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THE ABDOMINAL EXAM
ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum
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CREDITS Author
Ebondo Mpinga, MD,FACS Contributors
Michael Hughes, MD ,FACS (expert performance video) Richard Damewood, MD,FACS (modified score assessment tool) Duane Patterson, PhD (technical support) Paul Schreck (videographer )
Editors Keith Clancy, MD, FACS Amanda Beattie, MD , R5
York Hospital Department of Surgery, York, PA
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OBJECTIVES
After the completion of this module the student should be able to:
1. Perform a complete abdominal exam.
2. Recognize the signs of peritonitis.
3. Arrive at a differential diagnosis based upon the findings elicited during the exam.
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ABDOMINAL EXAM Although we will focus on the abdominal exam, it cannot
be overemphasized that a thorough physical exam (head to toes) is important to help in arriving at a comprehensive differential diagnosis list. Examples :
presence of jaundice may add consideration of a biliary /hepatic etiology
Irregularly irregular heart rate atrial fibrillation-> mesenteric ischemia
Crackle at lung bases pneumonia Skin lesions (pyoderma gangrenosum) -> IBD
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ABDOMINAL WALL DESCRIPTION
The abdomen is generally divided into four quadrants by two artificial lines that intersect at the umbilicus
Other systems exist to further subdivide these four quadrants into nine regions/sections
RUQ LUQ
LLQRLQ
EpigastricRightHypochondrium
Rightflank
Leftflank
Umbilical
RightIliac
LeftIliac
Hypogastric / suprapubic
LeftHypochondrium
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ABDOMINAL EXAM The exam should be performed in this specific order
General appearance Vital signs Inspection Auscultation Percussion Palpation
It should include An examination of the inguinal area
including the external genitalia in males (testes) A rectal exam (discussed in a separate module) A pelvic exam in women (discussed in a separate module)
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DESCRIPTION OF TECHNIQUES
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General Appearance Head-to-toe (skin, eyes, LOC,
position, demeanor) Inflammation, peritonitis
Lies perfectly still Or in bed with thighs and knees
flexed
Obstruction / colic Restless, writhing Abdominal distension?
Shock Pallor/ cyanosis/ diaphoresis/
decreased mental status
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Vital Signs Tachycardia
? Early shock (may present prior to hypotension) May be absent if on Beta blockers
Rapid shallow breathing (splinting) Peritonitis
Hypotension May be late finding depending on pre-existing state of health Fever Infectious etiology or perforation
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Inspection Abdominal contour
Distended vs. scaphoid Irregular -> mass /
volvulus / obstruction / hernias
Skin Ecchymosis around
umbilicus, flanks pancreatitis? Trauma
(seat belt sign)? Scars Prominent veins on the
abdominal wall Portal hypertension
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Auscultation Bowel Sounds
Auscultate all regions Listen in each region Listen before feeling Absent bowel sounds
ileus, peritonitis, shock Hyperactive
Enteritis / obstruction (high pitched or distant)
Bruits AAA / Reno-vascular
diseases Iliac and Femoral
arteries
Aorta
Femoral arteries
Iliac arteries
Renal Renal
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Percussion Hyperresonance
(tympani) Bowel distension with
air->obstruction In all quadrants but
RUQ (liver dullness) Loss of liver dullness in
RUQ-> Free air
Fluid wave Ascites (may be hard to
elicit in the obese)
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Palpate each region Work toward area of pain Warm hands Communicate with patient
Let the patient know what you are about to do
Place Patient supine knee bent (if possible)
Epigastric LeftHypochondriac
RightHypochondriac
Rightflank
Leftflank
Umbilical
RightIliac
LeftIliac
Hypogastric
Palpation
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Palpation Note tenderness
Localize vs. diffuse Rigidity Rebound
Press on the abdomen and release Present if pain is worse upon
release Avoid too sudden of a release
(may startle patient -> false +) Involuntary & voluntary guarding
Distract the patient while palpating to detect involuntary guarding
Feel for masses
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Signs highly suggestive of peritonitis Tenderness to percussion
Tenderness elicited when the examiner firmly taps on the Iliac crest
