Examinationof The Abdomen

Question 1

What are the borders of the abdomen ?

Answer 1

Cranial border : costal margin and xiphoid process
Caudal border : anterior superior iliac spine (ASIS), the iliac crest and the pubic bone.

Question 2

What is the main center reference point of the abdomen and how is named its vertical line ?

Answer 2

The umbilicus / navel and the vertical line passing through is called the linea alba.

Question 3

What are intra-peritoneal organs ? Who are they ?

Answer 3

Organs that are inside the peritoneum cavity / sac. Covered by the visceral peritoneum.
Stomach, jejunum, ileum, Cecum, transverse colon, sigmoid, liver and gallbladder, spleen, ovaries.

Question 4

What are retroperitoneal organs ? Who are they ?

Answer 4

Organs outside the peritoneal cavity, generally backyard.
Most of the pancreas, duodenum, kidney and adrenal glands, abdominal aorta, ascending and descending colon, rectum, IVC

Question 5

What are infra-peritoneal organs ? Who are they ?

Answer 5

Organs beneath the peritoneal cavity.
Rectum, bladder, distal ureters, uterus, Fallopian tubes.

Question 6

What does the coeliac trunk supply ?

Answer 6

The stomach, pancreas, liver, 1/3 duodenum, spleen

Question 7

What does the superior mesenteric artery supply ?

Answer 7

Jejunum, ileum, appendix, ascending colon, 1/3 of transverse colon

Question 8

What does the inferior mesenteric artery supply ?

Answer 8

2/3 of transverse colon, descending colon, sigmoid, upper rectum

Question 9

What does the internal iliac artery supply ?

Answer 9

The lower rectum

Question 10

Where is the groin ?

Answer 10

The inguinal region where the abdomen meet the legs, a vulnerable part where hernia can occur.

Question 11

What is an hernia ?

Answer 11

When abdominal content bulge through the abdominal wall. If the hernia has a narrow neck its content might be entrapped, causing mechanical ileus and acute necrosis.

Question 12

What is a reducible hernia ?

Answer 12

An hernia where the content can slide back into the abdominal cavity.

Question 13

What is a non reducible hernia ?

Answer 13

An hernia where the content have fused with the peritoneal sac.

Question 14

Where is the rectum, what is it closed by ?

Answer 14

It is the continuation of the sigmoid at the level of S3.
Closed on the distal side by external and internal anal sphincter.

Question 15

In which order do you do the general examination of the abdomen ? Why ?

Answer 15

Inspection, auscultation, percussion, palpation.
Palpation is last because if could cause a patient pain thus over-tensing the muscle and making further investigation difficult.

Question 16

What do you observe during inspection ?

Answer 16

General shape and symmetry of abdomen
Skin and navel
Any local swelling
Visible movement

Question 17

What could cause diffuse swelling of the abdomen ?

Answer 17

Obesity : accumulation of fat
Gas accumulation : due to severe constipation
Free fluid accumulation (ascites) : common in elderly
Pregnancy : enlargement of uterus
Cyst or tumour : enlargement of ovaries
Full bladder

Question 18

What abnormalities of the navel could there be ?

Answer 18

Bulging => intra-abdominal tension
Sunken => obesity

Question 19

What abnormalities of the skin could there be ?

Answer 19

Exanthema = rashes
Spider naevi = spider web shaped veins
Surgery scars

Question 20

What could be the cause of local swelling ?

Answer 20

Liver or spleen enlargement
Abdominal wall hernia : often only visible standing

Question 21

What kind of movement do you observe during inspection ?

Answer 21

Breathing : loss of diaphragmatic breathing means a peritoneal irritation
Visible peristalsis : chance of small bowel obstruction
Pulsation of aorta : maybe sign of abdominal aortic aneurysm

Question 22

What sounds do you hear during auscultation ?

Answer 22

Bowel sounds, vascular sounds and liver sounds.

Question 23

What are bowel sounds and their clinical significance ?

Answer 23

Sound from the stomach that have limited clinical value, their frequency vary from 30/min to 1/4min.
Hyperactivity or absent sounds = obstruction of the bowel.

Question 24

What are vascular sounds ? What are causes of their abnormalities ?

Answer 24

Sounds from the coeliac artery.
Abnormal bruit can be caused by renal artery aneurysm, arteriovenous fistula, compression syndrome, ischemic bowel disease.

Question 25

What can you hear in the liver ?

Answer 25

Abnormal vascular sound linked to perihepatitis or perisplenitis.

Question 26

How do you do a scratch test ?

