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.
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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.
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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.
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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 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.
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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.
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'.
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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.
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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.
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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'.
|
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).
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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.
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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.
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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.
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Figure 8.17 Palpation of the liver: preferred method.
Figure 8.18 Palpation of the liver: alternative method.
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.
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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. |
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).
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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).
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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).
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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.
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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.
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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. |
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.
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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.
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Surface, edge and
consistency |
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