THE ABDOMINAL EXAM

ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum

CREDITS Author

Ebondo Mpinga, MD,FACS Contributors

Michael Hughes, MD ,FACS (expert performance video) Richard Damewood, MD,FACS (modified score assessment tool) Duane Patterson, PhD (technical support) Paul Schreck (videographer )

Editors Keith Clancy, MD, FACS Amanda Beattie, MD , R5

York Hospital Department of Surgery, York, PA

OBJECTIVES

After the completion of this module the student should be able to:

1. Perform a complete abdominal exam.

2. Recognize the signs of peritonitis.

3. Arrive at a differential diagnosis based upon the findings elicited during the exam.

ABDOMINAL EXAM Although we will focus on the abdominal exam, it cannot

be overemphasized that a thorough physical exam (head to toes) is important to help in arriving at a comprehensive differential diagnosis list. Examples :

presence of jaundice may add consideration of a biliary /hepatic etiology

Irregularly irregular heart rate atrial fibrillation-> mesenteric ischemia

Crackle at lung bases pneumonia Skin lesions (pyoderma gangrenosum) -> IBD

ABDOMINAL WALL DESCRIPTION

The abdomen is generally divided into four quadrants by two artificial lines that intersect at the umbilicus

Other systems exist to further subdivide these four quadrants into nine regions/sections

RUQ LUQ

LLQRLQ

EpigastricRightHypochondrium

Rightflank

Leftflank

Umbilical

RightIliac

LeftIliac

Hypogastric / suprapubic

LeftHypochondrium

ABDOMINAL EXAM The exam should be performed in this specific order

General appearance Vital signs Inspection Auscultation Percussion Palpation

It should include An examination of the inguinal area

including the external genitalia in males (testes) A rectal exam (discussed in a separate module) A pelvic exam in women (discussed in a separate module)

DESCRIPTION OF TECHNIQUES

General Appearance Head-to-toe (skin, eyes, LOC,

position, demeanor) Inflammation, peritonitis

Lies perfectly still Or in bed with thighs and knees

flexed

Obstruction / colic Restless, writhing Abdominal distension?

Shock Pallor/ cyanosis/ diaphoresis/

decreased mental status

Vital Signs Tachycardia

? Early shock (may present prior to hypotension) May be absent if on Beta blockers

Rapid shallow breathing (splinting) Peritonitis

Hypotension May be late finding depending on pre-existing state of health Fever Infectious etiology or perforation

Inspection Abdominal contour

Distended vs. scaphoid Irregular -> mass /

volvulus / obstruction / hernias

Skin Ecchymosis around

umbilicus, flanks pancreatitis? Trauma

(seat belt sign)? Scars Prominent veins on the

abdominal wall Portal hypertension

Auscultation Bowel Sounds

Auscultate all regions Listen in each region Listen before feeling Absent bowel sounds

ileus, peritonitis, shock Hyperactive

Enteritis / obstruction (high pitched or distant)

Bruits AAA / Reno-vascular

diseases Iliac and Femoral

arteries

Aorta

Femoral arteries

Iliac arteries

Renal Renal

Percussion Hyperresonance

(tympani) Bowel distension with

air->obstruction In all quadrants but

RUQ (liver dullness) Loss of liver dullness in

RUQ-> Free air

Fluid wave Ascites (may be hard to

elicit in the obese)

Palpate each region Work toward area of pain Warm hands Communicate with patient

Let the patient know what you are about to do

Place Patient supine knee bent (if possible)

Epigastric LeftHypochondriac

RightHypochondriac

Rightflank

Leftflank

Umbilical

RightIliac

LeftIliac

Hypogastric

Palpation

Palpation Note tenderness

Localize vs. diffuse Rigidity Rebound

Press on the abdomen and release Present if pain is worse upon

release Avoid too sudden of a release

(may startle patient -> false +) Involuntary & voluntary guarding

Distract the patient while palpating to detect involuntary guarding

Feel for masses

Signs highly suggestive of peritonitis Tenderness to percussion

Tenderness elicited when the examiner firmly taps on the Iliac crest

Tenderness elicited when the examiner firmly taps on the heel of the patient’s extended leg