Answer 26

Place the stethoscope above the liver next to the xiphoid process. Scratch near the lower border of the liver. The sounds will be a lot louder when scratching the skin above the liver

Question 27

What are the 2 types of percussion ?

Answer 27

Exploratory percussion : percuss in star shape or over the 9 regions Topographic percussion : percuss specific organs

Question 28

What kind of sound do you expect in percussion ? What is abnormal ?

Answer 28

Tympanic : gas in the stomach or bowel Dull : content of the GI tract Unusual dullness in large area : enlarged organ, full bladder, large tumor Unusual dullness in the flanks : ascites

Question 29

How do you diagnose a enlarged spleen with percussion ?

Answer 29

Upper border : 9th rib (mid-axillary line). Ventrally, does not extends further than anterior axillary line. Lower border : lower edge of the left costal arch. The distance between the upper and lower borders is 4-6 cm. Splenomegay is considered if the dullness is on a larger area. Sometimes the spleen is so small that dullness cannot be observed.

Question 30

What abnormalities can you detect by percussing the liver ?

Answer 30

Loss of dullness : gastrointestinal perforation causing air in the abdominal cavity Increased liver surface : right congestive heart failure, steatosis, hepatitis and tumors Percussion tenderness below the costal arch : inflammatory gallbladder

Question 31

Are abnormal liver border signs of a disorder ?

Answer 31

Not always, due to the large variation of the diaphragm position.

Question 32

What is superficial palpation ?

Answer 32

Assess muscle tension, locate tender spot, detect abdominal wall abnormality (hernia, ACNES, small tumors) and local infiltrate.

Question 33

What do you do do if there is superficial resistance in the abdominal wall ?

Answer 33

Ask the patient the raise head and shoulder. If the swelling is in the abdominal wall and not the peritoneal cavity then it will cause a lot of pain and still be palpable.

Question 34

What is the difference between parietal and visceral pain ?

Answer 34

Parietal pain : inflammation local or diffuse of the parietal peritoneum. - steady aching and more severe than visceral pain - sharp and you pinpoint the part. - aggravated by movement or coughing because it increase intra-abdominal pressure - peritonitis - very shallow chest breathing Visceral pain : - hollow abdominal organs contract unusually forcefully or are distended - solid organ become painful when their capsule is stretched - non specific pain, difficult to localise - varying in quality : gnawing, cramping, aching, colic

Question 35

What are the types of muscle guarding ? What is it due to ?

Answer 35

Voluntary muscle guarding : due to fear, pain, agitation, cold. Can be lessened by distracting the patient. Involuntary muscle guarding : due to local or generalised irritation of the parietal peritoneum.

Question 36

What are the types of deep palpation ?

Answer 36

Deep exploratory palpation : used to locate abnormal resistance Deep topographic palpation : used to palpate various abdominal organ

Question 37

What do you look for in deep topographic palpation of the liver ? What can you find ?

Answer 37

Look for : size, consistency, surface characteristics and tenderness. You can find : cirrhosis (granular and firm swelling), tumours (coarse and firm irregularities swelling), tenderness (acute swelling or abscesses)

Question 38

Why can you sometimes feel the spleen ? What are the reasons ?

Answer 38

The spleen can only be palpated if enlarged or hard. When it moves caudally and medially during inspiration. Enlargement due to infection, haemolysis, thrombosis, hematological and lymphatic malignancies and metabolic disease.

Question 39

Why do you examine the kidney ?

Answer 39

To detect an enlarged kidney or cyst. Also to test costovertebral angle tenderness if pyelonephritis aortic renal colic is suspected.

Question 40

What do you examine in the kidney ?

Answer 40

There is no point in auscultating and percussing the kidney. You try the palpation but it cannot be felt normally.

Question 41

How do you palpate the kidney ?

Answer 41

Bimanual palpation : patient lie supine. Left hand between the iliac crest and costal arch, finger parallel to the ribs. Right hand above, lateral to the rectus abdominis muscle. Move hand towards each other. Ask patient to breath deeply. Contraction of the diaphragm cause the kidney to move causally, so you may feel a firm lower pool.

Question 42

How do you assess tenderness of the kidney ?

Answer 42

Gently strike on the costovertebral angle : on the back below the costal arch. Either, with the side of the hand or with the fist on the back of the other hand.

Question 43

Clinical significance of palpable kidney ?

Answer 43

Only one palpable kidney : cyst, tumor, compensatory hypertrophy Both palpable kidney : cystic kidney disease

Question 44

What do you expect to hear at the percussion of bladder ?

