#261, #262 Abdominal Pain: Physical Exam Series

March 15, 2021 | By Justin Berk

Common Abdominal Exam Maneuvers and Which Ones Actually Matter

#261 Acute Abdominal Pain

#262 Subacute and Chronic Abdominal Pain

Learn how the abdominal exam affects our imaging choices, when to call a surgeon, and which classical maneuvers may not be so helpful. You may find it gut-wrenching! In this evidence-based physical exam series, we discuss how to approach abdominal pain with Dr. Andrew Olson (Minnesota). He’s the leader of the DX: Diagnostic Excellence Project. 

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Credits

• Producer: Justin Berk MD MPH MBA and Sam Masur MD
• Writer: Sam Masur MD
• Cover Art and Infographics by: Beth Garbitelli
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Justin Berk MD MPH MBA (written materials); Clair Morgan of nodderly.com
• Guest: Andrew Olson MD

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Physical Exam Series: Approach to Abdominal Pain Pearls

1. To assess for peritonitis and “Does this patient require an operation?”, Dr. Olson recommends examining for rigidity (+LR 3.6) and tenderness to percussion (+LR 2.4).
2. Physical exam can help guide our choice in imaging. The Right Upper Quadrant (RUQ) ultrasound is more valuable than CT scan in patients with RUQ pain. 
3. The abdominal exam cannot diagnose peptic ulcer disease or pancreatitis, but it can rule out peritonitis and the need for an operation
4. Ascites should be diagnosed with ultrasound because it is available, the gold standard, and more accurate than physical exam
5. Dr. Olson treats laboratory testing, advanced imaging, and the physical exam the same. They are all diagnostic tests that modify probabilities.

Physical Exam Series: A case-based Approach to Abdominal Pain

Acute abdominal pain

The Case of the Surgical Abdomen:

1. Does this patient require an urgent operation? 

To answer that question, we must ask, does this patient have peritonitis? And is this patient systemically ill? If the answer is yes, this patient needs an operation. The best way to assess for parietal inflammation is the following:

Rigidity: involuntary contraction of the abdominal wall. For peritonitis, +LR 3.6 (-LR 0.8) 

• How Dr. Olson performs the maneuver: start away from the most painful spot. Palpate at all three levels. To build rapport, ask the patient to push your hands so he/she is in control. The patient’s abdomen is firm and unable to relax. 

Percussion Tenderness: The goal of rebound is to push hard enough and release to create a vibration of the parietal peritoneum. Percussion Tenderness can be used as a surrogate for rebound tenderness because attempting rebound HURTS.  For peritonitis, +LR 2.4 (-LR 0.5)

Kashlak Pearl: it is OK to give opioids to patients with severe abdominal pain even if you are concerned it will alter your exam. It may change your exam, but it will not change outcomes [Cochrane 2007].

2. Dr. Olson’s take on the classically taught maneuvers for appendicitis:

Tenderness to palpation in the right lower quadrant of the abdomen (RLQ) highlights the difference between positive and negative likelihood ratios. These probabilities are affected by the sensitivities and specificities of our tests. 

Tenderness to palpation at McBurney’s point, located ⅓ of the way between the anterior superior iliac spine (ASIS) and the umbilicus, is a helpful test in diagnosing acute appendicitis, +LR 3.4. 

Whereas tenderness to palpation in the RLQ, a more sensitive yet less specific test, is not as helpful in diagnosing acute appendicitis, +LR 1.9. Yet, the absence of RLQ tenderness to palpation is a very good test for excluding acute appendicitis (-LR 0.3) compared to tenderness to palpation at McBurney’s Point (-LR 0.4). 

On the other hand, Rosving’s Sign (+LR 2.3, -LR 0.8), Psoas Sign (+LR 2, -LR 0.9), and the Obturator Sign (+LR 1.4, -LR 1) are not that helpful. These tests came about prior to consistent imaging with the goal of decreasing negative appendectomy rates, which are now quite low [Radiology 2010]. 

3. How to approach right upper quadrant (RUQ) abdominal tenderness

To begin with, the clinical gestalt, which includes history, physical, and lab tests, for acute cholecystitis is quite good, LR+ 25-30 [JAMA 2003]. The caveat, per Dr. Olson, is these studies were completed by expert clinicians in the field. With acute right upper quadrant pain and clinical gestalt for a surgical abdomen, we are likely to order imaging. In this case, our exam helps dictate the type of imaging to order, which is primarily the RUQ ultrasound, which can provide the following information:

• Sonographic Murphy’s Sign: pressure on gallbladder (with ultrasound probe) produces cessation of inspiration. For acute cholecystitis, +LR 9.9 (-LR 0.4). This is a better test than the regular Murphy’s sign (with hands), which has a +LR for acute cholecystitis of 3.4.
• Ultrasound can distinguish cholecystitis from cholangitis with dilation of the common bile duct.

1. How do I diagnose a bowel obstruction?

Bowel sounds and abdominal distention are useful in a true mechanical obstruction. The hyperactive, or tinkling, bowel sounds have a +LR 5 (-LR 0.6) for bowel obstruction. For bowel obstruction, the distended abdomen has a +LR 9.6 (-LR 0.4). But this patient is also not subtly ill – he/she will be vomiting and in significant pain. The exam findings are more useful to follow over time and to answer the question, “does this patient STILL have a bowel obstruction?”

