Musculature and Connective Tissues

The rectus abdominis muscles anteriorly and the internal and external oblique muscles laterally form and protect the abdominal cavity ( Fig. 18.1, A ). The linea alba, a tendinous band, is located in the midline of the abdomen between the rectus abdominis muscles. It extends from the xiphoid process to the symphysis pubis and contains the umbilicus. The inguinal ligament (Poupart ligament) extends from the anterior superior spine of the ilium on each side to the pubis.

Alimentary Tract

The alimentary tract, a tube approximately 27 feet long, runs from the mouth to the anus and includes the esophagus, stomach, small intestine, and large intestine. It functions to ingest and digest food; absorb nutrients, electrolytes, and water; and excrete waste products. Food and the products of digestion are moved along the length of the alimentary tract by peristalsis under autonomic (involuntary) nervous system control.

The esophagus, a collapsible tube about 10 inches long, connects the pharynx to the stomach. Just posterior to the trachea, the esophagus descends through the mediastinal cavity and diaphragm, entering the stomach at the cardiac orifice.

The stomach lies transversely in the upper abdominal cavity, just below the diaphragm. It consists of three sections: the fundus, lying above and to the left of the cardiac orifice; the middle two-thirds, or body; and the pylorus, the most distal portion that narrows and terminates in the pyloric orifice. The stomach secretes hydrochloric acid and digestive enzymes that break down fats and proteins. Pepsin acts to digest proteins, whereas gastric lipase acts on emulsified fats. Little absorption takes place in the stomach.

The small intestine, about 21 feet long, begins at the pylorus. Coiled in the abdominal cavity, it joins the large intestine at the ileocecal valve. The first 12 inches of the small intestine, the duodenum, forms a C-shaped curve around the head of the pancreas. The common bile duct and pancreatic duct open into the duodenum at the duodenal papilla, about 3 inches below the pylorus of the stomach. The next 8 feet of intestine, the jejunum, gradually becomes larger and thicker. The ileum makes up the remaining 12 feet of the small intestine. The ileocecal valve between the ileum and large intestine prevents backward flow of fecal material.

The small intestine completes digestion through the action of pancreatic enzymes, bile, and several other enzymes. Nutrients are absorbed through the mucosa of the small intestine. The functional surface area of the small intestine is increased by its circular folds and villi.

The large intestine begins at the cecum, a blind pouch about 2 to 3 inches long ( Fig. 18.1, B ). The ileal contents empty into the cecum through the ileocecal valve, and the vermiform appendix extends from the base of the cecum. The ascending colon rises from the cecum along the right posterior abdominal wall to the undersurface of the liver. The ascending colon turns toward the midline at the hepatic flexure and becomes the transverse colon. The transverse colon crosses the abdominal cavity toward the spleen and turns downward at the splenic flexure. The descending colon continues along the left abdominal wall to the rim of the pelvis, where it turns medially and inferiorly to form the S-shaped sigmoid colon. The rectum extends from the sigmoid colon to the muscles of the pelvic floor. It continues as the anal canal and terminates at the anus.

The large intestine is about 4.5 to 5 feet long, with a diameter of 2.5 inches. Its main functions are to absorb water and transport waste. Mucous glands secrete large quantities of alkaline mucus that lubricate the intestinal contents and neutralize acids formed by intestinal bacteria. Live bacteria decompose undigested food residue, unabsorbed amino acids, cell debris, and dead bacteria through a process of putrefaction.

Liver

The liver lies in the right upper quadrant of the abdomen ( Fig. 18.1, C ), just below the diaphragm and above the gallbladder, right kidney, and hepatic flexure of the colon. The heaviest organ in the body, the liver weighs about 3 pounds in the adult. It is composed of four lobes containing lobules, the functional units. Each lobule is made up of liver cells radiating around a central vein. Branches of the portal vein, hepatic artery, and bile duct penetrate to the periphery of the lobules. Bile secreted by the liver cells drains from the bile ducts into the hepatic duct, which joins the cystic duct from the gallbladder to form the common bile duct.

The hepatic artery transports blood to the liver directly from the aorta, and the portal vein carries blood from the digestive tract and spleen to the liver. Repeated branching of both vessels makes the liver a highly vascular organ. Three hepatic veins carry blood from the liver and empty into the inferior vena cava ( Fig. 18.1, D ).

The liver plays an important role in the metabolism of carbohydrates, fats, and proteins. Glucose is converted and stored as glycogen until, in response to varying levels of insulin and regulator hormones, it is reconverted and released again as glucose. The liver also can convert amino acids to glucose (gluconeogenesis). Fats, arriving at the liver in the form of fatty acids, are oxidized to two-carbon components in preparation for entry into the tricarboxylic acid cycle. Cholesterol is used by the liver to form bile salts. Synthesis of fats from carbohydrates and proteins also occurs in the liver. Proteins are broken down to amino acids through hydrolysis, and their waste products are converted to urea for excretion by the kidneys.

Other functions of the liver include storage of several vitamins and iron; detoxification of potentially harmful substances; production of antibodies; conjugation and excretion of steroid hormones; and the production of prothrombin, fibrinogen, and other substances for blood coagulation. The liver is responsible for the production of the majority of proteins circulating in the plasma. It serves as an excretory organ through the synthesis of bile, the secretion of organic wastes into bile, and the conversion of fat-soluble wastes to water-soluble material for renal excretion.

