(1) Inspection

1 Outline the topographic divisions of the abdomen.

See Figure 15-1.

Figure 15-1 Topographic divisions of the abdomen. On the left are the regions of the abdomen as defined in the BNA (Barker, Anatomical Nomenclature) terminology. Most of the nine regions are too small so that enlarged viscera and other structures occupy more than one. On the right is a simpler plan with four regions; it is preferred by most clinicians and is used in this book. Many occasions arise when the quadrant plans need supplementing by reference to the epigastrium, the flanks, or the suprapubic region.

(From DeGowin RL: DeGowin and DeGowin’s Diagnostic Examination, 6th ed. New York, McGraw-Hill, 1994, with permission.)

I Evaluation of the Abdominal Contour

3 What are the most important contours on lateral inspection?

Figure 15-2 Lateral abdominal contours. A, Cupid’s bow of pancreatitis. B, Fat. C, Bladder distention.

(Adapted from Sapira J: The Art and Science of Bedside Diagnosis. Baltimore, Williams & Wilkins, 1990.)

Figure 15-3 The appearance of moderate distention of the large gut.

(From Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 19th ed. New York, Oxford University Press, 1996, with permission.)

Figure 15-4 The ladder pattern of abdominal distention dictating obstruction of the lower ileum.

(From Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 19th ed. New York, Oxford University Press, 1996, with permission.)

II Evaluation of the Umbilicus

4 What are the major abnormalities of the umbilicus?

Appearance of the umbilicus can provide valuable information (Fig. 15-5). There are three possible abnormalities: (1) protuberances, (2) purplish discolorations, and (3) a shift along the vertical line.

Figure 15-5 A, Visible peristalsis. Peristaltic waves in the stomach or small bowel sometimes can be seen in the upper abdomen. They usually appear as oblique ridges in the wall that begin near the left upper quadrant and gradually move downward and rightward. Occasionally, parallel ridges form a “ladder” pattern. Visibility may be caused by normal waves showing through a thin abdominal wall or by abnormally powerful waves beneath a normal wall. The latter indicates obstruction of a tubular viscus. B, Diastasis recti. This is abnormal separation of the abdominal rectus muscles. It is frequently not detected when the patient is supine unless the patient’s head is raised from the pillow so the abdominal muscles are tensed. C, Abdominal profiles. Careful inspection from the side may give the first clue to abnormality, directing attention to a specific region and prompting search for more signs.

(From DeGowin RL: DeGowin and DeGowin’s Diagnostic Examination, 6th ed. New York, McGraw-Hill, 1994, with permission.)

5 What are the most common protuberances?

Primarily two: (1) an eversion of the umbilical scar and (2) the Sister Mary Joseph nodule.

6 What is an eversion of the umbilical scar?

It is the most common of all umbilical protuberances, usually due to increased intra-abdominal pressure from either fluid or masses, the most frequent cause being ascites. Eversion, however, also can occur with simple obesity and a very lax abdominal wall.

7 What is Sister Mary Joseph’s nodule?

It is the most ominous of all umbilical protuberances, since it represents a metastatic node by an intra-abdominal malignancy (see Chapter 18, questions 45 and 46). It presents as a nontender, irregular, and often exfoliative protuberance, either completely replacing the umbilicus or being palpable through it. It should not be confused with an omphalith, which is another umbilical nodule, but due instead to poor personal hygiene, resulting in collection of sebum and keratin.

8 What is the significance of a purplish discoloration of the umbilicus?

It is a sign of subcutaneous intraperitoneal bleed, usually from acute hemorrhagic pancreatitis. A periumbilical ecchymosis is commonly referred to as Cullen’s sign, and it is often encountered in association with Grey Turner’s, a bilateral reddish/purplish discoloration of the flanks. Both are poorly sensitive and poorly specific markers of hemorrhagic pancreatitis (see below, questions 13 and 116).

9 What are the most common vertical shifts of the umbilicus?

10 What other important points should be included in the inspection of the abdominal wall?

In addition to an overall evaluation of abdominal contour and the umbilicus, general inspection of the abdomen should include an assessment of (1) abdominal respiratory motion (i.e., abdominal paradox, respiratory alternans, and the still abdomen of peritonitis); (2) abnormal skin markings (such as ecchymoses, striae, and surgical scars); and (3) abnormal venous patterns.

III Abdominal Respiratory Motion

IV Abnormal Skin Markings

13 What are ecchymoses?

They are soft tissue bruises, caused by bleeding into the subcutaneous fascial planes. These are commonly seen with retroperitoneal or intraperitoneal hemorrhage. Frequent in the periumbilical and flank areas, they often carry the names of physicians who first reported them—like the Canadian gynecologist T.S. Cullen (who in 1922 described periumbilical ecchymosis in a case of ruptured ectopic pregnancy) and the British surgeon Gilbert Grey Turner (who in 1920 reported flank ecchymosis in a case of hemorrhagic pancreatitis).

14 What are striae?

They are stretch marks, usually located on either flanks or lateral aspects of the abdomen. They are 1–6   cm long, often multiple, and typically presenting in other regions of chronic stretching—such as the shoulders, thighs, and breasts. Although usually due to rapid weight gain (and loss), they also may represent a sequela of pregnancy. They can be seen, though, in Cushing’s syndrome too, including its iatrogenic variety. Yet, since Cushing presents with erythrocytosis, the striae of this condition tend to be purplish, a hue usually absent in weight loss or pregnancy.

15 What about surgical scars?

Every surgical scar should be investigated and inquired about, since they can often be the telltale sign of old (and possibly current) pathology. Scars also should be reported in the patient’s record, by using a sketch to indicate their location in the four abdominal quadrants (Fig. 15-6).

Figure 15-6 Surgical scars seen commonly on the abdomen.

(From Epstein O, Perkin CD, de Bono DP, Cookson J: Clinical Examination, 2nd ed. St. Louis, Mosby, 1998.)

V Abnormal Venous Patterns

16 What are the collateral venous circulations of the abdominal wall?

They are abnormal venous networks that appear on the wall in cases of obstruction to (1) the superior vena cava, (2) the inferior vena cava, and (3) the portal venous system (Fig. 15-7).

Figure 15-7 Abdominal venous patterns. A, Expected. B, Portal hypertension. C, Inferior vena cava obstruction.

(From Seidel HM, Ball JW, Dains JE, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

17 How can you distinguish them?

By identifying their location and direction of blood flow (Fig. 15-8):

Figure 15-8 Testing direction of blood flow in superficial veins. The examiner presses the blood from the veins with his or her index fingers in apposition (1). The index fingers are slid apart, milking the blood from the intervening segment of vein (2). The pressure upon one end of the segment is then released (3) to observe the time of refilling from that direction. The procedure is repeated and the other end released first (4). The flow of blood is in the direction of the faster flow.

(From DeGowin RL: DeGowin and DeGowin’s Diagnostic Examination, 6th ed. New York, McGraw-Hill, 1994, with permission.)

18 How can you assess the direction of blood?

By “milking” the vein. To do so, place your two index fingers over the engorged vein, and collapse it. Then slide the fingers apart, producing a 1-inch stretch of empty vein. Now, release first the pressure on the caudal end of the vein, and then on the rostral end. By doing so, it will be easy to visualize whether the direction of refilling is upward or downward.

19 What is caput medusae?

It is the name given to the abnormal venous networks of portal hypertension. It is most commonly seen in cirrhotics whose umbilical vein has reopened (see Cruveilhier-Baumgarten murmur, disease, and syndrome, discussed in question 34). This presents with a tuft of veins radiating from the umbilicus as spikes of a wheel or a nest of snakes; hence, the name. Some of these engorged veins drain rostrally into the internal mammary, whereas others drain caudally into the inferior mammary.

20 Who was Medusa?

She was one of the three Gorgon sisters, and a rather wicked figure in Greek mythology. Her hair was made of snakes (hence, the expression “caput medusae” [i.e., Medusa’s head in Latin]), and her face was so horrifying that whoever gazed upon it turned into stone. Perseus was eventually able to slay her by looking at her image across a specially polished shield he had received from Athena, goddess of wisdom (a metaphor for the value of rationality as defense against the wickedness of life). Afterward, Perseus pinned Medusa’s head on his shield, using it as a primitive biologic weapon to turn enemies into stone. Many Greek foot soldiers followed his lead, painting the Gorgon’s head on their hoplite shield. Yet, today Medusa is much more famous for being the trademark of the Versace Fashion & Design Company.

(2) Auscultation

Bowel Sounds

23 Where are these bowel sounds produced?

Mostly in the stomach, with the rest originating in the large and, for a lesser part, small intestine.

24 Is the abdominal location indicative of the production site?

No. Bowel sounds can be transmitted very well across the abdomen, and so detecting them in a particular quadrant doesn’t necessarily reflect the site of production. Hence, the need for a thorough examination of all quadrants (and also the little clinical value of these findings).

25 What causes these sounds?

It is not entirely clear. The most likely explanation is the propulsion of food through the various segments of the gastrointestinal tract, as suggested by the tendency of bowel sounds to become more prominent after meals. Still, a rise in the tone of bowel loops also is important, which explains why these sounds tend to increase in intestinal obstruction. (Yet, years ago the author—asked to produce a recording of increased bowel sounds for a board examination question—was unable to elicit enough noise for a decent tape, even though he had ingested a concoction that made him detonate several times. This unfortunate experience confirms how unpredictable these sounds can be.)

26 What is the significance of increased bowel sounds?

It is in the ears of the beholder, since even normal individuals may exhibit great variation from time to time. For example, it is not unusual to have no sounds for 5   minutes and then experience a burst of as many as 30   sounds per minute. Still, the increased bowel sounds of small intestinal obstruction (described as frequent and high-pitched rushes interspersed with periods of silence) are poorly sensitive for this condition, even though quite specific. This may be due to their fleeting nature (in animal models they increase in number only during the first 30   minutes after obstruction, eventually abating over time).This is probably why bowel sounds are increased in only one half of small intestinal obstructions, and diminished or absent in one quarter.

