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You are watching: What should you do if a patient is ticklish when you are palpating the abdomen?

Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and also Laboratory Examinations. third edition. Boston: Butterworths; 1990.


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Definition

Inspection is composed of visual examicountry of the abdomales through note made of the form of the abdomen, skin abnormalities, abdominal masses, and also the movement of the abdominal wall with respiration. Abnormalities detected on inspection provide clues to intra-abdominal pathology; these are better investigated through auscultation and palpation.

Auscultation of the abdomales is performed for detection of altered bowel sounds, rubs, or vascular bruits. Normal peristalsis creates bowel sounds that might be changed or missing by disease. Irritation of serosal surfaces might produce a sound (rub) as an body organ moves against the serosal surchallenge. Atherosclerosis may transform arterial blood flow so that a bruit is produced.

Palpation is the examicountry of the abdomen for crepitus of the abdominal wall, for any type of abdominal tenderness, or for abdominal masses. The liver and kidneys might be palpable in normal individuals, however any kind of various other masses are abnormal.


Technique


Inspection

The abdomales is inspected by positioning the patient supine on an researching table or bed. The head and knees need to be supported with little pillows or folded sheets for comfort and also to relax the abdominal wall musculature. The entire abdominal wall must be examined and drapes should be positioned accordingly. The patient"s arms need to be at the sides and not folded behind the head, as this tenses the abdominal wall. Good lighting is essential, and also it is helpful to have actually tangential lighting available, for this can create subtle shadows of abdominal wall masses.

First, the basic contour of the entire abdominal wall is oboffered. The contour need to be checked carefully for distention and note made regarding whether any type of distention is generalised or localized to a part of the abdomales. Similarly, the flanks have to be checked for any kind of bulging.

The abdominal wall skin have to be inspected closely for abnormalities. Any areas of discoloration must be provided, such as the bluish discoloration of the umbilicus (Cullen"s sign) or flanks (Grey Turner"s sign). The skin have to be inspected for striae, or "stretch marks," and also surgical scars. Careful note of surgical scars should be made and correlated through the patient"s rearsenal of previous operations. The skin of the abdomales have to likewise be checked closely for engorged veins in the abdominal wall and also the direction of blood flow in these veins. This is performed by placing the tips of the index fingers together, compushing a visible vein. The fingertips are then slid apart, preserving compression, developing an empty venous segment in between the fingers. A finger is removed from one finish and also the vein is watched for filling. The procedure is then recurring, however the opposite finger is removed and also the vein aobtain checked for filling. Above the umbilicus, blood circulation is usually upward; listed below the umbilicus, it is normally downward. Obstruction of the inferior vena cava will certainly reason reversal of flow in the lower abdomen. In addition to these large dilated veins, note need to be made of any type of spider angiomas of the abdominal wall skin.

Next off, the abdomales have to be inspected for masses. This must be percreated from several angles. It is essential to identify abdominal wall from intra-abdominal masses. A mass of the abdominal wall will come to be even more influential through tensing of the abdominal wall musculature, whereas an intra-abdominal mass will certainly end up being less prominent or disappear. Useful maneuvers are to have the patient hold his head unsupported off the studying table, to hold his nose and blow, or to raise his feet off the table. Abdominal wall masses are many commonly hernias (either umbilical, epigastric, incisional, or spigelian), neoplasms (benign and malignant), infections, and hematomas.

Once a mass is determined to be intra-abdominal, its area must be defined in relation to the abdominal quadrants (Figure 93.1). The partnership of intra-abdominal organs to these quadrants must be taken into consideration in attempting to recognize the cause of the mass. The mass should be examined for movement through respiration or for pulsation with each heartbeat. Also, the mass should be observed for peristalsis, as it might well represent dilated bowel.


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Lastly, the abdominal wall must be observed for movement through respiration. Usually, the abdominal wall moves posteriorly in a symmetrical fashion via incentive. With peritonitis, there might be localized or generalized rigidity of the abdominal wall so that this motion is lacking.


