Fig. 5D.15: Planes and nine areas of the abdomen.

Finding Seen in

Normal Gentle rise in the abdominal wall during inspiration and a fall during expiration

Corresponding areas move equally on both sides

Diminished or absent movements Generalized peritonitis (the still, silent abdomen)

Visible peristalsis:

Site of obstruction Direction of peristalsis

Obstruction at the pylorus Peristalsis from left costal margin to right

Obstruction in the distal small bowel Right to left (or)

Irregular pattern

Note: Visible peristalsis may be a normal finding in very thin elderly patients with lax abdominal muscles.

Visible mass:

Figure 5D.16 demonstrates the underlying intra-abdominal structures with respect to the regions.

Divarication of recti (diastasis of recti):

It is a gap between the rectus abdominis muscle which becomes prominent on straining (Fig. 5D.17). Make the patient lie supine and tense the abdominal muscles by lifting the head (Fig. 5D.18), a midline

defect can be seen and felt. It is common after postpartum, and also can be seen with tense ascites.

AUSCULTATION

Note that the abdomen should be auscultated prior to palpation. Auscultate in all four quadrants of the

abdomen.

Bowel sounds

Bruits

Venous hum

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Fig. 5D.16: Pictorial representation of corresponding areas and underlying structures.

Fig. 5D.17: Divarication of recti.

Fig. 5D.18: Midline defect suggestive of divarication of recti, on asking the patient to raise the head off

the bed. Also patient has umblical hernia.

Rubs

Succussion splash.

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Bowel sounds (Fig. 5D.19):

Normal 7–35 per minute

Increased (borborygmus) Intestinal obstruction

Diarrhea

Laxative use

Carcinoid syndrome

Massive GI bleed

Decreased Paralytic ileus and peritonitis

Note: When bowel sounds are not present, one must auscultate for a full 3 minutes before saying that

bowel sounds are absent.

Bruits:

Renal artery bruit (Fig. 5D.20) 2.5 cm above and lateral to the umbilicus in transpyloric plane

Indicates partial renal artery stenosis

Abdominal aorta (Fig. 5D.21) Epigastrium in aortic aneurysm or aortoarteritis

Hepatic bruit (Fig. 5D.22) Hepatocellular carcinoma (HCC)

Acute alcoholic hepatitis

Hemangioma

Iliac bruit (Fig. 5D.23) 2.5 cm below and lateral to the umbilicus

Venous hum:

Cruveilhier–Baumgarten murmur (Fig. 5D.24):

It is a continuous murmur, produced due to the opening of the paraumbilical vein in the falciform

ligament.

It is heard midway between the xiphisternum and umbilicus on the right side of the epigastrium.

Fig. 5D.19: Auscultation of bowel sounds.

Fig. 5D.20: Renal artery bruit—2.5 cm above and later to umbilicus

in transpyloric plane.

Fig. 5D.23: Iliac bruit—2.5 cm below and lateral to umbilicus

Fig. 5D.21: Abdominal aorta bruit in the epigastrium in the midline.

Fig. 5D.24: Cruveilhier–Baumgarten murmur heard midway

between the xiphisternum and umbilicus on the right side of th

epigastrium.

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Fig. 5D.22: Hepatic bruit.

A patent umbilical vein excludes an extrahepatic cause of portal hypertension because the

umbilical vein arises from the intrahepatic portion of the left portal vein.

4. Rubs:

Hepatic friction rub is a superficial, scratchy sound heard on the liver.

Commonly seen with:

HCC

Postliver biopsy

Hepatic infarcts and

Gonococcal peritonitis (Fitz–Hugh–Curtis syndrome).

Splenic rub is a coarse, scratching sound coinciding with inspiration over the left upper quadrant

due to splenic infarct.

Commonly seen with:

Subacute bacterial endocarditis

Chronic myeloid leukemia.

Sickle cell anemia.

After splenic puncture (e.g. in diagnosis of chronic kala-azar).

Succussion splash:

When you auscultate the patient’s epigastrium/left upper quadrant and then shake the patient a

“splash-like” noise is heard

If heard after several hours after eating, it suggests delayed gastric emptying which may be due

to gastric outlet obstruction.

Thoracic succussion splash has been described in achalasia cardia, hydropneumothorax, and

large hiatal hernia.

PALPATION AND PERCUSSION OF THE ABDOMEN

The following scheme is suggested for palpating the abdomen:

Start in left lower quadrant of abdomen and repeat in all quadrants as described below.

Palpate lightly initially, followed by deep palpation.

Feel for left kidney→spleen→right kidney→liver→aorta and para-aortic glands→common femoral

vessels→urinary bladder→both groins→external genitalia.

