Right Upper Quadrant (RUQ)
Liver & Gallbladder
Pylorus & Duodenum
Head of pancreas
Hepatic Flexure of colon
R adrenal & upper kidney
Right Lower Quadrant (RLQ)
Lower R kidney & ureter
Cecum & appendix
Left Upper Quadrant (LUQ)
Left lobe of liver
Spleen & Stomach
Body of pancreas
Splenic flexure of colon
L adrenal & upper kidney
Left Lower Quadrant (LLQ)
Lower L kidney & ureter
Abdominal Cross Section T12 Level
Important strudtures: Liver, Stomach, Spleen , Kindeys
Pelvic Contents (female)
Important Structues: Decending colon, Sigmoid colon, Uterus, Urinary Bladder, Vermiform Appendix, Cecum, Terminal Ileum,Abdominal Aorta, Psoas Major & Minor
Loss of appetite
localized post-prandial epigastric discomfort
inability to consume a normal size meal
sense of retrosternal or epigastric burning with radiation to the neck often associated with possible gastric reflux (r/o coronary artery disease-CAD)
spasmodic movements of chest and diaphragm
raising gastric contents w/o N/V/Retching
forceful expulsion of gastric contents through mouth
vomiting blood (often “coffee-ground” appearance)
-usually peptic ulcer disease
pain on swallowing (burning or squeezing) – candidiasis vs muscular cause
Change in Bowel Function
- constipation (less than 3/week)
- obstipation(not even passing gas,secondary to obstruction)
- melena (upper GI bleed)/hematochezia
- greasy/oily stools (malabsorption vs
Symptoms Concerning for GI Pahologies
Anorexia, Indigestion, Early Satiety, Hertburn,Retching, Regurgitation, Vomiting,Hemetemesis, Dysphagia, Odynophagia, Change in Bowel function
Types of Abdominal Pain
Visceral Abdominal pain
-occurs when hollow organs (intestines or biliary
tree unusually contract, distend or stretch.
-difficult to localize.
-experienced at the midline.
-gnawing, burning, cramping, sweating, pallor,
-Early stages of appendicitis.
Parietal Abdominal Pain
-originates in the parietal peritoneum.
-caused by inflammation.
-steady aching pain over the involved structure.
- P > V (tenderness/guarding -> rigidity/rebound)
-aggravated by movement/coughing.
-Afferent (inflammation) signals are sent from the specific area and localized to the dermatome superficial to the site.
Referred Abdominal Pain
-experienced at a more distant site.
-innervated at approximately the same dermatomal level as the disordered structure.
-Often develops as the initial pain intensifies
and appears to radiate.
-radiating pain (acute cholecystitis=R sld,
Abdominal Exam: Examiner:
-Ensure that patient has an empty bladder
-Start on the right side of the patient
-Wash and warm hands; warm stethoscope
-Any areas of pain ?
Abdominal Exam: Positioning Patient
-Supine (with pillow under head)
-Abdomen exposed (“full exposure from below the xiphoid to the symphysis pubis”)
-Knees flexed and arms at side (to avoid
tightening of abdominal muscles)
Skin Inspection: Portal Circulation
Veins that transport blood from:
-Digestive organs (stomach, SB, Lg. Intestine) and
-Spleen, pancreas and gall-bladder to the liver.
Skin Inspection: Portal Hypertension
If blood can’t flow easily through the liver due to scarring (cirrhosis) or inflammation (hepatitis) portal vein pressure increases (hypertension) often causing weak-walled vessels (varices) that can rupture and cause hemorrhaging.
Inspection of Contour and Symmetry
Look for Hernias, Pulsations, Peristaltic Activity
above 3cm atotic
above 5cm = bad
Generalized: Obesity (protuberant),Ascites, Intestinal obstruction (gaseous distention), Peritonitis (ileus)
Upper Abdomen:Hepatomegaly, splenomegaly, pancreatic cyst or tumor, gastric outlet obstruction, aortic aneurysm, hernia
Lower Abdomen:Uterus, ovary, bladder, hernia, intestinal mass
Why Auscultation Before Percussion or Palpation ?
Auscultation first because percussion and palpation may alter the frequency of bowel sounds.
Auscultation: Increased Bowel Sounds
Increased:(gastroenteritis, laxatives, early intestinal obstruction, GI hemorrhage)
-Bowel sounds may be high pitched and occur in frequent waves (“rushes”) with early bowel obstruction.
