The Abdomen

Abdominal quadrants
The abdominal cavity is generally
divided into four quadrants
Two perpendicular lines cross at the
umbilicus to divide the abdomen into:
1. The right upper and lower quadrants
2. The left upper and lower quadrants

Abdominal structures by
quadrants
UPPER
RIGHT

LEFT

Liver

Liver, left lobe

Gallblader

Spleen

Pylorus

Stomach

Duodenum

Pancreas: body

Pancreas: head

Left adrenal gland

Right adrenal gland

Left kidney: upper pole

Right kidney: upper pole

Splenic flexure

Hepatic flexure

Transverse colon: portion

Ascending colon: portion

Descending colon: portion

Transverse colon: portion

Abdominal structures by
quadrants
LOWER
RIGHT

LEFT

Right kidney: lower pole

Left kidney: lower pole

Cecum

Sigmoid colon

Appendix

Descending colon: portion

Ascending colon: portion

Left ovary

Right ovary

Left fallopian tube

Right fallopian tube

Left ureter

Right ureter

Left spermatic cord

Right spermatic cord

Uterus (if enlarged)

Uterus (if enlarged)

Bladder (if enlarged)

Bladder (if enlarged)

Abdominal areas
The second way of dividing the abdominal surface is into 9
regions/areas:
1. left hypochondrium LHC
2. left lumbar LL
3. left inguinal (iliac) LI
4. epigastric E
5. umbilical U
6. Hypogastric (suprapubic) HY
7. right hypochondriac RHC
8. right lumbar RL
9. right inguinal (iliac) RI
These regions are formed by two vertical lines and two horizontal
lines. Two imaginary lines are drawn by extending the midlavicular
lines to the middle of the inguinal ligaments.
The two horizontal lines are drawn one at the costal margins and the
other at the anteriorsuperior iliac spines.

Organ location of the findings

Epigastrium - distal oesophagus, stomach, duodenum,
bile duct, and pancreas.
Right hypochondrium - liver, gallbladder, bile duct, and
transvers colon (hepatic flexure).
Left hypochondrium - spleen, transvers colon (splenic
flexure), pancreas, and left kidney.
Right lumbar - right kidney and ascending colon.
Left lumbar - left kidney, descending colon, and sigmoid
colon.
Periumbilical region - small intestine and pancreas.
Right inguinal (hypogastrium) - appendix, caecum,
terminal ileum, and right ovary.
Left inguinal (hypogastrium) - rectum and left ovary.
Suprapubic region - urinary bladder and uterus.

Physical examination
The patient should be lying flat in bed,
and the abdomen should be fully
exposed from the sternum to the knees.
The arms should be at the sides, and the
legs flat.
The examinator should be standing on
the patients right side.
If the patient has complained of
abdominal pain, examine the area of
pain last.

Physical examination
Includes the following:
1. Inspection
2. Auscultation
3. Percussion
4. Palpation

Inspection
Evaluate general appearance:
Patients with renal or biliary colic writhe in
bed; they squirm constantly and can find no
comfortable position.
Patients with peritonitis who have intense
pain on movement characteristically remain
still in bed because any slight motion worsens
the pain. They may be lying in bed with their
knees drawn up to help relax the abdominal
muscles and reduce intra-abdominal pressure.

Inspect the abdomen

THE CONTOUR
A scaphoid or concave cachexia
A protuberant gaseous distention of the
intestines, ascites, organomegaly, obesity.
The examiner should focus attention on the
abdomen to describe the presence of any
asymetry, distention, masses or visible
peristaltic waves.

Colour of the skin

Diffuse yellow in icterus, de-colouring is slower
compared to the plasmatic level of bilirubin.
Paraumbilical violet (Cullen's sign) occurs due to
propagation of retroperitoneal haematoma in
severe acute pancreatitis.
Blue - haematomas of various age in
haemorrhagic diathesis, related to
subcutaneous application of heparin or
insulin.
Pigmentation in the extent of linea alba in
Addison's disease or after radiotherapy.

