PHYSICAL EXAMINATION OF THE GI TRACT AND ABDOMEN - M. Glynn

PHYSICAL EXAMINATION OF THE GI TRACT AND ABDOMEN GENERAL SIGNS

Figure 8.1 A typical spider naevus, with a central arteriole and fine radiating vessels

Figure 8.2 Palmar erythema in chronic liver disease (sparing the centre of the palms).

Assessment of the nutritional state (Chapter 5) is particularly important in patients with suspected GI disease. Systemic features of GI disease may be evident on general examination. Peripheral signs of chronic liver disease are listed in Box 8.3. Of these, the most common and useful are spider naevi (Fig. 8.1) (the presence of up to five small ones can be normal) and palmar erythema (Fig. 8.2) (the blotchy appearance often being more important than the overall redness). Inflammatory bowel disease may give rise to clubbing, arthritis, uveitis and skin changes, including erythema nodosum (tender raised red lumps on the extensor surface of the limbs) and the much rarer pyoderma gangrenosum. Anaemia accompanies many GI diseases, as does oedema, and lymphadenopathy can be secondary to GI malignancy.

It is helpful when examining the patient, recording in notes or communicating information to colleagues to remember the surface anatomy of the structures related to the GI tract and abdomen (Figs 8.3, 8.4) and to think of the abdomen as being divided into regions (Fig. 8.5). The two lateral vertical planes pass from the femoral artery below to cross the costal margin close to the tip of the ninth costal cartilage. The two horizontal planes, the subcostal and interiliac, pass across the abdomen to connect the lowest points on the costal margin and the tubercles of the iliac crests, respectively.

Remember that the area of each region will depend on the width of the subcostal angle and the proximity of costal margin to iliac crest, in addition to other features of body habitus, which vary greatly from one patient to the next. INSPECTION The patient should be lying supine with the arms loosely by his or her sides, on a couch or mattress, the head and neck supported by enough pillows - normally one or two - for comfort (Fig. 8.6). A sagging mattress makes examination, particularly palpation, difficult. Make sure there is good light, that the room is warm and that the hands are warm. A shivering patient cannot relax and vital signs may be missed, especially on palpation. Stand on the patient's right side and expose the abdomen by turning down all the bedclothes except the upper sheet. The clothing should then be drawn up to just above the xiphisternum and the sheet folded down to the level of the symphysis pubis Fig. 8.6. Traditional teaching was to expose the patient 'from nipples to knees'. In the modern era, however, when patient dignity is of paramount importance, this approach is not acceptable. However, inspection of the groins and genitalia must not be neglected and needs to be carried out with discretion, with full explanations as to the reasons, and leaving these areas exposed for the minimum time. There have been many patients presenting with intestinal obstruction due to a strangulated femoral or inguinal hernia where the diagnosis has been missed initially owing to lack of a proper inspection of the groins in an effort to save embarrassment. Inspection is an important and neglected part of abdominal examination. It is well worth spending 30 seconds observing the abdomen from different positions to note the following features. SHAPE

Is the abdomen of normal contour and fullness, or distended? Is it scaphoid (sunken)? Generalized fullness or distension may be due to fat, fluid, flatus, faeces or a fetus. Localized distension may be symmetrical and centred around the umbilicus, as in the case of small bowel obstruction, or asymmetrical as in gross enlargement of the spleen, liver or ovary. Make a mental note of the site of any such swelling or distension; think of the anatomical structures in that region and note if there is any movement of the swelling, either with or independent of respiration. Remember that chronic urinary retention may cause palpable enlargement in the lower abdomen. Figure 8.3 Anterior view of external relations of the abdominal and thoracic organs.

A scaphoid abdomen is seen in advanced stages of starvation and malignant disease, particularly carcinoma of the oesophagus and stomach. THE UMBILICUS Normally the umbilicus is slightly retracted and inverted. If it is everted then an umbilical hernia may be present, and this can be confirmed by feeling an expansile impulse on palpation of the swelling when the patient coughs. The hernial sac may contain omentum, bowel or fluid. A common finding in the umbilicus of elderly obese people is a concentration of inspissated desquamated epithelium and other debris (omphalolith).

Figure 8.4 Posterior view of the external relations of the abdominal and thoracic organs. The liver is not shown.

