Examination of organs

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

Liver
 
is not visible, its right lobe does not exceed costal arch, left lobe reaches to one third to a half of the distance between xiphoid process and navel (umbilicus), its movements correspond with breathing, the edge is clearly defined, the surface is smooth, with soft consistency, painless. The liver is wide 8 to 12 cm in the midclavicular line (detectable by percussion).
 
The examination can be more difficult in obesity and distended colon.
 
Size:
 
Hepatomegaly - in cardiac decompensation, hepatic cirrhosis, steatosis, or haematological diseases.
 
Edge
 

	Blunt, rounded – hepatic venostasis.
	Sharp, thin - hepatic cirrhosis.
	Uneven, rugged - metastases, hepatic cirrhosis.

 
Surface
 

	Smooth - venostasis, hepatitis.
	Uneven - macronodular cirrhosis, metastases.

 
Consistency
 

	1st grade - soft, elastic - healthy liver.
	2nd grade - tougher in venostasis, in inflammatory and infiltration liver diseases.
	3rd grade - tough, inflexible – hepatic cirrhosis.
	4th grade - very tough (rock) is found in cancer infiltration.

 
Soreness originates in acute enlargement of the liver (hepatomegaly) due to tension of the capsule (acute venostasis, infectious hepatitis, acute cholangitis).
 
Pulsation of the liver is present in serious tricuspid valve insufficiency of the heart.
 
Hepatojugular reflux is produced by the manual pressure on the venostatic liver; it is manifested by the increased filling of cervical veins.
 
Riedel´s lobe is characterised by extension of the lateral part of the liver lobe downwards.

 
Gallbladder
 
is neither visible, nor palpable, nor painful.
 

	Visible - remarkably enlarged in an asthenic patient.
	Hydropic - tense, elastic, egg-shaped, painful palpation (condition after a biliary colic, concrement in the cervix), consequently pericholecystitis may develop.
	Intermittently hydropic - fluctuating closure - description see above.
	Shrunken - usually not palpable.
	Courvoisier´s symptom - extended, pear-shaped (piriform), painless gallbladder in patients with obstructive icterus in pancreas head cancer.
	Murphy's symptom - painful gallbladder in deep palpation due to irritation of its wall or acute cholecystitis (intersection of the costal arch with the midclavicular line on the right).
	Resistance - painless, tough, or uneven; suspected tumour of the gallbladder.

 
Differential diagnostic problems, mainly those originating from the palpation, are caused mostly by Riedel´s lobe, liver metastases, infiltration of the omentum, colon cancer, and the right kidney ptosis.
 
Spleen
 
is neither visible nor palpable; during examination it shows associated movements (synkinesis) with breathing.
 
(The patient is examined lying on the right side, the physician stands behind the patient's back at the left bed side.)
 
Difficulties in examination are caused by obesity, tension of the abdominal wall, meteorism, ascites.
Local evaluation of the finding is – can be confounded with the enlarged left lobe of the liver, tumour of the left kidney and adrenal gland, tumour of the splenic (lienal) flexure or the cauda of the pancreas.
 
Splenomegaly can be visible in case of the extreme enlargement in asthenic patients.
 

	Pronounced - is found especially in myelofibrotic syndrome, chronic myeloid leukaemia, or thrombosis of the portal vein.
	Moderate - in lymphomas, thrombosis of the portal vein and liver cirrhosis.
	Mild - present in infectious diseases (typhoid fever, brucellosis, infectious mononucleosis), sepsis, or infectious endocarditis.

 
Soreness
 
pronounced in perisplenitis joined with splenic infarction (mitral stenosis, infectious endocarditis), simultaneous frictional murmur can be palpable and audible.
 
Kidneys and urinary duct
 
are commonly neither visible nor palpable; they are not painful.
 

