2. Tropical medicine department
• Gastroentrology and hepatology unit
• Faculty of medicine
• Zagazig university
• Egypt

4. Also, The abdomen is divided into 9 regions by:
2 lateral vertical planes; passing from the mid-clavicular
lines, continued downwards, to the mid-point between the
anterior superior iliac spine and the pubic symphysis (right
and a left lateral line drawn vertically through points halfway
between the anterior superior iliac spines and the middle
line).
2 horizontal planes; the subcostal (passing across the
abdomen to connect the lowest points on the costal margin);
and the interiliac (passing across the abdomen to connect the
tubercles of the iliac crests)

5. subcostal
interiliac

8. Anterior
Anterior Back
Back

9. Inspection of the Back
 Swelling
 Deformity
 Loin masses
 Pigmentation
 tuft of hair

10. Inspection of the Anterior Abdominal Wall
Inspection of mid-line Inspection of the sides
from above downward
1- Subcostal angle 1- Contour of the abdomen
2- Epigastric pulsation 2- Collateral (dilated veins)
3- Divarication of recti 3- Skin
4- Umbilicus 4- Scars
5- Suprapubic hair distribution 5- Movement with respiration
6- Hernial orifices 6- Visible peristalsis

15. III. Hernia
 Expansile impulse in cough
IV. Dilated veins
 Caput medusa in portal hypertension
V. Skin
 Pigmentation around umbilicus (T.B. peritonitis, Addison dis.)
 Nodules “sister Mary-Joseph nodules” (abd. malignancy)
 Ecchymosis “Cullen's sign” (hemorrhagic pancreatitis and
internal hemorrhage)
VI. Discharge:
 Pus  inflammation
 Stool  intestinal fistula
 Urine  patent urachus

20. slightly full abdomen Scaphoid abdomen
but not distended

21. • examination of abdominal
contours
– Standing at the foot of the table
– Lower yourself until the anterior
abdominal wall
– ask the patient to breathe
normally while you are inspect
the abdomen.

22. Generalized abdominal Localized abdominal
distension distension
1- Fluid (ascites) 1- Site
2- Fat (obesity) 2- Shape and size
3- Flatus and Faeces 3- Pulsate on cough (hernia
4- Foetus (pregnancy) or not)
5- Full urinary bladder 4- Movement with
respiration
5- Extra-abdominal or Intra-
abdominal (by asking the pt.
to sit up in bed unsupported)

23. Localized bulge

24. Generalized abdominal distension

25. IVC obstruction Portal vein obstruction
1- Site of Laterally (Sides) Around umbilicus (caput
collaterals medusa)
2- Blood From below upwards Away from the
flow “towards the head” umbilicus”towards the legs”
(to bypass the (the blood pass from the left
obstruction the blood branch of portal vein to para
bypass the IVC via umbilical vein to anterior
abdominal wall veins to abdominal wall veins through
the thorax) the umbilicus)
3- cause in Functional compression Intra-hepatic causes of portal
hepatic Pt on IVC by tense ascites hypertension

26. Methods of Detection
- The 2 index fingers of both hands are used to milk the blood
away from one segment of a dilated vein then, applying
firm pressure on both ends of the segment  the fingers
then can be lifted one by one, while observing the rate of
filling at which the vein fills from each direction the blood
will be seen coming more rapidly from the direction of blood
flow.

27. Head of medusa
Caput medusa

28. Caput medusae accentuated by marked ascites.
An extensive plexus of veins is seen radiating from the umbilical region
and radiating across the anterior abdominal wall. Note the large vein
coursing inferiorly along the right flank (arrows). This is the superficial
epigastric vein.

33. Echymosis
Abdominal
petichae
It is often difficult to understand whether tiny red spots arising on skin
surface are Petechiae or Purpura. However, Petechiae spots have a very
small diameter that is maximum 3 mm in size. Purpura rashes are larger
in size. These have a diameter that is about 5 mm. A spot that is bigger
than Purpura is known as common bruise or echymosis

39. General rules for palpation

40. General rules for palpation

42. Normally palpable structures
1. Contracted muscles of abdominal wall in muscular persons
2. Colon (caecum and sigmoid) is felt when it is spastic (full of gas or
fluid)
3. Vertebra (L4 – L5)
4. Pulsations of abdominal aorta (usually felt below the umbilicus)
in thin persons
5. Lower pole of Rt. Kidney (especially in female with thin lax
abdominal wall)
6. Liver edge descends 1-3 cm below the costal margin on deep
inspiration, but the consistency is soft and difficult to feel.
7. Occasionally, a tongue-like process (reidel’s lobe) is felt (which is
an anatomical variation of the Rt. lobe), moves with respiration

