What should you do if a patient is ticklish when you are palpating the abdomen?

Palpation should generally occur with the examiner on the patient's right side. Warm hands and a relaxed patient are essential for palpation to be successful. To help the patient relax:

• Start slowly and gently with light palpation, avoiding any areas of tenderness.
• Ask the patient to bend his knees to help relax the abdominal wall.
• Have ticklish patients place their hand on top of yours during palpation.

Adopt a systematic approach to evaluate the suprapubic, periumbilical and epigastric regions in addition to all four quadrants. Note any masses, areas of tenderness or guarding. Follow light palpation with deep palpation.

Palpating the liver:

After general palpation, the examiner should specifically palpate the liver, assessing its contour and consistency, size, and the presence of tenderness or pulsatility. If palpable, the normal liver is smooth with a soft, distinct edge, is generally nontender and may be palpable several centimeters below the costal margin in the mid-clavicular line.

Palpating the spleen:

After palpating the liver, determine if a spleen tip is palpable, noting location, contour, and presence of tenderness. Having the patient roll onto her right side will increase your ability to palpate subtle splenic enlargement. A spleen tip is rarely palpable in adults, and its presence should alert the examiner to possible splenomegaly.

Palpating for aorta and kidneys:

Lastly, assess for aortic aneurysm. Approximately 30% of asymptomatic abdominal aneurysms are picked up on physical examination of the abdomen. The normal aorta is less then 3.0 cm wide. A periumbilical or upper abdominal pulsatile mass is suggestive of an aortic aneurysm or ectasia. The ability to evaluate the aortic width by palpation is highly dependent upon body mass or abdominal musculature.

In adults, kidneys are rarely palpable, unless they are enlarged or very cystic. However, transplanted kidneys are palpable in the lower quadrants.

Inguinal region:

Often included in the abdominal exam is an evaluation of the inguinal region; evaluating the arterial pulses by palpation and auscultation and noting any enlargement of lymph nodes.

Click on the video icon for further discussion and demonstration of palpation techniques.

Introduction[1, 2]

A well-conducted abdominal examination can reveal a great deal of information but, if it is poorly performed, it can reveal nothing and lose the patient's confidence if it causes pain. Everyone develops a personal technique with time and adjusts it according to circumstances. Emphasis will be different if the problem is an acute abdomen or an abdominal mass. Not all of what is described below needs to be performed in full every time but knowledge of the full routine is important so that all parts may be brought in as required.

Preparation for an abdominal examination

• The patient should be adequately undressed (from xiphisternum to pubis) and lying comfortably with the head a little elevated and well supported (one pillow). The arms should be placed alongside the body. This relaxes the abdominal muscles.
• A warm room, a comfortable patient and a calm and reassuring approach from the doctor will create the necessary relaxation. If the patient is tense, very little information can be gained and if you hurt the patient there will be tension and loss of confidence.
• Explain what you are about to do and ask permission to start.
• Your own comfort is also important. The height of the examination couch should permit a comfortable examination whilst standing upright. A bed in a patient's home is usually lower and sitting on a chair may be preferable.
• Obesity and a pendulous abdomen in a patient may make abdominal examination more difficult.

Inspection[1, 2]

General inspection

• Does the patient look unwell?
• Is pain apparent? If the patient is writhing it could be due to colic in some form. A person with peritonitis lies still.
• Is there jaundice? This may not be easily apparent in artificial light.
• Is there evidence of dehydration?
• Are there signs of weight loss or wasting (may be a sign of malabsorption or malignancy)?
• Look for purpura (may be present in hypersplenism or impaired clotting function).
• Look for spider naevi (liver disease).
• Xanthelasma (symmetrical yellow plaques around the eyelids) may be present in primary biliary cirrhosis or chronic biliary obstruction.
• Kayser-Fleischer rings (a brown-yellow ring in the outer rim of the cornea) may be present in Wilson's disease[3].
• Leaning over the face to inspect respiration can be used to smell the patient's breath - eg, for alcohol. Hyperventilation may be a sign of acidosis (chronic kidney disease).

