abdomen examinaton

1. Abdomen
examination-
palpation

2. Palpation
• Palpation is one of the assessment techniques which
health providers use during physical examination to
determine certain characteristics of the body
Types of palpation:
• Light palpation
• Deep palpation
• Specific palpation of intra –abdominal organs

3. Light palpation
• It is used to feel the abnormalities that are on the
surface.
• Use the front of fingers, gently press down into the area
of the body about 1-2 cms.
• Then lift your fingers off the body and move to the next
nearby area.
• It helps to identify the texture, tenderness ,temperature
,moisture, elasticity ,pulsations and masses.
• All areas must be palpated systemically
• Use nine quadrants as a guide

4. Deep palpation
• Deep palpation is used to feel internal organs and masses .
• Use the front of fingers to firmly press down into the area of
the body about 4-5cms ,then lift your fingers off the body and
move to next area nearby .
• It helps to identify the size ,shape ,tenderness, symmetry and
motility .
• Deep palpation can be painful and uncomfortable for patients
while examining abdomen .
• Another way to palpate is to put one hand on top of another
when pressing down it is called bimanual technique .

5. Basic steps
• Inform the child or the attender .
• Ask where the pain is .
• Painful areas to be palpated last.
• Warm approach and warm hands are prerequisties for
successful abdomen examination.

6. In a Crying child
In a crying child, palpate when the child pauses to
take a breath.

7. In an older child
• Patient position.
• Good lighting.
• Empty the bladder
• Undressed nipple to knees.
• Flat on couch with single
pillow on head.
• Arms by their sides.
• Ask the patient to relax .
• If not, flex hips to 45
degrees, knees to 90
degrees.

8. Rebound tenderness
• If the area which is said to have pain is painless on
examination, press firmly and release suddenly for
rebound tenderness indicates peritoneal irritation like
appendicitis
• Pain due to spastic bowel is relieved by pressure or
squeeze
• Other causes like peritonitis , pain is aggravated

9. Abdomen as a whole :
• Feel of the abdomen
• Soft ( normal)
• Firm
• Doughy
• Rigid
 very soft …..prune belly
syndrome
 localised firmness….
swellings
 Doughy ….abdominal
tuberculosis
 Localised rigidity
…acute appendicitis

10. Palpation of
individual
organs

11. LIVER
• Start with hand at right iliac fossa, fingers pointed to head.
• Palpate deeply whilst patient breathes in and out deeply.
• If nothing is felt repeat the process moving the hand up slightly.
• If edge is palpable describe
size
shape
consistency
border
tenderness
pulsations

12. Causes of palpable liver
• Visceroptosis : here the upper border of liver is
displaced downwards and thus the liver span remains
normal .
• Pushed down liver: liver span remains normal eg
:emphysema, pneumothorax ,pleural effusion .
• True hepatomegaly.
• Upward enlargement of liver eg :
amoebic liver abscess.

13. Normal values of palpable liver
• Upto 6 months – 3cms or less.
• 6months to 4 years - 2-3 cms.
• >4years – 1-2 cms.

14. Spleen
• Spleen becomes palpable when it is enlarged at least
2-3 times its normal size.
• Palpate either in supine or right lateral position .
• In right lateral position ,palpate spleen with right
hand with the left hand encircling the left lower ribs
and pushing forwards .
• To avoid missing large spleen it is recommended to
start palpating from right iliac fossa ,the direction of
enlargement of spleen being that way .

15. Bimanual palpation of Spleen
• Patient should be supine and relaxed.
• Relaxation is improved if legs and neck are slightly
flexed.
• Start palpating from lower left quadrant in infants
as the spleen tends to enlarge inferiorly toward the
left iliac fossa.
• Palpation should be started from the right lower
quadrant in older children.

16. Characters to be noted in splenic swelling
• Size .
• Shape.
• Consistency(eg :soft in typhoid , firm in portal
hypertension).
• Surface (look for splenic notch on medial border ).
• Tenderness.
• Fingers cannot be insinuated between costal margin and
the mass.

17. Grading of splenomegaly
• Mild :spleen is of few cms -<3 cms(eg :typhoid
,endocarditis).
• Moderate :spleen measures several cms but does not
cross midline 4-7cms (eg :portal hypertension).
• Massive :spleen is hugely enlarged ,crosses midline in
the direction of right iliac fossa >7cms (eg :CML,
gaucher’s disease).

19. Kidney
Bimanual palpation :
• palpate with one hand placed anteriorly while the
other hand which is placed posteriorly pushes the
kidney upwards (ballonate swelling).
• Try to approximate both hands and see if kidney can
be felt in between .
• It is felt best moving down between examining
hands in deep inspiration .

20. Palpation of kidney contd….
• Right kidney being placed lower than the left,is more
likely to be palpable in the normal .
• Though its conventional for all examinations to be
done from right side<it is more rewarding to plapate
the left kidney from left side.
• The bimanual examination of a newborn can be done
with single hand,by placing the thumb anteriorly and
the fingers posteriorly.

21. Difference between kidney and splenic
swellings
SPLEEN  KIDNEY
Finger insinuation between swelling
and costal margin not possible
Possible to push fingers between kidney
swelling and costal margin
Splenic notch may be palpated No notch
Moves freely with respiration
,direction of movement is down and to
right
Moves with respiration but much less
readily ,direction of movement is
vertically down
Renal angle resonant Renal angle(angle between 12th rib and
lateral margin of erector spinae
muscle)may become dull

22. Dipping palpation
• In presence of ascites if ordinary palpation fails to
reveal the organ , one may resort to dipping palpation
• The hand is placed on the abdomen and the fingers are
suddenly dipped into the abdomen ,which displaces
fluid quickly for a short while giving time for the
examining fingers to have a feel of organs.

23. Demonstration of direction of flow in
distended veins
• Patient is best examined standing .
• Empty a segment of vein that does not have any
branching point ,then release one finger .
• If it is not filling try releasing the other finger and see
if it is filling from the other side (this methods fails to
give right info on direction of flow in long standing cases
due to incompetence in valves of veins) .
• In a normal child and in intrahepatic portal
hypertension direction of flow is away from umbilicus .

24. Contd….
• In extrahepatic portal obstruction ,the flow is
towards the umbilicus as the blood is passed via
paraumbilical veins to liver.
• In inferior venacava obstruction the distended veins
are seen in flanks with direction of flow upwards .
• In superior venacava obstruction distended veins
have flow downwards .

25. • If any other mass is palpated, define its
• size,
• consistency (soft firm ,hard ,cystic or varying consistency)
• surface (smooth or irregular ),
• tenderness ,
• location and
• movement with respiration
• To differentiate intra abdominal from parietal mass
• ask the patient to try get up from supine position ,if mass
disappears it is abdominal ;if it becomes more prominent
,it is parietal.