The Abdominal Examination

For descriptive purposes of location, the abdomen has been divided into four quadrants, constructed by an imaginary vertical line from the tip of the xyphoid process to the pubic symphysis and an imaginary horizontal line bridging the anterior superior iliac crests, referred to as the right upper (RUQ), right lower (RLQ), left upper (LUQ), and left lower (LLQ) quadrants (Bickley, 2008). The abdomen can be further divided into the epigastric, umbilical, hypogastric or suprapubic, and right and left flank regions. Knowledge of anatomic structures that lie in each of these quadrants and regions is imperative for the clinician to form an accurate differential diagnosis in relation to a patient's presenting symptoms (Box 38-1).

Clinicians should remember that a comprehensive physical examination, not just abdominal, should be performed in patients presenting with digestive complaints. The clinician should ensure patient comfort and modesty because the abdominal examination (and pelvic, if indicated) may cause significant pain, anxiety, and embarrassment to the patient. Infants, young children, and pregnant women may require additional care during the abdominal examination. A thorough explanation of examination techniques and findings is necessary to minimize patient anxiety.

The anorectal examination is an important component of the abdominal examination that may often be omitted. Although uncomfortable and embarrassing to the patient, it should not be neglected and should be approached with a calm, gentle attitude on the part of the clinician. The examiner should comment on both external and internal components of the anorectal examination, specifically anal sphincter tone; presence or absence of hemorrhoids, fissures, fistulas, or masses; prostatic abnormality in the male patient; and consistency of the stool. Anoscopy should be considered as an adjunct to the anorectal examination when indicated, allowing for direct visualization of the internal anorectal canal. In female patients, the pelvic examination may provide additional information in the diagnosis of abdominal symptoms, as it is often challenging to differentiate between GI and genitourinary complaints.

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