last authored: Sept 2009, David LaPierre
The abdominal history and physical exam is important to assess gastrointestinal concerns, but can also help identify problems with the heart, aorta, spine, kidneys, pelvis, and peritoneal cavity.
Common gastrointestinal concerns include abdominal pain, dyspepsia, nausea and vomiting, diarrhea, loss of appetite or weight, dysphagia, changes in bowel function, and jaundice. Each should be evaluated specificially if identified.
A good spot to begin is with "how's your appetite?"
Ask about diet, referring to Canada's Food Guide.
Ask about dysphagia or odynophagia.
Start with open-ended questions such as "how are your bowel movements?" "how frequent are they?" have you noticed any changes?"
Nocturnal defecation and urgency are important and should be specifically questioned.
Abodominal pain should be described in patient's own words, rated, localized, and described according to timing and aggrevating/relieving factors.
The history is tremendously important when weight loss is occurring. Intake, absorption, and metabolism should all be queried.
Previous surgeries should be discussed, as recurrence or complications are possible.
Directly inherited and polygenic disorders are important. Country of origin can also be helpful.
Smoking, alcohol, and employment can all be involved in GI disease.
Understanding hopes and expectations, the home situation, and social supports will help with planning the future.
Many drugs affect the GI tract, and drugs taken over the past several months should be identified. NSAIDs can cause hemorrhage, antibiotics can disrupt normal flora, andvarious drugs can cause liver toxicity.
It is quicker to run through all systems the first time a patient is interviewed rather than spend much time on fruitless investigations and find important information later.
Clubbing, leuchonychia, kolionychia, Dupuytren's contracture, and palmar erythema can all suggest liver disease, as can asteryxis.
Spider nevi and gynecomastia can suggest liver disease.
Look for the presence of pallor or jaundice.
Observe the contour and symmetry of the abdomen, looking for flank or local bulge.
Note any scars, striae, dilated veins, rashes.
Frequently, the normal aortic pulsation is visible.
Listen to the abdomen before percussing or palpating, as these can change the frequency of sounds. Normal sounds, such as clicks and gurgles, are normally heard 5-34 times/minute.
Bruits can be sometimes be heard in the epigastrium and upper quadrants due to renal artery stenosis. A bruit during both systole and diastole suggests renal stenosis is the cause of hypertension. Bruits can also be heard over the aorta, the iliac arteries, and the femoral arteries, but can be benign.
Percussion helps assess the amount and distribution of gas and stool, liver and spleen size, as well as ascites, and masses.
Gentle palpation is useful for helping relax the patient and identify areas of tenderness, muscular resistance, and some superficial masses. If the patient is frightened or ticklish, start with their hand under yours. Observe the patient's face while examining.
Deep palpation can be used to find abdominal masses.
Rebound tenderness begins with slow, moderately deep pressure and a quick withdrawal. Pain suggests peritoneal inflammation and can be felt at areas other than that of palpation.
Due to its location under the rib cage, the liver can be difficult to assess.
Normal liver spans are 6-12 cm in the midclavicular line and 4-8 cm in the midsternal line. While it is the most accurate method, percussion can often underestimate liver size.
Ask the patient to take a deep breath in and try to feel the liver edge as it descends. On inspiration, the liver edge is palpable about 3 cm below the right costal margin midclavicularly. Try to trace the liver edge across its span.
Other systemic signs of liver disease include clubbing, spider nevi, gynecomastia, ascites, and others.
An enlarged spleen usually points anteriorly, downward, and medially.
Percussion raises suspicion of splenomegaly but must be confirmed with palpation. Dullness in Traube's space, above the left midaxillary costal margin, suggests an enlarged spleen, and can occur on inspiration.
The spleen can be palpated with two hands.
A large belly with bulging flanks suggests ascites, as normally, obesity protrudes forwards.This is a sensitive, but not very specific, sign. Fluid-filled flansk will be dull on percussion.
Percuss for air resonance, starting at the middle. make a mark where the resonance becomes dull. Then, have the person roll onto their side and repercuss, noting potential changes in fluid markers. not very sensitive, but specific.
have someone push their hand down in the midline. tap one side and feel for a fluid wave across the abdomen. sensitive but not specific.
Although kidneys are not normally palpable, detecting an enlarged kidney may be very important.
abdominal exam video (St George's University Clinical Skills Online)