Tenderness when the bed is gently shaken or the patient coughs

Rebound tenderness

Abdominal exam: findings that suggest specific etiology Biliary / hepatic etiology

Courvoisier' sign Palpable gallbladder in the

presence of painless jaundice periampullary tumor

Caput medusa (Cruveilhier sign) Varicose veins at umbilicus

cirrhosis with portal HTN Murphy’s sign

Pain caused during inspiration while palpating the RUQ-> acute cholecystitis

Ransohoff sign Periumbilical yellow discoloration

-> ruptured CBD

Abdominal exam: findings that suggest specific etiology Appendicitis

Rovsing’s sign Palpation on the LLQ produces

tenderness at McBurney’s point

Ten Horn test Pain caused by gentle traction of the

right testicle

Aaron sign Persistent pressure applied at

McBurney ‘s point causes pressure in the epigatrium and upper chest wall

Abdominal exam: findings that suggest specific etiology

Pelvic inflammation/abscess Iliopsoas sign

Allow patient to lie on the opposite side of the pain

Extend the thigh on the affected side This should cause pain if there is

irritation of the iliopsoas muscle (seen with appendicitis as well)

Obturator sign Flexion and internal rotation of the

right thigh while supine elicits hypogastric pain

Indicates irritation of obturator internus muscle (seen with appendicitis as well)

Chandelier sign Extreme lower abdominal/pelvic pain

with movement of the cervix

Abdominal exam: findings that suggest specific etiology Hemoperitoneum

Hemorrhagic pancreatitis Cullen’s sign

periumbilical bruising-> hemoperitoneum Grey Turner’s sign

Local area of discoloration around the flanks-> acute hemorrhagic pancreatitis

Danforth sign shoulder pain on inspiration-> hemoperitoneum

Kehr’s sign Left shoulder pain when supine or pressure applied to LUQ->

splenic rupture

Inguinal exam Palpation of the inguinal area

with & without vasalva maneuver

Ask patient to cough Ask patient to take a deep

breath and bear down Pay attention to the femoral

area to rule out femoral hernias

In the male, the testis should be examined

to rule out testicular torsion

COMMON ERRORS Focus only on the abdomen Begin with palpation prior to inspection, auscultation and percussion Not asking the patient to localize the pain and therefore beginning palpation

of the affected area first, exacerbating the pain and thus precluding complete examination of the abdomen

Skipping the rectal, pelvic and groin exam Putting too much weight on the absence of rebound tenderness to r/o

peritonitis Putting to much weight on the physical exam in an immunosuppressed

patient who may not exhibit normal signs of peritonitis Forgetting to consider mesenteric ischemia when there is pain out of

proportion to clinical exam

GROUPING OF SIGNS AND SYMPTOMS

DIFFERENTIAL DIAGNOSIS

Severe central abdominal pain with shock and no peritoneal signs

Intra-abdominal causes Acute pancreatitis (pain

radiating to back)

Severe central abdominal pain with shock and no peritoneal signs

Intra-abdominal causes Acute pancreatitis (pain

radiating to back)

Rupture AAA (pulsatile

mass) STAT SURGERY

Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes

Acute pancreatitis (pain radiating to back)

Rupture AAA (pulsatile mass)

!! STAT SURGERY

Hemoperitoneum

!! STAT SURGERY

Spontaneous rupture of spleen/Splenic artery aneurysm (pain radiates to left shoulder)

Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes

Acute pancreatitis (pain radiating to back)

Rupture AAA (pulsatile

mass) !! STAT SURGERY

Hemoperitoneum

!! STAT SURGERY Spontaneous rupture of

spleen/Splenic artery aneurysm (pain radiates to left shoulder)

Ruptured ectopic pregnancy

Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes

Acute pancreatitis (pain radiating to back)

