- Gastrointestinal System Physical Exam
Vital Signs
For abdominal problems, it is important to have an accurate, up-to-date set of vitals available. Follow the directions for assessing vital signs.
Setting Up
The fidelity of the abdominal examination can be improved by taking the following into account:
- Assume the patient is supine unless otherwise stated.
- Drape the patient appropriately exposing the abdomen from below the breasts (or nipples on males) to the pubic symphysis.
- Ask the patient to put their arms to their side to prevent stretching of abdominal skin.
- Ensure that the patient is relaxed to prevent guarding.
- Ask the patient to point to areas of pain.
- Ask the patient to empty their bladder to prevent uncontrolled urination or the incorrect finding of abdominal mass in the suprapubic area.
Inspection
- Stigmata of liver disease
- Caput medusae
Dilated superficial veins near umbilicus
- Scleral icterus
Yellowing of sclera/jaundice See Image
- Spider angiomas
Central red arteriole with capillaries extending outward See Image
- Gynecomastia
Enlarged breasts in males
- Palmar erythema
Reddening of palms
- Dupuytren’s contracture in the hand
Flexion contracture of fingers towards palm of hand
- Abdominal countour
- Obese
- Thin or Emaciated
- Distended
- Scaphoid
- Bulging flanks or protuberant abdomen
- Observed from foot of bed
- Sign of ascites with a sensitivity or 73–93% and a specificity of 44-70%
- Visible peristalsis
- Masses or bulges
- If mass/bulge is present, ask patient to raise head and shoulders off examining table; accentuates hernias
- Rashes
- Lesions
- Striae
- Clubbing and schamroth sign
- Intra-abdominal/retroperitoneal bleeding
- Scars
- May indicate previous surgeries
- Pulsations
- Can be normal in lean individual
- May indicate an abdominal aortic aneurysm
- Peripheral edema
Auscultation
- Auscultate before percussion or palpation to prevent the alteration of bowel sounds
- Stethoscope instructions
- Bell – low-frequency sounds; rest the bell lightly on the patient
- Diaphragm – high-frequency sounds; use firm contact pressure
- Stethoscopes with one functional side: apply light pressure for bell mode and firm pressure for diaghragm mode
- Listen for bowel sounds
- Normal = 5-30 irregular gurgles/minute at varying pitches and intensity
- Listen in one location (e.g., LUQ) with diaphragmn of stethoscope until bowel sounds are heard or up to 1 minute
- Note frequency and characteristics (i.e. borborygmi of hyperperistalsis)
- Bruits
- Auscultate for bruits over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries
- As bruits may be high or low pitched, the bell of the stethoscope should be used (as the diaphragm would have picked up bruits during the bowel sounds assessment).
- If a bruit is heard it is a sign of turbulent blood flow in an artery (i.e occlusion or arterial insufficiency)
- Friction rubs
- Rarely heard
- Grating sounds caused by respiratory motion over the inflamed peritoneal surface of a liver or spleen
- Best heard with the diaphragm of the stethoscope
Percussion
- Percuss the four quadrants of the abdomen noting areas of tympany and dullness
- Tympany is normal
- Dullness may be abnormal (mass) or normal (stool)
- Tympany in periumbilical region and dullness in flanks may indicate ascites (May merit special tests, see Shifting Dullness and fluid Wave)
- Liver span
- Percuss upward along the right mid-clavicular line starting below the umbilicus (RLQ); note the point where dullness occurs
- Percuss downward along the right mid-clavicular line starting at the nipple line; note the point where dullness occurs
- Measure the distance between the two points of dullness
- Normal adult liver span 6-12 cm at the mid-clavicular line
- If hepatomegaly discovered (>6-12cm), repeat measurement in mid-sternal line.
