CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (PERCUSSION)

Far Eastern University – Nicanor Reyes Medical Foundation -Suprarenal gland

CD B PD LEC: ABDOMEN - PERCUSSION gland
Dr. Caballero, MD RIGHT LUMBAR UMBILLICAL LEFT LUMBAR
- Ascending - Omentum - Descending
PERCUSSION colon - Mesentery colon
- Lower half of - Transverse - Lower half of
right kidney colon left kidney
- Part of - Lower part of - Parts of
duodenum duodenum jejunum and
and jejunum - Jejunum and ileum
ileum
RIGHT ILIAC HYPOGASTRIC OR LEFT ILIAC
- Cecum PUBIC - Sigmoid
- Appendix - Ileum colon
- Lower end of - Bladder - Left ureter
ileum - Left ovary in
- Right ureter female
- Right ovary in
female

FOUR QUADRANT SYSTEM PERCUSSION OF ABDOMEN

RIGHT UPPER QUADRANT LEFT UPPER QUADRANT Help assess:
- Small bowel - Small bowel - The amount and distribution of gas
- Liver and Gallbladder - Left lobe of liver - Identify possible masses (solid or fluid filled)
- Pylorus - Spleen - Estimate size of liver and spleen
- Duodenum - Stomach - Presence of Ascites
- Head of Pancreas - Body of pancreas
- Hepatic flexure of colon - Splenic flexure of colon Percussion:
- Portions of ascending - Portions of transverse - Tympany predominates due to gas in the GI tract.
and transverse colon and descending colon - Dullness
- Right adrenal gland - Left adrenal gland
- Portion of right kidney - Portion of left kidney Liver span
RIGHT LOWER QUADRANT LEFT LOWER QUADRANT - below level of umbilicus, RMCL
- Small bowel - Small bowel - mark the site of dullness
- Cecum and appendix - Sigmoid colon Splenic dullness
- Portion of ascending - Portion of descending - along L MAL from 9th to 11th ICS
colon colon CVA tenderness ( kidney punch )
- Lower pole of right - Lower pole of left kidney - palm over CVA and strike with ulnar surface by another hand
kidney - Left ureter
- Right ureter PERCUSSION OF THE ABDOMEN: SOUNDS AND INDICATIONS
- (-) liver dullness  perforated PUD
NINE REGIONS OR SECTIONS o Most common site: DUODENUM (posterior, first
RIGHT EPIGASTRIC LEFT portion)
HYPOCHONDRIAC - Pyloric end of HYPOCHONDRIAC - tympanitic in ant but dull in flank areas  ascites
- Right lobe of stomach - Stomach - Shifting dullness  ascites
liver - Duodenum - Spleen - increasing dullness in L flank splenic rupture or hemorrhage
- Gallbladder - Pancreas - Tail of or splenomegaly
- Part of - Aorta pancreas
duodenum - Portion of - Splenic LIVER
- Hepatic liver flexure of - Size and shape can be estimated by percussion
flexure of colon - Decrease liver size
colon - Upper pole of o Liver Cirrhosis – liver shrinks due to fibrous
- Part of right left kidney replacement of parenchyma. May be accompanied by
kidney - Suprarenal

