Clinical Examination of the Abdomen (Normal Subject)

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

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

Step 1: General Examination (Before the Abdomen)

• 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

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

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

• 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.