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Gastrointestinal (GI)

Examination Study Guide Year 2

Clinical Skills Teaching & Learning Centre Written by: Clinical Skills Lecturing Team

Reviewed by:

Mr C Halloran – Gastroenterology System lead

Dr P Collins – Consultant Gastroenterologist

Miss R Hamm – Urinary and Renal System Lead (Consultant Urologist)

August 2020

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Contents Glossary ....................................................................................................................................... 4

Learning Objectives ..................................................................................................................... 5

Year 2 ....................................................................................................................................... 5

Year 1 ....................................................................................................................................... 5

Introduction .................................................................................................................................. 6

Surface Anatomy ......................................................................................................................... 8

History .......................................................................................................................................... 9

Abdominal pain ....................................................................................................................... 11

Preparation ................................................................................................................................ 12

Patient safety ............................................................................................................................. 12

Inspection ................................................................................................................................... 14

General Inspection .................................................................................................................. 14

Specific inspection .................................................................................................................. 14

Palpation (Abdomen) ................................................................................................................. 19

Superficial Palpation ............................................................................................................... 20

Deep palpation........................................................................................................................ 20

Describing a Mass .................................................................................................................. 20

Organ-Specific Examination ....................................................................................................... 22

Liver ........................................................................................................................................... 23

Spleen ........................................................................................................................................ 23

Kidneys ...................................................................................................................................... 25

Percussion (Abdomen)............................................................................................................... 26

Bladder ................................................................................................................................... 27

Auscultation (Abdomen) ............................................................................................................. 28

Aorta .......................................................................................................................................... 28

Shifting Dullness ........................................................................................................................ 29

Hernias....................................................................................................................................... 30

Examination of the Groin / Hernias ............................................................................................ 31

Specific Abdominal Signs........................................................................................................... 33

Documentation ........................................................................................................................... 34

Bibliography & Further Reading ................................................................................................. 35

Images ....................................................................................................................................... 35

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References ................................................................................................................................. 36

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Glossary

Borborygmus Bowel sounds

Distension Swelling

GI Gastrointestinal

LLQ Left lower quadrant

LUQ Left upper quadrant

Nine regions Theoretical divisions, used by clinicians to help localise, identify and

diagnose a patient’s symptoms

Organomegaly Swelling or enlargement of an organ

RLQ Right lower quadrant

RUQ Right upper quadrant

Tenesmus A continual or recurrent inclination to evacuate the bowels.

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Learning Objectives

Year 2 1. To revise anatomy and physiology of the GI System

2. To link the anatomy and physiology to the examination

3. To be able to perform a GI examination including an understanding of the common

abnormalities and examination of appropriate lymph nodes

Year 1 1. To revise anatomy and physiology of gastrointestinal system

2. To link anatomy and physiology to practical skill

3. To understand reasons for undertaking gastrointestinal examination

4. To be able to carry elements out gastrointestinal examination – more emphasis on

kidney palpation and the inclusion of bowel sounds

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Introduction

The Gastrointestinal Tract (GIT)

The gastrointestinal system is composed of two groups of organs: the gastrointestinal tract (GI)

and the accessory digestive organs.

The GI tract or alimentary canal is a continuum that extends from the mouth to the anus through

the ventral body cavity (comprised of thoracic and abdominopelvic cavities). Organs of the

gastrointestinal tract include the mouth, most of the pharynx, oesophagus, stomach, small and

large intestine.

The accessory digestive organs are the teeth, tongue, salivary glands, liver, gallbladder and

pancreas.

The function of the gastrointestinal tract is to take a bolus of food, masticate it, swallow it, digest

it, absorb it and to expel the unwanted products.

Abdominal + GI Examination

An abdominal examination is part of a full gastrointestinal (GI) examination and should be

performed when a patient presents with symptoms which indicate abdominal or GI pathology.

Abdominal examination should include:

• Inspection (General, Specific)

• Palpation (Superficial, Deep, Liver, Spleen, Kidneys, Bladder)

• Percussion (Abdomen, Liver, Spleen, Bladder)

• Auscultation (Bowel sounds, Bruits)

Full GI examination would include examination of the:

• Abdomen (as above)

• Both Groins

• External genitalia (covered in separate study guides)

• Rectum (PR Exam) (covered in a separate study guide)

Indications

The decision to undertake an abdominal or full GI examination will be based on the patient’s

presenting complaint, history and current clinical picture. There are many indications for

performing this examination and they include:

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• Chronic or Acute Vomiting

• Trauma

• Abdominal pain

• Change in bowel habit

• Abdominal distension

• Change in appetite

• Anaemia

• Swelling

• Unexplained weight loss

• Jaundice

Examination of Other Systems

If during a GI examination you notice abnormalities you may need to carry out an examination

of other systems, for example:

- Genitourinary examination (kidneys or bladder).

- Cardiovascular examination (aorta).

- Gynaecological examination (uterus and ovaries).

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Surface Anatomy

The Abdominal Cavity

The abdominal cavity (figure 1) is bounded superiorly by the costal margin and inferiorly by the

pelvis. It is conventionally divided into 9 regions created by 4 dividing lines (figure 2), or

alternatively 4 quadrants divided by 2 lines (figure 3). This is clinically important during your

examination and when describing and documenting you findings.