- Normal adult liver span 3-6cm at the mid-sternal line
- If liver disease is suspected, consider doing tests for ascites
- Spleen
- Traube's Space
- Triangular area bordered by costal margin inferiorly, anterior axillary line laterally, and the sixth rib superiorly
- Percuss on inspiration and expiration, a change in resonance may signify splenomegaly
- Normal percussion in Traube’s space is tympanic
- Sensitivity: 62%; Specificity: 72%
- Castell's Sign
- Percuss lowest costal margin at anterior axillary line while patient fully inspires
- If tympany changes with inspiration, may signify splenomegaly
- Sensitivity: 82%; Specificity: 83%
- Costovertebral Angle Tenderness
- Ask patient to sit upright
- Place ball of one hand on posterior costovertebral angle and strike with ulnar surface of other fist
- Use enough force to elicit a perceptible but painless sound in a normal person
- Pain may suggest nephritis or a musculoskeletal cause
Palpation
- To maintain patient comfort always begin at the furthest point from tender location of pain
- Ensure the patient is relaxed
- Palpate lightly in all four quadrants
- Feel for abdominal tenderness, rigidity, guarding (voluntary vs involuntary, masses, enlarged organs)
- Palpate deeply in all four quadrants
- Feel for abdominal tenderness, rigidity, guarding (voluntary vs involuntary), masses, enlarged organs)
- Assess for incisional, inguinal or umbilical hernias
- Assess for rebound tenderness
- Liver
- Place your left hand behind the patient on the 11th and 12th ribs to support the patient
- Palpate upwards from the inferior border of the lower right quadrant along the midclavicular line
- Have patient inhale deeply and exhale during each palpation
- Feel for liver enlargement, firmness/tenderness, bluntness/rounding, or irregularities of the liver edge
- The “Hooking Technique” may be helpful for obese patients
- Stand facing the patient's feet
- Place both hands side by side on patient's chest with fingers towards costal margin
- Have the patient inhale deeply and attempt to palpate the liver as it slides past
- Normally, the liver edge is palpable 3cm below the costal margin on inspiration
- Spleen
- Place your left hand across and behind the patient on the lower left ribs to provide support
- Start palpating from the right lower quadrant towards the spleen
- Have patient inhale deeply and exhale during each palpation
- Feel for spleen enlargement or tenderness
- May see splenic enlargement in portal hypertension, HIV infection, hematologic disease
- Palpation of spleen for detecting hypersplenism has a specificity of 98% and sensitivity of 27%
- Aorta
- Use the fingertips of both hands, place them a few cm left of midline and above the umbilicus
- Push deep and medially with increasing pressure.
- If a pulsating mass is felt, try to characterize its size and consider ultrasound imaging
- Greater than 3cm in diameter considered dilated
- Greater than 5.5cm diameter considered high risk for rupture
- Currently screening for AAA is only indicated for men between 65 and 75 who have ever smoked
- Risk factors for AAA include age >65, history of smoking, male gender, 1st degree relative with AAA
- Palpating aorta as a means of detecting AAA has a specificity of 56% and a sensitivity of 88%
- Kidneys
- Capturing a kidney on palpation is rare
- The right kidney is more easily captured than the left
- Use one hand to apply pressure just below the 12th rib in an attempt to bring the kidney forward.
- Use the other hand to press lightly on the lateral anterior abdominal wall, creating a thick sandwich of tissue between the two hands
- Ask the patient to take a deep breath and at peak inspiration, press more firmly in an attempt to squeeze
the kidney between the two hands
- If it slides between your hands, make note of its size, contour, and any tenderness
- Rectal exam
- Instructions for performing a rectal exam can be found elsewhere
- If appendicitis is suspected, consider doing the special tests for appendicitis such as
- If cholecystitis or cholangitis is suspected, consider palpating for Murphy’s Sign
- To differentiate between abdominal wall pain and intra-abdominal pathology consider doing Carnett’s Test
References
- Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolter Kluwer Health; 2009.
- Eskander A, Kandel C. The Abdominal Exam. In: Lincoln M, McSheffrey G, Tran C, Wong D, ed. Essentials of Clinical Examination Handbook. 6th ed. Toronto, ON: University of Toronto Medical Society; 2010:27-47.
- Rapini R, Sweeney S. Nevus Araneus. eMedicine. http://emedicine.medscape.com/article/1084388-overview. Updated October 2010. Accessed February 21, 2011
- Marinella M. Cullen’s Sign. Hosp Physician. 1999; 35(11): 35-36. http://www.turner-white.com/pdf/hp_nov99_rqcullen.pdf. Accessed February 21, 2011.
- Grover S, Barkun A, Sackett D. Does this patient have splenomegaly? JAMA. 1993;270(18): 2218-2221.
- Tsang K, Heim S. Splenomegaly. Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated August 2008. Accessed February 21, 2011.
- Cassar K. Aneurysm (abdominal aorta). Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated September 2009. Accessed February 21, 2011
- Dobson Roper, J. The abdomen: The complete examination. School Nurse News. 2006;5(6):41-42.
- McChesney J A, McChesney, J W. Auscultation of the chest and abdomen by athletic trainers. Journal of Athletic Training. 2001;36(2):190-196.
- 3M Littmann. Tunable technology. http://solutions.3m.com/wps/portal/3M/en_EU/3M-Littmann-EMEA/stethoscope/. Accessed September 14, 2013.