Assesment of Acute Abdomen

DR. Dr. Benyamin Lukito, SpPD

Siloam Hospital Lippo Village, University of Pelita Harapan School of Medicine

 Acute Abdomen
• It has an acute onset
• it can have many potential etiologies
• may required immediate medical or surgical
intervention
• mostly accompany by signs of peritoneal
irritation (with some exceptions) like:
– rigidity, tenderness (with or without rebound)
involuntary guarding
– may or may not have signs of hypotension and shock
 Acute Abdomen
• H&P:
– obtain a complete Hx
– vital signs (blood pressure, with pt standing or sitting position,
pulse, asses peripheral perfusion alertness, skin and extremities
temperature)

• Immediate management of life threatening problems:

– bleeding, shock, hypotension
 Acute Abdomen
• Location of Problem:
– Chest, abdomen (upper, middle, lower/ sides)
• Time of Onset:
– Date, time…?
• Type of Onset:
– How: Sudden? Gradual?
• Original Source:
– Triggers, what were you doing? (setting at time of occurrence)
• Severity:
– Interfere with medication?
• Time Relationship:
– How often, when?
• Duration:
– How long an episode?
 Acute Abdomen
• Course:
– Getting better, worse?
• Association:
– Any other manifestation?
• Source of Relief:
– Changes in medication, diet? What makes it better?
• Source of Aggravation:
– What makes it worse?
• Relevant Data & Pertinent Negatives
• Gynecological Hx for females:
– last menstrual period, pregnancies, STD’s
• Associated symptoms:
– nausea, anorexia, vomiting, change in bowel habits
 Acute Abdomen
• Dyspnea, pain, wheezing, crackles, orthopnea, cough,
sputum, emphysema, bronchitis, asthma, chest x-ray

• Changes in: appetite, weight, abdominal pain, (?) Diet,

digestion, tastes, bowel habits/ stool.

• Urine: color, polyuria, oliguria, nocturia, dysuria,

frequency, urgency, stones

• Hx: STD
 Acute Abdomen
• mental status
• exam abdomen (gently) looking for signs of acute
abdomen. Identify and describe the common
localized abdominal masses including umbilical
hernia, incisional hernia, epigastric hernia

• Pelvic(gynecological) exam for females and rectal

exam for both male and female (gross blood, asses
sphincter tone, and any other evidence of trauma)

• Check for blood in stools: UC, diverticular ds,

diverticulitis, hemorroids
 Assessment of the Abdomen
Inspection -- Contour
• Types of abdomen:
• Flat
• rounded or convex
• Scaphoid
• protuberant
 Assessment of the Abdomen
Inspection -- Contour
• Flat is normal
• Large convex abdomen -- 7 F’s
– Fat Feces
– Fluid (ascites) Fetus
– Flatus Fatal growth (malignancy)
Fibroid tumor
• Concave or scaphoid abdomen
– Decreased fat deposits
– Malnourished state
– Flaccid muscle tone
 Assessment of the Abdomen
Inspection -- Symmetry
• The abdomen should be symmetrical
bilateral
• Asymmetry indicates
– tumor
– cysts
– bowel obstruction
– enlargement of abdominal organs
– scoliosis
 Assessment of the Abdomen
• Masses or nodules -- tumors, metastasis,
internal malignancy, or pregnancy

• Visible Peristalsis -- indicative of obstruction

• Pulsation -- aortic aneurysm or may occur in

aortic regurgitation and in right ventricular
hypertrophy
 Assessment of the Abdomen
Auscultation
• Use diaphragm of
stethoscope lightly placed
• RLQ->RUQ->LUQ->LLQ
• Bowel sounds 5-30/min
• High-pitched always
heard RLQ-ileocecal area
• Borborygmi -- “stomach
growling” -- normal,
hyperactive, gurgling
sound
 Assessment of the Abdomen
Auscultation -- Bowel Sounds
• Absent bowel sounds -- no sound for 4-5
minutes -- late intestinal obstruction

