Inspection

Inspection should be performed in a warm, well-lit environment, and the patient should be in a comfortable position, with the abdomen exposed. Although assessment of the GI system classically begins with inspection of the abdomen, the patient’s oral cavity also must be inspected to determine any unusual findings. Abnormal findings of the mouth include temporomandibular joint tenderness, inflammation of gums, missing teeth, dental caries, ill-fitting dentures, and mouth odor.

Observe the skin for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and venous pattern. Pigmentation may vary considerably and still be within normal limits because of race and ethnic background, although the abdomen usually is of a lighter color than other exposed areas of the skin. Abnormal findings include jaundice, skin lesions, and a tense and glistening appearance of the skin. Old striae (stretch marks) usually are silver, whereas pinkish purple striae may indicate Cushing syndrome.⁴ A bluish discoloration of the umbilicus (Cullen sign) and of the flank (Grey-Turner sign) indicates retroperitoneal bleeding.¹

Observe the abdomen for contour, noting whether it is flat, slightly concave, or slightly round; observe for symmetry and for movement. Marked distention is an abnormal finding. In particular, ascites may cause generalized distention and bulging flanks. Asymmetric distention may indicate organ enlargement or a mass. Peristaltic waves should not be visible except in very thin patients. In the case of intestinal obstruction, hyperactive peristaltic waves may be observed. Pulsation in the epigastric area is often a normal finding, but increased pulsation may indicate an aortic aneurysm. Symmetric movement of the abdomen with respirations is usually seen in men.4,5

Auscultation

Auscultation of the abdomen provides clinical data regarding the status of the bowel’s motility. Initially, listen with the diaphragm of the stethoscope below and to the right of the umbilicus. The examination proceeds methodically through all four quadrants, lifting and then replacing the diaphragm of the stethoscope lightly against the abdomen (see Fig. 29-1). Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Colonic sounds are low pitched and have a rumbling quality. A venous hum may be audible sometimes.⁶ Table 29-1 provides a list of abnormal abdominal sounds.

Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush). Absent bowel sounds may result from inflammation, ileus, electrolyte disturbances, and ischemia. Bowels sounds may be increased with diarrhea and early intestinal obstruction.⁶

The abdomen should be auscultated for the presence of bruits, using the bell of the stethoscope (Fig. 29-2). Bruits are created by turbulent flow over a partially obstructed artery and are always considered an abnormal finding. The aorta, the right and left renal arteries, and the iliac arteries should be auscultated.^5,6

Percussion

Percussion is used to elicit information about deep organs such as the liver, spleen, and pancreas (Fig. 29-3). Because the abdomen is a sensitive area, muscle tension may interfere with this part of the assessment. Percussion often helps relax tense muscles, and it is performed before palpation. Percussion in the absence of disease helps delineate the position and size of the liver and spleen, and it assists in the detection of fluid, gaseous distention, and masses in the abdomen.⁵

Percussion should proceed systematically and lightly in all four quadrants. Normal findings include tympany over the empty stomach, tympany or hyper-resonance over the intestine, and dullness over the liver and spleen. Abnormal areas of dullness may indicate an underlying mass. Solid masses, enlarged organs, and a distended bladder also produce areas of dullness. Dullness over both flanks may indicate ascites and necessitates further assessment.⁶

Palpation

Palpation is the assessment technique most useful in detecting abdominal pathologic conditions. Light and deep palpation of each organ and quadrant should be completed. Light palpation, which has a palpation depth of approximately 1 cm, assesses to the depth of the skin and fascia (Fig. 29-4A). Deep palpation assesses the rectus abdominis muscle and is performed bimanually to a depth of 4 to 5 cm (see Fig. 29-4B). Deep palpation is most helpful in detecting abdominal masses. Areas in which the patient complains of tenderness should be palpated last.⁶

Normal findings include no areas of tenderness or pain, no masses, and no hardened areas. Persistent involuntary guarding may indicate peritoneal inflammation, particularly if it continues even after relaxation techniques are used. Rebound tenderness, in which pain increases with quick release of a palpated area, indicates an inflamed peritoneum.⁴

Assessment Findings for Common Disorders

Table 29-2 presents a variety of common GI disorders and their associated assessment findings.

