The abdom en
Fig. 4.19
109
Palpation of the right common femoral artery.
Causes of confusion on palpation
In m a n y p atie n ts, especially those w ith a thin o r lax a b d o m in a l wall, faeces in
the colon m a y s im u la te a n a b d o m in a l mass. T h e pelvic colon is freq uently
p alp a b le , p a rtic u la rly w h e n lo a d e d w ith h a r d faeces. It is felt as a firm tu b u la r
s tr u c tu r e so m e 12 cm in len gth situ a te d low d ow n in the left iliac fossa, parallel
to the in guinal lig am ent. T h e c a e c u m is often p a lp a b le in the right iliac fossa
as a soft r o u n d e d swelling w ith in distinc t borders. T h e tra n sv e rse colon is
s om etim es p a lp a b le in the ep ig a s triu m . It feels so m e w h a t like the pelvic colon
b u t r a th e r larg er a n d softer, w ith distinct u p p e r a n d lower b o rd e rs a n d a
convex a n te r io r surface.
In the e p ig a striu m , the m u s c u la r bellies o f rectu s a b d o m in is lying b e tw een
its te n d in o u s in tersectio ns c a n m im ic a n u n d e rly in g m a ss a n d give rise to
confusion. T h is can u su ally be resolved by asking the p a tie n t to tense the
a b d o m in a l wall, w h e n the 'm a s s ' m a y be felt to c o n tra c t.
What to do when an abdominal mass is palpable
W h e n a sw elling in th e a b d o m e n is p a lp a b le m a k e sure first th a t it is not a
normal s tru c tu r e , as d e sc rib e d ab ove. N ext c o n sid e r w h e th e r it could be d u e to
e n la r g e m e n t o f the liver, sp leen, right o r left kidney , g a llb la d d e r, u rin a ry
b la d d e r , a o r ta or p a r a - a o r ti c nodes.
N o w p a lp a te the sw elling ag a in . T h e a im o f e x a m in a tio n is to decide the
o r g a n o f origin a n d the p a tho lo gic al n a tu r e o f the m ass. In d o ing this it is
helpful to b e a r in m in d the following points:
110
The gastrointestinal tract and abdom en
Site
First make sure that the sw elling does indeed lie in the ab dom inal cavity
and not in the anterior abdom inal w all. Ask the patient to lift his head and
shoulders o ff the pillow and press firmly against his forehead. N ow feel the
sw elling again. If it disappears or becom es m uch less obvious then it lies within
the peritoneal cavity, w hereas if it rem ains the sam e size it m ust be within the
layers o f the abdom inal w all.
N ote the region occupied by the sw elling. T hink o f the organs that normally
lie in or near this region and consider w hether the sw elling could arise from one
of these organs. For instance, a sw elling in the right upper quadrant most
probably arises from the liver, right kidney, hepatic flexure o f colon, or
gallbladder.
Now. if the swelling is in th e u p p e r a b d o m e n , try a n d d e te r m in e if it is
possible to ’get above it' a n d sim ilarly, if it is in the low er a b d o m e n , whether
one can get below it’. By this is m e a n t th a t one c a n n o t feel the u p p e r , or lower,
bo rd e r of the swelling as it d is a p p e a r s ab ov e the costal m a rg in or in to the pelvis
respectively. If one c a n n o t 'get a b o v e ’ an u p p e r a b d o m in a l sw elling, a hepatic,
splenic, renal or gastric origin sho u ld be susp e cte d . I f one c a n n o t get below' a
lower a b d o m in a l m ass the swelling p ro b a b ly arises in the b la d d e r , uterus,
ovary or occasionally u p p e r rectum .
Size and shape
As a general rule, gross e n la r g e m e n t o f the liver, spleen,
uterus, b la d d e r or ovary p resen ts no u n d u e difficulty in d iagn osis. O n the
oth e r h a n d swellings arising from the s to m a c h , sm all o r large bowel,
re tro pe riton e al stru c tu re s such as the p a n c re a s , or the p e r ito n e u m I see section
on mobility, below), m a y be difficult to diag nose. T h e la rg e r a sw elling arising
from one of these stru c tu re s, th e m o re it tend s to d isto rt the o u tlin e o f the organ
of origin. For exam ple, the c h a ra c te ristic ou tlin e of the kidn ev is r e ta in e d early
on. but w hen there is a large renal m ass this o u tlin e is lost a n d recognition
becomes difficult.
