Abdominal examination.pptx

Abdominal examination
BY: BBY: Diriba Wakjira ( MSc in maternity health)in maternity health)

Session objectives
At end of this session students will be able to:-
 Explain common symptoms of gastrointestinal
disease.
 List common cause of Gastro-intestinal diseases.
 Discuss techniques in the physical examination of
the abdomen.
 Perform the physical examination of the abdomen
and interpret findings.

Introduction
 The human GI tract is a complex system of
serially connected organs approximately 8m in
length, extending from the mouth to the anus.
 Symptoms of gut disorders are often vague, and
needs careful examination before declare finding
of abnormality.
 Pain is the most common complaints of patients
with GIT problems.

Common Symptoms of GIT
problems
 Dysphagia
 Odynophagia
 Heart burn/pyrosis/
 Nausea and vomiting
 Abdominal pain
 Abdominal distension
 Diarrhea
 Constipation
 Hematemesis
 Melena
 Weight loss
 Jaundice

Dysphagia
 Is difficulty in swallowing
 Difficulty in initiating swallowing with fluid regurgitation
into the nose , or chocking on trying to swallow.
Causes
 mechanical obstruction(Osephageal obstruction by
food, goiter, Esophageal cancer…)
 Osephageal motor neuron dysfunction(myasthenia
gravis…)
Odynophagia is pain during swallowing

Heart burn(pyrosis)
 Substernal burning pain caused by regurgitation
of acidic stomach contents into the esophagus.
 The pain travels upward to the throat and occurs
after meals, and worsened by stooping or lying
supine and relieved by antacids.

Nausea and vomiting
 Nausea is involuntary effort to vomit.
 Vomiting is expulsion of gastric contents through the
mouth.
Mode of onset- Acute or chronic
 Acute onset occurs in food poisoning, raised
intracranial pressure or bowel obstruction.
 Chronic onset occurs in pregnancy, medications
(digoxin, dopamine agonists, chemotherapy), bowel
motor diseases.

Nausea and vomiting
Timing of vomiting
 Vomiting after one hour of meal is typical of gastric
outlet obstruction(GOO).
 Early morning vomiting before eating occurs in
pregnancy or raised intracranial pressure.
Content of vomitus
 Bilious vomiting signals some type of obstruction.
 Vomiting of blood suggests hematemesis (upper
gastrointestinal bleeding)
Projectile or not
 Projectile vomiting of non-bilious old food suggests
gastric outlet obstruction secondary to pyloric
stenosis, while projectile vomiting of bilious matter
occurs in raised intracranial pressure.

Abdominal pain
 Characterize mode of onset, course and duration,
frequency, character and pattern, areas of
radiation, aggravating and relieving factors.
Common causes of abdominal pain
 Acute appendicitis
 Acute cholecystitis
 Acute pancreatitis
 Peptic ulcer disease
 Intestinal obstruction
 Renal calaculi

Physical Examination
When examining the abdomen , the
abdomen should have to divided in to four
quadrants or nine regions.

Inspection
Preparation
 Prepare good lighted room with coach
 Make the patient comfortable in the supine
position
 The patient should keep the arms at the sides
 Exposure of the abdomen from the xiphoid
process to the mid thigh; covering the genitalia is
required

Inspection…preparation…
 The examiner should have warm hands, warm
stethoscope and short finger nails
 Approach the patient slowly and avoid quick,
unexpected movements.
 If the patient is not at ease, distract her/him with
conversation
 Monitor your examination by watching the patient’s
face for any sign of discomfort

What we look for …?
 Look for symmetry of the abdomen of patient
 Look for shape of the abdomen. Is scaphoid, flat or
distended?
 Look for contour of the umbilicus…Normally the
umbilicus is slightly retracted.
 Look for abdominal movements with
respiration…Markedly diminished or absent
abdominal movement (silent abdomen) signify
generalized peritonitis.

 Look for visible peristalsis…Vigorous peristalsis of
the abdomen signifies bowel obstruction.
 Look for scars and striae….marks due to gross
stretching of the skin
 Look for prominent superficial veins …Distended
abdominal wall veins which are draining away
from the umbilicus suggests presence of portal
hypertension .

 Look for hernia sites
• Support and lift patient’s head with the shoulder with
your left arm and let him cough repeatedly while
observing sites of hernia
• Sites of hernia: Incisional hernia at surgical scar
site, umbilical and periumbilical hernia at or around
the umbilicus, lumbar hernia in lumbar region, and
inguinal and femoral hernia in groin region.

Palpation
 Palpation is the most important part of abdominal
examination.
 It should be done with The patient relaxed and
breathing quietly.
 The examiner being gentle and ask the patient if
there is any area of pain and come to this region
last while palpating.
 Palpation has to proceed in a logical sequence;
one may start in the left iliac region; work anti-
clockwise coming to the suprapubic area last.
 Initial light palpation followed by deeper palpation

Light (superficial palpation)
Purpose:
 To identify Abdominal tenderness
 to assess the degree of tenderness
 Palpation over an area of mild tenderness just causes
pain moderately tender area causes the patient’s
abdominal muscles to tighten (guarding),Severe
tenderness is associated with guarding, but in addition
the sudden withdrawal of the manual pressure causes a
sharp exacerbation of the pain (rebound tenderness)

Deep palpation
 If systematic light palpation over the whole
abdomen elicits no pain, the process should be
repeated pressing firmly and deeply to see if there
is deep tenderness.
 Palpate for masses and if a mass is detected in
the abdomen, characterize its position , shape,
size,surface,edge,consistency,tenderness,Mobility
,pulstility..

