(11) Abdomen Flashcards
bony landmarks of abdominal wall and pelvis
xiphoid process iliac crest anterior superior iliac spine pubis tubercle symphis pubis
how to make rectus abdomens muscles more prominent
pt raised head and shoulders
or
lifts legs from supine position
abdominal structures: RUQ
liver - lower margin palpable @ right total margin
gallbladder - inferior surface of liver
pylorus
duodenum m- deep, not palpable
hepatic flexure of colon
head of pancreas
abdominal aorta - visible pulsation, palpable in upper abdomen
abdominal structures: LUQ
spleen - lateral to and behind stomach, protected by 9-11th ribs, tip may be palpable below left costal margin in small % of healthy adults (easily palpable in splenomegaly) splenic flexure of colon stomach body and tail of pancreas - not palpable transverse colon
abdominal structures: RLQ (4)
cecum
appendix
ascending colon
right ovary
abdominal structures: LLQ
sigmoid colon
descending colon
left ovary
abdomen or abdominopelvic cavity
- lies between thoracic diaphragm and pelvic diaphragm
- contain 2 continuous cavities: abdominal and pelvic cavities enclosed by flexible multilayered wall of muscles and sheet-like tendons
- houses most of digestive organs, spleen, parts of urogenital system
- lining this and folding over visor such s stomach and intestines are parietal and visceral peritoneum
CVA
costovertebral angle
formed by lower border of 12th rib and transverse processes of upper lumbar vertebrae
- where to check for kidney tenderness
Pelvic Cavity structures
terminal uterus
bladder
pelvic genital organs
loops of small and large intestine at times
Bladder
hollow reservoir w/ strong smooth muscle walls composed of detrusor muscle
- 400-500ml
- if distended palpable above symphysis pubis
GI: common or concerning symptoms
- abdominal pain (acute/chronic)
- indigestion, N/V including blood, loss of appetite, early satiety
- difficulty swallowing (dysphagia), painful swallowing (odynophagia)
- change in bowel function
- diarrhea, constipation
- jaundice
Urinary/Renal: common/concerning symptoms
- difficulty urinating, urgency, frequency
- suprapubic pain
- hesitancy, decreased stream in males
- excessive urination or excess urination at night
- urinary incontinence
- blood in urine
- flank pain and renal colic
3 broad categories of abdominal pain
visceral pain
parietal pain
referred pain
Visceral Pain
- occurs when hollow abdominal organs (intestine, biliary tree) contact unusually forcefully or are distended/stretched
- solid organs (liver) can also become painful when their capsules are stretched
- difficult to localize
- typically palpable near midlines at levels that vary according to structure involved
- also stimulated by ischemia
- varies in quality: gnawing, burning, cramping, aching (when severe: sweating, pallor, N/V, restlessness)
visceral pain in RUQ suggests?
liver distention against its capsule from hepatitis
Visceral periumbilical pain suggests?
acute appendicitis from distention of an inflammed appendix
- gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum
for pain disproportionate to physical findings suspect intestinal mesenteric ischemia
parietal pain
- originated from inflammation of the parietal perineum (peritonitis)
- steady, aching pain usually more severe than visceral pain and more precisely located over the involved structure
- typically aggravated by coughing or movement
- pts usually prefer to lie still
referred pain (abdominal)
- felt more in distant sites which are innervated at approx the same spinal levels as the disordered structures
- often develops as in initial pain becomes more intense and seems to radiate or travel from the initial site
- may be palpated superficially or deeply but is usually localized
abdominal pain may be referred to ?
chest
spine
pelvis
(complicates assessment of abdominal pain)
in contrast to peritonitis, patient with colicky pain from a renal stone ?
move around frequently trying to find a comfortable position
pain of duodenal or pancreatic origin may be referred to ?
back
pain from the biliary tree may be referred to ?
right scapular region or right posterior thorax
pain from pleurisy or inferior wall MI may be referred to ?
epigastric area
types of visceral pain
RUQ or epigastric = biliary tree, liver Epigastric = stomach, duodenum, pancreas Periumbilical = small intestine, appendix, proximal colon Suprapubic or sacral = rectum Hypogastric = colon, bladder, uterus
doubling over with cramping colicky pain signals ?
renal stone
sudden knife-like epigastric pain often radiating to back signals ?
pancreatitis
epigastric pain occurs with ?
