CHAPTER 8

The Abdomen

Examination of the abdomen is quick and painless and yields a great deal of information. [Figure 8A] Since only obvious deformities in the size or shape of the abdomen can be detected by observation, the physician's methods of palpation, auscultation, and percussion become relatively more important for the abdominal examination. Examination of the digestive (or gastrointestinal) system also includes an examination of the kidneys as well as the urinary and circulatory systems. In women, this procedure includes an examination of the reproductive system.

1. Correct Positioning: A patient's abdomen is best examined with the patient lying on his or her back, with hands to the side and legs slightly bent at the knees. This position is best for relaxing the muscles of the abdominal wall and allowing the doctor to palpate the deep organs more easily.
   
   The organs of the abdomen are located in the same position in nearly every patient. The symptoms for certain diseases have classic locations where people often describe their discomfort or pain as originating. For this reason, doctors have to think about which organs or diseases cause pain in particular regions. [Figure 8B]

   

2. Examining the Patient

   1. Looking (inspection): Several abnormalities can be detected by looking alone. These include obesity, abdominal swelling, defects in the abdominal wall, pulsations of the aorta as it courses through the abdomen, and in some patients, tumors large enough to be detected by observation.
      
      Obesity deserves special attention since it is common and since it is a contributing factor to many disease processes. Patients who are obese deserve special attention because the examination of their abdomens is made more difficult by obesity. For instance, it is difficult to palpate the pulsations of the abdominal aorta in obese patients and even more difficult to estimate the diameter of the aorta. In addition, it is difficult to palpate the organs and any masses or tumors which may be present.
      
      Abdominal distension is often a clue to the presence of some sort of obstruction. Obstructed bowels which do not move well because of constipation or disease will increase in diameter, causing the abdomen to distend. It is helpful to know what a particular patient's abdomen looks like normally, since some people have poor muscle tone in the abdominal muscles and may have abdomens which appear distended even when there is nothing wrong. An additional cause of abdominal distension is fluid which sometimes collects in the abdominal cavity in the presence of heart disease and some liver and kidney diseases. This fluid collects because it leaks out of the intestinal wall faster than the lymphatic system is able to absorb it. In addition, if the heart is weak or the kidneys are not working well, this fluid can collect because these organs are not able to assist in excreting this extra fluid fast enough. This fluid is called ascites and can collect in large enough quantities to cause abdominal distension.
      
      Defects in the muscles of the abdominal wall, called hernias, can occasionally be seen by inspection alone but are usually detected and best evaluated by palpation. These defects can be congenital (present at birth) or acquired after birth (as a result of abdominal surgery) and are usually not painful. There are several types, some of which will be discussed in a later chapter. Hernias, in general, pose no immediate threat, but since at times the intestines can bulge into the hernia and get blocked off, most doctors prefer to repair hernias on an elective basis. The exception to this is the umbilical or "belly button" hernia, which is fairly common in children. Some umbilical hernias resolve on their own, so many doctors prefer to wait and see if this happens first. If they do not disappear, surgery can always be done at a later date.
      
      Finally, there are some observations which can be made only rarely, but these are very important and should never be missed. In patients with severe pancreatitis (inflamation of the pancreas), for example, blood which leaks out of the pancreas is visible through the abdominal wall. This accumulated blood appears as a bluish/gray discoloration of the skin surrounding the flanks or umbilicus (belly button). This indicates that the pancreatitis is severe enough to have caused tissue death and bleeding. Another such important observation can be made in some patients with advanced liver failure due to cirrhosis. In this condition, blood has difficulty passing through the normal vessels in the liver, so it gets backed up and tries to reach the heart by alternate routes. One such route is for the blood to flow into the veins which are in the skin surrounding the umbilicus and to cause them to become dilated (enlarged) and visible on the skin as bluish-gray, snake-like discolorations. Since they are seen radiating like snakes from the center of the umbilicus, doctors have nicknamed this finding "caput Medusae" after the Greek goddess, Medusa, who had snakes in her hair.

   2. Listening (Auscultation): For most parts of the physical examination, doctors feel that auscultation should be conducted last. However, in the case of the abdominal examination, most doctors feel that auscultation should be done first, before the normal resting state of the abdominal organs have been changed by palpation. For example, the bowel sounds of a person might be more or less active after deep palpation than before.
      