Gallbladder

The gallbladder is a saclike, pear-shaped organ about 4 inches long, lying recessed in the inferior surface of the liver. It concentrates and stores bile from the liver. In response to cholecystokinin, a hormone produced in the duodenum, the gallbladder releases bile into the cystic duct. The cystic duct and hepatic duct join to form the common bile duct. Contraction of the gallbladder propels bile along the common duct and into the duodenum at the duodenal papilla. Composed of cholesterol, bile salts, and pigments, bile serves to maintain the alkaline pH of the small intestine, permitting emulsification of fats so that absorption of lipids can be accomplished.

Pancreas

The pancreas lies behind and beneath the stomach, with its head resting in the curve of the duodenum and tip extending across the abdominal cavity to almost touch the spleen ( Fig. 18.1, C ). As an exocrine gland, the acinar cells of the pancreas produce digestive juices containing inactive enzymes for the breakdown of proteins, fats, and carbohydrates. Collecting ducts empty the juice into the pancreatic duct (duct of Wirsung), which runs the length of the organ. The pancreatic duct empties into the duodenum at the duodenal papilla, alongside the common bile duct. Once introduced into the duodenum, the digestive enzymes are activated. As an endocrine gland, islet cells scattered throughout the pancreas produce the hormones insulin and glucagon.

Spleen

The spleen is in the left upper quadrant, lying above the left kidney and just below the diaphragm. White pulp (lymphoid tissue) constitutes most of the organ and functions as part of the reticuloendothelial system to filter blood and manufacture lymphocytes and monocytes. The red pulp of the spleen contains a capillary network and venous sinus system that allow for storage and release of blood, permitting the spleen to accommodate up to several hundred milliliters at once.

Kidneys, Ureters, and Bladder

The two kidneys are located in the retroperitoneal space of the upper abdomen ( Fig. 18.1, D ). Each extends from about the vertebral level of T12 to L3. The right kidney is usually slightly lower than the left, presumably because of the large, heavy liver just above it. Both kidneys are embedded in fat and fascia, which anchor and protect these organs. Each contains more than 1 million nephrons, the structural and functional units of the kidneys. The nephrons are composed of a tuft of capillaries, the glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule. The distal tubule empties into a collecting duct.

Each kidney receives about one-eighth of the cardiac output through the renal artery. The glomerular filtration rate (GFR), used to measure of kidney function, is typically 90 mL/min/1.73 m ² or higher in healthy individuals. Most of the filtered material, including electrolytes, glucose, water, and small proteins, is actively resorbed in the proximal tubule. Some organic acids are also actively secreted in the distal tubule. Urinary volume is carefully controlled by antidiuretic hormone (ADH) to maintain a constant total body fluid volume. Urine passes into the renal pelvis via the collecting tubules and then into the ureter. Peristaltic waves move urine to the urinary bladder, which has a capacity of about 400 to 600 mL in the adult.

The kidney also serves as an endocrine gland responsible for the production of renin, which controls aldosterone secretion. It is the primary source of erythropoietin production in adults, thus influencing the body’s red cell mass. In addition to synthesizing several prostaglandins, the kidney produces the biologically active form of vitamin D.

Vasculature

The abdominal portion of the descending aorta travels from the diaphragm through the abdominal cavity, just to the left of midline ( Fig. 18.1, D ). At about the level of the umbilicus, the aorta branches into the two common iliac arteries. The splenic and renal arteries, which supply their respective organs, also branch off within the abdomen.

Infants

The pancreatic buds, liver, and gallbladder all begin to form during week 4 of gestation, by which time the intestine already exists as a single tube. The motility of the gastrointestinal tract develops in a cephalocaudal direction, permitting amniotic fluid to be swallowed by 17 weeks of gestation. Production of meconium, an end product of fetal metabolism, begins shortly thereafter. By 36 to 38 weeks of gestation, the gastrointestinal tract is capable of adapting to extrauterine life. However the elasticity, musculature, and control mechanisms of the gastrointestinal tract continue to develop, reaching adult function at 2 to 3 years of age.

During gestation, the liver begins to form blood cells at about week 6, synthesize glycogen by week 9, and produce bile by week 12. The liver’s role as a metabolic and glycogen storage organ accounts for the large size at birth. The liver remains the heaviest organ in the body.

Pancreatic islet cells are developed by 12 weeks of gestation and begin producing insulin. The spleen is active in blood formation during fetal development and the first year of life. Afterward, the spleen aids in the destruction of blood cells and functions as a lymphatic organ for immunologic response.

Nephrogenesis begins during the second embryologic month. By 12 weeks, the kidney is able to produce urine, and the bladder expands as a sac. Development of new nephrons ceases by 36 weeks of gestation. After birth, the kidney increases in size because of enlargement of the existing nephrons and adjoining tubules. The glomerular filtration rate is approximately 0.5 mL/min before 34 weeks of gestation and gradually increases in a linear fashion to the adulthood rate.

Pregnant Patients

As the uterus enlarges, the muscles of the abdominal wall stretch and lose tone. During the third trimester, the rectus abdominis muscles may separate, allowing abdominal contents to protrude at the midline (diastasis recti).