43. Types of Palpation
Superficial
Superficial Deep
Deep

44. Superficial Palpation
For:
-Confidence of the patient
-Superficial masses
-Tenderness
-Rigidity
-Temperature
“from the Lt. iliac fossa  in anticlockwise direction
till the suprapubic area”

45. • Technique
– Use pads of three fingers (palmar surface of fingers) of
one hand and a light, gentle, dipping maneuver to
examine abdomen
– Abdominal wall depressed approximately 1 cm

46. Palpating the abdomen – Light palpation

47. Palpating the abdomen – Light palpation

48. Deep Palpation
For :
-Organs “liver, spleen, gall bladder, kidney, colon, urinary
bladder”
- Masses (ask the patient to flexes his neck as this contracts rectus muscles)
-Areas of deep tenderness and rebound (pain induced or
increased by letting go)
Deep palpation include the following methods
-Ordinary technique “classic”
-2 handed method
-Bimanual
-Dipping
-Hooking
-Rolling

49. • Technique
– Entire palm (use palmar surface of fingers of one hand; greatest
number of fingers) and a deep, firm, gentle maneuver to examine
abdomen
– Either one- or two handed technique is acceptable (When deep
palpation is difficult, examiner may want to use left hand placed
over right hand to help exert pressure)
– Palpate tender areas last
– Palpate deeply with finger pads (do not “dig in” with finger tips)
– Abdominal wall depressed around 4 cm or Push as deeply as
patient will allow without significant discomfort.

50. Palpating the abdomen – Deep palpation

53. Surface anatomy of the Spleen
9th rb Medial end
10th rb
Lateral
end
11th rb
10th rb

54. up
Diaphragmatic surface
pe
rb
or
de
r
Lower
border
Visceral surface

55.  The spleen is not normally palpable
 It has to be enlarged 2-3 times its usual size to be palpable
under the subcostal margin
 Enlargement occurs superiorly and posteriorly before it
becomes palpable subcostaly
 Once the spleen has appeared in this situation, the
direction of further enlargement is downward and towards
the Rt. Iliac fossa
 The spleen which is not felt doesn’t exclude splenomegaly
but it can be said that the spleen is not felt

56. Methods of Deep Palpation
 Classical method (single-handed method)
 Two handed method
 Bimanual examination
- in the supine position - in the Rt lateral position)
 Dipping method
 Hooking method

57. Classical method (single-handed method)

58. Two handed method

59. Bimanual examination in supine position

60. Palpating the spleen – Bimanual
palpation in supine position

61. Palpating the spleen – Bimanual palpation in
supine position

62. Palpating the spleen – Bimanual palpation in
Rt. Lateral position
With the patient in the right lateral position, minimal splenic
enlargement can be detected

63. Palpating the spleen – Bimanual palpation in Rt.
Lateral position

64. Palpating the spleen – Bimanual palpation
in Rt. Lateral position

65. Hooking method
Examining for the spleen from behind the patient, in the right
lateral position. In this case, the fingers are "hooked" over the
costal margin.

66. Nature of this palpable spleen (put a comment on):
1. Size
 Mild (just palpable to 5cm)
 Moderate (5 – 10 cm)
 Huge (more than 10 cm, below the umbilicus)
2. Border
3. Surface
4. Consistency
5. Tenderness (e.g. due to splenic infarction, septicemia,
SBE)

67. Applied anatomy and physiology of the spleen
The spleen is composed predominantly of lymphoid and R.E. tissues,
so, any condition “infectious; immunologic; metabolic; malignant or
idiopathic” that causes hyperplasia of the lymphoid/RES may cause
splenomegaly
The spleen is expansile organ containing many sinusoids, so,
interference with its venous drainage as in portal hypertension will
cause splenomegaly “congestive splenomegaly”
The spleen is a blood forming organ in fetal life and a potential blood
forming organ throughout life, so, in myelosclerosis and myelofibrosis,
extramedullary hematopoiesis may occur in the spleen with
splenomegaly
The spleen destroys senile and defective RBCs, so, in hemolytic
anemias, this function is increase with splenomegaly “except in sickle
cell anemia”