Auscultation

The patient is positioned comfortably in the supine place as described in Inspection. The stethoscope is supplied to listen over several areas of the abdomen for numerous minutes for the visibility of bowel sounds. The diaphragm of the stethoscope have to be used to the abdominal wall with firm but gentle press. It is often helpful to heat the diaphragm in the examiner"s hands prior to application, particularly in ticklish patients. When bowel sounds are not existing, one have to listen for a complete 3 minutes before determining that bowel sounds are, in truth, missing.

Auscultation for abdominal bruits is the next phase of abdominal examination. Bruits are "swishing" sounds heard over significant arteries in the time of systole or, less typically, systole and also diastole. The location over the aorta, both renal arteries. and also the iliac arteries must be examined very closely for bruits.

Rubs are ingenerally discovered on abdominal examicountry yet deserve to take place over the liver, spleen, or an abdominal mass.


Palpation and Percussion

The patient is positioned supine through head and knees sustained, as for Inspection and Auscultation. Take the background and perdevelop inspection and also auscultation prior to palpation, as this has a tendency to put the patient at ease and boosts participation. In enhancement, palpation may stimulate bowel task and thus falsely rise bowel sounds if perdeveloped before auscultation. Ask patients with abdominal pain to point to the area of best pain. Then reascertain them that you will certainly attempt to minimize their discomfort and research that allude last.

In palpating the abdomales, one have to first gently study the abdominal wall through the fingertips. This will demonstrate the crunching feeling of crepitus of the abdominal wall, a authorize of gas or liquid within the subcutaneous tworries. In enhancement, it will certainly demonstrate any type of irregularities of the abdominal wall (such as lipomas or hernias) and also give some idea regarding locations of tenderness.

Deep palpation of the abdomen is performed by placing the flat of the hand on the abdominal wall and using firm, steady push. It might be beneficial to usage two-handed palpation (Figure 93.2), specifically in evaluating a mass. Here the upper hand is supplied to exert press, while the reduced hand is supplied to feel. One have to start deep palpation in the quadrant straight opposite any kind of area of pain and closely research each quadrant. At each costal margin it is advantageous to have the patient inspire deeply to help in palpation of the liver, gallbladder, and spleen.


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In the flanks it is often beneficial to elevate the flank to be examined slightly and location one hand also on the lower ribs of that flank to "push" the retroperitoneal contents up to the examining hand also. In this method, tiny renal masses that would certainly otherwise be missed may be appreciated.

Abdominal tenderness is the objective expression of pain from palpation. When elicited, it should be described regarding its place (quadrant), depth of palpation compelled to elicit it (superficial or deep), and also the patient"s response (mild or severe). Spasm or rigidity is the involuntary tightening of the abdominal musculature that occurs in response to underlying inflammation. Guarding, in contrast, is a voluntary contraction of the abdominal wall musculature to prevent pain. Therefore, guarding tends to be generalised over the whole abdomen, whereas rigidity involves only the inflamed area. Guarding deserve to often be get over by having the patient purposely relax the muscles; rigidity cannot be. Rigidity is thus a clear-reduced sign of peritoneal inflammation.

Rebound tenderness is the elicitation of tenderness by swiftly removing the researching hand. Aget, this is a difficult sign for the start examiner to master. The a lot of common error is to remove the hand extremely easily through an exaggerated activity and also for this reason startle the patient. All that needs to be done is smoothly but easily to lift the palpating hand off the abdomen and observe for pain, facial grimace, or spasm of the abdominal wall. Both tenderness and also rebound tenderness may be elicited by palpation in a various quadrant. Thus, palpation of the left lower quadrant may develop tenderness and also rebound tenderness in the ideal reduced quadrant in appendicitis (Rovsing"s sign). This is dubbed referred tenderness and also referred rebound.

