Download 8 the abdomen

8
151
THE ABDOMEN
Although in many cases inspection of the abdomen
may have less to offer than palpation and percussion, a
good visual scan is still essential to obtain the most from
the subsequent examination. For example, the question of
whether an abdomen is protuberant because of obesity
and/or ascites may be difficult to resolve, without first scanning the patient both in the standing and lying positions.
In simple obesity, fat is laid down over many years and it
tends to gravitate in the suprainguinal and suprapubic
folds (8.1). This chronic fixed dependence can be better
8.1
8.3
8.2
8.4
appreciated by looking at the side view of the patient (8.2)
which also reveals fat-laden skin folds at the back.
In contrast, the patient with ascites shows mobile
dependence of the ascitic fluid, which, on standing, protrudes in the middle and overhangs the pubis (8.3). The
suprainguinal areas on either side show a furrow instead
of a fold and the umbilicus looks stretched, sometimes
everted, under the pressure of the fluid (8.4). These points
are reinforced by looking at the side view of this patient
with ascites (8.5) compared with Figure 8.2. The ascitic
8.1 and 8.2
Simple obesity:
deposition of fat in
suprainguinal,
suprapubic and
lateral abdominal
skin folds
8.3 and 8.4
Ascites: central
protuberance with a
stretched umbilicus
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ATLAS OF CLINICAL DIAGNOSIS
152
fluid has gravitated to the suprapubic region, leaving a
furrow in the left suprainguinal region where a redundant
fold of fat is seen in the obese patient (8.2). In addition,
gynaecomastia and dilated veins can be seen in Figure 8.5,
which are helpful clues about this patient’s underlying
portal cirrhosis. The lateral furrow is also seen when the
abdominal swelling is caused by a retroperitoneal cyst or
hydronephrosis (8.6, 8.7).
Only after attention to these details can a clinician
proceed to further examination with ample confidence.
Sadly, many postgraduate students let themselves down
in higher examinations by proceeding with palpation and
percussion of the abdomen without first looking at it. This
is the chief reason why they miss polycystic kidneys in an
obese subject.
The abdomen and the chest provide a large area for
looking for the various stigmata of liver disease such as
jaundice, gynaecomastia, telangiectasia and scratch marks
(8.8). In bright natural light, jaundice can be detected
easily by looking at the skin, as in this patient with a
cholangiocarcinoma (8.8).
Looking at a standing patient with suspected intraabdominal pathology should not be omitted in those with
no ascites, since a fullness caused by an enlarged liver (8.9)
or spleen, or both (8.10), may be made obvious by this procedure. A lateral view will also reveal the scar of a previous operation and a surface impression of a transplanted
kidney (8.11).
Dilatation of the abdominal wall veins (8.12) occurs in
portal hypertension and in inferior vena caval obstruction.
The flow of blood within the veins can be determined by
blanching the dilated vein (8.13) and then by releasing the
pressure at each end to see the refilling in the direction
of the flow (8.14). In intrahepatic portal hypertension,
8.5
Ascites: gravitation
of fluid centrally,
leaving a furrow in
the suprainguinal
region. Note
gynaecomastia and
dilated veins due to
underlying hepatic
cirrhosis
8.6 and 8.7
Bilateral
hydronephrosis
associated with a
large, retroperitoneal
cyst
8.8
Cholangiocarcinoma:
jaundice,
telangiectasis and
gynaecomastia
8.9
Hepatomegaly
8.5
8.7
8.6
8.8
8.9
THE ABDOMEN
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paraumbilical veins are enlarged and the flow is away from
the umbilicus towards the caval system (8.5, 8.15, 8.16).
In inferior vena caval (IVC) obstruction, the collateral
venous channels carry blood upwards to reach the supe-
rior vena caval system (8.17). The interpretation regarding
the flow should be made with caution in tense ascites, which
may cause functional obstruction of the inferior vena cava
(8.18). Rarely, a number of prominent collateral veins may
8.10
Hepatosplenomegaly
8.11
Transplanted kidney
8.11
8.10
Allow refilling
Empty the vein
8.14
8.13
8.12
Portal hypertension:
gynaecomastia and
dilated surface veins
8.12
8.13 and 8.14
Testing for the
direction of venous
flow
8.15
8.15 and 8.16
Portal hypertension:
dilated veins drain
away from the
umbilicus to the
caval circulation
Portal venous obstruction
8.16
8.17
IVC obstruction
8.17
Dilated veins drain
to superior vena
cava
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ATLAS OF CLINICAL DIAGNOSIS
154
be seen radiating from the umbilicus (caput medusae)
(8.19). Attention should be directed to the other clinical
features associated with chronic liver disease (8.20).
