Physical Examination for Abdominal Pain or Stomach Ache Include Inspection, Palpation and Auscultation
Inspection Of The Abdomen:
Inspection is an observation of abdomen under optimum visualization. Inspection is to evaluate changes in abdominal contour, color and observation of any abnormal vascular changes.
- Abdominal Contour: Abdominal shape is often altered with certain disease. Inspection of abdominal curve may show a change of generalized distension or localized bulge.
- Generalized Distension: Ascites (rounded symmetrical and bulge flank), hematoma – intra abdominal bleeding obesity, bowel distention by gas or liquid.
- Localized: Portion of the abdomen shows swelling or bulge as in following diseases:
- Right upper abdomen: Liver tumor, hepatitis.
- Left upper abdomen: Splenomegaly, gastric tumor.
- Upper half of the abdomen: Pancreatic cyst or tumor or acute gastric dilatation.
- Lower half of the abdomen: Pregnancy, ovarian tumor, uterine fibroids, or bladder distention.
- Scaphoid abdomen: Malnutrition.
- Flank: Bulge in area of flank is secondary to disease of kidney tumor and kidney abscess.
- Discoloration: Bluish discoloration seen with abdominal pain in following diseases:
- Umbilicus (Cullen’s sign) – Bluish bruises and edema around umbilicus seen in acute pancreatitis and ectopic pregnancy.
- Flanks (Grey Turner’s sign)- Bluish bruising of flank seen on pancreatic necrosis, retroperitoneal bleeding and intra-abdominal bleeding.
- Striae also known as stretch marks, striae atrophicae, vergetures, striae distensae, striae cutis distensae, striae gravidarum, lineae atrophica and linea albicante. Striae are a scarring of skin by separation of dermal elastic and fibrous tissues, commonly seen after pregnancy and loss of weight in obese patients. Abdomen is stretched considerably in obesity and pregnancy. After pregnancy and loss of weight in obesity stretch marks are very noticeable and detected in abdominal wall
- Surgical Scars: In most of the cases, scar is seen as a normal healing scar. In few cases, it may be presented as keloid or infected scar tissue.
- Abnormal Abdominal Wall Venous Flow: Changes in direction of venous flow is observed in patients experiencing partial or complete blockade of inferior vena cava by thrombosis or embolism. In a normal individual, blood in venous system of abdominal wall flows from umbilicus outward towards heart in upper half of abdomen and toward feet in lower half of abdominal wall. Blood flow changes direction in inferior vena caval blockage.
- Spider nevus of the abdominal wall: Also known as spider angioma and vascular spider. It is presented with central red bright spot of dilated arterioles and radiating branches spreading outward as spider web of venous branches carrying blood away from central arterioles. They are benign and seen in liver disease.
- Hormonal Contraceptive: Higher estrogen level pregnant woman.
- Liver Hepatic Disease: Unable to metabolize estrogen, cirrhosis.
- Hernia: Bulge is observed in umbilical, epigastric, incisional and spigelian hernia.
Palpation Of The Abdomen:
After inspection, the patient is examined with palm and fingers of one or both hands. Palpation is either gentle superficial and deep or vigorous superficial and deep.
- Intra-abdominal Crepitus: Palpation may produce a sound and feel of crepitus. Crepitus is a crackling and popping sound. Intra-abdominal crepitus is observed in necrotizing enterocolitis occurs in premature infants.
- Abdominal Tenderness: Tenderness is defined as pain and discomfort when affected area is touched. Generalized tenderness – Peritonitis causes severe generalized abdominal pain and presents other symptoms such as loss of appetite, fever, dehydration, anorexia, poorly localized pain, rigidity, and rebound tenderness.
- Appendicitis presented with localized tenderness in lower right quadrant of abdomen. Palpation over inflammatory mass such as appendix in right lower quadrant produces severe pain and tenderness.
- Stomach cancer mass felt in left upper quadrant.
- Mass: Diagnosis depends on location where mass is felt. Occasional cases liver, spleen and kidney may be palpable in normal individuals.
- Right Upper Quadrant: Liver hypertrophy, hepatic tumor, carcinoma of head of pancreases, gall bladder enlargement following cholecystitis.
- Epigastric Mass: Gastric enlargement, pancreatic pseudocyst, pancreatic cancer or abdominal aneurysm.
- Left Upper Quadrant: Splenomegaly.
- Flank: Renal cysts, polycystic kidneys, and renal malignancies may all be visible in asthenic patients.