When abdominal masses are palpated, the initially consideration is whether the mass is intra-abdominal or within the abdominal wall. This have the right to be established by having the patient raise his or her head or feet from the researching table. This will certainly tense the abdominal muscles, therefore shielding an intra-abdominal mass while making an abdominal wall mass even more prominent. If the mass is intra-abdominal, crucial points are its size, location, tenderness, and also mobility.

Palpation and also percussion are supplied to evaluate ascites. A rounded, symmetrical contour of the abdoguys through bulging flanks is often the first clue. Palpation of the abdoguys in the patient through ascites will certainly regularly show a doughy, almost fluctuant sensation. In progressed situations the abdominal wall will be tense due to distention from the contained liquid. Gas-filled intestines will float to the optimal of the fluid-filled abdomen. Hence, in the supine patient through ascites tbelow must be periumbilical tympany type of through dullness in the flanks. One must mark the level of dullness on the skin and then turn the patient on one side for a complete minute. A change in the level of dullness is termed shifting dullness and normally shows more than 500 ml of ascitic fluid. Anvarious other physical authorize of ascites is demonstration of a transmitted liquid wave. The patient or an assistant presses a hand firmly versus the abdominal wall in the umbilical area. The examiner areas the flat of the left hand also on the best flank and also then taps the left flank via his best hand. In the existence of ascites, a sharp tap will geneprice a press wave that will be transmitted to the left hand also. Unfortunately, fat will certainly likewise transmit a liquid wave, and also there are frequent false-positives with this test.

In addition to detection of ascites, percussion deserve to be used to aid define the nature of an abdominal mass. Tympany of an abdominal mass means that it is gas filled (i.e., intestine). Percussion is additionally offered to define liver size.


Basic Science

Typical peristalsis of the intestine produces bowel sounds as gas and also liquid are passed with the intestinal luguys. Typically, the bowel sounds are intermittent, low-pitched, chuckling sounds. Bowel sounds might be diminished or enhanced in condition says.

Ileus is a faientice of peristalsis and also is the normal physiologic response of the intestine to laparotomy or peritoneal inflammation. In addition, ileus is watched in a number of condition states that carry out not affect the peritoneum straight, consisting of pneumonia, congestive heart faitempt, and uremia. Bowel sounds will certainly be markedly diminiburned or lacking in ileus as the intestine distends via gas in its paralyzed state.

Early mechanical bowel obstruction produces hyperenergetic peristaltic waves proximal to the mechanical obstruction. These waves are increased in frequency and also pressure and also develop a concomitant boost in bowel sounds via characteristic "rushes." As the bowel progressively dilates with gas and fluid, the bowel sounds end up being high pitched and tinkling, and also tright here might be durations of hypoenergetic bowel sounds that different through hyperperistaltic rushes. These rushes correlate through the increased peristaltic task. Finally, in late intestinal obstruction tright here might be loss of all bowel sounds as a result of loss of peristaltic task from vascular damage.

Vascular bruits are the audible manifestation of unstable blood flow. They are found typically in thin patients, yet in heavier people will certainly be muffled because of the surrounding fat. Loud systolic bruits are due to atherosclerotic plaques within arteries, producing unstable circulation. These plaques are prevalent in the aorta and iliac arteries and less prevalent in the renal arteries. In addition, rough circulation within an abdominal aortic aneurysm might create a bruit. Bruits that are present in both systole and diastole are strongly suggestive of an arteriovenous interaction.

Rubs are unwidespread on abdominal auscultation but, once found, are the result of inflamed peritoneal surdeals with grating on each other in the time of respiration. This deserve to be the outcome of a neoplastic or transmittable procedure that destroys the usually smooth peritoneal surdeals with.