Figure 1

Dividing Lines

• Left Midclavicular – vertical line from the mid clavicular point to the mid inguinal point

• Right Midclavicular – vertical line from the mid clavicular point to the mid inguinal point

• Subcostal - transverse line joining the two lower most bony points of the rib cage,

usually 10th costal cartilage

• Trans-tubercular – transverse line joining the two tubercles of the iliac crests

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Figure 2

Nine Regions of the Abdomen

1. Right Hypochondrium

2. Epigastrium

3. Left Hypochondrium

4. Right Lumbar

5. Umbilical

6. Left Lumbar

7. Right Iliac Fossa

8. Suprapubic

9. Left Iliac Fossa

Four Quadrants

Alternatively, the abdomen can be split into 4 quadrants

created by 2 lines crossing at the umbilicus:

• RUQ – Right Upper Quadrant

• LUQ – Left Upper Quadrant

• RLQ – Right Lower Quadrant

• LLQ – Left Lower Quadrant

History Figure 3

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Prior to any clinical examination you should have taken a detailed history from the patient to

enable you to tailor the examination to the patient’s presenting complaint and current clinical

condition. For further guidance on history taking please see the history taking study guide.

Considerations in History (with associated examination findings)

Acute

appendicitis

Nausea, vomiting, central abdominal pain

that later shifts to right iliac fossa

Fever, tenderness, guarding or

palpable mass in right iliac fossa,

pelvic peritonitis on rectal

examination

Perforated

peptic ulcer

with acute

peritonitis

Vomiting at onset associated with severe

acute-onset abdominal pain, previous

history of dyspepsia, ulcer disease, non-

steroidal anti-inflammatory drugs or

glucocorticoid therapy

Shallow breathing with minimal

abdominal wall movement,

abdominal tenderness and

guarding, board-like rigidity,

abdominal distension and absent

bowel sounds

Acute

pancreatitis

Anorexia, nausea, vomiting, constant

severe epigastric pain, previous alcohol

abuse/cholelithiasis

Fever, periumbilical or loin

bruising, epigastric tenderness,

variable guarding, reduced or

absent bowel sounds

Ruptured

aortic

aneurysm

Sudden onset of severe, tearing

back/loin/abdominal pain, hypotension and

past history of vascular disease and/or high

blood pressure

Shock and hypotension, pulsatile,

tender, abdominal mass,

asymmetrical femoral pulses

Acute

mesenteric

ischaemia

Anorexia, nausea, vomiting, bloody

diarrhoea, constant abdominal pain,

previous history of vascular disease and/or

high blood pressure

Atrial fibrillation, heart failure,

asymmetrical peripheral pulses,

absent bowel sounds, variable

tenderness and guarding

Intestinal

obstruction

Colicky central abdominal pain, nausea,

vomiting and constipation

Surgical scars, hernias, mass,

distension, visible peristalsis,

increased bowel sounds

Ruptured

ectopic

pregnancy

Premenopausal female, delayed or missed

menstrual period, hypotension, unilateral

iliac fossa pain, pleuritic shoulder-tip pain,

‘prune juice’-like vaginal discharge

Suprapubic tenderness,

periumbilical bruising, pain and

tenderness on vaginal

examination (cervical excitation),

swelling/fullness in fornix on

vaginal examination

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Pelvic

inflammatory

disease

Sexually active young female, previous

history of sexually transmitted infection,

recent gynaecological procedure,

pregnancy or use of intrauterine

contraceptive device, irregular

menstruation, dyspareunia, lower or central

abdominal pain, backache, pleuritic right

upper quadrant pain (Fitz-Hugh–Curtis

syndrome)

Fever, vaginal discharge, pelvic

peritonitis causing tenderness on

rectal examination, right upper

quadrant tenderness

(perihepatitis), pain/tenderness on

vaginal examination (cervical

excitation), swelling/fullness in

fornix on vaginal examination

Abdominal pain

During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain

resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis

becomes established. For example, in acute appendicitis, pain is initially periumbilical (visceral

pain) and moves to the right iliac fossa (somatic pain) when localised inflammation of the

parietal peritoneum becomes established.

If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised

appendix abscess develops, with a palpable mass and localised pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the initial diagnosis was wrong or that

complications have developed. In acute small bowel obstruction, a change from typical intestinal

colic to persistent pain with abdominal tenderness suggests intestinal ischaemia, as in a

strangulated hernia, and is an indication for urgent surgical intervention.

Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute

appendicitis, cholecystitis or diverticulitis.

Pain exacerbated by movement or coughing suggests inflammation. Patients tend to lie still to

avoid exacerbating the pain. People with colic typically move around or draw their knees up

towards the chest during spasms.

Excruciating pain, poorly relieved by opioid analgesia, suggests an ischaemic vascular event,

such as bowel infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by

potent analgesia is more typical of acute pancreatitis or peritonitis secondary to a ruptured

viscus.