• Mechanical obstruction -- adhesions, hernias,

masses

• Non-mechanical obstruction -- no intestinal

contraction (paralytic ileus) -- physiological,
neurogenic, and chemical imbalances
 Assessment of the Abdomen
Auscultation -- Bowel Sounds
• Hypoactive bowel sounds -- indicates
decreased motility
– peritonitis
– non-mechanical obstruction
– inflammation
– gangrene
– electrolyte imbalances
– intraoperative manipulation of the bowel
 Assessment of the Abdomen
Auscultation -- Bowel Sounds
• Hyperactive bowel sounds -- increased
motility of the bowel
– gastroenteritis
– diarrhea
– laxative use
– subsiding ileus
 Assessment of the Abdomen
Auscultation -- Bowel Sounds
• High pitched tinkling hyperactive bowel
sounds
– caused by powerful peristaltic action
– indicative of partial obstruction
– abdominal cramping
Assessment of the Abdomen
Percussion -- General
• Visualize all organs as
you percuss all quadrants
• Tympany heard most --
hollow organs. Dull
sound over solid organs
– Dull sound in area
where it should be
tympanitic -- mass or
tumor, pregnancy,
ascites
 Assessment of the Abdomen
Percussion -- Liver Span

• Percuss upward -- midclavicular line above the

umbilicus -- typany to dull -- mark
• Percuss downward -- midclavicular line --
tympany to dull - mark
• N - 6-12 cm, male 10.5, female 7.0 cm
 Assessment of the Abdomen
Percussion -- Ascites (Shifting Dullness

• Percuss from above and below from dullness to

tympany while patient on their back
• Place patient on left side and percuss from
dullness to tympany
 Assessment of the Abdomen
Percussion -- Ascites
• The umbilical area percusses dull because
the ascitic fluid pools in the dependent
area

• Ascites is present in cirrhosis and other

liver diseases
 Assessment of the Abdomen
Fist Percussion -- Kidney

• Direct fist percussion -- strike the costovertebral

angle with one fist
• Indirect fist percussion -- place palm over
costovertebral angle and strike with other hand
• Pain indicative of infllammatory condition
Assessment of the Abdomen
Fist Percussion -- Liver
• Palm down RUQ --
strike with other hand
• Tenderness can
occur with:
– pyelonephritis
– cholecystitis
– hepatitis
 Assessment of the Abdomen
Percussion -- Bladder
• Percuss from symphasis pubis (urine
filled gives dull sound) - if patient unable to
empty it is secondary to:
– neurogenic dysfuntion
– benign prostatic hypertropy
– post-op
– urethral changes
– some medications
 Assessment of the Abdomen
Palpation
• Please warm your hands
• To start avoid known tender areas
• Have patient take slow deep breaths through
mouth
• Begin with gentle pressure then increase
• If ticklish or with children palpate through their
hand till ticklishness is gone
• Avoid quick, short jabs
• Observe patient’s face for expressions of pain
Assessment of the Abdomen
Palpation -- Light

• Lightly palpate to note

– skin temperature
– tenderness
– large masses
 Assessment of the Abdomen
Palpation -- Abdominal Muscle Guarding
• Use both hands -- one on each rectus

• Check for tensing during expiration

• When positive it is indicative of peritoneal

irritation -- peritonitis
 Assessment of the Abdomen
Palpation -- Deep

• You can use one or two handed method

• Two handed method is usually used in obese or
very muscular individuals
• Palpate all quadrants
Assessment of the Abdomen
Palpation -- Fluid Wave
• With an assistant
placing the ulnar
surface of their hand
firmly in the midline of
the patient
• You tap from one side
to feel the wave on
the other side
• Present with ascites
 Assessment of the Abdomen
Palpation -- Liver -- Bimanuel Method
• Left hand under patient’s
right flank (11th-12th
rib) press upward
• Place right hand at level
of dullness -- have patient
take a deep breath
• Push in deeply
• note -- size, shape,
consistency, or masses
Assessment of the Abdomen
Palpation -- Liver -- Hook Method
• Place both hands side by
side below the level of
liver dullness
• Hook fingers in and up
and have the patient take
a deep breath in
• Note the size, shape,
consistency, and any
masses
• I prefer to do this in a
sitting position
 Assessment of the Abdomen
Palpation -- Liver -- Hepatomegaly
• Enlarged liver
– congestive heart failure
– hepatitis
– encephalopathy
– cyst
– cancer
 Assessment of the Abdomen
Palpation -- Liver -- Murphy’s Sign
• Palpate the liver margin at the lateral
border of the rectus muscle