Surface, edge and consistency
T h e p a th o lo g ic a l n a t u r e o f a mass is
suggested by a n u m b e r of features. A swelling th a t is h a r d , ir r e g u l a r in outline
a n d n o d u la r is likely to be a n e o p la sm , w hilst a re g u la r, r o u n d , sm o o th , tense
swelling is likely to be cy stic, b u t r e m e m b e r d e g e n e ra tio n a n d so ftening with
cvst fo rm ation occurs not infrequently in m a li g n a n t tu m o u rs . A solid, illdefined a n d te n d e r m ass suggests a n in f la m m a to r y lesion as in C r o h n s disease
of the ileocaecal region.
Mobility and attachm ents C o n s id e r a b le in fo rm a tio n c an be g a in e d from
eliciting the m obility o r fixity o f a n a b d o m in a l m ass. Sw ellings a risin g in the
liver, spleen, kidneys, g a llb la d d e r a n d distal sto m a c h all show dow n w ard
m o v e m e n t d u r in g in sp ira tio n , d u e to c o n tra c tio n o f the d i a p h r a g m O n e
ca n n o t, how ever, move such s tru c tu r e s w ith th e e x a m in in g h a n d . In c o n tr a s t,
swellings o rig in a tin g in str u c tu re s th a t h a v e a m e se n teric o r o th e r b r o a d base
The abdom en
111
o f a t t a c h m e n t are u nin flu e n c e d by re sp ira to ry m o v em e n ts b u t can be m a d e to
m ove freely by p a lp a tio n , e.g. tu m o u r s o f the sm all bowel a n d tra n sv e rse colon,
cysts in th e m e se nte ry , a n d large s e c o n d a ry deposits in th e g re a te r o m e n tu m .
W h e n , on the o th e r h a n d , the swelling is com pletely fixed it u sually signifies
on e o f th re e things: a m a ss o f re tro p e rito n e a l origin, e.g. p a n c re a s ; p a r t o f an
a d v a n c e d t u m o u r w ith ex tensive sp re a d to the a n te rio r o r p o ste rio r a b d o m in a l
walls o r a b d o m in a l o rg a n s; o r a swelling resulting from severe chron ic
in f la m m a tio n involving o th e r o rg a n s, e.g. diverticulitis o f the sigm oid colon or
a colovesical a t ta c h m e n t o r fistula.
In the low er a b d o m e n , th e side-to-side m obility o f a fibroid o r p r e g n a n t
u te ru s r a p id ly estab lishes su c h a sw elling as ute rin e in origin a n d as not arising
from b la d d e r o r ovary.
Is it bim anually palpable or pulsatile? B im a n u a lly p a lp a b le swellings in
the lu m b a r region a re u sually re n a l in origin. J u s t occasionally, how ever, a
po steriorly s itu a te d g a llb la d d e r o r a m ass in th e postero in ferior p a r t o f the
right lobe o f the liver m a y give the im pressio n o f being b im a n u a lly p a lp a b le.
Finally, try to decid e w h e th e r a sw elling exhibits pulsation. It is often difficult
to be c e rta in w h e th e r a sw elling in the u p p e r a b d o m e n th a t is p ulsatile is
m erely tr a n s m ittin g p u lsa tio n from the u n d e rly in g a o r ta o r w h e th e r it is truly
expansile in n a tu re . T h e best w a y to d e te r m in e this is to pla c e tw o fingers on
the swelling a n d o bserve w h a t h a p p e n s to th e m in systole. I f the fingers re m a in
parallel, th e n the p u ls a tio n is tra n s m itte d . If, how ever, the fingers tend to
se p a ra te , th e n tru e e x pa nsile p u ls a tio n is p re sen t a n d th e swelling is arte ria l,
a n d m a y be a n a n e u r y s m (see p. 108).