MOVEMENTS OF THE ABDOMINAL WALL

Normally there is a gentle rise in the abdominal wall during inspiration and a fall during expiration; the movement should be free and equal on both sides. In generalized peritonitis this movement is absent or markedly diminished (the 'still, silent abdomen'). To aid the recognition of intra-abdominal movements shine a light across the patient's abdomen. Even small movements of the intestine may then be detected by alterations in the pattern of shadows cast over the abdomen.  Visible pulsation of the abdominal aorta may be noticed in the epigastrium and is a frequent finding in nervous, thin patients. It must be distinguished from an aneurysm of the abdominal aorta, where pulsation is more obvious and a widened aorta is felt on palpation. Visible peristalsis of the stomach or small intestine may be observed in three situations: Obstruction at the pylorus. Visible peristalsis may occur where there is obstruction at the pylorus, produced either by fibrosis following chronic duodenal ulceration or, less commonly, by carcinoma of the stomach in the pyloric antrum. In pyloric obstruction a diffuse swelling may be seen in the left upper abdomen but, where obstruction is long-standing with severe gastric distension, this swelling may occupy the left mid and lower quadrants. Such a stomach may contain a large amount of fluid and, on shaking the abdomen, a splashing noise is usually heard ('succussion splash'). This splash is frequently heard in healthy patients for up to 3 hours after a meal, so enquire when the patient last ate or drank. In congenital pyloric stenosis of infancy not only may visible peristalsis be apparent, but also the grossly hypertrophied circular muscle of the antrum and pylorus may be felt as a 'tumour' to the right of the midline in the epigastrium. Both these signs may be elicited more easily after the infant has been fed. Standing behind the mother with the child on her lap may allow the child's abdominal musculature to relax sufficiently to feel the walnut-sized swelling. Obstruction in the distal small bowel. Peristalsis may be seen where there is intestinal obstruction in the distal small bowel or coexisting large and small bowel hold-up produced by distal colonic obstruction, with an incompetent ileocaecal valve allowing reflux of gas and liquid faeces into the ileum. Not only is the abdomen distended and tympanitic (hyperresonant), but the distended coils of small bowel may be visible in a thin patient and tend to stand out in the centre of the abdomen in a 'ladder pattern'. As a normal finding in very thin, elderly patients with lax abdominal muscles or large, wide-necked incisional herniae seen through an abdominal scar.   Figure 8.5 Regions of the abdomen. 1 and 3: right and left hypochondrium; 2: epigastrium; 4 and 6: right and left lumbar; 5: umbilical; 7 and 9: right and left iliac; 8: hypogastrium or suprapubic. Figure 8.6 Position of the patient and exposure for abdominal examination. Note that the genitalia must be exposed. SKIN AND SURFACE OF THE ABDOMEN In marked abdominal distension the skin is smooth and shiny. Striae atrophica or gravidarum are white or pink wrinkled linear marks on the abdominal skin. They are produced by gross stretching of the skin with rupture of the elastic fibres and indicate a recent change in size of the abdomen, such as is found in pregnancy, ascites, wasting diseases and severe dieting. Wide purple striae are characteristic of Cushing's syndrome and excessive steroid treatment. Note any scars, their site, and whether they are old (white) or recent (red or pink), linear or stretched (and therefore likely to be weak and contain an incisional hernia). Common examples are shown in Figure 8.7. Look for prominent superficial veins, which may be apparent in three situations (Fig. 8.8): thin veins over the costal margin, usually of no significance; occlusion of the inferior vena cava; and venous anastomoses in portal hypertension. Inferior vena caval obstruction not only causes oedema of the limbs, buttocks and groins, but in time distended veins on the abdominal wall and chest wall appear. These represent dilated anastomotic channels between the superficial epigastric and circumflex iliac veins below and the lateral thoracic veins above, conveying the diverted blood from long saphenous vein to axillary vein; the direction of flow is therefore upwards. If the veins are prominent enough, try to detect the direction in which the blood is flowing by occluding a vein, emptying it by massage and then looking for the direction of refill. Distended veins around the umbilicus (caput medusae) are uncommon but signify portal hypertension, other signs of which may include splenomegaly and ascites. These distended veins represent the opening up of anastomoses between portal and systemic veins and occur in other sites, such as oesophageal and rectal varices. Pigmentation of the abdominal wall may be seen in the midline below the umbilicus, where it forms the linea nigra and is a sign of pregnancy. Erythema ab igne is a brown mottled pigmentation produced by constant application of heat, usually a hot water bottle or heat pad, on the skin of the abdominal wall. It is a sign that the patient is experiencing severe ongoing pain, such as from chronic pancreatitis. Finally, uncover and inspect both groins, and the penis and scrotum of a male, for any swellings and to ensure that both testes are in their normal position. Then bring the sheet up back up to the level of the symphysis pubis.  Figure 8.7 Some commonly used abdominal incisions. The midline and oblique incisions avoid damage to the innervation of the abdominal musculature and the later development of incisional herniae. Figure 8.8 Prominent veins of the abdominal wall. Figure 8.9 Correct method of palpation. The hand is held flat and relaxed, and 'moulded' to the abdominal wall. Figure 8.10 Incorrect method of palpation. The hand is held rigid and mostly not in contact with the abdominal wall. Figure 8.11 Method of deep palpation in an obese, muscular or poorly relaxed patient. PALPATION Palpation is the most important part of the abdominal examination. Tell the patient to relax as best they can and to breathe quietly, and assure them that you will be as gentle as possible. Enquire about the site of any pain and come to this region last. These points, together with unhurried palpation with a warm hand, will give the patient confidence and allow the maximum amount of information to be obtained. When palpating, the wrist and forearm should be in the same horizontal plane where possible, even if this means bending down or kneeling by the patient's side (Fig. 8.9). The best palpation technique involves moulding the relaxed right hand to the abdominal wall, not to hold it rigid. The best movement is gentle but with firm pressure, with the fingers held almost straight but with slight flexion at the metacarpophalangeal joints, and certainly avoid sudden poking with the fingertips (Fig. 8.10). Palpation of intra-abdominal structures is an imperfect process in which the great sensitivity of the sense of touch and pressure is heavily masked by the abdominal wall tissue. It is unusual for structures to be very easily palpable, and so it is necessary to concentrate fully on the task and to try and visualize the normal anatomical structures and what might be palpable beneath the examining hand. It may be necessary to repeat the palpation more slowly and deeply. Putting the left hand on top of the right allows increased pressure to be exerted (Fig. 8.11), such as with an obese or very muscular patient. A small proportion of patients find it impossible to relax their abdominal muscles when being examined. In such cases it may help to ask them to breathe deeply, to bend their knees up, or to distract their attention in other ways. No matter how experienced the examiner, little will be gained from palpation of a poorly relaxed abdomen. It is helpful to have a logical sequence to follow and, if this is done as a matter of routine, then no important point will be omitted. The following scheme is suggested, which may need to be varied according to the site of any pain: Start in the left lower quadrant of the abdomen, palpating lightly, and repeat for each quadrant. Repeat using slightly deeper palpation examining each of the nine areas of the abdomen. Feel for the left kidney. Feel for the spleen. Feel for the right kidney. Feel for the liver. Feel for the urinary bladder. Feel for the aorta and para-aortic glands and common femoral vessels. If a swelling is palpable, spend time eliciting its features. Palpate both groins. Examine the external genitalia. All the organs in the upper abdomen (liver, spleen, kidneys, stomach, pancreas, gallbladder) move downward with inspiration (with the spleen moving more downwards and medially). Thus asking the patient to take a deep breath while examining makes detection of these organs easier, as something that is moving is easier to detect than something stationary. However, to avoid confusing one's sensation, when the patient breathes the examining hand should be still so that the organ in question 'comes on to the examining hand', or 'slips by underneath it'.  