GERD
pancreatitis
perforated ulcers
RU and upper abdominal pain occurs with ?
cholecystitis
cholangitis
Angina from inferior wall CAD vs indigestion
angina is precipitated by exertion and relieved by rest
Dyspepsia
chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by postprandial fullness, early satiety, and epigastric pain/burning
bloating, nausea, belching occurring alone do not meet criteria for dyspepsia
Abdominal discomfort
subjective negative feeling that is non painful
can include various symptoms such as bloating, nausea, upper abdominal fullness, heartburn
bloating may occur with ?
lactose intolerance
inflammatory bowel disease
ovarian cancer
belching results from ?
aerophagia (swallowing air)
heartburn and regurgitation together more than once a one week suggests ?
GERD
heartburn
rising retrosternal burning pain or discomfort occurring weekly or more often
typically aggravated by ETOH, chocolate, citrus fruits, coffee, onions, peppermint, bending over, exercise. lifting, lying supine
respiratory symptoms w/ GERD
chest pain cough wheezing aspiration pneumonia pharyngeal symptoms (hoarseness, chronic sore throat, laryngitis)
Upper GI alarm symptoms
- difficulty swallowing (dysphagia)
- pain w/ swallowing (odynophagia)
- recurrent vomiting
- evidence of GI bleed
- early satiety
- weight loss
- anemia
- risk factors for GI cancer
- palpable mass
- painless jaundice
functional (nonulcer) dyspepsia
3 month hx of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or PUD
- symptoms usually recurring and present >6 months
Barret esophagus
metaplastic change in esophageal lining from normal squamous to columnar epithelium
Patients w/ uncomplicated GERD who fail empiric therapy, >55 y/o, w/ alarm symptoms suggests ????
esophagitis
peptic strictures
Barret esophagus
esophageal cancer
RLQ pain or pain that migrates from periumbilical region, combined w/ abdominal wall rigidity on palpation suggests ?
appendicitis
in women consider: pelvic inflammatory disease, ruptured ovarian follicle, ectopic pregnancy
cramping pain radiating to RorLLQ or groin suggests ?
renal stone
LLQ pain w/ palpable mass suggests ?
diverticulitis
diffuse abdominal pain w/ abdominal distention, hyperactive high-pitched bowel sounds, and tenderness on palpation suggests ?
small or large bowel obstruction
pain w/ absent bowel sounds, rigidity, percussion tenderness, guarding suggests ?
peritonitis
change in bowel habits w/ a mass lesion warns of ?
colon cancer
intermittent pain for 12 weeks of preceding 12 months w/ relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet like) linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity suggests ?
irritable bowel syndrome
regurgitation occurs in ?
GERD
esophageal stricture
esophageal cancer
vomiting w/ fecal odor and pain suggests ?
small bowel obstruction
gastrocolic fistula
hematemesis suggests ?
esophageal or gastric varices
Mallory-Weiss tears
PUD
“food fear” w/ abdominal pain and slightly distended soft contender abdomen are hallmarks of ?
mesenteric ischemia
fullness or early satiety suggests ?
diabetic gastroparesis
anticholinergic medications
gastric outlet obstruction
gastric cancer
early satiety also suggests hepatitis
globus sensation
sensation of a lump or foreign body in throat unrelated to swallowing (not true dysphagia)
indicators of oropharyngeal dysphagia
drooling
nasopharyngeal regurgitation
cough from aspiration
diarrhea definition
painless loose or watery stools during >75% defecations for prior 3 months w/ symptom onset at last 6 months prior to diagnosis
-stool volume may increase to >200g in 24 hrs
Acute vs Chronic Diarrhea
acute <2wks (food borne, infection)
chronic >4wks (crohns, ulcerative colitis)
nocturnal diarrhea is usually ?
