Abdominal Aortic Pulsation

• Definition: The palpable pulsation of the abdominal aorta, usually felt just above the umbilicus and slightly to the left of midline.

• Clinical importance: A prominent or expansile pulsation may indicate an abdominal aortic aneurysm (AAA). Careful palpation is essential to avoid aneurysm rupture.

Ascites

• Definition: Accumulation of free fluid in the peritoneal cavity.

• Examination clues:

  • Shifting dullness: Percussion note shifts when patient changes position.

  • Fluid thrill (fluid wave): Tap on one flank transmits a wave felt on the opposite flank.

• Common causes: Liver cirrhosis, heart failure, malignancy, tuberculosis.

Bowel Sounds (Borborygmi)

• Definition: Noises made by the movement of the intestines.

• Assessment: Listen with a stethoscope over all quadrants for frequency and character.

• Clinical relevance:

  • Hyperactive: May suggest diarrhea, early intestinal obstruction.

  • Hypoactive or absent: May indicate ileus or peritonitis.

Bradykinesia (Abdominal)

• Definition: Reduced abdominal movement during respiration, sometimes seen in peritonitis.

• Note: Usually subtle and less commonly described but may assist in diagnosis.

Caput Medusae

• Definition: Dilated paraumbilical veins radiating from the umbilicus.

• Significance: Indicates portal hypertension, often due to liver cirrhosis.

Cullen’s Sign

• Definition: Periumbilical bruising.

• Clinical importance: Sign of intra-abdominal bleeding, commonly associated with pancreatitis or ruptured ectopic pregnancy.

Deep Palpation

• Technique: Press firmly but gently with fingertips, feeling deeper structures and organs.

• Purpose: Identify masses, organomegaly, tenderness.

• Caution: Avoid causing undue pain, especially in acute abdomen.

Dullness to Percussion

• Definition: A thud-like sound heard when percussing over solid organs or fluid collections.

• Clinical use: Helps map liver size, detect masses, and locate ascites.

Epigastric Tenderness

• Location: Upper central abdomen just below the sternum.

• Significance: Suggests gastric or duodenal ulcer, pancreatitis, or myocardial ischemia.

Fascial Hernia (Linea Alba Hernia)

• Definition: Protrusion of abdominal contents through a defect in the linea alba.

• Examination: Palpate along the midline during abdominal straining or coughing.

Flank Tenderness

• Significance: May indicate renal pathology such as pyelonephritis or renal calculi.

Fremitus

• Definition: Vibration felt on palpation during vocalization.

• Application: Less commonly used in abdomen but can assess abdominal wall masses.

Guarding (Voluntary vs. Involuntary)

• Voluntary guarding: Patient consciously tenses abdominal muscles due to pain or anxiety.

• Involuntary guarding: Reflex muscle contraction indicating peritoneal inflammation (more clinically significant).

• Examination: Observe abdomen at rest and during palpation.

Hepatomegaly

• Definition: Enlargement of the liver, palpable >1-2 cm below the right costal margin.

• Significance: Liver disease, heart failure, malignancy.

• Technique: Palpate in right upper quadrant during deep inspiration.

Hypoactive Bowel Sounds

• Definition: Decreased intestinal activity heard on auscultation.

• Clinical context: Seen in paralytic ileus, peritonitis, late intestinal obstruction.

Iliopsoas Sign

• Definition: Pain on passive extension of the right thigh with patient lying on the left side.

• Clinical relevance: Suggests irritation of the iliopsoas muscle by inflamed appendix (appendicitis).

Murphy’s Sign

• Definition: Sudden cessation of inspiration during deep palpation of the right upper quadrant.

• Indicates: Acute cholecystitis (inflamed gallbladder).

Palpable Mass

• Types: Cystic, solid, pulsatile.

• Important to characterize: Location, size, consistency, mobility, tenderness.

Percussion of the Liver

• Method: Percuss from lung resonance down to liver dullness in the midclavicular line.

• Purpose: Estimate liver span (normal 6-12 cm).

• Changes: Enlarged liver in hepatitis, congestion; small or nodular liver in cirrhosis.

Percussion of the Spleen

• Technique: Percuss the lowest intercostal space in the left anterior axillary line.

• Significance: Dullness replacing tympany suggests splenomegaly.

Peritonism

• Definition: Signs of peritoneal irritation, including rebound tenderness, guarding, rigidity.

• Clinical importance: Indicates acute abdomen requiring urgent evaluation.

Psoas Sign

• See Iliopsoas sign.

Rebound Tenderness

• Definition: Increased pain upon sudden release of deep abdominal pressure.

• Indicates: Peritoneal inflammation.

Rigid Abdomen

• Definition: Board-like abdominal wall rigidity.

• Significance: Suggests peritonitis, an emergency.

Shifting Dullness

• See Ascites.

Skin Changes

• Look for scars, striae, erythema, dilated veins, or bruising indicating previous surgery, stretch from ascites, infection, or portal hypertension.

Tenderness

• Assessment: Localized vs. generalized.

• Note: Tenderness with rebound suggests peritonitis.

Thrills and Bruits

• Thrill: Palpable vibration over arteries, suggesting turbulent blood flow.

• Bruit: Audible murmur over an artery with a stethoscope, can indicate vascular abnormalities such as renal artery stenosis or abdominal aortic aneurysm.

Umbilicus Examination

• Inspect for hernia, discharge, or abnormalities.

Vascular Sounds

• Auscultate over aorta, renal, iliac, and femoral arteries to detect bruits.

Venous Patterns

• Dilated veins over the abdomen may indicate portal hypertension or inferior vena cava obstruction.

Visible Peristalsis

• Seen in intestinal obstruction, thin patients.