68. Causes of Huge Spleen (below the umbilicus)
 Bilharzial splenomegaly
 Kala azar “visceral leishmaniasis”
 Chronic malaria causing TSS “Tropical splenomegaly syndrome”
 CML
 Myelofibrosis and Myelosclerosis
 Polycythemia rubra vera
 Beta-thalassemia major
 Amyloidosis
 Gaucher’s disease

69. Hypersplenism
- Whenever the spleen is enlarged, hypersplenism may occur
-It is characterized by
 Pancytopenia in the peripheral blood (Normocytic
normochromic anemia, neutropenia, thrombocytopenia in
the CBC) due to hyperfunction of the spleen
 One element or two may be decreased only
 B.M examination: hypercellular or normal
 CR-51 labelled RBCs and platelets
 Splenectomy returns the CBC to normal

70. Characters of splenic swelling to be differentiated
from the Lt. kidney
-By inspection  Moves with respiration down and medially
-By palpation  it has a notch on the lower part of the anterior
(upper) border “PATHOGNOMONIC”
hand can't be insinuated between the mass and the
costal margin to get above its upper pole
 negative ballottement (can’t be pushed in the renal
angle)
-By percussion  dull on percussion and continuous with the splenic
dullness

73. Upper border is marked by joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point Xiphisternal joint.
3rd point Upper border of 5th rib in Rt. MCL
4th point 7th rib at RT MAL.
5th point  9th rib at RT scapular line.
Lower border is marked by curved line joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point  8th costal cartilage in the Lt. parasternal line.
3rd point midway between xiphisternal junction and the umbilicus
4th point  9th costal cartilage in the Rt. MCL.
5th point  10th rib in the Rt. MAL.
6th point  12th rib in Rt. Scapular line

74. Xiphisternal junction
Rt. 5th rib
LT. 5th space
Rt. 7th rib
Rt. 9th rib
umbilicus

75. LT. 5th space
LT. 8th costal
cartilage
Midway
Rt. 10th rib Rt. 9th costal between
cartilage umbilicus umbilicus
&xiphisternum

76. Technique of detecting the liver
 Upper border is detected by heavy percussion “hepatic
dullness”
 Lower border is detected by deep palpation and light
percussion
After palpation of the lower border of the liver, you must
comment on
I. Liver span : Distance between the upper and lower
borders of the liver; which is
4 – 8 cm in the middle line “represents the Lt.
lobe”
9 – 14 cm in the Rt. MCL “represents the RT.
lobe”

77. II.Nature of this palpable liver (put a comment on):
1. Size “in finger breadth or cm”
 Normally: not felt below the costal margin
 Abnormally: enlarged “causes of hepatomegaly” or shrunken
“liver cirrhosis and fibrosis”
2. Surface
 Normally: smooth
 Abnormally:
- smooth “congestion, inflammation, infiltration”
- fine irregular “cirrhosis”
- nodular “malignancy”
2. Edge
 Normally: sharp
 Abnormally:
- sharp “cirrhosis, fibrosis”
- rounded “congestion, inflammation, infiltration”

78. 4. Consistency
 Normally: soft
 Abnormally:
- soft “congestion, inflammation, infiltration”
- firm “cirrhosis, fibrosis”
- hard “malignancy”
5. Tenderness: congestion, inflammation, infiltration, malignancy
6. Pulsation: TI, TS, hemangioma

79. Methods of Palpation
 Classical method (single-handed palpation)
 Two-handed method
 Bimanual examination
 Dipping method
 Hooking method
- Single-handed palpation is used for lean individuals, while the
bimanual technique is best for obese or muscular individuals. Using
either technique, the liver is felt best at deep inspiration.

80. Single-handed
method
- For single-handed palpation, the examiner's right hand is initially placed on the
patient's abdomen in the right lower quadrant and parallel to the rectus muscle in
the MCL. This is done so that palpation of the rectus is not confused with palpation
of the underlying and adjacent liver
- Gently pressing in and up, ask the patient to take a deep breath.
 Palpating hand is held steady while patient inhales
 Palpating hand is lifted and moved while the patient breathes out
 If the liver is enlarged, it will come downward to meet your fingertips and will
be recognizable.

81.  Another method of palpating the liver uses the radial border of the
index finger. In this method the anterior hand is placed flat on the
anterior abdominal wall with fingers parallel to the costal margin

82. Bimanual palpation
of Liver
the left hand is held posteriorly,
between the 12th rib and the iliac crest.
It is lifted gently upward to elevate the
bulk of the liver into a more easily
accessible position, while the right
hand is held anterior and lateral to the
rectus musculature. The right hand
moves upward using gentle, steady
pressure until the liver edge is felt.

