Digestive System

Abdominal Structures of the Abdominal Cavity

Inspection

For the purposes of examination, the abdomen is commonly divided into four quadrants, first by drawing an imaginary line from the sternum to the pubis through the umbilicus.
- Draw a second imaginary line perpendicular to the first, horizontally across the abdomen through the umbilicus.
- Alternatively, the abdomen is divided into nine regions using following imaginary lines: two horizontal lines, one across the lowest edge of the costal margin and the other across the edge of the iliac crest, and two vertical lines running bilaterally from the midclavicular line to the middle of the Poupart ligament, approximating the lateral borders of the rectus abdominis muscles.

Four quadrants of the abdomen

Nine regions of the abdomen.

1, Epigastric; 2, umbilical; 3, hypogastric; 4 and 5, right and left hypochondriac; 6 and 7, right and left lumbar; 8 and 9, right and left inguinal.

Landmarks of the abdomen

Auscultation

Unlike the usual sequence, always perform auscultation of the abdomen before percussion and palpation because these maneuvers may alter the frequency and intensity of bowel sounds.

Bowel Sounds

Lightly place the diaphragm of a warmed stethoscope on the abdomen
Some healthcare providers say they prefer to use the bell; in reality, they tend to pull the skin tight with the bell and, in effect, make a diaphragm
Listen for bowel sounds and note frequency and character
- They are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute
- Bowel sounds are generalized so most often they can be assessed adequately by listening tin one place
- Lound prolonged gurgles are called borborygmi (stomach growling)
- Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger
- High-pitched tinkling sounds suggest intestinal fluid and air under pressure, as in early obstruction
- Decreased bowel sounds occur with peritonitis and paralytic ileus
- Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 minutes of continuous listening, is typically associated with abdominal pain and rigidity nd is a surgical emergency.

Sites to auscultate for bruits: renal arteries, iliac arteries, aorta, and femoral arteries.

Additional Sounds and Bruits

Listen with the diaphragm for friction rubs over the liver and spleen.
- Friction rubs are high pitched and are heard in association with respiration.
- Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct.
- A bruit is a harsh or musical intermittent auscultatory sound, which may reflect blood flow turbulence and indicate vascular disease.
Listen with the bell of the stethoscope in the epigastric region and in the aortic, renal, iliac, and femoral arteries.
- Vascular sounds are usually well localized.
Auscultate with the bell of the stethoscope in the epigastric region and around the umbilicus for a venous hum, which is soft, low pitched, and continuous.
- A venous hum occurs with increased collateral circulation between the portal and systemic venous systems.

Percussion

Percussion is used to assess the size and density of the organs in the abdomen and to detect the presence of fluid (as with ascites), air (as with gastric distention), and fluid-filled or solid masses.
Percussion is used either independently or concurrently with palpation of specific organs and can validate palpatory findings.

Liver percussion routes along midclavicular and midsternal lines.

Percussion of the spleen

Percuss in several directions beginning at areas of lung resonance.
You may hear a small area of splenic dullness from the sixth to the ninth rib.
Traube space is a semilunar region defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margin inferiorly.
- This area is typically tympanitic because it overlies the fundus of the stomach.
With splenic enlargement, tympany changes to dullness as the spleen is brought forward and downward with inspiration (splenic percussion sign).
- However, a full stomach, feces-filled intestine, or left-sided pleural effusion may also produce dullness.

Fist percussion of the costovertebral angle for kidney tenderness.

A, Indirect percussion.

To assess each kidney for tenderness, ask the patient to assume a sitting position.
Place the palm of your hand over the right costovertebral angle and strike your hand with the ulnar surface of the fist of your other hand.
Repeat the maneuver over the left costovertebral angle.

B, Direct percussion

Direct percussion with the fist over each costovertebral angle may also be used.
The patient should perceive the blow as a thud, but it should not cause pain.
For efficiency of time and motion, this maneuver is performed while examining the back rather than the abdomen.

Palpation

Use palpation to assess the organs of the abdominal cavity and to detect muscle spasm, masses, fluid, and areas of tenderness.
Evaluate the abdominal organs for size, shape, mobility, and consistency.
Stand at the patient’s right side with the patient in the supine position.
Ticklishness may be a challenge.

Light palpation of the abdomen. With fingers extended and approximated, press in no more than 1 cm.

Moderate palpation using the side of the hand.

Deep palpation of the abdomen. Press deeply and evenly with the palmar surface of extended fingers.

Deep bimanual palpation.

Abdominal structures commonly felt as masses.

Masses

Identify any masses and note the following characteristics: location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration.
To determine whether a mass is superficial (i.e., located in the abdominal wall) or intraabdominal, have the patient lift his or her head from the examining table, thus contracting the abdominal muscles.
Masses in the abdominal wall will continue to be palpable, but those located in the abdominal cavity will be more difficult to feel because they are obscured by abdominal musculature.
The presence of feces in the colon, often mistaken for an abdominal mass, can be felt as a soft, rounded, boggy mass in the cecum and in the ascending, descending, or sigmoid colons.
Other structures that are sometimes mistaken for masses are the lateral borders of the rectus abdominis muscles, uterus, aorta, sacral promontory, and common iliac artery.
By mentally visualizing the placement of the abdominal structures, you can distinguish between what ought to be there and an unexpected finding.

