ppt by ROHEEDA RIAZ KHAN

1. ASSESSMENT OF THE ABDOMEN, ANUS & RECTUM
Prepared By: Roheeda Riaz Khan
MSN,INS,KMU

2. LEARNING OBJECTIVES
At the completion of this unit learners will be
able to:
1. Discuss the pertinent health history questions
necessary to perform the assessment of
Abdomen, Anus and Rectum.
2. Describe the specific assessment to be made
during the physical examination of the abdomen.
7/28/2019

3. OBJECTIVES
3. Discuss components of a rectal examination.
4. Document findings.
5. List the changes in abdomen that are
characteristics of aging process.
7/28/2019

4. EXAMINATION
The order for examining the abdomen is:
Inspection, auscultation, percussion,
palpation
1) INSPECTION
2) AUSCULTATION
3) PERCUSSION
4) PALPATION

5. THE FOUR QUADRANTS
Physicians locate findings in the abdomen in one of four
quadrants or one of nine regions.
The four quadrants are:

6. © Clinical Skills Resource Centre, University of Liverpool, UK
THE 9 ABDOMINAL REGION ARE:
Pancreas, stomach and
common bile duct.
Small intestine
Kidneys Kidneys
Bladder and
uterus.
Sigmoid
Colon
&
Ovaries
Cecum,
Appendix
&
Ovaries
Liver
and gall
bladder
Spleen and
stomach
Umbilical:
the small
intestine.

7. ISPECTION

8. INSPECTION
Signs of liver disease:
Jaundice (yellow cast to skin)
Spider angiomas: subcutaneous vessels that look
like spiders. They fill from the center when
pressed.
The liver enlarges early, later shrinks with
cirrhosis
Prominent veins at umbilicus
Hemorrhoids & Ascites

9. SOME COMMON FINDINGS ON ABDOMINAL
INSPECTION
Scars
Striae (stretch marks)
Colors
Jaundice
Prominent veins

10. SCARS
Explain every scar. Each one is evidence
of surgery or injury that the patient may
have forgotten to mention to you.
The injury that caused a visible scar may
have also caused internal scarring
(grips) - which can cause intestinal
obstruction

11. STRIAE (Stretch Marks)
On the abdomen may be a
sign of past weight changes,
such as pregnancy.
An endocrine disease,
Cushing's disease , may
cause purple Striae.

12. COLORS
Bluish color at the umbilicus is
Cullen's sign - a sign of bleeding in
the peritoneum.
Bruises on the flanks are Grey
Turner's sign (retroperitoneal
bleeding - e.g. from inflamed
pancreas)

13. PROMINENT VEINS
Prominent veins may be due to portal vein
obstruction or inferior vena cava obstruction.
The portal veins and systemic veins connect in
3 locations; the umbilicus is one of it.

14. OTHER FINDINGS ON INSPECTION: PERISTALSIS
AND SCAPHOID ABDOMEN
Visible peristalsis is usually abnormal, unless
the patient is emaciated.(shrunken)
Otherwise, it is a sign of intestinal
obstruction.
In thin adults, the abdomen may be concave
- scaphoid

15. HERNIAS
Not all hernias happen in the inguinal area. Some
abdominal hernias include:
Umbilical hernias: protrude out of the umbilicus
Incisional hernias: occur at old scars
Diastasis recti: this is not a true hernia, but a
separation of the rectus abdominal muscles. You
can see this best by asking the patient to tighten the
abdominal muscles (lift head when supine, or sit
up).

16. AUSCULTATION

17. STAY, LOOK AND LISTEN
Always auscultate before touching the abdomen .
Touching the abdomen, even to percuss, may change
the bowel sounds.
Before you proceed, consider your patient's comfort. Is
your stethoscope warm? Are your hands warm? Are
your fingernails short? Has the patient emptied
his/her bladder?
Place a pillow under your patient's head. Asking your
patient to bend his/her knees may help relax the
abdominal muscles.

18. GUT SOUNDS
Use the diaphragm of your stethoscope to
listen to gut sounds
Normal gut sounds are gurgling, 5 to 35 per
minute
Borborygmi: Are loud, easily audible sounds.
They are normal, too.
High pitched : Tinkling (raindrops in a barrel)
sounds are a sign of early intestinal
obstruction

19. GUT SOUND
Decreased sounds: (none for a minute) are a sign of
decreased gut activity. Gut sounds may be markedly
decreased after abdominal surgery; abdominal
infection (peritonitis) or injury.
Absent Sounds : (no sounds for 5 minutes) are a bad
sign. They can be caused by longer-lasting intestinal
obstruction, intestinal perforation or intestinal
(mesenteric) ischemia or infarction.
Mesenteric ischemia is a medical condition in which injury to the small
intestine occurs due to not enough blood supply. It can come on suddenly,
known as acute mesenteric ischemia, or gradually, known as chronic
mesenteric ischemia.

