Abdomen Flashcards
Nine regions of abdomen
Right hypochondriac / Epigastric / Left hypocondriac
Right lumbar / Umbilicus / Left lumbar
Right inguinal / Suprapubic / Left inguinal
Divided at midclavicular line and subcostal (10th costal cartilage) or transpyloric (L1 vertebra + tip of 9th costal cartilage) and transtubercular line (through iliac tubercle - 5cm posterior to ASIS) or supracristal line (top of iliac crest)
Quadrants of abdomen
Vertical (mid-sagittal) and transverse (transumbilical) through umbilicus
End of ninth cc
L1
Transpyloric
Lower edge of tenth cc
L3
Subcostal
Highest point on iliac crest
L4
Supracristal
Tubercle of iliac crest
L5
Intertubercular
ASIS
S2
Liver surface marking
- right 5th rib at MCL
- lower end of sternum
- left 5th ICS at MCL
- costal margin at right MAL
Gallbladder surface marking
- tip of right 9th CC (on transpyloric plane)
- where transpyloric plane intersects MCL plane
Spleen surface marking
- along medial surfaces of left 9th, 10th and 11th ribs
- between lateral borders of left erector spinae muscles and left MAL
Kidney surface marking
Left:
- at level of L1
- 4-5cm from posterior midline
- 3-4cm from supracristal plane
Right:
- same as left but hilum is offset 2-3cm downwards
Ureter surface marking
- starts 5cm lateral to midline at L1
- end at PSIS
Abdominal aorta surface marking
Palpate xiphisternal joint and draw a vertical line through umbilicus to supracristal plane L4
Myotome
Set of muscles innervated by a single spinal nerve root
Dermatomes
Area or strip of skin innervated by a single spinal nerve root
Tenderness with minimal pressure over a wider area of the abdomen
Peritonitis or in some cases is due to anxiety of the patient.
Guarding of the abdomen
Abdominal wall tends to contract voluntarily when palpation causes pain. This is called voluntary guarding.
Rigidity of the abdomen
When there is inflammation of the parietal peritoneum, the abdominal wall muscles undergo a reflex contraction. This is called involuntary guarding.
Here the abdominal wall may not show any movements with respiration, and may show a board like rigidity.
Rebound tenderness
In patients with generalised or localised peritonitis, if the abdominal wall is compressed slowly and then released suddenly they will experience a sharp stabbing pain.
Normal bowel sounds
Gurgling due to peristalsis
Absent bowel sounds
Paralytic ileus or peritonitis
High pitched frequent bowel sounds
Intestinal obstruction
Bruits
Abnormal created by turbulent blood flow
Hernia
A direct hernial defect tends to go through Hesselbach’s Triangle (inguinal triangle) which is always MEDIAL to the inferior epigastric vessels
An Indirect hernial defect is always goes the internal ring which is always LATERAL to the inferior epigastric vessels
Femoral hernia
Femoral pulse
Mid inguinal point between ASIS and pubic symphysis
Hepatomegaly
Congestive heart failure, hepatitis (viral and bacterial), tumours and cirrhosis.
Liver extends down in children
Cholelisthiasis or cholecystitis pain
First to epigastric then with involvement of overlying parietal peritoneum, the pain will migrate to the right hypochondriac region towards the tip of the right 9th costal cartilage. In a patient with inflamed gallbladder palpation at this point will elicit pain, and it may also cause a ‘catch’ in the breath.
Causes of distended abdomen
Fluid, fat, faeces, fetus & flatus
Causes of fluid accumulation
Hepatic cirrhosis with portal hypertension, liver and peritoneal malignancies.
Other causes include cardiac failure, peritonitis, malnutrition, hypoproteinaemia, pancreatitis, lymphatic obstruction, hypothyroidism, and renal dialysis.
McBurney’s point
Junction of middle and lower thirds of a line joining ASIS to umbilicus
Pain referral
Referred to regions of skin supplied by somatic nerves with same segmental supply.
Foregut - epigastric pain
Midgut - umbilical colicky pain (appendix - periumbilical until spread to surrounding peritoneum, when it becomes localised)
Hindgut - suprapubic pain
Splenomegaly
Portal hypertension secondary to liver cirrhosis, haemolytic anaemia, congestive heart failure
Caput medusa
Varicose veins (from portal hypertension - hepatomegaly) radiating from umbilicus
Enlarged kidney
Hydronephros, polycystic disease, renal neoplastic disease
Imaging of kidneys
Renal ultrasound is a non-invasive method to examine kidney enlargement, and it is useful in differentiation of solid and cystic lesions. It can also define the size, shape and positions of urinary stones within the kidney, but it is not useful in detecting stones in the ureters.
Computed Tomography is the best and reliable method for imaging the urinary tract including detecting stone in the ureters. A non-contrast CT (no contrast medium injected into the patient) can provide rapid results with high definition imaging for patients undergoing investigation of ureteric colic and renal stones.
Abdominal aortic aneurysm
In a healthy person, it is around 2 cm wide. If the width of the abdominal aorta is greater than 3 cm then it is considered aneurysmal.
Pulsatile mass which is also expansible is a clear indication of an aneurysm and it needs urgent investigation.
Bruits will be heard over abdominal aortic aneurysms and other aneurysms of hepatic, renal, iliac and femoral arteries.
Abdominal aortic aneurysms are corrected by means of tube grafts of synthetic material in an open abdominal aortic surgery.
