Abdomen 2 Flashcards
How can all visceral structures in the abdominal cavity be surface marked?
- anterior
- lateral
- posterior abdominal wall regions
What areas does the liver occupy?
most of the right hypochondrium and the epigastrium in the upper part of the abdominal cavity
Where is most of the liver under?
under cover of the ribs and costal cartilages
Does the liver move with the diaphragm in respiration?
Yes
What happens to the liver on the right side during quiet respiration?
- upper surface of the liver follows the right dome of the diaphragm and lies at the level of the 5th costal cartilage or the 4th intercostal space (just above the 5th rib) at the midclavicular line
- lower border of the liver closely follows the costal margin (rib cage margin)
What happens to the liver during full inspiration?
anterior (lower margin) of the liver projects just beyond the costal margin on the right side but it is not sufficient enough to be readily palpable
What part of liver would be palpable and when?
only the lower edge of the liver, in some people, may become palpable in deep inspiration along the right costal margin
Why is it not possible to palpate the lower border of liver in the epigastrium?
- Even though lower border of the liver crosses the epigastrium (without the cover of costal cartilages or ribs)
- not possible to palpate the lower border of liver in this region of the abdominal wall, because of strong rectus abdominis muscle
During what conditions does the liver become palpable?
Hepatomegaly (happens in some pathological conditions e.g. congestive heart failure, hepatitis, tumours, cirrhosis)
Where is the liver palpable in these conditions?
ower border of the enlarged liver becomes palpable below the costal margin
Why can you usually palpate the lower border of normal healthy liver in an infant or child?
liver extends below the costal margin to about 1.0 - 3.5 cm
Why is the gallbladder not palpable?
because of its pliable nature
Is the gallbladder palpable if it is enlarged?
No
Where is the fungus of the gallbladder located?
just under the tip of the 9th costal cartilage on the right side
Where does the tip of the 9th costal cartilage lie on the anterior abdominal wall? What can be marked here?
- just below a point at which the lateral border of the rectus abdominis muscle intersects the costal margin in the transpyloric plane
- Fundus of the gallbladder can be surface marked at this position in the right hypochondriac region of the abdominal wall
What is any gallbladder pain a result of? Where is it referred to?
- gallstones (cholelithiasis) 2.inflammation (cholecystitis) -usually referred first to the epigastric region
Where will the gallbladder pain progress to?
progress of the disease and involvement of the overlying parietal peritoneum, the pain will migrate to the right hypochondriac region towards the tip of the right 9th costal cartilage
What can be elected in a patient with inflamed gallbladder?
Murphy’s sign
How is Murphy’s sign elicted?
asking the patient to breathe in whilst palpating the right subcostal area, causing pain on inspiration
Where does the spleen lie? Is it palpable?
- lies under cover of the ribs on the left hypochondrium
2. Usually not palpable even during deep inspiration
When does the spleen become palpable?
has to enlarge at least 3 – 4 times before it becomes palpable below the left costal margin
What are the three borders of the liver?
- upper border
- oblique border
- right border
Where is the upper border of the liver?
- closely follow the right dome of the diaphragm in mid inspiration is marked by a line from the right 5th rib and costal cartilage
- which extends across the lower end of the sternum
- to the left 5th intercostal space at the mid-clavicular line (point 3)
Where is the oblique border of the liver?
- follows the right costal margin from the right mid-axillary line
- through the tip of right 9th costal cartilage through the tip of left 8th costal cartilage (difficult to palpate)
- to the left 5th intercostal space in the mid-clavicular line
Where is the right border of the liver?
starts from point 4 and ascends upwards along the right margin of thoracic cage to meet on the right 5th rib at mid-clavicular plane
Where does the gallbladder lie?
- at point where the lateral border of the rectus abdominis muscle crossed the costal margin
- also where the trans-pyloric plane intersects the midclavicular plane
Where does the train-pyloric plane run through?
tips of the 9th costal cartilages
Where does the right mid clavicular line run?
along the lateral border of the rectus abdominis muscle
Where does the spleen lie?
along the medial surfaces of the left 9th, 10th and 11th ribs
Where are the surface projection of the spleen mapped?
between the lateral borders of the left erector spinae muscles and the left mid-axillary line
How is the spleen separated from the rib cage inside the abdominal cavity?
by the diaphragm and the costodiaphragmatic recess
Where does the liver gallbladder and spleen lie inside the abdominal cavity?
deep to the anterior abdominal wall
Why do you use percussion?
determine the extent or the size of these organs
particularly useful for the liver and spleen
How does the liver affected by disease enlarge?
inferiorly from the right costal margin towards the right iliac fossa
How do you palpate the liver?
