Abdomen Assessment Flashcards
1
Q
When is an assessment of the newborn abdomen best performed?
A
during the first few hours of life, when the bowel is not yet filled with gas; quiet state with relaxed abdominal muscles
2
Q
What antenatal ultrasound findings would alert the clinician to evaluate the abdomen throughly on initial assessment?
A
enlarged kidneys, dilated bowel or unusual masses
3
Q
What percentage of infants with a history of polyhydramnios have major structural malformations?
A
20-30%
4
Q
The risk of structural anomaly increases in relation to what physical finding?
A
with greater amount of amniotic fluid
5
Q
A maximum vertical pocket of amniotic fluid >16cm increases the chance of anomaly to what percent?
A
90%
6
Q
What are the most common GI abnormalities a/w polyhydramnios?
A
esophageal atresia and duodenal atresia
7
Q
What physical finding at delivery may indicate the presence of duodenal atresia?
A
the finding of an extremely large amount of amniotic fluid in the stomach
8
Q
What physical findings may indicate esophageal atresia, usually a/w tracheoesophageal fistula?
A
the presence of copious oral secretions coupled with the inability to pass a soft catheter to the stomach
9
Q
What might the presence of bilious gastric secretions at delivery indicate?
A
abnormal finding; possible intestinal obstruction
10
Q
Describe the skin in the abdominal region of a newborn.
A
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
11
Q
What is the shape and movement of a normal term infant?
A
soft and rounded with easy movements a/w respiratory effort (parallel abdomen and chest movement)
12
Q
What might asynchronous abdominal and chest movement indicate?
A
respiratory distress
13
Q
Where should abdominal girth be measured?
A
at the greatest diameter, just above the umbilicus
14
Q
How does abdominal girth relate to OFC?
A
abdOFC after 36wk GA
15
Q
What does a sunken, or scaphoid, abdomen indicate?
A
CDH
16
Q
How might a normal preterm infant’s abdomen present and why?
A
may appear distended r/t lack of muscle tone
17
Q
Why might a term infant have decreased abdominal muscle tone?
A
effects from maternal medications during labor
18
Q
What are the typical features a/w prune belly syndrome?
A
a flaccis, lumpy abdomen (congenital absence of and musculature); occurs mostly in males and is a/w severe renal and urinary tract anomalies
19
Q
How does bowel obstruction present?
A
distension and vomiting, the timing and character of which can vary depending on the location of the obstruction
20
Q
What is included in the differential diagnosis of an isolated lower abdominal dissension?
A
bladder distension, GU anomalies, female reproductive tract anomalies or teratomas
21
Q
As the level of obstruction progresses down the intestinal tract, how does symptomatology change?
A
abdominal dissension and bilious vomiting
22
Q
What is bilious emesis the result of?
A
obstruction beyond the level of the ampulla of Vater, where bile from the gallbladder enters the small intestine
23
Q
What is the only bowel obstruction that can p/w abdominal dissension at birth?
A
meconium ileus; abd dissension otherwise presents only after the infants has swallowed air to fill the bowel
24
Q
What is the etiology of a meconium ileus?
A
it is the abnormal result of pancreatic enzyme function seen with CF
25
The presence of bilious emesis with or without abdominal dissension requires assessment to investigate what pathologic state?
malrotation with midgut volvulus
26
What is the etiology of malrotation?
results from abnormal fixation of the intestine in the abdomen
27
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
28
Why does the presence of a midgut volvus necessitate immediate surgical intervention?
to avoid irreversible infarction of the intestine
29
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.
30
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
31
What is the significance of a diastasis recti?
a normal finding and will resolve without intervention
32
In what population are umbilical hernias more common?
African American, LBW males, hypothyroidism
33
What is an umbilical hernia?
a protrusion of abdominal contents into the hernia, which is soft and reducible
34
When are umbilical hernias expected to resolve?
spontaneously resolve by 2 years of age
35
What is an epigastric hernia?
a small, from, palpable nodule seen between the umbilicus and the xiphoid process
36
What is the etiology of an epigastric hernia?
it results from fat protruding through a small opening in the muscle
37
What is the prognosis of an epigastric hernia?
surgical intervention is required
38
Describe the umbilical cord of a typical term infant.
shiny, pearly white and gelatinous; AVA; avg size is 1.5-2cm at the base
39
What is the role of Wharton's jelly?
protects the vessels
40
What is the relative size of the umbilical cord an indicator of?
the nutritional status of the fetus
41
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
42
If any bulges or herniations are observed in the umbilical cord, what condition should be investigated for?
omphalocele
43
Describe the appearance of umbilical arteries.
the paired arteries are small, thick walled and constricted
44
Describe the appearance of the umbilical vein.
is large, thin walled and open
45
In what percentage of the population is the absence of 1 artery seen?