Figure 8.12 Palpation of the left kidney. LEFT KIDNEY The left hand is placed anteriorly in the left lumbar region and the right is placed posteriorly in the left loin (Fig. 8.12). Ask the patient to take a deep breath in, press the right hand forwards and the left hand backwards, upwards and inwards. The left kidney is not usually palpable unless it is either low in position or enlarged. Its lower pole, when palpable, is felt as a rounded firm swelling between both right and left hands (i.e. bimanually palpable) and it can be pushed from one hand to the other, in an action known as 'ballotting'. Figure 8.13 The direction of enlargement of the spleen. The spleen has a characteristic notched shape and the organ moves downwards during full inspiration. SPLEEN Like the left kidney, the spleen is not normally palpable. It has to be enlarged to two or three times its usual size before it becomes palpable, and then is felt beneath the left subcostal margin. Enlargement takes place in a superior and posterior direction before it becomes palpable subcostally. Once the spleen has become palpable, the direction of further enlargement is downwards and towards the right iliac fossa (Fig. 8.13). Place the flat of the left hand over the lowermost ribcage posterolaterally, thereby restricting the expansion of the left lower ribs on inspiration and concentrating more of the inspiratory movement into moving the spleen downwards. The right hand is placed beneath the costal margin well out to the left. Ask the patient to breathe in deeply, and press in deeply with the fingers of the right hand beneath the costal margin, at the same time exerting considerable pressure medially and downwards with the left hand (Fig. 8.14). Repeat this manoeuvre with the right hand moving more medially beneath the costal margin on each occasion (Fig. 8.15). If enlargement of the spleen is suspected from the history and it is still not palpable, turn the patient half on to the right side, ask them to relax back on to your left hand, which is now supporting the lower ribs, and repeat the examination as above. Alternatively, the spleen may be very large and the lower edge much lower than at first suspected. It may help to ask the patient to place their left hand on your right shoulder while you are palpating for the spleen. In minor degrees of enlargement the spleen will be felt as a firm swelling with smooth, rounded borders. Where considerable splenomegaly is present, its typical characteristics include a firm swelling appearing beneath the left subcostal margin in the left upper quadrant of the abdomen, which is dull to percussion, moves downwards on inspiration, is not bimanually palpable, whose upper border cannot be felt (i.e. one cannot 'get above it'), and in which a notch can often - though not invariably - be felt in the lower medial border. The last three features distinguish the enlarged spleen from an enlarged kidney; in addition, there is usually a band of colonic resonance anterior to an enlarged kidney. RIGHT KIDNEY Feel for the right kidney in much the same way as for the left. Place the right hand horizontally in the right lumbar region anteriorly with the left hand placed posteriorly in the right loin. Push forwards with the left hand, ask the patient to take a deep breath in, and press the right hand inwards and upwards (Fig. 8.16). The lower pole of the right kidney, unlike the left, is commonly palpable in thin patients, and is felt as a smooth, rounded swelling which descends on inspiration and is bimanually palpable and may be 'ballotted'. LIVER Figure 8.14 Palpation of the spleen. Start well out to the left. Figure 8.15 Palpation of the spleen more medially than in Figure 8.14. Sit on the couch beside the patient. Place both hands side by side flat on the abdomen in the right subcostal region lateral to the rectus, with the fingers pointing towards the ribs. If resistance is encountered, move the hands further down until this resistance disappears. Exert gentle pressure and ask the patient to breathe in deeply. Concentrate on whether the edge of the liver can be felt moving downwards and under the examining hand (Fig. 8.17). Repeat this manoeuvre working from lateral to medial regions to trace the liver edge as it passes upwards to cross from right hypochondrium to epigastrium. Another commonly employed though less accurate method of feeling for an enlarged liver is to place the right hand below and parallel to the right subcostal margin. The liver edge will then be felt against the radial border of the index finger (Fig. 8.18). The liver is often palpable in normal patients without being enlarged. The lower edge of the liver can be clarified by percussion (see below), as can the upper border in order to determine overall size: a palpable liver edge can be due to enlargement or to displacement downwards by lung pathology. Hepatomegaly is conventionally measured in centimetres palpable below the right costal margin, which should be determined with a ruler if possible.  Figure 8.16 Palpation of the right kidney Try and make out the character of the liver's surface (i.e. whether it is soft, smooth and tender as in heart failure, very firm and regular as in obstructive jaundice and cirrhosis, or hard, irregular, painless and sometimes nodular, as in advanced secondary carcinoma). In tricuspid regurgitation the liver may be felt to pulsate. Occasionally a congenital variant of the right lobe projects down lateral to the gallbladder as a tongue-shaped process, called Riedel's lobe. Though uncommon, it is important to be aware of this because it may be mistaken either for the gallbladder itself or for the right kidney. GALLBLADDER The gallbladder is palpated in the same way as the liver. The normal gallbladder cannot be felt. When it is distended, however, it forms an important sign and may be palpated as a firm, smooth, or globular swelling with distinct borders, just lateral to the edge of the rectus abdominis near the tip of the ninth costal cartilage. It moves with respiration. Its upper border merges with the lower border of the right lobe of the liver, or disappears beneath the costal margin and therefore can never be felt (Fig. 8.19). When the liver is enlarged or the gallbladder grossly distended, the latter may be felt not in the hypochondrium but in the right lumbar or even as low down as the right iliac region. The ease of definition of the rounded borders of the gallbladder, its comparative mobility on respiration, the fact that it is not normally bimanually palpable, and that it seems to lie just beneath the abdominal wall helps to identify such a swelling as gallbladder rather than a palpable right kidney. A painless gallbladder can usually be palpated in the following clinical situations: In a jaundiced patient with carcinoma of the head of the pancreas or other malignant causes of obstruction of the common bile duct (below the entry of the cystic duct), the ducts above the obstruction become dilated, as does the gallbladder (see Courvoisier's Law, below). In mucocele of the gallbladder a gallstone becomes impacted in the neck of a collapsed, empty, uninfected gallbladder and mucus continues to be secreted into its lumen (Fig. 8.20). Eventually, the uninfected gallbladder is so distended that it becomes palpable. In this case the bile ducts are normal and the patient is not jaundiced. In carcinoma of the gallbladder the gallbladder may be felt as a stony, hard, irregular swelling, unlike the firm, regular swelling of the two above-mentioned conditions.  