Teaching Plan 1

Abdominal Examination Wang Ailiang Vice professor

resume  

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Vice professor Director of gastrointestinal department 12 years work of surgery Two years work in Musoma Hospital of Tanzania

Introduction

Question1 : What do you think is the better or more appropriate sequence of abdominal examination compared with that in other areas? And why?

Normal sequence:

inspection, palpation, percussion, and auscultation 

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Abdominal examination: inspection,

auscultation, percussion, and palpation It’s convenient to perform the auscultation of abdomen after the auscultation of the heart. To avoid the negative impacts of a series of palpations on auscultation of bowel sounds due to the alteration of

Question 2: Can we say that abdominal examination will be outmoded and superseded because of remarkable advances in supplementary examination methods such as X-ray, ultrasound, endoscopy, isotope, angiography, CT, MRI, etc. ?

Definitely Not. 

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Because the abdominal examination is a fundamental method of detecting abnormal signs of abdomen. Palpation is the most difficult step of abdominal examination, requiring more practice.

xiphoid process

腹中线 midabdominal line

costal margin

Anterior superior iliac spine

Lateral border of rectus muscle

umbilic us

腹股沟韧带 耻骨上缘 superior margin of os pubis

inguinal ligament

right upper quadrant

left upper quadrant

right lower quadrant

left lower quadrant

percussion

Percussion General percussion  All four quadrants of the abdomen are evaluated by percussion. Light percussion is preferable, since it produces a clearer tone.  Tympany( 鼓音 ) is the most common percussion sound in the abdomen due to gas collection. It is appreciated over the stomach, small intestine, and colon.

Percussion of the liver..\..\教学相关图片\ 

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肝脏叩诊.rm

Percussion of the upper border of liver( 肝上界 ) is executed along the right midclavicular line( 右锁骨中线 ), right midaxillary line( 右腋中线 ), and right scapular line( 右肩胛线 ). The level of the shift from resonance downward into dullness is defined as the upper border of liver. At this level, the liver is covered by lung and hence the border is also called the relative dullness border of liver( 肝相对浊音界 ).

Percussion of the liver 

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Then percussing downward 1-2 intercostal space, the level of the shift from dullness into flatness( 实音 ) is identified as the absolute dullness border of liver( 肝绝对浊音界 ), without lung covering, and also called the lower border of lung( 肺下界 ). Normally the the upper border of liver locates at the 5th intercostal space along the right midclavicular line, the 7th intercostal space along the right midaxillary line, and the 10th intercostal space along the right scapular line.

Percussion of the liver Percussion of the lower border of liver( 肝下界 ) is executed along the right midclavicular line or anterior midline.  The level of the shift from tympany upward into dullness is defined as the lower border of liver. 

Percussion of liver span ( 肝上下 径) 

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Percussion of liver span should be done with the patient breathing normally. Percussion should occur through the right midclavicular line from resonance over the lung field downward to dullness and from tympany over abdomen upward to dullness. Measure from upper to lower border of dullness for liver span. It is normally about 9-11 cm in the midclavicular line.

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Dullness extending into the normally tympanitic right upper quadrant indicates hepatic enlargement, a mass adjacent to the liver, or downward displacement of the liver.

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There may be an absence of liver dullness following perforation of a hollow viscus, which allows free air to enter the abdominal cavity. This indication of an intraabdominal catastrophe must be correlated with the clinical situation, since on occasion interposition of the hepatic flexure of the colon between the diaphragm and the liver ( 间位结肠 [ 结肠位于肝与横膈之间 ]) will produce the same finding with no clinical consequences.

Percussion of the spleen..\..\ 教学相关图片\脾脏叩诊.rm

To percuss for splenic dullness √This should be done when splenic enlargement is suspected. √ Normally splenic dullness can be percussed between 9 intercostal space to 11 intercostal space along left midaxillary line, the scope that is 4-7cm, without passing over left anterior axillary line.

spleen

presence or absence of free fluid in the abdominal cavity (ascites)  This

may be detected by several maneuvers(1) shifting dullness, (2) fluid wave, and (3) elbow-knee position.

Percussion for shifting dullness( 移动性浊音 )..\..\教学相关图片\

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移动性浊音.rm The examiner should first tell the patient to lie on his back (in the supine position). tympany at midabdomen could be found because of the underlying bowel. At the same time, dullness at the bilateral flanks could be found during percussion due to the accumulation of ascites. The reason is that when the patient with ascites lies on his back, the fluid will migrate into the flanks, producing dullness laterally.

