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Lecture 3: 12/02/2023 Made by: Mohamad Abou-Eid & Deniz Koku Presented by: Deniz Koku Abdominal Examination SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents 1. The abdominal examination 2. Surface anatomy 3. Referred pain 4. Ureteric stones 5. AAA 6. Hernias 7. AXR S U R G S O C J A S | C P A L E C T U R E S E R I E S Structure of the abdominal examination Introduction Position Inspection Palpation Percussion Auscultation S U R G S O C J A S | C P A L E C T U R E S E R I E S Introduction 1. Hello, my name is [name] and I am a second-year First, always introduce yourself medical student 2. Can I confirm your full name and date of birth? 1. State your name and role 3. I have been asked by the doctor today to examine 2. Confirm the patient’s full name and date of your tummy. This will involve me having a look, feel birth and listen to your tummy. Is that okay? 4. Thank you. 3. State the purpose for meeting with the patient 4. Gain verbal consent 5. Wash/sanitize hands 5. Wash hands S U R G S O C J A S | C P A L E C T U R E S E R I E S Position & Exposure • For this examinationI require you to lay completely flat. • I also require you to be exposed from the waist upwards, 0 degrees would you be okay removing your top? For the abdominal examination, the patient will need to lay completely flat on the bed and be • IF female: you may keep your bra on. exposed from the waist upwards • IF bed is not flat: may I adjust the bed for you? • Before we begin, are you in any pain? S U R G S O C J A S | C P A L E C T U R E S E R I E S Inspection • Actively look for: • Scars (previous surgery) When prompted, actively look at the patient’s abdome• Symmetry/masses • Ascites/diffuse swelling • Jaundice • The normal abdomen is usually flat and • The umbilicus symmetrical • Hernias • At rest, the respiration is mainly • Distended veins diaphragmatic S U R G S O C J A S | C P A L E C T U R E S E R I E S Inspection Normal abdomen Obesity Umbilical hernia Caput medusae Ascites or bowel obstruction Mass S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation Order*: 1. Light palpation 2. Deep palpation 3. Liver Some physicians tend to do the auscultation before anyen palpation or percussion in order to prevent the5. Kidneys (x2) sounds being disturbed by deep palpation. 6. Abdominal aortic pulse *you will be prompted to do any of these in your exam S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpation You must know the nine regions of the abdomen 1 2 3 6 4 5 S U R G S O C J A S | C P A L E C T U R E S E R I E S 1. Perform light palpation in each abdominal Light palpation region with the palmar surface of the fingers acting together 2. Your palm of the hand should be molding over the abdominal surface while the fingers flex at • Palpation of abdomen may be facilitated if patient is the metacarpophalangeal joints. You should not asked to flex the hip & knee joints (to relax the press too deep. anterior abdominal wall muscles) 3. You will look for tender areas and any lumps in the abdominal wall structure in each region. • Ask the patient to show you where any pain is present, and to report any tenderness during palpation. -> Start furthest away from the pain TIP: KEEP LOOKING AT THE PATIENT’S FACE • Look at the patient’s face and observe any discomfort S U R G S O C J A S | C P A L E C T U R E S E R I E S • Start furthest away from pain + look at the Deep palpation patient’s face • You will use both hands where the upper hand (usually the left hand) is used to exert pressure, while the lower hand is used to feel the organs or masses much deeper in the abdominal cavity. Same as light palpation, but use both hands • The lateral (radial) surface of the forefinger (index finger) is most sensitive. • For palpation of edges of organs (liver, spleen) or masses S U R G S O C J A S | C P A L E C T U R E S E R I E SSigns to look for on • Tenderness during palpation is a sign of underlying pathology. palpation • Guarding is when the abdominal wall contracts voluntarily when palpation causes pain • Tenderness • Rigidity is when there is inflammation of the parietal peritoneum (PERITONITIS!), the • Guarding contraction.ll muscles undergo a reflex • Rigidity • Rebound tenderness is when there is pain when • Rebound tenderness you remove your hand after pressing the abdomen. It is a sign of peritonitis S U R G S O C J A S | C P A L E C T U R E S E R I E S 1. Start in the right iliac fossa (RIF) Palpating