• Have the patient take a deep breath

• If patient exhibits pain and stops inhaling

this is a positive Murphy’s Sign present in
– Cholecystitis
 Assessment of the Abdomen
Palpation -- Spleen -- Bimanuel Technique
• Pull up with left hand and
push in with right hand on
inspiration
• Will only be able to feel if
3 times normal size
• Splenomegaly
– inflammation
– congestive heart
failure
– cancer
– cirrhosis
 Assessment of the Abdomen
Palpation -- Kidney -- Bimanuel Technique
• Place one hand on
the costovertebral
angle of the back and
the other hand just
below the costal
margin
• Increase pressure
during inspiration then
have patient hold
breath
 Assessment of the Abdomen
Palpation -- Kidney
• The right kidney maybe difficult to
distinguish from an enlarged liver
• Left kidney enlargement maybe difficult to
distinguish from an enlarged spleen
• Enlarged palpable kidneys are secondary
to:
– hydronephrosis
– neoplasms
– polycystic disease
Assessment of the Abdomen
Palpation -- Aorta
• Assess the width of
the aorta by placing
your hands on each
side of the aorta just
above the umbilicus
• Abdominal aortic
aneurysm -- width
greater than 4 cm
with lateral pulsations
 Assessment of the Abdomen
Rebound Tenderness

• Apply firm pressure for several seconds to the abdomen

with hand at right angles and fingers extended
• Quickly release the pressure
• Test away from site where pain is initially determined
 Assessment of the Abdomen
Rebound Tenderness
• Pain at site is direct rebound tenderness

• Pain at another site is referred rebound

tenderness

• Indicative of peritoneal inflammation

• If in the RLQ think appendicitis (McBurney’s

point -- to be discussed later)
 Assessment of the Abdomen
Cutaneous Hypersesitivity

• Either lift the skin or stimulate the skin with gentle

jabbing with a sterile pin
• Indicates a zone of peritoneal irritation
– RLQ -- appendicitis
– Midepigastrium -- peptic ulcer
Assessment of the Abdomen
Ileopsoas Muscle Test
• Place your hand over
the right thigh and
push downward as
the patient is trying to
raise the leg, flexing
the hip
• Positive RLQ pain
associated with a
retrocecal or
perforated
appendicitis
Assessment of the Abdomen
Obturator Muscle Test
• Flex the right leg at the
hip and knee at a right
angle then rotate the leg
internally and externally
• Pain indicative of
inflammatory process
over obturator muscle
– ruptured appendix
– pelvic abscess
Appendicitis
Assessment of the Abdomen
Ballottement
• Used to displace
excess fluid in the
abdominal cavity by
using stiffened fingers
in a jabbing motion
• Determines a free
floating mass
• If pain is associated
with an inflammatory
process
Assessment of the Abdomen
Bladder Palpation
• Using deep palpation
start at the symphasis
pubis and palpate up
• Nodular bladder --
malignancy
• Asymmetrical bladder
– tumor in the bladder
– abdominal tumor
causing compression
 Assessment of the Abdomen
• Hernia Examination
• Pelvic Examination
• Rectal examination
• Laboratory Examination
• Diagnostic Imaging
The Acute Abdomen
Rapid Onset of Pain
The Acute Abdomen
Slow Onset of Pain
Acute Cholecystitis
Acute Cholecystitis
Acute Cholecystitis
Acute Cholecystitis -- Gangrene
Pneumatobilia
Pneumoperitoneum
Intestinal Obstruction
Intestinal Obstruction
Intestinal Obstruction
Adhesive Band
Intestinal Obstruction
Intestinal Obstruction
Gallstone Ileus
 Intestinal Obstruction
Incarcerated Strangulating Hernia
 Intestinal Obstruction
Incarcerated Strangulating Hernia
 Intestinal Obstruction
Incarcerated Strangulating Hernia
 Intestinal Obstruction
Incarcerated Strangulating Hernia