 Venous pattern
"Caput medusae" - the veins radially converge to
the navel or are visible in lateral parts of
the abdomen. Both findings occur in portal
hypertension.
Anasarca
Means advanced generalised effusion of
the epidermis. The fluid is gathered also in
the abdominal, thoracic, and pericardial cavities.
It occurs in advanced right heart failure, hepatic
cirrhosis, and serious hypoproteinaemia.

Anasarca

Inspect the abdomen

STRIAE (stretch marks)
silver, pearly are formed by the rapid
distension of the abdominal wall in
extension of the volume of the abdomen
due to ascites, obesity, or pregnancy.
pinkish purple classic signs of adrenocortical
excess.

STRIAE (stretch marks)

Postoperative scars
have typical localisation according to the type of operation. The most
frequent are:
After the upper middle laparotomy (surgeries of the stomach and
duodenum, gallbladder, and biliary duct).
After lower middle laparotomy (gynaecologic, obstetric and urologic
surgeries).
After the combined laparotomy (extensive abdominal surgery).
Right subcostal region (operation of the gallbladder).
In the right hypogastrium (appendectomy).
Suprapubic area (gynaecologic surgeries).
After the right-sided and left-sided lumbotomy (kidney surgery).
Combination of the mentioned scars with small scars of irregular shape
(operations connected with drainage).
Short scars in various locations after diagnostic or therapeutic
laparoscopy.
The colour of the scar indicates its age (red-pink - recent surgery, skincoloured scar - of older date). The complicated healing can result in
formation of a hernia in the scar. In some patients, keloid scars can be
found.

Postoperative scars

Physiological abdomen is
symmetrical
Pathological features that can be seen:
Overall arch (bulge) in obese patients, in meteorism, iliac
disorders, and in ascites (the shape of the abdomen
changes relative to its position)
Local bulge due to cysts, hernias, diastases of the straight
abdominal muscles, tumours, enlarged liver, or spleen,
distended full stomach and/or intestine, and urinary
bladder.
Hernias occur most often in the navel, groin, and
postoperative scars (the size fluctuates depending on
the intra-abdominal pressure).
Eversion of the navel occurs in extensive ascites.
Peristalsis of the stomach and intestine is usually visible in
pylorostenosis or intestinal obstruction (ileus).

Arch in the
epigastrium Overall arch
(bulge) of the
abdomen, eversion
of the navel

hepatocellular
carcinoma
with ascites

Obesity, monstrous ventral hernia and

ascites

Inspect for hernias

The patient lying in bed should be asked
to cough while the examiner inspects
the inguinal, umbilical and femoral
areas.
This maneuver, by increasing intraabdominal pressure, may produce a
sudden bulging in these areas.

Auscultation
Auscultation of bowel sounds can
provide information about the motion of
air and liquid in the gastrointestinal
tract.
Auscultation of the abdomen should be
performed first in order to produce a
more accurate assessment, because
percussion or palpation may change the
intestinal motility.

Evaluate bowel sounds

The patient is placed
in a supine position
Auscultation of the
abdomen is
performed by placing
the diaphragm of the
stethoscope over the
midabdomen, and
the examiner listens
for bowel sounds.

Evaluate bowel sounds

Normal bowel sounds occur approximately
every 5-20 seconds and have a highpitched sound
If after 2 minutes no bowel sounds are
heard we can state absent bowel
sounds, what suggests a paralytic ileus
We can also determine bruits, which may
result from stenosis of the renal artery or
of the abdominal aorta or abdominal
aortic aneurysm

Bruits

Percussion
Is used to assess the resistance of the abdominal
wall, its tenderness, content of the abdominal
cavity and the size of its organs.
To demonstrate the presence of gaseous
distention and fluid or solid masses.
In the normal examination, generally only the size
and location of the liver and spleen can be
determined.
Soreness of the abdominal wall corresponds to
localised peritonitis.