I Murmurs and Bruits

28 How frequent are these findings?

They have been reported in 4–20% of healthy individuals and 1–2% of unselected patients on a medical ward. Prevalence declines as a result of age.

29 What is the significance of an abdominal murmur/bruit?

It depends on its location. This may be either epigastric or right/left upper quadrant.

30 What is the significance of an epigastric murmur?

A systolic, medium- to low-pitched murmur over the epigastrium is not uncommon in healthy individuals. It occurs especially often in pregnancy, and, in fact, as many as one fifth of normal and thin women may have it, too (this frequency is a little lower in men). In contrast to a pathologic finding (like the murmur of renal artery stenosis, which tends to be louder outside the epigastrium [see below, questions 122 and 123]), a benign murmur is characteristically limited to the area between the xiphoid process and umbilicus. It usually originates from a normal celiac tripod.

31 What is the significance of a right or left upper quadrant murmur/bruit?

II Venous Hums

33 What is the mechanism of production of this sound?

The recanalization of the umbilical vein caused by portal hypertension. This results in reverse flow (from a cirrhotic liver into the abdominal wall veins), with final decompression into various portosystemic shunts. The Cruveilhier-Baumgarten murmur softens with epigastric pressure, while intensifying with the forced expiratory phase of Valsalva (which increases back-flow to the umbilical vein through reduced right-sided venous return). It is often accompanied by a thrill.

34 What are Cruveilhier-Baumgarten disease and Cruveilhier-Baumgarten syndrome?

They are both characterized by “feeding” of the caput medusae through the (para)umbilical vein. Yet the disease and the syndrome may actually be two separate entities:

35 Who were these guys?

Léon Jean Baptiste Cruveilhier (1791–1874) was a French pathologist and the son of an army surgeon. Raised by Mom (because Dad was away fighting the Napoleonic wars), little Cruveilhier developed a strong interest in priesthood and very little stomach for medicine. This got him into trouble when Dad eventually came home, determined more than ever to turn his reluctant son into a well-respected physician. Forced to enter medical school, Cruveilhier fled after his first autopsy, finding temporary refuge in the nearby St. Sulpice seminary. Chased by Dad (and forced to re-enter medical school), he was finally entrusted to an old family friend, Baron Guillaume Dupuytren. This turned out to be a good idea, since Dupuytren became a mentor to Cruveilhier and a lifelong inspiration for the study of pathology. After graduating from Paris in 1816 (the same year Laënnec invented the stethoscope), Cruveilhier practiced in Limoges before becoming professor of surgery at Montpellier in 1823. Two years later, he moved to Paris, where in 1836 he took the chair of the newly created department of pathological anatomy. A modest man with neither clinical acumen nor eloquence, he was primarily a researcher who owed his fame to the books he wrote rather than the teaching he imparted. Author of a popular pathology textbook, he eventually reported the case of a French soldier who in 1813 had been captured by Hungarian troops, beaten with rifle butts to the belly, and left for dead. After spending 6 months in the hospital, he developed abdominal swelling and a loud umbilical murmur. Following his death in 1833, the autopsy had revealed a small and noncirrhotic liver, with a portosystemic shunt operated by large umbilical veins. Cruveilhier interpreted this as either a congenital variant or an acquired lesion provoked by war trauma.

Paul Clemens von Baumgarten (1848–1928) was a German pathologist. Also the son of a physician, he graduated from Leipzig a year before Cruveilhier’s death, and from 1874 to 1889, he taught at Königsberg, until moving to Tübingen, where he remained for the rest of his life. He also is famous for describing the tubercle bacillus in 1882, the same year as Koch but independently.

III Friction Rubs

IV Succussion Splash

(3) Percussion

39 How should one percuss?

Usually, lightly and in all four quadrants. Percussion should guide palpation, by eliciting tympanitic notes over gas-filled areas, and dull notes over solid areas. It should always be performed after auscultation, since doing otherwise might alter bowel sounds.

(4) Palpation

41 What is the difference between a light and a deep palpation?

Figure 15-9 Technique for deep palpation.

42 How can one distinguish between an intra-abdominal and an intramural mass?

By palpating the mass while the patient is raising the head from the pillow. This tenses the abdominal wall muscles, thus pushing away an intra-abdominal mass but not an intra-mural mass (i.e., one localized in the abdominal wall). This technique also can be used to separate the abdominal wall from peritoneal tenderness (see below, questions 153–160).

Examples of Abnormalities Detectable On Palpation

44 When is this maneuver considered positive?

It depends on the abdomen, since fat bellies are more difficult to examine than thin ones. Overall, the test is positive when the diameter of the expansile mass is >3   cm (with diameter of pulsation reflecting the diameter of the aneurysm). In cases of small aneurysms (3–5   cm in diameter), the finding is very specific, with the few false positives usually reflecting a tortuous aorta (yet, it is also poorly sensitive, detecting only one of five cases). In patients with large aneurysms (>5   cm), sensitivity increases to four out of five patients. In fact, lack of expansile pulsation in a thin patient should strongly argue against the presence of a large aneurysm.

45 What are the two goals of bedside evaluation of the liver?

Yet the role of physical diagnosis has become increasingly questionable. Assessment of hepatomegaly, for example, has proven highly unreliable, and some authors have even suggested scrapping it altogether.

(1) Palpation of the Liver

46 Which edge can be palpated? How?

Only the lower edge is accessible, since the upper border is tucked deep into the rib cage and thus beyond the reach of the examiner’s fingers. To access the lower margin, ask the patient to lie supine, ideally with flexed hips and knees to better relax the abdominal wall (Fig. 15-10). To feel the edge, you can use one of three strategies, differing more in personal preference than value:

Cephalad approach: Place one hand on the patient’s abdomen, keeping the edge parallel to the rectus muscle and the fingers pointing toward the head. Place the other hand behind the patient’s back, to help support it. Then, while the patient is taking a deep breath, press the anterior hand downward and cephalad, so that the respiratory excursion of the diaphragm displaces the liver edge downward, bringing it into contact with the fingertips.

Transverse approach: Place your hand parallel to the costal margin (with fingers pointing toward the patient’s flank). This is probably not as good a maneuver as the other two, since it relies primarily on the hand’s margin, which is not as sensitive as the fingertips.

Hook technique: Point your fingers toward the patient’s feet, while trying to gently hook the liver with both hands.

Figure 15-10 Palpating the liver. A, Fingers are extended, with tips on the right midclavicular line below the level of liver tenderness and pointing toward the head. B, Alternative method with fingers parallel to the costal margin. C, Palpating the liver with fingers hooked over the costal margin.

(From Seidel HM, Ball JW, Dains JE, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

If you cannot feel the edge, you should probably end your liver exam at this point. If instead you do feel the edge, then determine its characteristics, and finally listen for rubs or bruits.

47 What can be learned from palpation of the liver?

What cannot be learned is the presence (or absence) of hepatomegaly, since palpation allows only an assessment of lower liver edge characteristics, such as (1) consistency and contour, (2) abnormalities of surface (e.g., presence of nodules), (3) tenderness, (4) presence of systolic pulsations, and (5) presence of frictions and thrills.

48 How reliable is palpation of the liver edge as a measure of hepatic consistency?

Not reliable at all. Interobserver variability is in fact huge. In two studies of alcoholic and jaundiced patients, multiple experts had a mere 11% chance-corrected agreement for abnormal consistency of a palpable liver edge, and a 26–29% agreement for the presence of nodules. Only agreement on tenderness reached a more acceptable 49%.

49 What is the significance of liver tenderness?

It usually indicates distention of the hepatic capsule, as may be encountered in patients with passive liver congestion. It is, however, a nonspecific finding that also may be due to inflammation, or even tension, of the abdominal wall muscles.

50 What is the significance of a firm and hard liver edge?

A very hard edge suggests tumor, whereas a sharp one suggests cirrhosis. A firm liver, neither sharp edged nor stone hard, is usually passively congested. Nodules may indicate cirrhosis but are more often related to cancer. The size of the nodules also may help distinguish the two conditions (with larger nodules being more likely neoplastic).

51 What is the significance of a pulsatile liver edge?

It may represent transmission of aortic pulsations through an enlarged liver, but usually indicates one of two conditions: (1) constrictive pericarditis or (2) tricuspid regurgitation (where it is encountered in 30–90% of cases, usually indicating moderate to severe disease).

52 How can one distinguish these two entities?

By an inspiratory increase in magnitude of pulsations. This occurs in tricuspid regurgitation (TR) (especially in held mid- or end-inspiration), but not in constrictive pericarditis. In TR, the hepatic pulsations are felt as a double movement of the liver edge, usually synchronous with a giant jugular “V” wave at the neck and a strong diastolic dip immediately after the carotid pulse. Pulsatility in a setting of hepatomegaly is instead such a good indicator of constrictive pericarditis (present in 65% of patients) that its absence argues strongly against the diagnosis.

53 What is the hepatojugular reflux?

More of a cardiac than an abdominal maneuver. In fact, it is commonly used to unmask subclinical congestive heart failure (for its description and clinical significance, see Chapter 10, questions 106–114).

(2) Percussion of the Liver

55 Does a palpable liver edge reflect hepatomegaly?

Not at all. Although many physicians do indeed screen for hepatomegaly by checking whether the liver is palpable at peak inspiration (and, if so, by measuring the number or centimeters—or finger breadths—below the costal margin), palpability of the edge is a highly inaccurate marker of organomegaly. A normal liver, for example, may become palpable simply because it is pushed down by an emphysematous lung. In fact, Palmer found a palpable edge in 57% of military personnel with normal liver tests and no history of liver disease (in 28% the edge was palpable ≥2   cm below the costal margin). Similarly, Riemenschneider found hepatomegaly at autopsy in less than one half of all patients with palpable liver on exam. In fact, there is no correlation between edge palpability and liver scan/autopsy data because palpability may have more to do with consistency of the edge, with the firmer liver of cirrhotics being more easily palpable.

