Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Epigastric pain |
Gastro-Oesophageal Reflux Disease (GORD) |
Risk factors: obesity, smoking, stress, alcohol use, NSAID use, hiatus hernia, diet e.g., caffeine, greasy/spicy foods.
Associated w/bloating, night-time cough, acid taste, wind. |
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H. Pylori |
Patient with GORD symptoms as above.
Positive stool antigen or CLO (biopsy) test. |
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Peptic Ulcer Disease |
Risk factors: as for GORD plus H. Pylori.
Epigastric pain, nausea. Gastric ulcer pain worse w/eating, duodenal ulcer pain better w/eating and worse 2-3h after food. Bleeding ulcer: haematemesis, malaena, iron def. anaemia. Perforated PU: severe epigastric pain, guarding, peritonism. |
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Pancreatitis |
Risk factors: gallstones, alcohol, ERCP.
Epigastric pain radiating through to back, vomiting, unwell. Raised amylase, lipase, inflammatory markers on bloods. |
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Ruptured AAA |
Important differential for epigastric pain.
Very unwell patient, haemodynamic instability. Severe abdominal pain radiating to back or pelvis. Pulsatile and expansile mass in abdomen. May be associated with collapse & loss of consciousness. |
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| Right upper quadrant pain |
Biliary Colic |
Risk factors: fat, female, fair, age forty+. Intermittent right upper quadrant pain caused by gallstones and often triggered by eating fatty foods. |
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Acute Cholecystitis |
Complication of gallstone disease.
RUQ pain associated with fever, nausea and vomiting, tachycardia. RUQ tenderness +/- Murphey’s +; raised inflammatory mx. |
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Acute Cholangitis |
Risk factors: gallstone disease, recent ERCP procedure.
Charcot’s triad: RUQ pain, fever, jaundice. |
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| Right iliac fossa pain |
Acute Appendicitis |
Peak incidence age 10-20 years old.
Anorexia, nausea, low grade-fever, RIF pain, vomiting. Tender RIF over McBurney’s point, Rosving+, guarding. Ruptured: rebound/percussion tenderness, peritonititis. |
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Ectopic Pregnancy |
Risk factors: prev ectopic, PID, IUD, older age, prev surgery.
6-8 weeks gestation is most common presentation time. RIF (or LIF) pain, PV bleeding, lightheadedness. Ruptured ectopic: severe pain, LOC, shoulder tip pain. |
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Ovarian Cyst |
Common in pre-menopausal women.
May be asymptomatic, may cause pelvic pain in RIF/LIF. Severe acute pelvic pain in torsion/rupture/haemorrhage. |
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| Jaundice |
Liver Cirrhosis |
Causes: ALD, NAFLD, hepatitis, haemochromatosis, drugs.
Jaundice, hepatomegaly, spider naevi, palmar erythema, gynaecomastia, bruising, ascites, caput medusa, tremor. |
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| Jaundice |
Cholangiocarcinoma |
Risk factors: PSC, liver parasite, age, bile duct stones.
RUQ pain, jaundice, weight loss, pale stool, dark urine. RUQ tenderness, palpable gallbladder, hepatomegaly. |
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Pancreatic Cancer |
Painless jaundice, dark urine, pale stool, itching, weight loss, change in bowel habit, new or worsening type 2 DM.
May be a mass in the epigastrium on palpation. |
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Hepatocellular Carcinoma |
Risk factors: liver cirrhosis of any cause & screening exists.
Abdominal pain, weight loss, jaundice, itching, nausea. May be a mass in upper abdomen on palpation. |
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Hepatitis (viral) |
RF: depends on virus; faecal-oral transmission (A/E), exposure to infected blood/body fluids (B/C).
Abdominal pain, flu-like illness, jaundice, nausea/vomiting. |
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Primary Biliary Cholangitis |
Risk factors: female, white, age 40-60 years.
