From the Guidelines
When assessing abdominal pain, a thorough physical examination including inspection, auscultation, percussion, and palpation is essential to guide decision-making and risk stratification. On inspection, look for abdominal distention, visible peristalsis, pulsations, scars, discoloration, or asymmetry. Note any jaundice, spider angiomas, or caput medusae suggesting liver disease. For auscultation, listen for bowel sounds in all four quadrants for 30-60 seconds each; normal sounds occur every 5-15 seconds, while high-pitched, tinkling sounds may indicate obstruction and absent sounds could suggest ileus or peritonitis, as noted in the management of intra-abdominal infections 1. Vascular bruits over the aorta or renal arteries may indicate vascular disease. During percussion, assess for tympany (normal over gas-filled bowel) versus dullness (suggesting fluid or solid masses). Percuss the liver span (normal 6-12 cm) and check for shifting dullness indicating ascites. For palpation, begin with light palpation away from the painful area, progressing to deep palpation. Note any masses, organomegaly, tenderness, guarding, or rigidity. Specific signs to check include Murphy's sign (RUQ pain with inspiration during palpation) for cholecystitis, McBurney's point tenderness for appendicitis, and rebound tenderness or Rovsing's sign suggesting peritoneal inflammation.
Some key points to consider during the physical examination include:
- Severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven, as recommended by the World Society of Emergency Surgery 2.
- Clinical findings can be used to guide decision-making in the risk stratification of patients with possible appendicitis, as discussed in the clinical policy for the evaluation and management of emergency department patients with suspected appendicitis 3, 4.
- The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis, while the presence of vomiting before pain makes appendicitis unlikely, as noted in the management of intra-abdominal infections 1.
These findings help differentiate between various causes of abdominal pain such as inflammatory, obstructive, vascular, or perforated conditions, and can inform the need for further diagnostic testing or immediate intervention.
From the Research
Inspection
- The patient's abdomen should be inspected for any visible signs of distress, such as distension, guarding, or discoloration 5, 6
- The presence of scars, striae, or other skin lesions should be noted, as they may indicate previous abdominal surgery or other underlying conditions 6
- The patient's overall appearance, including their level of discomfort and ability to move, should be assessed 7
Auscultation
- Bowel sounds should be assessed using a stethoscope, listening for the presence, absence, or alteration of sounds 5, 6
- The presence of bruits or other abnormal sounds may indicate vascular or other underlying conditions 6
- Auscultation can help identify conditions such as bowel obstruction or ileus 8
Percussion
- The abdomen should be percussed to assess for tenderness, guarding, or rebound tenderness 5, 6
- The presence of a dull sound may indicate the presence of a mass or other underlying condition 6
- Percussion can help identify conditions such as liver or spleen enlargement 8
Palpation
- The abdomen should be palpated to assess for tenderness, guarding, or masses 5, 6
- The presence of a palpable mass or other abnormality may indicate an underlying condition such as a tumor or cyst 6
- Palpation can help identify conditions such as appendicitis or diverticulitis 9, 7
- The patient's abdominal wall should be palpated to assess for muscle tension or other abnormalities 6