Deep palpation…
 Usually required to delineate abdominal mass or
presence of organomegaly (enlarged liver, spleen
or kidney)
 Check for guarding, rigidity and rebound
tenderness…. generalized peritonitis.
 Rebound tenderness is eliciting pain while the
examiner suddenly releases his palpating hand.

Abdominal organ palpation
Spleen
 The spleen has to be 2-3 times its normal size to be
palpable.
Procedure
 Start palpating from the right iliac fossa and move to the left
hypochondrium.
 Ask the patient to breathe in deeply and press in with the
fingers of examining right hand beneath the costal margin
while supporting and pressing the left costal margin with
left hand.
 If not palpable, turn the patient to half on to the right side
(with right leg extended and left leg flexed at hip and knee
joint) and repeat the examination.

Cause of massive splenomegaly
 Hyperactive malarial splenomegaly
 Hepatosplenic schistosomiasis
 Kala-azar (Visceral leishmaniasis)
 Chronic myeloid leukemia
 Non-Hodgkin’s lymphoma
 Thalassemia

Liver
Procedure.
 Ask the patient to breathe, and start palpation from
right lower abdomen towards the right
hypochondrium with the right hand below and
parallel to the right costal margin.
 The liver edge may be felt against the radial border
of index finger.
 Characterize the enlarged liver - size (below the
right costal margin), tenderness, consistency,
surface, edge.

Kidney…
Left kidney
 The left hand is placed posteriorly in the left loin
and right hand is placed anteriorly in the left
lumbar region.
 Ask the patient to take deep breath in, press the
left hand forwards and the right hand backwards,
upwards and inwards
 The left kidney is often not palpable

Kidney…
Right kidney
 Place the right hand horizontally in the right
lumbar region anteriorly with left hand placed
posteriorly in the right loin.
 Ask the patient to take a deep breath in, and
press the left hand forwards and the right hand
backwards, upwards and inwards
 The lower pole of the right kidney is often
palpable in healthy individuals.

Gall bladder…
 The normal gall bladder can’t be felt
 When it is distended, it may be palpated as a firm,
smooth or globular swelling with distinct border, just
lateral to the edge of rectus muscle near the tip of
ninth costal cartilage.
 The upper border merges with the lower border of
the right lobe of the liver or disappears beneath the
right costal margin.
 Distended gall bladder indicates acute cholecystitis.

Percussion.
Technique
 Put the left pleximeter finger of the examiner on
the abdomen in horizontal position and percuss
with the right plexor finger from upper to lower
abdomen and sideways of the abdomen.
 Percuss if there is enlarged organ or any
swelling in the abdomen.

Percussion
Light percussion of the abdomen reveals the
normal tympanitic note over most of the
abdomen.
Hyper resonance indicates excess amount of
gas in the peritoneal cavity.
Percussion is also carried out to detect ascites
(fluid in the peritoneal cavity) and to
differentiate it from other causes of diffuse
enlargement of the abdomen.
Two signs, shifting dullness and fluid thrill,
when present either singly or together, make
the diagnosis of ascites certain.

Percussion…
Shifting dullness
 Demonstrated by asking the patient to lie supine
and percussing laterally from the midline to the
right side, keeping the fingers in the longitudinal
axis, until dullness is detected.
 Then, keeping his/her hand over the abdomen,
the examiner asks the patient to roll away from
him/her onto the left side. Percussion is carried
out in the new position; if the previously dull note
becomes tympanitic then ascitic fluid is probably
present and shifting dullness is said to be
positive.

Percussion…
Fluid thrill
 The examiner places one hand flat over the lumbar
region of the left side, with the patient supine and
gets an assistant to put the side of a hand firmly in
the midline of the abdomen.
 The right lumbar region is tapped with a finger.
 A fluid thrill or wave is felt as a definite and
unmistakable impulse by the left hand flat in the
lumbar region.

Percussion
Liver:
 The note over the liver is dull.
 Percussion can map out the upper and lower
borders of the liver accurately.
 Marks of the upper border of the liver …resonant
to dullness.
 A change in percussion note from tympanitic to
dullness signals the lower border of the liver.

Auscultation
 The stethoscope should be placed on one siteon
the abdominal wall, preferably on the right lower
quadrant, to listen for bowel sounds, and kept
there until sounds are heard.
 It should not be moved from site to site

Auscultation
 Normal bowel sounds are heard as intermittent, low
or medium pitched gurgles interspersed with an
occasional high-pitched noise or tinkle.
Frequency of bowel sounds
 Ranges from 5 to 34 per minute.
 Bowel sounds may be normal, increased or absent.
 Increased frequency of bowel sounds occur in
diarrhea and mechanical intestinal obstruction.

Auscultation…
 In generalized peritonitis, bowel activity rapidly
disappears and a state of paralytic ileus ensues
and the abdomen will be silent.
 One has to listen for several minutes before
declaring such a state

Abdominal examination.pptx

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Abdominal examination.pptx