Clinical Surgery: Examination of Acute Abdomen and Abdominal Lumps
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Clinical Surgery: Examination of Acute Abdomen and Abdominal Lumps
Clinical Surgery: Examination of Acute Abdomen and Abdominal Lumps
Comprehensive Audio Script for Medical Students
Part 1: Examination of an Acute Abdomen
Introduction
Welcome to this comprehensive guide on examining an acute abdomen case. This is one of the most important clinical skills you'll need as a surgeon. An acute abdomen presentation can be life-threatening, and your ability to quickly and systematically assess the patient can literally save lives. We'll take you through the entire examination process—from history taking all the way to investigations and differential diagnoses. Pay careful attention, because this knowledge will be tested rigorously in your exams.
Section 1: History Taking
Part A: Patient Particulars (The Foundation)
Before you even ask about the pain, you need to establish who you're talking to. This foundation is crucial because certain diseases have specific predilections.
Age: This matters tremendously. Is this a child, a young adult, middle-aged, or elderly person? Why? Because acute appendicitis peaks between 20 to 30 years. In children, think intussusception. In elderly patients, think about diverticulitis and vascular emergencies.
Gender: Certain conditions are gender-specific. Women can present with ruptured ectopic pregnancy or ruptured ovarian cysts. These must never be missed because they're lethal.
Occupation: This might seem trivial, but it matters. A manual laborer might have different stress patterns compared to an office worker. Certain occupations expose people to different risk factors.
Residence: This is important for epidemiology. If your patient is from an area endemic for parasites or specific diseases, certain diagnoses become more likely. For example, if they're from a region where filariasis is common, you need to think about this as a differential diagnosis.
Social Status: Here's something they may not teach you in detail, but it's important for your exams: Low social status patients with peptic ulcer disease tend to ignore symptoms and present late with perforation. High social status patients tend to get acute appendicitis more often—why? Possibly due to diet and lifestyle factors.
Part B: Chief Complaints - Pain (The Heart of the Matter)
Pain is your primary clue. Listen carefully to every detail. Remember, we're not just asking "where does it hurt?" We need to understand pain like we're decoding a message from the body.
1. Time of Onset - When Did It Start?
This seems simple, but it tells you so much:
- Acute appendicitis: Pain typically starts in the early morning
- Peptic ulcer perforation: Usually occurs in the afternoon after lunch
- But the patient gets brought to hospital at night, so timing might be confused
Why is timing important? It helps you understand the natural history of the disease.
2. Mode of Onset - How Did It Begin?
Sudden Onset (Acute):
- Perforation of peptic ulcer - sudden, dramatic
- Colic (biliary, renal, intestinal) - sudden
- Torsion - sudden
- Volvulus - sudden
- Ruptured ectopic pregnancy - sudden
Gradual Onset:
- Acute intestinal obstruction - pain gradually increases in intensity
- Acute appendicitis (in the beginning) - starts mild, boring pain
- But here's the catch: Obstructive appendicitis can suddenly become severe, actually waking the patient in the early morning
Precipitating Factors:
- Administration of purgatives can precipitate acute appendicitis
- Straining can precipitate peptic ulcer perforation
- Jolting can precipitate ureteric colic
3. Duration - How Long Has This Been Going On?
Ask the patient: "How long have you been having this pain?"
This is crucial:
- First episode: Think acute appendicitis, acute cholecystitis
- Recurring episodes over years with varying intensity: Think chronic appendicitis, recurrent cholecystitis, peptic ulcer disease that's now perforating
This history of intermittent attacks over time is very characteristic of certain conditions.
4. Site of Pain - Where Exactly? (Use the Pointing Test)
This is not just trivia—it's diagnostic gold. Here's the systematic approach:
Tell your patient: "Show me with one finger exactly where it hurts most." Listen carefully.
Location Guide (Remember these associations):
- Flank pain Suspect renal colic
- Below right costal margin to Suspect liver or gallbladder disease
- Epigastric region to Suspect peptic ulcer perforation or acute pancreatitis
- Right iliac fossa Suspect acute appendicitis
- Periumbilical/around umbilicus Suspect appendicitis in early stages
The patient using their whole hand instead of one finger suggests diffuse pain to suggests peritonitis or widespread inflammation.
5. Shifting of Pain - Does It Move? (This Is Diagnostic!)
This is pathognomonic—meaning it practically tells you the diagnosis:
Classic Shifting of Pain in Acute Appendicitis:
- Pain initially felt around the umbilicus (because the appendix is a midgut structure)
- Then shifts to the right iliac fossa as parietal peritonitis develops
- This shifting happens because the pain starts visceral (deep inside) then becomes parietal (affecting the peritoneum)
If a patient tells you the pain started in the umbilicus and moved to the right iliac fossa, you're 90% sure it's appendicitis.
6. Radiation of Pain - Does It Spread?
In spreading peritonitis, this is what happens:
- Pain starts in the region of the affected organ
- Then spreads gradually all over the abdomen
Special Example - Peptic Ulcer Perforation:
- Initial pain in right hypochondriac region (where the perforation is)
- Radiates toward the right iliac fossa as gastric contents gravitate down the right paracolic gutter
- This can mimic acute appendicitis! That's why careful history is so important.
7. Referred Pain - Felt Somewhere Else? (Nerve Segments Matter!)
This is neurophysiology applied to clinical practice. Pain follows segmental innervation.
Visceral Segmental Supply (Remember these segments):
- Stomach, duodenum, jejunum (T 5 through T 8) arrow Referred to epigastrium
- Ileum and appendix (T 9 through T 10) to Referred to periumbilical area
- Colon (T 11 through T 12, L 1 through L 2) to Referred to hypogastrium
Most Important Referred Pain - Diaphragmatic Irritation:
The diaphragm is supplied by the phrenic nerve (C.3, C.4, C.5). The skin above the shoulder is also supplied by the same segments (via supraclavicular nerves).
Therefore: Any irritation under the diaphragm leads to referred pain to the shoulder
Examples:
- Subphrenic abscess to Shoulder pain
- Blood under diaphragm to Shoulder pain
- Bile or inflammatory exudate leads to Shoulder pain
Bed Maneuver (Exam Tip): If you suspect subphrenic irritation, raise the foot end of the bed 18 inches. This allows exudates to gravitate down and increase shoulder pain, confirming diagnosis.
Other Important Referred Pains:
- Renal colic: Pain referred from loin to groin, testis, and inner side of thigh (via genitofemoral nerve L.1-L.2)
- Biliary colic: Pain radiates from right hypochondrium to the inferior angle of the right scapula
8. Character of Pain - What's It Like?
Different types of pain suggest different diagnoses. This is absolutely crucial for diagnosis.
colikkee Pain (Sharp, Intermittent, Griping):
- Comes on suddenly, disappears suddenly
- Indicates obstruction to a hollow organ
- Examples:
- Intestinal colic (bowel obstruction)
- Biliary colic (stone in bile duct)
- Renal/ureteric colic (stone in ureter)
Constant Burning Pain:
- Indicates peritonitis
- Characteristic of perforated peptic ulcer
Severe Agonizing Pain:
- Characteristic of acute pancreatitis
- Also seen in torsion of organs
Throbbing Pain:
- Suggests inflammation
- Example: Hepatitis, acute cholecystitis
Change in Character (Important):
- Colicky pain that becomes constant to Indicates strangulation in intestinal obstruction (this is serious!)
- Pain that diminishes to not always good news! In appendicitis, diminishing pain might indicate perforation of a gangrenous appendix
9. Effect of Pressure on Pain
Simple question: "Does pressing on the pain make it better or worse?"
- Colics to Pressure gives relief
- Inflammatory conditions leads to Pressure aggravates the pain
This is a quick discriminator between colic and peritonitis.
