PACES abdominal station: common cases and how to present them
The PACES abdominal encounter: chronic liver disease, splenomegaly, polycystic kidneys, transplants, dialysis access and stomas, with the signs, scars and devices that give the diagnosis away.
The short answer
- The abdominal encounter is the second half of Station 4, after the communication encounter: up to 6 minutes to examine, then at least 4 minutes of questions.
- The common cases are chronic liver disease, splenomegaly, polycystic kidneys, kidney transplants, dialysis access, inflammatory bowel disease with stomas or scars, and haemochromatosis.
- Many abdominal cases are really “cause, treatment, complications” cases: a kidney transplant, a fistula and a Cushingoid face tell one story. Read the scars and devices as carefully as the organs.
A 6-minute routine
- Introduce, consent and position the patient lying flat with one pillow and the abdomen exposed appropriately.
- Bedside clues and general inspection: jaundice, scratch marks, pigmentation, muscle wasting, lactulose, a transplant card, a glucose sensor, stomas, scars, dialysis access and feeding tubes.
- Hands: clubbing, leukonychia, palmar erythema, Dupuytren's contracture, flapping tremor.
- Arms, face, neck and chest: AV fistulas, jaundice and pallor, lymph nodes (including Virchow's node), spider naevi, gynaecomastia, a tunnelled line.
- Abdomen: light then deep palpation; liver and spleen from the right iliac fossa; ballot the kidneys (and check both iliac fossae for a graft); percuss the liver and spleen and test for shifting dullness; listen for bruits.
- To complete: say you would examine the hernial orifices and external genitalia, perform a rectal examination if indicated and dipstick the urine.
Presenting chronic liver disease
A clear four-part structure works well: chronic liver disease; compensated or decompensated (jaundice, ascites, encephalopathy, bruising); the likely cause (clues such as tremor, central obesity, tattoos, pigmentation, an inhaler or a stoma); and signs of treatment (ascitic tap marks, a transplant scar).
Common cases
| Case | Key signs | Points to raise |
|---|---|---|
| Chronic liver disease | Clubbing, leukonychia, palmar erythema, Dupuytren's contracture, spider naevi, gynaecomastia; with portal hypertension, splenomegaly, ascites and caput medusae | Causes: viral hepatitis, alcohol, metabolic dysfunction-associated steatotic liver disease, autoimmune and cholestatic disease, haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, drugs |
| Decompensated cirrhosis | Jaundice, ascites, flapping tremor, bruising, muscle wasting | Precipitants (infection, bleeding, constipation, drugs); spontaneous bacterial peritonitis; varices; transplant referral |
| Cholestatic liver disease | Jaundice with scratch marks; xanthelasma (primary biliary cholangitis); a stoma or IBD signs (primary sclerosing cholangitis) | A stoma in a jaundiced patient is a clue to PSC, not an incidental finding |
| Splenomegaly | Left upper quadrant mass with a notch that you can't get above, moving towards the right iliac fossa on inspiration, dull to percussion | Massive: myelofibrosis, chronic myeloid leukaemia, malaria, visceral leishmaniasis. Also portal hypertension, lymphoma, haemolysis |
| Polycystic kidney disease | Bilateral ballotable flank masses, sometimes hepatomegaly from liver cysts, a fistula or transplant scar | Autosomal dominant; hypertension, intracranial aneurysms, mitral valve prolapse; tolvaptan for rapidly progressing disease; family screening |
| Kidney transplant | Curved iliac fossa scar over a smooth palpable graft; signs of immunosuppression (Cushingoid features, tremor, gum hypertrophy, skin cancers) | Present as cause (the original kidney disease), treatment (transplant, immunosuppression) and complications (graft dysfunction, infection, malignancy). A diabetic with a central scar may have a pancreas graft too |
| Chronic kidney disease and dialysis access | AV fistula (look, feel for a thrill, listen for a bruit), needle marks, a tunnelled line, a peritoneal dialysis catheter | Needle marks mean the fistula is in active use; a working fistula without needle marks suggests a transplant has taken over |
| Inflammatory bowel disease and stomas | Laparotomy or laparoscopic scars, a stoma, a healed stoma site; extraintestinal signs | Ileostomy: usually spouted with liquid output. Colostomy: usually flush with formed output. Urostomy: spouted, draining urine. Judge by spout and output, not side alone |
| Haemochromatosis | Slate-grey pigmentation, hepatomegaly, signs of chronic liver disease, arthropathy, signs of diabetes | HFE testing, ferritin and transferrin saturation, venesection, family screening |
Scars and devices
| Finding | Usually means |
|---|---|
| Bilateral subcostal ("Mercedes-Benz" or rooftop) scar | Liver transplant or major hepatobiliary surgery |
| Curved iliac fossa scar | Kidney transplant |
| Flank or subcostal scar on one side | Nephrectomy (right or left), or splenectomy on the left |
| Midline laparotomy | Emergency or bowel surgery; look for a stoma or incisional hernia |
| Lower abdominal catheter with an exit site | Peritoneal dialysis: check the exit site and tunnel for infection |
| Upper abdominal feeding tube | PEG or gastrostomy; think about the reason (bulbar disease, cancer) |
Spleen or kidney?
| Spleen | Kidney |
|---|---|
| You can't get above it | You can usually get above it |
| Has a notch | No notch |
| Moves towards the right iliac fossa on inspiration | Moves down on inspiration |
| Dull to percussion | Usually resonant over it (overlying bowel) |
| Not ballotable | Ballotable |
Likely viva topics
- A liver screen for chronic liver disease, and how to stage severity (Child-Pugh, MELD).
- Ascites: diagnostic tap; a serum–ascites albumin gradient of 11 g/L or more suggests portal hypertension; spontaneous bacterial peritonitis.
- Surveillance in cirrhosis: endoscopy for varices and 6-monthly ultrasound for hepatocellular carcinoma.
- Causes of massive splenomegaly and how you would investigate them.
- Complications of immunosuppression after transplantation, and the causes of kidney failure.
Common pitfalls
- Starting palpation too high and missing the edge of a very large spleen or liver.
- Confusing a kidney with a spleen.
- Missing a fistula, transplant scar or dialysis catheter that gives the diagnosis away.
- Naming a stoma by its side alone.
- Forgetting to say how you would complete the examination.
Sources
Frequently asked questions
What are the common abdominal cases in PACES?
Chronic liver disease (compensated or decompensated), splenomegaly, polycystic kidney disease, kidney transplant, chronic kidney disease with dialysis access, inflammatory bowel disease with stomas or scars, and haemochromatosis.
How do you tell a spleen from a kidney on examination?
You can’t get above a spleen, it has a notch, it moves towards the right iliac fossa on inspiration, it is dull to percussion and it is not ballotable. A kidney can usually be got above, is ballotable and is often resonant because bowel overlies it.
How do you tell an ileostomy from a colostomy?
An ileostomy is usually spouted with liquid output, and a colostomy is usually flush with formed output. Ileostomies are usually on the right and colostomies on the left, but judge by the spout and output rather than the side alone.
How should you present a kidney transplant case in PACES?
Think in terms of cause (the original kidney disease, such as diabetes or polycystic kidneys), treatment (the transplant and immunosuppression) and complications (graft dysfunction, infection, malignancy and drug side effects).
Where is the abdominal station in PACES?
The abdominal examination is the second encounter at Station 4, following a 10-minute communication encounter.
Written by The Ace PACES team. Exam facts are taken from the Federation of the Royal Colleges of Physicians’ published PACES guidance, linked in the sources above. This guide supports exam preparation and is not a clinical guideline.
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