Abdomen

Question 1

Nine regions of abdomen

Answer 1

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)

Question 2

Quadrants of abdomen

Answer 2

Vertical (mid-sagittal) and transverse (transumbilical) through umbilicus

Question 3

End of ninth cc

Answer 3

L1

Transpyloric

Question 4

Lower edge of tenth cc

Answer 4

L3

Subcostal

Question 5

Highest point on iliac crest

Answer 5

L4

Supracristal

Question 6

Tubercle of iliac crest

Answer 6

L5

Intertubercular

Question 7

ASIS

Answer 7

S2

Question 8

Liver surface marking

Answer 8

• right 5th rib at MCL​
• lower end of sternum​
• left 5th ICS at MCL​
• costal margin at right MAL​

Question 9

Gallbladder surface marking

Answer 9

• tip of right 9th CC (on transpyloric plane)​

- where transpyloric plane intersects MCL plane

Question 10

Spleen surface marking

Answer 10

• along medial surfaces of left 9th, 10th and 11th ribs​

- between lateral borders of left erector spinae muscles and left MAL

Question 11

Kidney surface marking

Answer 11

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​

Question 12

Ureter surface marking

Answer 12

• starts 5cm lateral to midline at L1​

- end at PSIS

Question 13

Abdominal aorta surface marking

Answer 13

Palpate xiphisternal joint and draw a vertical line through umbilicus to supracristal plane L4

Question 14

Myotome

Answer 14

Set of muscles innervated by a single spinal nerve root

Question 15

Dermatomes

Answer 15

Area or strip of skin innervated by a single spinal nerve root

Question 16

Tenderness with minimal pressure over a wider area of the abdomen

Answer 16

Peritonitis or in some cases is due to anxiety of the patient.

Question 17

Guarding of the abdomen

Answer 17

Abdominal wall tends to contract voluntarily when palpation causes pain. This is called voluntary guarding.

Question 18

Rigidity of the abdomen

Answer 18

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.

Question 18

Rebound tenderness

Answer 18

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.

Question 19

Normal bowel sounds

Answer 19

Gurgling due to peristalsis

Question 20

Absent bowel sounds

Answer 20

Paralytic ileus or peritonitis

Question 21

High pitched frequent bowel sounds

Answer 21

Intestinal obstruction

Question 22

Bruits

Answer 22

Abnormal created by turbulent blood flow

Question 22

Hernia

Answer 22

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

Question 23

Femoral pulse

Answer 23

Mid inguinal point between ASIS and pubic symphysis

Question 24

Hepatomegaly

Answer 24

Congestive heart failure, hepatitis (viral and bacterial), tumours and cirrhosis.

Liver extends down in children

Question 25

Cholelisthiasis or cholecystitis pain

Answer 25

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.

Question 26

Causes of distended abdomen

Answer 26

Fluid, fat, faeces, fetus & flatus

Question 27

Causes of fluid accumulation

Answer 27

Hepatic cirrhosis with portal hypertension, liver and peritoneal malignancies.

Other causes include cardiac failure, peritonitis, malnutrition, hypoproteinaemia, pancreatitis, lymphatic obstruction, hypothyroidism, and renal dialysis.

Question 28

McBurney’s point

Answer 28

Junction of middle and lower thirds of a line joining ASIS to umbilicus

Question 29

Pain referral

Answer 29

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

Question 30

Splenomegaly

Answer 30

Portal hypertension secondary to liver cirrhosis, haemolytic anaemia, congestive heart failure

Question 31

Caput medusa

Answer 31

Varicose veins (from portal hypertension - hepatomegaly) radiating from umbilicus

Question 32

Enlarged kidney

Answer 32

Hydronephros, polycystic disease, renal neoplastic disease

Question 33

Imaging of kidneys

Answer 33

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.

Question 34

Abdominal aortic aneurysm

Answer 34

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.