Unit # 05

Assessment of Abdomen , Anus & Rectum

Ms. Irum Hassan

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 Structure and Function
• Surface landmarks
– Borders of abdominal cavity
– Abdominal muscles
• Internal anatomy (viscera)
– Solid viscera
• Liver
• Pancreas
• Spleen
• Adrenal glands
• Kidneys
• Ovaries
• Uterus
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 Structure and Function
• Internal anatomy (viscera) (cont.)
– Hollow viscera
• Stomach
• Gallbladder
• Small intestine
• Colon
• Bladder

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Internal Anatomy

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Structure and Function
(cont.)
• Abdominal wall divided into four quadrants
– Right upper (RUQ)
– Left upper (LUQ)
– Right lower (RLQ)
– Left lower (LLQ)

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General Considerations
• The patient should have an empty bladder.
• The patient should be lying supine on the exam table and
appropriately draped.
• The examination room must be quiet to perform adequate
auscultation and percussion.
• Watch the patient's face for signs of discomfort during
the examination

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Subjective Data— Health History Questions
• Appetite
• Dysphagia
• Food intolerance
• Abdominal pain
• Nausea/vomiting, Regurgitation
• Bowel habits
• Abdominal history
• Medications
• Nutritional assessment

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Objective Data—The Physical Exam
• Preparation
– Lighting and draping
– Measures to enhance abdominal wall relaxation

• Equipment needed
– Stethoscope
– Small centimeter ruler
– Skin-marking pen
– Alcohol swab
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 PREPARATION
• Patient lie on back, pillow under head, knees slightly flexed
• Empty bladder
• Short fingernails
• Proper light
• Privacy maintain e.g. side screen

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 SEQUENCE OF ASSESSMENT
• Inspection
• Auscultation
• Percussion
• Palpation

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Objective Data—The Physical Exam
Inspect the abdomen:
• Contour
• Symmetry
• Umbilicus
• Skin (Pigmentation, Lesions, Striae (elevated/depressed), Turgor
• Pulsation or movement
• Hair distribution
• Demeanor
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Contour

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Conti….

Look for discoloration over the umbilicus:

• Cullen’s Sign: discoloration over the umbilicus
• Grey Turner’s Sign: discoloration over the flanks
These are both late signs suggesting intra-
abdominal bleeding

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Objective Data—The Physical Exam
Auscultate the abdomen for bowel sounds and vascular sounds
• Active bowel sounds 5-35/min
• Hypoactive 4/min or less( K , Paralytic Ileus, Chronic use of Laxative)
+

• Hyperactive 35 or more /min (Dysentery, Diarrhea, Early sign of Intestinal Obstruction).

• Bruits (blowing sound)
– Aorta
– Renal
– Iliac
• Friction rub (Obstruction two layers of organs rubbing each
other).
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 GUT SOUNDS
Use the diaphragm of your stethoscope to listen to gut sounds
• Normal gut sounds are gurgling, 5 to 35 per minute
• Borborygmi (Rumbling sounds caused by gas moving through the intestines
(stomach "growling“) are loud, easily audible sounds. They are normal, too.
• High pitched , Tinkling (raindrops in a barrel) sounds are a sign of early
intestinal obstruction
• Succession splash, A loud sound like splashing water, is often heard without
a stethoscope as the patient moves from side to side. It occurs when the
abdomen is filled with air or fluid and indicates delayed gastric emptying
from an obstruction or gastric dilatation.

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Conti….
• Decreased sounds: (none for a minute) are a sign of decreased gut
activity. Gut sounds may be markedly decreased after abdominal
surgery; abdominal infection (peritonitis) or injury.
• Absent Sounds : (no sounds for 5 minutes) are a bad sign.
They can be caused by longer-lasting intestinal obstruction, intestinal
perforation or intestinal (mesenteric) ischemia or infarction.

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BRUITS SOUNDS
• A sound, especially an abnormal one. A bruit may be heard over an artery or
vascular channel, reflecting turbulence of flow OR VENOUS HUMS.

