The Abdomen
Every month for three successive days they purge themselves, for their health’s sake, with emetics and clysters, in the belief that all disease comes from the food a man eats.
—HERODOTUS, THE HISTORIES, BOOK 2
POINTS TO REMEMBER:
Inspect the abdominal wall for asymmetry, distention, displacement of the umbilicus, respiratory motions, ecchymoses, and venous patterns.
Listen, especially for bowel sounds, before palpating. Also check for hums, bruits, and rubs.
Palpate the abdomen in an orderly sequence, reserving any painful areas for last.
Consider the possibility of pregnancy in all women of child-bearing age.
Palpate for tenderness, masses, abnormal pulsations, and enlargement of organs or the aorta.
Inspection
Contour
One should always take a moment to stand at the foot of the bed and look at the nude abdomen. This has been traditionally taught as a useful way to observe visible peristaltic waves in cases of intestinal obstruction. Dr A.I. Mendeloff of Maryland points out that it is even better for noticing asymmetry due to hepatomegaly and splenomegaly. These organs are sometimes more obvious on inspection than on palpation. (Also see “Ascites” discussed later in this chapter.)
Cope states that the ladder pattern of abdominal distention visualized on the anterior abdominal wall indicates obstruction of the lower ileum (Silen, 1979). He also states that moderate distention of the large bowel can be seen on the anterior abdominal surface as an inverted “U” extending from the right lower quadrant to the right upper quadrant, across to the splenic flexure, and down to the left lower quadrant. (In both cases, the drawings that are presented really resemble the patterns of dilated bowel seen on flat plates of the abdomen in those conditions.) In recent experience, these patterns are uncommon and incomplete. I suspect that Cope’s patients were much thinner.
Pseudocyst of the pancreas may produce a localized bulge.
When inspected from the side, patients with acute pancreatitis show a peculiar Cupid’s bow profile (Fig. 20-1A). The dimple in the Cupid’s bow is approximately at the umbilicus. The absence of this sign in a patient with a known elevation in amylase correctly suggests the diagnosis of macroamylasemia without pancreatitis. Conversely, the presence of this sign should cause one (correctly) to switch the preferred diagnosis from aortic aneurysm to acute pancreatitis. (The Cupid’s bow is not pathognomonic; it can be seen in other gastrointestinal conditions causing adynamic ileus.)
The epigastric bulge due to massive pericardial effusion is known as the Auenbrugger sign. This is the same Auenbrugger we met at the opera in Chapter 16.
The term “scaphoid” does not mean “unremarkable.”
It means “shaped like a skiff or dinghy,” that is, with the patient in the supine position, the sides of the boat are represented by the costal margins and the pubis and anterior iliac spines, while the bottom of the boat is represented by the abdominal wall sunken in under the effects of gravity. The significance of the scaphoid abdomen is that none of the above findings are seen, and in contrast to the situation with an obese abdomen, they would be seen if present.
Abnormalities of the Umbilicus
Normally, the umbilicus is located within 1 cm of the midpoint between the xiphoid and the symphysis pubis unless there are scars or a history of pregnancy carried to term. A deviation of more than 1 cm is often the clue that leads to an extremely thorough palpation.
Dr Frank Iber of Illinois notes that hepatomegaly of 1 or 2 years’ duration will stretch the upper abdominal segment so that the distance between the xiphoid and the umbilicus is 2 cm longer than the distance from the umbilicus to the symphysis pubis. Such a downward displacement of the umbilicus can also be caused by ascites. In this case, it is known as the Tanyol sign.
Upward displacement of the umbilicus occurs in pelvic tumors, but the most common cause of upward displacement is still pregnancy.
Eversion or outward protrusion of a previously inverted umbilicus (Fig. 20-2) was thought to be a sign of chronic ascites, but there are false positives.
Respiratory Motion
The importance of examining the total abdominal surface for the phenomena of respiratory alternans and respiratory paradox (Macklem, 1986) is discussed in Chapter 16.
Additionally, Cope suggests looking for local limitations of respiratory movement of the abdominal wall in patients suspected of having an acute abdomen. For instance, in appendicitis with acute peritonitis, the right iliac region will very frequently remain selectively immobile during inspiration. In some cases of acute pancreatitis, the epigastric zone may be motionless. In generalized peritonitis, there is hardly any abdominal wall motion.