10. Relationship of Pain to Movements
Ask about very specific movements:
Jolting and Walking aggravate pain in:
- Amoebic hepatitis
- Cholecystitis
- Appendicitis
- Sometimes ureteric colic
Deep Inspiration and Coughing aggravate pain in:
- Diaphragmatic pleurisy
During mikchurishun ("Strangury" - painful, frequent urination):
- Ureteric colic
- Pelvic appendicitis
- Pelvic abscess
11. Aggravating and Relieving Factors
What Makes It Worse?
- Peritonitis to Any movement makes it worse, patient lies still
- Diaphragmatic irritation leads to Deep inspiration aggravates
- Cholecystitis leads to Fatty foods aggravate
- Peptic ulcer to Alcohol, spicy food, aspirin aggravate
- Hiatus hernia/reflux Stooping makes it worse
What Makes It Better?
- Peptic ulcer leads to Alkali gives relief (this can be diagnostic!)
- Colics Local pressure application gives relief
- Acute pancreatitis Sitting up from recumbent position gives some relief
- Peritonitis to Lying still gives slight relief
- Peptic ulcer to Vomiting sometimes relieves pain (bizarre but true!)
Part C: Chief Complaints - Vomiting
Vomiting is the second major complaint. Pay attention to details because they're diagnostic.
1. Character of the Act - How Does the Vomiting Happen?
Projectile Vomiting (Forceful, involuntary ejection):
- Seen in high intestinal obstruction
- Seen in toxic enteritis
- Large quantity expelled
Quiet regurgitashun (Just comes out):
- Seen in peptic ulcer perforation
- Seen in generalized peritonitis
- Just mouthfuls of vomitus
2. Character of the Vomitus - What's Being Vomited?
This is like reading a story of progression:
In Acute Intestinal Obstruction (The classic sequence):
1. First: Stomach contents only
2. Then: Bilious contents (duodenal) - yellowish/greenish
3. Finally: Feculent contents (intestinal) - dark, smelly
- True fecal vomiting is rare
In Biliary Colic:
- Vomitus is usually bilious (greenish)
In Peptic Ulcer:
- Vomitus contains gastric contents
In Late Peritonitis (Dangerous stage):
- Dark brown, feculent vomitus mixed with altered blood
- This also seen in uraemia
3. Frequency and Quantity
Constant, Frequent, Profuse vomiting:
- Acute intestinal obstruction
- Acute pancreatitis
Periodic vomiting:
- Peptic ulcer disease
In Peptic Perforation (Peculiar pattern):
- May vomit once or twice in first stage
- More or less absent in second stage
- May reappear in last stage with characteristic vomitus of diffuse peritonitis
In Acute Appendicitis:
- May or may not have vomiting
- But nausea is more often present
- Both nausea and vomiting are characteristic in pre-ileal or post-ileal appendicitis
4. Relationship of Vomiting with Pain
Pain Precedes vomiting:
- Acute appendicitis
- Acute pancreatitis
- Peptic ulcer
- Biliary and renal colics
Vomiting and pain Simultaneous:
- High intestinal obstruction
Vomiting Delayed:
- Lower ileal obstruction (may not occur at beginning)
- Large bowel obstruction (vomiting is absent or very late)
Vomiting Relieves pain:
- Peptic ulcer (vomiting actually gives relief—unusual!)
- In colics, vomiting temporarily relieves pain but it reappears immediately
Part D: Chief Complaints - Bowel Habits
Absolute Constipation (Both Feces and Flatus Arrested):
This is pathognomonic for:
- Acute intestinal obstruction
- Peritonitis
Note: A history of one motion at the beginning of intestinal obstruction is not unusual.
Special Patterns:
In Acute Appendicitis:
- History of constipation often present
In Pelvic Appendicitis or Pelvic Abscess:
- Tenesmus (ineffectual straining at stool)
- Passage of mucus and blood
In Children (Red Flag):
- Passage of mucus and blood per rectum + intestinal obstruction symptoms = Acute Intussusception
In Mesenteric Thrombosis:
- Blood and putrid stool noticed
In Acute Ulcerative Colitis, Regional Ileitis, Acute Enteritis:
- Diarrhea occurs
Part E: Chief Complaints - Micturition
strangyuree - Painful, frequent, small-volume urination:
Seen in:
- Stone impacted in lower ureter
- Bladder stones
- Inflammatory conditions near bladder and ureter:
- Retrocaecal appendicitis
- Pelvic appendicitis
- Pelvic peritonitis
Hematuria (Blood in urine):
- Can occur even from retrocaecal appendicitis lying close to ureter
- Can mislead the clinician into thinking it's a urinary problem!
Part F: Personal History (Critical in Women)
Menstrual History (Women - Never Miss This!):
- History of missed period + Acute abdominal pain = Suspect ruptured ectopic gestation until proven otherwise
- Pain in middle of menstrual period + Symptoms mimicking appendicitis = Suspect ruptured follicular (lutein) cyst
Other Personal History:
- Smoking habits
- Alcoholic habits
- Sexual history (in appropriate cases)
Part G: Past History
Perforation of Peptic Ulcer:
- Previous history of ulcer pain
- History of hematemesis (vomiting blood)
- History of melena (black stools—digested blood)
Acute Appendicitis, Biliary and Renal Colics:
- History of previous similar attacks
- Patient often doesn't connect previous episodes with current illness
Intestinal Obstruction:
- History of previous abdominal surgery (crucial!)
- Adhesions from old surgery are common cause
Acute Cholecystitis:
- Past history of biliary colic
- High fever previously
- History of jaundice
Section 2: Physical Examination
Part A: General Survey
1. Appearance - The "Facies"
The patient's appearance tells you a story before they even speak.
"Abdominal fay-sheez" - Characteristic Expression:
- Anxious look
- Bright eyes
- Pinched face
- Cold sweat
- This appearance alone helps discriminate between abdominal and extra-abdominal causes
"fay-sheez hippokratika" (Terminal stage of peritonitis):
- Characteristic appearance (once seen, never forgotten)
- Anxious, drawn, with pinched features
- Indicates severe, life-threatening peritonitis
fay-sheez of Dehydration:
- Sunken eyes
- Drawn cheeks
- Dry tongue
sy-uh-no-sis (Bluish/livid appearance):
- Characteristic of acute hemorrhagic pancreatitis
- Though not common, when present, it's diagnostic
Pallor (Extreme paleness) + Gasping respiration:
- In a woman of childbearing age = Suspect ruptured tubal gestation
2. Attitude - How is the Patient Lying?
The patient's position and movements tell you if it's colic or peritonitis.
in Colic (Hollow organ obstruction):
- Patient is restless
- Tossing on the bed
- Doubled up
- Rolling in agony seeking position of comfort
- Can't find comfort
in perituh-ny-tis (Inflammation of peritoneum):
- Patient is absolutely quiet
- Lies still
- Any movement increases pain
- Prefers not to move
in Late perituh-ny-tis or postoperative perituh-ny-tis:
- Patient becomes highly excitable (contrary to early peritonitis!)
- Throws bed clothes
- Tosses head
- Grumbles
- Ineffective movements of hands and feet
- Nothing gives comfort
3. Pulse - Rate, Volume, and Tension
Early Stage of many acute abdominal conditions:
- Pulse remains normal in rate, volume, and tension
- Examples: Acute intestinal obstruction, acute hemorrhagic pancreatitis, peptic perforation (early)
- But in acute appendicitis, pulse is actually a good diagnostic guide
Important: Some patients who can't localize pain properly show diagnostic pulse changes
In Internal Hemorrhage:
- Pulse becomes immediately rapid (rapid + weak = shock)
- This is a red flag
In Peptic Perforation (Progressive changes):
- Early: Pulse normal
- With spreading peritonitis: Pulse quickens and becomes small in volume
In Acute Intestinal Obstruction:
- Begins normal
- With dehydration: Volume and tension fall, rate increases
- Pulse doesn't return to normal (unlike simple colic)
4. Respiration - Rate and Character
Generally:
- High respiratory rate is rare in acute abdominal conditions (except hemorrhage and late peritonitis)
- If temperature is high, respiration rate increases proportionally
Red Flag:
- Increased rate with working of alae nasi (flaring of nostrils) to Direct attention to the chest, not abdomen!