20. BRUITS
Aortic bruits: Are heard in the epigastrium.
They may be a sign of abdominal aortic
aneurysm;
Renal artery bruits: Are in each upper
quadrant. They may be a sign of renal artery
stenosis, which is a potentially treatable cause
of hypertension;
Iliac/femoral bruits: Are in the lower
quadrants. They may be a sign of peripheral
atherosclerosis.

22. CASE 1
A 50 year old man has nausea and vomiting for two
days and no bowel movement. His abdomen is
somewhat distended.
Does he have intestinal obstruction ?
Signs of intestinal obstruction are:
High-pitched tinkling bowel sounds
Later: bowel sounds absent
Visible peristalsis

23. PERCUSSION

24. PERCUSSION
What is to finds?: liver size , spleen, fluid.
PERCUSSING THE BODY GIVES ONE OF THREE
NOTES:
Tympany: is found in most of the abdomen, caused
by air in the gut. It has a higher pitch than the
lung.
Resonance: is found in normal lung. It is lower
pitched and hollow.
Dullness: is a flat sound, without echoes. The liver
and spleen, and fluid in the peritoneum (ascites),
give a dull note.

25. PERCUSSING OF LIVER and SPLEEN
A normal liver measures 6
to 12cm, usually 8 to
12cm.
The reliability of percussion
to assess liver size is
limited
(Am J Gastroenterology 1995; 90:1428-32)

26. Cont.…
To percuss the spleen :
Percuss in left anterior axillary line, just above
lowest rib.
Ask your patient to take a deep breath and
percuss again. Dullness with full inspiration
may be a sign of enlarged spleen.
(splenomegaly)

27. CASE 2
A 55 year old women with a distended
abdomen
She drinks half of cup daily and notes gradually
increasing abdominal girth. She has no pain.
Does she have ascites (fluid) caused by liver
failure?

28. USING PERCUSSION to DIAGNOSE ASCITES
Physical signs of ascites include fluid wave,
shifting dullness and puddle sign( lake,
Pool). Two of these are done by percussion.
Shifting dullness : Start with your patient
supine. Percuss down the lumbar area
closest to you; mark the point where note
turns dull.
Now turn the patient onto his/her side facing
you and percuss down again. If the dull
area is now higher (closer to the
umbilicus), this suggests fluid in the
peritoneum (ascites).

29. CONT…..
Puddle sign (rarely done): Patient is on all
fours, (hands and knees)
Percuss for a dull area around the umbilicus
(lowest point)
Grading of puddle signs
TEST Minimal Fluid In ML
Diagnostic Tape 10-20ml
Ultra Sound 100ml
CT Scan 100ml
Puddle signs 120ml
Shifting 500ml
Fluids thrill 1000-1500ml

31. PERCUSSION FOR RENAL ANGLE TENDERNESS
To look for renal causes of
pain, such as
pyelonephritis (kidney
infection), you may
percuss the back in the
region of the costo-phrenic
angle. Tenderness on one
side may come from that
kidney.

32. PALPATION

33. PALPATION
Use palpation to assess:
Liver, spleen and kidneys for enlargement and
consistency .Masses .Tenderness .Spasm of abdominal
muscles
Guarding= spasm, when you push; sign of tenderness
or inflammation
Rigidity= board-like spasm all the time; sign of bad
things like perforated intestine, dead intestine from
lack of circulation (infarction), or diffuse infection
peritonitis.
Oversensitivity of skin = cutaneous hyperesthesia: a sign
of inflammation of underlying structure

34. PALPATION TECHNIQUE
Warm hands; use two hands and
focus on what your lower hand
feels.
Bend your patient's knees to relax
abdominal muscles
If the patient is ticklish, include
patient's hand between your
two hands - a "hand sandwich"
Examine tender areas last

35. PALPATION OF LIVER
Some hints:
Push in fairly deeply, 5cm deep or more
Inch your right hand up toward the
patient's lower costal margin with
each breath.
The liver edge should be palpable, if at
all, at the lower costal margin. It
should feel rubbery and smooth

36. PALPATION OF THE KIDNEYS
Palpation of the kidneys :
• Kidneys are usually not palpable in
adults unless quite enlarged (e.g.
polycystic)
• The right is palpable more often than
the left
• Kidneys are deep in the flank and move
down with inspiration.
Palpation for masses :
Use deep pressure with the palmar aspect
of your fingers, with a rolling motion.

