Henry Lin, MD, a pediatric gastroenterologist at The Children's Hospital of Philadelphia, reviews how to evaluate the spleen, liver and bowel through an abdominal exam. He also demonstrates an exam in a patient with ascites.
Pediatric Exams: Abdominal Exam
Dr. Henry Lin: Hi, my name is Henry Lin. I’m a pediatric gastroenterologist here at The Children’s Hospital of Philadelphia. Today I’m going to show you the basics of an abdominal exam in a pediatric patient, and to go over how to palpate the liver and the spleen. And at the very end of this, we’ll show a clip in a patient who has ascites to show certain techniques on detecting ascites.
So as we get started, I would like to introduce Nate, he’s our model patient today. How are you doing Nate?
Nate, Patient: Good
Dr. Henry Lin: Good, all right, so can you lay back for me real quick. And so the keys to the abdominal exam here are first we usually like to examine the patient from the right side. So can you put your head over here? And stretch all the way out for us. There you go, good job. And so first thing is first, there are four parts to the abdominal exam. There’s inspection, then auscultation, and then there’s palpation and percussion.
First part is we’re just going to take a look; it’s called inspection. So Nate, if you can go ahead and lift up your shirt for me, all the way up. There you go, thank you. And what we’re doing here is we’re just going to take a quick look at the belly, looking for any bumps, bruises, scrapes, scars, things like that that might give us any clues if there’s anything else going on underneath. And Nate, your belly looks wonderful.
After we take a look, the next step is going to be auscultation, which is we take a quite listen with the stethoscope. The abdomen can be divided into four quadrants, you know, upper and lower, and then right and left side. And typically what we’re doing is we’re listening for the presence and quality of bowel sounds in all four quadrants. And so we’ll take a quick listen here. All right, just going to take a listen.
And so after the auscultation part, the next two parts of the exam are going to be percussion and palpation. And so what we’re doing is we’re going to do palpation first. So I’m going to have you stretch out for me; stretch your legs out real quick. All right, and just relax. And so with palpation there’s two parts to the exam. First you do gentle palpation, which is I’m going to lightly touch right around on the superficial surface of the belly. And what I’m doing is I’m just trying to get a sense of, is there any tenderness in the belly. And so again, you try to palpate all four quadrants. And just gently just to see if you’re seeing any tenderness, any rebound, any guarding. And right now Nate has a very nice and soft belly.
After that the second part is to do deep palpation. And this is designed to really take… get a good sense of what the organs feel like. So you’re trying to get a sense of the contour, the textures of the organs. The main things we’re going to feel for are the liver on the right side, and then the spleen on the left side. In a typical pediatric patient, you should not actually be able to feel either of these organs. Or if you do feel, you should really feel the edge of the liver right underneath their costal margin here.
What I usually do for the liver, you can notice I start further down, lower in the abdomen and I’m going to palpate up. And normally the liver is right underneath the costal margin of your ribs. You really shouldn’t be able to feel the edge of the liver. And if you do, you’re going to end up feeling it right underneath the rib cage here. But in Nate’s case, everything feels great.
Same thing for the spleen over here on the left side. One more time Nate, good job. We’re just going to start low, and slowly move our way up. All right, and again, feeling for the spleen, which usually hides right under the rib cage here, again. We don’t feel anything so that’s a good sign.
And now for the last part of the exam, is actually called percussion. Percussion can be very beneficial in helping us figure out what the span is of the liver and the spleen. And so for percussion what you do is I’m going to put my fingers here and you’re just going to hear me lightly tap. You see how that sounds a little dull, little hollow right there. So what you’re going to do, you’re going to start low and you’re going to keep on coming up. And at some point and time, you hear a little bit of change. See how it goes from hollow to a little bit duller. And as you go up, once you get here, you hear another change. And that change right there usually marks the end of the liver.
So just repeat that, this is light and airy right here, that’s the belly. Once you hear the dullness, that’s going to be the start of the liver. So in Nate’s case, maybe right about here. And you want to mark that border, and you’re going to keep on going up, and how you hear that difference. And so in Nate’s case, his liver is about this big, and then you would generally measure the span of the liver.
