Abdomen Assessment Flashcards
When is an assessment of the newborn abdomen best performed?
during the first few hours of life, when the bowel is not yet filled with gas; quiet state with relaxed abdominal muscles
What antenatal ultrasound findings would alert the clinician to evaluate the abdomen throughly on initial assessment?
enlarged kidneys, dilated bowel or unusual masses
What percentage of infants with a history of polyhydramnios have major structural malformations?
20-30%
The risk of structural anomaly increases in relation to what physical finding?
with greater amount of amniotic fluid
A maximum vertical pocket of amniotic fluid >16cm increases the chance of anomaly to what percent?
90%
What are the most common GI abnormalities a/w polyhydramnios?
esophageal atresia and duodenal atresia
What physical finding at delivery may indicate the presence of duodenal atresia?
the finding of an extremely large amount of amniotic fluid in the stomach
What physical findings may indicate esophageal atresia, usually a/w tracheoesophageal fistula?
the presence of copious oral secretions coupled with the inability to pass a soft catheter to the stomach
What might the presence of bilious gastric secretions at delivery indicate?
abnormal finding; possible intestinal obstruction
Describe the skin in the abdominal region of a newborn.
newborn rash may be present, bruising r/t delivery (rare); a few large visible veins, especially on light skinned infants, marked venous dissension should not be present; post term infant may have superficial cracking and peeling
What is the shape and movement of a normal term infant?
soft and rounded with easy movements a/w respiratory effort (parallel abdomen and chest movement)
What might asynchronous abdominal and chest movement indicate?
respiratory distress
Where should abdominal girth be measured?
at the greatest diameter, just above the umbilicus
How does abdominal girth relate to OFC?
abdOFC after 36wk GA
What does a sunken, or scaphoid, abdomen indicate?
CDH
How might a normal preterm infant’s abdomen present and why?
may appear distended r/t lack of muscle tone
Why might a term infant have decreased abdominal muscle tone?
effects from maternal medications during labor
What are the typical features a/w prune belly syndrome?
a flaccis, lumpy abdomen (congenital absence of and musculature); occurs mostly in males and is a/w severe renal and urinary tract anomalies
How does bowel obstruction present?
distension and vomiting, the timing and character of which can vary depending on the location of the obstruction
What is included in the differential diagnosis of an isolated lower abdominal dissension?
bladder distension, GU anomalies, female reproductive tract anomalies or teratomas
As the level of obstruction progresses down the intestinal tract, how does symptomatology change?
abdominal dissension and bilious vomiting
What is bilious emesis the result of?
obstruction beyond the level of the ampulla of Vater, where bile from the gallbladder enters the small intestine
What is the only bowel obstruction that can p/w abdominal dissension at birth?
meconium ileus; abd dissension otherwise presents only after the infants has swallowed air to fill the bowel
What is the etiology of a meconium ileus?
it is the abnormal result of pancreatic enzyme function seen with CF
The presence of bilious emesis with or without abdominal dissension requires assessment to investigate what pathologic state?
malrotation with midgut volvulus
What is the etiology of malrotation?
results from abnormal fixation of the intestine in the abdomen
What is the etiology of a midgut volvus?
the abnormal rotation of the bowel around the mesentery and subsequent obstruction of blood flow to the bowel
Why does the presence of a midgut volvus necessitate immediate surgical intervention?
to avoid irreversible infarction of the intestine
What is the significance of visible loops of bowel?
more common in preterm, only of concern if it remains fixed in one spot or is a/w generalized distention and symptoms of bowel obstruction.
What is diastasis recti and how does it present?
a midline separation of the rectus abdomens muscles and can be seen as a midline, elevated ridge extending from below there sternum to the umbilicus when the infant is crying
What is the significance of a diastasis recti?
a normal finding and will resolve without intervention
In what population are umbilical hernias more common?
African American, LBW males, hypothyroidism
What is an umbilical hernia?
a protrusion of abdominal contents into the hernia, which is soft and reducible
When are umbilical hernias expected to resolve?
spontaneously resolve by 2 years of age
What is an epigastric hernia?
a small, from, palpable nodule seen between the umbilicus and the xiphoid process
What is the etiology of an epigastric hernia?
it results from fat protruding through a small opening in the muscle
What is the prognosis of an epigastric hernia?
surgical intervention is required
Describe the umbilical cord of a typical term infant.
shiny, pearly white and gelatinous; AVA; avg size is 1.5-2cm at the base
What is the role of Wharton’s jelly?
protects the vessels
What is the relative size of the umbilical cord an indicator of?
the nutritional status of the fetus
How can the umbilical cord of a fetus be translated into an indicator of nutritional status?
a thick cord is often seen in LGA infants, whereas a small, thin cord is often seen in babies who are SGA, post mature or who had placental insufficiency
If any bulges or herniations are observed in the umbilical cord, what condition should be investigated for?
omphalocele
Describe the appearance of umbilical arteries.
the paired arteries are small, thick walled and constricted
Describe the appearance of the umbilical vein.
is large, thin walled and open
In what percentage of the population is the absence of 1 artery seen?