37. CASE 3: What is that lump?
You feel a mass when palpating your
fellow student's abdomen.
Normal "masses" include:
Feces in the sigmoid colon (often
slightly tender)
Distended bladder
The uterus (e.g. pregnant)
The aorta (it's pulsation).

38. AAA
Aorta is just to the left of the midline
and is pulsatile
If it seems 5 cm or wider: evaluate
for abdominal aortic aneurysm .

39. HOW SENSITIVE IS PALPATION FOR
DETECTING ABDOMINAL AORTIC ANEURISM?
Aneurysms require surgery if larger
than 5cm. Examination for
abdominal aortic aneurysm (AAA)
has sensitivity of:
82% if patient's girth is under 100 cm
(40 inches)
100% if patient's girth is under 100 cm
and aneurysm is over 5 cm
JAMA 2000; 160(6):833-836.)

40. PHYSICAL FINDINGS
Fever (often low-grade, around 38 degrees) 79% sensitive 21% of
patients are afebrile
Abdominal rigidity
Tenderness on right side on rectal examination
Rebound tenderness : Push gently until pain decreases, then lift
your hand suddenly. The pain is worse when you lift your hand - a
sign of peritoneal irritation. A kinder way to test for rebound
tenderness is called
Rovsing's sign : you push down on the non tender side of the
abdomen and lift your hand suddenly. Patient feels pain in the
affected area (RLQ) when you lift your hand.

41. The area of tenderness in appendicitis should
be Burney's point: 1/3 of the way up a
oblique line from iliac crest to the umbilicus.
Pain in RLQ near inguinal ligament in young
women is most likely pelvic (ovarian cyst,
pelvic inflammatory disease, abscess in
fallopian tube) or urinary tract and NOT
usually appendicitis.

42. MANTRELS Score
Established in
1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left

43. Cont.……
RLQ tenderness and leukocytosis = 2 points
each ; all others 1 point
Score of 5 to 6 = possible appendicitis
Score of 7 to 8 = probable appendicitis
Score of 9 to 10 = very probable appendicitis
up to 25% under age 20 – 50+have
appendicitis

44. CAUSES of ABDOMINAL DISTENSION
Distension of the lower abdomen only can be caused by
Pregnancy.
Full bladder.
Ovarian tumor,
Uterine fibroids (common benign growths)
Diffuse abdominal distension can be caused by any of
The 6 Fs:
Feces (constipation & Fat (obesity)
Fluid (ascites - peritoneal fluid - or obstructed viscera
filled with fluid)
Flatus (air) air swallowing or intestinal obstruction
Fetus (pregnancy) & Fatal cancer and jaundice

45. USEFUL CLINICAL SIGNS of CHOLECYSTITIS
Right upper quadrant tenderness
Murphy's sign : when you push
toward the liver at the right costal
margin, patient has pain and stops
breathing:
Is a sign of gall bladder infection
(cholecystitis).
Palpable mass

48. Rectal examination
© Clinical Skills Resource Centre, University of Liverpool, UK
 Rectal examination may be required for many
reasons some of which are:
 Rectal bleeding/Rectal itching
 Rectal Pain
 Abdominal Pain / Pelvic pain (as part of an
abdominal examination)
 Passing blood/Passing mucus
 Presence of lumps or other palpable
abnormalities
 Neurological symptoms

49. Preparing the patient 1
© Clinical Skills Resource Centre, University of Liverpool, UK
 Introduce yourself fully including your role within the
patients care
 The reason and nature of the technique of rectal
examination should be explained to the patient,
informed consent can then be gained.
 Reassure the patient the that examination
may be uncomfortable, but it should not be
painful
 The clinical room must be ready for an intimate/
Examination
49

50. PREPARATION OF PATIENT 2
 Patient should be asked to lie in the
lateral position, close to the edge of the
bed with the hips and knees flexed.
Expose only as much as necessary.
 A blanket should be draped across the
patient to minimize exposure and reduce
level of patients vulnerability
 Assistance by yourself or the speculum
should be offered to help the patient get
into position
 Have a clean tray containing water
soluble gel and tissues
© Clinical Skills Resource Centre, University of Liverpool, UK

