What is the step‑by‑step technique for a comprehensive abdominal examination?

How to Conduct a Full Physical Examination of the Abdomen

The American College of Physicians recommends a systematic four-step approach: inspection, auscultation, percussion, and palpation, performed in this specific order to avoid altering bowel sounds before auscultation. 1, 2

Patient Preparation

• Have the patient empty their bladder before the examination to minimize discomfort and improve accuracy of palpation 1
• Position the patient supine with arms at their sides or folded across the chest, ensuring adequate exposure from the xiphoid process to the symphysis pubis 2
• Ensure the room is warm and private, with appropriate draping to maintain dignity while allowing full visualization of the abdomen 2

Step 1: Inspection

Systematically observe the abdomen from multiple angles, looking for specific abnormalities that may indicate underlying pathology.

• Observe for abdominal distension, which may indicate ascites, bowel obstruction, or organomegaly 1, 2
• Look for visible peristalsis (suggests bowel obstruction), visible pulsations (may indicate aortic aneurysm), and asymmetry 1, 2
• Examine the skin for surgical scars, striae, dilated veins (caput medusae suggests portal hypertension), ecchymosis (Grey Turner's or Cullen's sign), and any rashes or lesions 1, 2
• Note any signs of peritonitis including the patient lying still and guarding the abdomen, which may indicate perforation or acute inflammation 1

Common pitfall: In patients with excess skin or flaccid abdomen (such as post-bariatric surgery patients), clinical examination may be unreliable and imaging should be obtained earlier 1

Step 2: Auscultation

Always auscultate before percussion or palpation to avoid artificially altering bowel sounds.

• Listen in all four quadrants, noting the character, frequency, and pitch of bowel sounds 1, 2
• Absent bowel sounds (after listening for at least 2 minutes per quadrant) may suggest peritonitis or ileus 1
• Hyperactive, high-pitched bowel sounds (borborygmi) may indicate early bowel obstruction 1
• Auscultate over the aorta and renal arteries for bruits, which may indicate vascular pathology such as renal artery stenosis or abdominal aortic aneurysm 2

Step 3: Percussion

Percussion helps identify fluid, masses, organomegaly, and the character of underlying structures.

• Percuss all four quadrants systematically, noting areas of tympany (gas-filled bowel) versus dullness (solid organs, masses, or fluid) 1, 2
• When ascites is suspected, assess for shifting dullness by percussing from the umbilicus laterally with the patient supine, then having the patient roll to one side and re-percussing 1, 2
• Test for fluid thrill by placing the ulnar edge of one hand in the midline while tapping one flank and feeling for transmitted impulse on the opposite flank (have an assistant or the patient place their hand in the midline to prevent transmission through the abdominal wall) 1
• Percussion can help identify tympany associated with bowel distension or pneumoperitoneum (loss of liver dullness) 1
• Palpate and note the presence of aortic pulsation and estimate its maximal diameter 2

Step 4: Palpation

Begin with light palpation in non-tender areas, progressing systematically to deeper palpation.

Light Palpation

• Start away from areas of reported pain, using the flat of your hand to gently depress the abdominal wall approximately 1 cm 1, 2
• Assess for superficial masses, tenderness, and muscle guarding (involuntary contraction suggesting peritoneal irritation) 1, 2

Deep Palpation

• Progress to deeper palpation (4-5 cm depth) to assess for masses, organomegaly, and deeper tenderness 1, 2
• Palpate the liver edge by placing your hand below the right costal margin and asking the patient to take a deep breath 2
• Palpate the spleen by approaching from the right side with your left hand supporting the left costovertebral angle, asking the patient to breathe deeply 2
• Assess for rebound tenderness (Blumberg's sign) by pressing deeply and releasing quickly—pain on release suggests peritoneal irritation 1

Special Maneuvers

• Murphy's sign: Place your hand below the right costal margin and ask the patient to take a deep breath; sudden cessation of inspiration due to pain suggests acute cholecystitis 1
• Psoas sign: Have the patient lie on their left side and extend the right hip; pain suggests appendicitis or psoas abscess 1
• Obturator sign: Flex the patient's right hip and knee to 90 degrees and internally rotate the hip; pain suggests appendicitis or pelvic abscess 1

Digital Rectal Examination

Perform when indicated for suspected lower GI pathology, constipation evaluation, or when assessing for occult blood.

• Obtain verbal informed consent, explaining the purpose and steps of the examination 3
• Position the patient in left lateral decubitus position with knees drawn toward the chest 3
• Inspect the perianal skin for fissures, hemorrhoids, fistulas, or evidence of fecal soiling 3
• Test the anal reflex with light stimulation 3
• Lubricate the gloved examining finger and warn the patient before insertion 3
• Apply gentle pressure to the anal sphincter and wait for relaxation before insertion 3
• Assess resting sphincter tone immediately upon insertion, then ask the patient to squeeze to evaluate voluntary contraction 3
• Palpate anteriorly (prostate in males, cervix in females), laterally, and posteriorly for masses, tenderness, or blood 3
• Ask the patient to bear down as if having a bowel movement to assess for appropriate relaxation and expulsionary forces 3

Critical caveat: If a sharp foreign body or rectal trauma is suspected, obtain imaging before performing digital rectal examination to avoid injury 3

Mandatory Laboratory Assessment for Acute Abdomen

• Complete blood count to assess for leukocytosis, anemia, or thrombocytosis 1, 2
• Comprehensive metabolic panel including electrolytes, liver enzymes, and renal function 1, 2
• Inflammatory markers (ESR, CRP) which correlate with clinical severity 1, 2
• Serum albumin and pre-albumin to assess nutritional status and degree of inflammation 1
• Lipase or amylase if pancreatitis is suspected 1
• Lactate level if ischemia or perforation is suspected 1

Imaging Studies When Indicated

CT scan with IV contrast is the gold standard for evaluating acute abdominal pathology, with sensitivity of 93-96% and specificity of 93-100%. 1, 2

• For suspected bowel obstruction, perforation, or abscess: CT abdomen and pelvis with IV contrast is the primary imaging modality 1
• For pregnant patients or women of childbearing age: obtain pregnancy test first, then use ultrasound or MRI to limit radiation exposure 1
• For suspected appendicitis: helical CT of abdomen and pelvis with IV contrast 1
• Abdominal ultrasound can be used as a screening test with moderate sensitivity (88%) when CT is unavailable or contraindicated 1
• Plain abdominal X-rays have limited sensitivity (74-84%) and specificity (50-72%) and should only be used when other modalities are unavailable 1

Critical Pitfalls to Avoid

• Do not delay surgical consultation or exploration if there is high clinical suspicion and alarming signs/symptoms, even with negative radiological assessment 1, 2
• CT scan should never expose the patient to unsafe delays in appropriate treatment for conditions requiring immediate intervention such as perforated viscus with diffuse peritonitis 1
• Clinical examination may be unreliable in post-bariatric surgery patients due to excess skin and flaccid abdomen—maintain a lower threshold for imaging 1
• A normal digital rectal examination does not exclude pelvic floor dysfunction or more proximal pathology 3
• Early involvement of a surgeon is required in cases of suspected perforation, ischemia, or obstruction 1, 2