- Lower Quadrants: Inflammatory or neoplastic disorders of the intestine. In the right lower quadrant appendicular abscess and cecal carcinoma are most likely, while in the left lower quadrant diverticular abscess or carcinoma of the sigmoid colon is most likely.
- Hypogastric Quadrant: Pain cause by pelvic organs.
- Soft: Ovarian cyst, volvulus, bladder distention, cholecystitis.
- Firm: Splenomegaly, neuroblastoma, kidney cancer, aortic aneurysm, bowel obstruction.
- Hard: Uterine leiomyoma, stomach ulcer, hepatomegaly, liver cancer, kidney cancer, colon cancer, gallbladder tumor.
- Guarding: Peritonitis, appendicitis, diverticulitis, rupture ovarian cyst, twisted ovarian cyst, rupture aortic aneurysm, spleen rupture, uterus rupture, mesenteric embolism, pancreatitis, intestinal obstruction, ectopic pregnancy, rupture gallbladder, perforated ulcer, volvulus, intussusception, abdominal injury.
- Rigidity: Peritonitis, appendicitis, diverticulitis, rupture ovarian cyst, twisted ovarian cyst, rupture aortic aneurysm, spleen rupture, uterus rupture, mesenteric embolism, pancreatitis, intestinal obstruction, ectopic pregnancy, rupture gallbladder, perforated ulcer, volvulus, intussusception and abdominal injury.
- Rebound Tenderness (Rovsing’s sign): Tenderness and rebound tenderness on palpation. This is seen in appendicitis, peritonitis and ulcerative colitis.
- Normal Peristalsis: Normal peristalsis of the intestine produces bowel sounds as gas and fluid are passed through the intestinal lumen. Normally, the bowel sounds are intermittent, low-pitched, chuckling sounds. Bowel sounds may be decreased or increased in few diseases.
- Absence of Bowel Sound (paralytic ileus): Late stage of intestinal obstruction, paralytic ileus seen in congestive heart failure, pneumonia and uremia.
- Hyperactive Peristalsis(rushes): High pitch and tinkling sound, earlier phase of intestinal obstruction.
- Rubs: Irritation of inflamed serosa surface of peritoneum rubbing against diseased organs during inspiration and expiration of breathing cycle e.g. liver, spleen and abdominal mass. Normal peritoneal surface when inflamed from infection or neoplasm causes adherence to vascular structure and surrounding organ.
- Vascular Bruits: Audible turbulent blood flow conducting swishing sound over major arteries during systole. Observed in aortic aneurysm and atherosclerosis of aorta and renal artery. Occasional bruits are heard during systole and diastole in a patient suffering with arteriovenous communications.
- Crepitus: Sound is produced by friction between gas and fluid within the viscous of organ or air entrapped in subcutaneous tissue following infection such as gas gangrene. Penetrating chest wall injury can cause subcutaneous emphysema secondary to air leaking from alveoli into subcutaneous tissue through a track of air fistula. Post surgery claustredial infection can cause intra-abdominal gas gangrene.
- Vomiting: Persistent and continuous vomiting causes dehydration.
- Diarrhea: Continuous several episodes causing dehydration.
- Profuse hemoptysis: Peptic perforation, gastric bleeding tumor. Bleeding per rectum- hemorrhoids, tumor.
- Bleeding Abdomen: Ruptured aneurysm.
- Peritonitis caused by Perforation of Abdominal Organs. Ulcer from esophagus, stomach, intestine and large bowel can perforate and cause peritonitis. Gastric carcinoma, intestinal tumor, inflamed appendix, Meckel’s diverticulitis or intestinal infarction can cause perforation and severe peritonitis. Rare causes of peritonitis are ingestion of foreign bodies and abdominal surgery. Auto or work injury may cause blunt or penetrating abdominal trauma causing injury to internal organ and tear. Peritonitis is cause by feces in the peritoneal cavity inducing E.Coli and anaerobic bacterial (bacteroides fragilis) infection. Surgical trauma or injury causes peritonitis mostly infected by staphylococcus aureus or coagulase negative staphylococci and may include fungi and Candida.
- Non-infected Peritonitis: Sterile fluid from body if leaked into peritoneal cavity causes inflammatory reaction. Non-infected peritonitis is observed with leakage of blood, endometriosis, gastric juice, urine, menstruum, pancreatic juice or ovarian cyst rupture.
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