Observation - inspection
- Total
- Extra-abdominal
- Abdominal
 
Percussion
 
Palpation
- Superficial (abdominal wall)
- Deep
 
Examination of organs
- Liver
- Gallbladder
- Spleen
- Kidneys and urinary tract
- Stomach
- Pancreas
- Sigmoid colon
- Caecum
- Appendix
- Small intestine
 
Auscultation
 
Ascites
 
Examination per rectum

Percussion
 
is used to assess the resistance of the abdominal wall, its tenderness, content of the abdominal cavity and the size of its organs.
 
In a healthy man, the abdominal wall is firm not tender; percussion produces a differentiated tympanic resonance (i.e. tympanic resonance above the abdominal organs produces a different sound in accordance with the volume of gaseous filling).
 
Soreness of the abdominal wall - so called Plenies´s symptom corresponds to localised peritonitis.
 
Percussion
 

	Tympanic resonance occurs:   - In case of the increased content of gas in the digestive tract (ileus of the small intestine and colon).   - In presence of free gas in the peritoneal cavity (pneumoperitoneum). Perforation of the stomach, duodenum, or gut; artificially after laparoscopy.
	Abbreviated percussion is caused by the presence of fluid or airless tissue.   - In ascites (variable borderline in dependence on the body position).   - Above extensive cystic or tumorous formations or a full urinary bladder.

 

Palpation
 
is considered the most important examination method of the abdomen.
 
Superficial palpation is concentrated on the abdominal wall, its tonus, tenderness, soreness, and the presence of superficially localised resistances.
 
Deep palpation is directed at penetration into the depth, collecting information on soreness, intensity of propagation, organs, abdominal aorta, and pathological resistances. High quality examination requires experience, careful and systematic attitude. It starts from the area where no pain is reported, most frequently from the left hypogastrium. Good cooperation of the patient is a necessary prerequisite of the examination. Palpation is quite difficult in obese patients.
 
Abdominal wall of a healthy man is firm, smooth, elastic, and painless. Organs accessible through palpation are not tender; their size is adequate. Pathological resistances in the abdomen are not palpable.

Examination of the
abdomen by means
of percussion
 

Examination of the
abdomen by means
of percussion
 

Percussion findings
in the abdomen
(ileus)
 

Percussion findings
in the abdomen
(ascites)
 

Ovarian cyst,
filling of the
urinary bladder

Superficial palpation - abdominal wall
 

	Tense wall - the patient is not able to relax (release) muscular tension (patients with neurovegetative lability).
	Tense wall, painfully contracted (défense musculaire) - in accordance with the extent of localised or diffuse peritonitis.
	Tense wall - caused by the processes in the vicinity or general influences (basal pleuritis, diaphragmatic cardiac infarction, inflammation of the abdominal wall, diabetic coma – pseudo-peritonitis).
	Thickened wall - subcutaneous fat in obese individuals, thick muscular layer.
	Effused wall - in anasarca (serious cardiac decompensation).
	Lobular structures - subcutaneous fat, lipomas, or fibromas.
	Crepitations - subcutaneous emphysema, or gaseous gangrene of the abdominal wall.
	Protuberant wall    Painless with possible reposition of the structure by means of the preformed opening into the abdominal wall;    Painful - fixed, reposition is not possible. These findings correspond with free or fixed umbilical, or inguinal, or scar hernia. Bulging of the free hernia corresponds with the increased intra-abdominal pressure; a fixed hernia remains unchanged.

 
Deep palpation
 
allows to find soreness deep in of the abdominal cavity - assess its intensity and propagation; and based on the localisation, to determine the place of origin. Pain intensity depends on its cause, reactivity, and patient’s sensitivity. It is influenced by the age (reduced in the old age), medication, or alcohol consumption. During the examination, it is advisable to observe the face expression of the patient.
 
Deep palpation is important for detecting formations (resistances) in the abdominal cavity. It allows determination of location, surface, size, shape, consistence, relation to their surrounding (mobility, fixation), and pulsation (aorta - aneurysm).
 
Organ location of the findings (orientation):
 

	Epigastrium - distal oesophagus, stomach, duodenum, bile duct, and pancreas.
	Right hypochondrium - liver, gallbladder, bile duct, and transvers colon (hepatic flexure).
	Left hypochondrium - spleen, transvers colon (splenic flexure), pancreas, and left kidney.
	Right mesogastrium - right kidney and ascending colon.
	Left mesogastrium - left kidney, descending colon, and sigmoid colon.
	Periumbilical region - small intestine and pancreas.
	Right hypogastrium - appendix, caecum, terminal ileum, and right ovary.
	Left hypogastrium - rectum and left ovary.
	Suprapubic region - urinary bladder and uterus.

Subcutaneous
fibromas
 

Hernias