Synopsis
Perform a respectful, reproducible abdominal examination; recognise peritonism, decompensated liver disease, portal hypertension and an abdominal mass; and describe physical signs as probability-changing evidence rather than diagnoses.
- Introduce yourself, confirm identity, explain the examination, obtain consent, offer a chaperone where appropriate, preserve dignity and ask about pain before positioning or exposure.
- Start at the end of the bed: distress, colour, body habitus, muscle wasting, mobility, drains, stomas, oxygen and mental state may be more important than a single abdominal sign.
- Examine hands, pulse, face, mouth, chest, abdomen, legs and cognition because chronic liver disease and systemic abdominal illness are not confined to the abdomen.
- Inspect before touching, auscultate before prolonged palpation when bowel sound interpretation matters, and examine the painful area last.
- Guarding, percussion tenderness, rigidity, shock or pain out of proportion is an emergency surgical phenotype; do not repeat forceful manoeuvres while delaying imaging or senior review.
- Spider naevi, palmar erythema, gynaecomastia, testicular atrophy, bruising, asterixis and Dupuytren contracture are neither individually sensitive nor specific for cirrhosis.
- A palpable liver edge is described by distance, surface, consistency, tenderness and pulsatility; splenic enlargement is confirmed by movement with inspiration and imaging, not percussion alone.
- Shifting dullness supports moderate ascites but ultrasound is more sensitive and guides safe paracentesis.
Key red flags
Involuntary guarding, rigidity, percussion tenderness, absent movement with breathing, tachycardia, hypotension, cool peripheries or altered mental state suggests perforation, ischaemia, bleeding or severe inflammation.
Jaundice, ascites, oedema, bruising, sarcopenia, asterixis and confusion form a decompensation cluster. Seek infection, gastrointestinal bleeding, renal injury, alcohol-related hepatitis and medicine precipitants.
A persistent mass, succussion splash, visible peristalsis, distension, vomiting, obstipation or a tense hernia needs urgent investigation, particularly with weight loss or anaemia.
Investigation priorities
Record NEWS2 elements, perfusion, urine output and glucose when acute abdominal or hepatic illness is possible.
Management branches
A stable patient consents to a clinically indicated abdominal assessment.
- Introduce, identify, explain, consent and position; ask about pain, expose appropriately and preserve dignity with a chaperone where indicated.
- Assess from the end of the bed, hands, pulse, face, mouth and chest, then inspect the abdomen before gentle and deep palpation.
- Percuss liver, spleen and fluid, auscultate for the defined question, and complete groins, legs, cognition or rectal and pelvic assessment only when indicated.
- Summarise positive and important negative findings, propose the leading mechanisms and state the next tests rather than claiming a diagnosis from one sign.