pathological
high volume frequent watery stool are usually from ?
small intestine
small volume stools w/ tenesmus or diarrhea w/ mucus, pus, blood occur in ?
rectal inflammatory conditions
steatorrhea
oily residue, sometimes frothy or floating occurs
- from malabsorption in celiac sprue, pancreatic insufficiency, small bowel bacterial overgrowth
diarrhea and medications
common w/ PCN, macrocodes, magnesium based antacids, metformin, herbal/alternative medications
consider cdiff if recent hospitalization
types primary/functional constipation
normal transit
slow transit
impaired expulsion(pelvic floor disorders)
constipation-predominant irritable bowel syndrome
secondary constipation causes include:
medications amyloidosis diabetes CNS disorders hypothyroidism hypercalcemia MS Parkinsons systemic sclerosis
thin pencil-like stool occurs in ?
obstructing “apple core” lesion of sigmoid colon
constipation causing medications
anticholinergic agents
CCB
iron supplements
opiates
mechanisms of jaundice
- increased production of bilirubin
- decreased uptake of bilirubin by the hepatocytes
- decreased ability of the liver to conjugate bilirubin
- decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood
(predominately unconjugated bilirubin occurs from 1st 3 mechanisms like in hemolytic anemia (increased production) and Gilbert syndrome)
Intrahepatic jaundice
- can be hepatocellular from damage to hepatocytes OR cholestatic from impaired excretion as a result of damaged hepatocytes or intrahepatic bile ducts
Extrahepatic jaundice
arises from obstruction of extra hepatic bile ducts most commonly the common bile ducts
when excretion of bile into intestine becomes completely obstructed stools become ?
gray or light colored or “acholic” (seen in viral hepatitis)
impaired excretion of conjugated bilirubin is seen in ?
viral hepatitis
cirrhosis
primary biliary cirrhosis
drug induced cholestasis from oral contraceptive, methyl testosterone, chlorpromazine
what may obstruct the common bile duct
gallstones
pancreatic, cholangio-, or duodenal carcinoma
painless jaundice suggests ?
malignant obstruction of bile ducts seen in duodenal or pancreatic cancer
painful jaundice suggests ?
infectious origin: hep A or cholangitis
risk factors for liver disease
- hepatitis
- alcoholic hepatitis / alcoholic cirrhosis
- toxic liver damage from meds, industrial solvents, environmental toxins, anesthetic agents
- gallbladder disease/surgery: may result in extra hepatic biliary obstruction
- hereditary
Hep A
travel/meals in areas poor sanitation
ingestion of contaminated water/food
Hep B
parenteral or mucous membrane exposure to infectious body fluids (blood, serum, semen, saliva - sex, IV needles)
Hep C
illicit IV drug use or blood transfusion
involuntary voiding or lack of awareness suggests
cognitive or neurosensory deficits
stress incontinence arises from ?
decreased intraurethral pressure
Pain from sudden over distention accompanies ?
acute urinary retention
disorders in the urinary tract may cause pain in ?
bladder disorders cause pain in ?
- bladder infection pain location ?
abdomen or back
suprapubic pain
- lower abdomen, typically dull and pressure-like
sudden bladder over distention pain vs. chronic bladder pain
sudden - agonizing
chronic - usually painless
painful urination accompanies
cystits urethritis UTIs bladder stones tumors acute prostatitis
women report internal burning in ?
external burning in ?
