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Imperial College London Surgical Society Junior Anatomy Series CPA SUMMARY GUIDE Abdominal Examination Deniz Koku and Mohamad Abou-Eid Defne Artun (CPA Lead) Anya Nanchahal (Phase 1a Lead) Andrea Perez Navarro (Phase 1b Lead) Imperial College London Surgical Society Junior Anatomy Series Abdominal exam – Introduction & Position Introduce yourself and gain consent 1. Hello, my name is [name] and I am a second-year medical student 2. Can I confirm your full name and date of birth? 3. I have been asked by the doctor today to examine your tummy. This will involve me having a look, feel and listen to your tummy. Is that okay? 4. Thank you. 5. Wash/sanitize hands (at the beginning and end of examination) Position and exposure • For this examination I require you to lay completely flat. • I also require you to be exposed from the waist upwards, would you be okay removing your top? • IF female: you may keep your bra on. • IF bed is not flat: may I adjust the bed for you? • Before we begin, are you in any pain? Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Inspection From the end of the bed, inspect the patient’s abdomen: • Normal abdomen is usually flat and symmetrical. • At rest, the respiration is mainly diaphragmatic. • During inspiration, the abdominal wall moves out and the liver, spleen and the kidneys move downwards. Signs • The umbilicus (sunken in obese patients, distension if there is an umbilical hernia) • Abnormally enlarged veins on the anterior abdominal wall indicate portal hypertension or an obstructed inferior vena cava. • Ascites (fluid collection in peritoneal cavity) or intestinal obstruction may cause diffuse abdominal swelling. • Any asymmetry of the abdominal wall may be due to a localised mass. Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Palpation Perform light and deep palpation in all 9 regions of the abdomen Tenderness Tenderness is a sign of pathology. Tenderness with minimal pressure over a wider area of the abdomen may be due to peritonitis or in some cases is due to anxiety of the patient. Guarding Guarding of the abdomen: The abdominal wall tends to contract voluntarily when palpation causes pain. This is called voluntary guarding. Rigidity Rigidity of the abdomen: When there is inflammation of the parietal peritoneum, the abdominal wall muscles undergo a reflex contraction. This is called involuntary guarding. Rebound tenderness Rebound tenderness: In patients with generalised or localised peritonitis, if the abdominal wall is compressed slowly and then released suddenly, they will experience a sharp stabbing pain. Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Palpation Palpating the liver and the spleen 1. Start in the right iliac fossa 2. Ask the patient to take some deep breaths at their own pace 3. Place two fingers on the abdomen parallel to the right costal margin 4. When the patient exhales, relocate closer to the liver ~1-2cm upwards 5. When the patient inhales, push down on abdomen and focus, try to feel if the organ will touch you 6. Finish at the right costal margin Palpating the spleen Same as palpating the liver but keep your fingers parallel to the left cost margin and finish at the left costal margin Palpatingthe abdominal aorta 1. You will use both hands with the palm facing downwards with pads of the fingers pressing deeply into the abdominal wall. 2. The fingers of both hands will be pointing towards the epigastrium whilst the ulnar borders (little finger side) lie parallel to the right and left costal margins. Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Palpation Palpating the kidneys 1. Place your left hand under the flank into the renal angle (costovertebral angle) • Angle is made by the posterior median line and lower border of rib 12 2. Place your right hand on the abdomen (this is the hand that will try to feel the kidney) and use your left hand as a guide 3. Press down with both your hands 4. Ask the patient to take some deep breaths in and out 5. You will try to feel the kidney as it moves down with inspiration 6. Repeat on the other side again with your left hand under Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Percussion Percussion is done to look for signs of organomegaly and shifting dullness in ascites Liver (normal length ~13 cm) 1. Locate the 4 ICS at the MCL 2. Ask the patient to take a deep breath in and hold 3. Percuss down noting the change in percussion note from resonant to dull to resonant • First change is top border (~5 ICS) • Second change is bottom border (liver to bowel at costal margin) Spleen 4. Follow the left costal margin to its trough 5. Percuss just under it - 10 ICS at left anterior axillary line 6. If note change from normal on expiration to dull on inspiration, then that is abnormal Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Percussion Percussion is done to look for signs of organomegaly and shifting dullness in ascites Shifting dullness 1. Place your hand on the midline of the patient's abdomen with your fingers parallel