Markings
Ecchymoses
Subcutaneous blood from intraperitoneal or retroperitoneal hemorrhage may dissect to the skin overlying the flanks or to the
anterior abdominal wall and cause a discoloration resembling a bruise or a subcutaneous injection site of heparin.
anterior abdominal wall and cause a discoloration resembling a bruise or a subcutaneous injection site of heparin.
 FIGURE 20-1 Lateral abdominal contours. A: Cupid’s bow of pancreatitis. B: Fat. C: Bladder distention. |
A periumbilical bruise is known as the Cullen sign, for the Baltimore doctor who described it in a case of ruptured ectopic pregnancy ( Cullen, 1918). (This sign is to be distinguished from a green or jaundiced lesion at the umbilicus, which is the Ransohoff sign of a ruptured bile duct.) A similar discoloration in the flanks is called the Turner sign (not the Grey-Turner sign; there was no Dr Grey). This was described in a patient with acute pancreatitis by G. Grey Turner, 2 years after Cullen’s report. In the same article, he described an earlier case of pancreatitis in which the bruising was periumbilical (Turner, 1920).
Preservation of the two different eponyms has obscured the fact that these are the same sign. The topographic location of the ecchymosis does not point to the etiology. In fact, the same pancreatitis patient may have “both” signs (Dickson and Imrie, 1984). Other locations have been at an appendectomy scar, a laparotomy scar, and umbilical and femoral hernias.
The sensitivity is less than 1% for ruptured ectopic pregnancy (Smith and Wright, 1935) and only 3% for acute pancreatitis, appearing late, between the second and sixth hospital day (Dickson and Imrie, 1984). Furthermore, it is not diagnostically specific, being also seen in ovarian cyst hemorrhage, strangulated umbilical hernia, bilateral acute salpingitis in the presence of intrauterine pregnancy, hemoperitoneum (not from ectopic pregnancy), hemorrhagic ascites from adenocarcinoma of the liver or renal sarcoma metastatic to the peritoneum (Smith and Wright, 1935), carcinoma of the liver (Mabin and Gelfand, 1974), strangulation of the ileum with hemorrhage, hypothyroid myopathy, and cirrhosis with portal hypertension (Kelley, 1961).
Striae
Abdominal striae are the longitudinal stretch marks seen in pregnancy, Cushing syndrome, and rapid gain and loss of weight. It has been taught that striae are usually red, but that they are purple in cases of idiopathic (noniatrogenic) Cushing syndrome because of the erythrocytosis resulting from the excess adrenal androgens.
 FIGURE 20-2 A: The everted umbilicus sign of chronic ascites. Drawing of an Igbo female tutelary spirit pit display in the Baltimore Museum of Art. B: A false positive everted belly button seen in an obese patient possessing a lax abdominal wall. There was no evidence of portal hypertension, hypoalbuminemia, liver disease, or ascites by any imaging procedure. Another false positive is shown in Fig. 20-4. (Courtesy of Dr Tim Rice of Missouri.) |
Venous Pattern
Prominent venous patterns may be seen in portal hypertension or inferior vena caval syndrome (Fig. 20-3) or even in some aged normal persons (Snapper and Kahn, 1967). The clinician should note both the location of the veins and the direction of blood flow. In pure portal hypertension, the visible collateral veins tend to occur around the umbilicus. Those cephalad to the umbilicus drain in a cephalad direction, while those veins caudad to the umbilicus drain caudally. Thus, the direction of flow in pure portal hypertension is merely an exaggeration of the normal, but invisible, situation. Another way of describing this is that with portal hypertension, the direction of blood flow in superficial abdominal veins is away from the umbilicus (Bhaskar, 2009).
Perseus slew the Medusa by using his shield as a mirror so that he did not have to look at her directly and thereby share the fate of others who had become transfixed by her horrible appearance.
Her head (the caput Medusa) was surrounded by a bunch of snakes in place of hair. Before the age of surgery for portal hypertension, a rare patient with severe chronic portal hypertension could develop such large periumbilical venous collaterals that the veins stuck out like a bunch of snakes, the caput Medusa. However, caput Medusa should not be diagnosed just because there is a visible vein or two somewhere on the abdomen; otherwise this rare sign loses its diagnostic significance.
