Abdomen Flashcards
GI Exam (3)
referred to as Abdominal Exam
GI Examination covers from mouth to anus.
GI Exam covers stomach, liver, gall bladder, pancreas, small and large bowel, rectum and anus.
Abdominal Exam also covers the spleen, kidneys, abdominal aorta, bladder, and female reproductive structures.
Vascular component of the abdominal exam
Relates to inspection Look for pulsations, pulsatile masses Relates to auscultation Listen for bruits: aortic, renal, iliac, femoral Relates to palpation Palpate for pulsatile masses, thrills
4 Quadrants of the Abdomen
Right Upper Quadrant (RUQ)
Left Upper Quadrant (LUQ)
Left Lower Quadrant (LLQ)
Right Lower Quadrant (RLQ)
The orientation is always from the patient’s perspective.
There are the epigastric, periumbilical, and suprapubic areas.
Disorders of Digestion
Anorexia – loss of appetite (distinguish from abdominal fullness) Anorexia is a common GI complaint. Needs to be distinguished from non GI causes of anorexia. Early satiety (gastric outlet obstruction, Gastric CA, hepatitis)
Unintentional Weight loss with Anorexia
Weight loss can have multiple causes Malignancy Malabsorption Liver Dz Consider non GI causes Depression Thyroid Non GI malignancy
Indigestion or difficulties with digestion
Difficulty swallowing (dysphagia)
Painful swallowing (odynophagia)
May be manifest as nausea, vomiting, heartburn, excessive belching/flatus.
Nausea – with/without vomiting
Heartburn – reflux (GERD), ? medication induced (ASA, NSAID’s), ? postural
Dysphagia– motor or mechanical
Mechanical
Stricture
Cancer or Mass
Obstruction (foreign body)
Motor
Neurological disorder
Spasm
Scleroderma
Achalasia
(esophageal musculature does not relax enough) – liquids & solids – nocturnal regurg with cough, and supine/chest pain possible.
Patients who point to their throat as source of problem often have transfer problem/those who point to their chest often have an esophageal problem
transfer dysphagia
attempts to swallow result in aspiration of food into nose/lungs – suggests CNS problem (stroke, neuromuscular condition).
Mechanical Dysphagia
Regurgitation of food bolus suggests mechanical problem.
Intermittent solid > liquid suggests stricture.
Intermittent solid then progressing to liquid and progressively worsening w/pain suggests esophageal cancer.
4 types of Odynophagia
Painful Swallowing Esophagitis (GERD induced) Foreign body (chicken or fish bone) Pharyngitis (MOST common cause) Achalasia – dysfunction of normal wave like esophageal peristaltic contractions
Symptoms of Odynophagia
Sharp & burning suggest mucosal inflammation (reflux esophagitis or infection).
Sharp & sticking suggest – mechanical (fish or chicken bone)
Squeezing/cramping suggest muscular etiology (esophageal spasm, achalasia).
Disorders of Digestion– nausea& vomiting
Nausea/Vomiting:
Precipitating factors
Quantity/Quality
Presence of blood (hematemesis)
Retching and Regurgitation for nausea& vomiting
Bringing up gastric contents w/o nausea or vomiting is called regurgitation.
Vomiting is forceful – sometimes referred to as retching.
You need to ask patient to describe nature, quantity and presence of blood in vomitus.
Small bowel blockage or fistula may cause vomiting of fecal like material.
Hematemesis
Presence of bright red blood indicates esophageal or upper GI bleed (acute)
Presence of coffee ground material suggests partially digested blood (altered by stomach acid).
Any suggestion of blood in vomitus is called hematemesis.
Prolonged vomiting will cause fluid and electrolyte imbalance (loss of Na, K, Cl) which needs to be treated (Pedialyte, plasmalyte, or IV).
Excessive bleching/flatus
Aerophagia (swallowing air) can result in this problem.
Determine if it is related to certain foods (dairy products, legumes, IBS)
Disorders of Bowel Function
Diarrhea Constipation (difficult passing of hard dry stools) Obstipation (usually implies constipation occurs as a result of intestinal obstruction)
Causes of Constipation
Low fiber diet low bulk stool
IBS (hard stools w/mucus – can also be associated w/episodes of diarrhea)
Non GI causes (CNS – spinal cord injury, MS)
Drugs (opiates, anticholinergics, antacids)
Hypothyroidism
Mechanical obstruction (CA narrowing lumen)
Volvulus / Diverticulitis
Fecal Impaction
Diarrhea
Large volumes of watery diarrhea (osmotic diarrhea) – lactose intolerance.
Infections – bacterial/viral – fever, travel or common food source w/other sick individuals
IBS – mucus but not bloody alternates w/constipation
Diarrhea with IBD and Colon CA
Inflammatory Bowel Disease (Ulcerative Colitis) – soft, watery with blood or Crohn’s disease – small, soft, watery w/o blood
Colon CA – age > 55, alternate w/constipation (diarrhea around obstruction), blood streaked.