The umbilicus flattens or protrudes. Striae may form as the skin is stretched. A line of pigmentation at the midline (linea nigra) often develops ( Fig. 18.2 ). Abdominal muscles have less tone and are less active. The abdominal contour changes when lightening, or dropping, occurs (about 2 weeks before term in a nullipara), and the fetal presenting part descends into the true pelvis. After pregnancy, the muscles gradually regain tone though diastasis recti may persist.

Linea nigra in the third trimester of pregnancy.

During the second trimester lower esophageal sphincter pressure decreases. Peristaltic wave velocity in the distal esophagus also decreases. Gastric emptying appears to be normal; however, gastrointestinal transit time is prolonged, at times leading to constipation. Incompetence of the pyloric sphincter may result in alkaline reflux of duodenal contents into the stomach. Due to relaxation of the lower esophageal sphincter, heartburn (gastroesophageal reflux) often occurs.

The gallbladder may become distended, accompanied by decreased emptying time and change in tone. The combination of gallbladder stasis and secretion of lithogenic bile increases formation of cholesterol crystals and the development of gallstones. Gallstones are more common in the second and third trimesters.

The kidneys enlarge slightly (by about 1 cm in length) during pregnancy. The renal pelvis and ureters dilate from the effects of hormones and pressure from the enlarging uterus. Dilation of the ureter is greater on the right side than on the left, probably because it is affected by displacement of the uterus to the right by an enlarged right ovarian vein. The ureters also elongate and form single and double curves of varying sizes and angulation. These changes can lead to urinary stasis and pyelonephritis in gravid women with asymptomatic bacteriuria. Renal function is most efficient if the individual lies in the lateral recumbent position, which helps prevent compression of the vena cava and aorta. These changes can last up to 3 or 4 months after delivery.

The bladder has increased sensitivity and compression during pregnancy, leading to frequency and urgency of urination during the first and third trimesters. After the fourth month, the increase in uterine size, hyperemia of all pelvic organs, and hyperplasia of muscle and connective tissue elevate the bladder trigone and cause thickening of the posterior margin. This process produces a marked deepening and widening of the trigone by the end of the pregnancy and may result in microhematuria. During the third trimester, compression may also result from the descent of the fetus into the pelvis; this, in turn, causes a sense of urgency and/or incontinence, even with a small amount of urine in the bladder.

The colon is displaced laterally upward and posteriorly, peristaltic activity may decrease, and water absorption is increased. As a result, bowel sounds are diminished, and constipation and flatus are more common. The appendix is displaced upward and laterally, away from McBurney point, an anatomic landmark one-third of the distance from the anterior superior iliac spine to the umbilicus.

In the postpartum period, the uterus involutes rapidly. Immediately after delivery, the uterus is approximately the size of a 20-week pregnancy (palpable at the level of the umbilicus). By the end of the first week, it is about the size of a 12-week pregnancy, palpable at the symphysis pubis. The muscles of the pelvic floor and the pelvic supports gradually regain tone during the postpartum period and may require 6 to 7 weeks to recover. Stretching of the abdominal wall during pregnancy may result in persistent striae.

Older Adults

The process of aging results in changes in the functional abilities of the gastrointestinal tract. Motility of the intestine is the most severely affected; secretion and absorption are affected to a lesser degree. Altered motility may be caused by age-related changes in neurons of the central nervous system and by changes in collagen properties that increase the resistance of the intestinal wall to stretching. Reduced circulation to the intestine often follows other system changes associated with hypoxia and hypovolemia. Thus functional abilities of the intestine can decrease secondary to systemic changes in the older adult.

As a result of epithelial atrophy, the secretion of both digestive enzymes and protective mucus decreases in the intestinal tract. Particular elements of the mucosal cells show a lesser degree of differentiation and are associated with reduction in secretory ability. These cells are also more susceptible to both physical and chemical agents, including ingested carcinogens. Bacterial flora of the intestine can undergo both qualitative and quantitative changes and become less biologically active. These changes may impair digestive ability and thereby cause food intolerances in the older adult.

Liver size decreases after 50 years of age, which parallels the decrease in lean body mass. Hepatic blood flow decreases as a result of a decline in cardiac output associated with aging. The liver loses some ability to metabolize certain drugs. Increasing obesity and the development of type 2 diabetes mellitus also put the liver at risk for the development of nonalcoholic steatohepatitis.

The size of the pancreas is unaffected by aging, although the main pancreatic duct and branches widen. With aging there is an increase in fibrous tissue and fatty deposition with acinar cell atrophy; however, the large reserve of the organ results in no significant physiologic changes.

There may be an increase of biliary lipids, specifically the phospholipids and cholesterol, resulting in the formation of gallstones.