 FIGURE 20-3 Inferior vena caval obstruction, resulting from carcinoma in the body of the pancreas. This is not a caput Medusa of portal hypertension, even though the individual veins look snakelike. The caput Medusa radiates out from the umbilicus. The veins of inferior vena caval syndrome simply pass the umbilicus on their north-south route. (Courtesy of Dr Syed A. Hoda of Louisiana and Consultant Magazine.) |
In those rare cases of superior vena caval syndrome (see Chapter 19) in which collaterals can be found in the upper abdomen, the normal direction of drainage is reversed, with the veins superior to the umbilicus actually draining caudally.
In cases of pure inferior vena caval syndrome, the collateral veins tend to appear more laterally in the flanks. They drain in a cephalad direction regardless of whether they are above or below the umbilicus. In the inferior vena caval syndrome, it is more difficult to determine the direction of flow by stripping the veins and seeing in which direction they fill than it is in portal hypertension (Missal et al., 1965).
(In chronic liver disease with portal hypertension and ascites compressing the inferior vena cava, there may be a mixed picture in which the veins are lateral and periumbilical. The venous flow is cephalad in the veins superior to the umbilicus but may be indeterminate in the veins inferior to the umbilicus.)
In cases in which the direction of venous flow cannot be determined, the consultant should be prepared to discount the finding of flank veins as being indicative of inferior vena caval disease, especially if there are no other signs of such disease. However, if one has previously examined the patient and that venous pattern has just recently appeared, it is in itself collaborative evidence of inferior vena caval disease.
Self-assessment
Before reading the legends, write down your diagnosis for the patients pictured in Figs. 20-4 and 20-5.
 FIGURE 20-4 Drawing of the lateral profile autopsy photograph of Pepper’s 1901 case of neuroblastoma metastatic to the liver. Notice that the tumorous liver is holding the abdomen up, whereas ascites alone would fall into the flanks in response to gravity with the patient supine. Note also the protuberant umbilicus. |
 FIGURE 20-5 Ward Rounds, lithograph by Robert Riggs. What is your diagnosis? Three that have been offered are pregnancy, ovarian cyst, and ascites. What do you think of each of these? (Appendix 20.1.) What is the patient holding in her left hand? (From Medicine and the Artist [Ars Medica], with permission of the Philadelphia Museum of Art.) |
Palpation
The palpation of the abdomen should be done in an orderly sequence, beginning with the right upper quadrant and proceeding to the left upper quadrant, the left lower quadrant, the right lower quadrant, and the periumbilical area, with particular attention to the aorta (see Chapter 18). If the patient is complaining of pain, the order should be altered so that the painful area is examined last.
To help the patient relax the abdominal musculature, it is often helpful to have him flex his knees and hips and rest his soles on the bed. Have him place his hands on his chest (as recommended by Dr Thomas Dorman); this has the added advantage of getting them out of the examiner’s way.
The palpation of specific organs, such as the liver, gallbladder, spleen, and kidneys, is discussed in detail in their respective sections later in the chapter.
One also palpates for masses. Colonic carcinoma may present as a palpable mass in any one of the four abdominal quadrants. Pseudocolonic tumors or phantom tumors due to stool are frequent in the left lower quadrant, but less frequent in the left upper quadrant. Wiener and Nathanson (1976-1977) state that such phantom tumors may also occur in the right colon.
A giant phytobezoar in the left hypochondrium felt like a head of lettuce (iceberg or Boston, not Romaine).
Palpating the Abdomen in the Presence of Abdominal Pain
A Note on the Female Patient
It is assumed that you will take a careful menstrual history at the beginning of every encounter with every female patient, particularly if she has abdominal pain. This point cannot be overemphasized. Many conditions covered in Chapter 22 need to be kept in mind as you proceed with the examination, the most perilous one being an ectopic pregnancy.
Local Rigidity (Local Guarding)
Local muscle rigidity over an area of peritonitis is frequently present (but by no means invariable). In the most extreme case, the particular section of the abdominal wall is persistently stiff and will not move with respiration. In the less extreme case, the muscle stiffens almost as soon as the hand touches the skin. In the least case, the rigidity occurs only when the fingers are pressed in more deeply. Take care to exclude the rigidity due to patient apprehension or to a rough or cold examining hand. Cope emphasizes that there are many false negatives and that an appendix may be on the verge of rupturing into the peritoneal cavity even though the abdominal wall is flaccid (Silen, 1979).
