADDER
To feel for gallbladder tenderness
(in cholecystitis):
Murphy's sign
common with pt with
inflammed gall bladar
(cholycestitis)

Abdominal Mass Characteristics

MASS IN ABDOMEN
Site
Size
Shape
Rec
Surface
Consistency-How do feel it? soft , hard, Firm >
Pulsatile
Fixity
)
> to the skin arround it ...
Trans elimination
Tenderness
Temperature
Intraabdominal/abdominal wall ? Rec

Palpable Abdominal Abnormalities

Palpable abnormalities in the abdomen
Epigastric mass
· Gastric cancer
· Pancreatic cancer
· Aortic aneurysm
Hepatomegaly
· Palpable liver not always enlarged
.
· Always percuss upper border
· Palpable gallbladder
Generalised distension
1
· Fluid (ascites)
· Flatus (obstruction/ileus)
· Faeces (constipation)
1
Left upper quadrant mass
· ? Spleen:
Edge
Can't get above it
Moves towards right iliac fossa
on inspiration
Dull percussion note to
9th-11th ribs mid-axillary line
Notch
· ? Kidney:
Rounded
Can get above it
Moves inferiorly on inspiration
Resonant to percussion above it
Ballottable
Tender to palpation
· ? Peritonitis:
Guarding
· Fat (obesity)
1
1
-
-
-
Rebound
Absent bowel sounds
Rigidity
· ? Obstruction:

Enlarged Organs

Enlarged organspt with RHF - will have pulsatile liver
Hepatic enlargement
Chronic parenchymal liver disease
. Alcoholic liver disease
· Hepatic steatosis
· Autoimmune hepatitis
· Viral hepatitis
· Primary biliary cirrhosis
Malignancy
. Primary hepatocellular cancer
. Secondary metastatic cancer
Right heart failure
. -
Haematological disorders
· Lymphoma
· Myelofibrosis
· Leukaemia
· Polycythaemia
Rarities
· Amyloidosis
· Sarcoidosis
. Budd-Chiari syndrome
· Glycogen storage disorders