1%
What other anomalies is a single umbilical artery associated with?
CV, GI, GU or may be an isolated finding in an otherwise normal baby
Under what conditions might an umbilical cord present with a yellow or green color?
meconium staining that occurred 6-12hours prior to delivery; green may rarely be an indicator of infx
How does omphalitis present?
as redness encircling the cord and extending onto the abdomen
When should omphalitis be treated?
promptly and properly bc it can spread rapidly to underlying structures causing severe systemic disease and even death
What is a typical finding after initial cutting of the umbilical cord?
ooze a small amount of clear, sticky fluid, but it will dry quickly
When should the umbilical cord be expected to shrivel and fall off?
in normal situations, the cord will begin to dry soon after birth and will fall off within 10-14 days
What does purulent discharge from the umbilical cord indicate?
the presence of an abcess
What does excessive amounts of clear drainage from the umbilical cord indicate?
the presence of a patent urachus; this patient will have leakage of ileal contents through the umbilical cord
What is a patent urachus?
the persistence of the embryologic tract connecting the ileum to the umbilicus
What is the name for the embryologic tract connecting the ileum to the umbilicus?
omphalomesenteric duct
What is an umbilical polyp>
a small, red, raw-appearing granuloma which will occasionally form at the site of separation from the umbilical cord
What is an omphalocele?
the herniation of abdominal contents into the umbilical cord; hernia is contained in a translucent sac that is contiguous with the umbilical cord
Why should the examiner be careful during an assessment of an omphalocele?
the translucent sac may rupture at or before delivery
What is the mechanism for the presentation of an omphalocele?
thought to result from failure of the bowel to reenter the abdominal cavity after its normal extrusion into the cord before the 10thwk GA
The failure of bowel to reenter the abdominal cavity results from what?
from faulty migration and fusion of embryonic tissues
An omphalocele is associated with what other congenital anomalies?
cardiac, neurologic, GA, skeletal or chromosomal abnormalities in 67% of infants
What syndromes are most likely to present with an omphalocele?
Beckwith-Wiedemann, trisomies 13, 18 and 21
What is a gastroschisis?
a defect in the abdominal wall through which the viscera protrude; there is no sac enclosing contents; discrete from the umbilical cord
Where is a gastroschisis typically located in relation to the umbilical cord?
usually to the right of midline
What are the possible etiologies of a gastroschisis?
1) in utero rupture of an umbilical cord hernia; 2) vascular accident interfering with normal formation of abdominal musculature
What is the incidence of additional associated anomalies?
lower incidence with gastroschisis than omphalocele
What additional associated anomalies may present with a gastroschisis?
atresias of the bowel and/or ischemic enteritis; resulting from constriction of the mesenteric blood flow
Why does extrophy of the bladder occur?
very rare defect; malformation sequence resulting from lack of normal formation of the lower abdominal wall early in gestation
What is extrophy of the bladder?
the posterior wall of the bladder is exposed and urine drains into the abdomen
In what gender is extrophy of the bladder more common?
Males
What other associated abnormalities typically present with extrophy of the bladder?
may be associated with urogenital anomalies in both males and females
What features should be investigated when assessing the perianal area?
the presence and placement of the anus, for anal sphincter tone and for the presence of anomalies (ex: fistulas)
How can anal sphincter tone be assessed?
gentle digital stroking the anal area; an anal wink will occur
What does the absence of anal winking suggest?
an abnormality of the CNS
Where can anal atresia and stenosis occur and when can patency be established?
atresia and stenosis can occur at any level of the anorectal canal; patency cannot be established until the passage of meconium
Why is digital examination of the rectum, or the insertion of instruments not recommended in the newborn exam?
the risk of damage to the anal canal
When is the passage of meconium expected?
within 24h of birth, often within 12h. however, a normal infant may not stool until 48h of life
What does the continued absence of meconium suggest?
anal atresia
What does the passage of very small caliber stool suggest?
anal stenosis
What is perianal fistula?
an anomalous connection between the intestinal tract and the GU tract
What presentation suggests the presence of a rectovaginal fistula?
meconium in the vagina
What presentation suggests the presence of a rectourethral fistula?
meconium in the urethral orfice
Why should auscultation be performed before palpation in the abdominal assessment?
bc palpation can interfere with normal bowel sounds as well as cause agitation
When can bowel sounds be appreciated?