urethritis
vulvovaginitis
urinary urgency suggests
UTI
irritation from urinary calculi
urinary frequency suggests
UTI
bladder neck obstruction
in men, painful urination w/o frequency suggests
urethritis
urinary symptoms w/ flank/back pain suggests
pyelonephritis
where is prostatic pain usually felt
perineu and occasionally in rectum
Polyuria
significant increase in 24 hr urine volume
>3000ml
(urinary frequency can be high volume: polyuria or low volume: infection)
Nocturia
urinary frequency at night, awakens pt more than once
- urine volumes may be large or small
causes of polyuria
high fluid intake of psychogenic polydipsia
poorly controlled diabetes
decreased secretion of ADH of DI
decreased renal sensitivity to ADH of nephrogenic DI
stress incontinence
increased abdominal pressure causes bladder pressure to exceed urethral resistance - there is poor support of bladder neck
urge incontinence
urgency is followed by involuntary leakage d/t uncontrolled detrusor contractions that overcome urethral resistance
overflow incontinence
neurologic disorders or anatomic obstruction from the pelvic organs or the prostate lift bladder emptying until the bladder overcomes distention
functional incontinence
arises from impaired cognition, musculoskeletal problems, immobility
mixed incontinence
stress + urge incontinence
pink urine in absence of red cells suggests
myoglobin from rhabdomyolosis
flank pain, fever, chills signal
actue pyelonephritits
renal or ureteral colic is caused by
sudden obstruction of a ureter
ex: renal/urinary stones or blood clots
kidney pain vs ureteral pain
kidney “flank”: at or below posterior costal margin near CVA, may radiate anteriorly toward umbilicus, visceral pain usually produced by distention of the renal capsule and typically dull, aching, steady
ureteral: severe colicky pain radiating toward trunk into lower abdomen and groin or into upper thigh, testicle, or labrum (results from sudden distention of ireter and renal pelvis)
abdomen: important topics for health promotion and counseling
- ETOH abuse screening
- viral hepatitis: risk factors, vaccines, screening
- screening for colon cancer
Addiction
chronic relapsing behavioral disorders w/ substance-induced alterations of brain neurotransmitters resulting in tolerance, physical dependence, sensitization, craving, relapse
exam findings of alcoholism
liver disease: hepatosplenomegaly, ascites, caput medusae (dilated abd vessels)
- janudice
- spinder angiomas
- palmar erythema
- Dupuytren contractures
- asterisks
- gynecomastia
initial drinking screening question
how many times in the pst year have you had 4(W)/5(M) or more drinks a day?
moderate drinking
W = 1 or less drinks/day M = 2 or less drinks/day
unsafe drinking levels
W = >3/day and >7/wk M = >4 / >14
binge drinking
W = 4 or more on one occasion
M 5 or moe
Hepatitis A
- transmission fecal-oral
- fecal shedding followed by poor hand washing contaminates water and foods, leading to infection of household and sexual contacts
- infected kids often asymptomatic increasing spread
- diluted bleach to clean surfaces
- rarely fatal, doesn’t cause chronic hepatitis
Hep A vaccination recs
- all kids 1 yr old
- chronic liver disease
- increased risk: travel, gay, IV drugs, work w/ nonhuman primates, clotting factor disorders
Hep A postexposure prophylaxis
- give Hep A vaccine or dose of immune globulin w/in 2 weeks
Hepatitis B
- more fatal than Hep A and can become chronic
- usually self limiting and develop immunity
- risk highest in kids (immature immune system)
Hep B screening
- high risk country
- HIV
- IV drug user
- gay
- household contacts
- pregnant
Hep B vaccination recs
- childhood immunization
- sexual contacts
- blood expsoure
- travel
- high risk lifestyles
Hepatitis C
- no vaccine, prevention targets high risk groups
- most prevalence blood borne pathogen in US
- sexual transmission rare
- chronic illness
- risk factor for cirrhosis, hepatocellular carcinoma, liver transplant, liver failure
Colorectal Cancer: risk factors
age personal hx of colon CA adenomatous polyps IBS family hx male black tobacco, ETOH use red meat obesity
Colorectal Cancer: prevention
most effective = screen and remove pre-cancerous adenomatous polyps
physical activity
ASA, NSAIDS
estrogen/progesterone postmenopause
Colorectal Cancer: screening guidelines
50-75 routine screenings
76-85 individualized
>85 stop
arching the back: does what to abdominal muscles
pushes abdomen forward and tightens abdominal muscles
arms above head: does what to abdominal muscles
stretches abdominal wall and tightened muscles which inhibits palpation (keep arms at side)
abdominal pink-purple striae suggest?