May be asymptomatic, jaundice, itching, abdominal pain. Xanthoma/xanthelasma, excoriation, hepatomegaly. End-stage disease will show signs of liver cirrhosis. Raised ALP and positive AMA seen on bloods. |
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Primary Sclerosing Cholangitis |
Risk factors: male, age 30-40 years, IBD (UC), family hx.
RUQ pain, jaundice, fatigue, itching, hepato/splenomegaly. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient reclining 45° | ||
| Appropriate exposure of abdomen | ||
| General Inspection | Systemic appearance (well/unwell) | |
| Body habitus | ||
| Colour | ||
| Obvious scars | ||
| Abdominal distension | ||
| Oedema | ||
| Clues in bed space | ||
| Hands | Colour | |
| Palmar erythema | ||
| Tendon xanthomata | ||
| Dupytren’s contracture | ||
| Finger clubbing | ||
| Koilonychia | ||
| Leuconychia | ||
| Temperature | ||
| Capillary refill | ||
| Tremor | ||
| Arms | Bruising | |
| Track marks | ||
| Excoriation | ||
| Radial pulse | ||
| Face | Colour | |
| Cushingoid appearance | ||
| Eyes | Conjunctival pallor | |
| Jaundice | ||
| Xanthelasma | ||
| Kayser-Fleischer rings | ||
| Mouth | Breath odour | |
| Oral candida | ||
| Mouth ulcers | ||
| Angular stomatitis | ||
| Glossitis | ||
| Neck | Lymphadenopathy | |
| Chest | Spider naevi | |
| Loss of body hair | ||
| Gynaecomastia | ||
| Abdomen Inspection | Reposition patient lying flat | |
| Abdominal distension | ||
| Scars | ||
| Striae | ||
| Caput medusae | ||
| Hernias | ||
| Stomas | ||
| Abdomen Palpation | Observation of patient’s face throughout palpation | |
| Light general palpation | ||
| Deep general palpation | ||
| Palpation of liver | ||
| Palpation of spleen | ||
| Ballot the kidneys | ||
| Palpation of abdominal aorta | ||
| Abdomen Percussion | Percussion of liver | |
| Percussion of spleen | ||
| Percussion of bladder | ||
| Shifting dullness | ||
| Abdomen Auscultation | Auscultation of bowel sounds | |
| Renal bruits | ||
| Aortic bruits | ||
| Back | Sacral oedema | |
| Legs | Pedal oedema | |
| Legs | Erythema nodosum | |
| Pyoderma gangrenosum | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your abdomen. This involves looking at your hands and face, then looking at and feeling your abdomen. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclining on the examination couch at 45° – you will ask them to lie flat later in the examination
Ask the patient to expose their abdomen.
General Inspection
Look at the patient and around the bed space for useful signs:
- Systemic appearance (e.g., do they look unwell? Are they confused or agitated?)
- Body habitus – are they overweight or underweight? Do they look malnourished?
- Colour – are they flushed and sweaty, plethoric, pale, jaundiced?
