Abdomen Flashcards
Presenting GI complaints
- Abdominal pain, acute and chronic
- Indigestion, nausea, vomiting including blood, loss of appetite, early satiety
- Dysphagia +/or odynophagia
- Change in bowel pattern
- Diarrhea, constipation
- Jaundice
- Weight loss (unintentional)
Abdomen: quadrants
9 sections of abdomen
Location of spleen
lateral to and behind stomach, just above left kidney in left midaxillary line.
upper margin rests against dome of diaphragm.
Which ribs protect most of the spleen?
9, 10, 11
Presenting urinary and renal sx
- Suprapubic pain
- Dysuria, urgency, or frequency
- Hesitancy, decreased stream
- Polyuria or nocturia
- Urinary incontinence
- Hematuria
- Kidney or flank pain
- Ureteral colic
Types of abdominal pain
- Visceral Pain: organ pain, often in hollow organs – intestine, biliary tree. Also liver. Dull & achy, difficult to localize
- Parietal Pain: often caused by peritoneum. Often sharp, can be localized and very severe. Aggravated by movement/coughing
- Referred Pain: occurs elsewhere - sites innervated at approximately same spinal levels as disordered structures. Radiating. Superficial or deep but usually localized. E.g. shoulder in cholecystitis
Types of visceral pain
Visceral pain: RUQ/epigastric
biliary tree & liver
Visceral pain: epigastric
stomach, duodenum, pancreas
Visceral pain: periumbilical
small intestine, appendix, proximal colon
Visceral pain: suprapubic or sacral
rectum
Visceral pain: hypogastric
colon, bladder, uterus
colonic pain may be more diffuse than illustrated
Referred pain: duodenal or pancreatic origin
to the back
Referred pain: biliary tree
right shoulder or right posterior chest
Referred pain: plueurisy or inferior wall MI
epigastric area
Possible movement of pain from appendicitis, visceral & parietal
visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix
Gradually changes to parietal pain in RLQ from inflammation of adjacent parietal peritoneum
Doubling over w/cramping colicky pain indicates…
renal stone
Sudden knifelike epigastric pain indicates…
gallstone pancreatitis
Epigastric pain commonly…
gastritis and GERD
RUQ pain and upper abdominal pain, think first of….
cholecystitis
Dyspepsia
chronic or recurrent discomfort or pain centered in upper abdomen
Discomfort
subjective negative feeling that is nonpainful, can include bloating, nausea, upper abdominal fullness, heartburn, etc.
Do bloating, nausea, or belching alone meet the criteria for dyspepsia?
No. Can be seen w/other d/os.
E.g., bloating w/IBD and belching w/aerophagia (swallowing air)
Functional / nonulcer dyspepsia: what is it?
3 month history of nonspecific upper abdominal discomfort or nausea not attibutable to structural abnormalities or PUD. Sx usually recurring and present >6mths
dyspepsia: causes
multifactorial, including delayed gastric emptying, gastritis from *H. pylori, *PUD, psychosocial factors
Diagnostic criteria for GERD
- chronic abdominal discomfort/pain w/primary symptoms of heartburn, acid reflux, regurgitation >once/week
OR
- mucosal damage on endoscopy
Risk factors GERD
- reduced salivary flow - prolongs acid clearance by damping action of bicarbonate buffer
- delayed gastric emptying
- selected medications
- hiatal hernia
Foods and positions that aggravate heartburn
etoh, chocolate, citrus, coffee, onions, peppermint
bending over, exercising, lifting, lying supine
atypical respiratory symptoms of GERD
cough, wheezing, aspiration pneumonia
pharyngeal symptoms: hoarseness, chronic sore throat, laryngitis
What factors indicate ordering an endoscopy (GERD)?
- uncomplicated symptoms of GERD but not responding to empiric therapy
- >55yo
- alarm Sx: dysphagia, odynophagia, recurrent vomiting, evidence of GI bleed, weight loss, anemia, risk factors for gastric cancer, palpable mass, jaundice
What are you worried about when ordering an endoscopy (GERD)?