the liver 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 S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpating the 1. Start in the right iliac fossa (RIF) 2. Ask the patient to take some deep spleen breaths at their own pace 3. Place two fingers on the abdomen parallel to the left costal margin 4. closer to the spleen ~1-2cm upwards diagonally 5. When the patient inhales, push down on abdomen and focus, try to feel if the organ will touch you 6. Finish at the left costal margin S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpating the 1. Place your left hand under the flank into the renal angle (costovertebral angle) kidney • Alower border of rib 12sterior median line and 2. (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 S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpating the 1. Keep the left and right hands where they are kidney: Balloting 2. Keep the right hand flexed at the metacarpophalangeal joints 3. Ask the patient to take a deep breath in 4. Swiftly flex the index and middle fingers at the metacarpophalangeal joints in order to push the lower pole of the kidney anteriorly to “strike” the right (palpating) hand. 5. Kind of like throwing a ball (kidney) from bottom up S U R G S O C J A S | C P A L E C T U R E S E R I E SPalpating the Abdominal Aorta 1. facing downwards with pads of thepalm Located superior and lateral (left side of patient) to the umbilicufingers 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. • When to suspect a AAA? • Pulsatile and expansile mass • Pushes your fingers up AND OUT S U R G S O C J A S | C P A L E C T U R E S E R I E SPercussion of the Liver (normal length ~13 cm) th 1. Locate the 4 ICS at the MCL Liver and Spleen 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 1. Follow the left costal margin to its trough th 2. Percuss just under it - 10 ICS at left anterior axillary line 3. If note change from normal on expiration to dull on inspiration, then that is abnormal S U R G S O C J A S | C P A L E C T U R E S E R I E SPercuss of 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. Wwould be resonant percussiongain. Positive test • Tseconds ideallyr you would wait 30 S U R G S O C J A S | C P A L E C T U R E S E R I E SHow does cirrhosis Cirrhosis is a sign of end-stage liver failure cause ascites? • A cirrhotic liver has a lot of scar tissue deposition Accumulation of fluid in peritoneal cavity therefore can cause portal hypertension. • This increased backflow leads to increased hydrostatic pressure in the portal venous system. This leading to ascites.asation into the peritoneal cavity • Poor liver function may also cause hypoalbuminemia. This can lead to reduced oncotic pressure in blood peritoneal cavity and cause ascitesasate into the S U R G S O C J A S | C P A L E C T U R E S E R I E S 1. Place the diaphragm of the stethoscope Auscultation anywhere on the abdomen 2. Listen for sounds Can auscultate bruits which is due to turbulent flow of blood 3. Do this on at least 2 locations due to a narrowing of vascular lumen 4. Listen for <30 seconds each and tell the “I Really Like Sara A lot” examiner you would do it for 3-4 minutes without time constraints 1. Iliac arteries -- in the iliac fossa 2. Renal arteries -- 2-3 cm superior and lateral to the umbilicus • Normally you will hear gurgling sounds of 3. Liver tumours -- over the liver peristalsis 4. Superior mesenteric or coeliac arteries -- epigastrium 5. Abdominalaorta -- just above and left of the umbilicus • High pitched & frequent (tinkling) is a sign of? • Bowel obstruction • Reduced/absent sounds are a sign of? • Paralytic ileus or peritonitis S U R G S O C J A S | C P A L E C T U R E S E R I E S Summary Palpation Poexposurend Inspection Percussion Auscultation Umbilicus, Light and deep Padown flatng respiration, Liver and spleen Liver and Bowel Patient veins, Kidneys – spleen sounds adequately masses, biballotingd exposed from the swelling Shifting Bruits waist upwards AAA dullness S U R G S O C J A S | C P A L E C T U R E S E R I E SLiver and gallbladder Causes of hepatomegaly: • Congestive heart failure (CHF) surface anatomy • Hepatitis (viral or alcoholic (early)) Need to learn the surface markings • Tumours, cirrhosis(alcoholic late) In these conditionsthe lower border of the enlarged liver becomes palpablebelow the costal margin • Can also be felt normally in children GB pain referred to epigastrium that migrates to RUQ • Gallstones (cholelithiasis) • Inflammation (cholecystitis) Murphy’s