Cushing syndrome
dilated abdominal veins suggest ?
portal hypertension from cirrhosis (caput Medusa) or inferior vena cava obstruction
ecchymosis of abdominal wall is seen in
intraperitoneal or retroperitoneal hemorrhage
normal aortic palpation is frequently visible is? (abdominal exam)
epigastrium
bulging flanks suggest ?
ascites
abdominal asymmetry suggests ?
hernia
enlarged organ
mass
increased peristaltic waves suggest ?
intestinal obstruction
increased epigastric pulsations suggest ?
AAA
increased pulse pressure
abdominal bruits suggest ?
vascular occlusive disease
altered bowel sounds are common in ?
diarrhea
intestinal obstruction
paralytic ileum
peritonitis
bruit w/ both systolic and diastolic components in epigastrium or upper quadrants suggests
renal artery stenosis as cause of HTN
bruits w/ both systolic and diastolic components over abdominal arteries suggests ?
turbulent blood flow from atherosclerotic arterial disease
friction rub over liver or spleen suggests ?
hepatoma
gonococcal infection around liver
splenic infarction
pancreatic carcinoma
protuberant abdomen that is tympanitic throughout suggests ?
intestinal obstruction or paralytic ileus
abnormal abdominal dullness suggests ?
pregnant uterus
ovarian tumor
distended bladder
larger liver or spleen
dullness in both flanks suggests ?
ascites
normal costal margin palpation
left - liver dullness
right - tympany over gastric air bubble and splenic flexure of colon
(situs inverses its opposite b/c organs reversed)
involuntary abdominal rigidity that persists despite relaxation maneuvers suggests
peritoneal inflammation
abdominal masses may be categorized in several ways:
- physiologic: pregnancy
- inflammatory: diverticulitis
- vascular: AAA
- neoplastic: colon cancer
- obstructive: distended bladder, dilated loop of bowel
signs of peritonitis
positive cough test
guarding - voluntary contraction of abdominal wall w/ pt grimace, may diminished if pt distracted
rigidity - involuntary reflex contraction of abd wall that persists
rebound tenderness - pain after pressing then removing hand
percussion tenderness
span of liver dullness is ? when liver is enlarged
increased
percussion: lower liver border
start at level well below umbilicus in RLQ (in tympany not dullness), percuss upward toward liver along midclavicular line
percussion: upper liver border
starting at nipple line, percuss downward in midclavicular line until lung resonance shifts to liver dullness
liver span measurements
midclavicular line: 6-12cm
midsternal line: 4-8 cm
span of liver dullness decreased when ?
liver is small
free air below diaphragm (perforated bowel, hollow viscus)
liver span may decrease w/
resolution of hepatitis, heart failure
or progression of fulminant hepatitis
liver dullness may be displaced downward by
low diaphragm of COPD
-but span remains normal
what may falsely increase estimated liver size
dullness from right pleural effusion or consolidated lung if adjacent to liver dullness
gas in colon and liver percussion
may produce tympany in RUQ, obscuring liver dullness and falsely decreasing estimated liver size
in chronic liver disease, finding an enlarged palpable liver edge roughly doubles the likelihood of ?
cirrhosis
measurements of liver span are more accurate when liver is ?