- Obvious scars visible from the end of the bed
- Abdominal distension obvious from the end of the bed
- Stomas (e.g., colostomy, ileostomy, nephrostomy)
- Oedema (e.g., pedal, abdominal)
- Clues around the bed space (e.g., feeding tubes, IV lines, blood transfusions, vomit bowls, medications, alcohol)
Hands
Examine both hands together noting:
- Colour (e.g., pale/mottled indicate poor peripheral perfusion, jaundice, tar-staining)
- Palmar erythema
- Tendon xanthomata
- Tremor – flapping tremor (asterixis) indicating hepatic encephalopathy, fine tremor seen in alcohol withdrawal
- Dupuytren’s contracture
- Finger clubbing – associated gastrointestinal causes: Inflammatory bowel disease, liver cirrhosis, GI lymphoma, Coeliac
- Koilonychia – concave deformity of nails, may indicate iron deficiency anaemia
- Leuconychia – white discolouration of the nail, can be full or part of the nail
- Temperature (e.g., cold hands indicate poor peripheral perfusion)
- Capillary refill time of the fingertip, if delayed (>2 seconds), assess centrally at the sternum (indicates poor peripheral perfusion)
Arms
Examine both arms together noting:
- Bruising – may indicate hepatic failure as synthetic function of liver includes clotting
- Track marks – Intravenous drug use is a risk factor for contracting Hepatitis B & C
- Excoriation – increase in bilirubin causes itching (pruritus)
- Radial pulse – rate, volume
Face
Examine the patient’s face to assess:
- Colour (e.g., Pallor, flushing, plethoric, jaundice)
- Cushingoid appearance (e.g., Moon face, puffiness, redness) – may indicate frequent steroid use for treatment of GI conditions including IBD, autoimmune hepatitis, organ transplant; and alcohol can cause pseudo-Cushing’s
Eyes
Look at the patient’s eyes examining for:
- Conjunctival pallor indicating anaemia
- Jaundice
- Xanthelasma
- Kayser-Fleischer rings – associated with increased copper deposition: liver cirrhosis, Wilson’s disease
Mouth
Examine inside the patient’s mouth. Observe any unusual breath odour (fetor hepaticus) indicative of hepatic failure. Inspect for oral candidiasis which may indicate immunocompromise (e.g., from frequent oral steroid use). Check for mouth ulcers (occurring in inflammatory bowel disease) and signs of vitamin/iron deficiency including angular stomatitis or glossitis, which may occur due to malnutrition or malabsorption in the GI tract.
Neck
Examine the patient’s neck for any lymphadenopathy, paying particular attention to supraclavicular lymphadenopathy. A left–sided supraclavicular lymph node, referred to as Virchow’s node, is indicative of gastric carcinoma.
Chest
Examine the chest for stigmata of chronic liver disease including spider naevi (more than 5 is considered pathological), gynaecomastia (growth of male breast tissue) and loss of body hair (e.g., in axilla and on chest). These signs are associated with increased circulating levels of oestrogen which occur in chronic liver disease.
Abdominal Inspection
Reposition the patient to lie flat; ensuring this is comfortable for them and checking for pain or breathlessness which may limit ability to lie flat.
Perform a closer inspection of the abdomen, looking for:
- Abdominal distension – remember differentials using the 6Fs: Fat, Fluid, Flatus, Faeces, Foetus, Flipping huge mass
- Scars – see diagram for common abdominal scars
- Striae – stretch marks associated with rapid abdominal distension
- Caput medusae – engorged and dilated veins around the umbilicus indicating portal hypertension in CLD
- Hernias – epigastric, para-umbilical, inguinal etc.
- Stomas (e.g., colostomy, ileostomy, nephrostomy)
Abdominal Palpation
Palpate the patient’s abdomen, ensuring that you keep observing the patient’s face during examination to ascertain if they are experiencing pain or discomfort. Palpation should be performed with the patient at roughly the same height as your outstretched arms. You may need to adjust the couch or crouch down to the patient’s level.
Palpate the abdomen in each of the 9 regions below*:
- Right upper quadrant
- Epigastrium
- Left upper quadrant
- Left flank
- Umbilical
- Right flank
- Right iliac fossa
- Suprapubic
- Left iliac fossa
Check if the patient is in any pain at present; if they are, begin your examination away from the site of their pain.
First, light palpation is performed, checking for discomfort or tenderness in all regions of the abdomen. Observe for any guarding (tensing of the abdominal muscles when a specific area is palpated indicating significant tenderness in that area) or rigidity (the whole abdomen feels rock solid indicating peritonism).
Next perform deeper palpation, feeling for any masses in all regions. If any masses are palpated, assess size, shape, mobility, character e.g., fluctuance, pulsatility.
