Cilinical examination of the abdomen on normal subject

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Clinical Examination of the Abdomen (Normal Subject)

The abdominal examination follows a strict sequence: General Examination → Inspection → Palpation → Percussion → Auscultation. On a normal subject, all findings are used as the baseline against which pathology is detected.

Preparation & Positioning

The patient lies flat on their back, legs extended (a pillow under the head is acceptable).
For palpation, hips and knees are flexed to relax abdominal muscles.
The abdomen is fully exposed from the nipple line above to the saphenous openings (inguinal/femoral rings) below.
Examination is performed in good light, preferably daylight.
The examiner inspects first from the side, then tangentially, then from either end of the bed.
S Das A Manual on Clinical Surgery 13th Edition, p. 460

Surface Anatomy Reference

The abdomen is divided into nine regions by two horizontal and two vertical lines:

No.	Region
1	Right hypochondrium
2	Epigastrium
3	Left hypochondrium
4	Right lumbar (flank)
5	Umbilical
6	Left lumbar (flank)
7	Right iliac fossa
8	Hypogastrium (suprapubic)
9	Left iliac fossa

Alternatively, a simpler 4-quadrant scheme (RUQ, LUQ, RLQ, LLQ) is used for quick clinical description.

S Das A Manual on Clinical Surgery 13th Edition, p. 523

Step 1: General Examination (Before the Abdomen)

Before focusing on the abdomen, a general survey is done:

Hands: Pallor of palmar creases (anaemia), clubbing, leukonychia, Dupuytren's contracture (liver disease), flapping tremor (hepatic encephalopathy).
Eyes: Jaundice (scleral icterus), anaemia (conjunctival pallor), xanthelasma.
Face/Mouth: Parotid enlargement, angular stomatitis, glossitis, telangiectasia (Osler-Weber-Rendu).
Neck: Left supraclavicular lymphadenopathy (Virchow's node / Troisier's sign) - suggests intra-abdominal malignancy.
Vital signs: Heart rate, BP, respiratory rate, temperature, weight/BMI.
Bailey and Love's Short Practice of Surgery 28th Edition, p. 1076

Step 2: Inspection

Inspect systematically:

1. Hernial Orifices (inspect first)

Look at the inguinal, femoral, and umbilical rings. Ask the patient to cough - a cough impulse indicates a hernia.
S Das advises inspecting hernial orifices first, as they may be the cause of acute abdominal symptoms.

2. Skin

Normal: No scars, erythema, pigmentation, or rash.
Note any scars - linear (healed by first intention) vs. broad/irregular (wound infection).
Engorged superficial veins:
- Around umbilicus ("caput medusae") - portal hypertension.
- On flanks running upward - IVC obstruction.
Hard subcutaneous periumbilical nodule (Sister Mary Joseph's nodule) - intra-abdominal carcinoma.

3. Umbilicus

Normal position: Midway between the xiphoid tip and the pubic symphysis.
Normal appearance: Inverted (slit-like), central.
Displacement upward - pelvic mass; downward - ascites (Tanyol's sign).
Eversion - ascites; deep inversion - obesity.

4. Contour / Shape of the Abdomen

Normal: Flat or gently scaphoid (concave) in a lean person; slightly protuberant in a well-nourished adult.
Normal umbilicus: Inverted in obesity vs. everted in intra-abdominal distension - a key distinguishing feature.
The 5 "Fs" of distension: Fat, Fluid, Flatus, Faeces, Foetus.

5. Respiratory Movements

Normal: The abdominal wall rises gently with inspiration (predominantly abdominal breathing in males; thoracic in females).
Reduced or absent movement indicates peritoneal irritation (localized or diffuse).

6. Visible Peristalsis

Normal: Not visible.
Visible peristalsis indicates obstruction (gastric outlet - left to right; small bowel - "ladder pattern"; transverse colon - right to left).

7. Pulsations

Normal: A faint aortic pulsation may occasionally be seen in thin individuals in the epigastrium.
A prominent expansile pulsation suggests abdominal aortic aneurysm.

Step 3: Palpation

Technique

The examiner's forearm must be horizontal at the level of the patient's abdomen.
Use the volar (palmar) surfaces of the fingers - never the fingertips pointing downward.
Begin palpation in the quadrant furthest from the site of pain (if any) and end at the painful area.
Watch the patient's face for signs of discomfort during palpation.

Superficial (Light) Palpation

Detect tenderness, superficial masses, rigidity, guarding.
Normal: Soft, non-tender abdomen, no involuntary guarding.
Voluntary guarding: Patient tenses abdomen in anticipation; can be overcome by distraction.
Involuntary guarding/rigidity: True sign of peritoneal irritation.

Deep Palpation

Used to examine the solid organs and identify deeper masses.