Common Mimicker:
- Referred pain from lobar pneumonia or basal pleurisy can mimic acute abdomen
5. Temperature - Fever Pattern
In Infective Conditions:
- Temperature rises
- The rise varies by condition:
- Acute appendicitis: Often quite high (especially in children)
- Acute cholecystitis: Moderate rise
- Acute pancreatitis: May not be raised that much
- Acute diverticulitis: May not be raised that much
Critical Teaching Point: Rise of temperature is a Late sign, not an early sign
Murphy's Syndrome in Acute Appendicitis:
1. Pain comes first
2. Vomiting comes second
3. Fever comes last
This sequence is pathognomonic!
6. Tongue - Index of Digestive System State
Look at:
- Is it dry or moist?
- Is it coated?
Dry tongue = Dehydration Dry brown tongue = Toxemia Even in early appendicitis = May be dry and thinly coated (due to vomiting)
7. Anemia, Cyanosis, and Jaundice
Pallor (Pale appearance):
- Seen in hemorrhagic conditions
- Example: Ruptured ectopic gestation
sy-uh-no-sis (Bluish tint):
- Seen in hemorrhagic acute pancreatitis
Jaundice (Yellowish tint):
- Often follows biliary colic
- Occasionally seen in acute pancreatitis
Part B: Examination of the Abdomen - Inspection
Patient Position: Lie flat on back with legs extended Exposure: Entire abdomen from nipples to saphenous openings (inguinal and femoral rings visible) Lighting: Good light, preferably daylight
1. Inspect All Hernial Orifices First
This is unconventional (usually done last) but crucial!
Why start here? Because if left for last, it may be missed, and the actual cause of acute abdomen may remain unknown!
Examine:
- Inguinal rings (both sides)
- Femoral rings (both sides)
- Umbilicus
- Any previous surgical scars (sites of incisional hernias)
Look for:
- Swelling
- Reducibility
- Signs of strangulation
2. Contour of the Abdomen
Distension pattern tells you the type of obstruction:
In Acute Intestinal Obstruction:
- Distension occurs gradually
- May not be evident immediately
- Central distension = Small bowel obstruction
- Peripheral distension = Large bowel obstruction
In Volvulus of Sigmoid or Caecum:
- Distension appears almost immediately
In Peptic Perforation (2nd stage):
- Slight distension may be evident
In These Conditions (Normal contour):
- Biliary colic
- Acute cholecystitis
- Acute appendicitis
- Renal colic
3. Respiratory Movements
Look at how the abdominal wall moves with breathing.
Sluggish or no respiratory movement:
- Indicates widespread irritation of peritoneum
- Seen in:
- Diffuse peritonitis (perforation of peptic ulcer)
- Hemorrhage into peritoneal cavity (ruptured ectopic gestation)
Localized limitation of respiratory movement:
- Indicates localized peritoneal irritation
- From inflammation of underlying organ
- Examples: Acute cholecystitis, appendicitis
4. Peristaltic Movements
Look carefully for visible waves of contraction.
The "Ladder Pattern" or "Ladder-LIKE" peristalsis:
- Characteristic of small bowel obstruction
- Horizontal bands visible moving across abdomen
- Watch patiently—it may take a while to see
5. Pulsating Swellings
Look for a visible, rhythmic bulge.
Leaking Abdominal Aortic Aneurysm:
- Patient presents with acute abdominal pain
- Visible pulsating swelling may be seen
- This is a surgical emergency!
6. Skin Changes
Grey Turners Sign - Discoloration:
- Discoloration in the left flank
- Seen in late cases of acute hemorrhagic pancreatitis
- Indicates massive pancreatic destruction with retroperitoneal bleeding
Cullens Sign - Bluish Hue:
- Bluish color around the umbilicus
- Also seen in late acute hemorrhagic pancreatitis
- Again, massive destruction
Local Redness or Blisters:
- At site of pain
- Indicates patient has applied hot water bottle for relief
- Not diagnostic but informatory
Part C: Examination of the Abdomen - Palpation
Two Key Principles:
1. Use volar surfaces of fingers (flexor surfaces, flat on abdomen)
2. Keep forearm horizontal at the level of the abdomen
3. Never poke vertically into the abdomen—this causes defensive muscle guarding
4. Use gentle "pill-rolling" movements
5. Always keep your hands warm to gain patient confidence
1. Hyperesthesia
Sometimes cutaneous hypersensitivity is elicited.
Sherren's Triangle:
- Triangle formed by lines drawn from:
- Anterior superior iliac spine
- Umbilicus
- Midaxillary line
Significance: Hyperesthesia in Sherren's triangle is seen in acute appendicitis
How it works: The inflammatory process from the appendix irritates the overlying skin nerves
2. Tenderness
The most important finding in palpation.
Look for:
- Exact location of tenderness
- Whether tenderness is direct or localized to specific areas
In Acute Appendicitis:
- Tenderness at McBurney's point
- Located at junction of lateral and middle third of line from anterior superior iliac spine to umbilicus
- But see special tests below for atypical locations
3. Rebound Tenderness (Blumberg's Sign)
Technique:
- Press slowly into the abdomen at a point away from tenderness
- Then suddenly release the pressure
- If patient experiences sharp pain on release, then rebound tenderness is present
Significance:
- Indicates peritoneal irritation
- Positive rebound = peritonitis is present
- Very important finding
4. Rovsing's Sign
Technique:
- Palpate the ascending colon (left lower abdomen)
- Press upward (pushing fecal contents toward cecum and appendix)
- If this causes pain in the right iliac fossa, then Rovsing's sign is positive
Significance:
- Highly suggestive of acute appendicitis
- But absent doesn't exclude appendicitis
5. Bed-Shaking Test
Technique:
- Ask the patient to cough or gently shake the bed
Significance:
- Pain on jarring/bed-shaking = Peritoneal irritation
- Patient prefers to lie still
- Coughing worsens pain
6. Psoas Test (For Retrocaecal Appendicitis)
Technique:
- Place hand over patient's flank
- Patient raises right lower limb keeping knee extended
- Psoas muscle contracts during hip flexion
- This stretches the retrocaecal appendix
Positive Sign:
- Patient immediately complains of pain
- Indicates retrocaecal appendicitis
7. Obturator Test (For Pelvic Appendicitis)
Technique:
- Flex patient's hip and internally rotate the hip joint
- This stretches the obturator internus muscle
- If inflamed pelvic appendix is nearby, it's stretched too
Positive Sign:
- Patient winces in pain
- Indicates pelvic appendicitis
8. Baldwin's Test (For Retrocaecal Appendicitis - Alternative)
Technique:
- Same as psoas test
- Patient raises right lower limb with knee extended
Positive Sign:
- Immediate complaint of pain
- Shows retrocaecal appendix inflammation
9. Muscular Rigidity (Muscle Guard)
This is one of the most important findings, as it indicates underlying peritonitis.
Involuntary Muscular Rigidity (Muscle Guard):
- Excellent indication of parietal peritonitis irritation
- Can be due to:
- Inflammation
- Blood in peritoneal cavity
- Contents of hollow organs
- Part of protective mechanism
Part of a broader protective reflex seen in:
- Irritation of parietal pleura leads to restricted chest movement
- Irritation of synovial membrane leads to Restricted joint movement
- Irritation of meninges leads to Neck rigidity
How to Differentiate from Voluntary Rigidity:
Involuntary rigidity:
- Indicates underlying peritonitis (serious)
- May not disappear on expiration
- May not disappear when patient opens mouth
- Feels hard/tense all the time
Voluntary rigidity:
- Due to fear of being hurt
- Due to resentment at abdominal exposure
- Will disappear on expiration
- Will diminish when patient opens mouth
- Disappears with relaxation
Clinical Trick to Differentiate:
- Ask patient to open mouth and breathe deeply
- Voluntary rigidity will disappear during expiration
- Involuntary rigidity persists
Distribution of Rigidity:
Localized Muscle Guard:
- Corresponds to area of inflammation
- Examples:
- Upper half of right rectus muscle in peptic perforation arrow Acute rigidity equals Emergency!