Percussion
D etails o f how to perc u ss co rrectly are given on p a g e 194. In the a b d o m e n only
light p ercu ssion is n e cessary —a r e s o n a n t (ty m p a n itic ) n ote is h e a rd th r o u g h ­
ou t except over the liver, w h e re th e note is dull. P ercussio n is p a rtic u la rly
useful for c o n firm in g the p r es e n c e o f a n e n la rg e d liver or spleen su sp e cte d on
p a lp a tio n . T h e a b se n c e o f du llness over the su s p e c te d m ass m a k e s the
diagn osis o f h e p a to m e g a ly or s p le n o m e g a ly unlikely.
Defining the boundaries of abdominal organs and masses
Liver T h e u p p e r a n d low er b o rd e rs o f the righ t lobe o f the liver c a n be
m a p p e d o u t a c c u ra te ly by p e rc u ssio n . S ta r t a n te rio rly , at the fo urth interco stal
sp a ce , w h e re the n o te will be r e s o n a n t ov er the lungs, a n d w ork vertically
d o w n w a r d s . In th e n o rm a l liver the u p p e r b o r d e r is found at a b o u t the fifth
in te rc o sta l space, w h e re the n o te will be c om e dull; this dullness e x te n d s d o w n
to th e lo w er b o r d e r fo u n d a t or j u s t below the right su b c o sta l m a rg in . T h e
n o r m a l dullness over the u p p e r p a r t o f th e liver is re d u c e d in severe
112
The gastrointestinal tract and abdom en
e m p h v s e m a . in th e presence o f a large right p n e u m o th o r a x a n d w h e n there is
gas o r a ir in the pe rito n e a l cavity. T h e la tte r, o c c u r rin g in a p a tie n t w ith severe
a b d o m in a l p a in , in dicates pe rfo ra tio n o f a viscus (un less th e p a tie n t has
recentlv u n d e rg o n e la p a ro to m y ). T h is sign, h ow ev er, is not o n e th a t should be
relied on as th ere h a s to be a large v o lu m e o f a ir or gas p re se n t to reduce the
n o rm a l liver d ullness, a n d this is not usually the case.
Percussion ju s t below the right costal m a rg in is useful in h ep a to m e g a ly . Ask
the p a tie n t to b re a th e deeply w hile you p e rcu ss lightly, ke e p in g th e finger
parallel to the rib m a rg in . As th e liver d e sc e n ds d u r in g in s p ir a tio n a change in
percussion note from re so n a n c e to du llness signals the edge o f the liver. The
u p p e r m a rg in o f the liver c an also be assessed, so giving a d irect m easure of
hepatic size, n o rm ally 12-15 cm in height, i.e. e x te n d in g to the fifth rib, or just
below the right nipple in men.
Spleen
Percussion over a n e n la rg e d spleen p rov id e s ra p id confirm ation of
the findings d etected on p a lp a tio n (p. 102 a n d Fig. 4.11). D u lln e ss extends
from the left lower ribs into the left h y p o c h o n d r iu m a n d left l u m b a r region.
T h e lower b o rd e r of a n en la rg e d spleen is read ily m a p p e d out: splenic dullness
gives w a \ to the reso n an c e o f s u r r o u n d in g bowel.
B l a d d e r T h e findings in a p a tie n t w ith re te n tio n o f urin e a r e usualh
un m ista k a b le on p a lp a tio n p. 106 a n d Fig. 4.17). T h e d u lln e ss on percussion
provides re a ssu ra n c e th a t the swelling is cystic o r solid a n d n o t gaseous; its
sup erio r an d lateral borders c an be readily defined from a d ja c e n t bowel, which
is resonant.
Other m asses T h e b o u n d a rie s of anv localized sw elling in the abdominal
cavity, or in the walls of the a b d o m e n , can so m e tim e s be defined more
a ccu rately by p ercussion th a n p a lp a tio n . T h e d u lln e ss of a solid or c ysuc mass
c o ntrasts w ith th e ty m p a n itic no te o f s u r r o u n d in g loops o f bow el.