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Preparation

Patient safety

• Introduce yourself

• Check the patient’s identity and allergies

• Explain what you want to do

• Gain informed consent

• Consider an appropriate chaperone

• There is no need for the patient to undress for this examination

• Position the patient appropriately – consider moving and handling – the patient can be examined in a chair or on the couch / bed

• Wear Personal Protective Equipment as required.

• Wash your hands before and after you touch the patient (as per WHO guidelines)

On first meeting a patient introduce yourself and confirm that you have the correct patient with

the name and date of birth, if available please check this with the name band, written

documentation and the NHS number/ hospital number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your

examination.

Ensure the procedure is explained to the patient in terms that they understand and gain

informed consent.

This procedure requires the presence of a chaperone. A chaperone is someone who is familiar

with the examination and can ensure that nothing inappropriate occurs by either party. The

chaperone can be a useful resource, not just being present to ensure the patient is treated

appropriately, but to help and support the patient.

Don personal protective equipment as required, especially if you are likely to come into contact

with bodily fluids and you may need to carry out a rectal exam at the end of the examination.

Also ensure good hand hygiene and wash your hands before and after touching the patient. As

per

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

Patient Positioning / Exposure

As this is an intimate examination in which the patient’s whole chest abdomen and groins will be

exposed;

• The environment should be warm and private,

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• Provide the patient with a gown or blanket to maintain their modesty,

• The groins and external genitalia are covered over until they are examined,

• A chaperone must be present.

For this examination you will need the patient to be

lying flat on their back, or with their head on a single

pillow and their hands by their sides.

The examiner should be positioned so they are on a

level with the abdominal surface (sat down next to

the patient).

If the patient complains of abdominal pain, allowing

them to flex their hips and knees during the

examination will relax the abdominal muscles and

may help to reduce the pain.

Equipment

For this examination you will need;

1. Hand wash

2. Stethoscope

3. Alcohol swabs (to clean the stethoscope).

4. Further equipment would be needed if a PR examination were undertaken.

Figure 4

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Inspection

General Inspection

• This can be undertaken with the patient sat upright.

• Observe the patient’s environment and their general appearance.

• Also check vital signs (respiratory rate, SPO2, pulse, BP, CRT, Temperature, Urine,

ACVPU/GCS and BM as appropriate).

In the environment there may be many indicators of possible abdominal conditions including:

• Vomit bowls

• Supplemental nutrition including tube feeding paraphernalia

• Uneaten meals

• Odours such as vomit, faeces, hepatic fetor and pear drops (associated with diabetes)

• Commode

• Alcohol containers

Their general appearance may show some signs of possible abdominal conditions such as:

• Signs of pain including facial expression and patient positioning

• Are they curled up in a ball? Have they got their arms clutching their abdomen? These

are some signs the patient may be in pain.

• Cachexia: wasting of the body due to severe chronic illness.

• Vomit or faecal soiling of bed linen or clothing.

• A change in colour such as yellow (jaundice) associated with hepatobiliary conditions, pallor

due to anaemia which may be secondary to bleeding into the bowel or a flushed appearance

secondary to inflammation / infection and scars.

Specific inspection

A systematic inspection should be undertaking to look closely for signs of abdominal conditions.

• Check the patient’s hands, fingers, eyes, mouth, teeth, tongue and breath.

• With the patient supine, inspection of the torso (front and back) should be done to observe

• Abdominal wall movement

• Scars

• Rashes

• Distension

• Swellings

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Hands (see hand and nail study guide)

Look for nail signs which may develop over a period of time and indicate a chronic disease

process. These signs may include:

• Clubbing – in chronic disease the finger tips

take on a bulbous (swollen) appearance.

• Koilonychia – another sign of chronic disease.

Koilonychia is commonly termed as spooning. It

occurs secondary to a chronic iron deficiency

anaemia which may be secondary to dietary

influences or chronic bowel problems such as

ulcerative colitis.

• Leukonychia – white nails due to problems

associated with protein metabolism.

• Nicotine tar staining – indicating chronic / heavy smoking.

• Pale nail beds - may indicate acute / chronic anaemia.

Asterixis (Liver or Metabolic Flap)

• Ask the patient to stretch out their arms, abduct their fingers and cock their wrists back and

ask them to hold this position for at least 15 seconds

• If the patient is unable to maintain this position and the hands “flap” this is known as

asterixis.

• This flapping (tremor) may be due to liver or respiratory conditions so again is not specific to

abdominal conditions. However, all examination findings are considered together when

looking to make your diagnosis.

Face, mouth and neck

Eyes

• Are the sclera of the eyes yellow? - jaundice will be

evident in the sclera much earlier than the skin in

hepatobiliary conditions

• Are the tarsal conjunctiva (lining of the eye lids) pink or

are they pale which may indicate chronic or acute

anaemia?

Mouth

Figure 5

Figure 6

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• Is there inflammation evident at the corners of the mouth

(angular cheilitis / angular stomatitis) which can be

associated with some of the inflammatory bowel diseases,

diabetes, cancer, oral thrush and certain medications?

