Percussion and Palpation – Main Abdominal Examination Skills

The sequence of the examination of the abdomen changes according to the age and cooperation of the child. The four types of evaluations (inspection, auscultation, percussion, and palpation) are often performed at different times. For example, the clinician may listen for bowel sounds after evaluation of heart and lung sounds at the beginning of the exam when the child is calm. Percussion usually follows lung percussion and palpation can be done towards the end of the exam when the child is relaxed and more confident in medical practice.

For descriptive purposes, the abdominal cavity is divided into four compartments or quadrants by drawing a vertical line midway from the sternum to the pubic symphysis and a horizontal line across the abdomen through the umbilicus. This method of division actually includes the pelvic cavity. Each section is designated as follows: Right Upper Quadrant (RUQ), Right Lower Quadrant (RLQ), Left Upper Quadrant (LUQ), Left Lower Quadrant (LLQ).

Percussion of the abdomen is performed in the same way as percussion of the lungs and heart. Normally dullness or flattening is heard on the right side at the lower costal margin due to the location of the liver. The tympanism is usually heard over the stomach on the left side and usually in the rest of the abdomen. An unusually tympanic sound, like the beating of a tight drum, usually while breathing. However, it can also denote a pathologic condition such as lower intestinal obstruction or paralytic ileus. Lack of bloat can normally occur when the stomach is full after a meal, but in other situations it can indicate the presence of liquid or solid masses.

Two types of palpation are performed, superficial and deep. In superficial palpation, the doctor gently places the hand against the skin and palpates each quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such as cysts. The child usually perceives superficial palpation as a “tickling”. Which can interfere with its effectiveness. The nurse can avoid this problem by having the child “help” with the palpation by making statements such as, “I’m trying to feel what you had for lunch.” Admonishing the child to stop laughing only draws attention to the sensation and decreases cooperation. Placing the child in a supine position with the legs bent at the hips and the knees helps to relax the abdominal muscles.

Tenderness is always noted anywhere in the abdomen during superficial palpation. There are two types of abdominal pain:
1. Visceral, arising from the viscera or internal organs such as the intestines, and
2. Somatic, arising from the walls or linings of the abdominal cavity, such as the peritoneum.

Visceral pain is often dull, poorly localized, and difficult for the patient to describe. Somatic pain is generally sharp, well localized, and easier to describe. When evaluating abdominal pain, it is important to remember that the child will often respond with an “all or nothing” reaction: either no pain or a lot of pain. Therefore, all aspects of the exam must be carefully considered when ruling out conditions such as appendicitis.

A special phenomenon called rebound tenderness, or Blumberg’s sign, may be performed if the child complains of abdominal pain. It is done by pressing firmly on the part of the abdomen distal to the tender area. When the pressure is suddenly released, the child feels pain in the original area of ​​tenderness. This response is only found when the peritoneum overlying a diseased visceral or organ is inflamed, as in appendicitis.

Deep palpation is used to palpate organs and large blood vessels and to detect masses and tenderness that were not discovered during superficial palpation. If the child complains of abdominal pain, the abdomen area is palpated last. Normally, mid-epigastric palpation causes pain when pressure is exerted on the aorta, but this should not be confused with visceral or somatic tenderness.

The doctor palpates the abdominal organs by pressing on them with the free hand, which is placed on the child’s back. Palpation begins in the lower quadrants and continues upward. In this way, the edge of an enlarged liver or spleen is not lost. Except for palpating the liver, successful identification of other organs, such as the spleen, kidney, and part of the colon, requires considerable practice with guided supervision.

The lower border of the liver is sometimes palpable in infants and young children as a superficial mass 1/2 to 2 cm (1/2 to 2 cm) below the right costal margin (the distance is sometimes measured in finger width) . If the liver is palpable 3 cm (1/4 inch) or 2 finger widths below the costal margin, it is considered enlarged and this finding is referred to a physician. Normally, the liver descends during inspiration as the diaphragm moves downward. This downward displacement should not be confused with a sign of hepatomegaly. In older children, the liver is often not palpable, although its lower border can be estimated by percussing dullness at the costal margin.

The spleen is palpated by feeling it between the hand resting on the back and the hand palpating the left upper quadrant. The spleen is much smaller than the liver and is located behind the fundus of the stomach. The tip of the spleen is normally felt during inspiration as it descends into the abdominal cavity. It is sometimes palpable 1 to 2 cm below the left costal margin in infants and young children. A spleen that is easily palpable more than 2 cm below the right costal margin is enlarged and is always reported for further medical investigation.

Other anatomic structures that are sometimes palpable in children include the cecum and sigmoid colon. The cecum is a soft, gas-filled mass in the right lower quadrant. The sigmoid colon remains as a sausage-shaped mass that moves freely over the pelvic brim in the left lower quadrant and is normally tender.

Although most of these structures are not routinely palpated, their relative location and characteristics must be taken into account so as not to confuse them with abnormal masses. The most common palpable lower quadrant because with constipation the left colon fills with feces and gas until it reaches the ileocecal valve. The cecum is distended, causing pain, which may be mistakenly associated with appendicitis.

Special research methods.
laboratory exam
1. Routine blood test
2. Urine tests (bile pigments, ketonuria)
3. Biochemical analyzes (total bilirubin, unconjugated and conjugated bilirubin, proteins, cholesterol, AlAt, AsAt, amylase, trypsin and lipase)
4. Biochemical analysis of urine for diastase.

1. Cholestasis syndrome increased level of total and conjugated bilirubin and cholesterol).
2. Cytolysis syndrome (increased AtAs, AtAl, LDG levels)
3. Pancreas dysfunction syndrome (increased level of amylase, trypsin, lipase)
4. PCR reaction for hepatitis A, B, C virus
5. Examination of feces for intestinal parasites (ascarids, lamblia cysts, enterobiosis)
6. Cogram
• Undigested muscle fibers
• Steatorrhea
• Hospitality
• Bacteria in stool

Instrumental methods of examination.
1. Esophagogastroduodenoscopy
2. Ultrasound investigation
3. Intragastric pH-metry
4. Colonoscopy
5. Procto(sigmoid)scopy
6. Artificial contrast study of the gastrointestinal system.
7. Laparoscopy
8. Irrigoscopy and irrigography

Normal laboratory values ​​of biochemical blood tests.
Glucose 3.33-5.55mmol/L
Total bilirubin 8.5-2.0 mcmol/L
Unconjugated 2/3 of the total
Conjugated 1/3 of the total
Total protein 60.0-80.0 g/L
ALT 0.1-0.75 mcmol/g/L
AST 0.1-0.45 mcmol/g/L
Amylase 16-32 dye units/L

A number of gastrointestinal disorders are caused by disturbances in motor function. Some, such as Hirschsprung’s disease, produce typical signs of obstruction and are alternatively classified as obstructive disorders.

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