Black Tarry Stools and Bloody stools
Melena – black tarry stools
Melena means blood has passed through the digestive tract blackens suggesting an Upper GI bleed.
Bloody stools have not passed through digestive tract – suggesting lower GI bleed (colon, rectum or anus).
Ingestion of Iron can cause?
Look for associated symptoms and pain to help pinpoint location.
Presence or absence of change in bowel habits (+ w/red blood r/o colon or rectal CA)
Ingestion of Iron – can cause + fecal occult blood test.
Certain foods mistaken for blood (beets – can make urine pink before showing up in stool)
Jaundice
Hepatic Disease or lysis of RBC’s
Yellowish appearance of skin and can often be seen in the sclera
May be accompanied by severe itching
Look for enlarged liver, hx of alcohol or drug abuse, hepatitis or cirrhosis.
Causes elevated levels of bilirubin in the blood.
May or may not be accompanied by pain.
Urine becomes like tea and stools become light yellow or gray.
GI complaints– ab pain
Abdominal Pain:
Visceral pain
Parietal or Somatic pain
Referred pain
Visceral Pain
Hollow tube pain resulting from forceful contraction or distention of intestine, biliary tree, (obstruction, gallstone)
Stretching of the liver capsule can also cause visceral pain.
Quality of Visceral Pain
Usually not well localized by patient
Often described as a cramping pain but can also be noted as “gnawing,” burning, or achey in nature.
Cramping colicky pain may crescendo and decrescendo and can be related to intestinal peristalsis.
When visceral pain is severe it might be accompanied by?
Nausea/vomiting
Sweating
Pallor
Restlessness (these are the patients who sometimes describe themselves or are described as “writhing in pain”).
Parietal peritoneum
the part of the peritoneum that lines the abdominal and pelvic cavities – referred to as the peritoneal cavity.
Visceral peritoneum
the part of the peritoneum that covers the abdominal organs and intestines.
what does the kidneys being retroperitoneum mean
this means they protrude into the peritoneal cavity but are not encased in visceral peritoneum.
mesentery refers to?
The mesentery refers to that part of the parietal peritoneum that suspends organs in the abdominal cavity.
The mesentery also acts as a conduit for blood vessels, nerves, lymphatics usually supported in layers of fat adherent to the mesentery.
parietal pain
Occurs as a result of inflammation of the parietal peritoneum (sometimes called somatic pain).
Steady, aching, severe pain (worse than visceral pain).
Well localized over the precise structure.
Aggravated by moving/coughing.
These patients lie still.
Classic pain presentation of acute appendicitis
Sometimes in the normal course of a disease pain will start in one fashion and then evolve into another kind of pain.
Initial periumbilical visceral pain related to distention of inflamed appendix.
Gradually patient develops parietal pain well localized to RLQ as inflammation spreads to parietal peritoneum.
Referred Pain
Pain from original site radiates to a distant site.
Often at the same spinal level as affected structure.
May be superficial or deep and is well localized.
4 Exam methods used in the Abdominal Exam
Inspection Auscultation Percussion Palpation Special Tests
Inspection of the Abdomen
Inspect skin for scars/ rashes/ striae. Note umbilicus for bulge consistent with umbilical hernia. Note dilated veins present in liver Dz organomegaly Visible peristalsis Pulsations
2 Bulges Seen on Inspection
A separation of the two rectus abdominis muscles in the midline can sometimes be seen as a ridge when patient lifts head and shoulders off flat surface it is not pathological (called diastasis recti).
Incisional hernias / umbilical hernias
Pregnancy
Ascites
free fluid collection in abdomen. With patient lying flat will be seen as protuberance at flanks.
Auscultation of the Abdomen
Indicates bowel motility and can elucidate vascular pathology.
Wide array of “normal” bowel sounds and frequency.
Bowel sounds are usually well transmitted when listening w/stethoscope, but listen in all four quadrants.
Listen for hypo/hyper active frequency
Listen for Bruits in the aorta/renal/ iliac arteries
Hyper/hypoactive bowel motility could indicate what?
Hyperactive or increased with diarrhea or early obstruction.
Hypoactive or decreased with paralytic ileus and early peritonitis.
Absent with complete obstruction late peritonitis. You should listen for a full 2 minutes before declaring absent bowel sounds.
Percussion of the Abdomen
Percussion is also helpful in determining the borders (hence size) of the liver.
When percussing note the following:
Gas produces tympany or tympanic note
Liquid produces dullness
Solid produces an even more profound dullness
Areas that contain gas and fluid will produce a lower pitched tympanic note than gas alone.
Most Noteable areas for percussion is?
is the tympany of the gastric bubble (LUQ)
Tympany of the colonic splenic flexure (LUQ – mix of gas and liquid).
Dullness of liver (RUQ).
Light Palpation technique
Use the flat palmar surface of your hand and fingers – keeping fingers together. Use one hand for light palpation.
Palpate lightly – watch patients face/expression for pain.