TABLE 29-2

ASSESSMENT FINDINGS OF COMMON GASTROINTESTINAL DISORDERS

CONDITION	HISTORY	SYMPTOMS	SIGNS
Right Lower Quadrant (RLQ) of the Abdomen
Appendicitis	Children (except infants) and young adults	Anorexia	Signs may be absent early
		Nausea	Vomiting
		Early vague epigastric, periumbilical, or generalized pain after 12-24 hours; RLQ at McBurney point	Localized RLQ guarding and tenderness after 12-24 hours
			Rovsing sign: pain in RLQ with application of pressure, iliopsoas sign
			Obturator sign
			White blood cell count of 10,000/mm3 or shift to left
			Low-grade fever
			Cutaneous hyperesthesia in RLQ
			Signs highly variable
Perforated duodenal ulcer	Prior history	Abrupt onset pain in epigastric area or RLQ	Tenderness in epigastric area or RLQ
			Signs of peritoneal irritation
			Heme-positive stool
			Increased white blood cell count
Cecal volvulus	Seen most often in older adults	Abrupt severe abdominal pain	Distention
			Localized tenderness
			Tympany
Strangulated hernia	Any age	Severe localized pain	If bowel obstructed, distention
	Women: femoral	If bowel obstructed, generalized pain
	Men: inguinal
Right Upper Quadrant (RUQ) of the Abdomen
Liver hepatitis	Any age, often young blood product user	Fatigue	Hepatic tenderness
		Malaise	Hepatomegaly
	Drug addict	Anorexia	Bilirubin elevated
		Pain in RUQ	Jaundice
		Low-grade fever	Lymphocytosis in one third of cases
		May have severe fulminating disease with liver failure	Liver enzymes elevated
			Hepatitis A or B or antibodies to the viruses may be found
Acute hepatic congestion	Usually older adults with acute heart failure	Symptoms of acute heart failure	Hepatomegaly
	Pericardial disease		Acute heart failure
	Pulmonary embolism
Biliary stones, colic	“Fair, fat, forty” (90%) but can be 30 to 80 years old	Anorexia Nausea	Tenderness in RUQ Jaundice
		Pain severe in RUQ or epigastric area
		Episodes lasting 15 minutes to hours
Acute cholecystitis	“Fair, fat, forty” (90%) but may be 30 to 80 years old	Severe RUQ or epigastric pain	Vomiting
		Episodes prolonged up to 6 hours	Tenderness in RUQ
			Peritoneal irritation signs
			Increased white blood cell count
Perforated peptic ulcer	Any age	Abrupt RUQ pain	Tenderness in epigastrium, right quadrant, or both
			Peritoneal irritation signs
			Free air in abdomen
Left Upper Quadrant (LUQ) of the Abdomen
Splenic trauma	Blunt trauma to LUQ of abdomen	Pain: LUQ pain of the abdomen often referred to the left shoulder (Kehr sign)	Hypotension
			Syncope
			Increased dyspnea
			Radiographic studies show enlarged spleen
Pancreatitis	Alcohol abuse	Pain in LUQ or epigastric region radiating to the back or chest	Fever
	Pancreatic duct obstruction		Rigidity
			Rebound tenderness
	Infection		Nausea
	Cholecystitis		Vomiting
			Jaundice
			Cullen sign
			Turner sign
			Abdominal distention
			Diminished bowel sounds
Pyloric obstruction	Duodenal ulcer	Weight loss	Increasing dullness in LUQ
		Gastric upset	Visible peristaltic waves in epigastric region
		Vomiting
Left Lower Quadrant (LLQ) of the Abdomen
Ulcerative colitis	Family history	Chronic, watery diarrhea with bloody mucus	Fever
	Jewish ancestry
	Cachexia
		Anorexia	Anemia
		Weight loss	Leukocytosis
		Fatigue
Colonic diverticulitis	Older than 39 years	Pain that recurs in LUQ	Fever
	Low-residue diet		Vomiting
			Chills
			Diarrhea
			Tenderness over descending colon

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