Crepitus is produced by gas (air) and/or fluid within tissues. In the abdominal wall, it either is as a result of traumatic arrival of air or is additional to infection (gas gangrene). Subcutaneous emphysema can take place from rupture of a pulmonary bleb or penetrating chest injury via dissection of air into the subcutaneous spaces. In addition, penetrating abdominal trauma might present sufficient air into the abdominal wall to develop crepitus. Gas gangrene can occur as a complication of intra-abdominal surgical procedure and also develop crepitus of the abdominal wall. The gas is developed by anaerobic bacteria (commonly clostridia species) and is an extremely particular clinical sign when uncovered in the patient via wound infection.

Ab tenderness occurs as an outcome of irritation of the parietal peritoneum. While inflammation or irritation of the visceral peritoneum will reason abdominal discomfort, anorexia, and also poorly localized pain, it will not cause tenderness and also rigidity of the abdominal wall. Irritation or inflammation of the parietal peritoneum will stimulate the pain fibers of the parietal peritoneum and abdominal wall, creating the symptoms of localized pain and also the signs of tenderness, rigidity, and also rebound tenderness. Thus, if tbelow is diffuse irritation of the peritoneum, as in diffusage peritonitis, there will be diffusage tenderness and rigidity.

Ab masses aincrease from the surrounding frameworks, for this reason the importance of topographic relationships. The visibility or lack of tenderness of a mass gives vital information as to its etiology. An appendiceal abscess will certainly be tender as it inflames the parietal peritoneum, whereas carcinoma of the cecum will be nontender bereason there is no inflammation associated. Tympany type of over a mass means it is gas filled. In the abdoguys, this normally signifies the mass is dilated bowel, as just seldom will tright here be sufficient gas in any other mass to produce tympany kind of.

Ascites is the existence of intra-abdominal liquid and also occurs bereason of overmanufacturing of intra-abdominal liquid or absence of absorption. It is many commonly viewed in cirrhosis in which tbelow is a boost in portal pressure and also hypoalbuminemia. The enhanced portal pressure hydrostatically boosts transudation of fluid through capillaries, whereas the hypoalbuminemia hydrostatically favors ascites formation. Therefore, tright here is buildup of liquid in the peritoneal room, which signifies major liver disease. Other widespread causes of ascites include carcinomatosis in which tright here is both a boost in liquid development and also difficulties in clearing intraperitoneal liquid, and congestive heart faitempt in which there is a hydrostatic rise in venous press.


Inspection

Inspection of the abdomales gives hints to the diagnosis of intra-abdominal pathology. Combined via the patient"s history, inspection deserve to often carry out a preliminary diagnosis that can be shown by auscultation and palpation. In spite of the existing popularity of miscellaneous noninvasive and also invasive diagnostic tests, the proficient surgeon have the right to normally make an exact diagnosis of intra-abdominal pathology by background and physical examination. This is demonstrated by the patient through a several-day background of right top quadrant and earlier pain through connected nausea, vomiting, fever, and a visible mass in the appropriate top quadrant. Such a patient almost definitely has acute cholecystitis via hydrops of the gallbladder. The remainder of the physical examicountry merely confirms this and also detects extra illness. Though inspection alone never provides a clear diagnosis, it have to not be overlooked.

Generalized distention of the abdomen is commonly from obesity, bowel distention by gas or liquid, or ascites. Obesity can cause generalized disstress by either fat in the abdominal wall or intra-abdominal fat in the omentum or viscera. Generalized abdominal distention have the right to likewise be related to ascites, specifically once linked with an everted umbilicus. Distention of the upper fifty percent of the abdomen just may be due to pancreatic cyst or tumor or to acute gastric dilatation. Distention of the reduced fifty percent of the abdomen may be because of pregnancy, ovarian tumor, uterine fibroids, or bladder distention. A scaphoid abdomales is as a result of malnutrition.

Skin abnormalities detected on inspection of the abdominal wall must be correlated through the clinical history. Bruising need to be correlated via a background of trauma to determine the possible organs injured. Cullen"s and Grey Turner"s indications (bluish discoloration of the umbilicus and flanks, respectively) are pertained to intra-abdominal and also retroperitoneal bleeding, and it is thought the blood dissects alengthy fascial planes to reach these areas. Therefore, one would certainly desire to question the patient diligently for reasons of such bleeding—significant pancreatitis, trauma, or ruptured ectopic pregnancy.