History of Present Illness

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  Abdominal pain

  
  
  
  
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    Onset and duration: sudden or gradual; persistent, recurrent, intermittent

    
    
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    Character: dull, sharp, burning, gnawing, stabbing, cramping, aching

    
    
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    Location: at time of onset, change over time, radiation to another area, superficial or deep

    
    
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    Associated symptoms: vomiting, diarrhea, constipation, passage of flatus, belching, jaundice, change in abdominal girth, weight loss or weight gain

    
    
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    Relationship to: menstrual cycle, change in menses, intercourse, urination, defecation, inspiration, change in body position, food or alcohol intake, stress, time of day, trauma

    
    
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    Recent stool characteristics: color, consistency, odor, frequency

    
    
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    Urinary characteristics: frequency, color, volume congruent with fluid intake, force of stream, ease of starting stream, ability to empty bladder

    
    
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    Medications: high doses of aspirin, steroids, nonsteroidal antiinflammatory drugs (NSAIDs)

    
    
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    Indigestion

    
    
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    Character: feeling of fullness, heartburn, discomfort, excessive belching, flatulence, loss of appetite, severe pain

    
    
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    Location: localized or general, radiating to arms or shoulders

    
    
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    Relationship to: amount, type, and timing of food intake; menses

    
    
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    Onset of symptoms: time of day or night, sudden or gradual

    
    
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    Symptom relieved by antacids, change in diet, rest, activity

    
    
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    Medications: antacids (calcium carbonate, H2 blockers, proton pump inhibitors)

  
  
  
  
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  Nausea: associated with vomiting, particular stimuli (odors, activities, time of day, food intake), menses

  
  
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  Medications: antiemetics

  
  
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  Vomiting

  
  
  
  
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    Character: nature (color, bright red blood or coffee grounds, bilious, undigested food particles), quantity, duration, frequency, ability to keep any liquids or food in stomach

    
    
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    Associated symptoms: constipation, diarrhea, fever, chills, headache, nausea, weight loss, abdominal pain or cramping, heartburn

    
    
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    Relationship to: previous meal, change in appetite, medications, menses

    
    
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    Medications: antiemetics

  
  
  
  
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  Diarrhea

  
  
  
  
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    Character: watery, copious, explosive; color; presence of blood, mucus, undigested food, oil, or fat; odor; number of times per day, duration; change in pattern

    
    
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    Associated symptoms: fever, chills, thirst, weight loss, abdominal pain or cramping, fecal incontinence

    
    
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    Relationship to: amount, type and timing of food intake, stressful life events or daily stressors

    
    
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    Travel history and/or ill contacts

    
    
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    Medications: laxatives or stool softeners; antidiarrheals

  
  
  
  
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  Constipation

  
  
  
  
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    Character: presence of bright red blood, black or tarry appearance of stool; diarrhea alternating with constipation; accompanied by abdominal pain or discomfort

    
    
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    Pattern: last bowel movement, pain with defecation, change in consistency or size of stool

    
    
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    Diet: recent change in diet, intake of high-fiber foods, change in fluid intake

    
    
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    Medications: laxatives, stool softeners, iron, diuretics

  
  
  
  
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  Fecal incontinence

  
  
  
  
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    Character: stool characteristics, timing in relation to meals, number of episodes per day; occurring with or without warning sensation

    
    
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    Associated with: use of laxatives, presence of underlying disease (cancer, inflammatory bowel disease, diverticulitis, colitis, proctitis, diabetic neuropathy, spinal cord injury)

    
    
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    Relationship to: fluid and dietary intake, immobilization

    
    
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    Medications: laxatives, stool softeners, diuretics

  
  
  
  
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  Jaundice

  
  
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  Onset and duration

  
  
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  Color of stools or urine

  
  
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  Associated with abdominal pain, chills, fever

  
  
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  Exposure to hepatitis, use of recreational drugs, high-risk sexual activity

  
  
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  Medications: high doses of acetaminophen; antipsychotics, antiepileptics, antibiotics

  
  
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  Dysuria

  
  
  
  
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    Character: location (suprapubic, distal urethra), pain or burning, frequency or volume changes

    
    
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    Associated fever or other systemic signs of illness: bacterial infection, tuberculosis, fungal or viral infection, parasitic infection

    
    
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    Increased frequency of sexual intercourse or high-risk sexual activity

    
    
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    Amount of daily fluid intake

  
  
  
  
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  Urinary frequency

  
  
  
  
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    Change in usual pattern and/or volume

    
    
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    Associated with dysuria or other urinary characteristics: urgency, hematuria, incontinence, nocturia; increased thirst, weight loss

    
    
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    Change in urinary stream; dribbling

    
    
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    Medications: diuretics

  
  
  
  
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  Urinary incontinence

  
  
  
  
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    Character: amount and frequency, constant or intermittent, dribbling versus frank incontinence

    
    
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    Associated with urgency, previous surgery, coughing, sneezing, walking up stairs, nocturia, menopause

    
    
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    Medications: diuretics

  
  
  
  
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  Hematuria

  
  
  
  
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    Character: color (bright red, rusty brown, cola-colored); present at beginning, end, or throughout voiding

    
    
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    Associated symptoms: flank or costovertebral pain, passage of wormlike clots, pain on voiding

    
    
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    Alternate possibilities: ingestion of foods containing red vegetable dyes (may cause red urinary pigment); ingestion of laxatives containing phenolphthalein

    
    
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    Medications: aspirin, NSAIDs, anticoagulants, diuretics, antibiotics

  
  

Past Medical History

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  Gastrointestinal disorder: peptic ulcer, polyps, inflammatory bowel disease, irritable bowel syndrome, intestinal obstruction, pancreatitis, hyperlipidemia

  
  
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  Hepatitis or cirrhosis of the liver

  
  
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  Abdominal or urinary tract surgery or injury