Percussion
Tympanic resonance due to the presence of gas within the
stomach, small bowel and colon, occurs:
- In case of the increased content of gas in the digestive
tract (ileus of the small intestine and colon).
- In presence of free gas in the peritoneal cavity
(pneumoperitoneum). Perforation of the stomach,
duodenum, or gut; artificially after laparoscopy.
Dull sound is caused by the presence of fluid or airless
tissue.
- In ascites (variable borderline in dependence on the body
position).
- Above extensive cystic or tumorous formations or a full
urinary bladder.

Percuss the liver

The upper border of the liver is percussed in
the right midclavicular line, starting in the
midchest. As the chest is percussed downward,
the resonant note of the chest becomes dull as
the liver is reached. As percussion continues
still further, this dull note becomes tympanic
because the percussion is now over the colon.
The upper and lower borders of the liver should
be no more than 10 cm apart.

Rule out ascites

Ascites means the presence of free liquid in the peritoneal cavity.
It is detectable by physical examination if it exceeds 2000 ml.
Minor - in recumbent position does not influence the shape of
the abdomen, in standing position it is manifested by the bulging
in the lower abdomen (hypogastrium).
Major - the abdominal wall is above the level of the chest, it is
tense, and the umbilical scar is bulged (navel eversion).
The shape of the abdomen is changed in dependence on
the body position.
Ascites occurs in decompensated liver cirrhosis, advanced
congestive heart failure, nephrotic syndrome, portal vein
thrombosis, and carcinoma of the peritoneum. It is necessary,
using differential diagnostics, to differentiate ascites from
the encapsulated fluid in the abdominal cavity (ovarian and
pancreatic cystis).

Shifting dullness
Ascites is detectable by means of percussion.
Special test for shifting dullness may be performed. While
the patient is lying on the back, the examiner determines
the borders of tympany and dullness. The area of
tympany is present above the area of dullness and is due
to gas in the bowel that is floating on top of the ascites.
The patient is then asked to turn on the side, and the
examiner again determines the borders of the percussion
notes. If ascites is present, dullness will shift to the
more dependent position; the area around the umbilicus
that was initially tympanic will become dull.

Shifting dullness

Fluid wave
An additional test for
ascites is the presence of
a fluid wave. Another
examiners hand or the
patients own hand is
placed in the middle of
the patients abdomen.
The examiner then taps
one flank while palpating
the other side. Detection
of a fluid wave suggests
ascites.

Palpation
Is considered the most important examination method of
the abdomen.
Superficial (light) palpation is concentrated on the abdominal
wall, its tonus, tenderness, soreness, and the presence of
superficially localised resistances.
Deep palpation is directed at penetration into the depth,
collecting information on soreness, intensity of propagation,
organs size, abdominal aorta, and pathological resistances
(abnormal masses).
It starts from the area where no pain is reported, most frequently
from the left hypogastrium.
Palpation is quite difficult in obese patients.
Abdominal wall of a healthy man is firm, smooth, elastic, and
painless. Organs accessible through palpation are not tender;
their size is adequate. Pathological resistances in the abdomen
are not palpable.

Superficial (light) palpation abdominal wall

Is performed by using the flat part of the right hand or the pads
of the fingers, not the fingertips
Tense wall - the patient is not able to relax (release) muscular
tension (patients with neurovegetative lability).
Tense wall, painfully contracted - in accordance with the extent
of localised or diffuse peritonitis.
Rigidity - involuntary spasm of the abdominal muscles and is
indicative of peritoneal irritation. It may be diffuse or
localized
board-like abdomen in patients with generalized peritonitis
Thickened wall - subcutaneous fat in obese individuals, thick
muscular layer.
Effused wall - in anasarca (serious cardiac decompensation).
Lobular structures - subcutaneous fat, lipomas, or fibromas.
Crepitations - subcutaneous emphysema, or gaseous gangrene of
the abdominal wall.