Tenderness elicited when the examiner firmly taps on the heel of the patient’s extended leg
Tenderness when the bed is gently shaken or the patient coughs
Rebound tenderness
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Abdominal exam: findings that suggest specific etiology Biliary / hepatic etiology
Courvoisier' sign Palpable gallbladder in the
presence of painless jaundice periampullary tumor
Caput medusa (Cruveilhier sign) Varicose veins at umbilicus
cirrhosis with portal HTN Murphy’s sign
Pain caused during inspiration while palpating the RUQ-> acute cholecystitis
Ransohoff sign Periumbilical yellow discoloration
-> ruptured CBD
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Abdominal exam: findings that suggest specific etiology Appendicitis
Rovsing’s sign Palpation on the LLQ produces
tenderness at McBurney’s point
Ten Horn test Pain caused by gentle traction of the
right testicle
Aaron sign Persistent pressure applied at
McBurney ‘s point causes pressure in the epigatrium and upper chest wall
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Abdominal exam: findings that suggest specific etiology
Pelvic inflammation/abscess Iliopsoas sign
Allow patient to lie on the opposite side of the pain
Extend the thigh on the affected side This should cause pain if there is
irritation of the iliopsoas muscle (seen with appendicitis as well)
Obturator sign Flexion and internal rotation of the
right thigh while supine elicits hypogastric pain
Indicates irritation of obturator internus muscle (seen with appendicitis as well)
Chandelier sign Extreme lower abdominal/pelvic pain
with movement of the cervix
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Abdominal exam: findings that suggest specific etiology Hemoperitoneum
Hemorrhagic pancreatitis Cullen’s sign
periumbilical bruising-> hemoperitoneum Grey Turner’s sign
Local area of discoloration around the flanks-> acute hemorrhagic pancreatitis
Danforth sign shoulder pain on inspiration-> hemoperitoneum
Kehr’s sign Left shoulder pain when supine or pressure applied to LUQ->
splenic rupture
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Inguinal exam Palpation of the inguinal area
with & without vasalva maneuver
Ask patient to cough Ask patient to take a deep
breath and bear down Pay attention to the femoral
area to rule out femoral hernias
In the male, the testis should be examined
to rule out testicular torsion
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COMMON ERRORS Focus only on the abdomen Begin with palpation prior to inspection, auscultation and percussion Not asking the patient to localize the pain and therefore beginning palpation
of the affected area first, exacerbating the pain and thus precluding complete examination of the abdomen
Skipping the rectal, pelvic and groin exam Putting too much weight on the absence of rebound tenderness to r/o
peritonitis Putting to much weight on the physical exam in an immunosuppressed
patient who may not exhibit normal signs of peritonitis Forgetting to consider mesenteric ischemia when there is pain out of
proportion to clinical exam
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GROUPING OF SIGNS AND SYMPTOMS
DIFFERENTIAL DIAGNOSIS
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Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes Acute pancreatitis (pain
radiating to back)
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Severe central abdominal pain with shock and no peritoneal signs
Intra-abdominal causes Acute pancreatitis (pain
radiating to back)
Rupture AAA (pulsatile
mass) STAT SURGERY
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Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass)
!! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY
Spontaneous rupture of spleen/Splenic artery aneurysm (pain radiates to left shoulder)
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Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile
mass) !! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY Spontaneous rupture of
spleen/Splenic artery aneurysm (pain radiates to left shoulder)
Ruptured ectopic pregnancy
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Severe central abdominal pain with shock and no peritoneal signs Intra-abdominal causes
Acute pancreatitis (pain radiating to back)
Rupture AAA (pulsatile mass) !! STAT SURGERY
Hemoperitoneum
!! STAT SURGERY Spontaneous rupture of
spleen/Splenic artery aneurysm
Rupture ectopic pregnancy Late mesenteric ischemia
Extra- abdominal causes Acute MI with cardiogenic
shock
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Severe abdominal pain with diffuse peritoneal signs