- lay the palm of your right hand in the patient’s right iliac fossa with the lateral border of the index finger aligned parallel to the right costal margin
- At this position the tips of your index and middle fingers will lie parallel to the rectus sheath
- Apply sufficient pressure with your examining (right) hand and you will ask the patient to take slow deep breaths through the mouth
How do you keep your hand during inspiration?
keep your hand still during inspiration with your lateral border of the index finger expecting to feel the liver edge as it descends with inspiration
How do you move your hand between each breath?
move your hands progressively, about 1 cm at a time, towards the costal margin
How do you describe the liver’s edge if you do feel it?
whether its surface is smooth or irregular, soft or hard, or there is any tenderness and pulsations
How do you examine the gallbladder?
asking the patient to take a deep breath while palpating, for any tenderness, in the right upper quadrant region at the midclavicular line
Is it possible to measure the liver span?
yes, by percussing on the anterior chest/abdominal wall
Where is the upper border of the liver?
lies at the level of the 5th rib or 5th intercostal space in the right midclavicular line
How do you estimate the liver span?
- ask the patient to hold the breath in full expiration and percuss downwards from the right 4th rib along the midclavicular line
- while carefully listening for a change in the percussion note from a resonant note over the air filled lung tissue to a dull note over the solid liver tissue
- This indicates the position of the upper border of the liver which is usually around the 5th intercostal space
What is the start position for palpation of liver?
Right iliac fossa
What is the end position for palpation of liver?
Right costal margin
What is the start position for the percussion of liver? When does the dull note start?
Right 4th or 5th ribs at midclavicular plane - the dulls note begins at upper border. of liver
What is the end position of the percussion of liver? When does the dull note disappear?
Around right costal margin - dull note disappears at lower border of liver
In what direction do you continue to percuss liver?
- continue to percuss inferiorly until you reach the end of liver dullness (or the beginning of the resonant note of the viscera)
- Usually at the right costal margin for a normal liver
- You will measure the distance between the upper and lower limits of the liver which is usually around 13 centimetres in a healthy adult
Where is the spleen palpable when it is enlarged least three times its normal size?
- Indicates splenomegaly
- below the left anterior costal margin
How does the spleen enlarge?
inferiorly from the left costal margin across the umbilicus towards the right iliac fossa
What does palpitation of the spleen depend on?
downward movement when the subject takes a deep breath
What happens during splenic enlargement?
- sharp upper border a characteristic notch will be the leading edge of the organ which your palpating finger will encounter
- will help you to distinguish it from the lower pole of an enlarged left kidney
What is the start position for the palpitation of the spleen?
- Right iliac fossa
- Lateral border of right index finger aligned parallel to left costal margin
What is the end position for the palpitation of the spleen?
- Left costal margin
- Left hand firmly pulling left lower rubs and spleen forwards
How do you palpate the spleen?
- lay the palm of your right hand on the abdomen well below the umbilicus near the right iliac fossa region
- At this position the lateral border of the index finger of your right hand will be aligned parallel to the left costal margin with the finger tips pointing medially and downwards.
- Apply sufficient pressure with your examining hand and you will ask the patient to take slow deep breaths through the mouth.
How does the hand act during inspiration?
still during inspiration with your lateral border of the index finger expecting to feel the splenic edge as it descends with inspiration
How does the hand act between each breath?
move your hands progressively, about 1 cm at a time, towards the left costal margin across the umbilicus
How do you detect any splenic enlargement which does not cross over the costal margin?
- percuss over the lowest intercostal space (10th intercostal space between 10th & 11th ribs) in the left anterior axillary line whilst the patient lies in supine position
- You will percuss at this space both during inspiration and expiration
What does it mean if you find the percussion note becomes dull on full inspiration?
suspect splenomegaly
