For ease of description the abdomen may be divided into 9 areas or 4 quadrants as shown in the accompanying diagram.The patient’s description of the site of pain is generally placed in one of 4 quadrants with vertical and horizontal lines through the umbilicus giving right and left and upper and lower quadrants.For a description of examination findings the abdomen is divided into 9 areas with horizontal lines at the lower border of the costal magins and the upper border of the iliac crests and vertical lines through the midclavicular lines.This gives 9 areas;right and left hypochondria ,the epigastrium, right and left flanks and umbilical areas and right and left iliac fossa and suprapubic areas.
The abdomen is then examined in a careful systematic way.The actual examination performed will naturally be tailored to suit the individual patient and their presenting medical problem.A “neurological case” will not usually require an exhaustive search for ascites.
Observation of the abdomen is done to detect any abnormal contour due to masses, fluid or enlarged organs. Note should be taken of any abdominal scars and of any fistulae. Abdominal hernias may also be noted. The state of the umbilicus, be it effaced or flattened with ascites, or deeply buried in abdominal tissue in the obese patient should be observed. Dilated veins over the abdomen, may occur in portal hypertension. Where there is blood flow away from the umbilicus via dilated veins occurs in a caput medusae which is a very rare physical finding .Dilated veins over the periphery of the abdomen with blood flowing cephalad to return to the systemic circulation may occur in portal hypertension or in inferior vena caval obstruction.
Palpation of the abdomen needs to be gentle and meticulous. It is important to ascertain from the patient whether there is a site of discomfort and to examine this area last.Start in one area and then circle the abdomen and don’t forget the umbilical region. It is also appropriate if an obvious mass is seen on inspection in abdomen to examine the rest of the abdomen first. Otherwise other important findings may not be observed The abdomen should be examined with light palpation initially and then with deeper palpation. Remember that this is often an unpleasant examination for the patient. Palpation usually proceeds percussion, but there are certain instances where I believe this rigid pattern should be avoided. I believe it is much easier to quickly examine the liver and spleen without causing the patient discomfort by percussion before trying to palpate them.This should give a good guide to to the size of the organs and the systematic palpation should start 2 or 3 cm below the area of dullness.
Percussion should be gentle within the abdomen as the differences between the solid organs and the bowel, in terms of the percussion note are often subtle and best elicited with a gentle technique.
In the upper abdomen the main areas percussed are the liver and spleen. Note that percussion over the kidneys which are retroperitoneal organs with bowel gas anterior to them will be resonant and this can help the examiner differentiate between an enlarged left kidney and spleen. Dullness over the suprapubic region is usually due to an enlarged bladder
Percussion is a useful and kind test for abdominal tenderness or peritonism.If gentle percussion elicits localised tenderness this is good evidence for peritoneal irritation and certainly kinder than rebound testing where the palpating fingers are rapidly released from a tender part of the abdomen generally causing patient distress.
Auscultation generally will reveal the prescence of bowel sounds.Listen for at least 30 seconds.If you hear no sounds at all the patient probably has a paralytic ileus .Sounds may be high pitched or tinkling in a mechanical obstruction. Experience will tell you what are normal,increased or reduced bowel sounds.
Auscultation may reveal bruits either in the epigastrium where they are of uncertain significance and are quite frequent. Bruit over the liver may occur in association with hepatocellular carcinomas or rarely in acute alcoholic hepatitis. Over the flanks bruits associated with renal artery stenosis .Venous hums may be heard over the upper abdomen in patients with portal hypertension.These can be distinguished from arterial bruits in that they tent to be continuous whereas arterial bruits are systolic.Hums tend to vary in intensity with respiration and the position of the patient