• Look in the mouth, ensuring you look under the tongue:

▪ Is the mouth well hydrated? Dehydration may be a sign

of poor oral intake, acute kidney injury or chronic

vomiting / diarrhoea.

▪ Ulceration of the oral mucosa may be associated with

chronic inflammatory bowel conditions.

▪ Look for signs of oral thrush – there are a number of reasons patients may have this,

including poor oral hygiene, dry mouth, dentures – especially if they are poorly fitting.

• Whilst examining the face and oral cavity try to detect any abnormal odours on the breath

such as a faecal odour may indicate a bowel obstruction and hepatic fetor (sweet musty

smell) indicating liver disease (not to be confused with pear drops which are associated with

diabetes).

Lymph Nodes (See lymph examination study guide for further information)

• As part of an abdominal examination you should palpate for possible enlarged lymph nodes.

• As the GI system starts at the mouth, sites for enlarged lymph nodes include:

▪ Submental

▪ Submandibular

▪ Jugulodigastric

▪ Posterior cervical

▪ Deep cervical chain

▪ Superficial cervical chain

▪ Supraclavicular

▪ Infraclavicular

• A full GI examination should also look for enlarged lymph nodes in:

▪ Both axilla

▪ Both groins

• Troiser’s sign – Finding an enlarged left supra clavicular lymph node (Virchow’s node),

which may be associated with metastatic, spread of an abdominal malignancy.

Torso

Figure 7

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Inspection of the chest and abdomen should be done with the patient lying supine with hands by

their sides and a single pillow under their head.

It is important that the abdominal muscles are relaxed, even raising the head slightly can

increase abdominal tone. To relax a taught abdomen you can get the patient to flex their hips

and knees (“can you bend your knees and bring your feet towards your bottom”).

If the patient is sat up at this point you may wish to inspect the patient’s back before laying them

flat.

• Scars must be identified and the reason for the scar established. If the patient has had

previous abdominal surgery this

may help to rule out or indicate

some possible causes of abdominal

symptoms such as “adhesions”.

• Spider naevi / telangiectasia

(swollen blood vessels which

appear as a red central spot with

reddish blood vessels (figure 7)

which spread out from this central

spot) may be associated with liver

disease and increased oestrogen

levels. The presence of >5 on the

torso is abnormal.

• Gynecomastia (breast tissue in male patients) may develop with liver disease and an

increase in oestrogen levels.

• Abdominal distension – the causes of which can be remembered as the 6 F’s.

Causes of abdominal distension

Flatus (gas) – taut abdomen which is compressible.

Faeces – firm to hard mass take note of position as may be normal finding.

Fluid (ascites) – taut abdomen which may be non-compressible dependant on volume.

Fat – soft and compressible.

Foetus – a distended gravid uterus which will appear firm and distinct.

Fairly big tumours - firm to hard mass (Need to be pretty big!)

• Rashes - shingles may be a cause of pain and psoriasis may be associated with chronic

inflammatory bowel disorders.

• Mottled abdomen, can be associated with several disorders including pancreatitis, ruptured

aortic aneurysm, antiphospholipid syndrome or shock.

• Dilated veins on the torso or around the umbilicus may be associated with increased

pressure in the vena cava due to restricted flow through the liver in liver disease.

Figure 8

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• Abnormal abdominal movement i.e. visible peristalsis in bowel obstruction or pulsation

which may indicate an abdominal aortic aneurysm (AAA).

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Palpation (Abdomen)

Before we palpate we need to have an understanding of the underlying organs in each region

(figures 8 & 9).

There are 3 elements of abdominal palpation:

• Superficial palpation

• Deep palpation

• Specific organ palpation (Liver, Spleen, Kidneys and Bladder - discussed later)

Technique

• You should be positioned at the level of the patient’s abdominal surface to ensure you do not

apply too much pressure when palpating what may already be a painful / tender abdomen.

You will also be able to look across the abdomen for swellings and movement of the

abdomen.

• Palpation is performed using the palmar aspect of flat fingers, using the metacarpal

pharyngeal joints (knuckles) as a pivot on the abdomen.

• Always start palpation away from any site of pain and always observe patient’s face for signs

of discomfort.

Figure 9

Figure 10

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• Ensure that you palpate the whole of the abdomen not just 9 parts on the abdomen

Superficial Palpation

• Superficial palpation (figure 10) is using a light pressure to

depress the anterior wall of the abdomen allowing assessment

of muscle tone, tenderness and any obvious abnormalities.

• Palpate all 9 of the abdominal regions systematically.

▪ Guarding = contraction of the abdominal muscles in

response to pressure being applied over an area of

infection / inflammation.

▪ Rigidity = contraction of the abdominal muscles in

response to infection / inflammatory changes within the

abdominal / peritoneal cavity. This contraction is evident

prior to any palpation and the abdomen will be “rock”

hard. Normal abdominal movement with respiration will

be absent.

Deep palpation

• Deep palpation (figure 11) is using firm pressure to assess

more deeply for swellings, masses or other abnormalities.

• Palpate all 9 of the abdominal regions systematically.

