The Physical Examination of Abdomen 2nd Affiliated Hospital China Medical University

Abdominal landmarks
xiphoid process lower margin of costal arch iliac antero-superior spina umbilicus symphysis pubis abdominal middle line

Abdominal regions
four quadrants system nine regions system

seven regions system

four quadrants system

one line extending vertically from the xiphoid to the symphysis pubis, the other line extending horizontally at the level of the umbilicus

Right upper quadrant

liver gallbladder pylorus duodenum pancreas(head) right kidney hepatic flexure of colon

Right lower quadrant

cecum appendix ascending colon small intestine right ovary and tube

Left upper quadrant liver (left lobe ) spleen stomach pancreas (body tail) left kidney splenic flexure of colon

Left lower quadrant sigmoid colon descending colon small intestine left ovary and tube

Nine regions system

the abdomen is divided into nine regions by four intersecting lines, two horizontal linescostal arch line and iliac spina line, two vertical lines extending vertically across the middle point from iliac antero-superior spina to abdominal middle line.

Regions
right & left hypochondrial right & left lumber right & left iliac epigastric umbilical hypogastric

Right hypochondrial liver gallbladder right kidney hepatic flexure of colon right lumber ascending colon jejunum right kidney right iliac cecum appendix right ovary and tube

Epigastric
liver (left lobe) pylorus duodenum omentum transverse colon the head and body of pancreas

umbilical
duodenum jejunum ileum mesentery abdominal aorta lymph node omentum

hypogastric
bladder womb ureter

Left hypochondrial
spleen stomach splenic flexure of colon pancreas (tail part ) left kidney

left lumber
descending colon jejunum ileum

left iliac
sigmoid colon left ovary and tube

Seven quadrants system

Inspection

the contents of inspection 1. abdominal contour 2. respiratory movement 3. abdominal veins 4. peristalsis 5. abdominal skin

1. Abdominal contour
in healthy person abdomen is usually flat from xiphoid to symphysis pubis , we call abdominal flat or even abdomen. the umbilicus is located in the abdominal center. depending on the nutritional status, the abdominal contour may be lightly protuberant or scaphoid.

Abdominal bulge generalized abdominal bulge is usually caused by ascites some causes for ascites: heart failure cirrhosis of liver nephrotic syndrome TB peritonitis

When the patient is in supine position, the flanks of patient is bulging, the shape of abdomen is like frog we call frog abdomen. how to measure abdominal circumference? with a belt ruler go around abdomen through umbilicus to see how long it is (cm)

the other causes of abdominal bulge:

include the distention of the bowel with trapped gas, such as intestinal obstruction, massive tumor, such as ovariogenic cystoma, factitious abdominal fullness with air, pregnancy obesity

both the patients with massive ascites and obesity have abdominal distention, how do we distinguish from each other, you can observe the appearance of the umbilicus, umbilicus is usually deeply inverted in obesity and everted in longstanding ascites

located abdominal fullness

upper abdominal fullness may result from a mass in the upper abdominal structures, such as liver pancreas, stomach or transverse colon. similarly fullness in the lower abdomen may result from bladder distention, pregnancy or masses from the ovaries, uterus or colon

the mass or tumor may be on the abdominal wall or in the abdominal cavity, how to differentiate, you can ask patient to make abdominal muscles contract, if the tumor is more distinct the tumor is on the abdominal wall, if the tumor is not distinct the tumor is in the abdomen

Abdominal retraction
anterior abdominal wall is much lower than the level from xiphoid to symphysis pubis,

generalized abdominal retraction

we called scaphoid abdomen, mainly seen in sever malnutritional status, marasmus, cachexia, acute diffusive peritonitis due to muscle rigidity. located retraction: mainly seen in scar after operation.

2. Respiratory movement
the manner of breathing: in men and children, manner of breathing is abdominal respiration. But in women the manner of breathing is thoracic respiration. In some diseases such as perforation because acute peritonitis., the respiratory movement is limited or disappear.

3. Abdominal veins
in healthy person abdominal vein can not be seen or or can be seen a little in thin person, but not dilated, in patient with obstruction of the portal venous system or in the vena cava,You may find distended
vains.

when you find distended veins on the abdomen you should ascertain the direction of flow. the normal direction of flow is away from the umbilicus , that is the upper abdominal veins carry blood up ward to the superior vena cava. And the lower abdominal veins flow downward to the inferior vena cava.

how to ascertain the direction of blood flow you can choice a segment of vein, then the vein is emptied between two fingers to a distance of a few centimeters, then allows blood to refill the vein from one direction by removing one compressing finger

4. Gastric or intestinal pattern and peristalsis

in healthy person peristalsis is not visible, but in patient with pyloric or intestinal obstruction you can see peristalsis, in pyloric obstruction on epigastrium the peristalsis is from left costal margin to right, in intestinal obstruction you can see peristalsis around umbilicus the direction of peristalsis is irregular.

5. The skin of abdomen (1) skin eruption in some diseases especially infectious disease such as typhoid fever you can find roseolas on the skin of abdomen,

(2) Pigment
in normal condition, the pigment of abdomen is more decreased than exposed part of skin, in patient with chronic adrenocortical hypofunction also called addison s disease, hyperpigmentation can be found at the belt line.

There are two special sings of discoloration on the abdominal skin, One is Cullens sign: a bluish discoloration around the umbilicus, another is Turners sign: a bluish discoloration of the flanks. these two signs may occur as the result of hemoperitoneum such as hemorrhagic pancreatitis broken of ectopic pregnancy.

(3) Striae
silver striae distribute on the
lower quadrants of abdomen or iliac regions, it is seen after a large gain of weight or after pregnancy. bluish striae (purple) distribute on lower quadrants of abdomen upper legs or hips this is found in hypercortisolism.

(4) Scar when you find a operation scar on the patient abdomen, you should ask some question about the scar, when and why the patient got the scar, the history of operation may be helpful to diagnosis of the disease

(5). Hernia umbilical hernia may be seen in belly or patient with a massive ascites incisional hernia operation scar femoral hernia mainly seen in female inquinal hernia mainly seen in male

(6) Hair distribution

in female the pubic hair is roughly triangular with the base above the symphysis. where as in male it is in the shape of a diamond often with hair continuing to the umbilicus, the distribution and quantity of hair maybe changed by chronic liver disease and endocrine abnormalities

(7). Epigastric pulsation may be seen in the following condition: (1). thin person (2). Right ventricular hypertrophy COPD (3). Abdominal aneurysm