      Listening to the abdomen with a stethoscope reveals the presence or absence of bowel sounds, which are the continuous and regular movements of the stomach and the small and large intestines. All of us have heard a stomach "growl" or "rumble", and these are merely the normal sounds that food makes as it passes through the gastrointestinal system. Normal bowel sounds are the gurglings which can be heard several times per minute, as waves of peristalsis (muscular contractions) pass down through the walls of the intestines. Abnormal bowel sounds are simply too many, or too few, of the normal bowel sounds. Hyperactive bowel sounds occur when patients have diarrhea, for example, or when the intestines are in the early phase of obstruction. In the beginning of intestinal obstruction, the bowels move frequently and vigorously to try and get the contents of the intestines around the obstructed area. This sounds like hyperactive bowel sounds which are often of a higher pitch than normal bowel sounds.
      
      When no bowel sounds are heard after listening for one minute, the patient is said to have ileus, which means that the normal waves of peristalsis have ceased altogether. Common causes of ileus include peritonitis (inflammation in the abdominal cavity) and post-operative recovery from abdominal surgery (after the bowels have been manipulated during surgery, it takes several days for them to recover and start to function normally again).
      
      In addition to listening to bowel sounds, the abdomen should be auscultated for the presence of bruits, which are the rushing sounds made by abnormal blood flow. Abdominal bruits are occasionally heard in the aorta and the renal arteries and suggest narrowing of the vessels due to atherosclerosis. It is important to examine for these since they may be a sign of early atherosclerosis. Also, if the renal artery is stenosed (narrowed), it could be causing a form of high blood pressure which is often curable!

   3. Feeling (Palpation): Palpation of the abdomen yields a lot of useful information. There are several ways to palpate the abdomen: with one hand, with one hand on top of the other, and with one hand in front and one on the back of the patient.
      
      The one-handed method is the most widely used and is good for examining the internal organs such as the stomach, liver, spleen and intestines. The two-handed method is used to augment the one handed method and is especially good for examining the deep organs, such as the kidneys. In the two-handed method, the doctor palpates directly with his or her dominant or preferred hand while pressing over this hand with the other hand. It is thought by some that by applying pressure with the other hand, the dominant hand is better able to feel abnormalities. The method with one hand in front and the other at the back is also useful to palpate deep organs, which can occasionally be felt between the two hands as they press in towards one another.
      
      Generally, doctors palpate in all four quadrants to see if any organs can be identified. Usually, no organs are felt at all, and this can be entirely normal! In fact, it is more disturbing to feel organs than to feel nothing at all. Most often the liver can be felt if the doctor presses down during the patient's inspiration. This is entirely normal, but if the liver is felt, its size should be estimated to ensure that it is not enlarged. With special movements and deep palpation the spleen and kidneys can occasionally be palpated, but if the spleen, kidneys or bladder are palpated on routine abdominal examination, this is considered to be abnormal. A palpable spleen in an adult means it is abnormally large, as are palpable kidneys. If the bladder is palpated, this means that it is quite full, or possibly that an obstruction is preventing it from emptying. Similarly, if the uterus of a woman can be palpated, then it is abnormally large.
      
      Feeling the liver: The liver can usually be palpated during deep inspiration, and it feels like a soft but firm mass located in the right upper quadrant. It can sometimes be abnormally small or firm in diseases such as cirrhosis. At other times it can be tender to palpation such as in hepatitis or right-sided heart failure. Sometimes masses can be felt in the liver and numerous types of tumors become considerations in the diagnosis. If the liver can be palpated then its size should be measured, using percussion to determine if it is enlarged. Enlarged livers are seen in many diseases. Occasionally the gallbladder can be felt in patients with gallstones or cholecystitis (an inflamed, enlarged gallbladder). The gallbladder is located below the lower edge of the liver.
      
      Feeling the spleen: The spleen is not normally felt at all. If assessing the size of the spleen is important in a particular patient, she or he can be asked to roll slightly toward the right side, which will cause the spleen (located in the left upper quadrant) to fall forward and downward, making it easier and more likely to be felt. Enlarged spleens can be seen in many diseases, such as infections, connective tissue disorders, lymphomas, leukemia, portal hypertension or cirrhosis.
      