Describing a Mass

If a mass is palpated describe it by:

- Abdominal region - Surface (smooth or irregular)

- Underlying structures / organs - Consistency (hard, firm, soft or fluid)

- Size (in cm) - Edge (defined or diffuse)

- Shape - If pulsating

- Depth (superficial or deep)

See swellings study guide for further information

To determine if the mass is in the abdominal wall or in the abdomen itself you can ask the

patient to raise their head, this will cause the muscles to contract and allow you to differentiate

Figure 11

Figure 12

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whether the mass is on the wall or within the abdomen itself. A mass in the abdominal would

become harder to feel, as you would have to palpate through the abdominal wall as well.

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Organ-Specific Examination

During an abdominal examination these organs are routinely palpated;

• Liver

• Spleen

• Kidneys

Other organs which you may be able to palpate include:

• Bladder

• Aorta

General Points

• When palpating organs, feel for the edges as they

provide a better contrast between surrounding

tissues/organs and the organ you are palpating (figure

12).

• To detect organomegaly, palpation should start at the

furthest point that enlargement of the organ can occur

and be directed towards the position the organ normally

lies in.

• Palpation of organs may be assisted by assessment of

their mobility in relation to respiration, this is because the

diaphragm moves down on inspiration, pushing

abdominal organs downwards:

▪ The liver descends towards the right iliac fossa.

▪ The spleen descends inferio-medially towards the right iliac fossa.

▪ The kidneys descend inferiorly.

• If the liver or spleen are enlarged they may be felt below the costal margin.

Figure 13

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Liver

Position

• The liver lies predominantly under the ribs on the right side, although it

does cross the midline.

• The inferior border of the liver lies approximately parallel with the costal

margin.

Movement / Enlargement

• The liver moves inferiorly on inspiration.

• Enlargement also occurs in an inferior direction and may be due to a

number of reasons including fatty liver disease, alcohol liver disease,

cysts, cancer, cardiac failure, cirrhosis and infection.

Palpation of the Liver

• In view of the direction of enlargement, palpation of the liver should

commence well away from the costal margin in the right iliac fossa.

• The thumb is extended to expose the lateral margin of the index finger.

• The hand is position so that the lateral margin of the index finger is

parallel with the costal margin (and the liver edge).

• The patient is asked to take a deep breath in and pressure is applied

to the abdominal wall by the examining hand.

• If the liver is not palpated, the examining hand is moved closer to the

costal margin by about 1cm at a time and the patient is asked to

repeat deep inspiration.

• The process is repeated until the hand reaches the costal margin or

the inferior edge of the liver is palpated.

• A normal liver is impalpable or palpated close to the costal margin.

• An enlarged liver (hepatomegaly) may be palpated distal to the

costal margin and the distance is measured in cm from the costal

margin.

Spleen

Figure 14

Figure 15

Figure 16

Figure 17

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Position

• The spleen lies entirely under the ribs on the left side (figure 17). A

normal spleen is approximately fist sized and the long axis of the

spleen lies along the line of the 10th rib.

Movement / Enlargement

• The spleen moves inferio-medially on inspiration,

even on deep inspiration the normal spleen

cannot be felt on palpation (figure 18).

• Enlargement of the spleen also occurs in an

inferio-medial direction - a massive spleen may

extend into the right lower abdomen (figure 19).

• To be palpable, the spleen must enlarge to at

least twice normal size.

• With a very large spleen, you may be able to

palpate the distinctive splenic notch.

Palpation of the Spleen

• Palpation for the spleen is facilitated by placing the left hand under

and behind the lower left rib and pulling upwards and towards you.

This may encourage an enlarged spleen, otherwise not palpable, to

appear beyond the costal margin on inspiration. Some clinicians prefer

the patient to roll onto their right side to achieve the same effect.

• In view of the direction of enlargement, palpation for the spleen should

commence well away from the costal margin in the right iliac area.

• Use the flat of the palmar surface of finger tips (right hand) in a dipping

motion to palpate through the abdominal wall.

• The patient is asked to take a deep breath in and pressure is applied

by the examiner’s hand to the abdominal wall.

• If the spleen is not palpated, the examining hand is moved closer to

the costal margin by 1-2cm and the patient asked to repeat deep

inspiration.

• The process is repeated until the spleen is palpated or the costal

margin reached.

• A normal spleen will not be palpable.

Figure 20

Figure 18

Figure 19

Figure 21

Figure 22

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• An enlarged spleen (splenomegaly) may be palpatated distal to the costal margin and the

distance is measured in cm from the costal margin.

Kidneys

Position

• The kidneys extend from the 12th thoracic

vertebrae to the 3rd lumbar vertebrae

(figure 22).

• They are not normally palpable in health.

• The right kidney is lower than the left due

to the position of the liver

• In health they have firm consistency with a

smooth surface.

Movement

• The kidneys move inferiorly with

inspiration.

Palpation of the Kidneys

• The kidneys are retroperitoneal organs and therefore deep

bimanual palpation is required.

• On preparing for examination, position the patient close to the

edge of the bed, then tuck one hand under the patient so that

the fingers tips nestle in the renal angle (between the posterior

costal margin and spine)..