enlarged w/ palpable edge
Liver Palpation
left hand: support and press forward 11th/12th ribs and adjacent soft tissues
right hand: right abdomen lateral to rectus muscle w. fingertips well below lower border of liver dullness, point fingers towards face or oblique, press in and up when asking pt to take a deep breath
- on inspiration liver is palpable 3cm below right costal margin in midclavicular line
normal liver edge
soft, sharp, regular w/ smooth surface
liver palpation suspicious for liver disease
firmness, hardness of liver, bluntness or rounding of its edge, surface irregularity
liver hooking technique
helpful for liver palpation when obese
tenderness over liver suggests
inflammation (hepatitis)
congestion (heart failure)
when a spleen enlarges it expands:
anteriorly, downward, and medially often replacing tympany of stomach and colon w/ dullness of a solid organ
2 percussion techniques to detect splenomegaly
- percuss lower left anterior chest wall from border of cardiac dullness (6th rub) to anterior axillary line and down to costal margin (Traube space)
- dullness = splenomegaly, tympany prominent esp. lateral - splenomegaly unlikely
- more accurate - percuss lower interspace in left anterior axillary line (usually tympanic), ask pt to take a deep breath and percussion agin (should remain tympanic)
what may cause dullness in Traube space
splenomegaly
fluid or solids in stomach or colon
how to palpate spleen
pt supine, arms at side, flex neck/legs (repeat w/ pt on tight side, legs flexed at hips/knees - gravity might help)
left hand: support and press forward lower left rib cage and sift tissue
right hand: below costal margin press in toward spleen, start low enough so can detect enlarged spleen (if too close to costal margin can’t reach under rib cage)
-ask pt to take deep breath, note contour, any tenderness
5% adults have normal palpable spleen tip
causes of splenomegaly
portal HTN hetologic malignancies HIV infiltrative dz: amyloidosis splenic infarct or hematoma
palpating kidneys
usually not palpable
- CVA parallel to 12th rib
left flank mass suggests
splenomegaly ( suspect if palpable notch on medial border, the edge extends beyond midline, percussion is dull, fingers can probe deep to medial and lateral borders but not between mass and costal margin)
enlarged L kidney (normal tympani in LUQ, can probe fingers between mass and costal margin but not deep to its medial and lower borders)
causes of kidney enlargement
hydronephrosis
cysts
tumors
bilateral - polycystic kidney disease
CVA pain w/ pressure or fist percussion suggests
pyelonephritis (w/ fever an dysuria) but also may be musculoskeletal
when is the bladder palpable
distended above symphysis pubis
- percuss for dullness, >400-600ml urine must be present
causes of bladder distention
outlet obstruction from urethral stricture or prostatic hyperplasia
meds
neuro disorders: stroke, MS
suprapubic tenderness is common in
bladder infection
risk factors for AAA
> 65
smoker
male
first degree relative
periumbilical or upper abdominal mass w/ expansile pulsations >3cmm suggests
AAA (pain may signal rupture) - USPSTF recommended US screen for any male who ever smoked >65
average width of aorta (abdominal exam)
2.5 cm
palpate slightly left of midline deep in epigastrium
protuberant abdomen w/ bulging flanks suggests
ascites
-dullness in dependent areas b/c sinks w/ gravity
Ascites suggests
increased hydrostatic pressure in cirrhosis heart failure constrictive pericarditis inferior vena cave hepatic vein obstruction decreased osmotic pressure in nephrotic syndrome malnutrition ovarian cancer
how to test for ascites
- shifting dullness - dullness shifts to dependent side, tympany shifts to top when rolls to side
- fluid wave - tap one flank and feel for fluid on opposite flank
Ballotte
brief jabbing motion used to displace ascites fluid during abdominal palpation
assessing for appendicitis
peritoneal signs of acute abdomen
McBurney point tenderness - 2” from anterior spinous process of ilium on a line drawn from that process to umbilicus
Rovsing sign - press deeply in LLQ + pain in RLQ
psoas sign - place hand above R knee and have pt raise thigh to hand = increased abd pain OR pt on L side extend R leg at hip
obturator sign - flex R thigh at hip w/ knee bent, rotate leg internally at hip = R hypogastric pain (low sensitivity)
localized tenderness anywhere in RLQ even in R flank suggests
appendicitis
assessing for acute cholecystitis
(RUQ pain and tenderness)
Murphy Sign - hook L thumb or fingers of R hand under costal margin where lateral border of rectus muscle intersects w/ costal margin, take deep breath = sharp increase in tenderness w/ inspiratory effect
assessing ventral hernias
abdominal hernia not in groin
- pt supine, ask to raise head and shoulders off table
(same technique to assess for abdominal masses)