For the early diagnosis of the acute abdomen, Cope suggests the most likely (not the only) possibilities, as listed in Table 20.1.
Underdiagnosed conditions found at autopsy in patients presenting with an acute abdomen include mesenteric thrombosis, peritonitis, perforated peptic ulcer, acute pancreatitis, empyema of the gall bladder, pulmonary embolus, and acute pyelonephritis (Cameron and McGoogan, 1981).
Some causes of intermittent abdominal pain are listed in Table 20.2.
Induced Guarding
One portion of the interview can be combined with a physical maneuver in the differential diagnosis of abdominal pain. Ask the patient to rate his abdominal pain on a scale of 1 to 10 (first baseline). Second, press over the area of tenderness to see by how many points (if any) the pain increases with hand pressure. Then obtain a third, postpressure pain rating (second baseline). Finally, have the patient lift his head from the bed and put his chin on the chest to induce voluntary guarding. Press again and get a fourth rating. This is called the Carnett maneuver.
Caveat
It is essential that the pressure be the same each time. This can be difficult to ensure. One way is to allow one’s fist to fall on the abdomen each time from the same height. Of course, one must apologize to the patient for inducing pain, explaining that it is part of the examination. Alternately, one can place a blood pressure cuff and sphygmomanometer on the abdomen with the cuff partly inflated and the manometer screw valve well sealed. Press to produce the same amount of pressure each time.
Interpretation
Pain of intraperitoneal origin will be lessened by the maneuver of voluntary guarding, which protects the peritoneal contents. In such patients, the fourth rating should be less than the second. Pain originating in the abdominal wall, peripheral nerves, or higher centers will not be ameliorated and may be increased by this maneuver (a positive Carnett sign). Causes of such pain include abdominal wall hernia, nerve entrapment syndromes, myofascial pain syndromes, rectus sheath hematoma, and rib tip syndrome (Pasricha, 2003). The test has a positive likelihood ratio (LR) for peritonitis of 0.1 (95% CI 0, 0.7) and a negative LR of 1.9 (95% CI 0.9, 4.4) (McGee, 2001).
TABLE 20.1 Differential diagnosis of abdominal pain | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLE 20.2 Some causes of intermittent abdominal pain | ||||||||||||||||||||
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Alternate Method
In a modification of the Carnett maneuver, the guarding is induced by having the patient cross his arms while supine and then sit up. The abdomen is palpated as the patient reaches halfway between recumbent and sitting positions, the point of maximal abdominal musculature contraction and guarding.
This test was studied in a group of patients admitted to the emergency ward with localized abdominal pain (Thompson and Francis, 1977). (Patients with abdominal rigidity, in whom the test is useless and inappropriate, and those suspected of having an intra-abdominal abscess, in whom the test is needless and possibly dangerous, were excluded.) A positive test was reduction of abdominal wall tenderness at midway palpation. A negative test was worsening of pain at this point.
The predictive value (PV) of a positive test and the sensitivity were both 99% for appendiceal abscesses, cholecystitis, bowel obstruction, ruptured ovarian cyst, ureteral colic, urinary tract infection, and so forth. The PV of a negative test for patients who were “undiagnosable” was 96%. (Almost half of the latter group went to a negative surgical exploration.)
Rebound and Referred Tests
The Blumberg Sign (Rebound Tenderness)
The Blumberg sign is a general test for pain for picking up early peritonitis in any area.
A Method. Having palpated the tender areas as deeply as circumstances permit, the palpating hand is abruptly withdrawn. The previously stretched abdominal musculature will then spring back into place carrying with it the peritoneum. If the peritoneum is inflamed, the patient will wince or cry out. This sign is often called rebound tenderness. Bailey (Clain, 1973) correctly emphasizes that this test is quite unnecessary in patients with undoubted involuntary rigidity.
The Referred Rebound Test
Cope does not recommend the rebound tenderness test (the Blumberg sign, first method) because he considers it cruel and not useful. But this modification may be useful with patients suspected of being not completely cooperative or precise in reporting their sensations.