The Case of Peptic Ulcer Disease

The physical exam is more helpful in confirming a non-surgical abdomen than diagnosing peptic ulcer disease vs. cholelithiasis or gastritis. 

The Case of Acute Pancreatitis

The physical exam is used to exclude other diagnoses, similar to PUD. The diagnostic criteria for acute pancreatitis does not include the physical exam. Diagnosis of acute pancreatitis is elevated lipase, clinical symptoms, and imaging. Neither classic abdominal pain (note: this is not tenderness to palpation), elevated lipase, or imaging findings of pancreatitis are found on exam. 

The Case of Nephrolithiasis

The big difference between kidney stones and peritonitis is the patient cannot sit still and get comfortable, rather than refusing to move (expert opinion). On exam, flank tenderness radiating to the groin has a +LR 27 (-LR 0.9) for ureterolithiasis, which is a very good test. This pain is very different from true quadrant tenderness as discussed above.

The Case of Ascites

In the case of liver disease, some exam findings are related to liver synthetic dysfunction and others are related to portal hypertension. According to Dr. Olson, it is best to separate those findings on the initial abdominal exam, since not all portal hypertension is caused by liver dysfunction. 

Portal Hypertension

The first question often asked is, “Does this patient have ascites?” Classically, the exam findings include bulging flanks, shifting dullness, fluid wave, and lower extremity edema, with the reference standard being ultrasound. Dr. Olson no longer teaches these exam maneuvers because point-of-care ultrasound is ubiquitous enough to make the diagnosis at the bedside with the gold standard. Nevertheless, lower extremity edema is the most sensitive test for ascites with a -LR 0.2.

Kashlak Pearl: When using POCUS for ascites, Dr. Olson recommends looking for fluid in the RUQ between the liver and kidney, the pericolic gutters, the LUQ between the spleen and diaphragm, and around the bladder.

Liver Dysfunction

Gynecomastia is a helpful exam finding for cirrhosis with +LR 7 (-LR 0.6), which is important to teach because identifying it can help us empathize with our patients. For cirrhosis, palmar erythema is a good test with a +LR 9.8 (-LR 0.5).

Laboratory Testing and the Physical Exam

Dr. Olson treats laboratory testing, advanced imaging, and the physical exam the same. They are all diagnostic tests that modify probabilities. Similar to the physical exam, lab tests have likelihood ratios that can be used to determine just how much our pre-test probability for a specific diagnosis will change.

Lab testing most helpful in the diagnosis of cirrhosis [JAMA 2012]:

• Thrombocytopenia (< 160) has a LR+ 6.3, LR- 0.3
• Thrombocytopenia (< 110) has a LR+ 9.8, LR- 0.5
• Prolonged PT/INR has a LR+ 5.0, LR- 0.6
• Serum albumin < 3.5 has a  LR+ 4.4, LR- 0.6
• Bonacini Cirrhosis Score (AST:ALT >1, platelet count, INR) > 7 has a LR+ 9.4
• Bonacini Cirrhosis Score (AST:ALT >1, platelet count, INR) < 3 has a LR- 0.3

Take-Home Points

Dr. Olson recommends continuing to practice on patients with and without positive findings in order to calibrate your specific exam skills like rigidity or percussion tenderness.

Looking to learn how to perform a maneuver we just discussed?Check out the Stanford 25 and Society of Bedside Medicine’s 5 Minute Moment!

Links*

Links*

1. Stanford 25: Teaching and promoting bedside exam skills to students, residents and healthcare professionals both in person and online
2. The 5 Minute Moment at the Society of Bedside Medicine
3. The POCUS Atlas: Evidence-Based Point of Care Ultrasound

Goal

Listeners will feel confident how to optimally use the physical exam to guide clinical decision-making in patients presenting with abdominal pain. 

Learning objectives

After listening to this episode listeners will…  

1. Recognize when a patient may need an operation for abdominal pain
2. Identify specific exam maneuvers that can aid clinical decision making
3. Identify exam maneuvers that may not offer more information compared to imaging such as POCUS 

Disclosures

Dr Olson reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Masur S, Berk J, Olson A, Williams PN, Brigham SK, Garbitelli B, Watto MF. “#261 and #262 Abdominal Pain Part 1 and Part 2 Physical Exam Series”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 15 and March 17, 2021.

References

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2. Raja AS et al. Negative appendectomy rate in the era of CT: an 18-year perspective. Radiology. 2010 Aug;256(2):460-5. doi: 10.1148/radiol.10091570. Epub 2010 Jun 7. PMID: 20529988.
3. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003 Jan 1;289(1):80-6. doi: 10.1001/jama.289.1.80. Erratum in: JAMA. 2009 Aug 19;302(7):739. PMID: 12503981
4. Williams JW Jr, Simel DL. The rational clinical examination. Does this patient have ascites? How to divine fluid in the abdomen. JAMA. 1992 May 20;267(19):2645-8. doi: 10.1001/jama.267.19.2645. PMID: 1573754.
5. Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM. Does this patient with liver disease have cirrhosis? JAMA. 2012 Feb 22;307(8):832-842. doi: 10.1001/jama.2012.186. PMID: 22357834
6. McGee, Steven. Evidence-based physical diagnosis[4th edition] Elsevier, 2018. Clinical Key