56 Should the lower liver edge then be assessed by percussion alone?

This has indeed been suggested. It is, however, counterintuitive, considering that percussion is notoriously inaccurate even in locating the upper liver border, especially when done with light intensity. Indeed, most errors in measuring liver span occur when the lower margin is not palpable and the examiner has to rely on percussion alone to locate both the upper and lower edge.

57 So what is the best way to determine liver size on physical exam?

There is no best way. Definitely not palpation alone, since half of all palpable livers are not enlarged and half of truly enlarged livers are not palpable. Hence, to guestimate size, measure the longitudinal (or vertical) liver span (i.e., the distance in centimeters between the lower and upper borders along the midclavicular line [MCL]). These can be located as follows:

58 How can one best determine hepatic size by percussion?

Through direct or indirect percussion (Fig. 15-11). Both are carried out during quiet respiration. The direct technique consists of a light abdominal percussion by the index finger alone. Indirect percussion is instead the more traditional combination of plexor and pleximeter, as, respectively, the striking and stricken finger. The pleximeter (usually the middle finger of one hand) is applied to the abdominal wall only by its distal interphalangeal joint (to avoid dampening of vibrations); the middle finger of the other hand is then used as a plexor against the pleximeter, usually tapping along the right MCL. Even when performing indirect percussion, it is important that you tap lightly, making the note barely audible to only yourself. By doing so, you can more easily identify the hepatic area as a change in percussion note, from resonant (pulmonary parenchyma), to dull (liver), and to resonant again (air-filled bowel loops). Yet, even this may lead to inaccuracies. Vertical liver span is the distance between two resonant points along the MCL, detected during either quiet breathing, or at the same phase of respiration. Direct percussion performed by gastroenterologists has been found to be more accurate than indirect percussion, yet a normal range of liver span for this technique has not been determined. Thus, indirect percussion should still be the maneuver of choice.

Figure 15-11 Technique for liver palpation.

(Adapted from Swartz MH: Textbook of Physical Diagnosis, 3rd ed. Philadelphia, WB Saunders, 1997.)

59 What is a normal liver span?

A variable figure, since it depends on body size and shape. Overall, a normal liver span is <12–13   cm on MCL, as assessed by indirect percussion or a combination of percussion/palpation.

60 What is the scratch test?

It is a combined auscultatory/percussive maneuver aimed at localizing the inferior hepatic border (Fig. 15-12). Place the stethoscope either beneath the xiphoid or over the liver, just above the costal margin of the MCL. Then administer “scratches” in a cephalad fashion, by moving the finger along the MCL—from the right lower quadrant toward the costal margin. The point at which the scratching sound intensifies indicates a change in underlying tissue, and thus the presence of the lower liver edge. A variation of the test is auscultatory percussion, in which the examining finger does not scratch the abdominal wall but gently percusses it (or flickers it).

Figure 15-12 Scratch technique for auscultating the liver. With the stethoscope over the liver, lightly scratch the abdominal surface, moving toward the liver. The sound will be intensified over the liver.

(From Seidel HM, Ball JW, Dains JE, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

61 How reliable is the scratch test in localizing the lower liver edge?

One study found it to be more accurate than percussion or palpation. Others have found it to be instead more wanting, especially when compared to palpation, or ultrasound. Moreover, there is very little consensus about the technique, in terms of positioning the stethoscope (near the umbilicus, on the liver, or at the costal margin?), scratching methodology (finger alone, finger plus pleximeter, a bristle brush or a corrugated rod?), and direction of the stroke (circular, left to right, longitudinal?). Thus, additional validation is needed before the scratch technique may become more than a simple adjunct to either palpation or percussion.

62 How accurate are these bedside techniques in diagnosing hepatomegaly?

Poorly accurate. Palpation of the lower liver edge has interobserver variability of 6   cm and intraobserver variability of 1–2   cm. Determination of liver span by percussion alone has interobserver variability of 2.5–8   cm, and intraobserver variability of 1–2   cm. Variability in measurement by percussion is usually due to changes in intensity of percussion, which may yield differences in span as great as 3   cm, primarily because of the difficulty in localizing the upper edge through interposed lung tissue. Direct percussion was shown by Skrainka et al. to be as accurate as ultrasound in estimating liver span, but this relied on skilled consultants. Other studies conducted among general practitioners, however, have yielded disappointing results. Overall, indirect percussion underestimates liver size (the lighter the percussion, the greater the underestimation). This may be overcome by using a firm technique and by comparing the measured span to the span predicted by nomograms, which take into account patients’ weight and height. A span >95% confidence intervals predicted by these tables most likely represents hepatomegaly. Nomograms also are available for a light percussive maneuver.

63 In summary, what are the pros and cons of bedside assessment of liver size?

(3) Auscultation of the Liver

I Hepatic Friction Rubs

II Hepatic Arterial Murmurs

67 What is the significance of a hepatic murmur associated with a rub?

It should be considered cancer until proven otherwise.

III Hepatic Venous Hums

69 How can one differentiate a venous hum from an arterial murmur?

By the presence (or absence) of a diastolic component. Whereas arterial murmurs are primarily systolic, venous hums are both systolic and diastolic (and thus they resemble bruits more than murmurs). Hums originate in a communication between the umbilical veins and the abdominal wall veins. They do not originate in arteriovenous fistulas or hepatic hemangiomas—lesions that are instead responsible for the production of true arterial continuous murmurs (i.e., bruits).

(4) Special Problems

71 Is there any diagnostic difference in the hue of pigmentation?

Although some differences have been traditionally reported between various types of jaundice (pale-yellow = hemolytic jaundice; orange-yellow = hepatocellular jaundice; yellow-green = prolonged obstructive jaundice), these differences are not clinically relevant. It is instead important to separate jaundice from pseudojaundice. The latter is usually due to:

Once jaundice and pseudojaundice have been differentiated, bedside evaluation should search for extrahepatic findings of hepatocellular but not obstructive disease.

72 How can you separate obstructive from hepatocellular jaundice?

Obstructive jaundice usually presents acutely or subacutely—often with a dilated and palpable gallbladder (Courvoisier’s sign). Hepatocellular jaundice presents instead more slowly, often with the following signs of chronic liver disease: (1) spider telangiectasias, (2) palmar erythema, (3) dilated abdominal veins, (4) palpable spleen, (5) asterixis, and (6) fetor hepaticus.

73 What are spider nevi (telangiectasias)?

They are dilated blood vessels that primarily affect areas of intense blushing, like the face and neck, but also the shoulders, arms, hands, and torso (they are instead quite rare on the palms, scalp, and below the umbilicus, probably reflecting regional differences in neurohormonal control of the microcirculation). They should not be confused with cherry angiomas, which are instead round, venous, and commonly encountered as a result of aging. Spider angiomata are spider-like, insofar as they consist of a central arteriole (the spider) with radiating thin-walled branches (the legs). They have a surrounding area of erythema (with a temperature 2–3°C higher than the surrounding skin), and vary in size from a tiny pinhead to a diameter of 0.5   cm. When the “body” is compressed with a cover glass slide, it appears to pulsate and eventually blanches. The body and branches then refill rapidly upon release of pressure.

74 Can spider nevi occur in normal individuals?

Yes, they may occur in 10–15% of healthy adults and young children, but usually in fewer number (average three) and smaller size. When not congenital, spider nevi suggest four conditions:

75 What is the hepatopulmary syndrome (HPS)?

A condition seen in 8% of cirrhotics and characterized by hypoxemia and spider nevi. The mechanism is bibasilar intrapulmonary arteriovenous shunt, due to multiple “spider angiomata.” These, in turn, cause clubbing, orthodeoxia, and platypnea (see Chapter 13, questions 46 and 47). Diagnosis is confirmed by a positive bubble echocardiogram, and liver transplant is often curative. HPS should not be confused with portopulmonary hypertension (PHTN), which is instead a condition of cirrhotics with portal and pulmonary hypertension (the latter being akin to primary pulmonary hypertension). Oxygenation is normal at rest, but not on exercise; there is orthopnea (but not platypnea), plus right-sided failure. Pulmonary hypertension does not respond to transplant.

76 What is palmar erythema?

Another vascular anomaly of liver disease. It is characterized by symmetric reddening of the palms, mostly over the thenar and hypothenar eminences. In fact, it often coexists with spider nevi, waxes and wanes together with them, and is frequently associated with the same underlying conditions. When examining the palm of cirrhotic patients, also look for Dupuytren’s contracture.

77 What is Dupuytren’s contracture?

It is a benign and slowly progressive fibroproliferative disease, characterized by thickening of the palmar fascia on the ulnar side, eventually leading to flexural contraction of the digits, especially the fourth and fifth (the index finger and thumb are instead typically spared) (Fig. 15-13). In addition to the flexion deformity of the metacarpophalangeal (MCP) and the proximal interphalangeal (PIP) joints, there also may be firm palmar nodules (possibly tender to palpation) and palpable “cords” (proximal to the nodules and usually painless). Most patients are bilaterally affected (65%), whereas unilateral cases tend to be mostly right sided. The hand of Dupuytren is so typical to have been dubbed “the hand of Papal benediction” (which is different from the “obstetrician’s hand” of Trousseau’s sign—see Chapter 2, questions 104–107). Dupuytren’s also is familial (27–68% of cases), with males more frequently and more severely affected. It is very common in northern Europe and the United Kingdom, and especially in countries with large immigration from these areas. In Scotland, for example, it affects 39% of males and 21% of females older than 60. In the United States, it affects instead 5–15% of males older than 50. The basic pathophysiology is uncontrolled fibroblast proliferation of the palmar fascia. Etiology is unknown, but several associations are known: (1) 18–66% of patients with alcoholic liver disease (either cirrhotic or noncirrhotic); (2) 13–42% of patients with chronic pulmonary tuberculosis; (3) 8–56% of epileptics on treatment; (4) 35% of smoker males older than 60, usually. In some studies, manual laborers (and brewery workers) have a slightly higher predominance, but this is still controversial. Prior hand trauma is, however, a risk factor, present in 13% of cases. In addition, 31–48% of Dupuytren patients are just alcoholics (with or without liver disease); 10–35% have either peptic ulcer disease or cholecystitis; 6–25% have diabetes mellitus (strongly correlated with retinopathy); 93% have glucose intolerance; and 2.5% have Peyronie’s disease. Famous sufferers have included former British Prime Minister Margaret Thatcher and the late U.S. President Ronald Reagan, suggesting that conservative views might represent an additional risk factor.

