• Feel along the left costal margin and percuss over the

lateral chest wall. The normal spleen causes dullness to

percussion posterior to the left mid-axillary line beneath

the 9th–11th ribs.

There are many causes of splenomegaly (Box 6.13).

Massive enlargement in the developed world is usually due

to myeloproliferative disease or haematological malignancy;

worldwide, malaria is a common cause.

Important causes of hepatosplenomegaly include lymphoma

or myeloproliferative disorders, cirrhosis with portal hypertension,

amyloidosis, sarcoidosis and glycogen storage disease.

Ascites

Ascites is the accumulation of intraperitoneal fluid (see Fig. 6.6).

Examination sequence

Shifting dullness

• With the patient supine, percuss from the midline out to

the flanks (Fig. 6.17). Note any change from resonant to

dull, along with areas of dullness and resonance.

Fig. 6.17 Percussing for ascites. A and B Percuss towards the flank from resonant to dull. C Then ask the patient to roll on to their other side. In

ascites the note then becomes resonant.

Fig. 6.18 Eliciting a fluid thrill.

110 • The gastrointestinal system

characteristics, and attempt to differentiate between direct and

indirect inguinal hernias.

Examination sequence

• Examine the groin with the patient standing upright.

• Inspect the inguinal and femoral canals and the scrotum

for any lumps or bulges.

• Ask the patient to cough; look for an impulse over the

femoral or inguinal canal and scrotum.

• Identify the anatomical relationships between the bulge,

the pubic tubercle and the inguinal ligament to distinguish

a femoral from an inguinal hernia.

• Palpate the external inguinal ring and along the inguinal

canal for possible muscle defects. Ask the patient to

cough and feel for a cough impulse.

• Now ask the patient to lie down and establish whether the

hernia reduces spontaneously.

• If so, press two fingers over the internal inguinal ring at the

mid-inguinal point and ask the patient to cough or stand

up while you maintain pressure over the internal inguinal

ring. If the hernia reappears, it is a direct hernia. If it can be

prevented from reappearing, it is an indirect inguinal hernia.

• Examine the opposite side to exclude the possibility of

asymptomatic hernias.

An indirect inguinal hernia bulges through the internal ring and

follows the course of the inguinal canal. It may extend beyond

the external ring and enter the scrotum. Indirect hernias comprise

85% of all hernias and are more common in younger men.

A direct inguinal hernia forms at a site of muscle weakness in

the posterior wall of the inguinal canal and rarely extends into the

scrotum. It is more common in older men and women (Fig. 6.20).

A femoral hernia projects through the femoral ring and into the

femoral canal. Inguinal hernias are palpable above and medial

to the pubic tubercle. Femoral hernias are palpable below the

inguinal ligament and lateral to the pubic tubercle.

In a reducible hernia the contents can be returned to the

abdominal cavity, spontaneously or by manipulation; if they

cannot, the hernia is irreducible. An abdominal hernia has a

covering sac of peritoneum and the neck of the hernia is a

common site of compression of the contents (Fig. 6.21). If the

• Now listen 2–3 cm above and lateral to the umbilicus for

bruits from renal artery stenosis.

• Listen over the liver for bruits.

• Test for a succussion splash; this sounds like a half-filled

water bottle being shaken. Explain the procedure to the

patient, then shake their abdomen by rocking their pelvis

using both hands.

Normal bowel sounds are gurgling noises from the normal

peristaltic activity of the gut. They normally occur every 5–10

seconds but the frequency varies.

Absence of bowel sounds implies paralytic ileus or peritonitis.

In intestinal obstruction, bowel sounds occur with increased

frequency and volume, and have a high-pitched, tinkling quality.

Bruits suggest an atheromatous or aneurysmal aorta or superior

mesenteric artery stenosis. A friction rub, which sounds like

rubbing your dry fingers together, may be heard over the liver

(perihepatitis) or spleen (perisplenitis). An audible splash more than

4 hours after the patient has eaten or drunk anything indicates

delayed gastric emptying, as in pyloric stenosis.

Hernias

The inguinal canal extends from the pubic tubercle to the

anterior superior iliac spine (Fig. 6.19). It has an internal ring at

the mid-inguinal point (midway between the pubic symphysis

and the anterior superior iliac spine) and an external ring at the

pubic tubercle. The femoral canal lies below the inguinal ligament

and lateral to the pubic tubercle.

Hernias are common and typically occur at openings of the

abdominal wall, such as the inguinal, femoral and obturator

canals, the umbilicus and the oesophageal hiatus. They may

also occur at sites of weakness of the abdominal wall, as in

previous surgical incisions.

An external abdominal hernia is an abnormal protrusion of bowel

and/or omentum from the abdominal cavity. External hernias are

more obvious when the pressure within the abdomen rises, such

as when the patient is standing, coughing or straining at stool.