Figure 8.17 Palpation of the liver: preferred method. Figure 8.18 Palpation of the liver: alternative method. Murphy's sign In acute inflammation of the gallbladder (acute cholecystitis) severe pain is present. Often an exquisitely tender but indefinite mass can be palpated; this represents the underlying acutely inflamed gallbladder walled off by greater omentum. Ask the patient to breathe in deeply, and palpate for the gallbladder in the normal way; at the height of inspiration the breathing stops with a gasp as the mass is felt. This represents Murphy's sign. The sign is not found in chronic cholecystitis or uncomplicated cases of gallstones. Courvoisier's Law   Figure 8.19 Palpation of an enlarged gallbladder, showing how it merges with the inferior border of the liver so that only the fundus of the gallbladder and part of its body can be palpated. This states that in the presence of jaundice a palpable gallbladder makes gallstone obstruction of the common bile duct an unlikely cause (because it is likely that the patient will have had gallstones for some time, and these will have rendered the wall of the gallbladder relatively fibrotic and therefore non-distensible). However, the converse is not true, because the gallbladder is not palpable in many patients who do prove to have malignant bile duct obstruction. THE URINARY BLADDER Normally the urinary bladder is not palpable. When it is full and the patient cannot empty it (retention of urine), a smooth firm regular oval-shaped swelling will be palpated in the suprapubic region and its dome (upper border) may reach as far as the umbilicus. The lateral and upper borders can be readily made out, but it is not possible to feel its lower border (i.e. the swelling is 'arising out of the pelvis'). The fact that this swelling is symmetrically placed in the suprapubic region beneath the umbilicus, that it is dull to percussion, and that pressure on it gives the patient a desire to micturate, together with the signs above, confirms such a swelling as the bladder (Fig. 8.21). In women, however, a mass that is thought to be a palpable bladder must be differentiated from a gravid uterus (firmer, mobile side to side, and vaginal signs different), a fibroid uterus (may be bosselated, firmer, and vaginal signs different) and an ovarian cyst (usually eccentrically placed to left or right side). THE AORTA AND COMMON FEMORAL VESSELS  Figure 8.20 A mucocele of the gallbladder that is distended and thin walled. Figure 8.21 Physical signs in retention of urine; a smooth, firm and regular swelling arising out of the pelvis which one cannot 'get below' and which is dull to percussion Figure 8.22 Palpation of the abdominal aorta. Figure 8.23 Palpation of the right femoral artery. In most adults the aorta is not readily felt, but with practice it can usually be detected by deep palpation a little above and to the left of the umbilicus. In thin patients, particularly women with a marked lumbar lordosis, the aorta is more easily palpable. Palpation of the aorta is one of the few occasions when the fingertips are used as a means of palpation. Press the extended fingers of both hands, held side by side, deeply into the abdominal wall in the position shown in Figure 8.22; make out the left wall of the aorta and note its pulsation. Remove both hands and repeat the manoeuvre a few centimetres to the right. In this way the pulsation and width of the aorta can be estimated. It is difficult to detect small aortic aneurysms; where an aneurysm is large, its presence and width may be assessed by placing the extended fingertips on either side of it with the palms flat on the abdominal wall and the fingers pointing towards each other. When the fingertips are either side of an aneurysm it should be clear that they are being separated by each pulsation, and not just moved up and down (this latter manoeuvre can involve very deep palpation, and the patient should be warned). The common femoral vessels are found just below the inguinal ligament at the midpoint between the anterior superior iliac spine and the symphysis pubis. Place the pulps of the right index, middle and ring fingers over this site in the right groin and palpate the wall of the vessel. Note the strength and character of its pulsation and then compare it with the opposite femoral pulse (Fig. 8.23). Lymph nodes lying along the aorta (para-aortic nodes) are palpable only when considerably enlarged. They are felt as rounded, firm, often confluent fixed masses in the umbilical region and epigastrium along the left border of the aorta. CAUSES OF DIAGNOSTIC DIFFICULTY ON PALPATION In many patients, especially those with a thin or lax abdominal wall, faeces in the colon may simulate an abdominal mass. The sigmoid colon is frequently palpable, particularly when loaded with hard faeces. It is felt as a firm, tubular structure about 12cm in length, situated low down in the left iliac fossa parallel to the inguinal ligament. The caecum is often palpable in the right iliac fossa as a soft, rounded swelling with indistinct borders. The transverse colon is sometimes palpable in the epigastrium. It feels somewhat like the pelvic colon but rather larger and softer, with distinct upper and lower borders and a convex anterior surface. A faecal 'mass' will usually have disappeared or moved on repeat examination, and may retain an indentation with pressure (not the case with a colonic malignancy). In the epigastrium, the muscular bellies of the rectus abdominis lying between its tendinous intersections can mimic an underlying mass and give rise to confusion. This can usually be resolved by asking the patient to tense the abdominal wall (by lifting the head off the pillow), when the 'mass' may be felt to contract. WHAT TO DO WHEN AN ABDOMINAL MASS IS PALPABLE When a swelling in the abdomen is palpable first make sure that it is not a normal structure, as described above. Consider whether it could be due to enlargement of the liver, spleen, right or left kidney, gallbladder, urinary bladder, aorta or para-aortic nodes. The aim of examination of a mass is to decide the organ of origin and the pathological nature. In doing this it is helpful to bear in the mind the following points. Site Feeling the swelling while the patient lifts their head and shoulders off the pillow to tense the anterior abdominal wall, will differentiate between a mass in the abdominal wall and one within the abdominal cavity. Note the region occupied by the swelling. Think of the organs that normally lie in or near this region, and consider whether the swelling could arise from one of them. For instance, a swelling in the right upper quadrant most probably arises from the liver, right kidney, hepatic flexure of colon or gallbladder. Size and shape   Now, if the swelling is in the upper abdomen, try and determine whether it is possible to 'get above it' - that is, to feel the upper border of the swelling as it disappears above the costal margin, and similarly, if it is in the lower abdomen, whether one can 'get below it'. If one cannot 'get above' an upper abdominal swelling, a hepatic, splenic, renal or gastric origin should be suspected. If one cannot 'get below' a lower abdominal mass the swelling probably arises in the bladder, uterus, ovary, or occasionally the upper rectum. Surface, edge and consistency

