Evaluation of the abdomen: Positioning, inspection, Palpation, Investigations

February 20, 2013 | By | Reply More

Evaluation of the abdomen: Positioning, inspection, Palpation, Investigations

Positioning and inspection
The patient should be supine with adequate support for the head to ensure the abdominal muscles are relaxed. The arms should be by the sides to relax the lateral abdominal muscles. The patient may be rolled into left or right lateral positions during palpation and percussion. Asking the patient to cough once or twice during inspection may reveal hernias.
The patient may need to stand up for examination of the groin, although most hernias and groin pathology can be fully assessed in the supine position with care.
Inspection should be done during both normal and deep respiration and include the following:
  • General features. Is there evidence of jaundice? Are there signs of anaemia? Does the patient looked underweight, malnourished, or frankly cachectic?
  • Scars. Where are they? How old do they appear? Is there evidence of herniation on coughing?
  • Is there a stoma? What type? Does it look healthy or abnormal? What is the content in the stoma appliance?
  • Overall appearance. Is the abdomen symmetrical? Is there evidence of global distension (e.g. ascites, distended bowel)? Is there evidence of local distortion (e.g. a local mass or organomegaly)? Does the abdomen move well and symmetrically with deep respiration (reduced in peritoneal irritation)? Is there any discoloration (peri-umbilical bruising (Cullen’s sign) or flank bruising (Grey Turner’s sign), where either suggests retroperitoneal haemorrhage)?
  • Umbilicus. Is it herniated? Is there discharge or ulceration suggestive of infection or a malignant deposit?
  • Pulsation. Is there visible pulsation? (Further assessment requires palpation.)
  • Persistalsis. Is there visible peristalsis? (Identification may take several minutes of observation.) It is rarely possible to suggest a cause or level of obstruction related to the pattern of visible peristalsis.
Palpation
Be methodical. Use the flat of one hand (usually the right). It is usual to examine and describe the abdomen in areas. It can be divided it into nine regions or five ‘quadrants’ (Fig. 2.2). Examine the areas lightly at first in a set order. Identify any masses or areas of tenderness. Repeat the examination with deeper palpation. Go back to any identified masses and try to ascertain their key features.
Palpation should be directed towards assessing the following:
  • Signs of peritoneal irritation. Are there signs of local visceral peritoneal irritation (tenderness and pain on palpation)? If so are there signs of mild parietal peritoneal irritation (guarding) or signs of marked parietal peritoneal irritation (rigidity)? Rebound tenderness is an unnecessary test; it merely confirms the presence of guarding and is often excessively painful for the patient.
  • Masses. Assess their surface, edge, consistency, movement with respiration, and overall mobility.
  • Organs.
    • Liver. Palpate from right lower quadrant into right upper quadrant, feeling for the liver edge during inspiration every few cm upwards until it is found. Assess the edge. Is it smooth/nodular/craggy? Assess any palpable surface. Is it smooth/nodular/craggy?
    • Spleen. Palpate from right lower quadrant into left upper quadrant feeling for the spleen edge during inspiration as for the liver. Assess the edge and any palpable surface.
    • Kidneys. Palpate bimanually in each loin. ‘Ballotting’ (bouncing the kidneys between each hand) is of little additional value.
Percussion
Percussion identifies the presence of excessive amounts of gas or fluid. It is also useful, when done carefully, in the confirmation of the presence of mild to moderate parietal peritoneal irritation (‘percussion tenderness’).
  • Gas (hyperresonance). Is it generalized or localized? Is there evidence of loss of dullness over the liver (suggestive of copious free intraperitoneal gas)?
  • Fluid (ascites). Usually identified as ‘shifting dullness’; dullness in the flanks in the supine position moves to the lower portion of the abdomen on turning to the lateral position.
Auscultation
To fully assess bowel sounds it is necessary to listen for at least 1min. Bowel sounds should broadly be divided into:
  • absent;
  • normal;
  • active;
  • obstructive—characterized by high pitched, frequent sounds often with crescendos of activity (e.g. ‘tinkling’, ‘bouncing marbles’).
Abdominal assessment should always include a rectal examination in adults but this is rarely useful and should usually be avoided in children.
Abdominal investigations
Faecal occult blood testing
  • May be chemical or immunological.
  • Of little value in hospital.
  • Commonest use is one form of community screening for colorectal disease (especially carcinoma).
Rigid proctoscopy and sigmoidoscopy
Flexible sigmoidoscopy
  • Very low risk (perforation 1/5000) outpatient procedure usually performed without sedation.
  • Should visualize up to the descending colon.
  • Allows minor therapeutic procedures.
Colonoscopy
  • Low risk (perforation 1/1000) outpatient procedure usually performed with sedation; requires bowel preparation.
  • Should visualize the entire colon (95% of the time).
  • Allows minor therapeutic procedures such as polypectomy, injection of bleeding points, marking of colonic disease location, biopsy assessment of colonic mucosa and lesions.
  • Typically used for: assessment of (suspected) colitis; assessment of colonic neoplasia; investigation of rectal bleeding.
Transabdominal ultrasound
  • Easy, safe, and avoids radiation dose.
  • Typical uses include:
    • identification of ovarian disease, e.g. in suspected acute appendicitis;
    • primary investigation of the biliary tree for gallstones, bile duct size, and liver parenchymal texture;
    • investigation of suspected subphrenic or pelvic collections;
    • assessment of the splenic parenchyma;
    • identifying free fluid in abdominal trauma.
CT scanning
  • Easy, safe; requires significant radiation exposure and IV contrast.
  • Typical uses include:
    • primary assessment of all intrabdominal masses;
    • staging of intraabdominal and pelvic malignancy;
    • often the investigation of choice in acute abdominal pain of unknown origin;
    • often the investigation of choice in suspected intestinal obstruction;
    • may be specifically tailored for pancreatic, biliary, visceral vessel assessment;
    • investigation of choice for suspected postoperative complications.
MRI scanning
  • Conventional body scanner with external coils.
  • Avoids radiation dose.
  • Typically used for:
    • investigation of suspected bile duct disease;
    • assessment of pancreas;
    • assessment of pelvic and retroperitoneal soft tissue disease, e.g. pelvic cancers.
Plain abdominal radiograph
  • Limited use.
  • May identify intestinal obstruction, urinary tract stones, free intra-abdominal air, intraabdominal fluid.
Barium enema (double contrast, single contrast)
  • May be single contrast (contrast material filling the colon) or double contrast (dilute contrast and air to coat the mucosal surface of the colon).
  • Requires bowel preparation and relatively mobile patient.
  • Single contrast used to identify strictures and obstructions (used to assess colorectal anastomoses in dilute or water-soluble form).
  • Double contrast typically used to identify colonic neoplasia, assess colonic anatomy.
Intestinal transit studies
  • Serial abdominal X-rays to identify the progress of ingested radio-opaque markers.
  • Used to assess intestinal motility and transit time.
Positron emission tomography (PET) scanning
  • Injection of radioactive metabolic substrate to identify metabolically active tissue.
  • Typically used to:
    • identify tumour deposits;
    • assess CNS disease.
Physiological testing
  • Manometry testing of the oesophagus including lower oesophageal sphincter and the anal canal.
  • Pressure sensitivities of the oesophagus and anal canal.
  • Ph testing of the contents of the oesophagus (isolated or continuously for 24h).
  • Used to assess anorectal function, oesophageal motility and function, and gastro-oesophageal reflux.

Category: Surgery

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