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (PERCUSSION)
jaundice. Patient may manifest with hepatic - Normal spleen weighs 150g and approximately 11cm in
encephalopathy. craniocaudal length. If it weighs 400-500g it indicates
o Portal Hypertension – can lead to the development of splenomegaly.
esophageal and gastric varices, spider angioma and
ascites. CAUSES of SPLENOMEGALY
o CAUSES: - Immune response work hypertrophy
• Alcoholic liver disease – excessive intake of o Subacute bacterial endocarditis
alcoholic beverages o Infectious mononucleosis
• Viral hepatitis B & C – associated with chronic - RBC Destruction work Hypertrophy
hepatitis. o Hereditary spherocytosis
• NAFLD ( Nona Alcoholic Fatty Liver Disease) – o Thalassemia
May progress to cirrhosis. May be insidious. - Myeloproliferative – Chronic Myeloid metaplasia
Associated with metabolic syndrome (Obesity, - Infiltrative
DM Type 2 or Impaired Fasting Glucose, o Sarcoidosis
Dyslipidemia and Hypertension) o Neoplasms
• Hemochromatosis – excess iron - Neoplastic
• Autoimmune hepatitis o Chronic lymphocytic leukemia
o Perforation of hollow viscus or gas in colon o Lymphoma
• Free air below the diaphragm may decrease the - Others:
area of dullness. o Trauma, Cyst, Hemangioma, Abscess
• Gas in colon at RUQ may obscure liver dullness
PERCUSSION: Tenderness of the KIDNEYS
- Displaced liver
- Pyelonephritis
o The liver is displaced downwards in cases of COPD but
- Musculoskeletal problem
the LIVER SPAN remains NORMAL.
- INCREASED LIVER DULLNESS PERCUSSION: To detect Ascites
o Hepatomegaly - Shifting dullness
• Viral Hepatitis – A, B, C. D, E o Fluid-intestine interface shifts UP towards umbilicus
• Acute Hepatitis only: A&E when patient is turned on the side
• Chronic and Acute Hepatitis: B, C, & D o Or just look at the umbilicus, if it is everted (but make
sure patient hasn’t had that since birth)
Liver becomes SMALLER after CHRONIC viral hepatitis but initially
- Fluid wave
may develop HEPATOMEGALY during the ACUTE infection and
o Healthy men have little or no intraperitoneal fluid.
earlier during infection.
Women may normally have as much as 20mL,
o Alcoholic liver disease – early on alcoholic hepatitis.
depending on the phase of menstrual cycle. Portal
o NAFLD – develop hepatomegaly earlier due to
hypertension and Hypoalbuminemia often with ascites.
inflammation.
- Puddle’s Sign: Knee Chest
o Chronic passive congestion – hepatomegaly that can
o Flicking sound increased as the chest piece move away
be reverse once heart failure has been corrected.
from the examiner
o Hepatocellular Carcinoma – not expected to decrease
o (+) even 120 ml
in size.
o Hepatic Abscess (Amoebic & Pyogenic) – Liver size DIFFERENTIALS:
improves with treatment. - Acute liver failure
- Alcoholic hepatitis
- Pleural Effusion may falsely increase the estimate of liver size. - Budd Chiari Syndrome
- Restrictive and Dilated Cardiomyopathy
PERCUSSION: TENDERNESS of the LIVER
- Cirrhosis
- Suggest inflammation and congestion
- Hepatocellular Carcinoma
o Hepatitis
- Nephrotic Syndrome
o Congestive heart failure
- Protein losing enteropathy

SPLEEN CONDITIONS ASSOICATED WITH ASCITES

- Percussion is moderately accurate in detecting splenomegaly - Cirrhosis
(PALPATION CORRECTLY detects presence or absence of - Portal vein thrombosis
splenomegaly) - CHF

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (PERCUSSION)
- Constrictive pericarditis SHIFTING DULLNESS
- Hepatitis
- hepatoma
- Nephrotic syndrome
- Ovarian cancer
- Pancreatitis
- Protein-losing enteropathy

PERCUSSION: May also differentiate an ovarian tumor or cyst from

ascites.

DISEASE ENTITIES IN WHICH YOU CAN DEVELOP ASCITES

- Liver Cirrhosis PUDDLE SIGN
o Portal Hypertension

o Decreased oncotic pressure
▪ ↓Production of proteins specifically ALBUMIN
o Hepatitis end result is liver cirrhosis

