percussion of the abdomen
TRANSCRIPT
PERCUSSION OF THE ABDOMEN
Prof. R. Sukumar MD
Institute of Internal Medicine
MMC & GGH
A MUSICAL INTERLUDE Dr. Leopold Auenbrugger was the
inventor of percussion He got the idea by observing a wine
merchant percussing out a half-full barrel Later, he began to practice this
technique on his patients History tells us that he percussed
immediately with one hand, using all four fingertips
PERCUSSION OF THE ABDOMEN
Liver Spleen Kidneys Urinary bladder Free fluid
PERCUSSION OF LIVER Percuss downwards from the right 5th
intercostal space in the midclavicular line to locate the upper border of the liver
Patient's breath held in full expiration Measure the distance from the upper
border of dullness to the palpable liver edge in the midclavicular , midaxillary and midscapular line
LIVER SPAN
Normal span is 12-15 cm at midclavicular line
Loss of normal Liver Dullness Emphysema Large right pneumothorax Hollow viscus perforation Post Laparotomy/ Laparoscopy Massive hepatic necrosis. Interposition of the transverse
colon between the liver and the diaphragm (Chilaiditi's sign)
PERCUSSION OF SPLEEN
Nixon’s method
Castell’s method
Traube’s space percussion
NIXON’S METHOD The patient is placed on the right side so that
the spleen lies above the colon and stomach Percussion begins at the lower level of
pulmonary resonance in the posterior axillary line
Proceeds diagonally along a perpendicular line toward the lower midanterior costal margin
The upper border of dullness is normally 6–8 cm above the costal margin
Dullness >8 cm in an adult is presumed to indicate splenic enlargement
CASTELL’S METHOD Patient is poitioned supine Percuss in the lowest intercostal space
in the anterior axillary line (8th or 9th) Resonant note is produced if the spleen
is normal in size This is true during expiration or full
inspiration Dull percussion note on full inspiration
suggests splenomegaly
CASTELL’S METHOD
TRAUBE’S SPACE
TRAUBE’S SPACE Described by Ludwig Traube It is a semilunar space over the fundus of
stomach Bounded medially by the left lobe of the liver,
laterally by the spleen, superiorly by the left lung resonance and inferiorly by left costal margin
On the surface, it can be mapped by dropping perpendicular lines from the sixth rib at the costochondral junction and the ninth rib at the anterior axillary line to the costal margin
Tympanic on percussion Percussed in sitting or supine posture
Obliteration of Traube’s Space
Left sided Pleural Effusion Massive Splenomegaly Enlarged Left lobe of Liver Full Stomach Fundal Growth Massive Pericardial effusion
KIDNEYS Percussion over a right or left
subcostal mass To distinguish hepatic or splenic
from renal masses Resonant area is percussed over
renal mass because of overlying bowel
Sometimes a very large renal mass may displace overlying bowel
URINARY BLADDER
Percussion in the suprapubic region
Helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant)
ABDOMINAL DISTENTION
DEMONSTRATION OF FREE-FLUID
Fluid thrill
Shifting dullness
Puddle’s sign
FLUID THRILL An assistant (or the patient) to place the
medial edge of palm firmly on the centre of the abdomen
The examiner flicks the side of the abdominal wall
Pulsation (thrill) is felt by the hand placed on the other abdominal wall
Positive in massive ascites (>2L), massive ovarian cyst or a pregnancy with hydramnios.
FLUID THRILL
SHIFTING DULLNESS The percussion note over most of the
abdomen is resonant, due to air in the intestines
When ascites collects, the influence of gravity causes this to accumulate first in the flanks in a supine patient
When at least 1 litre of fluid have accumulated, a dull percussion note in the flanks
Even with gross ascites an area of central resonance will always persist
SHIFTING DULLNESS Percuss centrally and laterally until dullness is
detected Keep your finger pressed there Ask the patient to roll onto the opposite side Ask the patient to hold the new position for
about half a minute. Repeat percussion moving laterally to central
over your mark The fluid(dull note) will now be moved by
gravity away from the marked spot and the previously dull area will be resonant
SHIFTING DULLNESS
PUDDLE’S SIGN Ausculto percussion method Have the patient lie prone for 5 minutes and
then raise himself up to a knee elbow position Place the diaphragm of the stethoscope over
the most dependent portion of the abdomen. Flick with your finger, gradually moving it from
the periphery toward the stethoscope A positive sign consists of an abrupt perceived
increase in the intensity and clarity of the note just as the flicking finger moves beyond the edge of the pool of fluid
Detects as little as 120 mL of ascites
PUDDLE’S SIGN
THANK YOU
Medicine is learned by the bedside and not in the classroom.Sir William Osler (1849-1919)