EXAMINATION OF INDIVIDUAL ORGANS

Examination of Liver

Location

Right hypochondriac region

Epigastric region

Left hypochondriac region.

Extent

Upper border—6th rib anteriorly

Inferior border—crosses midline at the level of transpyloric plane (at the level of L1 vertebrae).

INSPECTION

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Watch for the fullness in the right hypochondrium and epigastrium (epigastrium usually represents left

lobe).

Direction of enlargement is towards the right iliac fossa.

Palpation

Following methods of palpation have been discussed:

Traditional method/conventional method

Preferred method

Alternate method

Hooking method

Dipping method

Traditional method/conventional method (Fig. 5D.25):

Place right hand on the right iliac fossa, parallel to the costal margin.

Keep the hand steady during inspiration and feel for the liver edge as it descends with each

inspiration.

If edge is not felt, move the hand upwards towards costal margin by 1 cm during expiration.

Repeat the procedure till the liver border is felt.

Fig. 5D.25: Traditional method of palpation of

Preferred method (Fig. 5D.26):

Sit on the right side the patient facing the head end of the patient.

Now place both hands side-by-side flat on the abdomen in the right subcostal region lateral to the

rectus with the fingers pointing towards the ribs.

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Fig. 5D.26: Preferred method of palpation of liver.

If resistance is felt, move the hands further down until resistance disappears.

Exert gentle pressure and ask the patient to inspire deeply.

The border of the liver can be felt on the tips of the fingers.

This procedure can be repeated from lateral to medial to trace the entire edge of the liver.

Alternate method (Fig. 5D.27):

Place the right hand below and parallel to the right subcostal margin.

The liver edge will then be felt against the radial border of the index finger.

Fig. 5D.27: Alternate method of palpation of liver.

Hooking method of liver examination (Fig. 5D.28):

Examiner stands at the patient’s right shoulder, facing the foot end and examines the lower edge

of the liver by curling the fingertips under the right costal margin.

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Fig. 5D.28: Hooking method of palpation of liver.

Dipping method of liver palpation in ascites (Fig. 5D.29):

Place both hands one over the other, over the area to be palpated.

Rapidly flex your metacarpophalangeal joints, so that your fingers suddenly dip into the patient’s

abdomen.

This displaces the fluid, enhancing the palpation of underlying organ.

Liver Span

The liver span is the distance in centimeters between the upper border of the liver in the right

midclavicular line, as determined by percussion (i.e. where lung resonance changes to liver dullness),

and the lower border, as determined by either percussion or palpation (Figs. 5D.30 to 5D.32).

The upper border of the liver is assessed using a heavy percussion technique. Light percussion is

used to locate the lower edge of the liver. Light percussion is required because heavy percussion may

underestimate the lower extent of the liver border.

The normal liver span is less than 13 cm.

In midclavicular line: Normally 6–12 cm.

In midsternal line (left lobe): Normally 4–8 cm.

The clinical estimate of the liver span is usually an underestimation of the actual liver size by about 2–

5 cm.

Liver span Condition seen

Increased Hepatomegaly

Decreased Shrunken liver as in cirrhosis

False positive for enlarged liver Right sided pleural effusion

Right lower lobe consolidation

Note: In conditions like emphysema of the lung, the liver may be pushed down. The edge may be palpable, leading the examiner

to believe that the patient has hepatomegaly when the real problem is a hyperinflated lung. Percussion will reveal that the upper

border is lower than expected.

Fig. 5D.29: Dipping method of palpation of liver.

Fig. 5D.30: Liver span.

Fig. 5D.31: Percuss along the midclavicular line.

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Fig. 5D.32: Mark the upper and lower border of dullness.

If the liver is enlarged and palpable, assess the following:

Location of the edge in cm below the costal margin in the midclavicular or anterior axillary line.

Span ( in cm)

Tenderness (tender/nontender).

Tender hepatomegaly Painless hepatomegaly

Right heart failure

Acute hepatitis (viral/alcoholic/drug induced)

Liver abscess (amoebic/pyogenic)

Hepatoma

Infarcts

Actinomycosis

Acute Budd–Chiari syndrome

Fatty liver

Infiltrative and storage disorders

Malaria

Leukemia

Lymphoma

Margins (regular, irregular, rounded or sharp). In cancers the liver edge may be irregular.

Rounded Infiltrative disorders

Sharp Secondary metastases, acute hepatitis

Biliary obstruction

Chronic hepatitis

Surface (smooth, nodular).

Smooth Malaria

Acute hepatitis

Infiltrative disorders, etc.