• Use the bell of your stethoscope to listen for bruits:

• Aortic bruits: Are heard in the epigastrium. They may be a sign of abdominal
aortic (a sac formed by localized dilatation of the wall of an artery, a vein)
• Renal artery bruits: Are in each upper quadrant. They may be a sign of
renal artery stenosis (A narrowing), which is a potentially treatable cause of
hypertension.
• Iliac/femoral bruits: Are in the lower quadrants. They may be a sign of
peripheral atherosclerosis
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 PERCUSSION

• Percussion helps to assess the amount and distribution

of gas in the abdomen and identify possible masses that
are solid or fluid- filled .its use in estimating the size of
the liver and spleen.

• Percuss to assess Tampany and dullness. Tampany

usually predominant because of gas in the
gastrointestinal tract and dullness in fluid filled area.

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PERCUSSION
•Percussing the body gives one of three notes:
1. Tympani is found in most of the abdomen, caused by air in the gut.
It has a higher pitch than the lung.
2. Resonance is found in normal lung. It is lower pitched and
hollow.
3. Dullness is a flat sound, without echoes. The liver and spleen, and
fluid in the peritoneum (ascites), give a dull note.

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 PALPATION
LIGHT PALPATION.
Feeling the abdomen gently is especially helpful in identifying
abdominal tenderness, muscular resistance, and some
superficial organs and masses.

Keeping your hand and forearm on a horizontal plane, with

fingers together and flat on the abdominal surface, palpate the
abdomen with a light, gentle, dipping motion.

When moving your hand from place to place, raise it just off the
skin. Moving smoothly, feel in all quadrants.

Identify any superficial organs or masses and any area of

tenderness or increased resistance to your hand. If resistance is
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 DEEP PALPATION.
• This is usually required to delineate abdominal masses.
• Again using the palmer surfaces of your fingers, feel in all
four quadrants.
• Identify any masses and note their location, size, shape,
consistency, tenderness, pulsations, and any mobility with
respiration or with the examining hand.
• Correlate your palpable findings with their percussion notes.

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 TENDERNESS AND REBOUND TENDERNESS
 Look for rebound tenderness. Press your fingers in
firmly and slowly, and then quickly withdraw them.
Watch and listen to the patient for signs of pain. Ask
the patient

(1) To compare which hurt more, the pressing or the

letting go, and

(2) To show you exactly where it hurt. Pain induced or

increased by quick withdrawal constitute rebound
tenderness. It results from the rapid movement of
an inflamed peritoneum.

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 LIVER
 Measure the vertical span of liver dullness in the right
midclavicular line

 Starting at a level below the umbilicus (in an area of tympany,

not dullness),lightly percuss upward toward the liver.

 Determine the lower border of liver dullness in the

midclavicular line

 Next, identify the upper border of liver dullness in the

midclavicular line

 Lightly percuss from lung resonance down toward liver

dullness.
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 Now measure in centimeters the distance
between your two points

The vertical span of liver dullness greater in

men than in women, in tall people than in
short .

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 PALPATION
Place your left hand behind the patient, parallel to
and supporting the right 11th and 12th ribs and
nearby soft tissues below

Remind the patient to relax on your hand if

necessary. By pressing your left hand forward, the
patient’s liver may be felt more easily by your other
hand

Place your right hand on the patient’s right

abdomen lateral to the rectus muscle, with your
fingertips well below the lower border of liver
dullness

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 Ask the patient to take a deep breath. Try to feel the
liver edge as it comes down to meet your fingertips

If you feel it, lighten the pressure of your palpating

hand slightly so that the liver can slip under your
finger pads and you can feel its anterior surface. Note
any tenderness. If palpable at all, the edge of a normal
liver is soft, sharp, and regular, its surface smooth. The
normal liver may be slightly tender

On inspiration, the liver is palpable about 3 cm below

the right costal margin in the midclavicular line.

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 Some people breathe more with their chests than with their
diaphragms. It may be helpful to train such a patient to “breathe
with the abdomen,” thus bringing the liver, as well as the spleen
and kidneys, into a palpable position during inspiration

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 HOOKING TECHNIQUE
The “hooking technique” may be helpful, especially when
the patient is obese.

Stand to the right of the patient’s chest. Place both hands,

side by side, on the right abdomen below the border of
liver dullness.

Press in with your fingers and up toward the costal

margin. Ask the patient to take a deep breath.