	Bulging of the subphrenic region or mesogastrium can be connected with hydronephrosis, polycystosis, or with a major kidney tumour.
	Bulging in the suprapubic region is caused by the full urinary bladder (prostate hypertrophy, cerebral thrombosis, effect of medication, tumours in the lesser pelvis); palpation can reveal voluminous, elastic, and painful resistance reaching sometimes as far as the umbilicus.
	Izraeli´s grasp - positive in hydronephrosis, polycystosis, solitary cyst, or renal neoplasm.
	Painful ureteral points occur in ureterolithiasis or inflammation (found in the intersection of the midclavicular and umbilical lines).
	Tenderness in suprapubic region - urine retention or inflammation; palpation causes urgent need to urinate, filling of the bladder may not be palpable
	Unilateral positive tapotement - acute pyelonephritis, perinephritis, with the presence of effusion into the vicinity.
	Bilateral positive tapotement - glomerulonephritis, bilateral pyelonephritis (obstructive uropathy).

 
Diagnostic problems in physical examination are caused by difficult differentiation of hydronephrosis, polycystosis, and renal tumour, in relation to the colon or gallbladder tumour, and on the left side, to splenomegaly.
 
Stomach
 
in a healthy person it is not detectable either by inspection or palpation, it is not painful.  

	Epigastrium bulging - corresponds with distension of the stomach in ulcerous or tumorous pyloric stenosis, or duodenal bulb, or motor insufficiency (diabetic gastroparesis).
	Pain in the epigastrium - occurs in gastric and duodenal ulcers, gastric carcinoma, and oesophageal reflux diseases.
	Resistance in the epigastrium - palpable in advanced gastric carcinoma.
	Splashing sounds - can be produced in stomach distension.

 
Pancreas
 
Due to its location in the retroperitoneum it is not accessible either by inspection or palpation.
 

	Painful transversely located resistance in the epigastrium - can be present in acute pancreatitis.
	Tough resistance in the epigastrium - extensive tumour or pancreatic cysts.
	Bulging on the left side from the umbilicus - pseudocyst.
	Periumbilical mauve coloration - Cullen's sign in severe acute pancreatitis.
	Inguinal bluish coloration - Grey-Turner's sign in severe acute pancreatitis.

 
Sigmoid colon
 
In a healthy man it is palpable in the left hypogastrium as a firm, smooth, cylindrical tube, sometimes tender on palpation.
 

	Tenderness - in inflammation (diverticulitis, idiopathic proctocolitis), or irritable colon.
	Resistance, fixation to the base - tumour, an advanced process with the infiltration into the surrounding.

 
Caecum
 
is sometimes accessible by means of deep palpation resulting in detection of a painless wider cylinder, slightly mobile against the base.
 

	Tenderness - corresponds with inflammations (idiopathic proctocolitis, Crohn's disease), or tumour.
	Resistance - mostly due to tumour.
	Distension - probably related to ileus condition.
	Variable picture - with temporary finding of spastic contracted intestine - occurs in irritable colon.

 
Appendix
 
requires extraordinary attention. In a healthy individual it is not painful even on deep palpation. It is palpable on the boundary line of the external and middle third of the umbilicospinal line (McBurney´s point).
 
Appendicitis is usually associated with the following findings:
 

	Breath wave skips the right hypogastrium.
	Percussion tenderness of the right hypogastrium (Plenies´s symptom).
	Increased muscular tonus of the right hypogastrium (défense musculaire) - corresponds with localised peritonitis.
	Palpation tenderness of the right hypogastrium.
	Tenderness following the releasing of palpation (Blumberg´s sign).
	Tenderness in the iliocecal region - elicited by palpation of the left hypogastrium after releasing of the pressure against the abdominal wall (Rowsing´s sign).
	per rectum tenderness of cavum douglasi.

 
Small intestine
 
is neither visible nor palpable. The jejunum is localised mostly in the left mesogastrium; the ileum in the right meso- and hypogastrium.
 

	Tenderness, rather diffuse - intestinal infection (enteritis), Crohn's disease, or distension.
	"Stiffening of the loops" - caused by the intensive peristalsis in the place of obstruction (ileus).

 
Auscultation
 
in routine examination of the abdomen is not usually used.
 
