Geriatric Assessment: Abdominal and Rectal Examination

Mark E. Williams, MD

Disclosures

August 02, 2012

In This Article

The Geriatric Abdominal and Rectal Examination

Overview and General Inspection of the Abdomen

We instinctively shield our abdomen when we are physically threatened, and we may feel vulnerable when someone puts his or her hand on our bare abdomen. Therefore, with an abdominal examination the patient directly experiences the skill and attentiveness of the examiner.

Positioning the Patient for an Examination

The examination should be done in a warm room with a good light. The patient should be supine with the arms at the side or over the chest but not behind the head, because this creates tension in the abdominal muscles. Support the head so that the abdomen is relaxed. Drape the groin with a simple sheet. Once the position is established, explain what you are going to do at each step of the examination.

Special circumstances require modification. If the patient has kyphosis, use extra pillows. Also, modify the position upward as needed if the patient has dyspnea from congestive heart failure. A wheelchair-bound patient, a patient with severe congestive heart failure, or a patient with back injury may not be able to lie flat. Under these circumstances, you may have to examine the patient upright, paying careful attention to the effects of gravity on the position of an organ, such as the liver. The main point is to be thorough and not to use the patient's disability as an excuse to cut corners.

General Appearance

The first consideration is whether the patient has a primary gastrointestinal symptom, and if so, what is his or her general demeanor. A patient writhing in pain may have obstruction, whereas a patient lying very still may have peritoneal inflammation. A scaphoid or boat-like abdomen suggests weight loss, with possible malnutrition. Localized distention usually indicates obstruction or enlargement of an individual organ or structure. Check for visible masses as signs of malignancy and include the left supraclavicular fossa, where finding a large, hard node can be indicative of cancer in the abdomen (Troisier sign).

Check for Abdominal Distention

Next, check for abdominal distention and, if present, determine whether it is general or localized. General distention is caused by fat, peritoneal fluid, or gas. The nature of the umbilicus can often help suggest the cause of the distention. For example, in cases of intra-abdominal inflammation, the umbilicus often deviates to the side of the inflammation (Schlesinger sign). Abdominal fat can sometimes be differentiated from other causes when the umbilicus is depressed.

Ascites is suggested by bulging flanks and a flat or protuberant umbilicus. (For more on ascites, see Special Tests, below.) In small or large bowel obstruction due to pancreatitis, it may be sunken like a cupid's bow and you may see peristaltic activity. Umbilical swelling suggests early small bowel obstruction (Leudet sign). A ladder-like appearance of the lower abdomen also suggests small bowel obstruction, whereas a large inverted "U" appearance suggests large bowel obstruction.

Other conditions that are indicated by distention are the following:

  • Hypogastric distention of an enlarged bladder tips the umbilicus up toward the head.

  • An enlarged right upper quadrant suggests hepatobiliary enlargement or mass, whereas a distended left upper quadrant suggests an enlarged spleen.

  • A deep crease on inspiration along the right costal margin suggests echinococcal cyst of the liver (Lennhoff sign).

  • Epigastric enlargement suggests an enlarged stomach or gastric outlet obstruction.

  • Intestinal dilatation above an obstruction and no peristalsis below suggests fecal impaction (Schlange sign).

Check for Hernias

Next, look for hernias. Have the patient raise the head off the pillow to accentuate the abdominal pressure. Common sites for hernias are midline (umbilical, epigastric), incisional, and the groin (inguinal and femoral).

Check the Venous Pattern

The venous pattern over the abdomen is usually not apparent unless there is obstruction or malnutrition. Note the direction of blood flow. To determine the direction, place your index fingers together over the enlarged vein. Move your left index finger along the vein about 5 to 6 cm to milk out the blood. Now, lift your right index finger and note the speed of filling. Repeat the procedure and lift your left index finger. The direction of flow is the more rapid direction of filling. Blood normally flows away from umbilicus. Above the umbilicus, it drains toward the head; below, it drains toward the groin. Blood flowing toward the umbilicus suggests inferior vena cava obstruction. Superficial venous distention with normal blood flow suggests portal vein obstruction.

Skin Findings

The abdomen has a generous expanse of skin so it can have a number of generalized skin lesions, including seborrheic keratoses, early scurvy (corkscrew hairs), and malignant melanoma. Jaundice may be more apparent over the abdomen. A transverse abdominal crease suggests previous vertebral compression fractures. Prominent flaccidity of the skin suggests recent significant weight loss. Fine telangiectasias can suggest arterial obstruction. Striae are usually in the lower quadrants and, rarely, around the shoulders. Old striae are silver and pale, whereas new striae are pink or purple.

Pay attention to surgical scars. The location may be useful to determine what procedure was done. (Some patients may not recall previous surgeries.) Check for possible scar-related cancer. Hyperpigmented scars suggest excess adrenocorticotropic hormone, possibly from Addison disease or an endocrine tumor.

Look for needle-stick bruises in recently hospitalized patients. Pay special attention to the course of the inferior hypogastric vessels. Injections of heparin or insulin into these vessels can cause significant bruising. A bruise around the umbilicus suggests retroperitoneal bleeding (Cullen sign). In this case, it may be accompanied by a bruise around the flank (Grey Turner sign). Jaundice around the umbilicus indicates common bile duct rupture (Ransohoff sign).

Abdominal Movements With Respiration

Abrupt stop (or catch) in the respiratory pattern with deep inspiration suggests pleuritic chest pain, a process involving the diaphragm, acute cholecystitis, or peritoneal inflammation. An area of reduced respiratory movement in the abdomen with deep inspiration suggests underlying inflammation. For example, sigmoid diverticulitis may reduce respiratory movement in the left lower quadrant. Abdominal distention with expiration (respiratory paradox) suggests a paralyzed diaphragm.

Pulsatile Movements

Pulsatile movements across the abdomen suggest vascular aneurysm or wide arterial pulse pressure.

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