Detection of ascites and its differentiation from ovarian cvst and
intestinal obstruction
T h r e e c o m m o n causes of diffuse e n la r g e m e n t of the a b d o m e n are:
1 T h e presence ol tree fluid in the p e r ito n e u m i ascites)
2 A m assive o v a ria n cyst
3 O b s tr u c t io n ot the large bowel, distal sm all bowel, or both
Percussion ra p id ly d istin g u ish e s b e tw e en these three, as can be seen in Fig.
4.20. O t h e r help tu l s y m p to m s or signs w h ic h a re usually p re s e n t a re listed in
the legend below Fig. 4.20.
It is unw ise a n d difficult to d ia g n o se ascites unless th ere is sufficient free fluid
p resent to give ge n e ra liz ed e n la r g e m e n t of the a b d o m e n . T w o signs, shifting
The abdom en
Fig. 4.20
113
Diffuse enlargement of the abdomen.
C ro ss ascites: dull in flanks; um bilicus is transverse and/or hernia present; shifting
dullness positive; fluid thrill positive.
Large ovarian cyst: resonant in flanks; umbilicus is vertical and drawn up; large swelling
felt arising out of pelvis which one cannot get below'.
Intestinal o bstruction : resonant throughout; colicky pain, vom iting; constipation;
increased and/or 'noisy' bowel sounds.
du llness a n d a fluid thrill, w h ic h p re s e n t e ith e r singly or to geth er, m a k e the
d iag no sis o f ascites c e rta in . U seful as these tw o signs are, they c an be elicited
in on ly a b o u t h a lf the cases o f ascites. A b se n c e o f shifting du llness or o f fluid
thrill o r b o th does not e x clu de a d iag no sis o f ascites.
T o d e m o n s tr a t e shifting dullness, lie the p a tie n t su p in e a n d percu ss laterally
from the m idlin e, ke e p in g y o u r fingers in the lo n g itu d in a l axis, un til dullness
is d e te c te d ; in n o r m a l in d iv id u a ls du llness is d e te c te d only over the lateral
a b d o m in a l m u s c u la tu r e . T h e n , keeping y o u r h a n d on the a b d o m e n , ask the
114
The gastrointestinal tract and abdom en
Fie. 4.21
Eliciting a fluid thrill.
patient to roll aw a y from you, on to the left side. P ercu ss a g a in in this new
position; if the previously dull note has now b ec o m e r e s o n a n t th e n ascitic fluid
is p ro b a b lv present. T o confirm its presence, r e p e a t the m a n o e u v r e on the left
side of the a b d o m e n .
T o elicit a fluid thrill the p a tie n t is a g a in laid on his back. Place on e h a n d flat
over the lu m b a r region of one side, get a n a ssista n t to p u t the side o f his hand
firm h in the m idline o f the a b d o m e n , a n d then flick or ta p the o p p o s ite lumbar
region (Fig. 4.21). A fluid thrill or w ave is felt as a definite a n d unm istakable
im pulse by the d e te c tin g h a n d held flat in the l u m b a r region. T h e purpose of
the a ssista n t's h a n d is to d a m p e n an y im p u lse th a t m a y be transm itted
th ro u g h the fat of the a b d o m in a l wall. As a rule a fluid thrill is felt only when
there is a large a m o u n t o f ascites p re se n t w h ic h is u n d e r tension.
Auscultation
A u sc u lta tio n is a useful w ay o f listening for bow el so u n d s a n d deciding
w h e th e r thev are n o rm a l, in c re a se d or a b se n t, a n d o f d e te c tin g b r u its in the
a o r ta a n d m a in a b d o m in a l vessels.
T h e stethoscop e sho uld be placed on on e site on the a b d o m in a l all just to
the right of the um b ilic u s is best) a n d k ept th e re u ntil so u n d s art- h eard . It
sho uld not be m ov e d from site to site. N o r m a l bow el so u n d s a re h e a rd as
i n te rm itte n t low- or m e d i u m - p itc h e d gurgles in te rsp e rs e d w ith a n occasional
h ig h -p itc h e d noise or tinkle.
