Which ancillary maneuvers may be required in an abdominal exam?

Answer

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	Peritonitis
Distension with fullness left lower quadrant	constipation
Diffuse tenderness with increased tympany	IBS vs small bowel obstruction
Tenderness at McBurney's point	Appendicitis
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	Ascites
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	Hepatitis
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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Table 2. Correlation of Physical Findings With Diagnostic Possibilities

Table 2. Correlation of Physical Findings With Diagnostic Possibilities

Physical Finding	Disease Process to Consider
Epigastric tenderness	Acid peptic disease (GER, gastritis, PUD)
Discomfort with minimal movement	Peritonitis
Distension with fullness left lower quadrant	constipation
Diffuse tenderness with increased tympany	IBS vs small bowel obstruction
Tenderness at McBurney's point	Appendicitis
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	Ascites
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	Hepatitis
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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