Intestinal phenomena, present in healthy people, are audible approx. 15x per minute. Loud sounds are sometimes of distant character.
 
The examination is performed in case of suspected disorder of the intestinal passage or vascular disorder (aortic aneurysm, arterial stenosis).
 
Peristalsis
 

	Sluggish - with isolated phenomena occurs in obstipation.
	Accelerated - occurs in diarrhoea, after using laxatives, in irritable colon.
	Obstructive - peristalsis is remarkably active, accelerated or even chaotic, phenomena of metallic tone colour.
	Paralytic ileus - peristalsis is absent, intestinal phenomena are not present ("deathly silence").

 
Splashing sounds are heard in examination of the undulation above the distended organ, e.g. the stomach in pyloric obstruction or gastroparesis.
 
Friction murmurs are heard in perihepatitis and perisplenitis in dependence on breathing. They are detected rather by auscultation than palpation.
 
Vascular murmurs are heard above the stenotic sections of the abdominal aorta, renal arteries, lineal artery, and celiac plexus.
 
Auscultation is indicated in hypertension, in suspected abdominal aorta aneurysm.
 

Liver demarcation
in hepatomegalia

Ascites
 
Ascites means the presence of free liquid in the peritoneal cavity. It is detectable by physical examination if it exceeds 2000 ml.
 

	Minor - in recumbent position does not influence the shape of the abdomen, in standing position it is manifested by the bulging in the lower abdomen (hypogastrium).
	Major - the abdominal wall is above the level of the chest, it is tense, and the umbilical scar is bulged (navel eversion).

 
The shape of the abdomen is changed in dependence on the body position.
 
Ascites is detectable by means of percussion. The limits are cranial-concave, variable in accordance with the patient's position. Major ascites is associated with the presence of undulation phenomenon (palpable rush of the liquid produced by the impact against the contralateral abdominal wall). The patient is examined both in recumbent (lying) and standing positions.
 
Ascites occurs in decompensated liver cirrhosis, advanced congestive heart failure, nephrotic syndrome, portal vein thrombosis, and carcinoma of the peritoneum. It is necessary, using differential diagnostics, to differentiate ascites from the encapsulated fluid in the abdominal cavity (ovarian and pancreatic cystis), which could be difficult or even impossible by means of a mere physical examination.
 
Per rectum examination
 
Is used as a routine preventive oncologic examination (prostate, rectal carcinoma), in developed or suspected enterorrhagia and melena and sudden abdominal emergencies.
 
The patient is in position "on all fours", supine, lying on the left or right side. Careful examination requires releasing of the abdominal wall.
 
Examination procedure
 

Localisation	Physiological Findings	Pathological Findings
vicinity of the rectum	without changes	irritation of the skin, excoriation, fibromas, fistulas, fibrosed nodules, bluish transparent external haemorrhoids, tense thrombotic haemorrhoidal nodule, postoperative scars
anus	without changes	half-open (hypotonia of the sphincters)
distended anus	without changes	temporary haemorrhoids fissure, excoriation
indagation per rectum		unfeasible in anal fissure (intensive pain)
tonus of the sphincters	adequate	increased: neurolability, fissure of the anus, the irritation of the canal, thrombosis decreased: atonia (at old age)
soreness	absent	present: fissure of the anus, irritation
anal canal	patent, free	small mobile formation - thrombotic internal haemorrhoid, polyp, anal papilla, tumour
rectal ampulla	spacious, the wall elastic, usual presence of the stools	infiltrated wall - with a tumour or inflammation (painful)
lumen of the intestine (within reach of approx. 8 – 10 cm)	without any pathological finding	polyp, tumour or lumen obstruction
cervix of uterus	smooth, painless, of medium tough consistency	condition after hysterectomy, tumour
prostate	symmetrical, soft, central line well palpable, painless	increased : - hypertrophy asymmetrical tough, uneven, the central line impalpable - carcinoma soft, tender - prostatitis

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Caput medusae
ascites, eversion
of the navel,
colateral venous
pattern
 

Limits of ascites
 

Variable limits
in accordance
with patient's
position