o Liver Size - (through percussion)
▪ Initially - enlarged liver

▪ Bleeding in end stage liver disease shrinkage

▪ If hepatocellular carcinoma develops enlarged liver
o Liver edge
▪ Sharp - not cirrhosis, may be viral hepatitis
▪ Nodular - cirrhosis OTHER DIAGNOSTIC METHODS
o Hepatic Liver Abscess - Small intestine is approximately 10-15 ft.
▪ Enlarged liver - Gastroscopy, colonoscopy: available, widely used
▪ RUQ pain - Blind Area enteroscopy
• (+) Murphy’s sign
 o Long scope can pass small intestine
• Be careful in doing this, may be very painful o Once you reach the most distal end, mark
• Abscess may rupture o Scope from rectal end up to marker to map whole GIT
▪ May use stethoscope to catch off guard - Capsule Endoscopy
malingering patients o Capsule that gives video signal to computer
▪ Binge drinking ↑risk of liver disease
- Right-sided Heart Failure STOMACH
o After prolonged condition  ascites develops PYLORIC VALVE
o CPC hypertension usually end stage - Very small opening that acts as stop valve & 
directs/regulates
- Urinary Bladder Distention flow of food to duodenum & prevents reflux 

o Female, 24 hours after normal delivery, developing mass - If patient accidentally swallowed a foreign body (coin) that is
(DULL on percussion) in hypogastric area small enough to pass through the pylorus it can pass the rest GI
o Do catheterization first tract. 


FLUID WAVE DULL

- Filled with fluid/food, recently ate 

- Obstruction in pyloric area food particles & fluid cannot 
pass
to duodenum accumulation in upper portions 


TYMPANITIC
- In supine position; fluid dependent settle posterior & air floats
anteriorly

HYPERTYMPANISM
- Possibly obstruction involving stomach or duodenum

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 CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS LECTURE – ABDOMEN (PERCUSSION)
PATHOLOGIC CAUSES OF HYPERTYMPANISM o If the gallstone is big enough for it NOT to pass through
- Pyloric stenosis the ileocecal bulb this will cause obstruction
o Usually in children (congenital pyloric stenosis) GALLSTONE ILEUS
- Polyp ▪ Ileocecal bulb (connection between terminal
o Size of a thumb, mushroom like 
 ileum and cecum; regulates flow from Small
o If the head of the polyp reaches pylorus can cause Intestine, Large Intestine)
obstruction - Ileocecal TB
- Mass: Gastric Malignancy 
 - Malignancy Involving the Colon
o Complete or Partial Gastric Outlet Obstruction: Near o Right sided tumors

pylorus, if the gastric cancer (or even gastric ulcer ▪ Large before obstructing Ascending Colon; fecal
causing edema) is close enough to the opening, material liquid form not easily detected., no
~obstruction 
 bowel movement changes
o Fundus or body of stomach may not cause obstruction o Left sided tumor

(no symptoms of vomiting etc) 
 ▪ Solid fecal material, obstruction occurs earlier,
o Linitis plastica or Diffused Gastric Cancer: develop easily detected with changes in bowel
throughout stomach (including cardia), result in a loss 
 movement
of distensibility of the gastric wall (“leather bottle”
appearance). Thick stomach wall w/o discrete mass
formn. 

o Poor gastric motility will cause accumulation of fluid and
food. Appears to be a mass on palpation. 

- Duodenal Ulcers 

o Can be so big, located near the pyloric opening ➞
Kissing ulcers
- Intestinal Adhesions
o Surgery - most common cause

o Open and manipulate abdomen fibrosis formn 

o Limits movement of the intestine (↓stretching capacity
of intestine) partial or complete obstruction 

o Usually causes distention of entire abdomen 

▪ Differential Diagnosis: Pyloric obstruction
(above) usually manifest w/distention of upper
abdomen (epigastrium)
o Patient will complain: “Doc, I feel like I want to flatulate
but I cannot.” 

o Lower GI obstruction  distention of larger area of
abdomen + hypertympanitic 

o Early GI obstruction  ↑bowel sounds ⋯ fatigues, air
accumulates distention + hypertympanitic. 


CAUSES OF GENERALIZED ILEUS, GENERALIZED ENLARGEMENT OF

ABDOMEN, AND HYPERTYMPANISM:
- Intestinal adhesions 

o By definition usually involves the lower GI
- Sepsis
o Poor circulation, hypotension → failure of organ.
- Gallstones
o Chronic cholecystitis: stones can erode (fistula formn)
and drop either to transverse colon or duodenum
▪ Drops and perforates the duodenum 
intestines evacuates

Notes from Lecture PPT, MRA Trans

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