(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?