- Right iliac fossa in paracaecal appendicitis
- Over the loin in retrocaecal appendicitis
- May be absent in pelvic appendicitis (no anterior wall rigidity)
Absence of Rigidity:
- Seen in all colics (biliary, ureteric, intestinal)
- Seen in uncomplicated acute intestinal obstruction
"Board-like Rigidity" (Whole abdomen):
- This is a late feature of peritonitis
- Surgeon must not wait for this!
- If you see localized rigidity in peptic perforation, operate immediately
Differentiating Rigidity Due to Thoracic Disease:
Technique:
- Ask patient to take deep breath with open mouth
- Rigidity due to thoracic disease will diminish on expiration
- Rigidity due to peptic perforation persists
10. Distension
Palpate for hardness and softness alternating.
In Acute Intestinal Obstruction:
- Coils of intestine feel to harden and soften alternately
- Central distension (small bowel) vs peripheral (large bowel)
Generalized Distension:
- Late feature of general peritonitis
- Never let patient reach this stage
11. Lump
Carefully palpate for any masses.
Appendicular Lump (Late presentation):
- Felt in right iliac fossa
- Note: Position, size, shape, consistency, mobility
- Differentiate from: Appendicular abscess, cold abscess, intersitial hernia
Sausage-shaped Lump:
- In acute intussusception
- Usually in epigastrium or left lumbar region
- Look for: Empty right iliac fossa ("Sign de danse")
12. Palpation of Hernial Sites
Critical Point: Large number of acute intestinal obstruction cases are due to strangulated hernias!
Carefully examine:
- Inguinal rings
- Femoral rings
- Umbilicus
- Incisional sites
Any irreducible hernia is a surgical emergency.
Part D: Examination of the Abdomen - Percussion
Shifting Dullness (Indicates Free Fluid)
Technique:
1. Patient lies on back
2. Fluid gravitates to flanks
3. Percussion from centre arrow Resonant (over floating intestine)
4. Percussion at flank arrow Dull (over fluid)
5. Patient turns to opposite side
6. Wait few minutes for fluid to shift
7. Percuss same area again to Should now be resonant
Positive Test: Note becomes resonant when fluid shifts
- Indicates free fluid in peritoneal cavity
Conditions with Free Fluid:
- Perforation of peptic ulcer
- Perforation of typhoid ulcer
- Acute pancreatitis
- Ruptured ectopic gestation
- Others
Important Fallacy:
- Abnormal retention of enema may cause apparent shifting dullness
- Due to fluid in descending or ascending colon
- Not true free fluid! So be careful.
2. Fluid Thrill
Another test for free fluid (especially large quantities).
- Flick one side of abdomen and feel for wave on opposite side
- Indicates significant free fluid
3. Obliteration of Liver Dullness
Technique:
- Percuss right mid-axillary line from above downward
- Upper part: Resonant
- At liver border: Changes to dull
Positive Sign:
- Liver dullness replaced by resonance
- Indicates free gas under diaphragm
- Seen in perforation of gastrointestinal tract
Important Caveat:
- Absence of this sign does not exclude perforation
- Only present if there's sufficient air leakage
- Many perforations don't show this sign
Fallacy:
- Considerable gut distension can obliterate liver dullness
- Lung emphysema can also cause this
- So interpret carefully
Part E: Examination of the Abdomen - auskul-tay-shun
Very Important: Never omit auscultation in acute abdomen!
First, familiarize yourself with normal peristaltic sounds in healthy abdomen.
1. The "Silent Abdomen"
Characteristic of: Diffuse peritonitis
- Bowel sounds completely absent
- Pathognomonic finding
- Life-threatening condition
2. Localized Absence of Peristaltic Sounds
- Around area of acute inflammation
- Indicates local peritoneal irritation
3. The "Noisy Abdomen" (Increased Sounds)
Characteristic of: Acute intestinal obstruction
Types of sounds:
- Normal: Clicks and gurgles
- Obstruction: Distinct metallic tinkles or borborygmi
- These sound like "tinkling bells" (musical)
4. Peculiar Sounds in Peritonitis
When intestinal sounds are absent, you may hear:
- Unusual respiratory sounds
- Cardiac sounds becoming audible
- Due to lack of normal bowel noise masking
Part F: Additional Examinations
Measurement
For obstruction or postoperative peritonitis:
- Repeated measurements of abdominal girth
- Assess rate of distension
- Helpful in monitoring progression
Rectal Examination
Essential: No examination of acute abdomen is complete without digital rectal exam!
Findings:
Tenderness of rectal wall:
- In pelvic type appendicitis
- May not show anterior abdominal wall tenderness/rigidity
Bulging anterior rectal wall + Tenderness:
- Indicates pelvic abscess
Rectal tenderness in rectovesical pouch:
- In perforated peptic ulcer
After Rectal Examination in Intussusception:
- Gloved finger smeared with mucus and blood ("red-currant jelly")
- No fecal odor
Ballooning of rectum:
- Seen in majority of acute abdomen cases
- Significance still unclear
Vaginal Examination (If Applicable)
In Acute Salpingitis:
- Purulent discharge
- Tenderness in both fornices
In Ruptured Ectopic Gestation:
- Cervix feels softer
- Any cervical movement causes pain
Part G: General Examination (Extra-Abdominal)
When abdominal findings don't fully explain symptoms, think extraabdominal causes!
Examine the Chest and Chest Wall
Many thoracic conditions mimic acute abdomen!
Referred Pain from Thorax to Abdomen:
- Diaphragmatic pleurisy
- Basal pneumonia
- Angina pectoris
- Myocardial infarction
Why Confusion?
- Right upper/middle lobe pneumonia to Pain referred to right hypochondrium (mimics acute cholecystitis!)
- Right lobe pneumonia to Pain referred to right iliac fossa (mimics acute appendicitis!)
- Abdominal distension (if present) adds to confusion
Diagnostic Findings:
- Fever + hurried respiration + low pulse/respiration ratio + working of alae nasi + absence of vesicular breathing = Likely pneumonia, not acute abdomen
Chest Compression Test:
- Compress lower chest from side to side
- If causes pain in thoracic disease but not typical acute abdomen
2. Examine Scrotum and Spermatic Cord
Look for evidence of filariasis!