A Method
If the patient has, for example, pain in the right upper quadrant, which was unconvincing to previous examiners, press slowly and deeply into a place where there is no pain, such as the left upper quadrant.
Then release the pressure suddenly, as if to test for rebound tenderness in the left upper quadrant, and ask, “Does that hurt?”
Interpretation
If the patient points to the right upper quadrant, at the same location as before, as the site of the pain while denying any pain in the left upper quadrant, the test is positive. That means that the patient is reporting accurately or else is an extremely clever and well-read dissembler.
The test is useful only if positive. A negative test does not prove that the patient has not been accurately reporting the original right upper quadrant pain.
Cope’s Method
It is useful to cross-palpate from the opposite side. For example, if you are evaluating pain in the left upper quadrant, press in the right upper quadrant and slowly move your palpating hand across the midline. If pressure in the right upper quadrant produces pain in the left upper quadrant before your hand crosses the midline, this tells you that the pain is coming from an abdominal condition and is not thoracic or referred. This also works well in the lower quadrants (Silen, 1979).
A Second Method of Blumberg
Blumberg also pressed in the left iliac fossa, and if the patient complained of pain anywhere in the lower abdomen (i.e., referred pain), he used this as evidence supporting the provisional diagnosis of acute appendicitis, although the sign is also positive in other acute abdominal conditions.
The Rovsing Sign
Rovsing also pressed on the left iliac fossa. If the direct pressure there produced referred pain in the right iliac fossa, the likelihood of appendicitis was increased. It is also a sign of distention of the colon (T. Dorman, personal communication, 1998). This is not a perfect test; there are both false positives and false negatives.
Note that the above assumes that the examiner is standing at the right side of the examining table and examining the patient with
the right hand. This assumption is traditional in medicine but not very important. If you feel more comfortable beginning on the left and examining with the left hand (or with the right hand for that matter), then perform the examination that way. If you modify the text to accommodate your own preference, knowledge of basic anatomy will permit you to alter the instructions mutatis mutandis.
the right hand. This assumption is traditional in medicine but not very important. If you feel more comfortable beginning on the left and examining with the left hand (or with the right hand for that matter), then perform the examination that way. If you modify the text to accommodate your own preference, knowledge of basic anatomy will permit you to alter the instructions mutatis mutandis.
Hyperesthesia
Hyperesthesia to light touch in the referred dermatomes may sometimes occur in acute abdominal conditions. Patients with appendicitis may have hyperesthesia in the anterior right lower quadrant.
Hyperesthesia in the region shown in Fig. 20-6 (the Boas sign) is a sign of gallbladder disease. This test is especially useful in patients who are schizophrenic or demented. They will grimace if the test is positive, even though they may not be able to report their experiences verbally. Few patients know about this test, so if it is positive, any suspicion of malingering should be discarded. Unfortunately, the Boas sign has a sensitivity of less than 7% (Gunn and Keddie, 1972).
In diabetic patients, thoracoabdominal neuropathy may mimic the symptoms of intra-abdominal pathology such as gallbladder disease or appendicitis. There may be hyperesthesia in a dermatomal distribution (Harati and Niakan, 1986). Another consideration in the differential diagnosis of abdominal pain accompanied by hyperesthesia is herpes zoster. The characteristic skin eruption may not appear for several days.
 FIGURE 20-6 Rectangle encloses area of possible hyperesthesia in gallbladder disease. (Bacchus, by Michelangelo.) |
Abdominal Wall
Sometimes one notices a different consistency to the abdominal wall on deep palpation. This consistency has been variously described as “doughy,” “grainy,” “stringy,” and “glandular.” The tissue feels a bit like postmenstrual breast tissue, which has lost some of its water content but is still glandular. The most benign cause of this sensation is residual fat following a period of weight loss, but granulomatous peritonitis, especially that caused by tuberculosis, may also cause this consistency, comparable to dough on a breadboard. And sometimes this sensation is a manifestation of peritoneal metastases, especially of malignant melanoma.
Peritoneal metastases may also feel discrete or lumpy. Plaques of “fatty” or glandular-feeling material are separated by areas of completely normal consistency a few centimeters in width. The mapped-out sensation of this abnormal resistance to palpation would resemble an abstract expressionist painting (as by Jackson Pollock), in which paint had been thrown on the canvas and allowed to drip, leaving clear spaces in between.