Rupture AAA (pulsatile mass) !! STAT SURGERY

Hemoperitoneum

!! STAT SURGERY Spontaneous rupture of

spleen/Splenic artery aneurysm

Rupture ectopic pregnancy Late mesenteric ischemia

Extra- abdominal causes Acute MI with cardiogenic

shock

Severe abdominal pain with diffuse peritoneal signs

Perforated viscous STAT SURGERY

Gastric/duodenal ulcers Gallbladder Complication of Small and

large bowel obstruction Maximal distention leading

to peroration (Cecum) Necrotic bowel due to

mesenteric ischemia or strangulated hernias

Patients will rapidly progress to septic shock if surgery is delayed

Severe central abdominal pain without associated signs

Intra-abdominal causes

Intestinal colic Early appendicitis Early/ mild pancreatitis Early mesenteric

thrombosis

Severe central abdominal pain without associated signs

Intra-abdominal causes Intestinal colic Early appendicitis Early/ mild pancreatitis Early mesenteric

thrombosis Extra- abdominal causes

Herpes Zoster (rash in dermatome distribution)

CAD (ECG/Enzymes) Glaucoma Tabes dorsalis (rare)

Severe central abdominal pain with distension, no vomiting & peritoneal signs Intra-abdominal causes

Large bowel obstruction while ileocecal valve is competent

Sigmoid diverticular stricture/ inflammation/ cancer

Volvulus Hernias Adhesions

Severe central abdominal pain with distension, no vomiting & peritoneal signs Intra-abdominal causes

Large bowel obstruction while ileocecal valve is competent

Sigmoid diverticular stricture/ inflammation/ cancer

Volvulus Hernias Adhesions

Extra- abdominal causes Uremia

Severe central abdominal pain with vomiting, distension & no peritoneal signs

Small obstruction Bilious vomiting in proximal

obstruction Feculent vomiting in distal

SB obstruction Gastric outlet obstruction

Non-bilious vomiting Undigested food particles

Severe abdominal pain with localized peritoneal signs RUQ

Acute cholecystitis (pain referred to back)

Severe abdominal pain with localized peritoneal signs RUQ

Acute cholecystitis Hepatic etiology: abscess/

hydatid cyst / Hepatitis Retrocecal appendicitis

Severe abdominal pain with localized peritoneal signs RUQ

Acute cholecystitis Hepatic etiology: abscess/

hydatid cyst/ Hepatitis Retrocecal appendicitis Leaking duodenal ulcer

Severe abdominal pain with localized peritoneal signs RUQ

Acute cholecystitis Hepatic etiology: abscess/

hydatid cyst/ Hepatitis Retrocecal appendicitis Leaking duodenal ulcer Pyelonephritis/stones

Severe abdominal pain with localized peritoneal signs RUQ

Acute cholecystitis Leaking duodenal ulcer Hepatic etiology: abscess/

hydatid cyst/ Hepatitis Retrocecal appendicitis Pyelonephritis/stones

Extra- abdominal causes Lobar pneumonia

Severe abdominal pain with localized peritoneal signs RLQ

Appendicitis Periumbilical at onset Shifts to RLQ

Severe abdominal pain with localized peritoneal signs RLQ

Appendicitis Cholecystitis (low lying GB) Leaking duodenal ulcer Terminal ileitis Meckel’s diverticulitis Right sided diverticulitis

(cecal) Mesenteric adenitis (children) Retained testis/ right testicular

torsion Urinary system (urteral

stones, pyelonephritis) Psoas abscess

Severe abdominal pain with localized peritoneal signs

LUQ Pancreatitis (most

common cause) Perforated gastric ulcer

localized by adhesions Splenic infarct/ injury Subphrenic abscess Jejunal diverticulitis Pyelonephritis

Severe abdominal pain with localized peritoneal signs

LLQ Diverticulitis of sigmoid

and left colon Colon cancer with

surrounding inflammation

Upper extension of pelvic abscess

IBD Pyelonephritis

Severe abdominal pain with localized peritoneal signs Hypogastric / Suprapubic area

Perforated diverticulitis or appendicitis

Appendicitis Pelvic appendix

Urinary tract Ureteral stones

lower ureter Bladder distention Cystitis

Severe abdominal pain with localized peritoneal signs Hypogastric / Suprapubic area

Perforated diverticulitis or appendicitis

Appendicitis (pelvic appendix)

Urinary tract Ureteral stones (lower ureter)/

Bladder distention / cystitis

Gynecologic / obstetric conditions

Uterine colic (Dysmenorrhea) Torsion/ ruptured ovarian cyst Ectopic pregnancy/ Threatened abortion PID