Filial funiculitis:
- Can cause acute abdominal pain
- Via retroperitoneal lymphangitis
- Associated with periodic fever and groin swelling/redness
3. Examine the Spine
Pott's Disease:
- Compression of spinal cord or intercostal nerves
- Can cause referred abdominal pain
- Mimic acute abdomen
4. Examine Nervous System
Tabes Dorsalis (Syphilis affecting spinal cord):
- Can cause "gastric crisis"
- Pain in abdomen + vomiting
- Look for:
- "Lightning pain" in legs
- Argyll-Robertson pupil (reacts to accommodation but not light)
- Absent ankle and knee jerks
5. Special Conditions Mimicking Acute Abdomen
Medical conditions that mimic surgical acute abdomen:
- Malaria
- Porphyria
- Diabetic crisis
- Sickle-cell anemia
- Hemophilia
- Uraemia
Section 3: Special Investigations
1. Blood Tests
Leucocytosis (Elevated W.B.C):
- Indicates inflammatory condition
- Very useful in diagnosing acute appendicitis
- Also seen in:
- Acute cholecystitis
- Acute pancreatitis
- Acute intestinal obstruction with strangulation
Sugar and Urea Estimations:
- Diabetic crisis can mimic acute abdomen
- Uraemia may present with vomiting + abdominal distension
- Can be confused with intestinal obstruction
Serum Amylase (For Pancreatitis):
- Normal: 80 to 150 Somogyi units
- 400 units suggests acute pancreatitis
- Highest levels: 1000 to 2000 units typical in acute pancreatitis
- Can go higher but degree doesn't always correlate with severity
2. Blood Pressure
Important for assessing:
- Shock
- Dehydration
- Cardiovascular stability
3. Urine Examination
- Look for: Blood, sugar, protein
- In renal colic: Hematuria often present
- In uraemia: Various abnormalities
4. X-ray Examination
Straight X-ray of Abdomen (Most Important):
Findings in Intestinal Obstruction:
- Multiple fluid levels (like a staircase pattern)
- Air in small bowel loops
- Central distension (small bowel) vs peripheral (large bowel)
Findings in Peptic Perforation:
- Free gas under diaphragm (visible on upright X-ray)
- Gas appears as crescentic radiolucency under diaphragm
Other Findings:
- Calcified pancreas (chronic pancreatitis + acute flare)
- Gallstones (if calcified—rarely visible)
- Foreign bodies
Disadvantage:
- Radiation exposure
- Not specific for many conditions
- Many conditions show normal X-ray
5. Barium Enema Examination
Useful Findings:
In Intussusception:
- "Pincer-shaped" ending (pathognomonic)
- Air enema can actually be therapeutic (pushes intussusceptum back)
In Regional Ileitis (Crohn's Disease):
- "Skip lesions" (apparently normal intervening bowel)
- "Cobblestone" or "sawgrain" appearance
- "Spicules" visible
In Acute Ulcerative Colitis:
- Mucosal ulceration
- Granular appearance
- Coarse nodularity
In Acute Diverticulitis:
- Segmental spasm
- Serrations ("saw-toothing")
- Mucosal edema
- Narrowing
Important Contraindication:
- Absolutely contraindicated in very acute conditions!
- Can be done once acute phase subsides
6. Endoscopy
Proctosigmoidoscopy in Acute Ulcerative Colitis:
- Rectum involved in 90 to 95% of cases
- Erythematous, granular mucosa
- Easy bleeding
- Superficial mucosal ulcers
In Crohn's Disease (Regional Ileitis):
- Cobblestone appearance
- Deep linear ulceration
- May be normal between lesions ("skip lesions" by colonoscopy)
Colonoscopy:
- Determines extent in ulcerative colitis
- Identifies "skip lesions" in Crohn's disease
In Acute Diverticulitis:
- Inflamed mucosa
- Diverticula visible
- But narrowing, spasm, fixation more common
Warning:
- Indiscriminate enema administration condemned!
- Nothing more harmful than enema in peritonitis
- Only suitable for acute intestinal obstruction
7. Intravenous Cholangiography
- Visualizes entire extrahepatic biliary tree
- Loses popularity for acute cholecystitis
- Oral cholangiography contraindicated in acute conditions
8. Ultrasonography
Most useful modern investigation:
- Demonstrates:
- Gallbladder stones
- Bile duct stones
- Gallbladder dilation with stone
- Stone in cystic duct
- Biliary tree dilation
- Pancreatic tumors
For Appendicitis:
- Overall specificity: 90%
- Overall sensitivity: 88%
- Very high diagnostic value
- Helps diagnose other causes of right lower quadrant pain
Advantages:
- Non-invasive
- No radiation
- Real-time imaging
9. Radioisotope Scanning
Cholescintigraphy (99mTeknetyum-I.D.A Scan):
- Most specific test for acute cholecystitis
- After 4 injection, material excreted by liver into biliary tree
- Shows extrahepatic biliary tree including gallbladder
- In acute cholecystitis: Gallbladder not visualized
- Reason: Cystic duct or gallbladder outlet obstructed
- Accuracy: Almost 100%
10. C.T Scan
Provides:
- Similar information as ultrasound
- Useful in obese patients
- Useful when excessive bowel gas present
- Three-dimensional visualization
11. Exploratory Laparotomy
Final Diagnostic Tool:
- On many occasions, diagnosis not established until laparotomy undertaken
- Sometimes necessary for both diagnosis and treatment
- Only when medical optimization done and other investigations inconclusive
Section 4: Major Causes of Acute Abdomen
Intra-Abdominal Causes:
A. Inflammation (Peritonitis):
- Acute appendicitis
- Acute cholecystitis
- Acute salpingitis (female)
- Acute diverticulitis
- Acute regional ileitis (Crohn's)
- Acute pneumococcal peritonitis
- Acute non-specific mesenteric lymphadenitis
- Amoebic liver abscess
B. Perforation:
- Peptic ulcer perforation
- Typhoid ulcer perforation
- Diverticular disease perforation
- Ulcerative colitis perforation
C. Acute Intestinal Obstruction:
Mechanical:
- In lumen: Gallstone, roundworms, faecolith
- In wall: Tuberculosis stricture, intussusception, growths
- Outside wall: Adhesive bands, volvulus, internal/external hernias
Toxic: Paralytic ileus Neurogenic: Hirschsprung's disease Vascular: Mesenteric vessel occlusion (embolism or thrombosis)
D. Hemorrhage:
- Ruptured ectopic gestation
- Ruptured Lutein cyst
- Spontaneous rupture of malarial spleen
- Rupture or leaking aortic aneurysm
- Aortic dissecting aneurysm
E. Torsion of the Pedicle:
- Twisted ovarian cyst
- Torsion of spleen (rare)
F. Colic (Non-obstructive):
- Biliary colic
- Ureteric colic
- Appendicular colic
- Intestinal colic
Extra-Abdominal Causes:
1. Parietal Conditions (Abdominal Wall):
- Superficial cellulitis of abdominal wall
- Gas gangrene of abdominal wall
- Abscess of abdominal wall
- Rupture of rectus abdominis muscle
- Tearing of inferior epigastric artery
2. Thoracic Conditions:
- Diaphragmatic pleurisy
- Lobar pneumonia
- Spontaneous pneumothorax
- Pericarditis
- Angina pectoris
- Coronary thrombosis
3. Retroperitoneal Conditions:
- Uremia
- Pyelitis
- Dietl's crisis
- Retroperitoneal lymphangitis/lymphadenitis
- Leaking aortic aneurysm
- Dissecting aneurysm
4. Diseases of Spine, Spinal Cord, Intercostal Nerves:
- Pott's disease
- Acute osteomyelitis of lumbar/lower dorsal vertebrae
- Gastric crisis in Tabes Dorsalis
- Herpes zoster of lower intercostal nerves
- Intercostal neuralgia
5. General Diseases:
- Malaria
- Typhoid fever
- Porphyria
- Diabetic crisis
- Sickle-cell anemia
- Hemophilia
- Purpura
- Smallpox
In Children - Common Acute Abdomens:
1. Acute appendicitis
2. Acute intussusception
3. Intestinal obstruction (roundworms, congenital bands, Meckel's)
4. Acute non-specific mesenteric lymphadenitis
5. Meckel's diverticulitis
6. Primary peritonitis
In Females - Common Acute Abdomens:
1. Ruptured ectopic gestation ⚠️
2. Ruptured Lutein cyst
3. Twisted ovarian cyst
4. Acute salpingitis
5. Tubo-ovarian abscess
6. Torsion or degeneration of uterine fibroid
Section 5: Differential Diagnosis
(Due to length constraints, here are the key differential diagnoses with identification points)
Acute Appendicitis (In Great Detail)
Etiology Factors:
- Low residue diet
- High social status
- European/American/Australian residence
- Familial susceptibility
- Obstruction of appendiceal lumen:
- Faecolith
- Foreign body
- Roundworm
- Stricture
- Indiscriminate purgative use
Incidence:
- Rare before age 2
- Increasingly common in childhood/adolescence
- Peak: 20 to 30 years
- Gradually drops thereafter
Two Varieties:
1. Non-obstructive: Progresses slowly
2. Obstructive: Progresses rapidly, gangrene and perforation common
Pathognomonic Feature - Shifting of Pain:
- Initial pain around umbilicus or epigastrium
- Shifts to right iliac fossa
- This sequence almost certainly = appendicitis
Why This Shift?:
- Appendix develops from midgut (median embryologically)
- Initial visceral pain felt at midline (T.9-T.10 segments)
- Then parietal peritoneal irritation arrow Localized to right iliac fossa
Character of Pain:
- Non-obstructive: Dull, aching
- Obstructive: Colicky
Murphy's Syndrome (Sequence):
1. Pain (first)
2. Vomiting/Nausea (second)
3. Fever (third)
This sequence is pathognomonic for appendicitis!