The umbilicus should be inspected for the presence
of umbilical and periumbilical herniae (8.21, 8.22), which
usually occur in obese subjects particularly after abdominal surgery. Nickel dermatitis (8.22) may be seen around
the umbilicus in sensitive subjects wearing nickel buckles
next to the skin.
The umbilicus is also a site of predilection for the dark
red papules of angiokeratoma corporis diffusum (Fabry’s
disease; 8.23), which is an X-linked recessive disease. This
is an inborn error of metabolism in which there is a deficiency of alpha-galactosidase A, leading to an accumulation of glycosphingolipid ceramide in endothelial cells,
and fibrocytes in the dermis, heart, kidneys and autonomic
nervous system. Progressive renal failure occurs in
adult life. Most patients have attacks of excruciating,
unexplained pain in their hands.
A valuable but rare sign of acute haemorrhagic pancreatitis is a bruise or pigmentation near the umbilicus termed
Cullen’s sign (8.24). This occurs when retroperitoneal
blood dissects its way anteriorly towards the umbilicus,
where the colour of the overlying skin depends on the age
Icterus
Spider naevi
Cyanosis
Scanty hair
Hepatomegaly
Gynaecomastia
(in males)
Purpura
Splenomegaly
Ascites
Scratch marks
Pigmentation
Distended veins
Tattoos
Flapping
tremor
8.18
Portal hypertension
with tense ascites:
the dilated veins are
draining towards the
superior vena cava
8.18
Palmar
erythema
Xanthomata
Dupuytren's
contracture
Leuconychia
Koilonchia
Paronychia
Clubbing
Testicular atrophy
Oedema
8.19
Caput medusae
8.20
Clinical features of
chronic liver disease
8.20
8.19
8.21
Umbilical hernia
8.22
Periumbilical hernia.
Note maculopapular
eruption caused by
nickel buckles
8.23
Fabry’s disease:
periumbilical rosette
of dark red papules
8.21
8.22
8.23
THE ABDOMEN
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of the resulting bruise. The blood may also dissect into the
flanks where a similar discolouration may be seen called
the Grey Turner’s sign (8.25).
As for the axillae, the groins should be inspected for
increased or decreased pigmentation, glandular swellings,
intertriginous infections, and for herniae. Small glands may
be palpable in normal subjects but visible large glandular
masses (8.26) are mostly pathological (e.g. suggestive of
infection, lymphoma or secondaries). Tuberculous adenitis
may involve the inguinal glands and form a cold abscess
(8.27). Lymphogranuloma venereum (8.28) is a sexually
transmitted disease caused by Chlamydia trachomatis.
Among heterosexuals, primary infection produces a
rarely observed genital ulcer 2–3 weeks after exposure,
followed later (2–4 weeks) by painful inguinal lymphadenopathy, often associated with signs of systemic
infection. It heals spontaneously. It must be distinguished
from a tumour, chancroid, syphilis and other granulomatous diseases.
An inguinal hernia (8.29) is not difficult to recognize
in a standing patient but it may regress in a recumbent
position.
8.24
Cullen’s sign. Note the
coincidental presence of
Campbell de Morgan
(cherry angiomas) spots
8.24
8.25
8.25
Grey Turner’s sign: a
bruise in the flank
caused by extravasated
blood from acute
haemorrhagic
pancreatitis
8.26
Bilateral inguinal
lymphadenopathy.
Note a reddened,
inflamed area
overlying an infected
lymph node
8.26
8.28
8.28
Lymphogranuloma
venereum; enlarged
inguinal and femoral
lymph nodes
separated by a
groove made by the
inguinal ligament
(groove sign)
8.27
Tuberculous adenitis
forming an inguinal
mass
8.29
8.27
8.29
Right inguinal hernia
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ATLAS OF CLINICAL DIAGNOSIS
156
It would seem logical to extend the examination of the
groins to that of the genitalia as part of the overall clinical
assessment. However, most clinicians limit this practice to
those occasions when they expect to find an abnormality.
Thus, testicular bulk would be assessed in chronic liver
disease and myotonia dystrophica, whereas under-
developed and infantile genitalia would be looked for in
Klinefelter’s syndrome (8.30) and in the growth hormone
deficiency syndrome (8.31).
A dermatologist may look routinely for genital lesions
when he or she has already diagnosed scabies (8.32) or
lichen planus (8.33).
8.31
8.30
Klinefelter’s
syndrome
8.31
Growth hormone
deficiency disease:
infantile genitalia
8.30
8.32
Scabies: crusted
papules on the
penile shaft and
erythematous
scrotum
8.33
Lichen planus: flattopped papules with
white, shiny surface
(Wickham’s striae) in
an annular
formation on the
proximal edge of the
glans and under the
prepuce
8.32
8.33