A Note on the McBurney Point
Classically, the tenderness of acute appendicitis is localized over the McBurney point (see the dotted line in Fig. 20-7) until rupture and generalized peritonitis supervene. This valuable point has been misidentified in so many works that McBurney’s own description is cited (McBurney, 1889):
 FIGURE 20-7 The McBurney point is on the dotted line, 1.5 to 2 in. from the anterior superior iliac spine. The area to check for the Murphy sign (see text) is marked by the “X.” (David, by Michelangelo.) |
And I believe that in every case the seat of the greatest pain, determined by the pressure of one finger, has been very exactly between 1.5 and 2 in, from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus. This may appear to be an affectation of accuracy, but, so far as my experience goes, the observation is correct.
Often, the patient with acute appendicitis may be able to localize his pain precisely with one finger, especially after a cough or the Valsalva maneuver. With aberrant locations of the appendix (such as retrocecal), the tenderness will not be in the expected location.
Tenderness at the McBurney point is the best single test for detecting appendicitis, with a positive LR of 3.4 (95% CI 1.6, 7.2) and a negative LR of 0.4 (95% CI 0.2, 0.7) (McGee, 2001).
Study Question: If the patient in Fig. 20-7 actually has a perinephric abscess, what side is it on? (See Appendix 20.2.)
Slipping-rib Syndrome
Slipping-rib syndrome, diagnosed by the “hooking maneuver” described in Chapter 16, may present with upper abdominal pain aggravated by certain postures and movements and relieved by a local anesthetic injection. In one gastroenterologic clinic, it was diagnosed in nearly 5% of patients, most commonly in those who had undergone a number of negative investigations (Wright, 1980). This maneuver might be worth considering in “undiagnosable” patients—with the caveat that it misdiagnosed a case of abdominal abscess in a patient with Crohn disease.
 FIGURE 20-8 Upright abdominal plate of a patient who had a hollow percussion note in his right midaxillary line where liver dullness would have been expected. Notice the air under the diaphragm. |
Percussion
There should always be hepatic dullness in the right midaxillary line, except in the presence of free air under the diaphragm, which produces resonance (Silen, 1979). The availability of upright films of the abdomen (Fig. 20-8) has made this a rare maneuver in the US.
Subphrenic abscess, an intra-abdominal disease, may be diagnosed by percussion of the chest (see Chapter 16, Fig. 16-4).
A distended, tympanitic abdomen is a sign of bowel obstruction.
The percussion of specific organs is discussed later in this chapter.
Auscultation
Bowel Sounds
Currently, this is a surprisingly controversial subject. Some gastroenterologists see no point in listening for bowel sounds, whereas others with gray beards find it valuable. Both groups would undoubtedly agree with the following consensus statements.
If you wish to hear bowel sounds, you should apply your stethoscope to the abdomen before performing palpation or percussion because these may disturb the peritoneal contents into silent pouting. (However, after percussion, the auscultation should be recorded in the case record in the usual sequence.)
As far as the routine screening physical examination is concerned, auscultation of the bowel sounds is of low yield.
A Method
Warm the chest piece of your stethoscope by rubbing it briskly in the palm of your hand.
Lightly rest the chest piece of the stethoscope in each of the four quadrants of the abdomen. Listen for bowel sounds. If no bowel sounds are heard, enter this fact in the case record, along with a note about the length of time that you listened. To hear the tinkles and rushes1 of small bowel obstruction, which occur between periods of silence every 10 to 20 minutes (during episodes of cramping abdominal pain), you must listen for 20 minutes! Major (Delp and Manning, 1975) cleverly makes the suggestion that if there is anything to suggest the presence of a small bowel obstruction, one should begin the auscultation of the abdomen during the interview. Remove one of the stethoscope earpieces from your ear to listen to the patient’s words. When the patient interrupts his story because of abdominal pain, switch your attention to the ear that is connected to the stethoscope.
Feel free to modify this method according to the comments below.
Interpretation
No particular type of bowel sounds, or absence of the same, is diagnostic of any one condition, except for the very high-pitched tinkles and rushes of small bowel obstruction.
