TRIPASS XR تري باس

 

• Begin with light superficial palpation away from any site of

pain.

• Palpate each region in turn, and then repeat with deeper

palpation.

• Test abdominal muscle tone using light, dipping finger

movements.

• 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

the mass fixed or mobile?

• 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.

Tenderness

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.

Palpable mass

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’).

Enlarged organs

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.

Palpation

Examination sequence

• Ensure your hands are warm and clean.

• If the bed is low, kneel beside it but avoid touching the

floor to prevent infection.

• 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

relax the abdominal wall.

• Use your right hand, keeping it flat and in contact with the

abdominal wall.

• Observe the patient’s face throughout for any sign of

discomfort.

Right subcostal

(Kocher’s)

Right paramedian

Appendicectomy

Suprapubic

(Pfannenstiel)

Upper midline

Lower midline

Left inguinal

Mercedes–Benz

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

Hepatomegaly

• Palpable liver not always enlarged

• Always percuss upper border

• Palpable gallbladder

Generalised distension

• Fat (obesity)

• Fluid (ascites)

• Flatus (obstruction/ileus)

• Faeces (constipation)

• Fetus (pregnancy)

Right iliac fossa mass

• Caecal cancer

• Crohn’s disease

• Appendix abscess

Epigastric mass

• Gastric cancer

• Pancreatic cancer

• Aortic aneurysm

Left upper quadrant mass

• ? Spleen:

 Edge

 Can’t get above it

 Moves towards right iliac fossa

 on inspiration

 Dull percussion note to

 9th–11th ribs mid-axillary line

 Notch

• ? Kidney:

 Rounded

 Can get above it

 Moves inferiorly on inspiration

 Resonant to percussion above it

 Ballottable

Left iliac fossa mass

• Sigmoid colon cancer

• Constipation

• Diverticular mass

Tender to palpation

• ? Peritonitis:

 Guarding

 Rebound

 Absent bowel sounds

 Rigidity

• ? Obstruction:

 Distended

 Tinkling bowel sounds