to their body 2. Percuss from the midline out to a flank noting where the change from resonant to dull occurs 3. Then mark that spot and ask the patient to turn to their side 4. Wait 10 seconds and percuss again. Positive test would be resonant percussion • Tell the examiner you would wait 30 seconds ideally Ascites can be caused by: • Liver cirrhosis → increased hydrostatic pressure on portal venous system → fluids leaks into abdominal cavity • Hypoalbuminaemia → liver fails to make albumin → decreased oncotic pressure of blood → less fluid retained in vasculature • Other causes: heart failure, liver cancer (and other cancers), nephrotic syndrome Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Auscultation You are listening for bowel sounds 1. Place the diaphragm of the stethoscope anywhere on the abdomen 2. Listen for sounds 3. Do this on at least 2 locations 4. Listen for <30 seconds each and tell the examiner you would do it for 3-4 minutes without time constraints Normally you will hear gurgling sounds of peristalsis High pitched & frequent (tinkling) is a sign of? • Bowel obstruction Reduced/absent sounds are a sign of? • Paralytic ileus or peritonitis Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Abdominal exam - Auscultation Can auscultate bruits which is due to turbulent flow of blood due to a narrowing of vascular lumen “I Really Like Sarah A lot” • Iliac arteries -- in the iliac fossa • Renal arteries -- 2-3 cm superior and lateral to the umbilicus • Liver tumours -- over the liver • Superior mesenteric or coeliac arteries -- epigastrium • Abdominal aorta -- just above and left of the umbilicus Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Presentations of Abdominal Conditions Bowel obstruction • Diffuse abdominal swelling • Generalized severe/cramping abdominal pain • Faecal vomiting (a late in in large bowel obstruction) • Bilious vomiting (early sign in small bowel obstruction) • Absolute constipation (not passing stools or flatus) Acute pancreatitis • Epigastric pain that radiates to the back, epigastric tenderness • Cullen’s sign (periumbilical bruising), Grey Turners sign (Flank bruising) but are rare • Vomiting, nausea • Low grade fever Bowel perforation • Rapid onset severe abdominal pain • Systemically unwell: Malaise, fever, chills, vomiting, tachycardia, tachypnea • Bloating • Peritonitis: rigidity and rebound tenderness • Risk factors: peptic ulcer disease, malignancy, bowel obstruction, diverticulitis Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series Presentations of Abdominal Conditions Ruptured abdominal aortic aneurysm • Patient will present with hemodynamic instability: tachycardia, tachypnea hypotension, sweaty, pale and clammy • Dizziness and fainting • Pulsatile and expansile feeling in the abdomen • Constant abdominal pain and radiates into the back • May present as loin to groin pain Kidney stone • Sudden flank pain radiating to the groin • Nausea and vomiting during the acute episode • Can cause testicular pain in males Acute cholecystitis • Constant right upper quadrant pain with a history of gallstones, may have shoulder pain • Nausea and vomiting • Anorexia • Fever • Murphy’s sign: asking the patient to take a deep breath when pressing on the right costal margin. Cessation of breathing (pain) = positive Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series A systematic approach to abdominal radiographs 1. Patient details + indication for scan 2. Image type (Plain CHEST/abdominal radiograph, PA/AP, ERECT/Supine) 3. Image quality (RIPE – rotation, inspiration, penetration, exposure) • Rotation → Spinous processes equidistant from pedicles • Inspiration → Pt fully inhaled? • Penetration → is the Xray too white or too dark or good penetration? • Exposure → bottoms of diaphragms to hernial orifices (pelvis) and left to right abdominal wall 4. AXR specific (BBC) • Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder. • Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs. • Calcification and artefact (e.g. renal stones, surgical clips) Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series A systematic approach to abdominal radiographs • Pink - Spleen • Light blue - Pedicles of L3 • Purple - Liver • Black - Transverse processes of L3 • Green - Left 11th rib • Yellow - Vertebral body of L4 • Orange - Kidneys • Dark blue - Urinary bladder • Red - Psoas muscle • Dotted green line - Path of the ureter (not usually visible) • Brown - Spinous process of L1 • Dotted white line - Left sacroiliac joint Defne Artun (CPA Lead) Deniz Koku & Mohamad Abou-Eid Imperial College London Surgical Society Junior Anatomy Series WE HOPE YOU ARE ENJOYING OUR SERIES! Feedback Please fill out the following feedback form. Let us know if there is anything we can improve on: ✓ Are we missing anything? ✓ Want to see more of something? ✓ What are we doing well? ✓ Finding anything confusing? Deniz Koku (Lecturer) dk520@ic.ac.uk Defne Artun (CPA Lead) da1019@ic.ac.uk Anya Nanchahal(Phase 1a Lead) sn1119@ic.ac.uk Andrea Perez Navarro (Phase 1b Lead) ap6418@ic.ac.uk
