3.6 Abdominal Examination
Key Takeaways
- The abdominal exam follows inspection, auscultation, percussion, palpation — auscultation comes before percussion and palpation because those maneuvers can artificially alter bowel sounds.
- Cullen's sign (periumbilical ecchymosis) and Grey Turner's sign (flank ecchymosis) both signal retroperitoneal or intra-abdominal hemorrhage, such as from hemorrhagic pancreatitis.
- Peritoneal irritation presents as guarding, rigidity, rebound tenderness, and positive Rovsing's, psoas, or obturator signs.
- Visceral disease (pancreatitis, biliary colic, renal colic, pyelonephritis, retroperitoneal hemorrhage) routinely presents as back pain and must be differentiated from mechanical low back pain.
- Abdominal aortic aneurysm should be suspected with a pulsatile midline mass wider than about 3 cm above the umbilicus, especially with age over 65, smoking history, or hypertension; avoid vigorous palpation and refer emergently if rupture is suspected.
Abdominal Examination
Quick Answer: The abdominal examination follows inspection, auscultation, percussion, then palpation — auscultation is performed before percussion and palpation to avoid artificially altering bowel sounds — and it matters for Part III largely because visceral disease (pancreatitis, biliary colic, renal colic, pyelonephritis, and especially abdominal aortic aneurysm) can present as low back pain that mimics a mechanical case.
Examination Sequence: Inspection, Auscultation, Percussion, Palpation
The abdominal exam deliberately departs from the head-to-toe order used elsewhere in the physical exam. Percussion and palpation can stimulate peristalsis and alter bowel sounds, so auscultation is always performed second, immediately after inspection and before percussion or palpation disturbs the abdomen.
Inspection
With the patient supine and the abdomen exposed from xiphoid to pubis, inspect for contour and symmetry, scars, striae, generalized or localized distension, visible peristalsis, visible pulsations, and hernias (umbilical, inguinal, incisional). Two named skin findings signal serious retroperitoneal pathology: Cullen's sign (periumbilical ecchymosis, associated with hemorrhagic pancreatitis or intraperitoneal hemorrhage) and Grey Turner's sign (flank ecchymosis, associated with retroperitoneal hemorrhage). Both are late findings that indicate an emergency, not a musculoskeletal complaint.
Auscultation
Listen in all four quadrants for bowel sounds, normally occurring at a rate of roughly five to thirty-four per minute. Hyperactive sounds suggest early mechanical obstruction or gastroenteritis; hypoactive or absent sounds (confirmed only after listening for a full two to five minutes) suggest ileus or peritonitis. Also listen over the aorta (just above and lateral to the umbilicus), the renal arteries (upper quadrants near the costal margin), and the iliac and femoral arteries for bruits, which suggest turbulent flow from atherosclerotic narrowing or an aneurysm.
Percussion
Percussion distinguishes tympany (the predominant note, reflecting gas-filled bowel) from dullness (reflecting fluid, a mass, an organ, or stool). Use percussion to estimate liver span at the midclavicular line (normally roughly six to twelve centimeters) and to assess splenic dullness in Traube's space. Shifting dullness and a fluid wave suggest ascites. Direct fist percussion over the costovertebral angle (posteriorly, at the twelfth rib) assesses for renal tenderness and is a key technique linking the abdominal and urogenital examinations.
Palpation
Begin with light palpation in all four quadrants to assess superficial tenderness and guarding before proceeding to deep palpation for organomegaly and masses. Peritoneal irritation produces a recognizable cluster of findings:
| Sign | Finding | Significance |
|---|---|---|
| Guarding | Voluntary or involuntary muscle tensing on palpation | Underlying inflammation or irritation |
| Rigidity | Board-like involuntary tensing, present even at rest | Peritonitis |
| Rebound tenderness | Pain on release of pressure, worse than pain on palpation | Peritoneal inflammation |
| Rovsing's sign | Pain in the right lower quadrant elicited by palpating the left lower quadrant | Suggests appendicitis |
| Psoas / obturator sign | Pain with hip extension or internal rotation against resistance | Suggests appendicitis or a retroperitoneal/pelvic inflammatory process |
Assess for hepatomegaly, splenomegaly (the spleen is not normally palpable, so palpability alone is abnormal), and renal masses, and note any pulsatile abdominal mass.
Visceral Mimics of Back Pain
Abdominal and retroperitoneal organs share segmental innervation with the spine, so visceral disease routinely presents as back pain rather than abdominal pain. Recognizing these patterns is central to chiropractic differential diagnosis.
| Condition | Typical Pain Pattern | Distinguishing Clue |
|---|---|---|
| Pancreatitis | Epigastric pain radiating straight through to the mid-back | Worse supine, eased by leaning forward; history of alcohol use or gallstones |
| Peptic ulcer disease (posterior penetration) | Epigastric pain radiating to the back | Relationship to meals; melena if bleeding |
| Biliary colic / cholecystitis | Right upper quadrant pain radiating to the right scapula or interscapular region | Worse after fatty meals; positive Murphy's sign |
| Renal colic (nephrolithiasis) | Colicky flank pain radiating to the groin | Hematuria; patient writhes and cannot find a comfortable position |
| Pyelonephritis | Flank and costovertebral pain | Fever, dysuria, costovertebral angle tenderness |
| Retroperitoneal hemorrhage or tumor | Dull, progressive back pain, not position-dependent | Cullen's or Grey Turner's sign may be present; unrelieved by rest |
Abdominal Aortic Aneurysm Considerations
Abdominal aortic aneurysm deserves special emphasis because it is the visceral mimic most likely to be missed as mechanical low back pain, and the consequence of missing it is catastrophic.
Risk factors include age over sixty-five, male sex, current or past smoking, hypertension, atherosclerotic disease, and a family history of aneurysm. On palpation, use a bimanual technique along the lateral borders of the aorta above the umbilicus; a width greater than about three centimeters (or more than roughly two finger-breadths) suggests aneurysmal widening, since the normal aorta measures approximately two to three centimeters. Auscultate for a bruit in the same region.
Two practice points matter on Part III. First, vigorous or deep palpation should be avoided when an aneurysm is strongly suspected, because of theoretical rupture risk; the priority shifts to careful assessment and referral rather than repeated manual confirmation. Second, any presentation of sudden, severe abdominal or back pain, especially with a pulsatile or expansile mass, syncope, or hypotension, is treated as a vascular emergency: refer for immediate emergency evaluation and imaging rather than any form of manipulation. Any atypical low back pain pattern — throbbing quality, unrelieved by rest or position change, present at night, or accompanied by the risk factors above — should prompt reconsideration of the abdominal exam and aortic screening even when the initial presentation looked mechanical.
What is the correct sequence for the abdominal examination, and why does it differ from the sequence used elsewhere in the physical exam?
A patient presents with sudden severe low back pain. On examination, a pulsatile midline mass is palpated above the umbilicus with a bruit on auscultation. What is the most appropriate action?
Periumbilical ecchymosis (Cullen's sign) and flank ecchymosis (Grey Turner's sign) are most associated with which underlying process?
Which pain pattern most clearly distinguishes renal colic from peritoneal irritation at the bedside?