Ch14: Abdominal Examination（腹部检查）

Preparatory Mindset

The abdominal examination follows a special order: Inspection → Auscultation → Percussion → Palpation (auscultation BEFORE percussion/palpation, unlike the chest). The patient lies flat, hips/knees flexed, examiner on the right. Master the 9-region/4-quadrant anatomy, the surface signs (Cullen's, Grey-Turner's, caput medusa), the liver/spleen/kidney palpation techniques, and the percussion findings (shifting dullness for ascites, Traube's space for splenomegaly). Always correlate with the common abdominal diseases and procedures (abdominocentesis).

Illustrations（图解速览）

Core Concepts — Anatomy & Preparation

Landmarks

Costal margin, xiphoid, umbilicus, anterior superior iliac spine, rectus abdominis lateral border, mid-abdominal line, inguinal ligament, pubic symphysis, costovertebral angle

Four quadrants / Nine regions

• Quadrants: RUQ (liver, gallbladder, hepatic flexure, right kidney), LUQ (spleen, stomach, splenic flexure, left kidney, pancreas tail), RLQ (cecum, appendix, right ovary/tube), LLQ (sigmoid, left ovary/tube)
• Nine regions (by costal arch + iliac spine lines × midclavicular lines): epigastric, left/right hypochondrium, umbilical, left/right lumbar, hypogastric, left/right iliac

Preparation

• Warm room, warm hands; supine, arms at sides, one pillow, hips/knees flexed; expose from pubis to costal margin (women: to below breasts)
• Stand on the patient's right side, face the patient
• Order: inspection → auscultation → percussion → palpation

Core Concepts — Inspection (视诊)

Abdominal contour

• Flatness (ideal level), fullness (above), bulge (obviously above), retraction/scaphoid (below — severe malnutrition, dehydration, cachexia, acute peritonitis)
• Whole bulge: ascites (frog abdomen — fluid sinks to flanks), pneumatosis (obstruction, ileus, perforation), large mass (ovarian cyst, teratoma); measure abdominal circumference at umbilicus
• Localized fullness: RUQ = liver/gallbladder; epigastric = stomach/pancreas/AAA (pulsatile); LLQ = sigmoid; suprapubic = bladder/uterus/ovary
• Masses by region: left subcostal = spleen/colon; RUQ = liver/gallbladder/pancreatic head; lumbar = kidney (cysts, tumor); RLQ = appendiceal abscess/cecal carcinoma; LLQ = diverticular abscess/sigmoid carcinoma; hypogastric = pelvic
• Abdominal wall vs intra-abdominal mass: ask patient to lift head off bed — if mass becomes more distinct = abdominal wall; if less = intra-abdominal

Respiratory movement

• Men & children: abdominal respiration; women: thoracic
• Peritonitis → absent or decreased abdominal wall movement (rigidity)

Abdominal veins & blood flow

• Caput medusa (dilated periumbilical veins radiating) = portal hypertension (umbilical vein collateral)
• IVC obstruction (Budd-Chiari): distended abdominal wall veins with cephalad flow
• Determine flow direction by emptying segment and refilling

Gastric/intestinal pattern & peristalsis

• Pyloric obstruction: peristalsis visible in epigastrium, left → right
• Intestinal obstruction: peristalsis around umbilicus, irregular

Other inspection findings

• Cullen's sign (periumbilical bluish) & Grey-Turner's sign (flank bluish) = retroperitoneal/intra-abdominal bleeding (severe pancreatitis, trauma, ruptured ectopic)
• Striae: silver (obesity/pregnancy), purple/bluish (Cushing's)
• Skin: rose spots (typhoid); pigmentation at belt line (Addison's)
• Hernias: umbilical (ascites), incisional (scar), femoral (female), inguinal (male)
• Hair distribution: male diamond (liver disease → female pattern); epigastric pulsation (thin, RVH/COPD, AAA)

Core Concepts — Auscultation (听诊)

