Measurements of abdomen

1. Abdominal girth should be measured at the level of umbilicus. 
2. Periodic measurement is done to assess prognosis in ascites, paralytic ileus.
3. Measure the distance between lower end of xiphisternum to umbilicus and from umbilicus to symphysis pubis. Normally umbilicus is in mid position, it is displaced down in ascites, upper abdominal mass, displaced upwards  in ovarian or pelvic tumors
4. Spinoumbilical measurement - It is the  distance between umbilicus and anterior superior iliac spines. Normally they are equidistant. Shift of umbilicus to one side will occur in case of tumors that originating from the other side of the abdomen.

Causes of Striae over the abdomen

Striae is due to stretching of the abdominal wall that is severe enough to cause rupture of the elastic fibres in the skin and produces pink linear marks with a wrinkled appearance indicates recent change in the size of abdomen.

Striae types:
White striae or striae albicans  is seen in 

• Obese persons who lost weight suddenly
• Following pregnancy 
• Relieving ascites

Purple striae usually represent the rupture of subepidermal connective tissue seen in

• Recent or past abdominal distension
• Cushing's syndrome
• Prolonged steroid therapy

Broad silvery lines (striae gravidarum) are seen after repeated pregnancies.

Significance of examination of Skin over the abdomen

Examine for the following in the skin over abdomen

• Moles, seborrhocic warts, angiomas (considered normal changes).
• Scars
• Haemorrhagic spots, marking for paracentesis abdominis (benzene stain or cotton scall)  parietal oedema, shininess etc.
• Vesicle of herpes zoster – produces abdominal pain which mimic acute abdomen
• Examine for Striae
• Erythema Ab Igne - Is a brown mottled pigmentation produced by constant application of heat.
• Pigmentation of midline below the umbilicusis the Linea nigra in pregnancy
• Bruising over the periumbilicus and flanks noted  in hemorrhagic pancreatitis [Cullen's sign and Grey Turner's sign respectively).
• Prominent superficial veins: Distended veins around umbilicus (caput medusae) signifies portal hyper tension, but this  is rarely seen.

Inspection of abdomen

Method

Patient should lie flat with one pillow under the head and the abdomen is exposed from the xiphisternum to the pubic symphysis.
Start inspecting the abdomen and note the following features.
Shape of abdomen
Normal shape of abdomen is scaphoid in supine position, moves freely with respiration in vertical direction. No visible mass, no visible peristalsis except in thin individual.

Causes of scaphoid (sunken) abdomen :

1. Severe dehydration.
2. Emaciation or cachexia.
3. Starvation.
4. Tuberculous peritonitis.
5. Malignant peritonitis.
6. Meningitis.

Skin over the abdomen
Distension of abdomen
Dilated vein over the abdomen 
Examination of umbilicus 

Pulsations of the abdomen
Visible pulsation of abdominal aorta is noted in thin persons.
Epigastric pulsation  are noticed in

1. Aortic aneurysm.
2. Right ventricular enlargement
3. Vascular tumors of the liver.

Movement of abdominal wall
To surprise the patient and to impress the examiners, squat down beside the bed so that the patient's abdomen is at eye level.
Ask him to take slowly take deep breaths through the mouth and watch for the movement of the abdomen.
Normally - Gentle rise in inspiration and fall in expiration
Markedly decreased or absent in peritonitis still silent abdomen.

Scar over the abdomen

1. Old scar - White in colour
2. Recent scar are Pink due to the presence of vascularity

Hair over the abdomen

1. Secondary sexual hair - Seen in male after puberty and adults
2. Absence of  secondary sexual hair - Indicates hypogonadism
3. Presence of secondary sexual hair - Above inguinal line in female indicate virilising tumors.

Pigmentation of scar seen in Addison's disease.

Causes of abdominal distension

Distension of abdomen is of two types :

• Generalised 
• Localised (visceromegaly, neoplasm  shifting dullness is absent).