Answer 44

It normally cannot be percussed but the sound expected sound be tympanic. There is no correlation between bladder enlargement and dullness.

Question 45

What are the causes of an enlarged bladder ?

Answer 45

Caused by urinary retention due to : Obstruction, infection, drug treatment, neurological disorder.

Question 46

Where do you feel an enlarged gallbladder ?

Answer 46

It is difficult to distinguish an enlarged gallbladder than enlarged liver. It is felt as a ball/pear-shaped resistance : right lateral side 9th ribs.

Question 47

Why and how do you palpate the gallbladder ?

Answer 47

Palpation indicated if percussion tenderness in the right upper quadrant. Palpate while following the lower boundary of costal arch from lateral to median.

Question 48

What are the clinical significances of the gallbladder examination ?

Answer 48

If pain on inspiration = positive Murphy’s sign : cholecystitis Painless but palpable gallbladder in jaundice patient (Courvoisier) : malignancy, choledocholithiasis

Question 49

What are ascites and how do you test for them ?

Answer 49

Ascites are an accumulation of free fluid in the abdomen. You can detect it using percussing or undulation.

Question 50

How do you detect ascites with percussion ?

Answer 50

Percuss when the patient is supine : tympanic and dull sound heard with a transition in the flank Percuss with patient on their side : the transition point between dull and tympanic change. This is shifting dullness.

Question 51

How do you detect ascites with undulation ?

Answer 51

Tap on the flank and feel the possible wave motion with the hand on the other side.

Question 52

What is an acute abdomen ?

Answer 52

It’s an acute onset abdominal pain requiring an urgent diagnosis. An acute abdominal pain : last less than 5 days. It is mostly diagnosed based on history taking and not physical examination.

Question 53

What is the meaning of absent dullness in the liver ?

Answer 53

Due to free gases below the diaphragm. Could be a sign of a perforation.

Question 54

What is POCUS, what is it used for ?

Answer 54

Point of care ultrasound : scanner used as a stethoscope. It can detect very small amount of fluid.

Question 55

What is very important to do before an anus or rectum examination ?

Answer 55

Explain clearly the procedure. Gain consent of the patient. Explain about side effect : feeling like you’re gonna poop or peep.

Question 56

How do you do a rectal examination ?

Answer 56

Use lubricant on one finger of the glove. Rotate finger to assess the canal for abnormal resistance. Describe resistance. Withdraw finger and inspect.

Question 57

Clinical significance of examination of the anus ?

Answer 57

Painful swelling : thrombosed external haemorrhoid Elevated sphincter tension : anal disorder or nervous Reduced sphincter tension : neurological disorder or age Soft painful swelling : high perianal abscesses

Question 58

What abnormalities can you find in the rectum ?

Answer 58

A painful or fixed mucosa, a polys (soft and smooth but not painful). Beware to differentiate feces and resistance.

Question 59

What is the result of an enlarged spleen ?

Answer 59

It can trap and store blood cells causing anemia.

Question 60

What are possible causes of an acute abdomen ?

Answer 60

Gastrointestinal : - acute : appendicitis, cholecyctitis, pancreatitis - complicated diverticulitis - inflammatory bowel disease - perforated gastric ulcer - trauma : perforation and ruptures Gynaecological tract : - Acute salpingitis : STD, deep infection could leak in the peritoneal cavity - ectopic pregnancy Urological tract : - pyelonephritis Vascular : - dissected AAA - myocardial infraction Neurological tract : - Abdominal wall pain

Question 61

What is referred pain ?

Answer 61

It is pain felt more distant site innervated at the same spinal level as the disturbed structures. Occurs when the initial pain becomes more intense and radiate. No palpation tenderness.

Question 62

ABCDE of acute abdomen ?

Answer 62

Airway : unusual - lateral position preferred to avoid patient choking on their vomit Breathing : unusual - depth can be limited by the pain Circulation : - check BP and pulse => check for shock - beware of internal bleeding Disability : - measure glucose in diabetics : vomiting and diarrhea can cause fast dysregulation Exposure : - temperature : fever indicate inflammation - skin - intoxication

Question 63

Physical examination for peritoneal irritation ?

Answer 63

Inspection - no movement due to pain Coughing test : - positive : pain Percussion : - tenderness may be present even gently Palpation : - superficial : voluntary / unvoluntary guarding - wall test - rebound tenderness - McBurney sign - Psoas sign

Question 64

Technique of wall test ?

Answer 64

Check whether or not a painful resistance is located in the abdominal wall. Raise head and shoulder. If the pain increase the problem is in the abdominal wall.