Check for rebound tenderness by informing the patient that you are going to press into their abdomen and then release and they should tell you which causes more pain. Increased pain reported on release indicates rebound tenderness and could indicate peritonism.
Palpation for specific structures is carried out as follows:
- Liver – ask the patient to take deep breaths in and out. Starting in the RIF, palpate in stages upwards towards the RUQ, pressing down on the abdomen in time with the patient’s inspiration. If hepatomegaly is present, you will feel the edge of the liver pushing against your hand on inspiration
- Spleen – as for liver but palpate in stages from the RIF diagonally upwards towards the LUQ. You will feel the edge of the spleen pushing against your hand if there is splenomegaly present.
- Kidneys – ballot the kidneys by placing one hand on top of the patient’s abdomen in the right flank and the other hand beneath the patient in the right flank. Push up with your posterior hand and down with your anterior hand. If you can feel the kidney between your hands this indicates an enlarged kidney and is pathological.
- Aorta – place both hands on the patient’s abdomen, with palms facing down and positioned vertically approximately 2 cm apart either side of the midline between the umbilicus and the xiphisternum. Feel for a palpable pulsation of the abdominal aorta. If a pulsation is felt and your hands move upwards only with each pulsation this may indicate a normal variant commonly seen in slim patients. If your hands move outwards with each pulsation this indicates an expansile aorta and is abnormal and concerning for abdominal aortic aneurysm (AAA).
Abdominal Percussion
Percuss specific structures as follows:
- Liver – beginning in the RIF, percuss over the abdomen, moving upwards towards the RUQ. A transition from resonant to dull indicates underlying liver.
- Spleen – as above for liver but percuss over the abdomen from the RIF moving diagonally upwards towards the LUQ. A transition from resonant to dull indicates the underlying spleen.
- Bladder – beginning just under the umbilicus, percuss downwards to the suprapubic region. A transition from resonant to dull indicates underlying bladder. The bladder will likely be distended if it can be percussed.
Percuss for shifting dullness to assess the presence of ascites by percussing from the umbilicus to the patient’s left flank. Then ask the patient to roll towards you onto their right side. Wait a few seconds then percuss the left flank again. If there is ascites present, the flank will have been dull to percussion when lying flat as fluid accumulates in the flank and then resonant once the patient has been repositioned due to the movement of fluid with gravity.
Abdominal Auscultation
Auscultate the abdomen for:
- Bowel sounds – listen in two separate areas for the presence and character of bowel sounds (e.g., normal, high pitched, tinkling, scanty). In theory you should listen for up to 1 minute.
- Renal bruits – auscultate over the left and right renal arteries, located approximately 5 cm supero–lateral to the umbilicus. A bruit indicates turbulent blood flow through the renal artery (e.g., renal artery stenosis)
- Aortic bruits – auscultate over the abdominal aorta in the midline between the umbilicus and xiphisternum; a bruit indicates turbulent blood flow through the abdominal aorta (e.g., AAA)
Back
Examine for sacral oedema by asking the patient to sit up and lean forward, examining the sacral region for any pitting oedema. Observe the level of the oedema. Presence of oedema indicates fluid retention which is multifactorial but GI causes include hypoalbuminaemia secondary to liver failure, protein losing enteropathy and severe malnutrition.
Legs
Examine the legs for pedal oedema by inspecting and palpating both legs and observing the level of the oedema. Presence of pitting oedema indicates fluid retention as above for sacral oedema.
Examine the legs for peripheral stigmata of Inflammatory Bowel Disease including Pyoderma Gangrenosum (blistered skin lesions which become ulcerated) and Erythema Nodosum (dark, painful patches on the skin of the lower legs).
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the abdominal examination findings you may wish to carry out further investigations, including blood gas sampling, blood tests, stool or urine sample testing, or further imaging (e.g., abdominal X-ray, ultrasound or CT scan).
[*Illustrations – coming 2025]
Last updated Dec 2024
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
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