Generalised fullness - all the causes of this will start with the letter ' F'

• Fat
• Flatus
• Fluid
• Foetus 
• Faeces

Differential diagnosis  of bulging or distension of abdomen :
Fat - Obesity (inverted umbilicus with absent fluid thrill and shifting dullness).
Faeces - Megacolon or low gut obstruction (symmetrical enlargement with visible peristalsis).
Foetus - Pregnancy (foetal parts are palpable: central dullness).
Flatus - Gaseous distension (flanks are not bulged: tympanitic note all over the abdomen).
Fluid - Ovarian cyst, ascites.
Full (urinary) bladder (flanks are tympanitic, palpation causes pain or discomfort and desire for
micturition: usually rounded cystlc swelling in hypogastrium which is dull on percussion :
Localised fullness is noted around umbilicus in Mesenteric cyst and Small intestinal obstruction
Asymmetrical fullness is observed in massive hepatomegaly, splenomegaly and ovarian tumor
Hernia - It is a protrusion of viscus through an abnormal opening .The different types are Incisional hernia, umbilical hernia, inguinal hernia.

What is Dyspepsia?

Dyspepsia is a term to denote a variety of alimentary symptoms arising form upper gastrointestinal tract.
Symptoms  includes 

• Upper abdominal pain ± related to food
• Heart burn, regurgitation, water brash
• Anorexia, nausea, vomiting
• Early repletion and satiety after meals
• Flatulence, belching and bloating.

Causes of dyspepsia
Organic dyspepsia
Functional dyspepsia
Organic causes of dyspepsia

• Peptic oesophagitis
• Peptic ulcer
• Upper GI malignancy
• Hepatobiliary disease
• C/c pancreatitis
• Other system disorders - CRF, CHF etc.
• Drugs - NSAID, corticosteroids
• Alcoholism, pregnancy

Functional dyspepsia [nonulcer dyspepsiaI
It is due to motor dysfunction of upper gastrointestinal tract mediated by neurohumoral mechanism
What are the Alarm features in Dyspepsia

• Weight loss
• Anemia
• Vomiting
• Hematemesis
• Melaena
• Dysphagia
• Palpable abdominal mass.

Importance of past history in GIT

Past history is very important in gastrointestinal system

• History of Jaundice indicate viral hepatitis
• Drug intake - history of drug intake such as rifampicin. INH. anabolic steroids pills are risk factors for jaundice .NSAID intake for melena  or history of any herbal remedies
• Blood transfusion or transfusion of any blood products (viral hepatitis C. D and G).
• Recent tattooing or acupuncture: Drug abuse.to rule out viral hepatitis
• Alcohol consumption predispose to cirrhosis
• Tuberculosis can cause ascites due to tuberculous peritonitis.
• Haematemesis or melena (peptic ulcer, ruptured oesophageal varices, gastric malignancy)-
• Fever seen in tuberculosis, hepatocellular failure
• Haematochczia occur due to lower G. 1. malignancy. haemorrhoid

Points to note in a renal lump :

Once the kidney is palpable examine for the folllowing

• Site
• Size.
• Shape (ovoid normally).
• Consistency (resilient or firm in feel).
• Margins (rounded).
• Surface (normally smooth surface: irregular in polycystic kidney).
• Tenderness.
• Movement with respiration (normally kidney shows slight movement with respiration).
• Whether bimanually palpable and ballottable.

Renal angle tenderness
In case of left sided renal lump—Examine for band of colonic resonance over the lump (by
Remember, a kidney lump is bimanually palpable and ballottable. The kidney is ballottable
Because it is a posterior abdominal organ.

How to elicit Tenderness over the renal angle?

Patient is asked to sit and the angle formed by the 12th rib and lateral border of erector spinae muscle is pressed by the ball of the thumb—"Murphys kidney punch". This  test is done on both sides.
Renal  angle is tender in the following conditions

• Acute pyelonephritis
• Perinephric abscess
• Nephrolithiasis, 
• Tuberculosis of kidney

How to do palpation of kidney?