Figure 15-13 In Dupuytren’s contracture, fibrous bands of diseased palmar fascia can contract to pull the finger into flexion. A, The fibrous band can be seen at the level of the proximal palmar crease of the ring finger. B, Early Dupuytren’s contracture producing flexion of the fifth finger.

(From Concannon MJ: Common Hand Problems in Primary Care. Philadelphia, Hanley & Belfus 1999.)

78 Who was Dupuytren?

A very weird character. Guillaume Dupuytren (1777–1835) was born just 1 year after the American Revolution, but some of the ideas of his times must have definitely rubbed off on him, since he remained all his life an eccentric and flamboyant character. For one, he was famous for operating in a cloth cap and carpet slippers. But he also was famous for being abrasive, cynical, and vindictive. Born of humble origins, he was an attractive and intelligent child, to the point of being kidnapped at age 4 by a rich lady from Toulouse (who later returned him to his family—probably after realizing what kind of “pain” the kid could be). As a teenager, he moved to Paris, where at age 24 he became prosector at the local School of Health. This gave him the opportunity to work directly with two of the giants of his time, Laënnec and Bayle, but this soon backfired, since Laënnec, realizing that Dupuytren was trying to gain credit for Bayle’s work, stopped any interaction. This did not prevent Dupuytren from joining the Paris Hôtel Dieu, where he eventually made a name for himself as a skilled surgeon and a gifted speaker. He remained, however, as obnoxious as ever, to the point of being called “first of surgeons and last of men.” Still, he was a great surgeon: he not only described his eponymous contracture, but even devised an operation to cure it. He also was the first to create a classification system for burns, and one of the first great promoters of plastic surgery. A workaholic rumored to see an average of 10,000 patients per year, Dupuytren also was very cheap. These two traits contributed to make him very rich, but not too popular. His motto was “fear nothing but mediocrity,” which, of course, did not win him many friends either, but contributed nonetheless to make him famous well beyond the borders of France and rendered him more arrogant than ever. When King Charles X got dethroned and needed money, Dupuytren even offered him 1   million francs, stating that he was keeping aside 2 more million: one for his daughter and the other for his own old age. The king graciously declined. In 1833, Dupuytren suffered a stroke while delivering a lecture. He did manage to finish it, but emerged from the experience as an invalid. Eventually, he developed aspiration pneumonia and empyema. Offered surgery, he refused, claiming that he “would rather die at the hands of God than of surgeons.” He died 12 days later, at 58. His description of the clinical manifestations and surgical management of the eponymous contracture was published in 1832, mostly by his students, since the Baron had a profound distaste for writing. Yet, it had already been reported by Felix Plater of Basel in 1614, and by Henry Cline Senior in 1777, the year of Dupuytren’s birth. Still, it was Dupuytren who established the palmar fascia as its site of origin. The familial nature of the disease was instead recorded by the French surgeon Jean-Gaspard-Blaise Goyrand, soon after Dupuytren’s report.

79 What is asterixis?

A common (and early) finding of hepatic encephalopathy and a classic sign of hepatocellular disease. Since it requires some degree of voluntary muscular contraction, it disappears in comatose patients. It is demonstrated by asking patients to stretch the arms while at the same time holding their fingers spread apart, as if they were “stopping traffic.” In the case of asterixis, the fingers and hands will start “flapping” in a myoclonic fashion, with brisk movements occurring at intervals of less than 1   second to more than 1   second (see Chapter 20, questions 50–52).

80 What is fetor hepaticus?

It is a sign of a severe portosystemic shunt from advanced hepatocellular disease. It is due to the accumulation of dimethyl sulfide in the breath, with an odor that has been compared to rotten eggs and garlic. Since it is caused by parenchymal disease (and not necessarily hepatic encephalopathy), it may be present in noncomatose patients.

81 What other physical findings can be encountered in patients with portal hypertension?

In addition to dilated abdominal wall veins (previously discussed), patients with portal hypertension from severe hepatocellular disease also present with an enlarged spleen.

(1) Murphy’s Sign

83 What are Murphy’s signs?

Additional maneuvers that, in addition to “the” original sign, also carry Dr. Murphy’s name. In fact, he humbly considered these techniques “the most valuable contributions I have made to medicine and surgery in the way of aids to diagnosis.” One of them (percussion of the costovertebral angle for presence of kidney pathology, especially a perinephric abscess) has long lost its linkage with Murphy’s name, even though it is still routinely used (see below, questions 118–120). The other ones are:

Murphy used the latter on more obese patients and considered it indisputably “the best test of all.” In his original description:

Dr. Murphy used deep-grip palpation routinely in the examination for suspected biliary disease, even though he did not consider it to be “as good a test as the perpendicular finger percussion test, i.e., the hammer stroke percussion.” Dr. Murphy described deep-grip palpation in 1903:

Notice that the current Murphy’s sign is not elicited by the original “hook” technique of Dr. Murphy (i.e., the deep-grip palpation), but by a variation, in which the examiner’s fingers are distended and pointed toward the head of the supine patient.

84 Who was Dr. Murphy?

John B. Murphy of Chicago (1857–1916) was an acclaimed leader in American surgery, who trained in Vienna with Billroth and established himself as the greatest surgical teacher of his day. A tall man with a parted red beard and a flamboyant character, Dr. Murphy linked his name to several diagnostic maneuvers for the evaluation of the acute abdomen, but also was the first to introduce in the United States the artificial immobilization and collapse of the lung for the treatment of pulmonary tuberculosis, a technique pioneered in Pavia by the Italian Carlo Forlanini.

85 How accurate is Murphy’s sign in predicting cholecystitis?

Decently accurate, with sensitivity and specificity of 50–80% (specificity usually a little higher than sensitivity). Its significance increases in patients whose presentation is consistent with cholecystitis (i.e., nausea, vomiting, and right upper quadrant pain), whereas it decreases in patients with back tenderness, where other conditions (pancreatitis/renal disease) become more likely.

86 What is the current role of Murphy’s sign in the evaluation of acute cholecystitis?

A helpful but limited role. In a 1914 article, Murphy had boasted that “you can make the differential diagnosis at the bedside. You do not have to go home for your instruments; you do not have to have a blood count made. You just have to use your brain and your fingers.” This is mildly exaggerated. A century later, his sign remains helpful if present, but nonetheless limited. Ultrasound can help more, by identifying cholelithiasis and eliciting a sonographic Murphy’s.

87 What is the sonographic Murphy’s sign?

It is a sort of Murphy’s on steroids. Since discovering stones by ultrasound (U/S) does not, in and of itself, link an episode of acute abdominal pain to cholecystitis, a sonographic Murphy’s has been proposed to confirm the diagnosis. Under U/S guidance, the examiner locates the gallbladder and then ascertains whether it corresponds to the point of maximal tenderness by pressing directly with the ultrasound transducer over the gallbladder. A positive sonographic Murphy’s has an accuracy of 87% for acute cholecystitis, suggesting that the lower sensitivity of the plain Murphy’s sign might reflect difficulty in localizing the gallbladder’s fundus.

88 Do patients with cholecystitis exhibit other findings?

They also may have an area of hypersensitivity over the right costophrenic angle (Boas’ sign; see acute abdomen) and, at times, an audible rub over the edge of the gallbladder. Still, they rarely have a palpable and tender right upper quadrant mass (see Courvoisier’s law).

(2) Courvoisier’s Law

90 Why should the gallbladder of patients with cholelithiasis remain small?

Two possibilities, the first proposed by Courvoisier himself and probably not as accurate:

91 How accurate is Courvoisier’s law?

Not much. In fact, it is a law that may not be as written in stone as originally claimed. To his credit, even Courvoisier had no intention to legislate when he first reported his original observation. The “law” was written later, and by other authors. What Courvoisier had written was a simple observation: that jaundiced patients with common duct obstruction were more likely to have a palpable and nontender gallbladder if afflicted by stones rather than cancer. In his original 187 cases of jaundice from common duct obstruction (87 due to stones and 100 to other causes), only 20% of cholelithiasis patients had an enlarged gallbladder, as opposed to 92% of those with other problems (of which malignancy was the most common). More recent series, however, suggest a lower sensitivity for malignant obstruction (25–50%), but still a good specificity (80–90%). In one study, only one half of patients with jaundice due to pancreatic carcinoma had a clinically palpable gallbladder (an incidence that increased considerably if operative or autopsy enlargement was taken into consideration—in this case, 80% of pancreatic cancers had an enlarged gallbladder at surgery, as opposed to 42% of common duct stones).

92 In the final analysis, what is the significance of Courvoisier’s sign?

A palpable and nontender gallbladder in a jaundiced patient strongly suggests that the jaundice is not due to hepatocellular disease, but to an extrahepatic obstruction of the biliary tract. Albeit not too sensitive, this finding is highly specific. Whether the obstruction is caused by tumor or stone is instead more difficult to say, even though the likelihood of tumor is a bit higher.

93 Is right upper quadrant tenderness indicative of cholelithiasis?

No. In cases of biliary colic, right upper quadrant tenderness does not separate patients with cholelithiasis from those without. U/S is the gold standard, with 95–99% accuracy for stones.