light palpation

Deep palpation
The flat portion of the right hand is placed on the abdomen, and
the left hand is placed over it. The fingertips of the left hand
exert the pressure, while the right hand should appreciate any
tactile stimulation. The patient should be instructed to breathe
quietly through the mouth and to keep arms at the sides.
The palpating hands should be warm, because cold hands may
produce voluntary muscular spasm called guarding.
Pain intensity depends on its cause, reactivity, and patients
sensitivity. It is influenced by the age (reduced in the old age),
medication, or alcohol consumption.
During the examination, it is advisable to observe the face
expression of the patient.
Deep palpation is important for detecting formations (resistances)
in the abdominal cavity.
It allows determination of location, surface, size, shape,
consistence, relation to their surrounding (mobility, fixation),
and pulsation (aorta - aneurysm).

Deep palpation

Rebound tenderness
In patient with abdominal pain, it should be
determined whether rebound tenderness is
present.
Its a sign of peritoneal irritation and can be
elicited by palpating deeply and slowly in an
abdominal area way from the suspected area of
local inflammation. The palpating hand is then
quickly removed.
The sensation of pain on the side of the
inflammation that occurs on release of pressure
is rebound tenderness.
The patient should be asked: "Which hurts more,
now (while pressing) or now (during release)?

Rebound tenderness

Liver palpation
Palpation of the liver is performed by placing the
examiners left hand posteriorly between the
patients right 12th rib and the iliac crest, lateral to
the paraspinal muscles. The right hand is placed in the
right upper quadrant parallel and lateral to the rectus
muscles and below the area of liver dullness. The
patient is instructed to take a deep breath as the
examiner presses inward and upward with the right
hand and pulls upward with the left hand. The liver
edge may be felt to slip over the fingertips of the right
hand as the patient breathes.
Start as low as the pelvic brim and gradually work
upward. If the examination does not start low, a
markedly enlarged liver edge may be missed.

Liver palpation

Liver palpation
The fingertips should be 2 to 3 cm below the costal
margin. The patient is asked to inspire deeply,
bringing the liver edge down to the fingertips. One
should note the consistency of the liver and whether
there is tenderness. It should be noted whether the
edge of the liver is sharp, blunted, or nodular. The
examiner's hand may be moved along the liver edge,
outlining the size of the liver.
An alternative method of palpating the liver is to hook
the fingers (hooking method) around the costal
margin and have the patient inspire deeply to bring
the liver edge down. This technique is particularly
effective in patients with normal liver size.

Liver palpation

The scratch test

Occasionally the liver appears to be enlarged,
but the actual border is difficult to determine.
The scratch test may be helpful in ascertaining
the livers edge.
The diaphragm of the stethoscope is held with
the left hand and is placed below the right costal
margin over the liver. While the examiner listens
through the stethoscope, the right index finger
scratches the abdominal wall at points in a
semicircle equidistant from the stethoscope. As
finger scratches over the livers edge, there will
be a marked increase in the intensity of the
sound.

Liver demarcation in hepatomegalia

Spleen palpation
Palpation of the spleen is more difficult than
palpation of the liver.
The patien lies on the back, with the examiner at the
patients right side. The right hand is placed flat the
left costal margin and presses inward and upward
toward the anterior axillary line. The left hand exerts
an anterior force to displace the spleen anteriorly.
The patient is instructed to take a deep breath as the
examiner presses inward with the right hand.
The examiner should attempt to feel the tip of the
spleen as it descends during inspiation.
The spleen is not palpable in normal conditions
Splenic enlargement may be due to hyperplasia,
congestion, infection, or infiltration by tumor or
myeloid elements.

Hepatic tenderness
It is elicited by placing the palm of the
left hand over the right upper quadrant
and gently hitting it with the ulnar
surface of the fist of the right hand
Inflammatory processes involving the
liver or gallblader produce tenderness on
fist palpation.

Renal tenderness
For this part of the examination, the
patient should be seated.
The examiner should make a first and
gently hit the area overlying the
costovertebral angle on each side.
Patients with pyelonephritis usually have
extreme pain even on slight percussion in
these areas.

Thank you for attention!