• Place one hand under the patient’s flank, with fingers in the

renal angle

• Place the other hand, with fingers flat, on the antero-lateral

abdominal wall below the costal margin, lateral to the rectus

muscle and opposite the other hand.

• Ask the patient to breathe in deeply and press the fingers of both

hands firmly together.

• The rounded lower pole of the kidney may be felt passing

between the opposing fingers as the patient breaths in and out.

Balloting the Kidneys

Figure 23

Figure 25

Figure 24

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To differentiate the kidneys from other organs or masses by using a

technique known as ‘balloting’ where a structure that is not fixed can

be patted between the examining hands.

Percussion

The kidneys are not routinely percussed as they lie retroperitoneal

and are therefore covered by air-filled bowel.

Percussion (Abdomen)

Percussion allows us to determine:

1. The consistency of the underlying tissues / organs.

2. The borders of a mass / organ.

A dull percussion note would generally indicate either an underlying organ (liver, spleen or

bladder) or fluid (ascites).

Generally the abdomen should have a resonant percussion note due to the underlying air-filled

bowel, because in the supine position any fluid in the bowel settles posteriorly.

All 9 regions of the abdomen should be percussed and any pain or tenderness should be noted

as this may indicate an inflammatory process within the abdominal / peritoneal cavity, e.g.

appendicitis or peritonitis.

Percussion Technique

Place the non dominant hand on the surface of

the body, with the fingers slightly spread. Press

the distal phalanyx of the middle finger firmly

on the body surface and snap the wrist of the

dominant hand downwards. The tip of the

middle finger should sharply tap the middle

phalanx that is pressing on the body surface.

Following this the striking finger is immediately

removed, repeating two to three taps only

(figure 26).

Percussion of the Liver

Figure 26

Figure 27

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The superior border of the liver is normally level with the 6th intercostal space in the

midclavicular line. The span of the liver (in the midclavicular line) is less than 13 cm; percussion

can check this.

Start at the chest apex where the percussion note should be

resonant. Gradually move inferiorly until the note becomes

dull (the upper liver edge). Start again at the right iliac fossa

where the note should also be resonant. Gradually move

inferiorly, towards the costal margin, until the note becomes

dull (the lower liver edge). This is not an exact measurement

and the clinical estimate of the liver span usually

underestimates its actual size by 2 to 5 cm. (figure 27).

The kidneys are not routinely percussed as they lie

retroperitoneal and are therefore covered by air-filled bowel.

Bladder

The bladder normally sits deep within the pelvis, however when it becomes distended it can

extend above the pubic bone in the direction of the umbilicus.

If there is a fullness felt within the suprapubic region during palpation of the abdomen,

percussion should be used to determine the upper border of the bladder.

With the examining finger parallel to the pubis, start in the midline at the level of the umbilicus

and percuss increasingly closer to the pubic bone.

The point at which the percussion note changes from resonant to dull would indicate the upper

margin of the distended bladder.

Note: An enlarged uterus would also extend in the same direction as a distended bladder,

however it would feel distinct/solid than fullness felt with a distended bladder.

Figure 28

28

Auscultation (Abdomen)

Bowel sounds (Borborygmus)

Bowels sounds are low to medium pitched grumbles/gurgles associated with the passage of

fluid and gases through the bowel as peristalsis occurs. Sounds should occur at least every 2 –

4 minutes in health.

You can listen in any area of the abdomen and bowel sounds should be heard, but when

examining a patient, use the diaphragm of the stethoscope and listen in the lower right quadrant

for 2-3 minutes (as soon as you hear sound you can stop listening).

If no sound is heard listen elsewhere on the abdomen for a further 2-3 minutes.

If there are no bowel sounds after listening in 2 regions you can confirm the absence of bowel

sounds. In this case you may hear referred heart and breath sounds, instead of bowel sounds.

• Increased bowel sounds may be an indication of inflammation, infection, recent intake of

food, partial obstruction or the initial stages of acute bowel obstruction – the sounds increase

in frequency and become higher in pitch as the peristaltic action of the bowel increases to try

to move the obstruction along.

• Tinkling bowel sounds may be an indication of acute bowel obstruction. They are increased

in frequency and higher in pitch due to the increased peristaltic action of the bowel trying to

move the obstruction along.

• “Absent” bowel sounds occur when there is an ileus present. This could be caused by

complete obstruction which may lead to necrosis and as a result peristaltic action may cease

(ileus).

Whilst auscultating the abdomen you should also take the opportunity to listen for abdominal

bruits as detailed within the cardiovascular examination study guide.

Aorta

In slim patients, whilst you are palpating the abdomen you may feel a discrete pulsatile structure

above the umbilicus and in the midline. This is likely to be the abdominal aorta and further

information can be found on this within the CVS study guide.

29

Shifting Dullness

In a patient with a distended abdomen, using percussion can elicit shifting dullness, which is a

sign that confirms the presence of fluid within the peritoneal cavity (ascites)

This test recognises that fluid will move with gravity to the lowest point within the abdomen,

whereas the gas-filled bowel will lie above the fluid level. Therefore, by moving the patient from

a supine to a lateral position, a change in the gas/fluid level will be detected on percussion

(figure 28).