Percussion for shifting dullness( 移动性浊音 ) 

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When dullness is found in the flanks, The line of demarcation between the dullness and tympany is marked. The examiner percusses the patient’s abdomen at the umbilicus level from the midabdomen toward the patient’s left side. If the examiner finds the point where percussion sound of tympany changes into dullness, the examiner should hold his pleximeter on that point, simultaneously, ask the patient to turn on his right side and then continue to percuss the same point again. If the sound changes from dullness to tympany, it means that the dullness has been shifted to a more dependent position. This implies that ascites is present.

Percussion for shifting dullness( 移动性浊音 ) 

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Similarly, the examiner percusses the patient’s abdomen toward the patient’s right side. If the examiner finds the point where percussion sound of tympany changes into dullness, the examiner should hold his pleximeter on that point, simultaneously, ask the patient to turn on his left side and then continue to percuss the same point again to confirm the shift of dullness. A volume of free fluid in the peritoneal cavity greater than 1000ml can be detected with this method.

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If the amount is too little, shifting dullness could not be found, the examiner could ask the patient to take elbow-knee position, letting the umbilicus at the lowest level, and then percusses the patient from flanks toward the umbilicus. If percussion sound could change from tympany to dullness, it indicates ascites.

Palpation

This procedure is usually the most important and often the most difficult to perform accurately.

1. the principle of palpation a) To relax the patient

√ During palpation the patient should continue to lie supine with arms relaxed on the chest or at the sides. √ The examiner should make certain that his hands are warm. √ He should assure the patient that he will make an effort not to cause discomfort and follow up this assurance by avoiding at the outset an area already described as painful. √ If the patient exhibits ticklishness, the examiner should disregard it and try to continue. √ If this proves unsuccessful, it is useful to have the patient place his own hand on his abdomen, since this

exert pressure on the abdomen through the patient’s own hand, and gradually increase the pressure, while assuring the patient that the examination will cause no discomfort. √ When the patient has relaxed, the examiner again places his own hand on the abdomen and allows the patient to maintain contact with his hand. This usually completes the relaxation of the ticklish patient, and the examination proceeds as usual.

gentle exploration of the abdominal wall and with no effort made to palpate deeply. √ The patient may be further relaxed by instructing him to breathe slowly and deeply. √ As with inspection, the initial step in palpation may be facilitated by distracting conversation or questions regarding the history. √ If the patient remains tense or if the abdominal wall is very muscular, better results may be

√ It should be emphasized

again that during the preliminary stages muscle relaxation is the goal. At this time no attempt should be made either to elicit discomfort or to palpate for a mass or enlarged viscus.

b) To palpate four quadrants superficially from LLQ counterclockwise

√ To palpate all areas of the

abdomen counterclockwise and superficially from left lower quadrant screening for tenseness( 紧张度 ), tenderness( 压痛 ), masses, etc.

√ Examination begins with

gentle maneuvers and then palpation occurs more deeply.

√ Examiner uses the palms of

his hands with fingers together and arm relaxed and forearm on a horizontal plane.

√ The examiner presses with

his fingers.

c) To palpate four quadrants deeply

√Using the palmer surface

of the fingers, examiner palpates in four quadrants to identify masses, tenderness, pulsations, etc. √ The abdominal wall should be depressed more than 2 cm. √ When deep palpation is difficult, examiner may want to use left hand placed over right hand to help exert pressure.

ight palpation of the abdome

Deep palpation of the

abdomen

Bimanual palpation of the abdomen

palpation of the abdomen Middleton method

触诊基本方法 浅部触诊 (light  palpation) 深部触诊 (deep  palpation) 深部滑行触诊 (deep slipping palpation) ： 腹腔包块、器官 双手触诊 (bimanual palpation) ： 肝、脾、肾、腹腔肿物。 深压触诊 (deep press palpation): 确定腹腔压痛点与反跳痛 冲击触诊 (ballottement): 适用于腹部大量积液时肝脾及腹腔包块难以触 及者。

√ If a mass is suspected, determine its size, contour, mobility, tenderness, smoothness, irregularity, the hardness or softness and listen with stethoscope for a bruit over the mass. √ If there is tenderness, determine the point of maximum tenderness and distribution.