• Lower Pole of right kidney is normally palpable.
• Left kidney is usually not palpable unless either low in position or enlarged 
• Though kidney is retroperitoneally situated, it moves with respiration as it is related to the crus of the diaphragm posteriorly, the movement of the diaphragm is reflected to kidney producing restricted movement during respiration.
• Use bimanual technique to palpate the kidneys.

How to palpate the kidneys?

• The lower pole of right kidney is commonly palpable in thin patients for obvious reasons. Previously it was told that left kidney is palpated best from left side but nowadays no such dogma is present.
• Both the kidneys are palpated from right side of the patient. The method of palpation goes like this :
• Preliminary preparations of the patient are the same as done during palpation of liver. Always sit on a stool for palpation of kidneys.
• To palpate the right kidney, place the right hand horizontally in the right lumbar region anteriorly and the left hand is placed posteriorly in the right loin region (bimanual palpation)
• Push the right hand in a backward, upward and inward direction, and ask the patient to take deep inspiration. A firm mass may be felt in between the two hands (if kidney is enlarged).
• Next, a sharp tap is given by the left hand placed in the loin region. The anteriorly placed right hand now feels the kidney and the kidney then falls back (by gravity) on the posterior abdominal wall which is felt by the left hand. This is ballottement. Firm pressure is exerted by both hands at the height of inspiration to trap the palpable kidney between the two hands, otherwise it will prevent the descend of kidney by the diaphragm
• The left kidney is then palpated by placing the right hand anteriorly and the left hand posterior- the left loin.

Common causes of palpable kidney

Unilateral causes of palpable kidney

• Dropped kidney (can be pushed to its normal position).
• Unilateral hydronephrosis or pyonephrosis.
• Wilms' tumour.
• Hypernephroma.
• Large cyst (solitary) in kidney.
• Compensatory hypertrophy (other kidney damaged).

Causes of bilateral  palpable kidney:

• Polycystic kidney (irregular surface).
• Bilateral hydronephrosis.
• Bilateral dropped kidney.
• Diabetes mellitus.
• Amyloidosis.
• Scleroderma.
• Acromegaly.

Causes of hepatic bruit :

Hepatic bruit is heard in the following situations

• Hepato-cellular carcinoma /hepatoma
• Acute alcoholic hepatitis.
• Haemangioma of liver.

Friction Rub -clinical significance in git examination

It is heard in perisplenitis or perihepatitis due to microinfarction and inflammation.
Splenic rub is heard in the following conditions:
Chronic myeloid leukaemia

Regions of abdomen and its contents

For purposes of description abdomen is conveniently divided into 9 regions by the intersection of imaginary planes there are 2 horizontal and 2 sagittal planes.
The horizontal planes
The upper horizontal plane[transpyloric] lies at a level midway between the suprasternal notch and the symphysis pubis,that is at the level of L1 vertebra (transpyloric plane)
The lower plane passed through the upper borders of the iliac crests at the level of tubercles of the iliac crest.
The sagittal planes or vertical planes
The sagittal planes are indicated on the surface by lines drawn vertically midway between the pubis and anterior superior iliac planes. You have to drop two vertical lines from the mid point of clavicle on either sides.
The regions of abdomen  are:

• Right hypochondrium
• Left hypochondrium
• Epigastrium
• Right lumbar region
• Left lumbar region
• Umbilical region
• Right iliac fossa
• Left iliac fossa
• Hypogastrium.

Contents of different regions of abdomen

• Right hypochondrium - Right lobe of liver, gallbladder, hepatic flexure of colon
• Epigastrium - Left lobe of liver, stomach, transverse colon, lower end of oesophagus and oesophagogastric junction
• Left hypochondrium - Fundus of stomach, spleen, tail of pancreas, splenic flexure of colon
• Right lumbar region - Right kidney and its suprarenal gland, right ureter, ascending colon
• Umbilical region - Aorta, IVC, portions of stomach, head and body of the pancreas, duodenal loop, mesentery, small intestinal loops, lymph nodes
• Left lumbar region - Left kidney and its suprarenal gland, left ureter and descending colon, spleen if it enlarges grossly
• Right iliac fossa - Caecum, appendix, part of ascending colon, lymph nodes, right ovary and fallopian tube
• Hypogastrium - Urinary bladder, uterus in females, sigmoid colon and rectum
• Left iliac fossa - Part of the descending colon, part of sigmoid colon, left ovary and fallopian tube, lymph nodes.