In simple acute mechanical obstruction o f the small bowel the bowel s o u n d s arc
excessive a n d e x a g g e ra te d . F r e q u e n t loud low -p itched g u rg le s : bu rb orx gmi
are h e a rd , often rising to a c re sc e n d o o f h ig h -p itc h e d tinkles a n d o c c u r r in g in
a rh y th m ic p a t t e r n w ith p e rista ltic activity. T h e p re se n c e of su ch so un ds
The groins
115
o c c u r r in g a t th e s a m e tim e as th e p a tie n t experiences bo uts o f colicky
a b d o m in a l p a in is p a th o g n o m o n ic o f sm all bowel o b stru c tio n . In b etw een the
b o u ts o f p eristaltic activity a n d colicky p a in , th e bowel is q u ie t a n d no sou nd s
are h e a r d on a u sc u lta tio n .
In a n o b s tr u c te d loop o f bowel, w h e n s tr a n g u la tio n a n d , later, g a n g re n e
su p e rv e n e , how ever, peristalsis ceases, a n d the bowel so u n d s ra p id ly becom e
less f re q u e n t a n d sto p alto g e th e r. In generalized peritonitis bowel activity ra pidly
d is a p p e a r s a n d a sta te o f paralytic ileus ensues, w ith g r a d u a lly increasing
a b d o m in a l distension . T h e a b d o m e n is ‘sile n t’ b u t one m u st listen for several
m in u te s before being c e rta in th a t su c h a sta te exists. F re q u e n tly to w a rd s the
en d o f this period a s h o rt r u n o f faint, very h ig h -p itc h e d tinkling so u n d s is
h e a rd . T h is re p re se n ts fluid spilling o ver from one d is te n d e d gas- a n d fluidfilled loop to a n o th e r a n d is c h a r a c te ris tic o f ileus.
A succussion splash m a y be elicited by p a lp a tio n (p. 99) a n d also on a u s c u lt a ­
tion. I t m a y be h e a r d in pyloric stenosis, a d v a n c e d in te stin al o b s tru c tio n w ith
grossly d iste n d e d loops o f bowel a n d in p a raly tic ileus. Lie the p a tie n t su p in e
a n d , using the p a lm o f the right h a n d , place the ste th o sc o p e ov er the
e p ig a striu m . T h e n roll the p a tie n t from side to side to a g ita te a n y fluid a n d gas
in the sto m a c h . A sp la sh in g s o u n d , like the noise m a d e by a h o t w a te r b ottle
pa rtia lly filled w ith w a te r a n d air, will be h e a rd if the sto m a c h is d is te n d e d w ith
fluid.
Bruits m a y also be h e a rd in the a b d o m e n . Place the ste th o sc o p e lightly on the
a b d o m in a l wall ov er th e a o r t a , a b o v e a n d to the left o f th e u m b ilicu s, a n d listen
for a bruit. D o likewise ov er e a c h iliac a rte ry in the c o r r e s p o n d in g iliac fossa,
a n d ov er the c o m m o n fem oral a rte ries in e a c h groin. I f a b r u it is h e a r d it is a
significant finding w h ic h in d ic a te s tu r b u le n t flow in th e u n d e rly in g vessel,
e ith e r d u e to stenosis o r to a n e u r y s m . V ery occasionally b r u its m a y be h e a rd
in the e p ig a s triu m w h e n th e re is stenosis o f th e coeliac axis o r s u p e rio r
m esen te ric arte ry , o r on e ith e r side o f the m id lin e in th e m i d - a b d o m e n in
p a tie n ts w ith h y p e rte n s io n d u e to stenosis o f the re n a l a r te r y (see C h a p t e r 13).