BS will be audible beginning 15 min after birth, although they are relatively quiet until feedings have begun
What features should be investigated as it relates to BS?
presence, quality and intensity
How are normal BS described?
have a metallic, tinkling quality and are heard every 15-20 sec
What must be done before a determination of absent BS can be made?
the examiner should listen for a full 5 min in each abdominal quadrant
What might hyperactive BS indicate?
in a healthy-appearing baby who has just been fed- normal; ill-appearing infant with a distended abdomen is not normal and could indicate an obstruction
What might be a cause of hypoactive BS?
maternal sedation
How should audible breath sounds in the upper abdomen be interpreted?
as a normal finding bc sounds transmit easily throughout an infant’s body
How should audible vascular sounds in the upper abdomen be interpreted?
not normally auscultated over the abdomen of a term infant
What is the cause of a bruit?
the sounds of turbulent blood flow through a restricted of tortuous vessel
The auscultation of a bruit over the abdomen may indicate what?
malformations of the hepatic or renal vessels or hemangiomas
What maneuver can aid in palpating the abdomen during a newborn exam?
if the baby is fussy, flexing the hip to relax abdominal muscles may help
What is the typical presentation of abdominal skin?
warm, pink and with brisk cap refill
What does hypertonicity of the abdominal musculature suggest?
may indicate psi or peritoneal irritation
What does hypotonicity of the abdominal musculature suggest?
neuromuscular disease, perinatal depression or if the mother has taken medications that cause neonatal depression
How should palpation of the abdominal region progress?
should begin with the superficial structures and then progress to the deeper organs
How does organ location differ in infants as compared to children?
the shape of the thorax in newborns is such that the upper abdominal organs are not as thoroughly covered but he anterior rib cage and can be easily felt on exam
What abdominal organ should be palpated first?
liver
Where is the normal newborn liver located?
occupies a wide area os the upper abdomen extending well into the left upper quadrant; extends 1-2cm below the right costal margin
How should the liver be palpated?
the examiner should begin just above the iliac crest on the right; using the palmar surface of the fingers parallel to the costal margin, gently palpate in a progressively caudal fashion; depression should be 1-2cm
When palpating the liver, why should care be taken to not lift the hands completely off the abdomen?
this may result in missing the edge of an enlarged liver
How does a normal liver edge typically present?
normally smooth, firm and sharp
What does a boggy liver indicate?
is a sign of congestion, may indicate congestive heart failure
What other liver presentations are abnormal?
a hard or nodular liver edge
Following the liver, what organ structure is then palpated for on the left side of the abdomen?
the spleen
What is typical of spleen palpation?
the tip of the spleen may be felt, but in many cases, is not palpable at all
What might indicate an enlarged spleen and warrant further investigation?
a spleen that is palpable more than 1cm below the costal margin
What is complete situs inversus?
reversal position of all the thoracic and abdominal organs
What is partial situs inversus?
the reversal position of some but not all of the abdominal organs
Situs inversus is associated with congenital anomalies of what other organ system?
CV, but such defects are more common in partial situs inversus
When are the kidneys most easily palpated?
When done early, before the infant has eaten or begun prolonged crying
How should the kidneys be palpated?
using deep palpation at 45 degree angle caudal and lateral to the umbilicus; one hand under the infant’s back and the other depressing the abdomen
How large is the normal newborn kidney?
4.5-5cm from the upper to the lower pole
Where is the right kidney typically positioned in relation to the left?
the right kidney is normally situated slightly lower than the left
What does a very easily palpated kidney indicate?
the kidney is usually enlarged and indicative of hydronephrosis or a cystic kidney
What consistency should a kidney feel like?
smooth and firm; similar to a large, ripe olive
Where is the bladder situated?
from 1-4cm above the symphysis pubis
How should the bladder be palpated?
begin at the level of the umbilicus and progress downward until the smooth upper aspect of the bladder is felt
If percussed, what does a dull sound indicate?
the presence of urine in the bladder
What does continuous bladder distention suggest?
a urinary tract obstruction or CNS abnormality
Once the abdominal organs have been located and palpated, what should the entire abdomen be assessed for?
the presence of masses
What are normal findings on abdominal palpation?
stool in the colon (sausage shape in the right and left lower quads) and gaseous distention
How can normal stool in colon that progresses be differentiated from an abnormal fixed mass?
serial examinations
How is the presentation of pyloric stenosis described?
a firm, oval shaped mass in the upper mid abdomen; does not usually present in the newborn period
What are the majority of abdominal masses palpated in the newborn?
involve the urinary tract and are cystic or solid on examination
How common is neoplasia in the newborn?
very rare
What is the final step in the abdominal assessment?
the groin and femoral region should be inspected and palpated
What is the normal presentation of the groins in a neonate?
normally flat; a visible femoral pulse may be present in a preterm infant of a thin term infant
An absent or weak femoral pulse is consistent with what congenital cardiac malformations?
COA or interrupted aortic arch
Full or bounding femoral pulses are consistent with what cardiac condition?
PDA
What is an inguinal hernia?
a defect in the muscle wall that allows the intestine to slip into the scrotum in males and into the soft tissue in females
What might a bulge in the labia majora indicate?
a hernia or an abnormal gonad
When is the presence of a hernia most easily evaluated?
when the infant is crying because intra-abdominal pressure increases
In what population are inguinal hernias most common?
M>F; more common in extremely preterm
What are typical features of a normally presenting hernia?
should be soft and capable of being pushed back into the body cavity without difficulty
When is surgical intervention required for inguinal hernias?
for all inguinal hernias; emergently if any evidence of strangulation is noted
What is a femoral hernia?
a small bulge adjacent and medial to the femoral artery
In what population do femoral hernias most commonly present?
an uncommon finding; F>M
