How to begin an abdominal exam with a visual inspection

After obtaining a thorough history from your patient presenting with abdominal pain or discomfort, it’s time to move on to the abdominal exam. The results from this examination will form part of your objective findings—one of the four components of a medical evaluation as represented by the acronym SOAP (Subjective, Objective, Assessment, and Plan).

Before we get into how to begin an abdominal exam, it’s important to remember that the abdomen is divided into regions or quadrants.

Recognizing the four quadrants of the abdomen is helpful for determining a diagnosis and for communication between physicians. There will be more detail about this when we cover the palpation portion of the abdominal exam.

For inspection purposes, the quadrants are the most helpful. They consist of the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ). It is common to see these quadrants abbreviated.

The four quadrants of the abdominal wall are used for general clinical descriptions. They are defined by two planes known as the horizontal or transumbilical plane (which passes through the umbilicus at the L4 level), and the vertical or medial plane (which divides the body into the right and left halves).

An abdominal exam consists of four main components:

1. Inspection
2. Auscultation
3. Percussion
4. Palpation

The remainder of this article will focus on the first part of the abdominal exam, which is the visual inspection.

Before you begin the exam, remember to always wash your hands. You may have done this upon entering the room, but in case you are only present during the examination, don’t forget it.

Make sure the patient is in the correct position for the abdominal exam which is supine (e.g., lying on their back), so the abdominal musculature is relaxed. Expose the abdomen so that you can observe the entire abdomen from the xiphoid to the suprapubic region.

Now that you’ve prepared yourself and the patient for the exam, you can begin. The abdominal inspection can often be done quickly, and no touching is needed. But, it is vital to do a thorough exam. In addition to noting any major abnormalities, there are four steps that will help you perform a comprehensive inspection:

1. Examine the contour of the abdominal wall
2. Notice any skin changes
3. Inspect for visible masses
4. Observe for motion with respiration

Step 1: Examine the contour of the abdominal wall

During your abdominal inspection, look at the general contour of the abdominal wall from the central aspect (xiphoid, umbilicus, and suprapubic regions) and the lateral aspect (the flanks). Let’s go over three findings to look for.

Distension

Distension might be easily identified by an everted umbilicus. The umbilicus in a nondistended abdomen that should be flat and inverted.

Masses

Central region distension may also be associated with an abdominal aortic aneurysm or intestinal bloating. As such, you also want to look for any pulsatile and expansile masses.

Bulging of the flanks

As well, look laterally at the flanks for bilateral or unilateral bulging.

Step 2: Notice any skin changes

The skin on the abdomen should be evaluated for abnormalities. Skin changes can aid the clinician in developing a differential diagnosis. Let’s review the six signs to look for.

Discoloration

Any discoloration should be identified and described. Examples include ecchymosis, bruising (possibly from trauma), and bluish or reddish erythematous discoloration.

Bluish discoloration of the umbilicus is known as Cullen’s sign and often indicates acute pancreatitis. A bluish discoloration in the flanks (e.g., Grey Turner’s sign) is a sign of a retroperitoneal hemorrhage and is often associated with acute hemorrhagic pancreatitis. An erythematous discoloration may be a sign of cellulitis (a skin infection).

Sinus or fistula

It’s possible to also find a sinus or fistula, which is an abnormal connection between a cavity and the skin. These can represent superficial changes from a sinus that is chronically draining from an underlying infection. Or, it can be the result of a deeper abnormality from a fistula that is connected to the gastrointestinal tract.

Striae

Also, note if there are striae which are often referred to as stretch marks. These are common and usually not pathological. They are often associated with weight gain or pregnancy. However, an exorbitant amount may be associated with certain diseases that have abnormal collagen production, such as Ehlers-Danlos syndrome.

Dilated veins

Dilated veins on the surface of the skin can indicate portal hypertension, often found in liver cirrhosis or obstruction of the vena cava. Caput medusa refers to distended or engorged superficial epigastric veins around the umbilicus. This occurs due to the increased pressure in the portal system from portal hypertension, which then affects the collateral flow between the portal and systemic systems.

Scars

Also, look for any scars. Surgical scars often provide the clinician with information about the patient’s surgical history. Occasionally, patients forget which surgeries they have had.

A long linear incision along the costal margin in the right upper quadrant is a Kocher incision used for an open cholecystectomy. A midline incision extending from the subxiphoid region to below the umbilicus is a laparotomy incision and can be from a variety of open exploratory surgeries, often emergency surgeries.

A low, suprapubic transverse scar is often from a Pfannenstiel incision used in obstetrics for cesarean sections, or gynecological surgeries such as a hysterectomy.

Stoma

In addition to scars, a patient may have a stoma from an ileostomy or colostomy. This surgery is where a portion of the large or small intestine is surgically brought up to the surface of the skin to a stoma bag for stool collection.

Note the location of the stoma and the contents of the bag. Succus and stool are normal, but frankly, blood or bile are not typical. These can signal a serious intraabdominal issue. Also, note the color of the stoma. Normal is beefy red or pink, but a dark color suggests ischemia. It should be a rosette shape or flush with the skin. If it is sunken in and separated from the edge of the skin, this can be problematic. As well, a bulge around the stoma can indicate a possible parastomal hernia.

Step 3: Inspect for visible masses

Inspect the abdomen for masses, which may be visible before palpating the abdomen.

The Valsalva maneuver

Ask the patient to tense up their abdominal wall (using the Valsalva maneuver) and to bear down or perform a partial sit-up by lifting their head and feet up off the table. An abdominal wall mass will usually become more prominent while an intraabdominal mass will become less prominent.

Abdominal wall masses usually present as bulges and are commonly hernias (a defect or weakness in the abdominal wall). These can be umbilical, epigastric, incisional, or spigelian (a lateral hernia between the rectus and lateral oblique muscles) in nature. They can be associated with pain and sometimes skin discoloration over the bulge if the hernia is incarcerated or strangulated.

Fothergill’s sign

A rectus sheath hematoma also presents as an abdominal wall mass. It can be differentiated from a hernia by Fothergill’s sign.

A positive Fothergill’s sign occurs when flexion of the rectus muscles does not cause the mass to change or cross the midline. This finding indicates that a mass may be a rectus sheath hematoma. A hernia would elicit a negative Fothergill’s sign if the mass changes with flexion and becomes more prominent.

Intraabdominal masses can also be caused by tumors, malignancies, or organomegaly (e.g., enlarged organs). Notice the size, location, and consistency of the mass—whether it is soft, smooth, hard, rough, or mobile.

Step 4: Observe for motion with respiration

During your inspection, it’s important to observe the abdominal wall for motion with respiration. Normally the abdominal wall moves posteriorly or depresses inward in a symmetric fashion with inspiration. It becomes distended or pushed outward with expiration.

Peritonitis can cause the abdomen to be rigid and motion may be absent with respiration. This is often obvious during a visual inspection before palpation.

Also, look for any fluid waves that may be present without touching the patient. This may represent ascites.