  
  
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  Urinary tract infection: number of episodes, treatment

  
  
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  Major illness: cancer, arthritis (steroids, NSAIDs or aspirin use), kidney disease, cardiac disease

  
  
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  Blood transfusions

  
  
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  Immunization status (hepatitis A and hepatitis B)

  
  
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  Colorectal cancer or related cancers—breast, ovarian, endometrial

  
  
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  Sexually transmitted infections

Family History

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  Colorectal cancer and familial colorectal cancer syndromes—familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer (Lynch syndrome)

  
  
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  Gallbladder disease

  
  
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  Kidney disease: renal stone, polycystic disease, renal tubular acidosis, renal or bladder carcinoma

  
  
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  Malabsorption syndrome: cystic fibrosis, celiac disease

  
  
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  Hirschsprung disease (aganglionic megacolon)

  
  
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  Familial Mediterranean fever (periodic peritonitis)

Personal and Social History

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  Nutrition: 24-hour dietary recall; food preferences and dislikes; ethnic foods, religious food restrictions, food intolerances, lifestyle effects on food intake, use of probiotics or dietary supplements; voluntary and involuntary weight gain or loss

  
  
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  First day of last menstrual period

  
  
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  Alcohol intake: frequency, type, and usual amounts

  
  
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  Recent major stressful life events or chronic daily stressors: physical, social, and psychological changes

  
  
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  Exposure to infectious diseases: hepatitis, influenza; travel history; occupational or environmental exposures

  
  
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  Trauma: through type of work, physical activity, physical or emotional abuse, intimate partner violence

  
  
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  Use of recreational or intravenous drugs

  
  
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  Tobacco use—smoking: frequency, amount, duration, pack-years

Equipment

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  Stethoscope

  
  
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  Centimeter measuring tape

  
  
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  Marking pen

Preparation

To perform the abdominal examination, you will need a good light source; full exposure of the abdomen; warm hands with short fingernails; and, ideally, a comfortable, relaxed patient. Have the patient empty his or her bladder before the examination begins; a full bladder interferes with accurate examination of nearby organs and makes the examination uncomfortable. Place the patient in a supine position with arms at the sides. Approach the patient from the right side. The patient’s abdominal musculature should be relaxed to allow access to the underlying structures. It may be helpful to place a small pillow under the patient’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Make your approach slow and gentle, avoiding sudden movements. Ask the patient to point to any tender areas, and examine those last.

For the purposes of examination, the abdomen is commonly divided into four quadrants, first by drawing an imaginary line from the sternum to the pubis through the umbilicus. Draw a second imaginary line perpendicular to the first, horizontally across the abdomen through the umbilicus ( Fig. 18.3 ). Alternatively, the abdomen is divided into nine regions using following imaginary lines: two horizontal lines, one across the lowest edge of the costal margin and the other across the edge of the iliac crest, and two vertical lines running bilaterally from the midclavicular line to the middle of the Poupart ligament, approximating the lateral borders of the rectus abdominis muscles ( Fig. 18.4 ). Choose one of these mapping methods and use it consistently. Box 18.1 lists the contents of the abdomen in each of the quadrants and regions. Mentally visualize the underlying organs and structures in each of the zones as you proceed with the examination. Certain other anatomic landmarks are useful in describing the location of pain, tenderness, and other findings. These landmarks are illustrated in Fig. 18.5 .

Four quadrants of the abdomen.

(From Wilson and Giddens, 2009 .)

Nine regions of the abdomen.

1, Epigastric; 2, umbilical; 3, hypogastric; 4 and 5, right and left hypochondriac; 6 and 7, right and left lumbar; 8 and 9, right and left inguinal.

(Modified from Wilson and Giddens, 2009 .)

Landmarks of the abdomen.

(From Wilson and Giddens, 2009 .)

Inspection

Surface Characteristics

Begin by inspecting the abdomen from a seated position at the patient’s right side. This position allows a tangential view that enhances shadows and contouring. Observe the skin color and surface characteristics. The skin of the abdomen will have the same expected variations in color and surface characteristics as the rest of the body. The skin may be somewhat paler if not exposed to the sun. A fine venous network is often visible. Above the umbilicus, venous return should be toward the head; below the umbilicus, it should be toward the feet ( Fig. 18.6, A ). When abdominal vessels appear distended or more pronounced, use the following procedure to determine the direction of venous return. Place the index fingers of both hands side by side perpendicularly over a vein. Press and separate the fingers, milking empty a section of vein. Release one finger and time the refill. Release the other finger and time the refill. The flow of venous blood is in the direction of the faster filling. Flow patterns are altered in some disease states (see Fig. 17.6, B and C ).

Abdominal venous patterns.

A, Expected. B, Portal hypertension. C, Inferior vena cava obstruction.

Unexpected skin findings include generalized color changes such as jaundice or cyanosis. A glistening, taut appearance suggests ascites. Inspect for bruises and localized discoloration. Areas of redness may indicate inflammation. A bluish periumbilical discoloration (Cullen sign) suggests intraabdominal bleeding. Striae often result from pregnancy or weight gain. Striae of recent origin are pink or blue in color but turn silvery white over time. Abdominal tumors or ascites can produce striae. The striae of Cushing disease remain purplish.