The liver edge shown below is palpable with the finger

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Spleen
When a spleen enlarges, it expands anteriorly, downward, and medially,
often replacing the tympani of stomach and colon with the dullness of a
solid organ.
It then becomes palpable below the costal margin.
PERCUSSION
Two techniques may help you to detect splenomegaly, an enlarged spleen:
Percuss the left anterior lower chest wall between lung resonance above
and the costal margin . As you percuss along the routes suggested by the
arrows in the following figures, note the lateral extent of tympani.

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 This is variable, but if tympani is prominent, especially
laterally, splenomegaly is not likely. The dullness of a
normal spleen is usually hidden within the dullness of other
posterior tissues.

Check for a splenic percussion sign.

Percuss the lowest interspace in the left anterior axillary

line, as shown below. This area is usually tympanitic. Then
ask the patient to take a deep breath, and percuss again.
When spleen size is normal, the percussion note usually
remains tympanitic.
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PALPATION
• With your left hand, reach over and around the patient to
support and press forward the lower left rib cage and nearby
soft tissue. With your right hand below the left costal margin,
press in toward the spleen. Begin palpation low enough so that
you are below a possibly enlarged spleen. Ask the patient to
take a deep breath ,
Try to feel the tip or edge of the spleen as it comes down to
meet your fingertips. Note any tenderness, and assess the
splenic contour. In a small percentage of normal adults, the tip
of the spleen is palpable.
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Repeat with the patient lying on the right side with
legs somewhat flexed at hips and knees. In this
position, gravity may bring the spleen forward and
to the right into a palpable location.

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 Palpation And Percussion Of Kidney
(Balloting Method)

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BLUNT PERCUSION OF KIDNEY

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Examination Of The Gallbladder

• Murphy's sign can be assessed by placing your examining

fingers over the gallbladder area and then asking the
patient to take a deep breath.

• If Murphy's sign is positive, there will be sudden inflection

of the pain on inspiration and inspiration will be inhibited.

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ABDOMINAL AORTIC EXAMINATION
•Method:
•The patient’s abdomen should be relaxed with the knees
flexed.
•Then examine umbilicus for the aortic pulsation.
•Place both hands on the abdomen with the index finger on
either side of the pulsating aorta. Estimate the width ( <2.5cm
in width).

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 Special Maneuvers
(Assignment for Students)
» Rebound tenderness (Blumberg sign)
» Inspiratory arrest (Murphy's sign)
» Iliopsoas muscle test
» Obturator test
» Fluid wave
» Shifting dullness
» Psoas sign
» Rovsings sign
» Cutaneous hyperesthesia
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 DOCUMENTATION

Abdomen is protuberant with active bowel sounds.

it is soft and non tender, no palpable mass or
hepatomegaly. Liver span is 7cm in the right
midclavicular line, edge is smooth and palpable 1cm
below the right costal margin, spleen and kidney not
felt, no costovertebral angle (CVA)tenderness.

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EXAMINATION OF THE ANUS AND
RECTUM
• This information is sometimes included with the
abdominal assessment and at times with
assessment of the male and female genitalia.

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 Examination of anus & Rectum.
• History:
• Bowel habits(Changes).
• Character of stools(Blood).
• Rectal Pain
• C/O, Constipation, Diarrhea
• Hemorrhoids
• Screening, (PR Proctoscopy)
• Use of Laxatives or medications
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•
Examination of anus & Rectum.
• Inspection:
• Position- Side lying is preferred or lithotomy if genitalia exam in
female or standing with upper body resting on a table for men.
• Inspect perianal tissue/ Sacrococygeal area by retracting buttocks.
• Look for skin characteristics, Lumps, lesions, hemorrhoids,
ulcers, Rashes, Redness, inflammation, pigmentation.
• Ask client to bear down prolapse of rectum or
hemorrhoids.

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Examination of anus & Rectum.
Palpation:
• Surrounding tissue for lumps and tenderness.
• Per rectal examination, anal sphincter, tone, grasp, laxity.
• Rectal wall, irregularity, tenderness nodular, lesions.
• Prostate gland, round, heart shaped, 2.5-4cm, firm & non tender,
palpable on anterior rectal wall.
• Observe fecal matter on gloved finger for color (blood) &
consistency.

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 Thank you

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