sign (present in acute cholecystitis) • Elicited by asking the patient to breathe in whilst palpating the right subcostal area, causing pain on inspiration (pleuritic pain on palpation of GB) ) S U R G S O C J A S | C P A L E C T U R E S E R I E SSpleen surface anatomy Spleen is along the medial surface of the 8th, 9th & 10th rib posteriorly between the mid axillaryline and lateral border Need to learn the surface markings of erector spinae muscle The spleen is separated from the rib cage by the diaphragm and the costodiaphragmatic recess It must enlarge 3 to 4 times its size to be palpable,but can be indicated via percussion S U R G S O C J A S | C P A L E C T U R E S E R I E SKidney and ureters • The kidneys sit at the L1 vertebral plane in the renal angle surface anatomy • The hila are about 4-5cm from the PML • Adult kidneys are about 9-12cm long x 5-7cm wide Need to learn the surface markings • The superior pole of the kidneys are covered by the 12th rib • The inferior poles are about 3-4cm above the iliac crest • The ureter is marked by drawing a line between 2 points • 5cm lateral to the PML at L1 • posterior superior iliac spine (PSIS – usually indicated by a skin dimple) Ureter runs along the tips of the transverse processes of the lumbar vertebra S U R G S O C J A S | C P A L E C T U R E S E R I E S It is important to know that pain can be Referred pain referred to parts of the abdomen because the visceral innervation of abdominal organs are poor at localising pain Pain from: • Foregut - referred to the epigastrium (T7/T8) • Midgut – referred to the umbilical region (T10) • Hindgut – referred to the suprapubic region (T11/T12) S U R G S O C J A S | C P A L E C T U R E S E R I E SUreteric stones Common sites of obstruction due to narrowing of ureter at these sites • Pelvi-ureteric junction • As the ureters cross over the sacroiliac joint (as the ureters cross over common iliac arteries) • Vesico-ureteric junction S U R G S O C J A S | C P A L E C T U R E S E R I E SAAA AAA is an abnormal dilation of the aorta at least 1.5x its normal diameter (usually >3cm for aorta) Awareness of abdominal pulsation or observation of ripples in water when they are in the bath (wave sign) • But MOST PATIENTS ARE ASYMPTOMATIC Decision to operate is if AAA >5.5cm or >4cm+>1cm growth rate/year Ruptured AAA → presents with a triad of back pain/flank pain + hypotension and a pulsatile expansile abdominal mass • On examination → likely to be sweaty & cold, weak & thready pulse and there’s likely to be a pulsatile expansile mass which could be tender & have a bruit • AIM of surgery → control bleed before repairing aneurysm S U R G S O C J A S | C P A L E C T U R E S E R I E SHernia Hernias are the passage of the peritoneum through a defect in the abdominal wall, possibly with abdominal contents • Direct (Hesselbach’s triangle) & indirect hernia (deep inguinal ring into patent processus vaginalis Hernias are usually asymptomatic lumps which can enlarge on coughing or straining Inguinal hernias and located superomedial to the pubic tubercle A non-reducible hernia (incarcerated) is at risk of strangulation S U R G S O C J A S | C P A L E C T U R E S E R I E S What are the six steps of the abdominal examination? Pain from the foregut and hindgutare referred to Introduction, position, inspection, palpation, which abdominalregions? percussion, auscultation Foregut – epigastrium,hindgut – suprapubic region A patient has loin to groin pain.They are also What are the 3 commonest sites of ureteric stone hemodynamically unstable. What is an important obstruction? PUJ, sacroiliacjoint, VUJ differential to consider? Ruptured AAA A 55-year-old female patient comes to the ED with diffuse abdominal distension and abdominal pain for the past 3 hours. She has not opened her bowels or passed flatus and has vomited yellow liquid a few times. Her past medical history is significant for a caesarian section at the age of 33. What is the most likely diagnosis? Small bowel obstruction S U R G S O C J A S | C P A L E C T U R E S E R I E S Summary Surface anatomy Referred pain Ureteric stones AAA Hernia Liver & Foregut – Usually, Gallbladder epigastrium Common sites Abnormal asymptomatic bulges Spleen Midgut – Umbilical of obstruction: dilation of aorta of abdominal region PUJ, pelvic is 1.5x normal contents through Kidneys and Hindgut – brim, VUJ size or >3cm defect iwalldominal Ureters suprapubic S U R G S O C J A S | C P A L E C T U R E S E R I E SDeniz Koku dk520@ic.ac.uk