94 Who was Courvoisier?

Not a cognac. In fact, despite his French-sounding name, Ludwig G. Courvoisier was from Basel, Switzerland, where he had been born in 1843. Not only was he not French, but he actually fought the French during the Franco-Prussian war of 1870. Afterward, he became professor of surgery at the local university, where he published extensively on the biliary tract. Courvoisier’s law originated in a monograph titled “The Pathology and Surgery of The Biliary Tract,” a review of more than 100 patients with jaundice.

95 How effective is abdominal examination in assessing the spleen?

Not too effective. The spleen is another subdiaphragmatic structure that, like the liver, does not lend itself easily to outside evaluation, especially in regard to size assessment. Both palpation and percussion have good specificity in detecting splenomegaly, but variable sensitivity. These techniques also are among the most difficult to master in the entire physical diagnosis repertoire. Examiners’ skills, therefore, play an important role.

(1) Palpation of the Spleen

97 What can be learned from palpation?

The major piece of information, of course, is to see whether the spleen is palpable—at least its tip. If so, you should conclude that splenomegaly is indeed present and then proceed with assessing the characteristics of its tip, such as consistency. In this regard, a firmer spleen indicates a more protracted and possibly fibrotic splenomegaly, as, for example, in cirrhosis.

98 What is the best way to palpate the spleen?

It varies, depending on the examiner. As for the patient’s position, some physicians prefer the supine approach (from either the right or the left side), whereas others have the patient in right lateral decubitus position. These have all been compared and found to be equivalent; hence, personal preference remains the major factor (Fig. 15-14). Overall, there are as many as four techniques: (1) bimanual, (2) ballottement, (3) palpation from above, and (4) one-hand hook technique. As in the case of the liver exam, any of these would benefit from having the patient flex the knees and hips.

Figure 15-14 Palpation of the spleen. A, Bimanual palpation with the patient in a supine position and the examiner at the patient’s right side. The examiner’s left hand is placed on the lower left rib cage, and the right hand explores for the spleen. B, Positioning of the examiner’s hands during ballottement of the spleen. C, Palpation of the spleen from above.

(From Yang IC, Rickman LS, Bosser SR: The clinical diagnosis of splenomegaly. West J Med 155:47–52, 1991, with permission.)

99 If the splenic tip is palpable, can you conclude that the spleen is enlarged?

Yes, detecting a splenic tip has high specificity for splenomegaly. This is in contrast to liver examination, where palpation of the edge does not necessarily indicate organomegaly.

100 Does lack of a palpable spleen rule out splenomegaly?

No, since many large spleens are not detectable. Hence, palpation has high specificity for splenomegaly, but variable sensitivity (20–70%), which depends not only on the operator’s skills but also the organ’s size (with larger spleens being more easily detectable). To better quantify size, Hacket has proposed a semiquantitative assessment that refers to three lines, passing respectively through the left costal margin, umbilicus, and symphysis. Spleen size is progressively numbered from 0–5, as not palpable (0), palpable only after deep inspiration (1), reaching between the left costal margin and a line halfway to the umbilical line (2), reaching the umbilical line (3), halfway between the umbilical line and the symphysis (4), or beyond the umbilical line (5). This method not only helps sharing information but also standardizes chart documentation.

101 How accurate are these bedside maneuvers in diagnosing splenomegaly?

Once again, they are more specific than sensitive. Yet, detecting splenomegaly should always raise two questions: (1) is it real, and (2) is it pathologic or just an incidental finding? Indeed, some “palpable spleens” are just a conglomerate of colonic feces, miraculously melting with enemas. Still, the specificity of bedside detection remains a respectable 90%, so that a palpable spleen should always be taken seriously. Yet, even truly enlarged spleens may not be pathologic. For example, they can be found in 3% of college students, 12% of postpartum women, 10.4% of hospitalized patients undergoing liver scans, and 2.3–3.8% of ambulatory patients.

102 Which other findings may help identifying the cause of splenomegaly?

103 What is Kehr’s sign?

It is referred pain (or hyperesthesia) to the left shoulder—a sign of left diaphragmatic irritation, usually from splenic rupture, with intraperitoneal spillage of blood. Since they represent “referred” symptoms, pain and hyperesthesia are not elicited by pressure or movement of the shoulder. Instead, they are induced by asking the patient to lie supine for 10–15   minutes in reverse Trendelenburg, so that the intraperitoneal blood can more easily reach the diaphragm.

(2) Percussion of the Spleen

104 How do you percuss the spleen?

Nixon’s technique (Fig. 15-15A) percusses the entire spleen outline while the patient is in the right lateral decubitus position. This allows the spleen to lie above the stomach and colon, thus permitting determination of both upper and lower margins. Nixon described it in 1954 as follows:

Percussion is initiated at the lower level of pulmonary resonance in approximately the posterior axillary line and carried down obliquely on a general perpendicular line toward the lowest mid-anterior costal margin. Normally, the upper border of dullness is measured 6–8   cm above the costal margin. In the adult, dullness over 8   cm indicates splenic enlargement.

Castell’s technique (Fig. 15-15B) percusses the lowest left intercostal space (eighth or ninth) along the anterior axillary line. The patient is instructed to breathe in deeply and then exhale, while percussion is carried out during both inspiration and exhalation. This should normally yield a resonant note, even on deep inspiration. However, enlarged spleens (even those missed on palpation, or just barely palpable) would yield a dull percussion note at peak inspiration. Castell described this technique in 1967 as follows:

With the patient in supine position, percussion in the lowest intercostal space (8th or 9th) in the left anterior axillary line usually produces a resonant note if the spleen is normal in size. Furthermore, the resonance persists with full inspiration. As the spleen enlarges, the lower pole is displaced inferiorly and medially. This may produce a change in percussion note in the lowest left interspace in the anterior axillary line, from resonance to dullness with full inspiration. The percussion sign is considered positive when such a change is noted between full expiration and full inspiration.

Percussion of Traube’s semilunar space (Fig. 15-15C): Described by Barkun et al. in 1989, Traube’s space is a triangular area bordered by the left sixth rib superiorly, the left midaxillary line laterally, and the left costal margin inferiorly. In the original description, dullness in this area suggested a pleural effusion. More recently, it has been thought to indicate splenomegaly.

Figure 15-15 Percussion of the spleen. A, Nixon’s method (see text). B, Castell’s method. The examiner percusses at the intersection of the left anterior axillary line and ninth intercostal space (marked). The lower diagonal line points to the normal spleen. C, Traube’s space is shown, as defined by Barkun et al.

(From Yang JC, Rickman LS, Bosser SK: The clinical diagnosis of splenomegaly. West J Med 155:47–52, 1991, with permission.)

Pearl:

Barkun compared percussion of Traube’s space with ultrasonography and found it 62% sensitive and 72% specific for the detection of splenomegaly. But Traube’s dullness becomes much less sensitive after meals or in patients who are overweight.

105 Who was Traube?

Ludwig Traube (1818–1876) was a member of the 19th-century school of great German clinicians, who also were excellent pathologists and often outstanding bacteriologists, too. Trained at the Berlin clinic, Traube was especially interested in the pathology of fever and the connections between diseases of the heart and kidneys. He introduced the thermometer into the clinic and described the peculiar dullness over the gastric bubble area (otherwise tympanitic) that still carries his name. He originally described this as a sign of left pleural thickening (caused, in his days, by tuberculous empyema) but did not name it after himself, nor did he associate dullness of the left upper quadrant with splenomegaly.

106 What are the limitations of percussion in detecting splenomegaly?

It is not that reliable. In a study of 65 patients undergoing liver scan, Sullivan and Williams compared percussion to palpation (using Nixon’s and Castell’s). Castell’s was more sensitive than palpation (82% versus 71% false negative rate) but less specific (16% versus 10% false positive rate). Nixon’s was instead less sensitive than palpation (59% versus 71%), but more specific (6% versus 16%). Castell’s technique appeared, therefore, to be more sensitive than Nixon’s (82% versus 59%, respectively). Still, Castell’s and Nixon’s had an overall combined false positive rate of 16.6%. In another study comparing physical exam with nuclear scintigraphy, Halpern et al. found a sensitivity of only 28% (and a specificity of 1.4%) for the bedside detection of splenomegaly. This study, however, was flawed by lack of a standardized method for physical exam. Hence, the best comparison of palpation, percussion, and technology-based assessment remains the study by Sullivan and Williams.

Although still widely cited, Castell’s technique was validated in only 10 male patients who had a positive percussion sign and an otherwise nonpalpable spleen. In this study, the gold standard was nuclear scan, and controls were males whose disease made hepatosplenomegaly not “expected.” It also is uncertain whether the percussion technique (light versus heavy) interferes with the sensitivity of this maneuver. Castell himself wrote a paper demonstrating that this variable is indeed important in determining liver size by percussion.

107 What are the recommendations for the bedside assessment of spleen size?

Both percussion and palpation have better specificity than sensitivity, with palpation being overall the most accurate. Hence, percussion should serve as an adjunct to palpation. The two techniques are indeed complementary, since each may fail to detect splenomegaly and thus be rescued by the other. Moreover, percussion by the Castell’s technique may even be more sensitive than palpation alone and thus unmask patients with barely palpable spleens. Yet, having to choose between the two, palpation should be the clear choice.

108 What are the technologic alternatives for assessing the spleen?

Given the limitations of physical diagnosis, imaging provides a very attractive alternative. Plain films of the abdomen are, however, poorly sensitive and unreliable for assessing splenomegaly, only helpful in cases of gross enlargement. Ultrasonography is instead the gold standard: quick, reliable, cheap, noninvasive, safe, and highly sensitive and specific. In a study of more than 3000 patients, Leopold and Asher found ultrasonic assessment to be a reliable index of splenomegaly in more than 90% of patients. Nuclear scintigraphy also is highly accurate in predicting and assessing splenic size, although limited by long acquisition time, need for immobility, vascular integrity and function of the spleen, and cost. Computed tomography (CT) scan is a highly accurate (albeit expensive) method to assess splenomegaly, producing a mean error of 3.59% (using 1-cm cuts) or 3.65% (using 2-cm cuts). Its major limitations are cost and exposure of the patient to radiation. Magnetic resonance imaging seems to offer no clear advantage over CT scanning.