The complete absence of sounds can be a sign of very advanced intestinal obstruction, a perforated viscus, intestinal ischemia, secondary ileus, or primary disease of the bowel, or it can be viewed as a normal acoustic occurrence between episodes of normal bowel motility.
Increased peristalsis can occur with any obstruction from the pylorus to the cecum, but also occurs during diarrhea of any etiology.
Murmurs
Arterial bruits in the abdomen are discussed in Chapter 18. It is rare for such bruits to have such a lengthy diastolic spillover that they sound continuous, and true continuous murmurs, such as those resulting from an arteriovenous fistula in the splanchnic circulation, are uncommon. Most continuous sounds in the abdomen are of venous origin.
Venous Hums
A high-pitched continuous “hepatic” venous hum, probably coming from the inferior vena cava and radiating along the line of that vessel (Bloom, 1950), is heard in less than 4% of normal persons (Rivin, 1972), more often in the presence of anemia. It is usually heard to the right of the umbilicus, and it has the same physiology as the cervical venous hums discussed in Chapter 19. Specifically, it diminishes or disappears during the forced exhalation phase of the Valsalva maneuver (Hardison, 1977).
A similar high-pitched venous hum of more variable radiation (see Chapter 17) is also heard in portal hypertension and in fact is considered diagnostic of that condition (Hardison, 1977). Usually, it is heard over the xiphoid or the umbilicus; more than one focus of sound may occasionally be present (Bloom, 1950). This hum, which has been called the Cruveilhier-Baumgarten murmur, originates from the paraumbilical anastomotic veins. (The umbilical vein is not recanalized in this syndrome [LaFortune et al., 1985], despite statements to the contrary.) Transmission to the precordium is generally by way of subcutaneous varices in the chest wall or dilated internal mammary veins (Bloom, 1950).
Unlike the hum sometimes heard in normal persons, the Cruveilhier-Baumgarten murmur (or hum) becomes louder during the forced expiratory phase of the Valsalva maneuver (Hardison, 1977). However, during normal respiration, it becomes louder during early inspiration but softer during later inspiration (Cheng et al., 1954). (Because there are those who believe that an increase in such a murmur during inspiration results from compression of the splenic vein and signifies no more than splenomegaly, it is hard to know the exact significance of these changes, especially considering that splenomegaly itself will be a frequent concomitant of portal hypertension.) Although any murmur that significantly diminishes or disappears with epigastric pressure is undoubtedly a Cruveilhier-Baumgarten murmur, not all Cruveilhier-Baumgarten murmurs will have this unique sign (Hardison, 1977). (Also see Table 17.5.) One constant is that the murmur increases or appears 30 to 60 minutes after an oral glucose load (Cheng et al., 1954; Ramakrishnan, 1978).
How was this latter phenomenon discovered? In the old days, it was convenient to make the diagnosis of portal hypertension by comparing the glucose content of the paraumbilical vein with that of a peripheral vein 30 to 60 minutes after a 50-g oral glucose load. The markedly higher values (20 to 50 mg per dL) in the paraumbilical vein showed convincingly that it was not simply a peripheral vein but an integral part of the portal venous system. During such a test, someone must have listened to the hum and made the observation. (There are still hundreds of such observations waiting to be made right now.)
Bloom claims that the paraxiphoid-umbilical hum is almost pathognomonic of hepatic cirrhosis, making liver biopsy unnecessary for making that diagnosis. In fact, he states that the sign indicates the presence of hepatic fibrosis even if such special investigations are negative (Bloom, 1950).
Rubs
Friction rubs over the liver can be heard in hepatoma, cholangiocarcinoma, and 10% of cases of metastatic carcinoma (Fenster and Klatskin, 1961). They also occur after a biopsy (Naylor, 1994). Rubs are less frequent in inflammatory conditions including pyogenic abscess, viral hepatitis, alcoholic hepatitis, cholecystitis, tuberculous peritonitis, and perihepatitis secondary to lupus erythematosus or gonococcal infections. If a murmur coexists, diagnose neoplasia, not inflammation (Sherman and Hardison, 1979).
It should not be surprising that it is also possible to auscultate a rub over an inflamed gallbladder or a splenic infarct.