Physical Findings:
- McBurney's point tenderness (classic)
- Rebound tenderness
- Rovsing's sign
- Muscle guard in right iliac fossa (unless retrocaecal/pelvic)
- Psoas test (if retrocaecal)
- Obturator test (if pelvic)
Special Tests (Important for unusual positions):
- Retrocaecal appendicitis: Psoas test/Baldwing's test positive, tenderness in loin
- Pelvic appendicitis: No anterior abdominal wall rigidity, rectal tenderness, obturator test positive
Differential Diagnoses: Must differentiate from acute cholecystitis, acute pancreatitis, regional ileitis, acute salpingitis, mesenteric lymphadenitis, ruptured ectopic pregnancy, gastroenteritis
Acute Cholecystitis (In Great Detail)
Key Features:
- Pain in right hypochondrium
- Tenderness Murphy's sign positive
- Referred pain to inferior angle of right scapula (biliary tract innervation T.7-T.9)
- Fever (moderate rise)
- Often history of biliary colic
- Ultrasound diagnostic (gallstones + pericholecystic fluid)
- Cholescintigraphy: Non-visualization of gallbladder = diagnostic
Differential: Must exclude appendicitis, pneumonia, hepatitis, pancreatitis
Acute Pancreatitis (In Great Detail)
Key Features:
- Severe agonizing pain (epigastric, radiating to back)
- Sitting up gives relief
- Elevated serum amylase (400+ units)
- Associated with biliary disease/alcohol
- Cyanosis and discoloration (Gray Turner's/Cullen's sign)
Differential: Perforated peptic ulcer, acute cholecystitis
Other Differential Diagnoses to Memorize:
- Acute colonic diverticulitis: Left lower quadrant pain, fever, altered bowel habits
- Acute regional ileitis (Crohn's): Right lower quadrant, "skip lesions" on imaging, mucous diarrhea
- Acute salpingitis: Bilateral lower abdominal pain/tenderness, purulent cervical discharge, menstrual history
- Acute non-specific mesenteric lymphadenitis: Right lower quadrant pain, history of viral illness, normal appendiceal findings
- Acute ulcerative colitis: Bloody diarrhea, fever, diffuse colitis on endoscopy
- Subphrenic abscess: Upper abdominal tenderness, Kehr's sign, imaging shows collection
Obstruction Differential Diagnoses:
- Acute intussusception (children): Sausage-shaped mass, empty right iliac fossa, "red-currant jelly" stool
- Volvulus of sigmoid: Left lower quadrant distension, "bird's beak" on barium enema
- Volvulus of caecum: Right-sided distension
- Meconium ileus (neonates): Meconium plug obstruction
- Volvulus of midgut: High obstruction, severe vomiting
- Mesenteric vascular occlusion: Severe pain out of proportion to findings, late diagnosis
- Mechanical obstruction by worms: History of worm infestation
- Ruptured ectopic gestation: Severe pain + vaginal bleeding/amenorrhea + shock in women
- Biliary colic: Colicky pain, right hypochondrium, no rigidity
- Ureteric colic: Flank pain to groin/testis/inner thigh, hematuria
- Appendicular colic: Periumbilical colicky pain
- Leaking aortic aneurysm: Severe back pain, pulsating mass, shock
- Aortic dissecting aneurysm: Tearing chest pain radiating to back
Summary - Key Teaching Points
1. Always start with History - Often diagnostic!
2. Shifting of pain = Appendicitis (pathognomonic)
3. Murphy's Syndrome (Pain-Vomiting-Fever sequence) = Appendicitis
4. Silent abdomen = Peritonitis (emergency!)
5. Tender, rigid abdomen = Peritonitis (operate!)
6. Never miss female causes = Ectopic, ovarian cyst rupture
7. Always examine hernial orifices first = May be strangulated
8. Shifting dullness/Free air = Surgical emergency
9. Serum amylase = Pancreatitis diagnostic
10. Ultrasound is your best friend = Safe, accurate, non-invasive
Part 2: Examination of an Abdominal Lump
Introduction
Welcome to the second part of this comprehensive guide. Now that you understand how to examine an acute abdomen, we're shifting focus to chronic abdominal conditions and the examination of abdominal lumps or swellings. This is equally important because many surgical pathologies present as lumps rather than acute pain. A systematic approach to examining any abdominal lump will help you arrive at the correct diagnosis.
Section 1: History Taking for Abdominal Lump
Part A: Patient Particulars (Foundation - Same as Acute Abdomen)
Before examining the lump, establish:
- Age: Congenital anomalies present from birth; certain tumors affect specific ages
- Gender: Some lumps gender-specific (ovarian cysts in women, scrotal in men)
- Occupation: Can indicate exposure history
- Residence: Geographic distribution of diseases
- Social Status: Affects disease patterns
Part B: Chief Complaints
1. Duration of Lump:
- Congenital (present from birth): Cystic hygroma, sacrococcygeal teratoma
- Lifelong presence: Suggests congenital origin
- Recent onset: Acute pathology or recent growth
- Slowly progressive: Chronic benign disease or malignancy
2. Rate of Growth:
- Rapid growth: Concerning for malignancy
- Slow growth: Benign pathology (lipoma, cyst)
- Sudden enlargement: Bleeding into cyst or acute inflammation
3. Associated Symptoms:
- Pain: Site, character, duration, relation to lumps
- Vomiting: Suggests obstruction or inflammation
- Bowel changes: Diarrhea, constipation, blood
- Weight loss: Suggests malignancy
- Fever: Suggests infection/inflammation
- Swelling of legs: Suggests lymphatic obstruction
- Jaundice: Suggests biliary obstruction or liver pathology
4. Effect on Health:
- No effect: Incidental finding
- Functional impairment: Organ compression or obstruction
- Systemic symptoms: Malignancy or inflammatory disease
5. Previous Similar Lumps: History of cysts or tumors elsewhere
Part C: Personal History
- Menstrual history (women): Important for gynecological lumps
- Sexual history: Risk factors for S.T.I's/gynekologikal pathology
- Smoking, alcohol: Risk for malignancy
- Radiation exposure: Risk for malignancy
- Chemical exposure: Occupational risk factors
Part D: Past History
- Previous abdominal operations: Adhesions, hernias
- Previous disease: T.B, cirrhosis, kidney disease
- Familial tendencies: Cancer history
- Treatment history: Previous chemotherapy, radiotherapy
Section 2: Physical Examination for Abdominal Lump
Part A: General Appearance and Vital Signs
Facies: Look for signs of illness, pain, malignancy
- Cachexia (weight loss) suggests malignancy
- Jaundice suggests biliary/liver pathology
- Pallor suggests anemia from chronic disease
Decubitus: Position of patient (any preference?)
Skin Color:
- Pallor: Anemia, hemorrhage
- Cyanosis: Cardiovascular compromise
- Jaundice: Biliary/liver pathology
Pulse, Respiration, Temperature, Blood Pressure: Assess cardiovascular status
Lymph Nodes: Examine supraclavicular nodes
- Left supraclavicular lymph node (Virchow's node): Metastatic gastric cancer
Part B: Examination of the Abdomen
Inspection (Look):
1. Condition of Skin Over the Swelling:
- Normal: Benign pathology
- Shiny, thinned, with prominent veins: Suggests subcutaneous pathology
- Redness, warmth, ulceration: Suggests infection or malignancy
- Scars: Previous surgery
- Striae: Suggests chronic distension
2. Position of Swelling:
- Note exact location on abdomen
- Map relative to anatomical landmarks (costal margin, anterior superior iliac spine)
- Which quadrant? Which region?