83. Bimanual palpation
of Liver

84. Hooking method
– Is useful when the
patient is obese or
when the examiner is
small compared to the
patient.
– Stand by the patient's
chest.
– "Hook" your fingers
just below the costal
margin and press
firmly.

85. Hooking
method

86. Causes of ptosed liver
 Emphysema
 Pneumothorax
 Pleural effusion
 Subphrenic abscess
Causes of upward displacement of the liver
 Lung fibrosis/collapse
 Diaphragmatic paralysis
 Ascites / abdominal tumours

87. Percussion is a method of tapping on a surface to determine the
underlying structure

88. plexor
pleximeter
Technique
-It is done with the middle finger of Rt. hand (plexor) tapping on DIP of
the middle finger of the Lt. hand (pleximeter) using a wrist action.
-The non striking finger (pleximeter) is placed firmly on the abdomen,
remainder of hand not touching the abdomen.
-Remember that it is easier to hear the change from resonance to
dullness – so proceed with percussion from areas of resonance to areas
of dullness.

89. There are two basic sounds
– Resonant sounds indicates hollow, air-filled structures. The
abdomen gives resonant note which varies according to the
amount of gas present in the intestine.
– Dull sounds indicates the presence of a solid structure (e.g. liver)
or fluid (e.g. ascites) lies beneath the region being examined

90. Percussion of the abdomen
-The abdomen gives a resonant note which varies according to the
amount of gas present in the intestine
-Type of percussion: Light percussion
-Values:
 Deleneation of borders of abdominal organs (& assessing for
organomegaly).
 Decetction of ascites
 Detection of gaseous distension “tympanic resonant note”
 Detection of acute abdomen (obliteration of normal liver
dullness) in;
- Perforated peptic ulcer and colon
- Subphrenic abscess with gas forming organisms

91. • The two solid organs which are
percussable in the normal
patient
– Liver: will be entirely covered by
the ribs.
– Spleen: The spleen is smaller and
is entirely protected by the ribs.

92. Percussion “liver”
Upper border  by deep percussion
Lower border  by light percussion
Upper border
 Define the sternal angle “angle of Louis” (2nd rib), then start
percussing the 2nd intercostal space in the Rt. MCL (Start just
below the Rt. breast in RT. MCL). Percussion in this area should
produce a relatively resonant note
 Percussing in the chest moving down towards the abdomen
about ½ to 1 cm at a time (in the intercostal spaces).
 Note where the percussion notes change from resonant to dull.
 The normal hepatic dullness will be reached at the 5th intercostal
space in the RT. MCL
Lower border
 Begin percussion below the umbilicus, in the Rt. MCL and
proceed upward until dullness is encounter.

93. The liver span is estimated by percussion
The distance between the two areas where dullness is first encountered is the liver span.

95. Percussion “spleen”
- Percussion of Traube’s area
- Splenic percussion sign “Castell’s method”
- Nixon’s method

96. Traube's area
It is a semilunar (crescent)-shaped area
It is area of tympanic resonance overlying the fundus of stomach
Boundaries
 Upper border lower border of Lt. lung (convex line from the Lt.
6th rib in MCL to the Lt 9th rib in mid-axillary line)
 Right border Lateral margin of left lobe of liver (from Lt. 6th rib
in MCL to the Lt. 8th costal cartilage)
 Left border anterior border of the spleen (Lt. 9-11 spaces in
mid-axillary line)
 Lower border Lt. costal margin (from the Lt. 8th costal cartilage
to Lt. 11th space in mid-axilary line )

98.  Causes of dullness of Traube’s area:
1. Full stomach/ gastric tumours.
2. Left sided Pleural effusion / pericardial effusion “from above”.
3. Ascites/abdominal tumour “from below”
4. Splenomegaly “from left side”.
5. Enlargement of left lobe of liver “from the right side”.