109 Summarize bedside and technology-based methods of assessing splenomegaly.

See Table 15-1.

(3) Auscultation of the Spleen

111 What is the role of physical diagnosis in assessing the stomach?

Very small, and usually limited to detecting gastric stasis or retention. The stomach traditionally has been off limits to physical diagnosis. It still is. The major value of the bedside exam may be in auscultation, which can indirectly confirm the position of endotracheal or nasogastric tubes.

112 What maneuvers can be used to test for gastric retention?

Clapotage and succussion splash.

113 What is clapotage?

It is a “splashing sound” produced by fluid moving around in the stomach (from the French clapotage—or clapotement—the whoosh of water after a passing boat). It can be elicited by tapping a relaxed epigastrium with fingertips held together, even though the tapping should first begin in the lower abdomen (slightly to the left of the midline) and then move gradually up to the xiphoid process. The splash should be detected as soon as the first few blows are struck because otherwise muscle guarding by the patient will interfere with the test.

114 What is a succussion splash?

It is another splashing sound, but this time elicited by first placing the stethoscope over the epigastrium and then rapidly jerking the patient from side to side (I am not making this up). Absent in an empty stomach, the splash indicates a delay in gastric emptying if present 5 hours after a full meal, and 2 hours after a simple glass of water. In addition to being a little rude, it is neither sensitive nor specific since the abdomen (as opposed to the chest) contains many viscera that might cause a “succussion.” Overall, a flat and upright film (which in gastric stasis will show air–fluid levels) is more valuable and dignified. Still, the splash has a (limited) role as a frugal way to screen for gastroparesis—especially in patients who get on our nerves.

115 Is there any role for auscultating the stomach?

Only to determine whether a nasogastric tube has been successfully placed in the stomach (if the tube is placed correctly, air injected through the tube produces a gurgling sound over the stomach). This maneuver, however, has limitations. Similarly limited is auscultation over the stomach (and lungs) after placement of an endotracheal tube.

116 What is the role of physical diagnosis in assessing the pancreas?

A very limited one since the organ traditionally has been off limits to physical diagnosis and still is. The major value of exam is in the occasional detection of massive pancreatic enlargements, such as pseudocysts and possibly cancer. As for acute pancreatitis, the role of bedside diagnosis is also limited, since retroperitoneal subcutaneous hemorrhages (traditional findings of acute hemorrhagic pancreatitis, visible on the abdominal wall as either Cullen’s or Grey Turner’s signs), are neither sensitive nor specific. Other findings of pancreatitis include:

117 What is the best way to assess renal size?

Not physical exam. This is because the kidneys are hidden within the retroperitoneal fat, far from reach of prodding fingers (especially in the typical and overweight patient). Hence, exam should concede to ultrasound the assessment of renal size and keep for itself the detection of costophrenic tenderness in acute renal inflammation and the identification of arterial bruits in renal vascular disease.

In the absence of ultrasound, various maneuvers of kidney palpation may be tried. Although these may detect polycystic kidney disease (bilateral renal enlargement) or hydronephrosis and carcinoma of the kidney (unilateral renal enlargement), they are difficult to perform and have low yield in patients who are not very thin.

118 What is the value of testing for costophrenic tenderness?

It is a good value. Percussion of costophrenic (or costovertebral) angles remains an excellent way to identify pyelonephritis or other conditions that distend the renal capsule and pelvis (like perinephric abscess and renal infarction, but stones, too—in fact, renal colic also may present with flank and costovertebral tenderness). Pioneered by J. B. Murphy, this technique served him well in differentiating renal from biliary, appendiceal, and pancreatic pathology.

119 How do you percuss the costophrenic angle?

By striking with the ulnar aspect of your hand the patient’s flanks (between the lumbar column and costal margin). Alternatively, in Dr. Murphy’s original method you could use both hands:

120 What is the thumb pressure test?

A variation on the theme, wherein costophrenic angle pressure is carried out by using the thumb. This maneuver may separate renal from abdominal wall tenderness; yet, like all other maneuvers, it has much greater specificity (80–100%) than sensitivity (15-80%).

121 What are the physical findings of a renal colic?

The most common is flank and costovertebral tenderness—a finding that also has greater specificity than sensitivity.

(1) Auscultation of the Kidneys

123 What is the significance of anterior bruits?

Bruits (i.e., murmurs that typically extend beyond the second heart sound and thus are continuous) have a sensitivity of approximately 50% for renovascular disease, but this may reach 80–90% in hypertensive patients with fibromuscular hyperplasia of the renal artery. The bruit also is much more specific than the systolic anterior murmur, with false positive rates less than 7%.

124 What is the main purpose of physical diagnosis in assessing the urinary bladder?

Physical diagnosis can still detect a full bladder. Tools include “subjective” palpation and percussion, aided or unaided by auscultation (i.e., auscultatory percussion).

125 Is the urinary bladder palpable?

Only when distended—and only in thin patients or bladders fibrotic from radiation therapy.

126 What is “subjective” palpation of the bladder?

A good way to detect a full bladder. To carry it out, push perpendicularly (and gently) one finger into the patient’s lower abdomen, starting at the umbilicus and then down toward the pubis in stepwise fashion. The test is positive when it causes an urge to urinate, indicating that the fundus of the bladder has been touched, and thus identifying the level of its distention.

127 How accurate is this technique?

It was evaluated in 50 consecutive patients undergoing cystoscopy. All 20 patients who experienced an urge to urinate after suprapubic palpation had at least 100   mL of urine in their bladder, and this even though only two of the bladders were objectively palpable and percussable. None of the 25 patients with negative findings had >200   mL of urine. Hence, when suprapubic pressure evokes a call to micturition, the bladder probably contains >100   mL of urine; whereas if it does not evoke an urge, the bladder probably contains <200   mL of urine.

128 What is the physical diagnosis gold standard for detecting a full bladder?

It remains percussion—either alone or coupled with auscultation:

129 How accurate is auscultatory percussion?

It depends. The likelihood of identifying a “full” bladder (defined as ≥250   mL of urine on catheterization) directly correlates with the distance above the symphysis pubis at which the percussion note changes. A distance of 6.5   cm or less has 0% likelihood, whereas a distance of 6.5–7.5   cm has 43% likelihood and >7.5   cm has 91% likelihood.

130 How accurate is plain percussion in diagnosing a full bladder?

Less sensitive than auscultatory percussion, since it requires at least 400–600   mL in order to yield suprapubic dullness. It also is nonspecific.

131 How useful is physical diagnosis of ascites?

Quite useful. Maneuvers that can help physicians identify patients with ascites are still quite valuable, especially if combined.

132 What is ascites?

It is the presence of free fluid in the abdominal cavity. This is an important clinical finding, and like pleural effusion is usually the result of one of three problems: (1) increased hydrostatic pressure (from either right-sided or biventricular failure); (2) decreased oncotic pressure, from either protein loss (as in nephrosis and enteropathy)—or reduced synthesis (as in malnutrition and cirrhosis); or (3) peritoneal inflammation (either neoplastic or infectious).

133 What are the best tools for diagnosing ascites?

A focused history for sure, since this may provide important diagnostic information even before resorting to physical exam. Inquire about (1) any current (or past) history of liver disease, since this greatly increases the pretest probability of ascites and (2) recent weight gain, especially a change in abdominal girth or a new ankle edema. If absent, these two symptoms strongly argue against ascites, particularly in cases of an already low pretest probability of disease. For example, in patients with less than a 20% chance of having ascites (because of no liver disease by history), absence of recent ankle swelling lowers the likelihood to less than 2.5%.

134 What are the causes of ankle edema in ascites?

They are both hydraulic causes (compression of leg veins by the ascitic fluid) and oncotic (concomitant hypoalbuminemia, frequently encountered in either hepatic or renal disease).

135 What is the role of physical diagnosis in assessing ascites?

It provides a quick, convenient, and inexpensive tool. Yet, exam is only valuable for large volumes of fluid (500–1000   mL). For smaller amounts, the gold standard remains ultrasound, which can detect as little as 100   mL of fluid at a cheaper cost than CT.

136 What bedside maneuvers may be used to detect ascites?

The classic four are: (1) inspection for bulging flanks, (2) percussion for flank dullness, (3) the shifting-dullness maneuver, and (4) the fluid-wave test. In addition, three other maneuvers have been found to be useful: the ballottement sign and two maneuvers that are instead an application of auscultatory percussion (the puddle sign and Guarino’s variation).

137 What are bulging flanks?

They are not a reference to Mae West’s silhouette, but rather to the peculiar abdominal shape of a supine patient with ascites. Because of the weight of intra-abdominal fluid (and the effect of gravity on fluid), the flanks of ascitic patients who lay supine are pushed outward, almost like the belly of a frog. This same shape, however, also may be seen in patients who are simply obese. To separate them, one has to resort to the flank-dullness maneuver.

138 How does one percuss for flank dullness?

By tapping the abdomen in a radiating pattern, from the umbilicus toward the flanks and symphysis. Since gas-filled intestinal loops (resonant) float on top of ascites (dull), the maneuver reveals a periumbilical rounded area of tympany, flanked by two areas of dullness. Tympany and dullness are separated by a horizontal border.

139 How is the shifting-dullness maneuver performed?

Ask the patient to lie supine. Then percuss the abdomen along one flank—from the umbilicus downward. Mark the level at which the percussion note turns from resonant to dull, and then ask the patient to roll over on the right side. Once the patient is in the right lateral decubitus position (and supported by a 45-degree–angle pillow), restart the percussion sequence. A gravity-dependent shift in dullness of at least 1   cm (with the shifting border still remaining horizontal) indicates that the dullness is due to fluid, whereas absence of a shift indicates that the dullness is due to a solid organ. Once again, tympany and dullness remain separated by a horizontal border (Fig. 15-16).

Figure 15-16 Technique for testing shifting dullness. The shaded areas represent the areas of tympany.