      Feeling the kidneys: Again, the kidneys can not usually be palpated except in very thin persons and in infants. The kidneys should be palpated for normal size in the examination of all infants because of two childhood diseases: polycystic kidney disease (kidneys with balloon type cysts) and Wilm's tumor which is a relatively common form of childhood cancer.
      
      Palpating for masses: A physician should always feel for masses (tumors) in all quadrants. Masses can occasionally be palpated in the liver, pancreas, stomach, small intestines, large intestine, bladder, uterus, ovaries, and kidneys.
      
      Palpating for pulsations: In thin individuals, the aorta can be seen to pulsate as it passes through the abdomen. In most individuals its pulsations can be palpated, and an estimate of its size should be made. If an abdominal aorta is felt to be greater than 4-5 cms in diameter, then further diagnostic workup is indicated to rule out an abdominal aortic aneurysm -- which is a dangerous ballooning or dilation of the aorta - which can be treated and even surgically repaired if necessary.
      
      In addition to the pulsations of the aorta, the liver can, on rare occasions, be felt to pulsate. This usually indicates that there is an abnormality with the right side of the heart, usually the tricuspid valve.

   4. Tapping (Percussion): Percussion of the abdomen is done primarily to determine the size of the liver and spleen and to determine if an abnormal collection of fluid exists in the abdominal cavity.
      
      The size of the liver is estimated in the following way. The doctor percusses, beginning over the right lung near the nipple, where a flat or slightly tympanitic sound is heard. As the percussing hand moves downward over the liver, the sound changes to being dull. Below the level of the liver the sound again becomes tympanitic, indicating that the hollow organs, such as the large and small intestines, are being percussed. The area of dullness corresponds to the size of the liver, and liver enlargement can be a clue to many disease processes.
      
      The spleen can be percussed in a similar way, except that the patient needs to be in the left lateral decubitus position -- which is lying on the back, rolled slightly to the left side, but not all the way onto the side. In this position, the spleen is located against the abdominal wall and can be percussed more easily. Beginning over the left lung the percussing hands move down over the dull area which represents the spleen. At the lower edge of the spleen, tympanitic sounds return, indicating that hollow organs (such as bowel) are beneath. In this way, the size of the spleen is measured.
      
      Finally, percussion is used to determine the presence of ascites -- an abnormal collection of fluid in the abdominal cavity, but outside of the organs themselves. If fluid has collected in the peritoneal cavity, it will locate at the bottom of that cavity due to gravity. The air-filled bowels will float on top of it. If one were to percuss someone with ascites beginning at the flank (lower back) and moving upwards toward the umbilicus (navel), one would notice a transition zone where the flat sound of percussing over the fluid was replaced by the tympanitic sound of percussing over the bowels. This would be the level of fluid in the peritoneum. In order to prove that the dullness was not a solid organ, but was indeed due to fluid levels, the doctor could then turn the patient onto her or his side and percuss again. Since the bowels would float up to the uppermost side of the abdominal wall and the fluid would sink to the lower flank, the area of dullness would shift just as the fluid had shifted. This would confirm to the doctor the presence of ascites.
      
      One additional application of percussion in the abdominal examination involves percussing the back to see if the kidneys may be irritated and painful. Doctors usually tap with a fist over the lower back just to the side of the spine and just below the last rib. This is not normally painful but may be extremely painful if the kidneys are infected. The patient may not have noticed this pain since it is related to sudden motion (the tapping of the fist), especially if the patient has been inactive.

3. The Rectal Examination: An important part of the abdominal examination is the rectal examination. It is usually conducted with the patient in the fetal (curled up) position but can also be comfortably conducted with the patient standing and bending over a table (in women, the rectal examination is often included as the final part of a pelvic examination in the standard position for a pelvic exam).
   
   Information gained through the rectal examination, in both men and women, includes assessing the tone of the sphincter (muscle which closes off the anus) -- which is especially important in patients with neurological complaints or problems with holding in their stool. Also, the end of the rectum can be palpated for polyps, which are abnormal growths that can become cancerous. A small sample of stool which inevitably remains on the doctor's glove can be tested instantly for the presence of undetected blood.
   
