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).