Nodular Metastatic cancers

Hepatoma

Alcoholic cirrhosis (micronodular)

Posthepatic cirrhosis (macronodular)

Consistency (soft/firm/hard): In metastatic cancers and in obstructive jaundice, the liver is typically

firm to hard.

Pulsatility (pulsatile/not pulsatile): A pulsatile liver may be present in tricuspid regurgitation (systolic),

tricuspid stenosis (diastolic), hepatocellular carcinoma, and hemangiomas.

Ausculto-Percussion Method (The Scratch Test)

The diaphragm of the stethoscope is placed either over the xiphoid process or just superior to the

costal margin along the midclavicular line.

The examiner then gently scratches the skin along the right midclavicular line, starting in the lower

abdomen and advancing towards the head (Fig. 5D.33).

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The sound produced by the scratching changes in quality and intensity when over the liver, as sounds

are much more easily transmitted through the solid organ.

Fig. 5D.33: Demonstration of ausculto-percussion method.

Causes of Hepatomegaly (Fig. 5D.34)

Causes of hepatomegaly can be grossly grouped under the headings of infections, malignancies,

infiltrative disorders, hematological disorders, and vascular disorders as shown in Figure 5D.34. Massive hepatomegaly (> 10 cm) seen with Hepatoma.

Fig. 5D.34: Causes of hepatomegaly.

Caudate Lobe (Fig. 5D.35)

Arises from the right lobe of the liver, on the postero-superior surface

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Fig. 5D.35: Caudate lobe location and boundaries.

Hypertrophy of caudate lobe is characteristic of hepatic outflow obstruction (Budd–Chiari syndrome).

Riedel’s Lobe (Fig. 5D.36)

Congenital variant projecting from the right lobe of the liver

May be mistaken for gallbladder or right kidney.

Fig. 5D.36: Anomalous lobe of the liver projecting from right lobe.

Examination of Spleen

Normal characteristics:

Dimensions 12 cm length, 7 cm width

13 cm craniocaudal diameter

Weight <250 g

Location (Fig. 5D.37) Along—9th, 10th, 11th ribs midaxillary line

Along the long axis of 10th rib

Extent Anteriorly (lower pole): Up to mid axillary line

Posteriorly: The superior angle of spleen is 4 cm lateral to T10 spine

Margin There is a notch on the inferolateral border, and this may be palpated when the spleen is enlarged

Normal spleen is not palpable clinically except in following scenarios:

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Only occasionally palpable in 1–3% of New Guinea population.

Tip may be palpable in newborn up to 3 months of age.

Splenic enlargement:

Before becoming clinically palpable—spleen enlarges in superior and posterior direction.

It has to enlarge two to three times of normal to become palpable.

Fig. 5D.37: Surface marking of spleen.

Once palpable, it appears (felt) below tip of 10th rib (beneath/under the left costal margin) and further

enlarges downwards, medially (inwards), and forwards towards umbilicus (LHC to RIF).

Grading of enlargement/splenomegaly:

Based on largest dimension

Moderate splenomegaly Severe splenomegaly

11–20 cm >20 cm

Based on distance from costal margin (Fig. 5D.38)

Mild (tip) enlargement Moderate enlargement Severe (marked) enlargement

1–2 cm

(<3 cm)

3–7 cm

(3–8 cm)

Between costal margin and umbilicus

7+ cm

>8 cm below left costal margin

>1000 g dry weight.

Crossing midline

Note: Size of the spleen is measured from the left costal margin to the tip along the long axis of spleen.

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Fig. 5D.38: Grading of splenomegaly.

Hackett’s grading system for palpable splenomegaly (Fig. 5D.39):

Grade Description

Grade 0 Normal impalpable spleen

Grade 1 Spleen palpable only in deep inspiration

Grade 2 Spleen palpable on midclavicular line half way between umbilicus and costal margin

Grade 3 Spleen expands towards the umbilicus

Grade 4 Spleen goes past the umbilicus

Grade 5 Spleen expands towards pubic symphysis

Inspection:

Fullness may be seen emerging from left upper quadrant extending diagonally towards the right lower

quadrant (RLQ).

Palpation:

Following methods of palpation have been discussed:

Classical method

Bimanual method

In supine position

In right lateral position

Hooking method

In supine position

In right lateral position

Middleton’s maneuver

Dipping method.

Classical method (Fig. 5D.40):

Patient in supine position, examine with single hand (right).

Place the hand in the RLQ in RIF and move diagonally towards left upper quadrant.

Hand should be firmly placed one the abdominal wall.

Keep the hand steady during inspiration and feel for the splenic edge as it descends with each

inspiration.

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