• Begin with light superficial palpation away from any site of
• Palpate each region in turn, and then repeat with deeper
• Test abdominal muscle tone using light, dipping finger
• Describe any mass using the basic principles outlined in
Box 3.8. Describe its site, size, surface, shape and
consistency, and note whether it moves on respiration. Is
• To determine if a mass is superficial and in the abdominal
wall rather than within the abdominal cavity, ask the
patient to tense their abdominal muscles by lifting their
head. An abdominal wall mass will still be palpable,
whereas an intra-abdominal mass will not.
• Decide whether the mass is an enlarged abdominal organ
or separate from the solid organs.
Discomfort during palpation may vary and may be accompanied
by resistance to palpation. Consider the patient’s level of anxiety
when assessing the severity of pain and degree of tenderness
elicited. Tenderness in several areas on minimal pressure may
be due to generalised peritonitis but is more often caused by
anxiety. Severe superficial pain with no tenderness on deep
palpation or pain that disappears if the patient is distracted also
suggests anxiety. With these exceptions, tenderness usefully
indicates underlying pathology.
Voluntary guarding is the voluntary contraction of the abdominal
muscles when palpation provokes pain. Involuntary guarding is
the reflex contraction of the abdominal muscles when there is
inflammation of the parietal peritoneum. If the whole peritoneum
is inflamed (generalised peritonitis) due to a perforated viscus,
the abdominal wall no longer moves with respiration; breathing
becomes increasingly thoracic and the anterior abdominal wall
muscles are held rigid (board-like rigidity).
The site of tenderness is important. Tenderness in the
epigastrium suggests peptic ulcer; in the right hypochondrium,
cholecystitis; in the left iliac fossa, diverticulitis; and in the right
iliac fossa, appendicitis or Crohn’s ileitis (Fig. 6.12). Ask the
patient to cough or gently percuss the abdomen to elicit any
pain or tenderness ‘Rebound tenderness’, when rapidly removing
your hand after deep palpation increases the pain, is a sign of
intra-abdominal disease but not necessarily of parietal peritoneal
inflammation (peritonism). Specific abdominal signs are shown
in Box 6.9. Typical findings may be masked in patients taking
glucocorticoids, immunosuppressants or anti-inflammatory drugs,
in alcohol intoxication or in altered states of consciousness.
A pulsatile mass palpable in the upper abdomen may be normal
aortic pulsation in a thin person, a gastric or pancreatic tumour
transmitting underlying aortic pulsation, or an aortic aneurysm.
A pathological mass can usually be distinguished from normal
palpable structures by site (Fig. 6.13), and from palpable faeces
as these can be indented and may disappear following defecation.
A hard subcutaneous nodule at the umbilicus may indicate
metastatic cancer (‘Sister Mary Joseph’s nodule’).
Examine the liver, gallbladder, spleen and kidneys in turn during
deep inspiration. Keep your examining hand still and wait for
the organ to move with breathing. Do not start palpation too
wall musculature and becomes more obvious as the patient
raises their head off the bed or coughs.
• Ensure your hands are warm and clean.
• If the bed is low, kneel beside it but avoid touching the
• Ask the patient to show you where any pain is and to
report any tenderness during palpation.
• Ask the patient to place their arms by their sides to help
• Use your right hand, keeping it flat and in contact with the
• Observe the patient’s face throughout for any sign of
Fig. 6.10 Some abdominal incisions. The midline and oblique incisions
avoid damage to innervation of the abdominal musculature and later
development of incisional hernias. These incisions have been widely
superseded by laparoscopic surgery, however.
Fig. 6.11 Surgical stomas. A An ileostomy is usually in the right iliac
fossa and is formed as a spout. B A loop colostomy is created to
defunction the distal bowel temporarily. It is usually in the transverse colon
and has afferent and efferent limbs. C A colostomy may be terminal: that
is, resected distal bowel. It is usually flush and in the left iliac fossa.
106 • The gastrointestinal system
• Palpable liver not always enlarged
Moves towards right iliac fossa
9th–11th ribs mid-axillary line
Moves inferiorly on inspiration
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