As a general rule, gross enlargement of the liver, spleen, uterus, bladder or ovary presents no undue difficulty in diagnosis. On the other hand, swellings arising from the stomach, small or large bowel, retroperitoneal structures such as the pancreas, or the peritoneum (see Mobility and attachments, below), may be difficult to diagnose. The larger a swelling arising from one of these structures, the more it tends to distort the outline of the organ of origin (e.g. a large renal mass can feel as if it is arising from intraperitoneal organs).

The pathological nature of a mass is suggested by a number of features. A swelling that is hard, irregular in outline and nodular is likely to be malignant, whereas a regular, round, smooth, tense swelling is likely to be cystic. A solid, ill-defined and tender mass suggests an inflammatory lesion, as in Crohn's disease of the ileocaecal region.

Mobility and attachments

Swellings arising in the liver, spleen, kidneys, gallbladder and distal stomach all show downward movement during inspiration, owing to the normal downward diaphragmatic movement, and such structures cannot be moved with the examining hand. Tumours of the small bowel and transverse colon, cysts in the mesentery, and large secondary deposits in the greater omentum, are not usually influenced by respiratory movements, but may move easily on palpation.

When the swelling is completely fixed it usually signifies one of three things: A mass of retroperitoneal origin (e.g. pancreas) Part of an advanced tumour with extensive spread to the anterior or posterior abdominal walls or abdominal organs A swelling resulting from severe chronic inflammation involving other organs (e.g. diverticulitis of the sigmoid colon or a tuberculous ileocaecal mass).

In the lower abdomen, the side-to-side mobility of a fibroid or pregnant uterus rapidly establishes such a swelling as uterine in origin and as not arising from the urinary bladder.

Is it bimanually palpable or pulsatile?

Bimanually palpable swellings in the lumbar region are usually renal in origin. Just occasionally, however, a posteriorly situated gallbladder or a mass in the posteroinferior part of the right lobe of the liver may give the impression of being bimanually palpable. Carefully note whether a swelling exhibits pulsation, and decide whether any pulsation comes from the mass or is transmitted.

PERCUSSION

Details of how to percuss correctly are given in Chapter 6. The normal percussion note over most of the abdomen is resonant (tympanic) except over the liver, where the note is dull. A normal spleen is not large enough to render the percussion note dull. A resonant percussion note over suspected enlargement of liver or spleen weighs against there being true enlargement.

In obese patients tympanic areas of the abdomen may not give a truly resonant percussion note, and palpation of such things as a large liver is more difficult. If hepatomegaly is suspected, rhythmic percussion just above the suspected lower border of the liver as the patient breathes in and out deeply can elicit a note that changes cyclically between dull and hollow, and eliciting this change may be more certain than the character of the fixed and unchanging note.

DEFINING THE BOUNDARIES OF ABDOMINAL ORGANS AND MASSES

Liver

The upper and lower borders of the right lobe of the liver can be mapped out accurately by percussion. Start anteriorly, at the fourth intercostal space, where the note will be resonant over the lungs, and work vertically downwards.

Over a normal liver, percussion will detect the upper border at about the fifth intercostal space (just below the right nipple in men). The dullness extends down to the lower border at or just below the right subcostal margin, giving a normal liver vertical height of 12-15cm. The normal dullness over the upper part of the liver is reduced in severe emphysema, in the presence of a large right pneumothorax, and after laparotomy or laparoscopy.

Spleen

Percussion over a substantially enlarged spleen provides rapid confirmation of the findings detected on palpation (see Fig. 8.14). Dullness extends from the left lower ribs into the left hypochondrium and left lumbar region.

Urinary bladder

The findings in a patient with urinary retention are usually unmistakable on palpation (see Fig. 8.21). The dullness on percussion, and clear difference from the adjacent bowel, provides reassurance that the swelling is cystic or solid and not gaseous.

The boundaries of any localized swelling in the abdominal cavity, or in the walls of the abdomen, can sometimes be defined more accurately by percussion than palpation, as for the urinary bladder.