Ausultation: Decreased Bowel Sounds
Decreased:(late bowel obstruction, paralytic ileus, peritonitis)
-Bowel sounds are typically absent with peritonitis.
Abdominal Exam: Percussion
-The predominant percussion note over abdomen
-Gaseous distention of viscera
Dullness: Ascites, organomegaly, tumor
Percussing Liver Span
6-12 cm in right midclavicular line
4-8 cm in midsternal line
Splenic Percussion Sign
Percuss the left lower anterior chest wall to detect splenomegaly in the area termed :
-change in percussion notre from tympany to dullness on inspiration suggests splenic enlargement: Positive splenic percussion sign
-Guarding: Rigidity (muscular spasm) vs. voluntary
-Organomegaly:Liver, spleen, kidneys, bladder
-Masses:Physiologic = pregnant uterus
Inflammatory = Diverticulitis, Crohn’s disease (iliocecal area)
Vascular = Aneurysms
Neoplastic = CA
Peritonitis: Differential Diagnosis
-Perforated viscus (e.g., perforated duodenal
ulcer, ruptured appendix, etc.)
-Pain and tenderness:
-May be well localized or referred
-Pain aggravated by movement and cough
-Rebound or percussion tenderness
-Guarding = Abdominal rigidity (“board-like
abdomen”)body's defense mechanism
-Absent or decreased bowel sounds
What is Ascites?
-Ascites is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity).
-Usually an indication of severe liver disease.
-Caused by high pressure in the venous blood vessels of the liver (portal hypertension) and low albumin levels.
Ascites Differential Diagnosis:
-Metastatic colon cancer
-Chronic liver disease (cirrhosis)
-Abdominal malignancy (carcinomatosis)
-Right sided heart failure
-Thrombosis of hepatic vein or inferior vena cava (Budd-Chiari syndrome)
Ascititc fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness)
Hepatomeglay Differential Diagnoses
-Malignancy (Metastatic cancer, primary liver cancer, lymphoma, leukemia)
-Fatty liver disease (alcohol, diabetes)
Splenomegaly Differential Diagnoses
Bacterial endocarditis, tuberculosis)
-Neoplasm (Lymphoma, acute and chronic leukemia, PCV)
(Shown Here: Rovising's Sign,McBurney's Point)
Psoas sign - pain on extension of right thigh (retroperitoneal/retrocecal appendix)
Obturator sign - pain on internal rotation of right thigh (pelvic appendix)
Rovsing's sign - pain in right lower quadrant with palpation of left lower quadrant (pain when pressing on oposite side at same point as apendix)
Dunphy's sign - increased pain with coughing
McBurney's Point - half way between ASIS & umbilicus, where you would make incision
Recognizing Apendicitis Cont.
-Right lower quadrant pain on palpation (the single most important sign)
-Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever can occur
-Localized tenderness to percussion
-Flank tenderness in right lower quadrant (retroperitoneal or retrocecal appendix)
-Patient maintains hip flexion with knees drawn up for comfort
-Pain/ Tenderness Pattern:
-Guarding/ Rebound Tenderness
Cough or percussion tenderness
Atypical Pain: Retrocecal Appendix
Atypical Pain: Pelvic Appendix
Recognizing Appendicitis: Psoas Sign
Psoas sign: Pain with extension of right hip or flexion of right hip against resistance.
Recognizing Appendicits: Obturator Sign
Obturator sign: Pain with internal rotation of the right hip.
Recognizing Appendicitis: Rectal & Pelvic Exams
Rectal and Pelvic Exams:
Rule out pelvic disease in women
Demonstrate tenderness of pelvic appendix (especially if atypical pain pattern)
Epigastic, Umbilical, hypogastric (suprapubic)
Hypochondrium, Lumbar (flank), Ingunal (iliac)
Order of performing the Abdominal Examination
Vascular Bruit - CAD will hear bruit
CVA tenderness = Pyelonephritis or MS cause
-Increased sensitivity to sensory stimuli, such as pain or touch.
At a series of points down the abdominal wall, gently pick up skin folds between finger and thumb without pinching the skin.
-Localized pain elicited in the RLQ may accompany appendicitis.
-When RUQ pain/tenderness are present, assess for acute cholecystitis
Move extended fingers of right under the costal margin, ask the patient to exhale and as they take a deep breath, advance the fingers under the costal margin.
-A sharp increase in tenderness with a sudden stop in inspiratory effort is a positive sign.