Special Maneuvers
The Valsalva Maneuver
After a 20-second vigorous Valsalva maneuver, the patient with an acute abdomen will often be able to point to a specific area of tenderness. Identifying this area first allows one to plan a strategy that minimizes discomfort to the patient, permitting a more adequate (as well as more humane) examination. Pathology in the hip can confound the results (see Chapter 25 and Fig. 25-20).
The Obturator Test
The purpose of the obturator test is to move the obturator muscle passively, an action that normally produces no pain. However, if the obturator muscle is inflamed because of pathology of a neighboring viscus, pain is produced.
A Method
With the patient supine, flex the thigh and rotate it fully inward (Fig. 20-9).
Repeat on the opposite side.
 FIGURE 20-9 The obturator test. Standing lateral to the leg, pull the ankle toward you and push the knee away from you. |
Interpretation
This test is positive if the inward rotation produces pain, usually referred to the hypogastrium (i.e., the central inferior abdomen where the bladder is located).
In appendicitis, the test is positive on the right but not on the left. It can be positive on either side in the case of pelvic abscesses or pelvic hemorrhage. It can also be positive if there is pus in the pelvis, even if the pus came from above.
The Reverse Psoas Maneuver
The reverse psoas maneuver, also called Cope’s iliopsoas test, is useful in detecting psoas irritation from appendicitis, psoas abscess, or psoas hematoma.
A Method
Have the patient roll onto his left side. Hyperextend the right hip (away from the position that the patient would naturally assume with a right psoas sign—see the drawing of St Sebastian, Fig. 5-2) to see whether pain can be elicited.
Repeat on the other side to check for nonappendiceal left psoas lesions.
Detecting a Ventral Hernia
If the supine patient places his chin on his chest, or attempts a sit-up with his hands folded on his chest, he will need to contract his rectus abdominus muscles, thereby making an abdominal ventral hernia more apparent to inspection and palpation.
A Valsalva maneuver may distend a hernia that can be seen more readily than felt.
Auscultation After Tube Placement
Instilling air into a feeding or gastric tube while listening distally, over the stomach, for a hissing or bubbling sound has been recommended as a means to check tube placement. When auscultation was compared with radiography to check for placement of a weighted enteral tube, sensitivity was 98% but specificity was an alarmingly low 6.3%, with a negative PV of 50%. Of 16 placements that were not gastric, 15 were incorrectly identified as being gastric by auscultation. Aspiration of fluid to check for pH was recommended in all cases, with radiography to check for tube placement unless the pH was less than 4.0 (Neumann et al., 1995).
Gary Albers of Missouri told of a comatose patient into whom a nurse passed a nasogastric tube and, hearing the expected bubbling sound near the stomach, began feedings. Soon the patient developed a left-sided pneumonia with empyema. Investigation revealed that the feeding tube had been passed into the left lower lobe of the lung and through the pleura into the subpleural space.
One should listen over the stomach after an endotracheal tube has been placed. A hissing or bubbling sound means that you have intubated the esophagus and must correct the problem immediately (also see Chapter 16).The Succussion Splash
The same principles described in Chapter 16 apply to gastric outlet obstruction or any other abdominal condition in which a nonviscous liquid forms the lower portion of a gas-liquid interface. Note that there must be a large amount of the gas over the liquid phase. Also, the patient must be in a condition that permits him to be passively shaken, and the splash must be located sufficiently close to the abdominal wall that it can be detected with a stethoscope.
Flat and upright films are superior to the succussion splash for finding air-fluid levels. However, the succussion splash, while an insensitive maneuver, is cheap and quick. Because there are many normally occurring gas-fluid interfaces in the abdominal cavity, the succussion splash is less specific than in the chest, where it is always abnormal (see Fig. 16-11).
The Hannington-Kiff Sign
The Hannington-Kiff sign for strangulated obturator hernia is given in Chapter 26.
Synthesis
Ascites
The presence of ascites has great diagnostic as well as prognostic importance. It raises the index of suspicion for a number of rather uncommon disorders; see the differential diagnosis listed in Table 20.3. The diagnosticity of various findings that
have been investigated in a comparative fashion is given in Tables 20.4 and 20.5.
have been investigated in a comparative fashion is given in Tables 20.4 and 20.5.
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