Examination of the hands

Look for:

• Whether the hands are warm and well perfused or cold and clammy.
• Finger clubbing: may occur with ulcerative colitis, Crohn's disease, coeliac disease, cystic fibrosis or other malabsorption syndromes.
• Koilonychia: suggests iron deficiency.
• Liver palms (palmar erythema): a sign of liver dysfunction.
• Asterixis or a flapping tremor: can be a sign of liver disease (hepatic encephalopathy). Asterixis is 'lapse of posture' or negative clonus exhibited by a flapping tremor at the wrist, metacarpophalangeal joints and hips. It can also be seen in the tongue, foot or any skeletal muscle. Take the fingers in your palm and hyperextend them. A positive flap is a flexion-extension movement at a slow rate. Alternatively, with the patient relaxed, supine and knees bent, feet flat on the couch, the knees may flap as the legs fall to the side. It is not specific for hepatic encephalopathy but occurs also in, for example, chronic kidney disease, respiratory failure, electrolyte disturbance and drug intoxication.

Examination of the neck

• Palpate the supraclavicular fossa: Troisier's sign is left supraclavicular lymphadenopathy due to metastatic thoracic or abdominal malignancy. The supraclavicular node is known as Virchow's node on the left or the right.

Examination of the mouth

• May show, for example, angular stomatitis (which may be due to iron deficiency), thrush, signs of dehydration, ulcers, etc. 

Inspection of the abdomen

• Note any distension, abdominal respiration, bruising, scars, stoma, herniae and any visible peristalsis.
• A mass may be apparent. To exaggerate the presence of a mass, inspect with the head raised from the bed to tense the abdominal muscles and with the Valsalva manoeuvre for lateral regions. Alternatives include Carnett's method of straight leg raising and Kamath's test of straining as if at stool (essentially the Valsalva manoeuvre). The Kamath's test may help to identify small anterior abdominal wall hernias.

Palpation of the abdomen[1, 2]

• Many of the instructions will have to be modified or reversed if you are left-handed and examine from the patient's left side.
• A pillow under the patient's knees may sometimes aid relaxation of abdominal musculature.
• Ask the patient to point to the site of any pain.
• During palpation, be aware of the response of the patient's abdominal muscles and watch their face for signs of discomfort.
• Start with light palpation to gain the patient's confidence and relax them and then perform deeper palpation.
• Use the flat of the hand with the flexor surfaces of the fingers for deep palpation, sometimes superimposing the other hand's fingers for an even distribution of pressure. This technique can reach progressively deeper through each relaxation phase of respiration.
• Develop your own routine, examining each region of the abdomen in turn, starting away from any site of pain.
• Look for signs of localised guarding (the reflex tensing of the abdominal muscles over the painful area which represents peritonism) and rebound tenderness (initial pressure does not cause pain but when the examining hand is released, pain is felt). Rebound tenderness suggests peritoneal irritation.
• Generalised 'board-like' rigidity indicates peritonitis. In peritonitis, the abdomen also does not move during respiration and bowel sounds are absent.
• The 'plastic abdomen' may also be detected and occurs with chronic peritonitis - eg, tuberculosis of the abdomen.
• It is useful to include the following techniques in your abdominal palpation to examine for enlargement of the liver, spleen, gallbladder or kidneys.

Examination of the liver

• Start in the right iliac fossa and move gently up towards the right hypochondrium.
• The examining hand should be flat on the abdomen and the fingers should be pointing upwards so that the fingertips are on a line parallel to the expected liver edge.
• Palpation should be gentle but deep if there is no pain.
• You should press inwards and upwards and hold this position while asking the patient to take a deep breath in through their mouth. At the patient's maximal inspiration, release your inward pressure but maintain your upward pressure. Your fingertips should then move over any palpable liver edge.

Examination of the gallbladder

• Murphy's sign can be elicited by placing your examining fingers over the gallbladder area and then asking the patient to take a deep breath.
• If Murphy's sign is positive, there will be sudden accentuation of the pain on inspiration and inspiration will be inhibited.

Examination of the spleen

• To detect splenomegaly, place the examining hand flat on the abdomen as before, well below the left costal margin. Press inwards and upwards and ask the patient to breathe in again. An enlarged spleen should be felt against the fingertips.
• If you cannot feel an enlarged spleen, move your hand upwards after each inspiration until your fingertips are under the left costal margin.
• If an enlarged spleen is still not palpable, ask the patient to lie on their right side, facing towards you and palpate up into the left hypochondrium as before, asking for deep breaths on the way. Your other hand can be placed behind the rib cage on the patient's left side for support.
• If this does not work, you can examine the patient from their left side, curling the fingers of your left hand beneath their left costal margin as they breathe deeply.
• If you can just feel the tip of the spleen, it is significantly enlarged and perhaps twice the size of normal.

