Abdomen 3 Flashcards
Where are the kidneys and what type of structures are they?
- retroperitoneal structures
- on the posterior abdominal wall
What is. landmark in predicting positions of kidneys?
transpyloric plane at L1
What is the transpyloric plane at L1 at the same horizontal level?
that passes through the tips of the 9th costal cartilages (at which the lateral margins of each rectus abdominis muscle meets the costal margin)
In a supine patient what does. the transpyloric plane at L1 guide you?
to the approximate level of the hila of the kidneys
What is the level of the kidneys like usually?
- right kidney lies slightly lower than the left
- sometimes ind the right and left kidneys at the same level, or the left kidney slightly higher
What do the ureters from the hill of the kidneys descend almost vertically downwards into?
iliac fossa
What are the ureters like in anteroposterior (AP) radiographs of lumbosacral region?
They lie close to the tips of the transverse processes of the lumbar vertebrae (L2, 3,4 & 5) and the sacroiliac joint
How are you able to make the position of the kidney on the posterior surface of the trunk?
ask the subject to sit on the side of the couch with the posterior side of their trunk exposed and facing towards you
What are the steps to label the position of the kidney?
- mark the position of the transpyloric plane on the anterior abdominal wall
- the extrapolate this plane to the posterior abdominal wall
- It is also possible surface mark the spine of the L1 vertebra directly on the posterior abdominal wall without first surface marking the transpyloric plane
How do you determine the position of the L1 vertebra?
- mark the position of the T12 vertebral level which is roughly half way between the inferior angle of the scapula and the highest point of the iliac crest at the scapular line
- From the T12 level you will count one vertebral spine downwards for the L1 vertebra
How do you know the scapular line?
runs vertically along the medial border of the scapula (or along the lateral border of erector spinae muscles)
Where is the hila (or medial border) of the kidneys?
-5 cm from the posterior median line
What are the dimensions of an adult kidney?
about 9 -12 cm long and 5- 7 cm broad depending on the body size
What are the superior poles of the kidneys covered by?
12th ribs
Where are the inferior poles of the kidney?
3 -4 cm above the iliac crests which are well below the 12th ribs
How do you surface mark the position of the ureter?
- choosing two points
1. first point is marked 5 cm lateral to the posterior median line at L1 level
2. second point at the posterior superior iliac spine (PSIS) which is usually indicated by a skin dimple on the posterior surface of the trunk
3. connect these two points to visualize the position of the ureter which runs along the tips of the transverse processes of the lumbar vertebrae
What are the kidneys palpated through?
anterior abdominal wall
What position should you ask the patient to be in when palpating the kidneys?
- supine position
- If necessary, the knees and hips may be semi flexed to relax the abdominal wall muscles
- entire abdomen should be exposed
Where do you palpate the lower poles of the kidneys?
through the anterior abdominal wall just below the costal margins
Where do you palpate the upper poles of the kidneys?
upper poles are not palpable because they are inaccessible
What is bimanual palpitation?
use both hands
How do you carry out bimanual palpitation with your left hand?
- Keep the left hand underneath the subject’s flank with palm facing upwards (anteriorly) and the fingers in the renal angle (costophrenic angle)
- Left hand pushed anteriorly from the loin region (in the renal angle region)
What is the renal angle?
the angle between the posterior median line and the lower border of the 12th rib
How do you carry out bimanual palpation with your right hand?
- Right hand presses deep into the flank region below the costal margin
- right hand to palpate the kidney through the anterior abdominal wall of the upper quadrant
What does the patient need to do in bimanual palpation?
- You should press down deeply below the costal margin
2. Ask the subject to take a deep breath whilst you try to “capture the kidney” between the two hands
How is the lower poles of the kidney felt?
descending during inspiration
Is an enlarged kidney easier to palpate?
Yes
What is balloting?
- Once you have palpated the kidneys by the bimanual method
- confirm this by pushing the kidney back and forwards between the two hands
What do the right hand do in balloting?
keep the right hand (anterior hand) in deep palpation position in the upper quadrant parallel to lateral border of the rectus abdominis muscle
What does. the left hand do in balloting?
left hand (posterior hand) will be in the renal (costophrenic) angle and you will swiftly flex the index and middle fingers at the metacarpophalangeal joints in order to push the lower pole of the kidney anteriorly to “strike” the right (palpating) hand
What is the path of the thoracic aorta?
passes through the aortic opening of the diaphragm and enters the abdominal cavity in the midline in front of the body of T12 vertebra
Where does the abdominal part of the aorta end?
descends vertically down along the midline and ends, slightly to the left, at the level of L4 vertebra (supracristal plane) where it divides into right and left iliac arteries
How do you determine the position of the abdominal aorta?
line drawn from the xiphisternal joint (palpable landmark, T8/9 level) through the umbilicus to the supracristal plane (L4 level)
What is the extension of the abdominal aorta?
T12 to L4
How do you surface mark the abdominal aorta?
palpate the xiphisternal joint and draw a vertical line from this point through umbilicus to the supracristal plane (4)
Where does the aorta bifurcate?
At level of L4
How do you palpate the abdominal aorta?
- palpated above the umbilicus just left of the midline
- use both hands with the palm facing downwards with pads of the fingers pressing deeply into the abdominal wall
- fingers of both hands will be pointing towards the epigastrium whilst the ulnar borders (little finger side) lie parallel to the right and left costal margins
- Ulnar border of hands parallel to costal margins
- Apply moderate pressure to feel the artery
- Medial surfaces and the pads of index fingers will palpate artery
When is it easier to palpate the abdominal aorta?
thin person
What do you feel in normal abdominal aorta?
able to feel a pulsation under your fingers
What do you feel in AAA?
if it was a pulsatile and expansile (pushes up against your fingers) mass
In what area to you auscultate for bruits? What would bruits suggest in each?
- Over the renal arteries - 2cm superior and laterally (on both sides), bruits would suggest renal artery stenosis
- Over the liver - bruits would suggest a liver tumour
- Over the iliac arteries - bruits would suggest artery stenosis
- Over the aorta - bruits would suggest AAA
What is shifting dullness a technique for?
examining for ascites
What is ascites?
the accumulation of fluid in the peritoneal cavity, classically due to liver cirrhosis
What would happen in the subsequent liver failure?
- a decreased metabolism of aldosterone and antidiuretic hormone by the liver
- leading to retention of salt and water
- decreased production of albumin leading to decreased oncotic pressure
- all causing a leak of fluid into the peritoneal space
- Ascites can also be caused by liver cancers and heart failure
How do you examine shifting dullness?
- patient lying supine
- percuss from the midline out to the flanks - noting where the change from resonant to dull occurs.
- hen mark that spot and ask the patient to turn onto the opposite side
- Once the patient has done that, we wait for 10 seconds to allow the fluid to shift and we will then palpate the spot, if the area of dullness is now resonant, this indicated that ascites is present
What does testing for abdominal thrills test for?
ascites, especially if the abdomen is tensely distended
How do you carry out abdominal thrills test?
- place the palm of your hand against the flat side of the patient’s abdomen
- then flick a finger of the other hand against the opposite side of the abdomen
What happens in you feel the flick against your hand?
- ask an assistant or the patient to place the edge of their hand on the midline of the abdomen so that the flick will only be transmitted via the ascites
- If you still feel it, an abdominal thrill is present suggesting ascites