Striae of the abdominal wall are an outcome of rupture of the reticular dermis that occurs with stretching. This is seen clinically in pregnancy, excessive weight, ascites, abdominal carcinomatosis, and also Cushing"s syndrome.

Surgical scars have to be examined closely, both regarding their place and their attributes. Often patients are unsure of what kinds of surgical treatment they have actually had, yet the place of the incision may give the examiner a clue. Even though a transverse ideal reduced quadrant incision says appendectomy, but, it in no method proves it, and one must be circumspect in making any kind of such assumptions. The svehicle tells the examiner around the surgical treatment. All scars are initially raised and red; they progressively fade to pink and by 6 months are mainly flat and skin colored or gray. Wounds that heal cleanly by initially intention are thin and also continuous, whereas those that are infected and heal by secondary intention are larger and also irregular. Keloids are wide, irregular scars via numerous hypertrophic tproblem outside the field of normal scarring. Keloid development tends to recur in specific individuals and also is especially common in blacks.

Enlarged veins are viewed in 3 clinical situations: emaciation, portal hyperstress and anxiety, and also inferior vena cava obstruction. In emaciation tbelow is loss of subcutaneous fat so that the usually invisible veins come to be influential. These veins end up being even more significant in the existence of portal hypertension. In portal hyperanxiety the umbilical vein becomes an outcirculation tract of the portal device and also creates collaterals via the veins of the abdominal wall. This is responsible for the caput medusa that is diagnostic of portal hyperstress and anxiety. The direction of blood flow in these veins in portal hyperstress is normal (i.e., upward in those over the umbilicus and downward in those below) as the blood is flowing from the high-pressure portal system to the low-pressure systemic device. Finally, the veins of the abdominal wall might be dilated due to obstruction of the inferior vena cava. This occurs bereason the abdominal wall becomes a collateral, or bypass, about the obstruction of the cava. In this situation the direction of blood flow will certainly be reversed below the umbilicus as the blood flows from the femoral vein to the premium vena cava. Obstruction of the inferior vena cava can occur as a result of a hepatic malignancy, as an expansion of hepatic vein obstruction (Budd–Chiari syndrome), as a result of thrombophlebitis, or as a result of trauma or surgical intervention.

Masses noted on inspection of the abdomales may be related to organs in that location. Therefore, a mass in the ideal top quadrant might represent hepatomegaly from hepatitis or hepatic tumor, a distfinished gallbladder from cholecystitis or pancreatic cancer, or a carcinoma in the head of the pancreas. An epigastric mass is likely to be from acute gastric distention. pancreatic pseudocyst, pancreatic cancer, or aneurysm of the abdominal aorta (which will be pulsatile). Masses in the left subcostal area are mostly because of splenomegaly, although carcinoma of the spenic flexure of the colon is additionally a possibility.

Masses in the lumbar region are primarily of renal beginning. Renal cysts, polycystic kidneys, and also renal malignancies may all be visible in asthenic patients.

Masses in the reduced quadrants may result from inflammatory or neoplastic disorders of the intestine. In the best reduced quadrant appendiceal abscess and also cecal carcinoma are most most likely, while in the left reduced quadrant diverticular abscess or carcinoma of the sigmoid colon is a lot of likely.

Hypogastric masses are the result of pelvic pathology. Acute urinary retention is the a lot of common reason of such a mass in males. In females, uterine or ovarian neoplasms may reason visible midline abdominal masses.

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Visible intestinal peristalsis is typically the result of intestinal obstruction. This deserve to be checked out in the stomach of the newborn with hypertrophic pyloric stenosis and also in the little intestine of patients with small bowel obstruction from miscellaneous etiologies.