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Clinical Exploration of the Abdomen: Anatomical Landmarks & Examination Methods

Explore the essential anatomical landmarks and clinical examination methods for assessing the abdomen, including topography, abdominal wall structures, organs, and examination techniques. Learn about pain assessment, percussion, palpation, auscultation, and rectal examination.

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Clinical Exploration of the Abdomen: Anatomical Landmarks & Examination Methods

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  1. ABDOMEN

  2. Anatomical landmark in clinical exploration of the abdomen

  3. What is normal?

  4. Bony landmarks • Lower ribs • Spine • Iliac bone • Inguinal ligament • Pubic bone • Sacrum – pelvic aperture

  5. Anatomic landmarks • Xifoid apendix • Costal margins • Spina iliaca antero-superior • Simphisis pubis • Umbilical scar

  6. Topography of abdomen

  7. Topography of abdominal wall • Vertical lines • Midline between pubis and antero-superior iliac spine • Horizontal lines • Through both iliac spines • Subcostal (lower most part of costal margin)

  8. Antero-lateral wall. Essentials of anatomy. I • Skin • Subcutaneous tissue • Vascular and nervous structures • Umbilical scar • Inguinal arrea

  9. Antero-lateral wall. Essentials of anatomy II • Muscles and corresponding fascia (internal and external oblique, transversalis and rectus abdomini) • Linea alba • Posterior aspect of the inguinal region • Umbilical region • Vessels and nerves

  10. Fascial structures in the middline

  11. Posterior wall. Essentials of anatomy • Diaphragm • Diaphragmatic communications • Muscles of the lumber region • Muscles of the pelvic diaphragm

  12. Arteries of the abdominal wall

  13. Veins of the abdominal wall

  14. Nerves of the abdominal wall

  15. Inguinal region • Skin projection of the region (triangle) • Inguinal ligament • Lateral aspect of rectus abdomini • Perpendicular through the middle of ilio-pubic line

  16. Inguinal region

  17. Inguinal region

  18. Examination of the abdomenThe abdominal wall • Inspection • Palpation • Percussion • Auscultation

  19. Inspection • Shape • Asymmetry • Changes in decubitus and standing • Scars • Cutaneous changes • Vascular pattern

  20. Palpation - superficial • The structure of the abdominal wall • Sensibility • Cutaneous reflexes • Subcutaneous tissue • Weak points and areas • Muscular structures • Check muscle position within the structures

  21. Clinical exploration of abdominal organs

  22. Anatomic landmarks

  23. Sagital and transverse sections

  24. Serial tomographic section

  25. Good light Relaxed patient Correct exposure. Whole abdomen to the level of symphisis and inguinal region Protect the genital areas Decubitus + pillow Arms close to the body Ask patient for painful areas and examine them later Warm hands Avoid sudden movements Distract his attention if anxious Follow his reactions – face changes Clinical examination of the abdomen

  26. Methods • Anamnesis • Inspection • Palpation • Percution • Auscultation • Rectal and vaginal examination

  27. History taking • PAIN • Onset and time changes • Location • How significant • Radiation of pain • Association with other symptoms

  28. Types of abdominal pain • Hollow organs • Paroxistic crampy pain • Difficult to pinpoint • Associated with peristaltic movement • Pacient is agitated – would not find a relaxed position • Perioneal inflamation • Constant or steadily increasing pain • Well circumscribed • Patient will be reluctant to move as it increases pain

  29. Radiated pain • Billiary colic • Duodenal ulcer • Renal pain • Genital originated pain

  30. Essentials of anamnesis • Nausea, vomiting, diarrhea, constipation • Stool – melena, blood, • Vomiting – blood, digested blood • Urinary symptoms : frequency, discomfort • Weight loss • Sexual history • Sexual activity, contraceptive pills, last cycle • Any fertile women may be pregnant • Pregnancy test if in doubt

  31. Skin Venous pattern Umbilical scar Shape of abdomen Peristaltic movement Pulsations Mobility during cough or respiration INSPECTION

  32. AUSCULTATION • Preferable before palpation – stimulates movements • Listen for sounds produced by bowels • Vascular abnormal sounds (stenotic vessels)

  33. First orientation – “in cross” in four quadrant Map of the abdomen Generalized/localized meteorism Dull area localized +/- movable Signs of peritoneal irritation PERCUSSION

  34. PALPATION • Essential and the most important • One or two hands are used for deep palpation depending mostly on muscular tonus • Systematic, avoid very painful areas at the beginning • After a screening examination – characterize different organs which are accessible • Sudden decompression

  35. Rectal examination • Sensible area • Put yourself (only in theory…) in his/her place • He/she should trust you • A special room – respect his/her dignity

  36. Rectal examination • Lateral decubitus or in all fours • Explain what you do. It is not painful nor pleasant • All you need is a glove and lubricant

  37. Rectal examination • Inspection: • Eritematous lesions • Incontinence for feaces • Scars • Fistula – puss • Tumors • Ulcerations • Fissura in ano

  38. Rectal examination • Palpation: • Sphyncter tonus • Fissura in ano • Prostate • Tumors • Rectal content • Cervix and uterus • Peritoneal “Coul de sac” or Douglas pouch • Bimanual examination • Look for faces aspect on you glove

  39. Exploration of the liver

  40. Inspection • Volume • Uniform distension in ascites • Asymmetric distension in tumors • Venous collateral circulation

  41. Inspection • Umbilical hernia • Spider hemangioma • Gynecomastia • Rinofima

  42. More often unhelpful Before ascites there is a period with paretic distension with dimished intestinal sounds Large tumors with lare tributaries – arterial murmurs Acoustic finding of liver edge Auscultation

  43. Percussion • Evaluate the area of liver dullness • If significantly increased you need to find both edges • In general the liver is underestimated

  44. Percussion • Meteorism before ascites • Movable dullness • Iceberg sign • Wave sign • Prehepatic tympanism • Sdr. Chilaiditi • Pneumoperitoneum • Situs inversus

  45. Palpation • Inferior limit of the liver • Limits • Morphologic aspect • Sensibility • Tumors • charcaterize

  46. Palpation

  47. Rectal examination • Faeces with melena aspects • Fresh • Old • Large volume internal hemorrhoids (portal hypertension) • Metastasis in the Douglas pouch

  48. Clinical exploration of the spleen

  49. Inspection • Changes determined by anemia or hematological diseases • Abdominal deformities • Peritoneal irritation in trauma with blood in peritoneum

  50. Percussion – dull area of the spleen - movable dullness – liquid in peritoneum

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