3.5 Abdominal examination – (El) examen abdominal
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Abdominal Examination
Introduction A well conducted examination of the abdomen will reveal a great deal of information but poorly performed it can reveal nothing and loose the patient’s confidence if you hurt him. You will develop your own technique with time and adjust it according to circumstances. Emphasis will be different if you suspect an acute abdomen or a mass.
The MRCGP is often criticised for having no clinical component. In the MRCP and FRCS attention to technique is essential for success. Getting the right answer by the wrong technique will result in failure but the wrong answer by the correct technique can still produce a pass.
Preparation The patient must be adequately disrobed and lying comfortably with the head just a little elevated and well supported. A warm room, comfortable patient and a calm and reassuring approach from the doctor will create the necessary relaxation. If the patient is tense very little information can be gained and if you hurt the patient there will be tension and loss of confidence. You should always explain what you're going to do, and why you're going to do it. Offer a chaperone for both sexes.
Your own comfort is also important. Sitting on the edge of the couch or bed, can be construed as unprofessional, an adjustable chair is preferable. If you are stooped you will be thinking about your back rather than your examination.
Obesity and a pendulous abdomen make the exercise very difficult. You may feel like the fairytale princess asked to feel a pea under 20 mattresses.
Technique
General inspection Start with inspection as always but not the abdomen.
Does the patient look unwell?
Is pain apparent? If the patient is writhing it is probably colic in some form. The person with peritonitis lies still.
Is there jaundice? (may not be visible in some artificial light).
Is there evidence of dehydration?
Are there signs of weight loss?
Leaning over the face to inspect respiration, can be used to smell the patient's breath.
Look at the hands.
Is there clubbing (ulcerative colitis, Crohn's, coeliac disease, cystic fibrosis or other maladsorption syndromes) or koilynychia (iron deficiency)?
Are there liver palms or even a flapping tremor? (Asterixis is "lapse of posture", or negative clonus exhibited by flapping tremor at wrist, metocarpalphalangeal joints and hips. It can also be seen in tongue, foot, or any skeletal muscle. Take the fingers in your palm and hyperextend them. A positive flap is a flexion-extension movement at a slow rate. Alternatively, with the patient relaxed, supine and knees bent, feet flat on couch, the knees may flap as the legs fall to the side). It is not specific for hepatic pre-coma, but occurs also in uraemia, respiratory failure, electrolyte disturbance, and drug intoxication amongst other causes.
Are the hands warm and well perfused or cold and clammy?
Don't forget the supraclavicular fossa (Trosier's sign - L supraclavicular lymphadenopathy from metastatic thoracic or abdominal, also known as Virchow's node when applied to either left or right).
Inspection of the abdomen Now look at the abdomen.
Note any distension, abdominal respiration, bruising, scars, colour, signs of weight loss or dehydration and any visible peristalsis. A mass may be apparent. Inspect with the head raised, tensing the abdominal muscles, and with the "blowing test" or valsalva for lateral regions (alternatives include: Carnett's method of straight leg raising, and Kamath's test of straining as if at stool).
Palpation Now palpate. A pillow under the knees may aid relaxation of abdominal musculature. In refractory cases resting the palm of the left hand firmly on the lower sternum will encourage abdominal respiration and relaxation (Nicholson's method). As you do, be aware of the response of the patient’s abdominal muscles and frequently check the face for signs of discomfort. Use the flat of your hand, for deep palpation the flexor surfaces of the fingers, sometimes superimposing the other hand's fingers for even distribution of pressure (this method can reach progressively deeper through each relaxation phase of respiration), and gliding palpation using the finger pulps typically across loops of the large intestine. Develop your own routine but the following is useful to detect enlargement of liver or spleen, modified to start diagonally opposite the site of any pain.
Start in the right iliac fossa and move gently up to the right hypochondrium. Palpation should be gentle but deep if there is no pain. Ask the patient to take a deep breath as you try to tip the liver edge (firmer palpation under the ribs elucidates Murphy's sign of inhibition of respiration with pain as the inflamed gall-bladder touches the fingertips or ultrasound probe, Moynihan's method uses the left hand resting on the costal margin with the thumb exerting moderate pressure over the gall-bladder. A single localised tender spot on the 8th rib edge, sometimes higher or lower, can be associated with cholecystitis, as can hyperaesthesia below the right scapula - Boas's sign). Repeat the action moving from the right ilac fossa to the left hypochondrium, again requesting a deep breath at the costal margin. Repeat from the hypogastrium to the epigastrium and the left iliac fossa to the left costal margin.
