Inspect the abdominal wall and pelvis, and visualize or palpate the landmarks illustrated. The rectus abdominis muscles become more prominent when the patient raises the head and shoulders from the supine position.
Rectus abdominis muscle
Midline, overlying linea alba
Anterior superior iliac spine
For descriptive purposes, the abdomen is often divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or supra-pubic.
When examining the abdomen, you may be able to feel several normal structures. The sigmoid colon is frequently palpable as a firm, narrow tube in the left lower quadrant, while the cecum and part of the ascending colon form a softer, wider tube in the right lower quadrant. Portions of the transverse and descending colon may also be palpable. None of these structures should be mistaken for a tumor. Although the normal liver often extends down just below the right costal margin, its soft consistency makes it difficult to feel through the abdominal wall. The lower margin of the liver, the liver edge, is often palpable. Also in the right upper quadrant, but usually at a deeper level, lies the lower pole of the right kidney. It is occasionally palpable, especially in thin individuals with relaxed abdominal muscles. Pulsations of the abdominal aorta are frequently visible and usually palpable in the upper abdomen, while the pulsations of the iliac arteries may sometimes be felt in the lower quadrants.
The abdominal cavity extends up under the rib cage to the dome of the diaphragm. In this protected location, beyond the reach of the palpating hand, are much of the liver and stomach and all of the usual normal spleen. The spleen lies against the diaphragm at the level of the 9th, 10th, and 11th ribs, mostly posterior to the left midaxillary line. It is lateral to and behind the stomach, and just above the left kidney. The tip of a normal spleen is palpable below the left costal margin in a small percentage of adults.
Most of the normal gallbladder lies deep to the liver and cannot be distinguished from it clinically. The duodenum and pancreas lie deep in the upper abdomen, where they are not normally palpable.
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