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
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 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 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 superior
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 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 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.
8.24It 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 underdeveloped
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).