Bowel sounds

• Normal: 4–5/min (gurgling)
• Increased/hyperactive: gastroenteritis, early obstruction, diarrhea (borborygmi)
• Decreased/absent: ileus, peritonitis, late obstruction
• Metallic tinkling: intestinal obstruction (fluid + air under tension)

Vascular bruits

• Abdominal aortic aneurysm: midline epigastric bruit + pulsatile mass
• Renal artery stenosis: systolic bruit in flanks/upper abdomen (hypertension)
• Hepatic bruit: hepatoma, AV malformation
• Venous hum (portal hypertension); friction rub over liver (perihepatitis/tumor); scratch test for liver edge

Core Concepts — Percussion (叩诊)

Liver

• Liver span: 9–12 cm in MCL (upper border at 5th ICS; lower border at costal margin)
• Dullness: enlarged liver (hepatitis, HF, tumor, cirrhosis early); upward displacement (ascites, pregnancy, tumor); loss of liver dullness + tympany = perforated viscus (free air under diaphragm)
• Floating liver ballottement in ascites

Spleen

• Traube's space (6th–9th ribs, left axillary to costal margin): normally tympanic
• Dullness in Traube's space = splenomegaly (or left pleural effusion, gastric mass)
• Splenic dullness: enlarge downward/medially; massive (leukemia, malaria, portal HTN, Gaucher's)

Kidney

• Costovertebral angle tenderness (pyelonephritis, stones)

Ascites — HIGH YIELD

• Shifting dullness: dull flanks → tympanic center in supine; roll to side → dullness shifts to dependent side (ascites ≥1000–1500 ml)
• Fluid thrill/wave (波动感): assistant's hand edge on midline, tap flank → transmitted wave (large ascites)
• Succussion splash (振水音): shake patient → splash sound (gastric retention/obstruction, or soon after drinking)
• Bladder: suprapubic dullness = distended bladder (retention)

Core Concepts — Palpation (触诊)

Abdominal wall & tenderness

• Light palpation first (muscle tenseness, guarding); then deep
• Rebound tenderness (反跳痛): deep press 2–3 s, release quickly → pain intensifies = peritonitis (with rigidity)
• Specific points: McBurney (appendicitis), gallbladder point (cholecystitis), ureter points (stones)
• Muscle rigidity: generalized (perforation — board-like), localized (localized peritonitis)

Liver palpation

• Bimanual: left hand supports right lower ribs posteriorly; right hand flat on abdomen below costal margin; palpate during deep inspiration
• Describe: edge (sharp = normal; blunt/rounded = congestion), surface (smooth = hepatitis/HF; nodular = cirrhosis/tumor), consistency (firm = cirrhosis; hard = tumor), tenderness (HF, hepatitis, abscess — tender; tumor — non-tender), pulsatility (TR)
• Enlarged tender liver + JVD + hepatojugular reflux → right heart failure
• Hepatojugular reflux: press RUQ → JVP rises (RHF, constrictive pericarditis)

Spleen palpation

• Start from left lower quadrant (RIQ approach if massive), move up toward LUQ; palpate during inspiration
• Splenomegaly grading: mild (below costal margin 2–3 cm), moderate (to umbilicus), massive (>umbilicus — CML, myelofibrosis, malaria, kala-azar)
• Notch on medial border confirms spleen (vs renal mass)

Gallbladder & kidneys

• Courvoisier's sign: painless palpable enlarged gallbladder + jaundice = pancreatic head carcinoma (vs tender + jaundice = stones)
• Murphy's sign: press gallbladder point, ask deep inspiration → arrested breath (acute cholecystitis)
• Kidneys: bimanual palpation (19CM exam tested); ballotment; enlarged = polycystic disease, tumor, hydronephrosis

Abdominal masses

Describe: location, size, shape, surface, consistency, tenderness, pulsatility (AAA), mobility (with respiration — liver/spleen/kidney move; fixed = malignancy/adhesion), bruit (AAA, renal artery)

Fluid thrill & succussion splash

As above in percussion.