esophagitis, peptic strictures, Barrett’s esophagus
Barrett’s esophagus
squamocolumnar junction is sisplaced proximally and replaced by intestinal metaplasia
30-fold increased risk of esophageal adenocarcinoma
RLQ pain or pain that migrates from periumbilical region, combined w/abdominal wall rigidity on palpation
most likely appendicitis
in women, consider PID, ruptured ovarial follicle, ectopic pregnancy
cramping pain radiating to right or LLQ
may be renal stone
LLQ w/palpable mass may be…
diverticulitis
Diffuse abdominal pain w/absent bowel sounds and firmness, guarding, or rebound on palpation may be…
small or large bowel obstruction
Chronic discomfort
change in bowel patterns w/mass lesion indicates …
colon cancer
IBS symptoms
Chronic discomfort
Intermittent pain for 12 weeks of preceding 12 months with relief from defecation, change in frequency of bowel movement, or change in form of stool (loose, watery, pellet-like), w/o structural or biochemical abnormalities
retching vs vomiting
retching = involuntary spasm of stomach, diaphragm, esophagus - precedes and culminates in vomiting (forceful expulsion of gastric contents out of mouth)
Regurgitation occurs in…
GERD, esophageal stricture, esophageal cancer
Fecal odor in vomitus/regurgitated contents indicates…
small bowel obstruction or gastrocolic fistula
Hematemesis may indicate…
esophageal or gastric varices, gastritis, or PUD
How much blood loss before lightheadedness, syncope
Typically >500mL
Abdominal fullness or early satiety, consider…
diabetic gastroparesis, anitcholinergic medications, gastric outlet obstruction, gastric cancer
early satiety in hepatitis
dysphagia - structural vs motility d/o
solid foods - more structural (e.g., esophageal stricture, web or schatzki’s ring, neoplasm)
solids & liquids: motility d/o more likely
odynophagia (pain on swallowing), consider…
esophageal ulceration from radiation, caustic indigestion, infection from candida, CMV, herpes simplex, HIV
can also be pill-induced from aspirin or NSAIDs
Excessive flatus, consider…
aerophagia, legumes or other gas-producing foods, intestinal lactase deficiency, IBS
Diarrhea defined
increased water content in stool, volume >200g in 24 hours
acute vs chronic diarrhea
acute: 2 weeks
chronic: 4+ weeks
quality of diarrhea from small intestine
high-volume, frequent watery stools
small-volume stools w/tenesmus, or diarrhea with mucus, pus, or blood occur in…
rectal inflammatory conditions
Significance of nocturnal diarrhea
usually pathologic
oily, sometimes frothy or floating diarrhea
steatorrhea - from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth
Medications commonly assoc w/diarrhea
PCN and macrolides, magnesium-based antacids, metformin, herbal and alternative meds
constipation defined
at least 12 weeks of prior 6 mths w/at least 2 of following:
- fewer than 3 bms/week
- 25% or more defecations w/either straining or sensation of incomplete evacuation
- lumpy or hard stools
- manual facilitation
thin, pencil like stools
possibly an obstrucing “apple-core” lesion of the sigmoid colon
Medications assoc w/constipation
anti-cholinergics, CCBs, iron supplements, opiates
diseases assoc w/constipation
diabetes, hypothyroidism, hypercalcemia, MS, Parkinson’s, systemic sclerosis
obstipation
no passage of feces or gas - indicates intestinal obstruction
melena
black tarry stools - upper GI bleeding
may occur w/as little as 100mL blood
hematochezia
stools that are red or maroon colored -
indicates >1000 mL blood, usually d/t lower GI bleed
mechanisms of jaundice
- increased production of bilirubin
- decreased uptake of bilirubin by hepatocytes
- decreased ability of liver to conjugate bilirubin
- decreased excretion of bilirubin into bile, resulting in absorption of conjugated bilirubin back into blood
first 3 result in predominately unconjugated bilirubin
conditions resulting in jaundice
predominately unconjugated bilirubin: e.g., hemolytic anemia (increased production), Gilbert’s syndrome
impaired excretion of conjugated bilirubin: viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis, as from OCs, methyl testosterone, chlorpromazine
What to ask about if see jaundice?
- Urine color: dark indicates impaired excretion of bilirubin into GI tract (only conjugated ends up in urine)
- Stool color: excretion of bile into intestine is completely obstructed, so stools are acholic (w/o bile). Occurs briefly in viral hepatitis, common in obstructive jaundice.
