Normal
Normoactive bowel sounds
Resonance on percussion of central abdomen, dullness on percussion of liver
Soft to palpation
No distension
No tenderness
Absence of hepatosplenomegaly
Absence of masses
Abnormal
Hyperactive, hypoactive, or absent bowel sounds
Hyperresonance to palpation
Rigid on palpation, voluntary or involuntary guarding
Distension
Tenderness to palpation
Hepatomegaly or splenomegaly
Mass present
Normal
Techniques
Inspection
- Look for distension, masses, equipment, etc.
Auscultation
- Listen in 4 quadrants.
Palpation
- Shallow
- Deep
- Costovertebral angle
- Audio – normal bowel sounds
Percussion
- General abdomen – tympany
- Liver length
Tips
- You can also check liver span by using the scratch test, where you listen with a stethoscope by periodically scratching as you move vertically.
- When palpating for hepatomegaly or splenomegaly, start in the pelvis and move upwards.
- If palpation on exam is resisted or unreliable, press with your stethoscope while listening to bowel sounds to get a better sense.
- If presence of peritoneal signs is unclear, try bumping the bed and seeing if patient reacts.
Abnormal
Physical Exam Signs
- Murphy’s sign – to assess gallbladder inflammation
- Psoas sign – to assess appendicitis; raising leg against resistance causes RLQ pain
- Obturator sign – to assess appendicitis; flexing and internally rotating leg causes pain
- Rovsing sign – to assess appendicitis; pressing on LLQ will cause RLQ pain
- McBurney’s point – to assess appendicitis; pushing down causing point tenderness
Non-Acute
Visual
Distension
Masses
- Pyloric stenosis – olive sign
- Wilms tumor
Holes in the belly
- Colostomies – for collecting stool; created by connecting intestine to abdominal wall
- G-tube – for administering feeds and medications; created by connecting stomach to abdominal wall
- GJ-tube – often medications are given through G port and feeds through J port; created by connecting stomach to abdominal wall and having internal tube from stomach to jejunum
- Malone antegrade continence enema – method of administering enemas to have bowel clean-out in children unable to stool on their own; created by connecting appendix to abdominal wall (if appendix removed, creating a neo-appendix with cecal flap)
- Mitrofanoff appendicovesicostomy – method of removing urine in children unable to urinate spontaneously; created by using appendix as tube to connect bladder to abdominal wall
Auditory
– Hypoactive bowel sounds
– Hyperactive bowel sounds
Palpation
Acute Abdomen
– Colicky abdominal pain – consider intussusception, which may also have vomiting without diarrhea, currant jelly stools is a sign that the patient has intestinal ischemia
– Rigidity
– Non-voluntary guarding
– Sudden onset pain – consider malrotation, seen with bilious emesis