Which ancillary maneuvers may be required in an abdominal exam?

Updated: Dec 02, 2020
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Kurt E Roberts, MD  more...
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Frequently, ancillary maneuvers are required to arrive at a diagnosis. Asking the patient to breathe in while gently pushing on the abdomen and then observing the response to rapid removal of the hands is an indication of rebound tenderness or peritoneal irritation. For a more anxious child, gently moving the feet or the bed may yield the same response. [8] If this finding is limited to the right upper quadrant (Murphy’s sign), it supports the presence of biliary disease. Eliciting pain by raising the right leg against pressure supplied by the examiner’s hand while in the supine position suggests psoas irritation. Besides providing the hallmark of appendicitis, it may suggest other, less common, retroperitoneal conditions (see Table 2 in Preparation).

Demonstrating pain with hopping, especially in a younger child, suggests peritoneal irritation. This may be an early sign of appendicitis, a diagnosis commonly missed in the young child. The most important of the ancillary maneuvers performed in conjunction with an abdominal examination is a rectal examination.

Inspection of the perineum for rashes, gluteal wasting, gluteal asymmetry, perianal disease, fistulas, areas of fluctuance, and fissures often yields important findings. If a digital examination is performed, anorectal stenoses, the presence and the consistency of stool, the presence and an estimation of the size of any polyps or other masses, stool guaiac, and tenderness should be recorded. If the patient has a history of constipation, a Valsalva should be performed to help address the contribution of dyschezia to the symptoms. If appendicitis is suspected, a bimanual examination should be performed during the rectal to assist in the diagnosis of retrocecal inflammation, which may otherwise be unappreciated. It has been suggested that abdominal pain with deep knee squats can also help to diagnose retrocecal appendicitis. [8]

Table 2. Correlation of Physical Findings With Diagnostic Possibilities (Open Table in a new window)

Physical Finding

Disease Process to Consider

Epigastric tenderness

Acid peptic disease (GER, gastritis, PUD)

Discomfort with minimal movement


Distension with fullness left lower quadrant


Diffuse tenderness with increased tympany

IBS vs small bowel obstruction

Tenderness at McBurney's point


Tenderness medial to McBurney's point

Meckels diverticulum

Increased tenderness with inspiration in RUQ (Murphy sign)

Gallbladder pathology

Pain with lifting extended right leg against resistance (Psoas sign)

Retrocecal appendicitis or other retroperitoneal irritation (abscess of Crohn disease, pancreatitis, pyelonephritis)

Bulging flanks

Ascites or obesity

Shifting dullness


Pain with deep knee squats

Retrocecal appendicitis

"Hepatosplenomegaly" with cephalad borders at lower ribs

Hyperinflation as seen in obstructive pulmonary disease

Hepatomegaly or hepatosplenomegaly with jaundice and/or caput medusae

Cirrhosis with portal hypertension

Hepatomegaly or hepatosplenomegaly without jaundice and normal consistency of enlarged organs

Congestion secondary to heart failure

Hepatomegaly or hepatosplenomegaly without jaundice and firm consistency of enlarged organs

Storage or Infiltrative disease process including leukemia and other neoplasia

Firm hepatomegaly without splenomegaly or jaundice, especially with increased blood pressure

Congenital hepatic fibrosis

Jaundice with liver tenderness, and/or enlargement


Jaundice with normal liver findings

Gilbert syndrome, hemolytic process, metabolic disease, early hepatitis

Pain relieved by sitting up

Pancreatitis, retroperitoneal pathology

Periumbilical bruising and edema (Cullen's sign)

Hemorrhagic pancreatitis

Bruising of flanks (Grey Turner sign)

Hemorrhagic pancreatic, renal hemorrhage

Isolated splenomegaly

Splenic trauma, extra-hepatic portal hypertension, splenic sequestration, hemolytic diseases, certain storage diseases

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