Liver

Begin in the right iliac fossa, move upward with each expiration.
The right hand is placed flat, fingers pointing toward the right costal margin.
Alternatively, use the bimanual method (left hand behind the right loin) or dipping method for tense ascites.
Normal: Not palpable below the costal margin (or just palpable with a smooth, firm, regular edge on deep inspiration in thin individuals).
Note: edge, surface, consistency, tenderness, pulsatility.

Gallbladder

Palpable just below the liver edge at the tip of the 9th costal cartilage, right of midline.
Normal: Not palpable.
Murphy's sign: Deep inspiration while pressure is applied at the gallbladder point produces inspiratory arrest in acute cholecystitis.

Spleen

Begin palpation from the right iliac fossa, move toward the left costal margin.
Bimanual: left hand behind the left lower ribs, right hand palpating.
The patient may be asked to roll to the right lateral decubitus (right lateral position) to bring the spleen forward.
Normal: Not palpable (must be 2-3 times its normal size to be felt).

Kidneys

Bimanual (ballottement): Left hand in the loin (posteriorly), right hand in the flank (anteriorly).
The kidney can be ballotted (bounced between the two hands).
Normal: Left kidney generally not palpable; right kidney occasionally palpable in thin individuals on deep inspiration.

Aorta

Palpate in the midline epigastrium.
Normal: A pulsatile, non-expansile aorta felt as a single midline structure in thin patients.
Widened or expansile pulsation - aneurysm.

Rebound Tenderness (Blumberg's Sign)

Press slowly and deeply, then release rapidly.
Pain on release = peritoneal irritation.
Normal: No rebound tenderness.

Fluid Thrill and Shifting Dullness

Tested during percussion (see below), but sometimes elicited during palpation by the fluid thrill test.

Step 4: Percussion

Used to delineate organ boundaries and detect free fluid or gas.

Liver Dullness

Percuss downward from the right 4th intercostal space in the mid-clavicular line.
Upper border: Where resonance changes to dullness (normally 5th ICS, MCL).
Lower border: Where dullness ends (normally at the costal margin in MCL).
Loss of liver dullness (gas over liver) is a critical sign of hollow viscus perforation (e.g., peptic ulcer perforation).

Splenic Dullness

Traube's space (lower left chest, bounded by stomach, diaphragm, splenic flexure): normally resonant.
Dullness in Traube's space suggests splenomegaly.

Percussion for Ascites

Shifting dullness: Percuss from umbilicus to flank - note level where dullness begins. Patient rolls to the opposite side; the dullness shifts (fluid follows gravity). Normal: No shifting dullness.
Fluid thrill: Place a hand flat on one flank; flick the other flank with a finger. An assistant's hand on the midline prevents conduction through fat. A transmitted impulse = free fluid. Normal: No fluid thrill.

Percussion of the Bladder

A distended bladder produces suprapubic dullness extending upward from the symphysis pubis.
Normal: Suprapubic area is resonant (empty bladder).

Step 5: Auscultation

Use the diaphragm of the stethoscope, held lightly on the abdomen.
Listen for at least 2 minutes before declaring bowel sounds absent.

Bowel Sounds

Normal: Soft gurgling sounds every 5-10 seconds, reflecting peristalsis.
Increased (tinkling, high-pitched): Mechanical obstruction, early peritonitis.
Absent: Paralytic ileus, advanced peritonitis, immediately post-operative.

Vascular Bruits

Auscultate over the aorta (epigastrium), renal arteries (just lateral to umbilicus bilaterally), and iliac arteries.
Normal: No bruits.
A bruit suggests arterial stenosis or aneurysm.

Succussion Splash

The patient is asked to move rapidly from side to side while the examiner listens over the epigastrium.
An audible splash indicates fluid + air in a hollow viscus (e.g., gastric outlet obstruction).
Normal: No succussion splash (or a mild splash if the patient has just eaten/drunk).

Step 6: Special Tests & Completion

Per rectal (digital rectal) examination: Should not be omitted. Assess anal sphincter tone, rectal mucosa, prostate (in males), cervix/uterus via posterior wall (in females). Note stool color/consistency.
Hernial orifices re-examined with the patient standing and coughing.
Examine external genitalia and scrotum (testicular malignancy can produce para-aortic masses).

Summary: Normal Findings on Abdominal Examination

Step	Normal Finding
Inspection	Flat/scaphoid contour; inverted or centrally placed umbilicus; no scars, no dilated veins, no visible peristalsis; active respiratory movements
Superficial palpation	Soft, non-tender, no guarding or rigidity
Deep palpation	Liver, spleen, kidneys not palpable (except occasionally in thin individuals); no masses
Percussion	Liver dull (5th ICS to costal margin); Traube's space resonant; no shifting dullness
Auscultation	Normal bowel sounds every 5-10 sec; no bruits; no succussion splash

Sources:

S Das, A Manual on Clinical Surgery, 13th ed. - Bailey and Love's Short Practice of Surgery, 28th ed. - Textbook of Family Medicine, 9th ed.

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