Question 65

Technique of rebound tenderness ?

Answer 65

If there’s local pain. Slowly and deeply depress the abdomen, then release the pressure suddenly. You can do the ipsilateral or contralateral side. If the abrupt movement cause more sharp pain => peritoneal irritation

Question 66

Technique of McBurney sign ?

Answer 66

Local pain in the right lower abdomen with local tenderness. Maximum tenderness at 1/3 of ASIS from the umbilicus.

Question 67

Psoas sign technique ?

Answer 67

Seen in retrocaecal appendicitis or abscess in the psoas region. Patient lies on their left side : hyperextending the right leg causes more pain in the right lower abdomen. Patient supine : flex right leg at the hip against resistance causes more pain in the right lower abdomen

Question 68

What are the LUTS ?

Answer 68

Lower urinary tract symptoms : - Cannot empty bladder fully or bladder fills too quickly - Polyuria - Difficulty controlling peeing urge - Nocturia & frequent peeing - Weak urine stream, dripping - Leaking during abdominal strain or others - Straining to pee

Question 69

What causes LUTS ?

Answer 69

Associated with irritation, infection or obstruction of urinary system : - Bladder : bladder outlet obstruction - Kidney : cysts, stones - Ureters : urethral obstruction - Urethra : urethral stricture

Question 70

What are the causes of hypovolemia ?

Answer 70

Excessive fluid loss : - from GI tract : diarrhea, vomiting - insensible loss from skin : sweat, fever, burns - Major bleeding - urinary loss : glucosuria, diuretic therapy, diabetes insipidus Inadequate fluid intake Third spacing : too much extravasation

Question 71

Why are children more vulnerable to hypovolumia ?

Answer 71

Higher incidence of gastroenteritis and higher insensible loss (greater surface area to volume ratio). Unable to independently access fluids to replenish loss.

Question 72

What are the signs of hypovolumia in children ?

Answer 72

Tachycardia can be the first sign of hypovolemic chock in children. Markedly sunken eyes and anterior fontanelle. Anuria and lethargy.

Question 73

How do you manage a hypovolemic child ?

Answer 73

If fluid support required : IV of crystalloid fluid. Control electrolytes, glucose and pH of child blood before adjusting the fluid. Switch to oral rehydratation asap but stay alert for glucose level.

Question 74

What are concerning signs for a child presenting with nausea / vomiting ?

Answer 74

Prolonged vomiting : risk of dehydration and electrolytes abnormalities Signs of obstruction. Neurological symptoms Hypotension disproportionate to the current illness : adrenal crisis Recurrent episodes : inborn error of metabolism, cyclic vomiting syndrome, migraine

Question 75

Signs of obstruction in vomiting children ?

Answer 75

Abdominal distension, visible bowel loops. Absent or increased peristalsis. Severe abdominal pain. Vomit with bile or fecal odor.

Question 76

What are neurological symptoms associated with vomiting in children ?

Answer 76

Headache, positional trigger for vomiting, vomiting upon awakening, lack of nausea. —> increase intracranial pressure Alerted conciousness, seizures, focal neurological abnormalities ⇒ toxic ingestion, CNS mass, inborn error of metabolism, diabetic ketoacidosis

Question 77

What is pyloric stenosis ?

Answer 77

Hypertrophy of the pyloric canal reducing its lumen => prevent normal passage between stomach and duodenum. Stomach produce strong peristalsis to push food down the duodenum. At some point it might overcome the pressure of the oesophageal sphincter leading to projectile vomiting.

Question 78

What is the clinical presentation of pyloric stenosis ?

Answer 78

Hungry baby, thin, pale, failing thrive. Sign : projectile vomiting, firm round mass of the stomach felt, hypochloric metabolic alkalosis. Treatment : laparoscopic pyloromyotomy.

Question 79

What is the most common cause of abdominal obstruction in young children ?

Answer 79

Intussusception is the most common cause of obstruction between 6-36 months. Characterised by sudden onset of intermittent, severe cramps, progressive abdominal pain

Question 80

What is Cullen’s sign ?

Answer 80

Ecchymoses / bruises around the umbilicus. Indicate intra or retroperitoneal hemorrhaging, produced when the bleeding diffuses through the falciform ligament. Caused mostly by : acute pancreatitis, ectopic pregnancy.

Question 81

What is Grey Turner sign ?

Answer 81

Ecchymoses / discoloration of the flank. Uncommon manifestation of intra-abdominal hemorrhage. Caused mostly by : acute pancreatitis,