Abdominal Examination and Physical Signs

Question 1

Examination steps for abdominal station

Answer 1

1. Exposure - ideally remove clothes and bra, expose LL and until inguinal region
2. Inspection
   - Palms, fingernails
   - Hepatic asterixis
   - CLD stimata
   - Renal stigmata
   - Eyes: anaemia and jaundice
   - Parotid enlargement
3. Supraclavicular and cervical lymph nodes
4. Loss of axillary hair
5. Gynaecomastia
6. Inspection of abdomen
7. Soft and deep palpation
8. Liver palpation, measurement, bruit
   9 Spleen palpation, measurement, bruit
9. Ballot kidneys
10. Shifting dullness and fluid thrill
11. Bowel sound auscultation
12. Inguinal hernia examination
13. Lower limb oedema
14. Wishlist - vitals, DRE, genitalia

Question 2

Inspection of abdomen station

Answer 2

Renal stigmata
1. Appearance: grey shallow, osteodystrophic
2. Anaemia
3. Modalities:
- AVF (and needling)
- Tunneled catheter or scar
- Peritoneal scar
- Iliac fossa scar
3. Parathyroidectomy scar and implantation
4. CNI toxicity - tremors, gum hypertrophy

CLD stigmata
1. Abdominal ascites
2. Spider naevi
3. Easy bruising
4. Gynaecomastia
5. Caput medusae
6. Jaundice
7. Dupuytren contracture

Question 3

What is jaundice?

Answer 3

Yellowish skin discolouration due to excess bilirubin in the blood (bilirubin >35umol/L)
Demonstrable clinically when bilirubin >40 with scleral jaundice or buccal jaundice

Question 4

What is cachexia?

Answer 4

Cachaexia demonstrable by muscle and fat loss
- Wasting of temporalis muscle
- Reduced triceps skin-fold thickness

Question 5

Where can you demonstrate anaemia?
Causes of anaemia in abdominal station

Answer 5

Anaemia is demonstrable by:
- Conjunctival pallor
- Skin crease pallor
- Nail pallor
- Mucosal membrane pallor

Causes of anaemia in abdominal station:
1. Portal hypertension variceal bleeding
2. Non-variceal GI bleeding
3. Alcoholism causing bone marrow suppression
4. Poor nutrition
5. Erythropoietin deficiency from ESRF (anaemia of chronic disease)
6. Malignancy - solid organ, haematological

Question 6

What are the gastrointestinal causes of clubbing?

Answer 6

1. Chronic liver disease
2. Inflammatory bowel disease
3. Coeliac disease
4. GI lymphoma
5. Tropical sprue
6. Whipple’s disease

Question 7

What is leuconychia?
What are the causes of leuconychia?

Answer 7

Whiteness of nails either partial or complete, in spots or streaks

Causes of leuconychia
1. Hypoalbuminaemia
2. Heart failure
3. Renal disease
4. Hodgkin’s lymphoma
5. Diabetes mellitus
6. Fingernail trauma

Question 8

How is sex hormone altered in chronic liver disease or pregnancy?
What are the consequent physical signs of such alterations?

Answer 8

Increase in oestradiol to free testosterone ratio

Presents with:
- Spider naevi: central arteriole supplying surrounding vessels, blanchable
- Palmar erythema
- Gynaecomastia
- Loss of body hair

Question 9

How would you describe an abdominal mass?

Answer 9

1. Size
2. Consistency - soft or firm
3. Border - well-defined or ill defined
   - Well-defined: liver, spleen enlargement
   - Ill-defined: bowel, neoplasm
4. Tenderness
5. Attachment to abdominal wall
   - Lipoma, rectus sheath haematoma, neoplasm
6. Movement with respiration - liver, spleen
   (retroperitoneal structure does not move - aorta, kidney)
7. Pulsatility - aneurysm, fistula
8. Ballotable mass - kidneys
9. Percussion - solid mass dull to percussion
   (Careful - intestinal gas may give false negative)
10. Auscultation - bowel sound, bruit, rub

Question 10

What are the causes of a right upper quadrant mass?

Answer 10

1. Liver - moves with respiration
2. Right kidney - ballotable, does not move with respiration
3. Gallbladder - moves with respiration
4. Colon - high pitched bowel sound

Question 11

What are the causes of a left upper quadrant mass?

Answer 11

1. Spleen - moves with respiration, medial notch, enlarges towards RIF
2. Left kidney - ballotable, resonant percussion
3. Pancreas mass
4. Colon mass
5. Stomach mass

Question 12

What are the causes of a right lower quadrant mass?

Answer 12

1. Colon, small intestine, appendix
2. Pelvic mass - needs bimanual palpation

Question 13

What are the causes of a left lower quadrant mass?

Answer 13

1. Sigmoid colon
2. Pelvic mass

Question 14

What are the causes of gynaecomastia?

Answer 14

Puberty and senility
Genetic: Kleinfelter’s
GI: Cirrhosis
Drugs: Spironolactone, Digoxin
Endocrine: Thyroid disease, Addison
Testicular tumour

Question 15

Approach to abdominal scars

Answer 15

Question 16

Presentation in short case

Answer 16

Question 17

Commonest small intestinal tumours

Answer 17

Small intestine tumours - rare (2%)

1. Sarcoma and gastrointestinal stromal tumour (GIST)
2. Adenocarcinoma
3. Lymphoma
4. Neuroendocrine tumour (NET) (Carcinoid tumour)