THE GROINS
O n c e th e groins h a v e b e e n in sp e c te d , ask th e p a tie n t to t u r n his h e a d to one
side a n d coug h. L ook a t b o th in g u in a l c a n a ls for a n y e x pa n sile im pulse. I f n o ne
is a p p a r e n t , pla c e th e left h a n d in th e left g ro in so t h a t the fingers lie over a n d
in line w ith th e in g u in a l c an a l; p lace th e rig ht h a n d sim ilarly in the r ig ht groin
(Fig. 4.22). N o w ask th e p a t ie n t to give a lo ud c o u g h a n d feel for a n y expansile
im p u ls e w ith e a c h h a n d . W h e n a p a tie n t cou gh s, the m uscles of the a b d o m in a l
w all c o n tr a c t violently a n d this im p a r ts a definite, th o u g h n ot expansile,
im p u ls e to th e p a lp a tin g h a n d s w h ic h is a sou rce o f confusion to the in e x p e ri­
e n ced. T r y i n g to d ifferentiate this n o r m a l c o n tr a c tio n from a sm all, fully
116
The gastrointestinal tract and abdom en
Fig. 4.22
Palpating the groins to detect an expansile im pulse on coughing.
reducible ing uinal h ernia is difficult, a n d the m a tte r c an u su a lly be resolved
onlv w h en the p atien t is s ta n d in g up.
T h e fem oral vessels have a lre a d y been felt (p. 108 a n d Fig. 4.19) and
a u sc u lta te d fp. 1 1 5 . Now p a lp a te alo ng the fem oral a rte ry for enlarged
in guinal nodes, feeling w ith the fingers o f the right h a n d , a n d c a m ' this
palp a tio n m edially b e n e a th the in g u in a l lig a m e n t to w a rd s th e perineum.
T h e n repeat this on the left side. I f the p a tie n t c o m p la in s o f a l u m p in the groin
he shou ld be e x a m in e d K ing dow n and standing up.
T H E M A L E G E N IT A L IA
I he e x a m in a tio n of the g e nitalia is im p o r ta n t in m e n p re se n tin g with abnor­
malities in the groin, a n d in m a n \ a c u te or s u b a c u te a b d o m i n a l svndromes
T h u s d i se as e of t h e g e n i ta l i a ma v le ad to a b d o m i n a l s\ m p t o m s . su ch as pain
o r swelling.
D i s p o s a b l e gloves s h o u l d be w o r n if th e re is a n y su spic io n o f venereal
infection. A d e t a i l e d d e s c r i p t i o n is giv en in C h a p t e r 16.
What to do if a patient complains of a lump in the groin
A lump in the groin or scrotum is a c o m m o n clinical p r o b le m in all age groups.
M o st lu m p s in the groin a re d u e e ith e r to h e r n ia e or e n la rg e d in g u in a l nodes;
inguinal h e rn ia e a re c o n sid e ra b ly m o re c o m m o n th a n fem oral w ith a n inci­
dence ra tio ot 4 :1. In the s c ro tu m , h y d ro c e le o f the tu n ic a vaginalis o r a cv sto f
the e p id id y m is a re c o m m o n cau ses o f pa inle ss swelling: a c u te e p id id v m o orchitis is the m ost fre q u en t ca u se of a painful swelling.
E x a m i n a t i o n o f the groins a n d sc r o tu m is p a r t o f a g en eral e x a m i n a t i o n and
m ust no t be c o n d u c t e d in iso l a t i on . G e n e raliz ed d iseases s u c h as h m p h o m a
Plate III
The Eye
(a) Acute central artery occlusion. The
v e sse ls are attenuated, the retina is
pale and oedem atous and there are a .
few flame-shaped haem orrhages. The
disc is slightly sw ollen and there is a
cherry red clot at the m acula indicating
preserved choroidal circulation.
(b) Chronic sim ple glaucoma.
Pathological cupping of the disc. The
cup is oval in the vertical plane and
appears pale. The retinal v e s s e ls are
displaced nasally b ecause of the
angulation of the optic cup.
(c) Conjunctival injection due to
hypercalcaem ia.
Plate IV
The Eye
(a) Normal fundus Note the yellowisr
colour of the optic disc and the retinal
veins (the larger, darker vessels) and
arteries leaving the centre of the disc
superiorly and inferiorly. A single
arterial branch p a s se s laterally to
supply the m acular part of the retina
(b) Primary optic atrophy. The disc is
pale and w hiter than normal, and its
e d g es are unusually sharply
dem arcated from the retina. The retinal
v e s s e ls are slightly attenuated.
(c) Papilloedema S e e c g 11.1
(P 428) for description