Abdomen Flashcards
Acute Abdomen
Intra-abdominal process that causes sudden, severe pain and requires surgery to prevent significant complications
- caused by bowel obstruction or peritonitis
Bowel Obstruction
partial or complete blockage of the bowel that results in failure of the intestinal contents to pass through
Peritonitis
Inflammation/infection of peritoneum
Peritoneum
silk-like membrane that lines the inner abdominal wall and covers the organs within the abdomen
Perforation
- perforated viscus
- Abnormal opening in a hollow organ (intestines)
- can result from inflammation/abscess
Examples:
untreated appendicitis, diverticulitis (or any hollow organ itits) can perforate - Serious and can be life threatening
Diverticulum
Abnormal sac or pouch formed at a weak point in the wall of the alimentary tract.
- LLQ is a common site for pain
- ex: infected diverticulum of the colon
Visceral Abdominal Pain
- occurs when organs such as the intestine or biliary tree contract forcefully or distend to stretch abdominally
- May be difficult to localize
- Varies in quality - may be gnawing, burning, cramping, aching
- When severe, can be associated with sweating, pallor, nausea, vomiting and restlessness
Parietal
- originates from inflammation of the parietal peritoneum (peritonitis)
- steady, aching pain usually more severe than visceral pain
- more precisely located over involved structure
- exacerbated by movement or cough
- patient attempts to remain still
Referred Pain
- felt in more distant sites that are innervated at approx,. the same spinal levels as the affected structures
- often develops as the initial pain, so pain may seem to travel
- may be felt superficially or deeply but is well-localized
- Pain of Ulcer, pancreas or gallbladder referred to back
- Pain of gallbladder/biliary tree may be referred to right shoulder or scapula.
- Pain from pleurisy or acute MI may be referred to epigastric area.
Cirrhosis
Liver scarring resulting in poor liver function
Portal Hypertension
high blood pressure in the portal vein
- due to liver disease
- resistance to flow in the portal system causes blood to back up and flow down alternate channels.
Ascites
Abnormal collection of fluid within the peritoneal cavity (intraperitoneal fluid)
Usu. due to cirrhosis
Pathophysiology not completely understood (“overflow”)
Ascites: free intra-abdominal fluid
Free fluid goes to the dependent part of the abdominal cavity
Gas-filled loops of bowel float to the top and the percussion sound is tympanitic until the fluid level is reached during percussion
Jaundice
Results from increased levels of bilirubin (aka hyperbilirubinenia)
(Bilirubin produced when rbc’s breakdown)
Normally the liver removes old rbc’s, conjugates bilirubin – then conjugated bilirubin is excreted in bile (byproduct of the liver that functions in digestion) into the small intestine into the stool
Liver cells secrete bile →
bile collected by system of hepatic ducts →
drain into common hepatic duct →
common hepatic duct joins with cystic duct from the gallbladder to form the common bile duct →
common bile duct transports bile into the duodenum (small intestine)
(Unconjugated hyperbilirubinemia)
E.g. Excessive # of dying rbc’s (Hemolytic jaundice, rare)
(Conjugated hyperbilirubinemia)
The liver is overloaded or damaged (Hepatic jaundice)
E.g. Hepatitis
Bilirubin from the liver is unable to move through the digestive tract properly (Biliary obstruction)
E.g. Bile duct obstruction
Bile Pathway
Liver cells secrete bile →
bile collected by hepatic ducts →
drain into common hepatic duct →
common hepatic duct joins with cystic duct from the gallbladder to form the common bile duct →
common bile duct transports bile into the duodenum (small intestine)
Unconjugated hyperbilirubinemia
Excessive # of dying rbc’s (Hemolytic jaundice, rare)
Conjugated hyperbilirubinemia
The liver is overloaded or damaged (Hepatic jaundice)
E.g. Hepatitis
Biliary Obstruction
Bilirubin from the liver is unable to move through the digestive tract properly (Biliary obstruction)
E.g. Bile duct obstruction
Preferred order for abdomen examination?
