October 2006

Abdominal palpation ‑‑ Part 2

by Dr. Howard Loomis

This is the second in a three‑part series on abdominal palpation. These articles are part of a continuing dissertation on the clinical correlations between structure (anatomy) and function (physiology). A deviation from normal in one inevitably has consequences in the other. The science of chiropractic has developed from its beginning with an appreciation of this truth, and it is still of enormous importance in the health care marketplace.

After outlining a simple examination for determining the patient's structural side of weakness, I began to equate that to abdominal palpation and determination of specific digestive inadequacies. I believe this to be very important to the clinician because digestive symptoms are vague, and Western medicine is unable or unwilling to perform tests that differentiate inadequate protein, carbohydrate, and lipid digestion.

In this column, I discuss palpation of the upper abdomen in search of visceral stress points.

First, it is necessary to briefly describe the topographic anatomy of the abdomen. The anterior surface of the abdomen can divided into four quadrants by two imaginary lines. One line extends vertically from the xiphoid to the symphysis pubis, and the other extends horizontally across the abdomen at the level of the umbilicus. This divides the abdomen into four quadrants: upper right, lower right, upper left, and lower left. We also use the term epigastrium to denote that area in the midline immediately below the xiphoid process.

Epigastrium ‑‑ The esophagus, T5 to T6

Pain impulses arising in the esophagus are carried by afferent nerve fibers, which course through the sympathetics and enter the spinal cord from the level of the lower cervical through the entire thoracic vertebrae. The fifth and sixth thoracic spinal segments are the most frequent. Referred pain corresponds well to the site of irritation:

Upper Esophagus = suprasternal notch or beneath the manubrium

Mid‑Esophagus = beneath the mid‑sternum

Lower Esophagus = beneath the xiphoid process or in the epigastrium

The most common pain in the esophagus is "heartburn," a burning pain felt substernally and well‑localized over the site of irritation. This pain has been shown to be a spasm of the cardiac end of the esophagus. The most common mechanism of heartburn is thought to include the regurgitation of acid gastric juice into the esophagus, which has already had its pain threshold lowered by the presence of inflammation.

Epigastrium ‑‑ The stomach, T7 to T9

Pain of gastric origin is most often felt in the epigastrium or in the upper left quadrant. Studies have shown that pain of considerable intensity is produced by either mechanical or chemical stimulation of the gastric mucosa when it is inflamed, congested, or edematous. Afferent impulses enter the cord at the level of the seventh to ninth dorsal roots.

Epigastrium ‑‑ The duodenum, T9 to T11

Ulceration of the duodenum is most often experienced in the epigastrium. Impulses from the small intestine travel in splanchnic pathways and enter the cord from T9 to T11, lower than those of the stomach. This pain usually begins one to two hours after eating and is relieved by eating or antacids (a pathognomonic sign of duodenal ulcer). A change of any kind in this pattern is suggestive of penetration into neighboring structures, such as the pancreas, which results in pain that will not be relieved by food or antacids.

Upper Right Quadrant ‑‑ The gallbladder and liver, T4 to T9

Pain of biliary tract origin is usually experienced along the distribution of the eighth and ninth thoracic nerve distribution in the upper right quadrant. Pain in this quadrant is most characteristic of acute cholecystitis. Pain referred posteriorly to the angle of the left or right scapula suggests a stone impacted in the cystic duct. Often overlooked is neck and shoulder pain referred from the phrenic nerve to the cervical spine.

Upper Left Quadrant ‑‑ The jejunum, T9 to L1

Problems arising in the jejunum are usually palpated in this quadrant. Often there is histologic alteration of the jejunal mucosa caused by a deficiency of one or more of the disaccharide‑hydrolyzing enzymes that complete the digestion of either maltose (gluten intolerance), lactose (lactose intolerance), or even sucrose. These inadequately digested disaccharides can damage the epithelial absorbing area of the small intestine and manifestations of malabsorption result.

Celiac disease (non‑tropical sprue or idiopathic steatorrhea) is one of the hereditary malabsorption syndromes. It is characterized by cramping pain and large, pale, fatty, bulky stools. Often diarrhea is a feature.

Midgastric ‑‑ The pancreas, T5 to T9

Involvement of the pancreas is one of the most difficult conditions to diagnose, although poorly localized pain in the upper left quadrant or epigastrium or back is frequently encountered. Anorexia, weight loss, and depression are suggestive.

Next time, I will describe palpation of the lower abdomen and related muscle contraction and stress points.

(Dr. Loomis can be reached by mail at 6421 Enterprise Lane, Madison,WI 53719 or by phone at 800‑662‑2630. Visit his website at http://www.loomisenzymes.com.)