• Start with the patient in a supine position.

• Percuss in the midline at the umbilicus, with the finger of the examining hand parallel to the

lateral abdominal wall. As can be seen in figure 28 the air (in blue) is lying above the fluid.

• Gradually move 1-2cm towards the left flank, testing the percussion note each time until it

changes from resonant to dull.

• Mark this transition point (the gas/fluid level) with your finger.

• Now ask the patient to change position onto their right side and wait for 30-60 seconds.

• Percuss again at the same spot and the percussion note will not be resonant, as the ascitic

fluid will have settled towards the right flank. This time the air (in the second image of figure

28) is to the patient’s lateral side, again having risen above the fluid.

Figure 29

30

Hernias

Hernias are abnormal protrusion of bowel

and/or omentum from the abdominal

cavity (figure 29). They are common and

typically occur at openings of the

abdominal wall, such as the inguinal,

femoral and obturator canals, the

umbilicus and the oesophageal hiatus.

They may also occur at sites of weakness

of the abdominal wall, as in previous

surgical incisions.

External hernias are more obvious when

the pressure within the abdomen rises,

such as when the patient is standing,

coughing or straining at stool. An impulse can often be felt in a hernia during coughing (cough

impulse).

Internal hernias can occur through defects of the mesentery or into the retroperitoneal space,

however they are not visible during a clinical examination.

Hernias can often be identified based on their anatomical site and characteristics:

Inguinal

Inguinal hernias are palpable above and medial to the pubic

tubercle.

An indirect inguinal hernia bulges through the internal inguinal

ring and follows the course of the inguinal canal. It may extend

beyond the external ring and enter the scrotum. Indirect hernias

comprise 85% of all hernias and are more common in younger

men.

A direct inguinal hernia forms at a site of muscle weakness in the posterior wall of the inguinal

canal and rarely extends into the scrotum. It is more common in older men and women

Figure 30

Figure 31

31

Other Hernia

Femoral hernia project through the femoral ring into

the femoral canal and are palpable below the inguinal

ligament, lateral to the pubic tubercle.

Umbilical hernia project through the umbilicus (figure

31).

Paraumbilical hernia project through around the

umbilicus.

Incisional hernia project through the site of a

previously made incision.

Characteristics

Reducible Hernia - when the herniated contents can be returned to the abdominal cavity,

spontaneously or by manipulation.

Strangulated Hernia - An abdominal hernia has a covering sac of peritoneum and the neck of

the hernia is a common site of compression of the contents. If the hernia contains bowel,

obstruction may occur. If the blood supply to the contents of the hernia (bowel or omentum) is

restricted, the hernia is strangulated. It is tense, tender and has no cough impulse, there may be

bowel obstruction and, later, signs of sepsis and shock. A strangulated hernia is a surgical

emergency and, if left untreated, will lead to bowel infarction and peritonitis

Incarcerated Hernia – an irreducible hernia, when the herniated contents cannot be returned to

the abdominal cavity, spontaneously or by manipulation.

Examination of the Groin / Hernias

Inspection

• With the patient standing up and both groins exposed, examine the patient’s inguinal and

femoral canals and, in male patients, the scrotum for any lumps or bulges.

• Ask the patient to cough; look for an impulse over the femoral or inguinal canal and scrotum.

• Identify the anatomical relationships between the bulge, the pubic tubercle and the inguinal

ligament to distinguish a femoral from an inguinal hernia.

Palpation

• Palpate the external inguinal ring and along the inguinal canal for possible muscle defects.

Figure 32

32

• Ask the patient to cough and feel for a cough impulse.

• Now ask the patient to lie down and establish whether the hernia reduces spontaneously. If

so, press two fingers over the internal inguinal ring at the mid-inguinal point and ask the

patient to cough or stand up while you maintain pressure over the internal inguinal ring.

• If the hernia reappears, it is a direct inguinal hernia.

• If it can be prevented from reappearing, it is an indirect inguinal hernia.

• Examine the opposite side to exclude the possibility of asymptomatic hernias.

33

Specific Abdominal Signs

Aaron's sign

Referred pain felt in the epigastrium upon continuous firm pressure over McBurney's point. It is

indicative of appendicitis.

McBurney’s Point

A point one third of the distance (approximately 2 inches) from the right anterior

superior iliac spine to the umbilicus

McBurney's sign

Deep tenderness at McBurney’s point is indicative of late stage acute appendicitis with an

increase in the risk of rupture.

Murphy’s sign

Placing fingers or thumb under right costal cartilage and asking the patient to breathe in. If there

is an increase in pain +/- catching breath then this is indicative of cholecystitis.

Obturator sign

Flexing the right hip and knee, then internally rotation the right hip will cause an increase in

abdominal pain in appendicitis.

Rosving’s Sign

Pressure over the patient's left lower quadrant causes pain in the right lower quadrant in

appendicitis, however this test is unreliable, with a poor sensitivity.

34

Documentation

Recording your findings

When recording your findings you must include the patient identifiers, date + time, your

signature and print your name and designation at the end of the entry.