Other masses

Three common causes of diffuse enlargement of the abdomen are: The presence of free fluid in the peritoneum (ascites) A massive ovarian cyst Obstruction of the large bowel, distal small bowel, or both.

DETECTION OF ASCITES AND ITS DIFFERENTIATION FROM OVARIAN CYST AND INTESTINAL OBSTRUCTION

The use of ultrasound to detect ascites has shown that quite a lot needs to be present to detect clinically - probably more than 2L. It is unwise and unreliable to diagnose ascites unless there is sufficient free fluid present to give generalized enlargement of the abdomen. The cardinal sign created by ascites is shifting dullness. A fluid thrill may also be present, but it would be unwise to diagnose ascites based on this sign alone.

Percussion rapidly distinguishes between these three, as can be seen in Figure 8.24. Other helpful symptoms or signs that are usually present are listed in Box 8.4.

Figure 8.24 Three types of diffuse enlargement of the abdomen.

To demonstrate shifting dullness, lie the patient supine. Place your fingers in the longitudinal axis on the midline near the umbilicus and begin percussion moving your fingers laterally towards the right flank. When dullness is first detected (in normal individuals dullness is only over the lateral abdominal musculature) keep your fingers in that position and ask the patient to roll on their left side. Wait a few seconds for any peritoneal fluid to redistribute, and if ascites is present the percussion note should have become resonant. This shift in the area of dullness can be confirmed by finding the left border of dullness with the patient still on their left side and seeing whether it shifts when the patient returns to the supine position, or by repeating the original manoeuvre but towards the other side of the abdomen.

To elicit a fluid thrill the patient is again laid supine. Place one hand flat over the lumbar region of one side and ask an assistant to put the side of their hand longitudinally and firmly in the midline of the abdomen. Then flick or tap the opposite lumbar region (Fig. 8.25). A fluid thrill or wave is felt as a definite and unmistakable impulse by the detecting hand held flat in the lumbar region. (The purpose of the assistant's hand is to damp any impulse that may be transmitted through the fat of the abdominal wall.) As a rule a fluid thrill is felt only when there is a large amount of ascites present which is under tension, and it is not a very reliable sign.

Box 8.4 Clinical features of marked abdominal swelling

Gross ascites Dull in flanks Umbilicus everted and/or hernia present Shifting dullness positive Fluid thrill positive Large ovarian cyst Resonant in flank Umbilicus vertical and drawn up Large swelling felt arising out of pelvis which one cannot 'get below' Intestinal obstruction Resonant throughout Colicky pain Vomiting Recent cessation of passage of stool and flatus Increased and/or 'noisy' bowel sounds

Figure 8.25 Eliciting a fluid thrill.

AUSCULTATION

Auscultation of the abdomen is for detecting bowel sounds and vascular bruits.

BOWEL SOUNDS

The stethoscope should be placed on one site on the abdominal wall (just to the right of the umbilicus is best) and kept there until sounds are heard. It should not be moved from site to site. Normal bowel sounds are heard as intermittent low- or medium-pitched gurgles interspersed with an occasional high-pitched noise or tinkle.

In simple acute mechanical obstruction of the small bowel the bowel sounds are excessive and exaggerated. Frequent loud low-pitched gurgles (borborygmi) are heard, often rising to a crescendo of high-pitched tinkles and occurring in a rhythmic pattern with peristaltic activity. The presence of such sounds occurring at the same time as the patient experiences bouts of colicky abdominal pain is highly suggestive of small bowel obstruction. In between the bouts of peristaltic activity and colicky pain, the bowel is quiet and no sounds are heard on auscultation.

If obstruction progresses, leading to bowel necrosis, peristalsis ceases and sounds lessen in volume and frequency. In generalized peritonitis bowel activity rapidly disappears and a state of paralytic ileus ensues, with gradually increasing abdominal distension. The abdomen is 'silent', but one must listen for several minutes before being certain that there are no sounds. Frequently towards the end of this period a short run of faint, very high-pitched tinkling sounds is heard. This represents fluid spilling over from one distended loop to another and is characteristic of ileus.

Figure 8.26 Palpating the groins to detect an expansile impulse on coughing

A succussion splash may be heard without a stethoscope and also on auscultation in pyloric stenosis, in advanced intestinal obstruction with grossly distended loops of bowel, and in paralytic ileus. Lie the patient supine and place the stethoscope over the epigastrium. Roll the patient briskly from side to side, and if the stomach is distended with fluid a splashing sound will be heard.

VASCULAR BRUITS

Listen for bruits by applying the stethoscope lightly above and to the left of the umbilicus (aorta), the iliac fossae (iliac arteries), the epigastrium (coeliac or superior mesenteric arteries), laterally in the mid-abdomen (renal arteries), or over the liver (increased blood flow in liver tumours - classically primary liver cancer). If an arterial bruit is heard it is a significant finding, which indicates turbulent flow in the underlying vessel, due either to stenosis or to aneurysm. THE GROINS Once the groins have been inspected, ask the patient to turn the head to one side and cough. Look at both inguinal canals for any expansile impulse. If none is apparent, place the left hand in the left groin so that the fingers lie over and in line with the inguinal canal; place the right hand similarly in the right groin (Fig. 8.26). Now ask the patient to give a loud cough and feel for any expansile impulse with each hand. When a person coughs, the muscles of the abdominal wall contract violently and this imparts a definite - though not expansile - impulse to the palpating hands, which is a source of confusion to the inexperienced. Trying to differentiate this normal contraction from a small, fully reducible inguinal hernia is difficult, and the matter can usually be resolved only when the patient is standing up. The femoral vessels have already been felt (Fig. 8.23) and auscultated. Now palpate along the femoral artery for enlarged inguinal nodes, feeling with the fingers of the right hand, and carry this palpation medially beneath the inguinal ligament towards the perineum. Then repeat this on the left side. A patient who complains of a lump in the groin should be examined both lying down and standing up.