- Pruritis
- Risk factors for liver Dz
Risk factors for liver Dz
- *hepatitis: *A (ass), B (body fluids, IV drugs), C (IV drugs, blood transfusion)
- *Alcoholic hepatitis/cirrhosis: *
- Toxic liver damage: meds, industrial solvents, environmental toxin, some anesthetic agents
- *Gallbladder dz or surgery: *may result in extrahepatic biliary obstruction
- hereditary d/os: in family Hx
Pruritis in jaundice indicates…
cholestatic or obstructive jaundice
pain in skin w/jaundice indicates…
distended liver capsule, biliary colic, pancreatic cancer
Symptoms of BPH or urethral stricture
Trouble starting, stand close to toilet to void, change in force/size of stream, straining to void, hesitate or stop in middle of voiding, dribbling when finished
Men: prostatic pain vs urinary infection pain
infection: burning proximal to glans penis
prostatic pain: in perineum and occasionally in rectum
Painful urination occurs in…
cystitis, urethritis, UTI
Dysuria, consider…
bladder stones, foreign bodies, tumors, acute prostatitis
burning on urination in women
internal: urethritis
External: vulvovaginitis
urgency in urination suggests…
bladder infection or irritation
in men, painful urination w/o frequency or urgency suggests…
urethritis
Urinary frequency: polyuria vs frequency w/small amts
polyuria - large amounts
frequency w/o polyuria - bladder d/o, impairment to flow at or below bladder neck
Types of incontinence
- Stress: increased abdominal pressure, d/t poor urethral sphincter tone or poor support of bladder neck
- **urge: **urgency then immediate leakage d/t uncontrolled detrusor contractions that overcome urethral resistance
- **overflow: **neurologic d/o or anatomic obstruction limits emptying until overflow
- **functional: **d/t impaired cognition, musculoskeletal problems, immobility
Sx acute pyelonephritis
kidney pain, fever, chills
typically dull, aching, steady
Sx sudden obstruction to ureter, e.g., d/t renal or urinary stones or blood clots
Renal or ureteral colic - severe, originates at CVA and radiates around trunk into lower quadrant of abdomen, possibly into upper thigh and testicle or labium. Ask about fever, chills, hematuria
Classic signs of alcoholism
hepatosplenomegaly, ascites, caput medusa, spider angiomas, palmar erythema, peripheral edema
caput medusa
collateral pathway of recanalized umbilical veins radiating up the abdomen that decompresses portal vein hypertension
Inspection: striae
silver normal
Purple – think Cushing’s syndrome
Inspection: dilated veins
can be indicative of hepatic cirrhosis or IVC obstruction
Inspection: ecchymosis of abdominal wall
intraperitoneal or retroperitoneal bleeding
Contour of abdomen: possibilities
flat, rounded, protuberant, scaphoid (markedly concave or hollowed)
Inspection: Bulging of flanks indicates…
ascites
Inspection: suprapubic bulge indicates
distended bladder or pregnant uterus
Inspection: lower abdominal mass indicates
ovarian or uterine cancer
Inspection: assymetrical abdomen suggests
enlarged organ or mass
Inspection: increased peristalsis indicates
intestinal obstruction
Normal bowel sounds
clicks and gurgles, 5-34/minute
occasionally borborygmi
borborygmi
prolonged gurgles of hyperperistalsis, “stomach growling”
Auscultation: what indicates renal artery stenosis?
bruit in one of the upper quadrants, w/both systolic & diastolic component
(4-20% of healthy individuals have abdominal bruits)
Friction rub over liver or spleen indicates…
hepatoma, gonococcal infection around liver, splenic infarction, pancreatic carcinoma
protuberant abdomen tympanitic throughout suggests…
intestinal obstruction
Percussion: Why might you find an air bubble on the right and dullness on the left of the abdomen
rare condition - situs inversus, organs are reversed
How to categorize abdominal masses
- physiologic: pregnant uterus
- inflammatory: diverticulitis of colon
- vascular: AAA
- neoplastic: colon cancer
- obstructive: distended bladder or dilated loop of bowel
Palpating the liver
left hand behind pt, parallel to and supporting right 11th and 12th ribs and adjacent to soft tissues below. Remind pt to relax on hand if necessary.
Right hand lateral to rectus muscle, fingertips well below lower border of liver dullness, press gently in and up as pt takes deep breath
How does the liver feel in your hands?
may not feel it, but if you do, normal liver is soft, sharp, regular, w/smooth surface
may be slightly tender
Tenderness over liver suggests…
inflammation, as in hepatitis
or congestion, as in heart failure
Percussion of spleen
Percuss left lower anterior chest wall roughtly from border of cardiac dullness at 6th rib to anterior axillary line and down to costal margin (Traube’s space)
if dullness, palpation correctly detects 80% of time
Splenic percussion sign
Percuss lowest interspace of left anterior axillary line. Percuss w/deep breath. Should be tympanitic on both.