Core Concepts — Common Abdominal Diseases (快速识别)

• Acute cholecystitis: RUQ pain after fatty meal, Murphy's sign, fever; USS → gallstones
• Cholangitis: Charcot's triad (RUQ pain + jaundice + fever) — emergency, IV antibiotics + drainage
• Acute pancreatitis: epigastric pain → back, after alcohol/meal, vomiting, ↑amylase/lipase; Cullen's/Grey-Turner's (severe)
• Appendicitis: periumbilical → RLQ migration, McBurney tenderness, Rovsing sign, fever, leukocytosis
• Perforated ulcer: sudden severe epigastric, board-like rigidity, free air under diaphragm on erect CXR
• Intestinal obstruction: colicky pain + vomiting + distension + constipation; hyperactive then absent sounds; metallic tinkling
• AAA: pulsatile midline mass, tearing back pain, hypotension — surgical emergency
• Hepatic cirrhosis: ascites, caput medusa, spider angioma, splenomegaly, palmar erythema, gynecomastia

Core Concepts — Abdominocentesis (腹腔穿刺术)

• Indications: diagnostic (new-onset/unknown ascites), therapeutic (severe distension, SOB, oliguria), SBP diagnosis, intraperitoneal drugs/chemotherapy
• Contraindications: acute surgical abdomen (absolute); late pregnancy, ovarian cyst, hydatid, distended bladder, cellulitis, severe distended bowel, severe adhesions, restless patient (relative); bleeding risk if PT >21 s, INR >1.6, platelets <50,000
• Sites: ①outer 1/3 of line between umbilicus and ASIS (left/right); ②umbilicus horizontal line × anterior/mid-axillary line (lateral decubitus); ③1 cm above umbilicus-pubis midpoint, 1.5 cm lateral; ④ultrasound-guided; avoid scars
• Procedure: consent → empty bladder → supine, head elevated 20–30° → sterile prep (15 cm, 3×) → lidocaine → Z-tracking (prevent leak) → slow advance with aspiration → diagnostic 50 ml; therapeutic up to 3 L (cirrhosis) with albumin if >4–5 L
• Complications: fluid not flowing, feculent/bloody tap, hypotension after large-volume paracentesis (IV saline, albumin), infection, bowel perforation
• Ascitic fluid analysis: SAAG, protein, cell count, culture, cytology, ADA (TB)

High-Yield Points

• Abdomen: auscultate BEFORE percussion/palpation (unlike chest)
• Shifting dullness = ascites ≥1–1.5 L; fluid thrill = large ascites; succussion splash = gastric retention
• Rebound tenderness + rigidity = peritonitis
• Cullen's (periumbilical) & Grey-Turner's (flank) = retroperitoneal bleeding (pancreatitis, ectopic rupture)
• Caput medusa = portal hypertension; loss of liver dullness + tympany = perforated viscus
• Courvoisier's sign (painless palpable GB + jaundice) = pancreatic head cancer
• Murphy's sign = acute cholecystitis; McBurney tenderness = appendicitis; Charcot's triad = cholangitis
• Traube's space dullness = splenomegaly; massive spleen (below umbilicus) = CML/myelofibrosis/malaria
• Abdominocentesis: Z-tracking, empty bladder, 50 ml diagnostic, ≤3 L therapeutic (albumin if >4–5 L)
• Ascites: SAAG ≥1.1 = portal hypertension (cirrhosis, HF); <1.1 = exudative (TB, cancer, nephrotic)

Topic Summary

Abdominal exam order: inspection → auscultation → percussion → palpation. Inspection: contour (scaphoid/frog abdomen), veins (caput medusa), Cullen's/Grey-Turner's, peristalsis. Auscultation: bowel sounds (absent = ileus, tinkling = obstruction), bruits (AAA, renal artery). Percussion: liver span, Traube's (spleen), shifting dullness (ascites), loss of liver dullness (perforation). Palpation: rebound (peritonitis), liver (edge/surface/tenderness), spleen (notch, massive = CML), Murphy's (cholecystitis), Courvoisier's (pancreatic cancer). Procedures: abdominocentesis with Z-tracking and SAAG interpretation. Correlate with common diseases (appendicitis, pancreatitis, cholangitis, obstruction, AAA).