Abdomen Examination: Techniques and Characteristics of the Skin

HUMANITAS RESEARCH HOSPITAL

Abdomen Examination Overview

Abdomen examination. Ask the patient to lie down and uncover the abdomen.

• Palpate landmarks to delineate the extent of the abdomen:

The costal margin above The pubic tubercle The anterior superior iliac spine The iliac crest belowThorax Diaphragm Costal margin Abdomen Iliac crest Anterior superior illac spine Inguinal ligament Pubic tubercle Lower limb Modified from Gray's Anatomy for Students, 2 nd Ed

Abdomen Examination: Inspection

• Inspect for:

  Symmetry Contour of the abdomen (flat, rounded, protuberant or scaphoid) Characteristics of the skin (striae, bruising or scratch marks) Umbilical scar and other scars Abdominal movements during a respiration cycle, also during a deep breath

Contour of the Abdomen

Flat Scaphoid Rounded Protuberant

Characteristics of the Skin

striae scratch marks bruising

Umbilical Scar and Other Scars

Umbilical scar and other scars

Abdomen Examination: Lumbar Vertebral Levels

. Identify landmarks to determine lumbar vertebral levels: they are useful for visualizing the positions of viscera and major blood vassels.

Transpyloric plane (medial end of 9th costal cartilage =L1 body) Subcostal plane (lower edge of 10th costal cartilage =L3 body) * Supracristal plane (highest point on the iliac crest=L4 body/spine) Intertubercular plane (tubercle of crest of ilium=L5 body) *(Umbilicus is normally on a horizontal plane that passes through the disc between L3-L4 vertebrae)

Jugular notch End of ninth costal cartilage- Transpyloric plane LI 9 LJI Subcostal plane 10 Umbilicus Highest point on ilac crest Supracristal plane LIV Intertubercular plane Tubercle of crest of ilium Public symphysis Modified from Gray's Anatomy for Students, 2 nd Ed Lower edge of tenth costal cartilage

Abdomen Examination: L1 Vertebral Level Structures

• Identify structures at the L1 vertebral level:

  The beginning and upper limit of the end of duodenum The hila of the kidneys The neck of the pancreas The origin of the superior mesenteric artery from the aorta

Jugular notch Neck of pancreas Duodenum L1 End of ninth costal cartilage- Transpyloric plane Kidney Superior mesenteric artery Pubic symphysis Modified from Gray's Anatomy for Students, 2 nd Ed

Abdomen Examination: Major Blood Vessels and Vertebral Levels

. Identify the position of major blood vassels related to the vertebral levels:

• The origin of celiac trunk at the upper border of vertebra L1
• The origin of the superior mesenteric artery at the lower

  border of vertebra L1

• The origin of renal arteries at the level of the L1-L2 vertebra
• The bifurcation of aorta into right and left common iliac

  artery at the level of L4 vertebra

• The origin of the inferior vena cava at L5 vertebral level

Jugular notch Aorta Inferior vena cava Upper border of LI Cellac trunk L1 Transpyloric plane 9 Lower border of LI Superior mesenteric artery Subcostal plane 10 LII Approximate origin of renal artery Umbilicus Lill Inferior mesenteric artery Supracristal plane LIV Bifurcation of aorta L4 Intertubercular plane LV Joining of common iliac veins to form the inferior vena cava L5 Pubic symphysis Modified from Gray's Anatomy for Students, 2 nd Ed

Abdomen Examination: Abdominal Regions

. Identify the lines dividing the abdomen into nine regions and list the regions:

• Midclavicular sagittal plane on each side
• Subcostal transversal plane
• Intertubercular transversal plane
• Three central regions: epigastric, umbilical and pubic
• Three regions on each side: hypochondrium, flank

  and groin

Mid clavicular planes Epigastric region referred pain from foregut E Right hypochondrium Left hypochondrium Subcostal plane Umbilical region -referred pain from midgut Right flank Left flank U Intertubercular plane Right groin Left groin Anterior superior illac spine Pubic region -referred pain from hindgut P Inguinal ligament Pubic tubercle Modified from Gray's Anatomy for Students, 2 nd Ed

Abdomen Examination: Quadrants and Viscera

. Identify the lines dividing the abdomen into quadrants and locate major viscera (vertical median plane and horizontal transumbilical plane):

• Liver and gallbladder in the right upper quadrant
• Stomach and spleen in the left upper quadrant
• Cecum and appendix in the right lower quadrant
• End of the descending colon and sigmoid colon in the left

  lower quadrant

. Identify the Mc Burney's point:

• one third of the way up along a line from the right anterior

  superior iliac spine to the umbilicus

Sagittal plane right left Liver Diaphragm U U Spleen RUQ Costal margin Stomach LUQ Gallbladder Transumbilical plane McBurney's point Descending colon Anterior superior iliac spine L L Appendix Sigmoid colon Inguinal ligament Pubic tubercle LLQ Modified from Gray's Anatomy for Students, 2 nd Ed

Abdomen Examination: Palpation Techniques

. Palpation: stand to the right of the patient (to the left if you are left-handed) and put the hand flat on the abdomen. Ask the patient to place the arms by the sides to help relax the abdominal wall. Ask the patient if he/she feels any pain* and start with a superficial, systematic palpation over the entire abdomen. Keep your hand and forearm on a horizontal plane, with fingers togheter and flat on the abdominal wall, palpating the abdomen with a light, gentle, dipping motion. (* If yes, start from a region away from painful area)

Abdomen Examination: Deep Palpation and Specific Organs

If the patient reports pain, start palpation from a region away from the painful area. Carry out deep palpation across all quadrants using one or two hands. Look for rebound tenderness (= Blumberg's sign) Find the painfulness of the Mc Burney appendicular point Perform palpation of the left and right kidney Perform palpation of the liver (measure the distance between the costal arch and the palpated edge; estabilish consistency; assess the edge) Perform palpation of the spleen (assess size, consistency)

Where to Find the Kidneys

XI XII Rib XI LI Rib XII Right kidney Left kidney Left ureter L3-L4 disc Transverse processes of lumbar vertebrae Modified from Gray's Anatomy for Students, 2 nd Ed

Where to Find the Spleen

IX Spleen IX Rib X Left kidney Modified from Gray's Anatomy for Students, 2 nd Ed