Causes of splenomegaly
portal hypertension, hematologic malignancies, HIV, splenic infarct or hematoma
2 positions to check for splenomegaly
- 1st, supine. Left hand supports and presses forward lower left rib cage (from below), right hand below Rt costal margin, palpation on inspiration
- 2nd: right lateral, legs somewhat flexed at hips and knees
splenomegaly vs enlarged left kidney
if both in left flank, suspect splenomegaly if notch is palpated on medial border, the edge extends beyond midline, percussion is dull, fingers can probe deep into medial and lateral borders, but NOT between mass and costal margin
palpate kidney
Left from left side
- right hand behind pt, just below and parallel to 12th rib, fingertips just reaching CVA.
- Lift.
- Place left hand on LUQ, lateral and parallel to rectus muscle.
- On deep inspiration, press left hand firmly and deeply down into LUQ, trying to capture kidney.
- Ask pt to breathe out then stop breathing briefly. Slowly release pressure as you feel for it to move back into position
OR similar to spleen, from right side
Right kidney: from right side, same method
causes of kidney enlargement
hydronephrosis, cysts,tumors
bilateral: PKD
CVA tenderness indicates
pylenephritis or musculoskeletal cause
How much bladder volume before dullness?
400-600mL
how to palpate aorta
press firmly deep in upper abdomen, slightly to left of midline. If >50, assess width
Normal is
Risk factors for AAA
>65yo, hx smoking, male, 1st degree relative w/hx of AAA repair
Distinguishing mass of abdominal wall from abdominal mass
abdominal wall: remains palpable if does half sit up or bears down
intra-abdominal: obscured by muscle contraction
history taking: significance of aspirin, steroids, PPIs
- Aspirin : increased risk of bleeding, assoc w/gastric ulcers
- Steroids: increase risk bleeding & ulceration
- PPIs treat reflux dz
Pain and structures: epigastric
Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen
Pain and structures: upper right corner
Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen
Pain and structures: upper left corner
Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen
Pain and structures: periumbilical
jejunum, ileum, appendix, ascending colon
Pain and structures: lower abdomen
GU structures: bladder, prostate, uterus
Pain and structures: Right lower quadrant
appendix, fallopian tube, ovary
Pain and structures: Left lower quadrant
sigmoid colon, fallopian tube, ovary
Pain and structures: Flanks
kidneys
Differential Dx: pain in RUQ
- Duodenal ulcer
- Hepatitis
- Hepatomegaly
- Pneumonia
- Cholecystitis
Differential Dx: Pain in RLQ
- Appendicitis
- Salpingitis
- Ovarian cyst
- Ruptured ectopic pregnancy
- Renal/ureteral stone
- Strangulated hernia
- Diverticulitis
- Regional ileitis
- Perforated Cecum
Differential Dx: pain in LUQ
- Ruptured spleen
- Gastric ulcer
- Aortic aneurysm
- Perforated colon
- Pneumonia
- Pyelonephritis
Differential Dx: pain in LLQ
- Sigmoid diverticulitis
- Salpingitis
- Ovarian cyst
- Ruptured ectopic pregnancy
- Renal/ureteral stone
- Strangulated hernia
- Perforated colon
- Regional ileitis
- Ulcerative colitis
Differential Dx: periumbilical pain
- Intestinal Obstruction
- Acute pancreatitis
- Early appendicitis
- Mesenteric thrombosis
- Aortic aneurysm
- Diverticulitis
Differential Dx: Pelvic pain
- Bladder
- Distension
- Infection
- Stones
- Prostatitis
- Uterus
- Urethritis, vulvovaginitis,
Preparation for abdominal exam
- Empty bladder
- Ask patient to point to painful areas
- Distract patient with conversation – esp when beginning palpation.
- Ensure proper draping
- Position properly
- Pillow under head
- Pillow under knees
- Arms at sides or cross chest
Linea nigra
black line down abdomen, normal in pregnancy
bruits: bell or diaphragm?
bell
friction rubs & venous hums: bell or diaphragm?
