Abdominal Examination: Findings

General

Generalized Peritonitis

• Diffuse abdominal tenderness and guarding
• 'Board like' rigidity
• No bowel sounds

Rebound tenderness

Visceral inflammation under this spot.

Jaundice

Courvosier's Law : In the presence of jaundice, an enlarged gallbladder is unlikely to be gallstones; rather it is more likely to be cancer of the pancreas (or biliary tree). Many exceptions exist but it is useful for undergraduate level.

Gallstones and cancer constitute 1/3 of cases of jaundice.

Other causes can be divided as follows:

Prehepatic

Haemolytic (most bilirubin is unconjugated): anaemia.

Hepatic

(Most bilirubin conjugated. Pale stools, dark urine, weightt loss.) Hepatitis, drugs (e.g. alcohol, paracetamol), cirrhosis, pregnancy, α-1 trypsin deficiency. Congenital (Gilbert's)

Posthepatic

(Most bilirubin conjugated) Common bile duct stone, cancer of the head of the pancreas, biliary stricture (incluing cancer, and cholecystitis), pancreatitis, sclerosing cholangitis, primary biliary cirrhosis.

Hepatomegaly

1. Cirrhosis: (usually alcoholic) signs of chronic liver disease
2. Secondary Carcinoma: hard, knobbly, cachexia
3. Congestive cardiac failure: raised JVP, ankle oedema, tender and pulsatile liver

Hepatosplenomegaly + generalised lymphadenopathy: Lymphoproliferative disorders

Splenomegaly

Examine all other LNs

1. Very big: CML, myelofibrosis, trauma
2. Big: Myeloproliferative, lymphoproliferative, portal hypertension (from cirrhosis)
3. Slightly enlarged: Myeloproliferative, lymphoproliferative, portal hypertension, infx (glandular fever, hepatitis, endocarditis)

Large kidneys

A common OSCE case. Large kidneys are identified as bilateral flank masses, bimanually ballotable, they are resonant to percussion, and it is possible to get above them.

The diagnosis is most often polycystic kidneys, so look for evidence of renal disease.

Ascites

Transudate

Cirrhosis (80% of causes, most commonly alcoholic), Heart failure (3%), hypoalbuminaemia (e.g. nephrotic syndrome).

Exudate

Cancer (10%), TB (2%), pancreatitis (1%), serosititis. nephrotic syndrome.

Gynaecomastia

The growing of breasts in men. Common causes:

Physiological

Young & old

Pathological

↓Testosterone (e.g. Klinefelters, trauma), ↑Estrogen (liver disease, thyrotoxicosis, testicular tumours)

Drug

Estrogen, testosterone, gonadotrophins (e.g. hCG, T inhibitors: spironolactone, ketoconazole, cimetidine)

Dupuytren's Contracture

Bilateral if cause is excess alcohol (beware the other hand might have thickening but not yet contraction). Other: trauma from vibrating tools.

Caput medusa

This is veins running from the umbilicus and indicates porto-venous shunt. Must squeeze blood out & see which way it now flows in, should come out from umbilicus

Spider naevi

Blanching lesions due to chronic liver disease. Consist of a large arteriole from which radiate small vessels that somenody once thought looked like spider's legs. Only present in the draining distribution of the SVC (i.e. nipple and up). May also originate in hyperthyroidism.

Koilonychia

Iron deficency anaemia

Leuchonychia

Low albumin, occurs in chronic liver disease.

Palmer erythema

Hyperdynamic circulation. Most often due to chronic liver disease. Also occurs in pregnancy, thyrotoxicosis, rheumatoid arthritis, polycythaemia.

Eponymous signs you should know about

Trossier's sign

Virchov's node: a lymph node in the right supraclavicular region classically related to gastric carcinoma.

Grey-Turner's sign

Bruising of loins due to subcutaneous intraperitoneal haemorrhage due to ruptured ectopic pregnancy, acute pancreatitis (2-3d after) or ruptured AAA.

Cullen's sign:

pancreatitis, ectopic pregnancy

Murphy's sign for acute cholecysititis

Hand in RUQ & asking pt to breathe deeply causes pain due to inflamed GB. Should be negative in LUQ.

Saint's triad

Gallstones, diverticulosis of the colon, and hiatus hernia. The pt presents with dyspepsia.

Scars

Kochers

Right Subcostal incision for cholecystectomy

Midline Laporotomy

Incision down the middle of the abdomen

McBurney's incision

Oblique right lower quadrant scar for appendicectomy. Made 1/3 of the way from the anterior superior iliac spine to the umbilicus.

Pfannenstiel

Low transverse incision for gynaecological procedures.

Nephrectomy

A loin incision

Liver Transplant

Known as the Mercedes incision, as you must be driving a car at least this expensive before you are allowed to make it.

Stomas

Tube Gastrostomy

Over stomach, LUQ

(Tube) Feeding jejunostomy

LUQ

Ileostomy

Spout. Usually RLQ sided. If 2 openings then loop ileostomy (temporarily bringing the bowel to the surface to avoid bad anastomosis), if 1 opening then end ileostomy.

Colostomy

No spout. Usually LLQ sided. Can be loop, defunctioning w mucous fistula (separating out the loop afferent and efferent to avoid contamination), Hartmans (bringing bowel to surface and temporarily sewing up distal end), or end (obliterating end, hence no anus).

Ileal conduit

Epigastric neobladder, connecting the urethra to the ski surface