Inspect for any lesions, particularly nodules. Lesions are of particular importance because gastrointestinal diseases often produce secondary skin changes. A pearl-like, enlarged and sometimes painful umbilical nodule from cancer metastasis, known as Sister Mary Joseph’s nodule, may be the first sign of an intraabdominal malignancy ( Iavazzo et al, 2012 ). Skin and gastrointestinal lesions may arise from the same cause or may occur without relationship to one another. See Clinical Pearl, “Scars.”

Clinical Pearl

Scars

Note any scars and draw their location, configuration, and relative size on an illustration of the abdomen. If the cause of a scar was not explained during the history, now is a good time to pursue that information. The presence of scarring should alert you to the possibility of intraabdominal adhesions.

Contour

Inspect the abdomen for contour, symmetry, and surface motion, using tangential lighting to illuminate contour and visible peristalsis. Contour is the abdominal profile from the rib margin to the pubis, viewed on the horizontal plane. The expected contours can be described as flat, rounded, or scaphoid. A flat contour is common in well-muscled, athletic adults. The rounded or convex contour is characteristic of young children, but in adults it is the result of subcutaneous fat or poor muscle tone. The abdomen should be evenly rounded with the maximum height of convexity at the umbilicus. The scaphoid or concave contour is seen in thin adults.

Note the location and contour of the umbilicus. It should be centrally located without displacement upward, downward, or laterally. The umbilicus may be inverted or protrude slightly, but it should be free of inflammation, swelling, or bulge that may indicate a hernia.

Inspect for symmetry from a seated position at the patient’s side, then move to a standing position behind the patient’s head, if possible. Contralateral areas of the abdomen should be symmetric in appearance and contour. Look for any distention or bulges.

Generalized symmetric distention may occur as a result of obesity, enlarged organs, and fluid or gas. Distention from the umbilicus to the symphysis can be caused by an ovarian tumor, pregnancy, uterine fibroids, or a distended bladder. Distention of the upper half, above the umbilicus, can be due to tumor, pancreatic cyst, or gastric dilation. Asymmetric distention or protrusion may indicate hernia, tumor, cysts, bowel obstruction, muscle or soft tissue hematoma, or enlargement of abdominal organs. See Clinical Pearl, “Abdominal Distention.”

Clinical Pearl

Abdominal Distention

You are with a patient whose abdomen is significantly distended and whose bowel sounds are hypoactive or even absent. There is no particular pain, and you feel no masses. The deep tendon reflexes are diminished. You know that the patient is on diuretics for treatment of hypertension. Think of hypokalemia as a cause of a paralytic ileus (intestinal pseudoobstruction): diuretics/distention/deficiency of potassium. Narcotics and hypothyroidism can do the same thing.

Ask the patient to take a deep breath and hold it. The contour should remain smooth and symmetric. This maneuver lowers the diaphragm and compresses the organs of the abdominal cavity, which may cause previously unseen bulges or masses to appear. Next, ask the patient to raise his or her head from the table. This contracts the rectus abdominis muscles, which produces muscle prominence in thin or athletic adults. Superficial abdominal wall masses may become visible. If a hernia is present, the increased abdominal pressure may cause it to protrude.

An incisional hernia is caused by a defect in the abdominal musculature that develops after a surgical incision, resulting in a protrusion in the area of the surgical scar. Protrusion of the navel indicates an umbilical hernia. The adult type develops during pregnancy, in long-standing ascites, or when intrathoracic pressure is repeatedly increased, as occurs in chronic respiratory disease. Hernias may also occur in the midline of the epigastrium (i.e., hernia of the linea alba). This type of hernia contains a bit of fat and is felt as a small, tender nodule. Most hernias are reducible, meaning that the contents of the hernia can be pushed back into place. If not, the hernia is nonreducible or incarcerated (blood supply to the protruded contents may become obstructed and require immediate surgery).

In addition to hernias, separation of the rectus abdominis muscles may become apparent when the patient raises his or her head from the table. Diastasis recti occurs more often in pregnancy and the postpartum period. The condition is of little clinical significance.

Movement

With the patient’s head again resting on the table, inspect the abdomen for movement. Smooth, even movement should occur with respiration. Males exhibit primarily abdominal movement with respiration, whereas females show mostly costal movement. Limited abdominal motion associated with respiration may indicate peritonitis in an ill-appearing adult male. Surface motion from peristalsis, seen as a rippling movement across the abdomen, may be seen in thin individuals but can also be a sign of intestinal obstruction. Abdominal aortic pulsations seen in the upper midline are often visible in thin adults. Marked pulsations may occur as the result of increased pulse pressure or abdominal aortic aneurysm.

Auscultation

Unlike the usual sequence, always perform auscultation of the abdomen before percussion and palpation because these maneuvers may alter the frequency and intensity of bowel sounds.

Bowel Sounds

Lightly place the diaphragm of a warmed stethoscope on the abdomen. Some healthcare providers say they prefer to use the bell; in reality, they tend to pull the skin tight with the bell and, in effect, make a diaphragm. A cold stethoscope, like cold hands, may initiate contraction of the abdominal muscles. Listen for bowel sounds and note frequency and character. They are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. Bowel sounds are generalized so most often they can be assessed adequately by listening in one place. Loud prolonged gurgles are called borborygmi (stomach growling). Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger. High-pitched tinkling sounds suggest intestinal fluid and air under pressure, as in early obstruction. Decreased bowel sounds occur with peritonitis and paralytic ileus. Auscultate in all four quadrants if you have a concern. Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 minutes of continuous listening, is typically associated with abdominal pain and rigidity and is a surgical emergency.