3. Size of Swelling:
- Measure dimensions in cm (length x width x height)
- Helps track progression
- Important for surgical planning
4. Shape of Swelling:
- Ovoid/round: Cyst, benign tumor
- Irregular: Possibly malignant
- Nodular: Suggests multiple lesions
5. Movement with Respiration: This is Crucial for determining whether lump is intra-abdominal or parietal!
- Moves with respiration: intraabdominal (moves with diaphragm/abdominal wall)
- Examples: Liver, spleen, kidney, ascites
- Does not move with respiration: puhryetal (in abdominal wall)
- Examples: Lipoma, hernia, fibroid
How to Test: Ask patient to breathe deeply, watch lump
6. Visible Peristalsis:
- Look for waves of bowel peristalsis
- Suggests intestinal lump
- Often seen in intestinal obstruction
7. Examine Hernial Orifices:
- Check all three sites: Inguinal, femoral, umbilical
- Look for:
- Bulge
- Irreducibility
- Signs of strangulation (redness, tenderness)
8. Examine Scrotum (in males):
- Any swelling? Tenderness?
- Look for testicular lumps (separate from abdominal lump)
9. Look for Left Supraclavicular Lymph Node:
- Virchow's node
- Pathognomonic for metastatic gastric cancer
- Examine in every abdominal lump case
Palpation (Feel):
Now comes the detailed examination of the lump itself. Use a systematic approach.
Technique:
- Use volar surfaces of fingers
- Flat hand on abdomen
- Gentle movements (pill-rolling)
- Warm hands
- Patient relaxed, legs flexed
1. Local Temperature:
Warm lump: Suggests infection or inflammation Cold lump: Typical of benign pathology or malignancy
2. Tenderness:
Tender lump: Infection, inflammation, malignancy, hemorrhage into lump Non-tender lump: Usually benign (lipoma, simple cyst)
3. Position:
Reconfirm exact position using bony landmarks.
4. Size:
Measure carefully with calipers or tape measure:
- Length (craniocaudal)
- Width (transverse)
- Height (if palpable)
- Important to document for follow-up
5. Shape:
- Round/ovoid: Cyst, benign tumor
- Irregular: Possibly malignant
- Annular: Intussusception, volvulus
6. Surface:
Smooth surface:
- Cyst
- Benign tumor
- Lipoma
Nodular surface:
- Malignant tumor
- Cirrhotic liver
- Tuberculous disease
- Colloid goiter
Irregular/bosselated surface:
- Suggests malignancy
- Multiple nodules
7. Margin:
Well-defined margins:
- Benign pathology
- Encapsulated lesion
- Cyst
Ill-defined/infiltrating margins:
- Malignant tumor
- Chronic inflammation
- Cirrhosis
8. Consistency:
This is very important for diagnosis!
Hard:
- Stone (renal/biliary)
- Malignancy
- Scirrhous carcinoma
- Cirrhotic liver
Soft:
- Lipoma
- Cyst
- Inflammatory mass
Sistik (Fluid-filled):
- Positive fluctuation
- Transillumination positive
- Cyst, abscess
Rubbery:
- Lymphoma
- T.B lymph node
Doughy:
- Edema, inflammatory mass
- Ascites
9. Mobility:
This determines if lump is intraabdominal or puhryetal!
Mobile in all directions:
- intraabdominal (free)
- Moves easily with hand
Limited Mobility:
- Adherent to structures
- puhryetal (abdominal wall)
- Moves with abdominal wall
Fixed (Immobile):
- Malignant tumor with invasion
- Severely adherent
- Dangerous!
Movement with Respiration (Re-test):
- Moves with respiration: Intra-abdominal
- Does not move: Parietal or fixed
10. Pulsatile or Not:
Pulsatile lump:
- Aortic aneurysm (abdominal)
- Femoral artery aneurysm
- Splenic artery aneurysm
- Expansile pulsation: Aneurysm
- Transmitted pulsation: Lump lying over pulsating vessel (different!)
Non-pulsatile: Most lumps
11. Palpation of Hernial Sites:
Systematically palpate:
- Inguinal rings (bilateral)
- Femoral rings (bilateral)
- Umbilical region
- Any previous surgical scars (incisional hernia site)
- Any irreducible/tender hernias (strangulation risk!)
12. Palpation of Liver:
How to examine the liver:
Position: Patient supine, legs flexed
Technique:
1. Place left hand under right lower ribs
2. Right hand on abdomen
3. Ask patient to take deep breath
4. Feel for liver edge with right hand
5. Compare with left side
Findings:
- Normal liver: Edge just palpable below costal margin
- Enlarged liver: Edge palpable greater than 2 centimeters below costal margin
- Tender: Hepatitis, liver abscess
- Hard: Cirrhosis, malignancy
- Smooth edge: Hepatitis
- Irregular edge: Cirrhosis, metastases
13. Palpation of Spleen:
Position: Patient supine or turned slightly to right
Technique:
1. Place left hand under lower left ribs
2. Right hand on abdomen at left costal margin
3. Ask patient to take deep breath
4. Feel for spleen tip with right hand
5. Must reach the lower pole
Findings:
- Normal: Not palpable
- Enlarged: Palpable below costal margin
- Tender: Mononucleosis, T.B, malaria
- Hard: Lymphoma, T.B
- Splenic infarction: Very tender
14. Palpation of Kidneys:
Position: Patient supine or turned toward opposite side
Technique for Right Kidney:
1. Place left hand under right loin (behind)
2. Right hand on abdomen just below costal margin
3. Push up with left hand (support kidney)
4. Feel for kidney with right hand during inspiration
Findings:
- Normal: Just palpable in thin people
- Enlarged: Palpable mass in flank
- Tender: Pyelonephritis, hydronephrosis
- Ballottable: Confirms renal origin (moves up and down with pushing)
Percussion (Tap):
1. Percussion Note:
- Resonant: Over air-filled bowel
- Dull: Over lump, fluid, or solid organ
- Helps confirm presence of fluid
2. Percussion for Ascites (Free Fluid):
Shifting Dullness Test:
1. Patient supine
2. Percuss from midline toward flank
3. Note where resonance becomes dull
4. Patient turns to opposite side
5. Percuss same spot again
6. If becomes resonant = Ascites present
Section 3: Examination of Lumps in Different Quadrants
This is crucial! You need to know differential diagnoses for each anatomical region.
The abdomen is divided into nine regions:
epigastryum Right hypokondryum Left hypokondryum | | | Right Lumbar | periumbilikal | Left Lumbar | | | Right Iliac fossa | hypogastryum | Left Iliac fossa
Right Hypochondriac Region:
Lumps felt here could be:
1. Enlarged liver (most common)
2. Enlarged gallbladder (hydrops, empyema)
3. Hepatic abscess
4. Hepatic cyst
5. Pyloric obstruction (visible peristalsis)
6. Duodenal ulcer (complications)
Identification Points:
- Moves with respiration Liver/gallbladder
- Below costal margin to Likely hepatic
- Tender Hepatitis, cholecystitis
- Hard to Cirrhosis, malignancy
- Murphy's sign positive implies Gallbladder pathology
Epigastric Region:
Lumps felt here could be:
1. Gastric carcinoma (most common mass)
2. Gastric ulcer (complications)
3. Pyloric obstruction
4. Pancreatic carcinoma (deep)
5. Pancreatic cyst
6. Aortic aneurysm (pulsatile!)
7. Hepatomegaly (extends here)
Identification Points:
- Pulsatile to Aortic aneurysm
- Epigastric tenderness plus vomiting implies Gastric disease
- Painless lump plus weight loss implies Gastric cancer
- Deep palpation needed for pancreas
Left Hypochondriac Region:
Lumps felt here could be:
1. Enlarged spleen (most common)
2. Renal mass (left kidney)
3. Left kidney stone (palpable mass)
4. Splenic infarction
5. Subphrenic abscess
6. Left hepatic lobe (extends here)
Identification Points:
- Ballottable to Renal
- Moves with respiration to Spleen/kidney
- Tender plus fever leads to Splenic infarction
- Notch palpable to Spleen
Right Lumbar Region:
Lumps felt here could be:
1. Renal mass (right kidney)
2. Renal stone (fixed tenderness)
3. Hydronephrosis (ballottable)
4. Renal abscess/cyst
5. Colonic mass
6. Appendiceal pathology (if right side)
Identification Points:
- Ballottable to Renal
- Loin tenderness arrow Renal pathology
- Colon tumor to Fixed, hard, irregular
- C.V.A tenderness leads to Renal/ureteric disease
Periumbilical/Umbilical Region:
Lumps felt here could be:
1. Umbilical hernia
2. Umbilical cyst
3. Persistent urachus
4. Omentum (in obstruction)
5. Intussusception (sausage-shaped)
6. Small bowel mass
Identification Points:
- Reducible to Hernia
- Non-tender, translucent arrow Cyst
- Sausage-shaped Intussusception
- Mobile to Omentum/small bowel
Left Lumbar Region:
Lumps felt here could be:
1. Left colon mass
2. Left renal pathology
3. Left ureter stone (rarely palpable)
4. Splenic pathology (if extending)
Identification Points:
- Left colon tenderness to Colon pathology
- Loin tenderness plus C.V.A sign implies Renal or ureteric
- Sausage-shaped to Diverticulitis (chronic)
Right Iliac Fossa:
Lumps felt here could be:
1. Inguinal hernia (most common)
2. Appendiceal pathology (mass, abscess)
3. Crohn's disease mass
4. Caecal mass/carcinoma
5. Femoral hernia
6. Psoas abscess (rare)
Identification Points:
- Irreducible with cough impulse to Hernia
- Tender with fever to Appendicitis/abscess
- Chronic history plus "skip lesions" arrow Crohn's
- Hard, fixed Caecal cancer
Hypogastrium:
Lumps felt here could be:
1. Bladder (distended)
2. Prostate (enlarged)
3. Uterine mass (in women)
4. Fibroid (common)
5. Ovarian mass
6. Small bowel mass
Identification Points:
- Suprapubic tenderness plus retention symptoms implies Bladder
- Large, firm, smooth to Fibroid
- Cystic, tender, mobile to Ovarian cyst
- Hard, irregular to Ovarian cancer
Left Iliac Fossa:
Lumps felt here could be:
1. Colon mass/sigmoid
2. Sigmoid diverticulitis
3. Ovarian pathology (women)
4. Ovarian fibroid (women)
5. Psoas abscess (rare)
6. Femoral hernia
Identification Points:
- Left-sided tenderness leads to Colon/sigmoid
- Female plus palpable mass plus pain implies Ovarian
- Hard, fixed to Sigmoid cancer
- Chronic fever plus lump arrow T.B (psoas abscess)
Section 4: Special Investigations for Abdominal Lumps
The investigation depends on suspected diagnosis. Here's the systematic approach:
For Stomach and Duodenum:
- Barium meal X-ray: Filling defect, ulcer, obstruction
- Upper G.I endoscopy: Direct visualization, biopsy
- C.T scan: Staging gastric cancer
For Liver and Gallbladder:
- Ultrasound abdomen: Hepatomegaly, cysts, stones
- C.T scan: Lesion characterization, metastases
- M.R.I: Cyst characterization, bile duct stones
- Liver function tests: Cirrhosis markers
- Alpha-fetoprotein (A.F.P): Hepatocellular carcinoma
- hida scan: Gallbladder function
- E.R.C.P: Bile duct obstruction/stones
For Spleen:
- Ultrasound: Size, echogenicity, rupture
- C.T scan: Infarction, abscess, lymphoma
- Platelet count: Hypersplenism
- Reticulocyte count: Hemolysis
For Pancreas:
- Serum amylase/lipase: Acute pancreatitis
- C.T scan: Pancreatitis, tumor, pseudocyst
- E.R.C.P: Ductal obstruction
- Endoscopic ultrasound: Small lesions, tissue diagnosis
For Urinary Organs:
- Ultrasound K.U.B: Hydronephrosis, stones, masses
- C.T urography: Stone composition, urothelium
- Renogram: Renal function
- Intravenous urography: Renal/ureteric pathology
- Urine routine: Hematuria, crystals
General Investigations:
- Complete blood count: Infection, malignancy
- Blood chemistry: Renal/liver function
- Tumor markers (if malignancy suspected): C.E.A, C.A-19 to 9, A.F.P
- Imaging (C.T, M.R.I, P.E.T): Staging, metastases
Section 5: Differential Diagnoses by Quadrant
(Summarized Identification Points for Exam Success)
Right hypokondryum:
- Liver enlargement: moves with respiration, below costal margin
- Cholecystitis: Murphy's sign positive, R.U.Q tenderness
- Hepatic abscess: fever, hepatomegaly, tender
epigastryum:
- Gastric cancer: painless, hard, weight loss, positive Virchow's node
- Aortic aneurysm: pulsatile, expansile
- Pancreatic cancer: deep, hard, painless initially
Left hypokondryum:
- Spleen: ballottable, moves with respiration, notch palpable, fever (enlargement cause)
- Renal mass: loin tenderness, moves with respiration, ballottable
Right Lumbar:
- Renal disease: loin tenderness, C.V.A sign positive, ballottable kidney
- Colon tumor: fixed, hard, irregular, obstruction symptoms
periumbilikal:
- Intussusception (child): sausage-shaped, empty right iliac fossa, current jelly stool
- Umbilical hernia: reducible, palpable defect, cough impulse
Left Lumbar:
- Colon mass: fixed, hard, obstruction
- Renal pathology: similar to right side
Right Iliac fossa:
- Appendiceal mass: fever, tender, palpable mass, McBurney's point
- Inguinal hernia: reducible, cough impulse, palpable ring
- Crohn's disease: chronic, "skip lesions", diarrhea
hypogastryum:
- Distended bladder: suprapubic tenderness, smooth, can percuss out upper border
- Uterine fibroid: large, firm, smooth, moves slightly with respiration
Left Iliac fossa:
- Sigmoid cancer: left-sided tenderness, obstruction, hard mass
- Ovarian cyst: mobile, cystic, tender, no hard margin
Final Summary - Key Examination Points
Abdominal Lump Examination Essentials:
1. Movement with respiration Determines if intra-abdominal or parietal
2. Consistency Hard (cancer/stone), soft (lipoma), cystic (cyst)
3. Margin arrow Well-defined (benign), ill-defined (malignant)
4. Tenderness implies Infection, inflammation, malignancy
5. Mobility to Free (benign), fixed (malignancy)
6. Pulsatile to Aortic aneurysm (emergency!)
7. Location arrow Determines differential by region
8. Size change to Rapid (malignancy), slow (benign)
9. Associated signs arrow Weight loss (cancer), jaundice (biliary), fever (infection)
10. Virchow's node to Metastatic gastric cancer (always check!)
Exam Tips and Mnemonics
Inspection Checklist: skin-pep
- Skin changes (scars, ulceration, redness)
- Keep looking (visible peristalsis, distension)
- Intestinal signs (visible bowel loops)
- Nhernial orifices (start here!)
- Position and size
- Eventration or bulges
- Perfusion (color, warmth)
Palpation Checklist: T.C.S.M.C.H.P
- Temperature
- Consistency
- Surface
- Mobility
- Character
- Height/size
- Pulsatility
Red Flags in Abdominal Lumps:
1. Rapid growth implies Malignancy
2. Weight loss plus lump implies Cancer
3. Pulsatile to Aortic aneurysm
4. Fixed/immobile to Advanced malignancy
5. Hard, irregular to Malignancy
6. Virchow's node leads to Metastatic disease
7. Jaundice plus R.U.Q mass leads to Pancreatic/biliary cancer
This completes your comprehensive audio script on clinical examination of acute abdomen and abdominal lumps. Use this as your study guide, referring back to specific sections as needed.
Best wishes for your clinical exams!
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