(From Swartz MH: Pocket Companion to Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1995.)

140 How accurate is this test?

It, too, has good sensitivity (≥83% in two separate studies, indicating the presence of at least 500–1000   mL of fluid), but low specificity (although one study yielded 90% specificity, a more accurate figure is probably 50%, with the most common confounder being the colonic fluid accumulation of patients with diarrhea). Nonetheless, due to its high sensitivity, a negative shifting dullness argues strongly against the presence of gross ascites.

141 How is the fluid-wave maneuver performed?

It requires two examiners, or one examiner assisted by the patient. With the patient supine, place one hand on one flank and tap gently on the opposite flank. In the meantime, ask the other examiner (if available) to place the ulnar surface of both hands over the patient’s umbilicus and along the abdominal vertical midline (from the xiphoid process to the symphysis pubis). This is done to prevent a false positive fluid wave, which may occur whenever flickering of the abdominal wall creates ripples of mesenteric fat (not of ascites) toward the contralateral side. If an assistant is unavailable, ask the patient to place the ulnar surface of one hand vertically over the umbilicus. The test is positive when you feel a fluid wave emanating into the contralateral side. This has to be of moderate to strong intensity. Slight fluid waves have high interobserver variability and should not be relied on for diagnosing ascites (see Fig. 15-17).

Figure 15-17 Technique for testing a fluid wave.

(From Swartz MH: Pocket Companion to Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1995.)

142 How reliable is this test?

Quite reliable, with specificity of 80–90%. In fact, this is probably the only truly specific bedside test for ascites. Hence, a positive fluid wave can help ruling in the disease. If negative, though, it should not exclude it, since its sensitivity is just 50% (it detects only large volumes).

143 What is the ballottement (or dipping) maneuver?

Another bedside test for ascites, and not a particularly sensitive one. To carry it out, roll the patient’s body toward the side of the organ to be palpated (usually the liver or spleen). Then apply with your fingers a quick pushing motion to the chosen organ. The test is positive when it elicits a feeling of displaced fluid before your fingers can actually touch the organ in question.

144 What is the puddle sign? How is it elicited?

It is a sign of auscultatory percussion, performed by asking patients first to lie on their belly for 5   minutes and then eventually to raise themselves by supporting their body weight on the knees and stretched forearms (Fig. 15-18). As a result, the middle portion of the abdomen becomes pendulous and dependent. At this point, you should place the diaphragm of your stethoscope over the lowest abdominal area, while at the same time flicking a finger over a localized flank area. Then gradually move your stethoscope over the opposite flank. The test is positive when there is a sudden increase in intensity and clarity of the sound, signaling that the stethoscope has passed the edge of the peritoneal fluid.

Figure 15-18 Patient positioning for eliciting the puddle sign.

(From Dioguardi N, Sanna GP: Moderni Aspetti di Semeiotica Medica. Milan, Societa Editrice Universo, 1975.)

145 What is the Guarino’s variation?

It is a maneuver that has been reported too recently for adequate validation. It consists of having the patient sit or stand for 3   minutes after voiding. This allows free abdominal fluid to gravitate into the pelvis. The examiner then places the stethoscope in the abdominal midline, immediately above the pubic crest, while at the same time percussing the abdomen (by finger-flicking) from the costal margin downward and perpendicularly toward the pelvis, along three or more vertical lines. Normally, the level where the percussion note turns from dull to loud is the pelvic border, just where the stethoscope resides. In patients with free fluid, however, this level is clearly raised above the pelvic baseline.

146 What is the overall accuracy of these signs for ascites?

No single sign is both sensitive and specific. Many, however, are quite sensitive or quite specific. Moreover, their detection has little interobserver variability, suggesting that physicians tend to agree on their presence or absence. Overall, the two most useful signs to rule in ascites in patients with abdominal distention are (1) a positive fluid wave and (2) a history of ankle edema. The least useful signs to rule in a diagnosis of ascites are (1) the puddle sign and (2) auscultatory percussion. Conversely, the two most useful signs to rule out ascites are: (1) absence of ankle swelling (or increased abdominal girth) and (2) absence of flank dullness.

147 How can one improve the diagnostic accuracy of these maneuvers?

By combining them. For example, fluid-wave has low sensitivity (50%) but high specificity (80–90%), whereas shifting-dullness has high sensitivity (≥83%) but low specificity (55%).

148 What is the role of the Bayes’ theorem in diagnosing ascites at the bedside?

A very important one, since interpreting each maneuver in light of the pretest probability of disease is the best way to improve accuracy. Because the predictive value of any test (including physical diagnosis) depends on the prevalence of the disorder in the population undergoing the test, a positive test in patients with low prevalence of the disease is more likely to represent a false positive than a true positive (like a positive pregnancy test in a man). This can be extended to the positive predictive values of shifting-dullness and fluid-wave for ascites. Hence, a prominent fluid wave has a high positive predictive value for ascites (96%) in patients with prolonged prothrombin time (PT), but a much lower one (48%) in patients with normal PT. Conversely, absence of shifting dullness makes ascites very unlikely in patients with normal PT (2%). Thus, a focused physical examination based on just two maneuvers (shifting-dullness and fluid-wave) and interpreted in light of patients’ pretest probability of disease (as based on PT) can allow physicians to use ultrasound more judiciously and cost effectively (see Table 15-2)

Table 15-2 Diagnosis of Ascites

149 Summarize the role of physical examination in patients with peritonitis.

It is crucial for the identification of surgical “abdomens.” To this end, a set of bedside maneuvers has been developed over the years to help diagnosis, and remains valuable even in our times of magnetic resonance imaging (MRI) and CT scan. Still, individual capabilities play an important role in the success (or failure) of these techniques.

150 What are the most commonly used maneuvers for the bedside evaluation of peritonitis?

151 What is guarding?

It is a diffuse (or localized) tension of the abdominal wall. This muscular stiffness can be involuntary (and thus commonly referred to as rigidity) or voluntary. In the latter case, it is usually elicited by pressure from the examiner’s fingertips. Voluntary guarding does not necessarily indicate peritoneal inflammation, since it also can result from the patient’s anxiety or the examiner’s cold hands. As a peritoneal sign, it is more sensitive than rigidity but less specific.

152 What is the significance of “localized” rigidity?

It refers to a focal area of peritonitis. In this case, the stiffness of the abdominal wall is limited to the region overlying the inflamed viscus. A good example of localized rigidity is the absence of respiratory motion in selective parts of the abdominal wall.

153 What is “induced guarding”? How can it be triggered?

Induced guarding is an induced tension of the abdominal wall. To trigger it, ask the patient to raise the head above the pillow until (s)he can touch the chest with the chin. This tenses the abdominal musculature, forming a sort of cuirass that protects any inflamed intra-abdominal organ against the examiner’s hand. Induced guarding can be used for eliciting Carnett’s sign.

154 What is Carnett’s sign?

It is a maneuver that uses induced guarding to differentiate the abdominal tenderness of an inflamed intra-abdominal viscus from that of an inflamed abdominal wall. To carry it out, first localize by palpation the area of tenderness. Then ask the patient to contract his or her abdominal muscles by raising the head from the couch. While the patient does so, maintain pressure on your examining fingers, and then ask whether there was any change in tenderness. An abdominal wall pain would increase (positive Carnett’s sign), whereas pain from an intra-abdominal viscus would decrease (negative Carnett’s sign). The sign was first described by Carnett in 1926.

155 What is abdominal wall tenderness (AWT)?

It is a variation of Carnett’s sign, also called modified induced guarding. As for the previous maneuver, first identify the site of maximal abdominal tenderness with the patient lying flat and relaxed. Then, with your examining hand still in place, ask the patient to cross arms and sit forward. While the patient is midway between a sitting and recumbent position (and with the anterior abdominal wall muscles being tensed), renew pressure on the previously tender spot. The test is positive when pain is increased at midway (positive abdominal wall tenderness) but negative if the pain is actually improved (negative abdominal wall tenderness).

156 What is the significance of a positive abdominal wall tenderness?

Very much the same as Carnett’s sign. Pain on palpation may arise from the abdominal wall, the parietal peritoneum, or an underlying viscus. Tensing the abdominal muscles allows the physician to separate the first from the other two. If tenderness on palpation is increased by abdominal muscular tension (positive abdominal wall tenderness), the pain originates from the abdominal wall itself because tensing of the wall will protect the parietal peritoneum and the intra-abdominal viscera against the prodding of the examiner’s hand.

157 What are the causes of abdominal wall tenderness?

They are mysterious. A common one is diabetic neuropathy of the lower thoracic segments, associated with abdominal wall hyperesthesia and weakness. Other causes include muscular strain, viral myositis, fibrositis, nerve entrapment, and trauma. Still, the most important value of a positive AWT is that it argues against intra-abdominal or peritoneal pathology.

158 Does the AWT maneuver have limitations?

159 When should one use the AWT maneuver?

Whenever laparotomy is considered in patients with acute abdominal pain, and always in the clinical context and in the setting of periodic reexaminations.

160 How accurate is the modified induced guarding technique (AWT)?

The AWT sign has been extensively studied and found to be clinically useful in the evaluation of either acute or chronic abdominal pain. Thomson and Francis used it in 120 patients admitted as surgical emergencies for acute localized abdominal pain. Only 1 of the 24 patients with positive AWT had an intra-abdominal inflammatory process (acute appendicitis). Conversely, all 96 with a negative test had intra-abdominal pathology. Gray et al. studied 158 patients admitted for acute abdominal pain. They found AWT to be less accurate, being present in only 28% of patients without intra-abdominal pathology (true positive) and 5% of patients with intra-abdominal pathology (false positive). They also found a predominance of young females among patients with positive AWT and no intra-abdominal pathology. Finally, Thomson et al. revisited this sign for the evaluation of chronic abdominal pain. Patients with positive AWT tended to undergo a great deal of studies (including surgical procedures) but only a minority turned out to have serious pathology. Hence, the AWT sign is quite useful in differentiating peritonitis or intra-abdominal pathology from inflammation of the abdominal wall.