When documenting or describing your findings remember to comment on inspection (describing

any abnormalities seen), the tone of the abdominal wall and any sign such as guarding or

rigidity, any masses found and findings on percussion and auscultation.

Remember to describe your findings as fully as possible, including details such as size, position

(relative to the regions or quadrants as previously described), shape and consistency.

A diagram will often be useful in written notes (figure 32). If the patient complains of pain it is

useful to use an acronym such as SOCRATES to work out the site, onset, character, any

radiation, associated factors, time, exacerbating or relieving factors, and the severity of the pain.

You will also need to understand different types of pain, such as sharp, stabbing, ache, cramp

like etc.

Be sure to report any abnormal findings to your supervisor

Figure 33

35

Bibliography & Further Reading

Innes, J Alastair, BSc PhD FRCP(Ed); Dover, Anna R, PhD FRCP(Ed); Fairhurst, Karen, PhD

FRCGP. Macleod's Clinical Examination, Fourteenth Edition

Macleod's Clinical Examination, Plevris, John; Parks, Rowan. Published January 1, 2018. Pages 93-117. © 2018.

Petroianu, A. (2012). Diagnosis of acute appendicitis. International Journal of Surgery, 10(3),

115-119.

Thomas, M., & Hollins, M. (1974). Epidemic of postoperative wound infection associated with

ungloved abdominal palpation doi: https://doi.org/10.1016/S0140-6736(74)91019-8

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/ [accessed

08/07/19]

Images All images CSTLC except

1. Sobotta Atlas of Anatomy, Vol. 2, 16th ed., English/Latin, Paulsen, Friedrich. Published January 1, 2018. Pages 95-206. © 2018.

2. The gastrointestinal examination, Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW),

PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. &

Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon), Talley & O'Connor's Clinical

Examination, Chapter 14, 229-271

3. The gastrointestinal examination, Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW),

PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. &

Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon), Talley & O'Connor's Clinical

Examination, Chapter 14, 229-271

4. Abdominal palpation CSTLC

5. Crash Course Metabolism and Nutrition, Vanbergen, Olivia, MA Oxon, MSc, MBBS

(distinction); Wintle, Gareth. Published January 1, 2019. Pages 191-211. © 2019.

6. Clinical Biochemistry: An Illustrated Colour Text, Murphy, Michael, MA MD FRCP

FRCPath; Srivastava, Rajeev, MS FRCS FRCPath...Show all. Published January 1, 2019.

7. Ferri's Clinical Advisor 2020, Ferri, Fred F., M.D. Published January 1, 2020. Pages

115.e2-115.e3. © 2020.

8. Talley & O'Connor's Clinical Examination. Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW), PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. & Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon); O'Connor, Simon, FRACP, DDU, FCSANZ. Published January 1, 2018. Pages 229-271. © 2018.

36

9. Seidel's Guide to Physical Examination, Ball, Jane W., DrPH, RN, CPNP; Dains, Joyce E.,

DrPH, JD, RN, FNP-BC, FNAP, FAANP...Show all. Published January 1,

2019. Pages 393-436. © 2019.

10. Image adapted from: Jmarchnderivated work from File:Abdominal Quadrant Regions.jpg:

[1] / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

11. Superficial palpation CSTLC

12. Deep palpation CSTLC

13. Organ specific palpation CSTLC

14. Palpation of the liver CSTLC

15. Palpation of the liver CSTLC

16. Palpation of the liver CSTLC

17. Palpation of the liver CSTLC

18. Palpation of the spleen CSTLC

19. Palpation of the spleen CSTLC

20. Palpation of the spleen CSTLC

21. Palpation of the spleen CSTLC

22. Palpation of the spleen CSTLC

23. Sobotta Atlas of Anatomy, Vol. 2, 16th ed., English/Latin, Paulsen,

Friedrich. Published January 1, 2018. Pages 95-206. © 2018.

24. Kidney palpation CSTLC

25. Kidney palpation CSTLC

26. Kidney palpation CSTLC

27. Textbook of Physical Diagnosis: History and Examination, Swartz, Mark

H. Published January 1, 2021. Pages 354-379.e1. © 2021.

28. Seidel's Guide to Physical Examination. Ball, Jane W., DrPH, RN, CPNP, Seidel's Guide

to Physical Examination, Chapter 18, 393-436, Liver percussion routes along midclavicular

and midsternal lines. (Modified from Wilson and Giddens, 2009.) Copyright © 2019

29. Textbook of Physical Diagnosis: History and Examination. Swartz, Mark

H. Published January 1, 2021. Pages 354-379.e1. © 2021.

30. Adapted from: Churchill's Pocketbook of Surgery. Raftery, Andrew T. Published January 1, 2017. Pages 216-229. © 2017.

31. Macleod's Clinical Examination, Plevris, John; Parks, Rowan. Published January 1, 2018.

Pages 93-117. © 2018.

32. Textbook of Physical Diagnosis: History and Examination, Swartz, Mark

H. Published January 1, 2021. Pages 354-379.e1. © 2021.

33. Documentation of abdominal findings CSTLC

References

37

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/