diaphragm
Abdomen: what to percuss
- 4 Quadrants for masses, fluid or gas
- Liver
- Spleen
- Costovertebral angle
Characteristics of tympany
- High pitch note
- Predominates due to gas in the intestines
- Protuberant abdomen with tympany may be intestinal obstruction
Characteristics of dullness
- Short, no resonance
- Scattered: feces
Dullness over large areas may be…
- Organ
- Enlarged liver
- Distended bladder
- Mass: ovarian tumor
- Pregnancy
Dulness at flanks may be…
Ascites
normal vertical span of liver
Adult:
6-12 cm in MRCL
4-8 cm at midsternal line
Image - location of abdominal pain and etiology
Fluid Wave test
- For ascites
- Patient or assistant presses edges of both hands down midline of abdomen
- Hold your hand on one flank, tap opposite side with other hand
Shifting dullness
- for ascites
- Percuss border of tympany and dullness with patient supine
- Ask patient to rotate to side and repeat
- In ascites, dullness shifts
Mc Burneys point
test for appendicitis
2 inches from anterior superior spinous process of ilium (1/3 way between ASIS & umbilicus) - pain w/pressure
Rovsing’s sign
test for appendicitis
Press gently on LLQ elicits pain in RLQ
Rebound tenderness
test for appendicitis
Quickly withdraw hand elicits increase in RLQ pain
Psoas sign
test for appendicitis
- Place hand above right knee
- Ask patient to raise leg
- Or patient turned on left side, extend right leg at hip
Oburator sign
test for appendicitis
- Flex patients right thigh at hip
- Knee bent
- Rotate leg medially and laterally
Special test for cholecystitis
Murphy’s sign
- Ask pt take deep breath out. When in full expiration, Hook left thumb and fingers of right hand under costal margin. Then ask to take deep breath in.
- A sharp increase in tenderness with sudden stop in inspiratory effort is positive sign
- Acute cholecystitis
Red alerts for abdominal emergency: subjective
- Progressive intractable vomiting
- Lightheadedness on standing (bleeding)
- Acute onset of pain
- Pain that progresses in intensity over hours
red alerts for abdominal emergency: objective
- Involuntary guarding
- Progressive abdominal distension
- Orthostatic hypotension
- Fever
- Leukocytosis (elevated WBC)
- Decrease urine output
Potential surgical emergencies
- Perforation: look for signs of peritonitis (generalized pain, fever, elevated WBC)
- Ectopic pregnancy: in any woman of childbearing years (positive pregnancy test, vag bleeding, abd pain)
- Appendicitis: RLQ pain (mean age, 22 – increases teenage years, starts to decline)
- Obstruction: elderly (tendency, +meds that cause. Hyperactive BSs above obstruction, diminished or absent below, + nausea, vomiting)
- Ruptured abdominal aortic aneurysm: when back pain is present (severe sharp back pain, can be fatal)
- Intussusception: in infants (telescoping of intestine onto self. Currant jelly stool, vomiting or lump in abdomen)
- Malrotation: infants < 1 month old (congenital abnormality; organs displaced w/in abdomen)
RED ALERTS: Peritonitis
- Pain: front, back, sides
- Electrolytes full-shock ensues
- Rigidity or rebound of anterior abdominal walls
- Immobile abdomen and patient
- Tenderness with involuntary guarding
- Obstruction
- Nausea and vomiting
- Increasing pulse rate, decreasing blood pressure
- Temperature falls and then rises, tachypnea
- Increasing girth of abdomen
- Silent abdomen: no bowel sounds
Lab Tests - abdomen
- Complete blood count with diff (leukocytosis)
- Qualitative urine (hCG)
- Erythrocyte Sedimentation Rate (inflammation marker)
- Urinalysis (urinary Sx, or older adults w/vague Sx)
- Urine C&S (for antibiotics)
- Cultures of STDs
- Fecal Occult Blood Tests
- LFT’s (e.g., if hepatomegaly)
- Amylase and Lipase (pancreatitis)
- Cardiac Enzymes (esp in women, who present w/MIs differently)
Diagnostic tests, abdomen
- Electrocardiogram (suspect MI)
- Radiography
- Anteriorposterior
- Abdominal/pelvic ultrasound (appendicitis, esp kids when don’t want to subject to radiation)
- Computed Tomography/ MRI
- Colonoscopy
Screening for ETOH abuse: who and how
US Preventive Services Task Force (USPSTF) recommend screening for all adults
CAGE
AUDIT
Screening for colon cancer: who and how
assess for risk beginning at age 20 and if high risk, refer for complex mgmt
If avg risk, offer screening options at 50yo
- High-sensitivity fecal occult blood test (annually)
- Sigmoidoscopy every 5 years w/ FOBT every 3 yr
- Screening colonoscopy every 10 years.
Life of bilirubin
- bile pigment derived chiefly from breakdown of hemoglobin
- Hepatocytes conjugate bilirubin (combine unconjugated bili w/other substances) so that it is water soluble, then excrete into bile.
- Bile passes through cystic duct into common bile duct, which also drains extrahepatic ducts from liver.
- More distally, common bile duct and pacncreatic ducts empty into duodenum at ampulla of Vater