Palpating the Liver

A, Fingers are extended, with tips on right midclavicular line below the level of liver dullness and pointing toward the head.

B, Alternative method for liver palpation with the fingers parallel to the costal margin.

Palpating the liver with fingers hooked over the costal margin.

Scratch technique for auscultating the liver. With the stethoscope over the liver, lightly scratch the abdominal surface, moving toward the liver. The sound will be intensified over the liver.

Palpating the Spleen

A, Press upward with the left hand at the patient's left costovertebral angle. Feel for the spleen with the right hand below the left costal margin.

B, Palpating the spleen with the patient lying on the side. Press inward with the left hand and tips of the right fingers.

Palpating the Kidney

Palpating the left kidney. Elevate the left flank with the left hand. Palpate deeply with the right hand.

Capture technique for palpating the kidney (left kidney palpation shown). As the patient takes a deep breath, press the fingers of both hands together. As the patient exhales, slowly release the pressure and feel for the kidney to slip between the fingers.

Palpating the Aorta

Palpating the aorta. Place the thumb on one side of the aorta and the fingers on the other side.

Advanced Skills

Ascites, a pathologic increase in fluid in the peritoneal cavity, may be suspected in the patient with risk factors who has a protuberant abdomen or bulging flank when lying supine.
- Percuss for areas of dullness and resonance with the patient supine.
  - Because ascites fluid settles with gravity, expect to hear dullness in the dependent parts of the abdomen and tympany in the upper parts where the relatively lighter bowel has risen.
- Mark the borders between tympany and dullness.

Testing for shifting dullness.

Dullness shifts to the dependent side.

In the patient without ascites, the borders will remain relatively constant.
With ascites, the border of dullness shifts to the dependent side (approaches the midline) as the fluid resettles with gravity.

Testing for fluid wave.

Strike one side of the abdomen sharply with the fingertips. Feel for the impulse of a fluid wave with the other hand.

An easily detected fluid wave suggests ascites.
However, a fluid wave can sometimes be felt in people without ascites and, conversely, may not occur in people with early ascites.

Pain Assessment

Testing for rebound tenderness.

Holding your hand at a 90-degree angle to the abdomen with the fingers extended, press gently and deeply into a region remote from the area of abdominal discomfort.
Rapidly withdraw your hand and fingers. The return to position—or “rebound” of the structures that were compressed by your fingers—causes a sharp stabbing pain at the site of peritoneal inflammation (positive Blumberg sign).
Rebound tenderness over McBurney point in the lower right quadrant suggests appendicitis (positive McBurney sign). The maneuver for rebound tenderness should be performed at the end of the examination because a positive response produces pain and muscle spasm that can interfere with any subsequent examination.
Because light percussion produces a mild localized response in the presence of peritoneal inflammation, assessing for rebound tenderness is considered unnecessary by many examiners.

A, Press deeply and gently into the abdomen.

B, Then rapidly withdraw the hands and fingers.

Iliopsoas Muscle Test

This test is performed when you suspect appendicitis because an inflamed appendix may cause irritation of the lateral iliopsoas muscle.
Ask the patient to lie supine and then place your hand over the lower right thigh.
Ask the patient to raise the right leg, flexing at the hip, while you push downward.
An alternative technique is to position the patient on the left side and ask that the right leg be raised from the hip while you press downward against it.
A third technique is to hyperextend the right leg by drawing it backward while the patient is lying on the left side. Pain with any of these techniques is considered a positive psoas sign, indicating irritation of the iliopsoas muscle.

A, The patient raises the leg from the hip while the examiner pushes downward against it.

B, Alternate technique. The examiner hyperextends the right leg by drawing it backward while the patient lies on the left side.

Obturator Muscle Test

This test can be performed when you suspect a ruptured appendix or a pelvic abscess due to irritation of the obturator muscle.
While in the supine position, ask the patient to flex the right leg at the hip and knee to 90 degrees.
Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially.
Pain in the right hypogastric region is a positive sign, indicating irritation of the obturator muscle.

Obturator muscle test.

With the right leg flexed at the hip and knee, rotate the leg laterally and medially.

Ballottement

Ballottement is a palpation technique used to assess an organ or a mass.
To perform abdominal ballottement with one hand, place your extended fingers, hand, and forearm at a 90-degree angle to the abdomen.
Push in toward the organ or mass with the fingertips.
If the mass is freely movable, it will float upward and touch the fingertips as fluid and other structures are displaced by the maneuver.
To perform bimanual ballottement, place one hand on the anterior abdominal wall and one hand against the flank. Push inward on the abdominal wall while palpating with the flank hand to determine the presence and size of the mass.