   In men, the rectal examination is useful for assessing the size of the prostate gland and whether any abnormal growths are located in the prostate. Prostate disease is one of the most common problems in aging men. Two conditions predominate: I)In benign hypertrophy of the prostate, the normal tissue of the aging prostate overgrows, and the prostate becomes enlarged. Since the tube that conveys urine from the bladder through the shaft of the penis must pass through the prostate, an enlarged prostate can block this tube and make it difficult for men to urinate or to empty their bladders completely. This is why most older men have a weaker stream of urine or may dribble more than younger men, and why many men have to get up several times at night and empty their bladders. Certain medication can often be taken to shrink the prostate gland. Surgery is sometimes required to remove the blockage. 2)In cancer of the prostate, nodules or growths are felt in the outer border of the prostate. When present, these need to be sampled to see if cancer cells are present. Most prostate cancer occurs in very old men, and it rarely spreads fast. For men who are diagnosed with cancer of the prostate, most will die of some other cause before the prostate cancer kills them. If found early, or in a younger man, the cancer usually responds well to surgical removal and chemotherapy. In women, the rectal examination is useful to assess for a rectocele, a condition where part of the rectum bulges into the vagina.

4. Peritonitis: The organs inside the abdominal cavity are each surrounded by a thin membrane called the visceral peritoneum. Similarly, the abdominal wall itself is surrounded by a thin membrane called the parietal peritoneum. These membranes are normally very close together and separated by a small amount of fluid, which is normally present for lubrication as the intestines move. (Imagine a long garden hose stuffed inside a garbage bag which is filled with water. The inner lining of the garbage bag would be the parietal peritoneum and the outer wall of the hose would be the visceral peritoneum. The water in the bag, which the hose is lying in, represents the fluid that is present in small quantities in our abdominal cavities.)
   
   Sometimes an abnormal amount of fluid collects in the potential space in the abdomen -- just as if extra fluid collected in the garbage bag. This is called ascites and is an abnormal amount, or type, of fluid which collects in the potential space between the visceral and parietal membranes. Irritation of these membranes leads to inflammation and is very painful. Whenever one of the hollow organs perforates (such as a ruptured appendix or a perforated ulcer -- just like the hose breaking inside the bag), the contents of the bowels (food) spill into the peritoneal space and cause severe pain. Such patients are said to have peritonitis (inflammation of the peritoneum) and are almost always in need of emergency surgery. When peritonitis occurs, the bowels stop moving completely and any movement or stretching of the peritoneal membranes causes extreme pain. For this reason, the abdominal muscles contract involuntarily, and the abdomen becomes rigid. There are several classic and easy signs of peritonitis which doctors routinely check for in very ill patients.

   1. Absent bowel sounds: the bowels have stopped moving altogether.

   2. Guarding: the patient has so much pain from the irritation of the peritoneal membranes that their abdominal muscles are contracted, and it is difficult to feel any other abdominal structures on examination.

   3. Rebound tenderness: any movement or stretching of the membranes causes severe pain. For instance, if the doctor presses firmly but gently and then rapidly withdraws his or her hand, this causes the membrane to suddenly stretch back into its original position -- and produces pain in the patient's abdomen. Similarly, even jiggling the bed would cause pain for the same reason.

   If any patient has evidence of these signs, she or he is said to have peritoneal signs and needs evaluation by a surgeon.

5. Location of pain: As a doctor examines the abdomen of a patient, the location of his/her pain is very useful in determining possible causes. This is too detailed and complex a problem to discuss fully here, but common types will be discussed briefly as examples.
   
   Pancreatic pain: Usually located above the umbilicus (belly button) in the middle of the abdomen and often radiates to the back.
   Spleen pain: Usually located in the left upper quadrant and may radiate to the left shoulder.
   Pain of diverticulitis: Pain from diverticulitis (abnormal outpouchings of the large intestinal wall which periodically become inflamed) and is often located in the right or left lower quadrant of the abdomen.
   Kidney pain: Often located in the flanks (lower back) and may radiate into the groin.
   Pain from appendicitis: This pain is usually located around the wnbilicus at first and then moves into the lower right quadrant as the condition worsens.
   Intestinal pain: Usually crampy in nature and can be located almost anywhere.
   
   When abnormalities are detected, additional tests may often be needed to make an accurate diagnosis. The imaging studies which are commonly used to evaluate the abdomen are ultrasound (sound waves), CAT (computed axial tomography, or computerized x-ray from many locations in the area), scanning (picture taken of radioactive substances injected into the patient which accumulates in the organ) and MRI (magnetic resonance imaging: means of creating images using magnetism).

Chapter 9