Inspection

Inspection

Scars, abdominal distension, visible peristalsis or abdominal masses, dilated veins, pulsation or abdominal wall swelling suggestive of hernia should all be carefully sought. The size and location of scars from previous surgery may provide some insight into the nature of the intervention that was performed (see Chapter 7 ). In an abdominal emergency look for Grey Turner’s sign – skin discoloration of the flanks due to retroperitoneal haemor rhage in severe acute pancreatitis and leaking abdominal aortic aneurysm. Cullen’s sign – discoloration around the umbilicus – may indicate sev ere acute pancreatitis, ruptured ectopic preg nancy or trauma to the liver . In these situations, blood tracks to the umbilicus along the ligamentum teres ( Figure 63.3 ). These signs are better appreciated in a fair-skinned patient. In a patient with acute abdominal pain, it is important to observe whether the abdominal wall moves with respira thin patient with di ff use peritonitis may be unable to lie George Grey Turner , 1877–1951, Professor of Surgery , at the University of Durham (1927–1934) and at the Royal Postgraduate Medical School, Hammersmith Hospital, London, UK (1935–1946). Thomas Stephen Cullen , 1868–1953, Professor of Gynecology , the Johns Hopkins University , Baltimore, MD, USA, described the sign in ruptured ectopic pregnancy in 1916. - - vi - - the abdominal wall will have a ‘scaphoid’ appearance owing to protective contraction of the rectus abdominis muscles. It is often appropriate to ask the patient to cough gently – this will evoke sudden discomfort in the area of underlying perito - - neal irritation (equivalent to eliciting rebound tenderness, but not as distressing for the patient). A visible ‘cough impulse’ will also help to identify an abdominal wall hernia, if present. - A rounded, symmetrical contour of the abdomen with bulg - ing flanks is seen in the presence of ascites. Visible abdomi - masses, mobility on respiration and peristalsis are all best nal observed if the clinician kneels by the patient’s bed so that the s eye is at the level of the patient’s anterior abdominal observer’ tion. A wall. The same position is useful during palpation for abdom - flat and inal masses ( Figure 63.4 ). In a thin patient, visible bowel loops give clues about the pathology: an overdistended, bean-shaped loop is seen in cae - h characteristically points towards the left cal volvulus, whic upper quadrant, and in sigmoid volvulus, which points towards the right upper quadrant.

Figure 63.3 Cullen’s and Grey Turner’s sign of skin discoloration of the /f_l anks and around the umbilicus (courtesy of Mr Pradip Datta, Honorary Consultant Surgeon, Wick, Scotland). Figure 63.4 Eye at the level of patient’s abdominal wall.