Additional Sounds and Bruits

Listen with the diaphragm for friction rubs over the liver and spleen. Friction rubs are high pitched and are heard in association with respiration. Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. A bruit is a harsh or musical intermittent auscultatory sound, which may reflect blood flow turbulence and indicate vascular disease. Listen with the bell of the stethoscope in the epigastric region and in the aortic, renal, iliac, and femoral arteries. Vascular sounds are usually well localized. Keep their specific locations in mind as you listen at those sites ( Fig. 18.7 ). Auscultate with the bell of the stethoscope in the epigastric region and around the umbilicus for a venous hum, which is soft, low pitched, and continuous. A venous hum occurs with increased collateral circulation between the portal and systemic venous systems.

Sites to auscultate for bruits: renal arteries, iliac arteries, aorta, and femoral arteries.

(Modified from Wilson and Giddens, 2009 .)

Percussion

Percussion (generally indirect; see Chapter 3 ) is used to assess the size and density of the organs in the abdomen and to detect the presence of fluid (as with ascites), air (as with gastric distention), and fluid-filled or solid masses. Percussion is used either independently or concurrently with palpation of specific organs and can validate palpatory findings. For simplicity, percussion and palpation are discussed separately.

First percuss all quadrants or regions of the abdomen for a sense of overall tympany and dullness ( Table 18.1 ). Tympany is the predominant sound because air is present in the stomach and intestines. Dullness is heard over organs and solid masses. A distended bladder produces dullness in the suprapubic area. Develop a systematic route for percussion.

Liver Span

Now go back and percuss individually the liver, spleen, and stomach. Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to an area of dullness because that sound change is easiest to detect. Percuss upward along the midclavicular line, as shown in Fig. 18.8 , to determine the lower border of the liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark the border with a marking pen. A lower liver border that is more than 2 to 3 cm (.75 to 1 inch) below the costal margin may indicate organ enlargement or downward displacement of the diaphragm because of emphysema or other pulmonary disease.

Liver percussion routes along midclavicular and midsternal lines.

(Modified from Wilson and Giddens, 2009 .)

To determine the upper border of the liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Continue downward until the percussion tone changes to one of dullness; this marks the upper border of the liver. Mark the location with the pen. The upper border is usually in the fifth intercostal space. An upper border below this may indicate downward displacement or liver atrophy. Dullness extending above the fifth intercostal space suggests upward displacement from abdominal fluid or masses.

Measure the distance between the marks to estimate the vertical span of the liver. The usual span is approximately 6 to 12 cm (2.5 to 4.5 inches). A span greater than this may indicate liver enlargement, whereas a lesser span suggests atrophy. Age and gender influence liver size. Liver span is usually greater in males and in tall individuals.

Percussion provides a gross estimate of liver size. Errors in estimating liver span can occur when the dullness of a pleural effusion or lung consolidation obscures the upper liver border. Similarly, gas in the colon may produce tympany in the right upper quadrant and obscure the dullness of the lower liver border.

If liver enlargement is suspected, additional percussion maneuvers can provide further information. Percuss upward and then downward over the right midaxillary line. Liver dullness is usually detected around the seventh intercostal space. You can also percuss along the midsternal line to estimate the midsternal liver span (see Fig. 18.8 ). The usual span at the midsternal line is 4 to 8 cm (1.5 to 3 inches). Spans exceeding 8 cm suggest liver enlargement.

To assess the descent of the liver, ask the patient to take a deep breath and hold it while you percuss upward again from the abdomen at the right midclavicular line. The area of lower border dullness should move downward 2 to 3 cm. This maneuver will guide subsequent palpation of the organ. See Clinical Pearl, “Assessing Liver Size.”

Clinical Pearl

Assessing Liver Size

It is best to report the size of the liver in two ways: liver span as determined from percussing the upper and lower borders, and the extent of liver projection below the costal margin. When the size of a patient’s liver is important in assessing the clinical condition, projection below the costal margin alone will not provide enough comparative information. Be sure to specify which landmarks were used for future measurement comparison (e.g., midclavicular line).

Spleen

Percuss the spleen just posterior to the midaxillary line on the left side as shown in Fig. 18.9 . Percuss in several directions beginning at areas of lung resonance. You may hear a small area of splenic dullness from the sixth to the ninth rib. Traube space is a semilunar region defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margin inferiorly. This area is typically tympanitic because it overlies the fundus of the stomach. With splenic enlargement, tympany changes to dullness as the spleen is brought forward and downward with inspiration (splenic percussion sign). However, a full stomach, feces-filled intestine, or left-sided pleural effusion may also produce dullness.

From Barkun & Grover, 2009 .

Evidence-Based Practice in Physical Examination

Detecting Splenomegaly

The prevalence of palpable splenomegaly in healthy individuals is low and the physical examination is more specific than sensitive (i.e., the inability to detect the spleen with palpation and/or percussion does not rule out splenomegaly). In general, when suspicion for splenomegaly is at least 10% based on history and other physical examination findings, begin with percussion of Traube space. If dullness is appreciated, palpation should follow. For thin patients, palpation may be more useful than percussion. If clinical suspicion is high, and splenomegaly is not appreciated on examination, radiologic imaging may be necessary.

