Common Abdominal Exam Maneuvers and Which Ones Actually Matter
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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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)
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].
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].
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:
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 physical exam is more helpful in confirming a non-surgical abdomen than diagnosing peptic ulcer disease vs. cholelithiasis or gastritis.
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 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.
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.
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.
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).
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]:
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.
Listeners will feel confident how to optimally use the physical exam to guide clinical decision-making in patients presenting with abdominal pain.
After listening to this episode listeners will…
Dr Olson reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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.
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