inspection, auscultation, percussion, palpation
Striae
Large normal-colored stretch marks Pregnancy Weight gain Rapid growth Large purple-colored stretch marks Seen in Cushing’s disease and steroid use
Cullen’s Sign
ecchymosis over the umbilicus
Both late signs suggesting intra-abdominal bleeding
Assoc. with severe, life-threatening acute pancreatitis
Grey Turner’s Sign
ecchymosis over the flanks
Both late signs suggesting intra-abdominal bleeding
Assoc. with severe, life-threatening acute pancreatitis
Normal Venous Flow
Normal venous flow above the umbilicus is upward
Normal venous flow below the umbilicus is downward
Normally, veins of the abdominal wall are scarcely visible
May be visible during normal pregnancy
Caput medusae
visible radiating veins from the umbilicus – may result from portal venous hypertension with ascites (due to collateral circulation)
diastasis recti
Separation of rectus abdominus muscles
Obvious with flexion of neck (flex abd muscles)
“Please lift your head up”
Increased Peristaltic activity
Visible waves of movement seen beneath the skin
May be seen with bowel obstruction or gastroenteritis (can be normal)
Borborygmi
hyperactive bowel sounds heard at auscultation
Hyperactive bowel sounds
Gastroenteritis
Early intestinal obstruction
Peritonitis (early)
Borborygmi – loud, active sounds
High pitched, tinkling bowel sounds
Early bowel obstruction (“mechanical SBO”)
Intestinal fluid under pressure, with rushes of fluid moving through bowel
Hypoactive
Are BS quiet or absent?
Listen for ≈ 5 min before determining BS are absent
Ileus – little to no bowel activity
Peritonitis – BS may be hyperactive initially, but eventually become hypoactive due to progressively severe inflammation; may progress to an “ileus”
Hepatomegaly may be due to
Congestive heart failure Cirrhosis Hepatitis Abscess Tumor Cysts
Shifting Dullness specialized exam
With patient supine, percuss the border of tympany & dullness
Have patient roll onto his/her side, then percuss the border again
An obvious shift in the location of the border suggests ascites is present
Splenomegaly may be due to
Mononucleosis (tender, fragile spleen)
Other viral, parasitic, or bacterial infections
Hematologic disorders
Lymphomas, some leukemias, hemolytic disease
Cirrhosis with portal hypertension
Cysts
Test for ascites
Shifting dullness
Fluid wave
Patient or assistant applies pressure down middle of abdomen to stop transmission of impulse through fat
Tapping on one side, assess for wave or vibration of fluid on other side
If present, indicates ascites
Test for peritoneal signs
Rebound tenderness
Rectal tenderness
Test for peritoneal signs associated with appendicitis
Rosving’s sign
Psoas sign
Obturator sign
Test for GB inflammation
Murphy’s sign
Succussion Splash
Infrequently done
“Shaking” the abdomen with the examiner’s hands or a brief thrust with one hand to create a “splash” sound
May be heard with or without a stethoscope
May indicate bowel obstruction or ascites
Evaluating for Peritoneal Signs
Evaluating for peritoneal signs – assessing for an “acute abdomen”
Guarding – tensing of the abdominal wall muscles to guard inflamed organs
Voluntary – distract patient
Involuntary – (involuntary guarding = rigidity)
Rebound tenderness
Note – part of evaluating for appendicitis involves evaluating for peritoneal signs
There are also specialized exams specific to appendicitis
Rebound Tenderness
A classic finding with peritonitis, but may be unnecessary
Technique – over site of most tenderness, press in, then suddenly release – observe!
Often part of evaluation for appendicitis (which causes peritonitis)
Rectal Exam
A digital rectal exam with fingertip palpation of the RLQ and LLQ may be helpful
Pain with RLQ rectal palpation suggests appendiceal inflammation (i.e. appendicitis)
Rovsing’s sign
Note – appendicitis causes peritonitis
So, patient may be guarding & may have rebound tenderness
Rosving’s sign tests for referred rebound tenderness
Press deeply and evenly in the LLQ, then quickly withdraw your fingers
Sudden pain in the RLQ is a positive Rovsing’s sign – suggests appendicitis
Psoas Sign
2 acceptable techniques:
1. Place your hand above
patient’s right knee and ask
him/her to raise his/her thigh
against resistance
2. With pt on his/her left side,
gently hyperextend his thigh
at the hip
Maneuver #1 tenses the iliopsoas muscle; maneuver #2 stretches the iliopsoas muscle
Both cause pain if there is irritation from appendeceal inflammation (ie. appendicitis)Obturator Sign
With patient supine and R knee bent, internally rotate the right leg at the hip
This stretches the internal obturator muscle – produces RLQ pain from obturator muscle irritation due to an inflamed appendix (ie. appendicitis)
Murphy’s Sign
Used to test for GB or liver inflammation – various techniques
Position fingers of R. hand or thumb of L. hand under R. costal margin & ask patient to take a deep breath
Sudden pain & abrupt cessation of inspiration suggests GB inflammation (cholecystitis) or liver inflammation
Alternate Murphy’s Sign
Lay left hand flat against liver; use fist to percuss (Murphy’s punch)