Percussion of the spleen.

(From Wilson and Giddens, 2009 .)

Gastric Bubble

Percuss for the gastric air bubble in the area of the left lower anterior rib cage and left epigastric region. The tympany produced by the gastric bubble is lower in pitch than the tympany of the intestine.

Kidneys

To assess each kidney for tenderness, ask the patient to assume a sitting position. Place the palm of your hand over the right costovertebral angle and strike your hand with the ulnar surface of the fist of your other hand ( Fig. 18.10, A ). Repeat the maneuver over the left costovertebral angle. Direct percussion with the fist over each costovertebral angle may also be used (see Fig. 18.10, B ). The patient should perceive the blow as a thud, but it should not cause pain. For efficiency of time and motion, this maneuver is performed while examining the back rather than the abdomen.

Fist percussion of the costovertebral angle for kidney tenderness.

A, Indirect percussion. B, Direct percussion.

Palpation

Use palpation to assess the organs of the abdominal cavity and to detect muscle spasm, masses, fluid, and areas of tenderness. Evaluate the abdominal organs for size, shape, mobility, and consistency. Stand at the patient’s right side with the patient in the supine position. Attempt to make the patient as comfortable and relaxed as possible. Use warm hands and bend the patient’s knees to help relax the abdominal muscles. Ticklishness may be a challenge ( Box 18.2 ).

Light Palpation

Begin with a light, systematic palpation of all four quadrants, or nine regions, initially avoiding any areas that the patient had identified as painful. Lay the palm of your hand lightly on the abdomen, with the fingers extended and held together ( Fig. 18.11 ). With the palmar surface of your fingers, depress the abdominal wall no more than 1 cm, using a light and even pressing circular motion. Avoid short, quick jabs. The abdomen should feel smooth, with a consistent softness. The patient’s abdomen may tense if you press too deeply, your hands are cold, the patient is ticklish, or inflammation is present. Guarding, tensing of the abdominal musculature to protect inflamed viscera, should alert you to move cautiously through the remainder of the examination.

Light palpation of the abdomen.

With fingers extended and approximated, press in no more than 1 cm.

Light palpation is useful in identifying muscular resistance and areas of tenderness. A large mass or distended structure may be appreciated on light palpation as a sense of resistance. If resistance is present, determine whether it is voluntary or involuntary in the following way: Place a pillow under the patient’s knees and ask the patient to breathe slowly through the mouth as you feel for relaxation of the rectus abdominis muscles on expiration. If the tenseness remains, it is probably an involuntary response to localized or generalized rigidity. Rigidity is a board-like hardness of the abdominal wall overlying areas of peritoneal irritation.

Moderate Palpation

Continue palpation with the same hand position and technique used for light palpation, exerting moderate pressure as an intermediate step to gradually approach deep palpation. Tenderness not elicited on light palpation may become evident with deeper pressure. An additional maneuver of moderate palpation is performed with the side of your hand ( Fig. 18.12 ). This maneuver is useful in assessing organs that move with respiration, specifically the liver and spleen. Palpate during the entire respiratory cycle. As the patient inspires, the organ is displaced downward, and you may be able to feel it as it bumps gently against your hand.

Moderate palpation using the side of the hand.

Deep Palpation

Deep palpation is necessary to thoroughly delineate abdominal organs and to detect less obvious masses. Use the palmar surface of your extended fingers, pressing deeply and evenly into the abdominal wall ( Fig. 18.13 ). Palpate all four quadrants or nine regions, moving the fingers back and forth over the abdominal contents. Often you are able to feel the borders of the rectus abdominis muscles, the aorta, and portions of the colon. Tenderness not elicited with light or moderate palpation may become evident. Deep pressure may also evoke tenderness in the healthy person over the cecum, sigmoid colon, aorta, and in the midline near the xiphoid process. If deep palpation is difficult because of obesity or muscular resistance, you can use a bimanual technique with one hand atop the other, as shown in Fig. 18.14 . Exert pressure with the top hand while concentrating on sensation with the other hand. Some examiners prefer to use the bimanual technique for all patients.

Deep palpation of the abdomen.

Press deeply and evenly with the palmar surface of extended fingers.

Deep bimanual palpation.

Masses

Identify any masses and note the following characteristics: location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To determine whether a mass is superficial (i.e., located in the abdominal wall) or intraabdominal, have the patient lift his or her head from the examining table, thus contracting the abdominal muscles. Masses in the abdominal wall will continue to be palpable, but those located in the abdominal cavity will be more difficult to feel because they are obscured by abdominal musculature. The presence of feces in the colon, often mistaken for an abdominal mass, can be felt as a soft, rounded, boggy mass in the cecum and in the ascending, descending, or sigmoid colons. Other structures that are sometimes mistaken for masses are the lateral borders of the rectus abdominis muscles, uterus, aorta, sacral promontory, and common iliac artery ( Fig. 18.15 ). By mentally visualizing the placement of the abdominal structures, you can distinguish between what ought to be there and an unexpected finding.

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