Abnormal findings

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Gaseous distension of the abdomen is resonant to per cussion. The gravid uterus, bladder enlargement, ovarian cysts, and other solid pelvic masses extend out of the pelvis into the abdomen to produce central abdominal dullness with resonance of the flanks caused by gas in the surrounding displaced gut. In contrast, ascites is suggested by the presence of dullness in the flanks with central abdominal resonance. Ascites is often first suspected from the convexity of the abdomen and flanks on inspection, but is confirmed by percussion. In lhe presence of ascites, the gas-containing bowel floats uppermost. The liquid gravitates to the dependent part of the peritoneal cavity, namely lhe Hunks and pelvis. Important causes of ascites are given in Table 5.30.

Bowel Sounds

TABLE 5.31 Causes of Increased bowel sounds

Intestinal obstruction (with a high-pitched, tinkling quality)

Severe gastrointestinal bleeding

Small bowel malabsorption

Carcinoid syndrome (marked borborygmi)

Fig. 5.16 Percussing for ascites. Percuss towards the flank from resonant 0 to dull E, then ask the patient to roll on the other side. When ascites is present, the note has become resonant, percuss back towards the midline to detect the new level of dullness [c]. (Note the bruising caused by subcutaneous heparin Injections.)

TABLE 5.30 Important causes of ascites

Exudate (> 30 g protein per litre) Transudate (< 30 g protein per litre)

Ovarian tumour (Meig's syndrome)

TABLE 5.31 Causes of Increased bowel sounds

Intestinal obstruction (with a high-pitched, tinkling quality)

Severe gastrointestinal bleeding

Small bowel malabsorption

Carcinoid syndrome (marked borborygmi)

Fig. 5.16 Percussing for ascites. Percuss towards the flank from resonant 0 to dull E, then ask the patient to roll on the other side. When ascites is present, the note has become resonant, percuss back towards the midline to detect the new level of dullness [c]. (Note the bruising caused by subcutaneous heparin Injections.)

The presence of small quantities of free fluid in the peritoneal cavity is not clinically detectable, since minor changes in percussion note may be due to gravitational shift of normal bowel. Minor degrees of ascites can only be detected by abdominal ultrasonography. Moderate ascites may be confirmed by demonstrating shifting dullness or eliciting a fluid thrill, hui an enormous ovarian cyst may also produce a fluid thrill. It is rare for a iluid thrill to be present in the absence of shifting dullness.

Absent bowel sounds suggest cessation of bowel peristalsis, which is known as ileus. Ileus may be due to reduced nervous stimulation to the bowel, or to drugs -paralytic ileus - or may be a response to intra-abdominal inflammation or infection, such as bacterial peritonitis, or to long-standing bowel obstruction. Causes of increased bowel sounds are shown in Table 5.31

The spleen. Percussion is of limited value in determining the size and position of the spleen as this can only be crudely assessed from the percussion note. However, dullness to percussion overlying a palpable mass in the left

TABLE 5.30 Important causes of ascites

Exudate (> 30 g protein per litre) Transudate (< 30 g protein per litre)

Carcinomatous infiltration of the peritoneum Acute pancreatitis Infection (pneumococcal, TB, collform) Inferior vena cava/hepatic vein obstruction (Budd-Chiari syndrome)

Hepatic cirrhosis (portal hypertension) Congestive cardiac failure Nephrotic syndrome

Ovarian tumour (Meig's syndrome)

TABLE 5.32 Causes of reduced liver dullness

Pulmonary hyperinflation, e.g. chronic obstructive airways disease Small, shrunken liver, e.g. cirrhosis Free air beneath the diaphragm, e.g. perforated hollow viscus Interposition of the colon between the liver and the diaphragm (an unusual anatomical variant known as Chilaiditi's syndrome)

upper quadrant indicates that the mass is likely to be splenic in origin.

The liver. Percussion can give only a rough estimate of the size of the liver, particularly in regard to the upper border. Although this may be raised above the level of the fifth rib by a greatly enlarged liver, the percussion note is largely dependent upon the state of the lung and pleura (see Table 5.32). The apparent level of the lower border of the liver varies with the amount of gas in the colon, and a palpable lower border may he 3—4 cm below the edge detected by percussion. However, a positive finding on percussion implies that the borders of the liver extend at least as far as the extent of dullness.

Arterial bruits. Arterial bruits (harsh systolic murmurs) in the abdomen may arise from the aorta, or any other narrowed or partially occluded artery. Bruits due to stenosis of mesenteric or renal arteries may be difficult to hear owing to the distracting effects of bowel sounds, and a conscious effort should be made to listen for them. Renal artery bruits may be best heard posteriorly. Rarely, a systolic bruit may be heard over the liver in hepatoma.

l/enoui hum. A venous hum is occasionally audible between the xiphisternum and the umbilicus owing to turbulent blood How in a well-developed collateral circulation from portal hypertension.

Friction sounds, Friction sounds resembling those of pleurisy may be present over an area of inflammation of the serosal surface of the spleen or liver (perisplenitis or perihepatitis).

Succussion splash. A sound like shaking a half-filled hot-water bottle is termed a succussion splash. This can be produced from a normal stomach up to 2 hours after food or drink. In other circumstances it is a feature of delayed gastric emptying, as seen in pyloric stenosis or diabetic autonomic neuropathy.

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Responses

  • geoffrey
    Can heparin injections be given in the abdomen when ascites is present?
    8 years ago
  • Filippa
    What is flank ascites testing?
    8 years ago
  • Mikael
    Can ascitis cause succusion?
    3 years ago
  • Salla
    What are abdominal floats?
    3 years ago

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