Palpation of the kidneys

• This technique uses two hands.
• Reach one hand round to the patient's right loin with your other hand over the right upper quadrant. Push your hands together whilst asking the patient to breathe in and out. Try to palpate any enlarged kidney between your two hands (called 'balloting').
• Repeat for the left kidney. This can either be done by examining the patient from the left side with your right hand under their left loin or by examining them from the right side with your left hand reaching round under their left loin area.
• In a very thin person who relaxes well, it may be just possible to feel a kidney, especially on the left but usually it is abnormal.
• Examine for enlarged kidneys, renal masses or loin tenderness.

Palpation for pelvic masses

• To look for masses arising from the pelvis, such as an enlarged bladder or an ovarian cyst, examine the abdomen as before but starting above the umbilicus and working down towards the pubis.

Examination for hernias

• Examination techniques for the presence of inguinal and femoral hernias are discussed in the separate Inguinal Hernias and Femoral Hernias articles.

Percussion of the abdomen[1, 2]

• Percussion of the abdomen can be very useful. It is really to allow you to determine if abdominal distension is because of solid or cystic tumours, ascites or gas.
• A generally resonant abdomen suggests much flatus whilst solid or liquid under the fingers will be dull.
• Sometimes it is helpful to use percussion to define the edge of the liver. It can also be used to delineate an enlarged bladder or a tumour arising from the pelvis.

Techniques to demonstrate ascites

Fullness of the flanks may be the first indication of ascites. Techniques to demonstrate ascites include:

• Percussion for shifting dullness: the patient should be lying on their back. Percuss from the umbilical region moving down towards one side. When the sound becomes dull, mark the spot (or keep your finger there) and ask the patient to move on to the opposite side. Give a short while for the fluid to sink and percuss again. If the marked spot now becomes resonant, that is a positive sign. Percuss back down towards the umbilicus until dullness is reached again. Repeat on the other side.
• Eliciting a fluid thrill: this is more difficult to demonstrate. With one hand on the patient's flank, flick the skin over the other flank using a finger. If an impulse or 'fluid thrill' is felt, this indicates a positive sign. However, to be certain, you should repeat the examination with the patient's hand along their midline in the sagittal plane to dampen any possible thrill transmitted by the abdominal wall.

Auscultation of the abdomen[1, 2]

• Bowel sounds can be irregular, so patience is required to decide if they are reduced or normal. On average, you can hear them every 5-10 seconds through a stethoscope.
• If bowel sounds are absent, this may indicate paralytic ileus or peritonitis.
• Diarrhoea is associated with increased bowel sounds.
• Intestinal obstruction produces a classical 'tinkling' bowel sound like water being poured from one cup to another.
• Listen for arterial bruits over the aorta. They may also arise from stenosis of mesenteric or renal arteries.

Pelvic examination

• Full abdominal examination includes pelvic examination.
• See the separate Gynaecological History and Examination article.

Rectal examination

• Examination of the abdomen is incomplete without a rectal examination. However, in primary care it is usual to perform such an examination only if there is a significant expectation of a finding that will influence management. For example, if you have already decided to refer a patient with suspected appendicitis, performing a rectal examination will not influence that decision. It will be performed by at least one admitting doctor, so if the GP does it too, this would be an additional unpleasant intrusion. This is most important in children.
• Pelvic peritonitis may only be detected by rectal examination in some cases.
• If a rectal or pelvic examination is about to be performed, it must be preceded by an abdominal examination. A bimanual vaginal examination can easily miss a large uterine or ovarian mass.
• See the separate Rectal Examination article.

Children[4]

Abdominal examination of children can be much more difficult. They often complain of 'tummy pain' and point to the umbilicus.

• Remember that the differential diagnosis can include tonsillitis, otitis media and meningitis.
• Children are often difficult to relax and may be both apprehensive and ticklish so that abdominal muscles are tense.
• Abdominal examination may be more useful with the child sitting on their parent's lap rather than on the couch.
• Too firm palpation will easily overcome guarding. Be gentle to avoid missing this important sign.
• Try to distract the child during the examination. Some people take the child's hand and use it to palpate the abdomen. Another technique is to ask the child to do a few jumps or hops. This will not be done freely if there is an acute abdomen.

When performing palpation of the abdomen on a patient that is ticklish what is the first maneuver you can employ to desensitize them?

How can you distract patient during palpation of the abdomen?

When palpating the abdomen which technique should be used?

When palpating the abdomen light palpation should feel?