161 What is rebound tenderness?

It is severe pain of the abdominal wall that is indirectly elicited by the sudden release of hand pressure. This maneuver (also called Blumberg’s sign) is carried out by palpating an area of tenderness as gently but as deeply as allowed, and by then suddenly releasing pressure. This will make the elastic abdominal wall spring back into its baseline position, thus eliciting an exquisite (and localized) pain whenever there is localized peritonitis (with the pain being caused by the sudden tension of the inflamed peritoneum). A less painful alternative may be a light indirect percussion over the area of pain. Still, rebound tenderness has modest sensitivity and specificity, is painful, and is totally unnecessary in patients who already have guarding or rigidity.

162 Who was Blumberg?

Jacob Moritz Blumberg (1873–1955) was a German surgeon and gynecologist, who trained both in Germany and England, where he investigated methods of surgical sterilization and even invented a type of rubber glove that became widely used. He fought with the German Army during World War I, managing to control a typhus epidemic in a prisoners of war camp by delousing 10,000 Russian prisoners in only a few days. After the war, he returned to his surgical practice in Berlin, where he founded a radiology institute and organized many prenatal clinics. With the rise of the Nazis, he eventually left Germany and moved to England, where he resumed his medical work with considerable success.

163 What is the referred rebound tenderness test?

It is a more humane variant of Blumberg’s sign and also a more correct application of the original technique. In this case, the examiner first compresses and then releases the abdominal wall of the quadrant contralateral to the one where the patient has pain. The maneuver is positive only when it elicits pain in the site where the patient originally felt it. Pain at the site of palpation represents instead a negative test. Yet, this should not rule out localized peritonitis and thus must be followed by a rebound tenderness maneuver over the painful area.

164 What is a cough test?

It is the sudden increase in abdominal pain caused by a brisk rise in intra-abdominal pressure, such as the one elicited by coughing. The maneuver is indicative of peritonitis, but since it has greater sensitivity than specificity, is more valuable when absent than present.

165 What is jar tenderness?

It is another maneuver aimed at detecting (and localizing) peritoneal irritation, very much like the cough test. First described by Dr. Markle, it is carried out in the ambulatory setting by asking the patient to first stand on outstretched toes and then let his or her body weight fall on the heels. The maneuver sets the abdominal wall into motion, thus allowing the patient to localize any area of pain. In addition to being a bit cruel, it is of obvious limited value in patients too ill to stand.

166 What is the role of a Valsalva maneuver in patients with acute abdomen?

It is another way to heighten peritoneal pain by inducing a sudden distention of the abdominal wall. This, in turn, may help the patient better identify a particular area of tenderness. For example, a 20-second Valsalva may allow someone with acute appendicitis to pinpoint the area of pain. Hence, it may be used to screen (very much like the cough test and the jar tenderness) and to guide (and possibly avoid) more painful tests—like rebound tenderness.

167 What is the stethoscope sign?

It is a sign elicited by palpating the abdomen twice, first with your hands and then with your stethoscope. When doing it with the stethoscope, you should preinform the patient that you are only trying to listen to the abdomen. This seems to have a distracting effect, often allowing you to compress the anterior abdominal wall all the way down in cases of unreal or exaggerated pain, when just a few seconds before there was flinching, grimacing, complaining, and quick abdominal tension in preparation for even the lightest finger touch.

168 How reliable is this sign?

It has not been studied prospectively. There is, however, a case report of a false positive outcome in a patient with acute appendicitis. As always, things should be evaluated in the context of the clinical picture and within the realm of periodic observation.

169 While performing these maneuvers, should you look at the patient’s face or abdomen?

At the patient’s face. It is essential that you observe facial expression while testing for guarding or rebound tenderness. Any grimacing/reaction is often the only clue to an acute abdomen.

170 What is the closed-eyes sign?

It is the peculiar face of patients with nonspecific abdominal pain (i.e., without a clear-cut intra-abdominal pathology), who often keep their eyes closed during abdominal palpation, with an embalmed and almost beatific smile. This is quite different from patients with true intra-abdominal pathology, who keep their eyes wide open, always monitoring what you are doing.

171 Explain the use and cause of a closed-eyes sign.

It is a relatively accurate test for nonspecific abdominal pain. It is not clear why patients with no intra-abdominal pathology should keep their eyes closed. It may be because, unlike patients with true pathology, they might not need to monitor the physician’s hand to avoid unnecessary pain. It also is possible that they may be aware (either consciously or unconsciously) that palpation will not produce severe pain, implying that their pain has a psychologic cause. Either way, a positive closed-eyes sign suggests no intra-abdominal pathology.

172 How accurate is the closed-eyes sign in diagnosing nonspecific abdominal pain?

Gray et al. studied it in 158 consecutive patients admitted for acute abdominal pain. Eyes were closed in 6/91 patients with true pathology (6.5%) and 22/67 patients with no pathology (33%); 22/28 patients with closed-eyes were females (p <0.01), usually young. In summary, the predictive power of a positive closed-eyes test is 79% and that of a negative test is 65%.

173 What is abdominal hyperesthesia?

It is hypersensitivity (hyperesthesia) to light touch in areas that overlie an inflamed viscus.

174 How can one detect abdominal hypersensitivity?

One can easily identify areas of hyperalgesia (increased pain) by lightly drawing across the abdominal wall with a cotton wisp, a pin, or even a fingernail. Head was the first to describe these areas of hypersensitivity. Since then, they have been referred to as Head’s zones (see Fig. 15-19).

Figure 15-19 Outline of the zones of hyperalgesia.

175 Is abdominal hyperesthesia specific to localized peritonitis?

No. It also may occur in herpes zoster (where it precedes the cutaneous rash by several days) and at times even in peptic ulcer disease (as an area of localized midepigastric tenderness)

176 What is Boas’ sign?

It is abdominal hyperesthesia as applied to the gallbladder. In Boas’ sign, patients with acute cholecystitis experience referred pain and hyperesthesia of the right costophrenic angle (which is indeed the referred site for gallbladder pain). Even a light touch in this area will elicit exquisite tenderness. The sign, unfortunately, has very low sensitivity (only 7%).

177 Who was Boas?

Ismar I. Boas (1858–1938) was a German gastroenterologist and the author of an acclaimed textbook on stomach diseases. After a brief stint in general practice, he joined the Augusta Hospital Faculty in Berlin, where building on Kussmaul’s recently introduced gastric tube, he used the test-meal to measure gastric secretion. He also became the first to recognize “occult blood” and its diagnostic importance. A world leader in his field, Boas was the founder of the German Gastroenterological Society. After Hitler’s ascent to power, he left Berlin for Vienna in 1936, dying there the year Austria was annexed to the Reich.

178 Which maneuvers can be used for evaluating patients with suspected appendicitis?

179 What is McBurney’s sign?

It is maximum tenderness and rigidity elicited by pressure of one finger over McBurney’s point. This is located 1.5–2   inches medial to the right anterosuperior iliac spine, on a line that joins it to the umbilicus. Although most patients with appendicitis have right lower quadrant tenderness, tenderness in the McBurney’s point has slightly better specificity (75–85%).

180 Who was McBurney?

Charles McBurney (1845–1913) was a graduate of Harvard and the New York College of Physicians, who became one of the leaders of 19th-century American surgery. Surgeon-in-chief at the Roosevelt Hospital of New York, he presented his classic report on the advantages of early intervention in patients with appendicitis before the 1889 meeting of the New York Surgical Society. In it he described the area of greatest abdominal pain that still carries his name. Five years later, he described instead the incision he used for patients with appendicitis, still called McBurney’s incision. An avid hunter and fisherman, McBurney died of myocardial infarction at age 68, while on a hunting trip.

181 What is Rovsing’s sign?

It is pain in the right iliac fossa, elicited by pressure over the left lower quadrant (indirect tenderness). This finding has similar specificity, but slightly lower sensitivity than McBurney’s.

182 Who was Rovsing?

Neils T. Rovsing (1862–1927) was a professor of surgery at the University of Copenhagen, who wrote extensively on gallbladder and bladder diseases, eventually becoming a surgical leader in Denmark. He also was an entrepreneur, who acquired a financial interest in a medical journal that he subsequently owned and finally presented to the Danish Medical Society. Forced to retire in 1926 due to heart disease, he died 1 year later of carcinoma of the larynx.

183 What is the obturator test?

It is a test carried out by asking patients to flex the hip and rotate it internally while lying supine. Examiners can help this movement by pulling the patient’s ankle toward themselves while pushing the knee away. The maneuver should be carried out on both thighs and should remain painless. Pain (usually referred to the suprapubic region) indicates inflammation in one of the organs surrounding the obturator internus muscle and is therefore specific (but poorly sensitive) for retrocaecal appendicitis. The obturator test (see Fig. 15-20 also may be positive in various obstetric-gynecologic conditions of intrapelvic pus; yet in these cases the test is usually positive in both legs, whereas in appendicitis, it is only positive in the right leg.

Figure 15-20 Method of performing the obturator test.

(From Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 19th ed. New York, Oxford University Press, 1996, with permission.)

184 What is the reverse psoas maneuver?

It is another test of irritation of the iliopsoas muscle, either because of retrocaecal appendicitis or some other localized collection of pus and blood. It is performed by having the patient roll toward the left side and hyperextend the right hip (see Fig. 15-21). The test is positive when it elicits pain. Like the obturator test, it has very low sensitivity for appendicitis, but high specificity. Still, given the low sensitivity, both maneuvers are of limited clinical value.

Figure 15-21 Method of performing the iliopsoas test.

(From Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 19th ed. New York, Oxford University Press, 1996, with permission.)

185 What is rectal tenderness?

It is tenderness on rectal exam elicited in patients with appendicitis confined to the pelvis. It is only helpful in patients with perforation, whose rectal exam reveals a right-sided tender mass representing the pelvic abscess.