Figure 8.27 Locating the pubic tubercle. Note the position of the examiner, at the side of the patient, with one hand supporting the buttock.

WHAT TO DO IF A PATIENT COMPLAINS OF A LUMP IN THE GROIN

A lump in the groin or scrotum is a common clinical problem in all age groups. Most are due either to herniae or to enlarged inguinal nodes; inguinal herniae are considerably more common than femoral, with an incidence ratio of 4:1. In the scrotum, hydrocele of the tunica vaginalis or a cyst of the epididymis are common causes of painless swelling; acute epididymo-orchitis is the most frequent cause of a painful swelling. Generalized diseases such as lymphoma may present as a lump in the groin. Usually the diagnosis of a lump in the groin or scrotum can be made simply and accurately. Remember that the patient should be examined not only lying down, but also standing up.

Ask the patient to stand in front of you, get him to point to the side and site of the swelling, and note whether it extends into the scrotum. Get him to turn his head to one side and give a loud cough; look for an expansile impulse and try to decide whether it is above or below the crease of the inguinal ligament. If an expansile impulse is present on inspection, it is likely to be a hernia, so move to whichever side of the patient the lump is on. Stand beside and slightly behind the patient. If the right groin is being examined, place the left hand over the right buttock to support the patient, the fingers of the right hand being placed obliquely over the inguinal canal. Now ask the patient to cough again. If an expansile impulse is felt then the lump must be a hernia.

Figure 8.28 Left hand: palpation of the pubic tubercle; index finger occluding the deep inguinal ring. Right hand: index finger on the pubic tubercle.

Next, decide whether the hernia is inguinal or femoral. The best way to do this is to determine the relationship of the sac to the pubic tubercle. To locate this structure push gently upwards from beneath the neck of the scrotum with the index finger (Fig. 8.27), but do not invaginate the neck of the scrotum as this is painful. The tubercle will be felt as a small bony prominence 2cm from the midline on the pubic crest. In thin patients the tubercle is easily felt, but this is not so in the obese. If there is any difficulty, follow upwards the tendon of adductor longus, which arises just below the tubercle.

If the hernial sac passes medial to and above the index finger placed on the pubic tubercle, then the hernia must be inguinal; if it is lateral to and below, then the hernia must be femoral in site.

If it has been decided that the hernia is inguinal, then one needs to know these further points: What are the contents of the sac? Bowel tends to gurgle, is soft and compressible, whereas omentum feels firmer and is doughy in consistency. Is the hernia fully reducible or not? It is best to lie the patient down to decide this. Ask the patient whether the hernia is reducible, and if so get them to reduce it and confirm it yourself. (It is more painful if the examiner reduces it.) Is the hernia direct or indirect? Again, it is best to lie the patient down to decide this. Inspection of the direction of the impulse is often diagnostic, especially in thin patients. A direct hernia tends to bulge straight out through the posterior wall of the inguinal canal, whereas with an indirect hernia the impulse can often be seen to travel obliquely down the inguinal canal. Another helpful point is to place one finger just above the midinguinal point over the deep inguinal ring (Fig. 8.28). If the hernia is fully controlled by this finger then it must be an indirect inguinal hernia.

In considering the differential diagnosis of a femoral hernia, one must think not only of an inguinal hernia but of a lipoma in the femoral triangle, an aneurysm of the femoral artery (expansile pulsation will be present), a sapheno-varix (the swelling disappears on lying down, has a bluish tinge to it, there are often varicose veins present and there may be a venous hum), a psoas abscess (the mass is fluctuant, and may be compressible beneath the inguinal ligament to appear above it in the iliac fossa), and an enlarged inguinal lymph node. Whenever the latter is found the feet, legs, thighs, scrotum, perineum and the pudendal and perianal areas must be carefully scrutinized for a source of infection or primary tumour.

Apart from a femoral hernia, the differential diagnosis of an inguinal hernia includes a large hydrocele of the tunica vaginalis, a large cyst of the epididymis (one should be able to 'get above' and feel the upper border of both of these in the scrotum), an undescended or ectopic testis (there will be an empty scrotum on the affected side), a lipoma of the cord, and a hydrocele of the cord.

The examination is completed by following the same scheme in the opposite groin.

THE MALE GENITALIA

It is important to examine the genitalia in men presenting with abnormalities in the groin, and in many acute or subacute abdominal syndromes; thus disease of the genitalia may lead to abdominal symptoms, such as pain or swelling. It is vital to give a careful and ongoing explanation of what is involved and why, throughout this part of the examination. A more detailed description of the examination of the male genitalia is given in Chapter 27.