Note the response of the patient as you do so. Guarding is the reflex tensing of the abdominal muscles over the painful area and represents peritonism. Some argue that rebound tenderness is unnecessary to elicit as it is too painful and guarding gives the same information. If guarding is obvious do not attempt it but if guarding is dubious press down over the point and then suddenly withdraw the hand. Look at the patient’s face as you do so. You do not have to ask if it hurt. The answer will be obvious.
Now try to palpate the kidneys. Reach the left hand round to the right loin and push forward using the right hand to try to tip the kidney. Now reach for the left loin with the right hand, pushing forward to the left hand to try to feel the left kidney. In a very thin person who relaxes well it may be just possible to feel a kidney especially on the left but usually it is abnormal. If the kidney is affected it may be tender as in pyelonephritis.
To detect tumours arising from the pelvis like an enlarged bladder or an ovarian cyst, examine the abdomen as before but starting above the umbilicus and work down to the pubis. Missing a gravid uterus is very embarrassing.
To detect a spleen, get the patient to lie on the right side, facing towards you, and palpate up into the left hypochondrium, asking for deep breaths on the way. If you can just feel the tip of the spleen it is at least one third as big again as normal. Alternatively a bimanual method can be used with the left hand on the lateral aspect of the costal margin gently pressing and drawing down a loose fold of skin under the costal margin, with the right hand on the abdominal wall just below the rib margin, fingers pointing towards the spleen. Just near the end of inspiration draw the hands slightly together and dip with the fingertips - the edge of the spleen will ride over the fingertips. The Middleton method of putting the patient's arm behind the left lower ribs will bring the spleen forward, and standing at the left side of the patient's head, tucking the fingers under the costal margin can sometimes be helpful in uncertainty.
Hernia Check for hernia.
Inguinal hernia is more common in men than women.
Femoral hernia is more common in women than men.
In women inguinal hernia is more common that femoral.
Percussion Percussion of the abdomen can be very useful. A generally resonant abdomen suggests much flatus whilst solid or liquid under the fingers will be dull. Sometimes it is helpful to use percussion to define the edge of the liver. It can also be used to delineate a bladder or other tumour arising from the pelvis.
Ascites Shifting dullness is used to detect ascites. Fullness of the flanks may be the first indication. Percuss just above the umbilicus and repeat moving down towards one side. When the sound become dull keep your fingers there to mark the spot and ask the patient to move on to the opposite side. Give a short while for the fluid to sink and percuss again. If it is now resonant that is a positive sign. Persuss down until dullness is reached again. Repeat on the other side. False positives do occur, probably from dilated coils of small intestine reacting to gravity. At least 1500ml of fluid must be present for a result. An ultrasound scan will detect much less fluid with greater certainty.
A succussion splash is much more difficult to demonstrate. It needs a 3rd hand in the examination and probably rather more fluid.
Occasionally an ovarian cyst is so large as to fill the abdomen invalidating percussion as a distinguishing test. Blaxland describes the phenomena of transmitted aortic pulsation if a ruler is laid across the abdomen above the anterior superior iliac spines, and pressing the fingers of both hands firmly towards the lumbar spine. In an ovarian cyst the pulsations can be felt with the fingers, and seen in the movement of the ruler, this is not present in ascites.
Auscultation Bowel sounds are very irregular, so patience is required to discern if they are reduced or normal. Peritonitis will cause ileus with reduced or absent sounds. Diarrhoea is associated with increased bowel sounds but intestinal obstruction produced a classical "tinkling" bowel sounds like water being poured from one cup to another.
Pelvic examination The dictum from Secondary Care is that examination of the abdomen is incomplete without a rectal examination. In Primary Care it is usual to perform such an examination only if there is a significant expectation of a finding that will influence management. For example, if you have already decided to refer a patient with suspected appendicitis performing a rectal examination will not influence that decision. It will be performed by at least one admitting doctor, so if the GP does it too this would be an additional unpleasant intrusion. This is more important in children.
On the other hand if a rectal or vaginal examination is about to be performed it must be preceded by an abdominal examination. A bimanual vaginal examination can easily miss a large uterine or ovarian mass. A large prostate may have induced a distended bladder.
Children Examining children can be much more difficult than adults. They often complain of "tummy pain" and point to the umbilicus when the problem is a throat or ear infection. They are often difficult to relax and may be both apprehensive and ticklish so that abdominal muscles are tense. Too firm palpation will easily overcome guarding, be gentle to avoid missing this important sign. Try to distract them during the examination. Some people take the child’s hand and use it to palpate the abdomen. Another technique is to ask the child to do a few jumps or hops. This will not be done with impunity if there is an acute abdomen.
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References Used
Clinical Examination. Owen Epstein 2003. Mosby
Clinical Examination. John Munro 2000. Churchill Livingstone