Move from one quadrant to the next always begin in the next quadrant from the one where the patient has localized his pain
What are you looking for during Light Palpation
Note areas of tenderness or suspicion of mass, organomegaly etc (to return to the area with deep palpation).
Note areas of muscular resistance – try relaxing techniques (i.e. ask pt to take deep breath and let it out – on exhalation abdominal musculature should relax or have pt flex hip and knees).
Is resistance voluntary – i.e. it goes away with relaxing techniques; or involuntary – it does not resolve. Muscular rigidity implies peritoneal irritation
Deep palpation technique
Begin in quadrant just after the area of pain (if any)
Use same technique of palmar surface of hand with fingers together.
For deep palpation use two handed technique – with one hand over the other. Use top hand to push probing lower hand. Lower hand will then be more sensitive to abnormalities.
What are you looking for with Deep Palpation
Masses can usually be characterized as:
Physiologic (pregnant uterus)
Neoplastic (tumors, firm, nodular)
Vascular (pulsatile aorta, aortic aneurysm)
Inflammatory – associated with tender- ness; mass felt with Diverticulitis (LLQ)
Rebound Tenderness– to determine presence of peritoneal inflammation (parietal peritoneum)
Have patient cough and see if this painful; if so where was pain localized.
Go to area of pain or any areas suspected of being tender and use one or two fingers to first gently then more firmly push into the patients abdomen.
Determine if there is any pain to this maneuver.
Then abruptly let go; if this produces > pain then patient’s exam is positive for rebound tenderness.
If both pushing and letting go hurt ask patient which hurt more. Rebound tenderness is the letting go part
Percussion of the liver
liver dullness is expanded when the organ is enlarged.
Begin percussing on the right below the umbilicus in the mid clavicular line (mcl) and percuss up– this will determine the lower border of the liver.
Now percuss over the ribs in the mcl – you should hear some resonance due to the lungs.
Continue to percuss downward in the mcl until the resonance of the lung is replaced by dullness. This is the upper border of the liver
Normal Sizes of livers
then measure in centimeters the distance from point to point (6 – 12 cm is normal span – men>women).
If enlarged percuss similarly in the midsternal line (4 – 8 cm is normal in midsternal line).
Palpation of the liver
A normal size liver may be palpable up to 3 cm below the costal margin in the mcl.
If palpable note quality of edge; firm, nodular, irregular, rock hard.
The normal liver has a smooth soft edge.
Note tenderness if present (should be non-tender)
Scratch Test to determine liver size
Can help to locate lower liver margin.
Place diaphragm of stethoscope over the right costal margin in the mcl line.
Begin below the umbilicus in the mcl and begin gently scratching the patients skin.
Move up toward the stethoscope and you will note a change in what you hear (increased volume as both finger and stethoscope are on liver) when you move onto liver tissue.
Palpation of the spleen
Spleen lies between the left 10th rib.
The normal spleen is not palpable so do not spend a long time “palpating the spleen.”
An enlarging spleen will “migrate” from its normal position in the LUQ toward the RLQ
Special Tests for the abdomen
Assessing Ascites Rebound Tenderness (already covered) Costovertebral Angle Tenderness (CVA tenderness) Psoas Sign Obturator Sign Rovsings Sign Murphys Sign
Assessing Ascites
Assess borders of dullness and tympany with patient lying supine.
Now roll patient to one side and note shifting dullness which is present with ascites (fluid shifts)
Have an assistant (or patient) place ulnar aspects of hands firmly on abdomen from caudad to cephalad.
Place one hand on opposite side of lateral aspect of abdominal cavity (flank).
With free hand tap the opposite side of the flank – if fluid is present you will feel and impulse on opposite side representing shifting fluid wave.
Costovertebral Angle Tenderness (CVA)
Place the heel of your fist over the midback at the Costovertebral angle (over kidneys).
Use your fist to firmly strike your other fist.
Report as + or – CVA tenderness
Psoas Sign
Test for Appendicitis (if +)
Patient lies on left side.
Examiner takes right leg and passively extends it (standing at back side of pt pull leg towards you) while simultaneously applying counter force to patients hip.
If patient reports abdominal pain (due to irritation of inflamed psoas muscle) it is +
Obturator Sign
Used in suspected appendicitis Pt lies supine Flex pts right hip Flex pts right knee Passively internally rotate hip and if patient reports abdominal pain it is like a positive psoas sign.
Rosving’s sign
Positive in appendicitis
Also referred to as indirect tenderness
Elicited same as rebound tenderness only doing rebound in the LLQ elicits tenderness the patient reports in the RLQ.
McBurney’s Sign
Imaginary point 1 ½ to 2 inches from the anterior superior iliac spine moving on a straight line to the umbilicus.
When you get to that point palpate – pain there is usually suggestive of appendicitis.
Digital Rectal Exam
There are only two reasons NOT to do a DRE on a patient as part of a complete abdominal exam or male GU exam.
1) No rectum on patient (it can happen)
2) No digit on examiner (less likely)
But we will discuss the digital rectal exam as part of the male GU exam