Perforated viscous STAT SURGERY
Gastric/duodenal ulcers Gallbladder Complication of Small and
large bowel obstruction Maximal distention leading
to peroration (Cecum) Necrotic bowel due to
mesenteric ischemia or strangulated hernias
Patients will rapidly progress to septic shock if surgery is delayed
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Severe central abdominal pain without associated signs
Intra-abdominal causes
Intestinal colic Early appendicitis Early/ mild pancreatitis Early mesenteric
thrombosis
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Severe central abdominal pain without associated signs
Intra-abdominal causes Intestinal colic Early appendicitis Early/ mild pancreatitis Early mesenteric
thrombosis Extra- abdominal causes
Herpes Zoster (rash in dermatome distribution)
CAD (ECG/Enzymes) Glaucoma Tabes dorsalis (rare)
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Severe central abdominal pain with distension, no vomiting & peritoneal signs Intra-abdominal causes
Large bowel obstruction while ileocecal valve is competent
Sigmoid diverticular stricture/ inflammation/ cancer
Volvulus Hernias Adhesions
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Severe central abdominal pain with distension, no vomiting & peritoneal signs Intra-abdominal causes
Large bowel obstruction while ileocecal valve is competent
Sigmoid diverticular stricture/ inflammation/ cancer
Volvulus Hernias Adhesions
Extra- abdominal causes Uremia
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Severe central abdominal pain with vomiting, distension & no peritoneal signs
Small obstruction Bilious vomiting in proximal
obstruction Feculent vomiting in distal
SB obstruction Gastric outlet obstruction
Non-bilious vomiting Undigested food particles
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Severe abdominal pain with localized peritoneal signs RUQ
Acute cholecystitis (pain referred to back)
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Severe abdominal pain with localized peritoneal signs RUQ
Acute cholecystitis Hepatic etiology: abscess/
hydatid cyst / Hepatitis Retrocecal appendicitis
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Severe abdominal pain with localized peritoneal signs RUQ
Acute cholecystitis Hepatic etiology: abscess/
hydatid cyst/ Hepatitis Retrocecal appendicitis Leaking duodenal ulcer
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Severe abdominal pain with localized peritoneal signs RUQ
Acute cholecystitis Hepatic etiology: abscess/
hydatid cyst/ Hepatitis Retrocecal appendicitis Leaking duodenal ulcer Pyelonephritis/stones
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Severe abdominal pain with localized peritoneal signs RUQ
Acute cholecystitis Leaking duodenal ulcer Hepatic etiology: abscess/
hydatid cyst/ Hepatitis Retrocecal appendicitis Pyelonephritis/stones
Extra- abdominal causes Lobar pneumonia
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Severe abdominal pain with localized peritoneal signs RLQ
Appendicitis Periumbilical at onset Shifts to RLQ
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Severe abdominal pain with localized peritoneal signs RLQ
Appendicitis Cholecystitis (low lying GB) Leaking duodenal ulcer Terminal ileitis Meckel’s diverticulitis Right sided diverticulitis
(cecal) Mesenteric adenitis (children) Retained testis/ right testicular
torsion Urinary system (urteral
stones, pyelonephritis) Psoas abscess
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Severe abdominal pain with localized peritoneal signs
LUQ Pancreatitis (most
common cause) Perforated gastric ulcer
localized by adhesions Splenic infarct/ injury Subphrenic abscess Jejunal diverticulitis Pyelonephritis
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Severe abdominal pain with localized peritoneal signs
LLQ Diverticulitis of sigmoid
and left colon Colon cancer with
surrounding inflammation
Upper extension of pelvic abscess
IBD Pyelonephritis
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Severe abdominal pain with localized peritoneal signs Hypogastric / Suprapubic area
Perforated diverticulitis or appendicitis
Appendicitis Pelvic appendix
Urinary tract Ureteral stones
lower ureter Bladder distention Cystitis
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Severe abdominal pain with localized peritoneal signs Hypogastric / Suprapubic area
Perforated diverticulitis or appendicitis
Appendicitis (pelvic appendix)
Urinary tract Ureteral stones (lower ureter)/
Bladder distention / cystitis
Gynecologic / obstetric conditions
Uterine colic (Dysmenorrhea) Torsion/ ruptured ovarian cyst Ectopic pregnancy/ Threatened abortion PID