√ To check for rebound tenderness, palpate deeply at the point of tenderness, pause briefly, then remove the fingers quickly. Watch the patient’s face to see whether it hurts. Then check other areas in the same manner for comparison.

a) abdominal tenseness 腹壁 紧张度 In normal persons, abdominal wall is somewhat tense, but usually soft when palpated and easily depressed , and is called abdominal softness( 腹壁柔软 ).

While some pathological conditions can lead to an abnormal increase or decrease of abdominal tenseness.

1) The increase of abdominal tenseness

√ Abdominal tenseness increases, not accompanyed by muscle spasm, is due to the increase of abdominal contents, as gastrointestinal flatulence( 肠胃胀气 ), artificial pneumoperitoneum( 人工气 腹 ), ascites, etc.

        Board-like rigidity 板状腹 √ If abdominal wall is palpated as obviously tense, even as rigid as a board, board-like rigidity is so called. √ This sign is caused by the spasm of abdominal muscle due to peritoneal irritation, as the perforation of the gastrointestinal diseases or

揉面感；柔韧感 √ If abdominal wall is palpated as pliable and tough, and if it has resistance and is not easily depressed, then the examiner feels the sensation of dough kneading. √ This sign is usually seen in tuberculose peritonitis or cancerous

 The decrease of abdominal tenseness √ caused by the decrease or disappearance of abdominal muscle’s tension( 张力 ), the sign usually found in chronic deeline( 消耗性疾病 ) or drainage of large amount of ascites

tenderness 压痛和反跳痛 √ After relaxation is obtained, the examining hand is first moved gently over the entire abdomen, and an estimate of the muscle tone in the various quadrants is made. √ Following general palpation an attempt should be made to detect and localize any painful area (i. e. tenderness) within the abdomen.

1. Visceral( 内脏的 ) √ arises from an organic lesion or functional disturbance within an abdominal viscus √ For example, it is the type seen in an obstructive lesion of the intestine in which there is a buildup of pressure and distention of the gut. √ sveral characteristics: dull, poorly localized, and difficult for the patient to characterize

√ similar to the distress noted in painful lesions of the skin √ sharp, bright, and well localized. √ not caused primarily by involvement of the viscera √ indicates involvement of one of the somatic structures, such as the parietal peritoneum or the abdominal wall itself √ an inflammatory process originating in a viscus will produce visceral pain that may extend to involve the

√ Inflammation of the peritoneum would then result in somatic pain. √ best illustuated by appendicitis( 阑尾炎 ) in which the pain is at first poorly localized, dull, ill defined, and primarily midiline (when it is entriely visceral in origin). Later, as the inflammation spreads to the peritoneum, the pain becomes sharp, bright, and well localized in the right lower quadrant over the involved region.

the examiner should determine whether the pain is constant under the pressure of the examing hand or if it is transient, tending to disappear even though pressure is continued over the area. √ Pain caused by inflammation usually remains unchanged or increases as pressure is applied. Visceral pain as the result of distention or contraction of a viscus tends to become less severe while pressure is

may have difficulty in distinguishing visceral pain from that arising in somatic structures, such as the spine and abdominal wall. An example of abdominal wall discomfort is seen in patients with fibrositis( 纤维组织炎 ). These types of pain may be differentiated by having the patient tense his abdominal muscles, which may be accomplished by forcefully elevating his head while keeping

√ Under these conditions

increased tension of the abdominal wall will accentuate the pain if it originates in somatic structures. √ On the other hand, discomfort from intra-abdominal sources will be less severe with the abdomen tense than when relaxed.

the examiner should test for the phenomenon of rebound tenderness. √ This is found only when the peritoneum( 壁层腹膜 ) overlying a diseased viscus becomes inflamed. √ Although it may be produced in different ways, the most common is to press firmly over a region distant from the tender area and then suddenly release the pressure. The patient will feel a sharp stab of pain in the area of

right lower quadrant and then suddenly released will cause a marked increase in pain over an area of diverticulitis( 憩室炎 ) in the left quadrant √ Rebound tenderness may also be elicited by having pressure over the tender area and having the patient cough or strain. √ Marked tenderness to percussion in the area is usually seen in

√ At times, if the area involved is small, rebound tenderness may be elicited only over the most tender area of the abdomen.

The end肠

梗 阻 （ intestinal obstruction ） 十胃 一肠 楼外 科