99. Castell’s method “Splenic percussion sign”
Put the patient in the supine position
Left anterior axillary line identified
Left lower costal margin identified
 Percuss in the lowest Left intercostal space in the anterior axillary
line (usually the 8th or 9th IC space) while patient inhales and
exhales deeply
This space should remain resonant during full inspiration
Dullness on full inspiration indicates possible splenic enlargement (a
positive Castell’s sign)

100. Castell’s point

102. Nixon’s method
Place the patient in Right lateral decubitus
Begin percussion midway along the Left costal margin
Proceed in a line perpendicular to the Left costal margin
If the upper limit of dullness extends >8 cm above the Left costal
margin, this indicates possible splenomegaly

103. Ascites is free collection of fluid within the peritoneal cavity.
The classical signs of ascites include; abdominal distension, shifting
dullness, fluid thrill.
Minimal ascites  detected in the knee elbow position
Moderate ascites  detected by the bilateral shifting dullness
Tense ascites  detected by transmitted fluid thrill “fluid wave”

104. Bilateral shifting dullness
1.The patient is examined in the supine position.
2.Percussion is done over the abdomen, from the umbilicus to one flank.
3.The spot of the transition from tympany to dullness is detected.
4.The patient is then turned to the opposite side, while the examiner keeps his
hand unmoved.
5. Percussion of the same spot (which is top now) gives a tympanic note.
Note: The tympany over the umbilicus occurs in ascites because bowel floats
to the top of the abdominal fluid.
air
air
fluid
fluid

105. Transmitted fluid thrill
Pathognomonic foe ascites when the amount of fluid is large
1.The patient is examined in the supine position.
2.The patient or an assistant places one hand in the midline and
presses firmly with the ulnar border of the hand , so cut off any
vibrations transmitted by the abdominal wall.
3.The examiner places one palm on one flank, while giving a sharp tap
with the finger tips on the opposite flank.
4.Positive test: a definite wave “impulse” will be distinctly felt by the
receiving hand.

107. • Diaphragm of stethoscope used
• Skin depressed to approximately 1 cm
• Listening in one spot is usually sufficient
• Listening for 15-20 or 30-60 seconds

108. Values of auscultation
1.To hear intestinal sounds  characteristic gurgling bubbling (gas and
fluid in intestine) sounds.
 Increase in: acute diarrhea (↑motility) and in early intestinal
obstruction
 Absent in: paralytic ileus
N.B. Bowel sounds cannot be said to be absent unless they are
not heard after listening for 3-5 minutes.

109. 2. To hear vascular sounds
Arterial bruit Venous hum
(Wind at sea shore)
Systolic murmur Systolic and diastolic sound in the
epigastrium, and Lt. hypochondrial
region “Kenawy sign”
Occurs in cases of Occurs in cases of
-Abdominal aortic aneurysm - portal hypertension due to porto-
-Renal artery stenosis systemic anastomosis (collateral)
-Over very vascular tumour
“e.g. hemangioma”

110. 3. Friction rub 
a dry, grating sound heard with a stethoscope during auscultation; may
be heared over enlarged liver or spleen
 Splenic rub: in Lt. hypochondrium; due to splenic infarction and
perisplenitis
 Hepatic rub: in Rt. Hypochondrium; due to hepatic malignancy
with perihepatitis (inflammatory changes or infection in or
adjacent to the liver). If detected in a young woman, the
examiner should consider gonococcal peritonitis of the upper
abdomen (Fitz–Hugh–Curtis syndrome).
N.B. A hepatic rub and bruit in the same patient usually indicates
cancer in the liver. A hepatic rub, bruit, and abdominal venous
hum would suggest that a patient with cirrhosis had developed a
hepatoma.

111. 4. To detect lower border of the liver (scratch method)
 Place the diaphragm over the area of the liver  scratch parallel to
the costal margin in MCLWhen the liver is encountered, the
scratching sound heard in the stethoscope will increase significantly
5. To detect minimal ascites (Puddle’s sign)
It is useful for detecting small amounts of ascites (as small as 120 mL;
shifting dullness and bulging flanks typically require 500 mL).
The steps are outlined as follows:
 Patient lies prone for 5 minutes
 Patient then rises onto elbows and knees
 Apply stethoscope diaphragm to most dependent part of the abdomen
 Examiner repeatedly flicks near flank with finger.
 Continue to flick at same spot on abdomen
 Move stethoscope across abdomen away from examiner
 Sound loudness increases at farther edge of puddle

112. Scratch Test
Start in the same areas
above and below the
liver as you would with
percussion. Instead of
percussing lightly,
scratch moving your
finger back and forth
while listening over the
liver. Since sound is
conducted better in
solids than in air, when
the louder sounds are
heard you are over the
liver. Mark the superior
and inferior boarders of
the liver span in the
midclavicular line

113. 6. Succusion splash  in case of pyloric obstruction (distended
stomach with gas and fluid)
 placing the stethoscope over the upper abdomen  rocking the
patient back and forth at the hips  Retained gastric material >3
hours after a meal will generate a splash sound.
7. To detect pregnancy  fetal heart sounds.