Surface marking of Kidney

Surface marking of kidney is done by drawing the Morris parallelogram .
Two parallel horizontal lines are drawn on the back at the levels of 11 th thoracic and 3rd lumbar spines.
These two horizontal lines are intercepted by 2 vertical lines drawn 3.75 and 8.75 cm respectively from midline.

Surface marking of Liver

Surface marking of upper border of liver
Upper border of right lobe corresponds to the level of 5th rib, 2.5 cm medial to the right midclavicular line.

• 5th Right intercostal space - Midclavicular line
• 7th Right intercostal space – Midaxillary line
• 9th Right intercostal space - scapular line -Inferior angle of scapula

Upper border of left lobe is at the level of 6th rib in left mid clavicular line.
In men, it corresponds to a line joining a point about 1 cm below the right nipple to a point about 2 cm below the left nipple.
Surface marking of lower border of liver 
Lower border  follows the right costal margin, in the epigastrium, it is from the tip of the 9th Right costal cartilage to the tip of the 8th costal cartilage on the left by an oblique line midway between the xiphisternum and umbilicus.
The left lobe extends to the left of the sternum about 5cm.

Surface marking of Spleen

Spleen is situated behind 9th, 10th and 11th ribs with its long axis along the line of 10th rib; anteriorly it extends to mid axillary line while posteriorly its superior angle is 4 cm  lateral to 10th thoracic spine. It is separated from 9th, 10th and 11th ribs by the diaphragm.
Surface marking of spleen can be done by joining 3 points

• 9th Left intercostal space – midclavicular line.
• 1.5" to the left of 10th spine
• 3.5" to the left of 1st lumbar spine

Surface marking of Gallbladder

Gall bladder is situated at the junction of 9th costal cartilage and outer border of right rectus abdominis muscle
Grey-Turner’s Method
Draw a line from left anterior superior iliac spine through umbilicus. At the junction of this and the costal margin, is the gallbladder, provided the shape of abdomen is normal. Gallbladder is better seen than felt when enlarged.

Shifting of upper border of liver dullness :

To delineate the upper border of liver dullness, you should percuss the anterior chest wall along right MCL from above downwards. Normally the upper border of liver dullness is present in right 5th ICS at MCL
Lowered or obliterated  of liver dullness is noted in 

• Emphysema.
• Pneumothorax (right sided).
• Perforation of abdominal hollow vtscus e.g. perforation of peptic ulcer.
• Cirrhosis of liver (liver becomes small).
• Visceroptosis of liver.

Elevated liverdullness :

• Amoebic or pyogenic liver abscess.
• Subdiaphragmatie abscess (right).
• Pleural effusion (right).
• Basal pneumonia (right).
• Increased intraabdominal tension due to ascites or pregnancy.

The upper border of liver dullness is present in right 7th and 9th ICS when percussed along
midaxillary and scapular line respectively.

Measurements of abdomen

Abdominal girth should be measured at the level of umbilicus.
Periodic measurement is done to assess prognosis in ascites, paralytic ileus
Measure the distance between lower end of xiphisternum to umbilicus and from umbilicus to symphysis pubis.
Normally umbilicus is in mid position, it is displaced down in ascites, upper abdominal mass, displaced upwards  in ovarian or pelvic tumors
Spinoumbilical measurement –It is the  distance between umbilicus and anterior superior iliac spines. Normally they are equidistant. Shift of umbilicus to one side will occur in case of tumors that originating from the other side of the abdomen.