THE FEMALE GENITALIA

These are described in Chapters 15 and 27. As in men, examination of the genitalia is an important part of overall examination and it is vital to give a careful and ongoing explanation of what is involved and why, throughout this part of the examination. THE ANUS AND RECTUM The left lateral position is best for routine examination of the rectum (Fig. 8.29). Make sure that the buttocks project over the side of the couch and that the knees are drawn well up, and that a good light is available. Put on disposable gloves and stand behind the patient's back, facing their feet. Explain what you are about to do, that you will be as gentle as possible, and that you will stop the examination if requested at any point. Figure 8.29 Left lateral position for rectal examination. INSPECTION Separate the buttocks carefully and inspect the perianal area and anus. Note the presence of any abnormality of the perianal skin, such as inflammation, which may vary in appearance from mild erythema to a raw, red, moist, weeping dermatitis, or in chronic cases thickened white skin with exaggeration of the anal skin folds. The latter form anal skin tags, which may follow not only severe pruritus but also occur when prolapsing piles have been present over a period of time. Tags should not be confused with anal warts (condylomata acuminata), which are sessile or pedunculated papillomata with a red base and a white surface. Anal warts may be so numerous as to surround the anal verge, and even extend into the anal canal. Note any 'hole' or dimple near the anus with a telltale bead of pus or granulation tissue surrounding it, which represents the external opening of a fistula in ano. It is usually easy to distinguish a fistula in ano from a pilonidal sinus, where the opening lies in the midline of the natal cleft but well posterior to the anus. There are a number of painful anorectal conditions that can usually be diagnosed readily on inspection. An anal fissure usually lies directly posterior in the midline. The outward pathognomonic sign of a chronic fissure is a tag of skin at the base (sentinel pile). If pain allows, the fissure can easily be demonstrated by gently drawing apart the anus to reveal the tear in the lining of the anal canal. A perianal haematoma (thrombosed external pile) occurs as a result of rupture of a vein of the external haemorrhoidal plexus. It is seen as a small (1cm), tense, bluish swelling on one aspect of the anal margin and is exquisitely tender to the touch. In prolapsed strangulated piles there is gross swelling of the anal and perianal skin, which looks like oedematous lips, with a deep red or purple strangulated pile appearing in between - and sometimes partly concealed by - the oedema of the swollen anus. In a perianal abscess an acutely tender, red, fluctuant swelling is visible which deforms the outline of the anus. It is usually easy to distinguish this from an ischiorectal abscess, where the anal verge is not deformed, the signs of acute inflammation are often lacking, and the point of maximum tenderness is located midway between the anus and the ischial tuberosity.  Figure 8.30 Correct method for insertion of the index finger in rectal examination. The pulp of the finger is placed flat against the anus. Note the presence of any ulceration. Finally, if rectal prolapse is suspected, ask the patient to bear down (as if trying to pass stool) and note whether any pink rectal mucosa or bowel appears through the anus, or whether the perineum itself bulges downwards. Downward bulging of the perineum during straining on bending down, or in response to a sudden cough, indicates weakness of the pelvic floor support musculature, usually because of denervation of these muscles. This sign is often found in women after childbirth, in women with faecal or urinary incontinence, and in patients with severe chronic constipation. DIGITAL EXAMINATION (PALPATION) Put a generous amount of lubricant on the gloved index finger of the right hand, place the pulp of the finger (not the tip) flat on the anus (Figs 8.30, 8.31) and press firmly and slowly (flexing the finger) in a slightly backwards direction. After initial resistance the anal sphincter relaxes and the finger can be passed into the anal canal. If severe pain is elicited on attempting this manoeuvre then further examination should be abandoned, as it is likely the patient has a fissure and the rest of the examination will be very painful and unhelpful. Figure 8.31 Incorrect method of introduction of finger into the anal canal. Feel for any thickening or irregularity of the wall of the canal, making sure that the finger is turned through a full circle (180° each way). Assess the tone of the anal musculature: it should normally grip the finger firmly. If there is any doubt, ask the patient to contract the anus on the examining finger. A cough will induce a brisk contraction of the external anal sphincter, which should be readily appreciated. In the old and infirm with anal incontinence or prolapse almost no appreciable contraction will be felt. With experience it is usually possible to feel a shallow groove just inside the anal canal which marks the dividing line between the external and the internal sphincter. The anorectal ring may be felt as a stout band of muscle surrounding the junction between the anal canal and rectum. Now pass the finger into the rectum. The examiner's left hand should be placed on the patient's right hip, and later it can be placed in the suprapubic position to exert downward pressure on the sigmoid colon. Try to visualize the anatomy of the rectum, particularly in relation to its anterior wall. The rectal wall should be assessed with sweeping movements of the finger through 360°, 2, 5 and 8cm inwards or until the finger cannot be pushed any higher. Repeat these movements as the finger is being withdrawn. In this way it is possible to detect malignant ulcers, proliferative and stenosing carcinomas, polyps and villous adenomas. The hollow of the sacrum and coccyx can be felt posteriorly. Laterally, on either side, it is usually possible to reach the side walls of the pelvis. In men one should feel anteriorly for the rectovesical pouch, seminal vesicles (normally not palpable) and the prostate. In a patient with a pelvic abscess, however, pus gravitates to this pouch, which is then palpable as a boggy, tender swelling lying above the prostate. Malignant deposits will feel hard and irregular. In infection of the seminal vesicles these structures become palpable as firm, almost tubular swellings deviating slightly from the midline just above the level of the prostate. The cervix is felt as a firm, rounded mass projecting back into the anterior wall of the rectum. This is often a disconcerting finding for the inexperienced. The body of a retroverted uterus, fibroid mass, ovarian cyst, malignant nodule or pelvic abscess may all be palpated in the pouch of Douglas (rectouterine pouch), which lies above the cervix. This aspect of rectal examination forms an essential part of pelvic assessment in female patients.   Assessment of the prostate gland is important. It forms a rubbery, firm swelling about the size of a large nut. Run the finger over each lateral lobe, which should be smooth and regular. Between the two lobes lies the median sulcus, which is palpable as a faint depression running vertically between each lateral lobe. Although it is possible to say on rectal examination that a prostate is enlarged, accurate assessment of its true size is not possible. In carcinoma of the prostate the gland loses its rubbery consistency and becomes hard, the lateral lobes tend to be irregular and nodular, and there is distortion or loss of the median sulcus. On withdrawing the finger after rectal examination look at it for evidence of mucus, pus and blood. If in doubt wipe the finger on a white swab. Finally, be sure to wipe the patient clean before telling them that the examination is complete, and also tell them to be careful as they roll to the supine position as they will be very near the edge of the couch or bed. Nguồn: Hutchison's Clinical Methods: An Integrated Approach to Clinical Practice - 22th Edition