You do the same thing over here with the spleen. So one last time Nate, you’re doing a great job. Hollow, hollow, hollow. And a little bit duller up there. And so basically what you’re doing is you’re just percussing up, just listening for the slight change in the sound. And that right there is the abdominal exam. All right, thank you Nate.
So now we’ll talk a little bit about an abnormal abdominal exam. Sometimes if you’re worried about ascites, or fluid in the belly, you’ll want to take a look and I’ll show you some different techniques to check for ascites.
So first things first is, again, if I can lift up your shirt and take a quick look here. And you can notice that the belly looks full, and that makes it suspicious for ascites. Even though we’re thinking about ascites, it’s still important in the abdominal exam to assess the liver and the spleen. So if you can go ahead and put your arm above your head. What I’ll do is I’m first going to look for the liver. So I’m going to start down here right around the hip and slowly move my fingers up as I palpate for the liver. And again, keeping in mind that in older children the liver may be right underneath the rib and it may be hard to actually feel.
Can you go ahead and take a deep breath in for me. And let it out. OK, and in this case, don’t really feel the liver edge. And same thing for the spleen, so working over here from the left side and working my way up. And here in this case, you can feel a little bit of a spleen edge right here. And if I measure from below the ribs to the spleen, you can say that the spleen is roughly two and a half fingertips below the costal margin.
For the abdominal exam looking for ascites, there’s three ways to actually check for ascites. The first way is called looking for a fluid wave. And so what you do is you put one hand on one side of the belly, one hand on the other side. And you basically just give a little push. As you can see I’m pushing with my right hand. And what I’m trying to do is to see if I feel the fluid wave vibrate off of my left hand here. So it’s harder to appreciate on the, you know, on the video, but I can definitely feel the fluid moving back and forth. So that’s one way.
The other way is to do something called ballottement, which basically means between the organs. So if you have a liver or spleen that you can actually feel or palpate, between the organ and the wall of the, just the skin. Whenever you have ascites, you can have a little space in between and that’s where you actually have fluid in between. And so all I’m going to do here is because, you know, we have, can feel the spleen over here, is I’m going to find that spleen tip again. And if I just put my finger right over where the spleen is and gently push down just like this, what I can do is I can actually feel the ascites fluid squishing out from underneath. And that’s another way to check for ascites.
The last way that’s probably most audio or visual is actually checking for shifting dullness. So the thought process behind this is that, you know, when you’re laying all the fluid goes to the deep-ended areas. So meaning towards the lower part or the side of the belly. And then the top of the belly you should have an air bubble. So if I percuss here, you’ll hear that it sounds a little bit more hollow. Whereas if I percuss lower down here, it sounds a little bit more solid.
And so the principle behind this is that you’re actually percussing starting from the middle. And you’re gonna percuss down until you hear a change in the sound. And when you find the change in the sound, what you want to do is you want to put one finger on the side where you think there’s air, and one finger on the side where you feel there’s fluid and then we’re gonna have the patient roll towards me and so that way we can go ahead and feel to see, you know, does any of the fluid shift. And then you’re gonna go ahead and percuss again to see if there a difference in where you feel that air/fluid level.
So it looks like this. So this sounds hollow, a little bit more air filled. I think right around here you can hear more fluid and air. So somewhere between here and here is where the fluid line shifts. So I think right around here. So I’m going to put one finger on the air side, one finger on the fluid side. And have you slightly rotate towards me just like that. And leave in that position for about 15-20 seconds to allow all the fluid to shift over. And the key part is to leave these fingers in that same position. You can notice that they haven’t changed yet. And if you listen now, and it sounds about the same which tells me that the fluid should have shifted over, and the way you’d confirm that is I’ll now percuss upwards, back up towards the belly button to see if I hear the air sound again. And here we hear the air sound again. And so that right there is shifting dullness.
So those are the three ways to check for ascites. You can go ahead and feel for the fluid wave, ballottement, and then shifting dullness. And that’s gonna be the abdominal exam for ascites. Thank you Peter.
Related Centers and Programs: Division of Gastroenterology, Hepatology and Nutrition