Abdominal percussion and palpation: technique and clinical significance

1. Principles of abdominal examination

1. Inspection (shape, respiratory movement, scars, pulsations, bulges).
2. Auscultation (bowel sounds, vascular bruits) — BEFORE palpation to avoid altering motility.
3. Percussion.
4. Superficial gentle palpation.
5. Deep methodical palpation by Obraztsov-Strazhesko.
6. Specific tests (Shchetkin-Blumberg, Murphy, Rovsing, etc.).

The patient lies on their back, arms at their sides, legs slightly bent. The examiner stands to the right of the patient with warm hands.

2. Inspection

• Shape: protuberant (obesity, ascites, meteorism), scaphoid ("navicular" in peritonitis, starvation), asymmetric (tumors, hernias).
• Respiratory movement — a board-like abdomen does not move with respiration (peritonitis).
• Scars — indicate past surgeries.
• "Head of Medusa" (caput medusae) — portal hypertension.
• Venous networks — vena cava obstruction.
• Visible peristalsis — stenoses, early stage of acute intestinal obstruction.

3. Auscultation

• Bowel sounds 5–35/min normally. High-pitched "splashing" — early acute intestinal obstruction; "grave silence" — late acute intestinal obstruction or peritonitis; ↑ sounds — enteritis.
• Systolic bruit over the aorta — stenosis, aneurysm.
• Bruit over the renal artery — renovascular hypertension.
• "Splashing sound" (Sklyarov's sign) — fluid and gas in the stomach (pyloric stenosis).

4. Percussion

General principles

• Over the intestines — tympany.
• Over the liver, spleen, bladder — dullness.
• Appearance of dullness in dependent areas upon changing position — ascites (fluid thrill sign).
• Disappearance of hepatic dullness — free gas in the abdominal cavity (perforation).

Liver percussion by Kurlov

Enlarged dimensions — hepatomegaly (hepatitis, cirrhosis, congestion). Decreased — atrophy, necrosis.

Spleen percussion

• Along the 10th rib: long axis 6–8 cm, transverse axis 4–6 cm.
• Enlargement — splenomegaly (portal hypertension, leukemias, lymphomas, infections).

5. Superficial gentle palpation

• Palm flat, light pressure.
• Begin on the side opposite to the pain (left iliac region).
• Systematically examine all 9 regions: epigastrium, right/left hypochondrium, mesogastrium, right/left flank, umbilical, suprapubic, right/left iliac.
• Assessment: tenderness, muscle guarding (defense musculaire), Shchetkin-Blumberg sign, hernia protrusions, masses.

6. Deep methodical palpation by Obraztsov-Strazhesko

The basis is a 4-step palpation: placement of fingers, displacement of the skin fold, deep immersion during exhalation, gliding during exhalation. Sequence:

1. Sigmoid colon — left iliac region, smooth elastic cylinder 2–3 cm wide, painless.
2. Cecum — right iliac region, soft cylinder 3–4 cm, gurgling.
3. Terminal ileum.
4. Ascending and descending colon — bimanual.
5. Greater curvature of the stomach — above or at the level of the umbilicus, "ridge".
6. Transverse colon — below the greater curvature.
7. Liver — according to Obraztsov: on exhalation, fingers "dive" under the costal arch, the edge is assessed on inhalation. Normal edge — smooth, elastic, painless, not protruding.
8. Spleen — in the right lateral position (according to Salit); normally not palpable.
9. Kidneys — bimanual according to Obraztsov; normally not palpable, except the right one in thin individuals.

7. Specific signs

Peritoneal signs

• Blumberg's sign: increased pain upon abrupt withdrawal of the hand — peritoneal irritation.
• Voskresensky's sign (shirt sign): sliding motion over a taut shirt — painful in inflammation.
• Kulenkampff's sign: tenderness on digital rectal/rectouterine pouch examination.
• Mendel's sign: pain upon light percussion with a finger on the anterior abdominal wall.

Appendicitis

• Rovsing's sign — pain in the right iliac fossa upon impacts in the left one.
• Sittkus' sign — increased pain in the right iliac fossa when turning onto the left side.
• Bartomier-Michelson sign — increased pain upon palpation in the left lateral position.
• Obraztsov's sign (m. psoas) — pain upon raising the straightened right leg.
• Kocher's sign — initial epigastric pain migrating to the right iliac fossa.

Cholecystitis and cholelithiasis

• Murphy's sign — breath holding during palpation of the right hypochondrium due to pain.
• Ortner's sign — tenderness upon percussion over the costal arch.
• Kehr's sign — tenderness on inhalation at the gallbladder point.
• Mussy-Georgievsky sign (phrenicus sign) — between the heads of the sternocleidomastoid muscle on the right.
• Courvoisier's sign — palpable painless gallbladder + jaundice → head of pancreas tumor.

Pancreatitis

• Kerte's sign — painful transverse ridge in the epigastrium.
• Mayo-Robson sign — tenderness in the left costovertebral angle.
• Voskresensky's sign — absence of aortic pulsation in the epigastrium.
• Grey Turner's sign — hematomas in the flanks (necrotizing).
• Cullen's sign — hematomas around the umbilicus.

Kidneys

• Pasternatsky's sign — tenderness upon percussion of the loin.
• In case of significant enlargement, the kidney is palpable bimanually (hydronephrosis, tumor, nephroptosis).

8. Palpation of ascites

• Fluid thrill sign: one hand applies an impact laterally, the other feels the wave on the opposite side (assistant blocks transmission through subcutaneous adipose tissue with the edge of the palm along the midline).
• Percussion — tympany over the upper pole, dullness in dependent areas, shifting of dullness borders when turning to the side.
• Ultrasound detects ascites > 100 ml, percussion — from 500 ml.

9. Palpation of abdominal lymph nodes

Normally not palpable. Enlargement ("Virchow's node" — left supraclavicular) in gastric cancer. Mesenteric lymph nodes are detected as dense conglomerates in patients with lymphoma.

10. Specifics in children and pregnant women

• In children under 3 years old, palpation of the liver edge 1–2 cm below the costal arch is possible — a normal variant.
• In pregnant women after 20 weeks — palpation through the enlarged uterus is difficult; Sims-Thomson position (left lateral).

11. FAQ

Why is auscultation performed before palpation?
Palpation stimulates bowel motility, distorting true bowel sounds. Assessment of peristalsis requires "neutral" auscultation.

How to distinguish defense musculaire from voluntary tension?
Defense — persists when the patient is distracted, during respiration and gentle palpation; voluntary — disappears with distraction and warm hands.

When is Blumberg's sign negative in peritonitis?
In the elderly, in immunosuppression, in patients on steroids — clinical presentation is masked. A negative sign does not rule out peritonitis.

Why is Kurlov percussion not always relevant today?
Ultrasound assesses liver dimensions more accurately (craniocaudal diameter of the right lobe, thickness of the left). The method remains useful when ultrasound is unavailable and as a training skill.

What is Chauffard's triangle?
The area between the midline, the bisector of the upper right angle, and a horizontal line at the level of the umbilicus. Tenderness = involvement of the pancreatic head and duodenum.

See also: Acute abdomen · Appendicitis · Peritonitis · Heart auscultation · Propedeutics catalog