51. INSPECTION OF THE ANUS
 Wash hands and put on a pair of
disposable gloves
 Gently separate the area and
inspect the natal cleft and anal
edge
 Look for fissures,
rashes, haemorrhoids,
warts etc
 The position of an anal lesion is
described in relation to the face
of a clock
 The anterior aspect of the anus
is assigned to 12 o’clock
Sunday, July 28, 2019

53. Rectal examination technique 1
 Lubricate (gloved) index finger
 Place pulp of index finger on
posterior anal verge so a small angle
exists between the palmar surface of
the finger and the natal cleft
 Press gently on the anus and slip the
tip of the index finger into the anal
canal by increasing the angle of the
finger
 Avoid using force, wait for the
sphincter to relax, if still difficult do
not continue with the examination
© Clinical Skills Resource Centre, University of Liverpool, UK

54. RECTAL EXAMINATION TECHNIQUE 2
 Insert the index finger into the rectum as
far as it will go, following the sacral curve
 If there is believed to be a problem with
the anal sphincter, ask the patient to
squeeze the examining finger to assess
anal tone
 Examine the posterior and lateral walls of
the rectum for palpable lumps or tears
(rectal walls should be smooth)
 Assess the presence or absence of
faeces: palpable as a mobile putty-like
substance (in constipation may be hard),
which you can indent with your fingertip.
© Clinical Skills Resource Centre, University of Liverpool, UK

55. Rectal examination technique 3
© Clinical Skills Resource Centre, University of Liverpool, UK
 Rotate wrist so that finger pulp
faces anteriorly and examine the
anterior rectal wall.
 In the male examine the prostate
gland (see slide 10) may be
palpated. In the female the cervix
may be palpable.

56. RECTAL EXAMINATION TECHNIQUE 4
 Rotate wrist, so that your examining
finger is facing posteriorly again
and then withdraw finger.
 On withdrawal check gloved finger
for stool (normal colour, pale stool,
malaena etc) and any blood or
mucus
 Clean patient, dispose of gloves
and wash hands
© Clinical Skills Resource Centre, University of Liverpool, UK

57. PROSTATE EXAMINATION
© Clinical Skills Resource Centre, University of Liverpool, UK
 The prostate gland is examined during a male
rectal examination.
 A normal prostate measures approximately 3.5cm
from side to side and protrudes 1cm into the
rectum. It can be felt through the anterior rectal wall
and has a median sulcus separating the two lobes.
 The prostate should not be tender to palpation but
the patient may experience discomfort or an urge to
urinate.

58. PALPATION OF THE PROSTATE GLAND
© Clinical Skills Resource Centre, University of Liverpool, UK
Palpation of the prostate gland aims to assess:
 Size
 Presence of two equally sized lobes with a
median sulcus
 Consistency (firm)
 Surface (smooth or nodular)
 Tenderness
 However assessment of prostatic size is
learnt through experience!

59. Abnormalities of the Prostate
© Clinical Skills Resource Centre, University of Liverpool, UK
 Benign Hypertrophy of the prostate is common in men over
the age of 60years.
 The enlargement is smooth and maybe unilateral or bilateral
the gland feels rubbery or slightly boggy.
 A cancerous prostate may feel asymmetric, with a stony
hard consistency maybe with the presence of palpable
nodules
 Tenderness of the prostate may be due to prostatic
inflammation or infection.
 All findings must be documented and further
investigations/treatment/management must be considered.

61. RECORDING YOUR FINDINGS
© Clinical Skills Resource Centre, University of Liverpool, UK
 Don’t forget when recording your findings to include the
patient identifiers, date (and time), your signature and
printed name at end
 When documenting or describing your findings remember
to comment on the anus (inspection), anal tone (if
performed), rectal walls, contents of rectum (stool etc),
the prostate and any abnormal masses palpated.
 Remember to describe your findings as fully as possible:
eg size, position (relative to face of clock), shape of a
swelling etc
 A diagram may often be useful in written notes

62. CHANGES IN ABDOMENAND CHARACTERISTICS OF AGING
PROCESS
.
ORAGAN:
STOMACH: Gastritis. Focal ulcer. Outlet Obstruction.
Masses
SMALL BOWEL: Enteritis. Obstruction & Perforation
COLON: Obstruction. Perforation. Colitis. Appendicitis
ANO-RECTUM: Proctitis (ulcers of stomach) and
Tumor
LIVER: Infiltration
BILARY TRACT: Cholecystitis, Papillary stenosis
PANCREASE: Inflammation ,Tumor
MYCENTRY PERITONIUM: AAA, Infiltration