1%
46
What other anomalies is a single umbilical artery associated with?
CV, GI, GU or may be an isolated finding in an otherwise normal baby
47
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
48
How does omphalitis present?
as redness encircling the cord and extending onto the abdomen
49
When should omphalitis be treated?
promptly and properly bc it can spread rapidly to underlying structures causing severe systemic disease and even death
50
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
51
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
52
What does purulent discharge from the umbilical cord indicate?
the presence of an abcess
53
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
54
What is a patent urachus?
the persistence of the embryologic tract connecting the ileum to the umbilicus
55
What is the name for the embryologic tract connecting the ileum to the umbilicus?
omphalomesenteric duct
56
What is an umbilical polyp>
a small, red, raw-appearing granuloma which will occasionally form at the site of separation from the umbilical cord
57
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
58
Why should the examiner be careful during an assessment of an omphalocele?
the translucent sac may rupture at or before delivery
59
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
60
The failure of bowel to reenter the abdominal cavity results from what?
from faulty migration and fusion of embryonic tissues
61
An omphalocele is associated with what other congenital anomalies?
cardiac, neurologic, GA, skeletal or chromosomal abnormalities in 67% of infants
62
What syndromes are most likely to present with an omphalocele?
Beckwith-Wiedemann, trisomies 13, 18 and 21
63
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
64
Where is a gastroschisis typically located in relation to the umbilical cord?
usually to the right of midline
65
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
66
What is the incidence of additional associated anomalies?
lower incidence with gastroschisis than omphalocele
67
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
68
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
69
What is extrophy of the bladder?
the posterior wall of the bladder is exposed and urine drains into the abdomen
70
In what gender is extrophy of the bladder more common?
Males
71
What other associated abnormalities typically present with extrophy of the bladder?
may be associated with urogenital anomalies in both males and females
72
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)
73
How can anal sphincter tone be assessed?
gentle digital stroking the anal area; an anal wink will occur
74
What does the absence of anal winking suggest?
an abnormality of the CNS
75
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
76
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
77
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
78
What does the continued absence of meconium suggest?
anal atresia
79
What does the passage of very small caliber stool suggest?
anal stenosis
80
What is perianal fistula?
an anomalous connection between the intestinal tract and the GU tract
81
What presentation suggests the presence of a rectovaginal fistula?
meconium in the vagina
82
What presentation suggests the presence of a rectourethral fistula?
meconium in the urethral orfice
83
Why should auscultation be performed before palpation in the abdominal assessment?
bc palpation can interfere with normal bowel sounds as well as cause agitation
84
When can bowel sounds be appreciated?
BS will be audible beginning 15 min after birth, although they are relatively quiet until feedings have begun
85
What features should be investigated as it relates to BS?
presence, quality and intensity
86
How are normal BS described?
have a metallic, tinkling quality and are heard every 15-20 sec
87
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
88
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
89
What might be a cause of hypoactive BS?
maternal sedation
90
How should audible breath sounds in the upper abdomen be interpreted?
as a normal finding bc sounds transmit easily throughout an infant's body
91
How should audible vascular sounds in the upper abdomen be interpreted?
not normally auscultated over the abdomen of a term infant
92
What is the cause of a bruit?
the sounds of turbulent blood flow through a restricted of tortuous vessel
93
The auscultation of a bruit over the abdomen may indicate what?
malformations of the hepatic or renal vessels or hemangiomas
94
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
95
What is the typical presentation of abdominal skin?
warm, pink and with brisk cap refill
96
What does hypertonicity of the abdominal musculature suggest?
may indicate psi or peritoneal irritation
97
What does hypotonicity of the abdominal musculature suggest?
neuromuscular disease, perinatal depression or if the mother has taken medications that cause neonatal depression
98
How should palpation of the abdominal region progress?
should begin with the superficial structures and then progress to the deeper organs
99
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
100
What abdominal organ should be palpated first?
liver
101
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
102
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
103
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
104
How does a normal liver edge typically present?
normally smooth, firm and sharp
105
What does a boggy liver indicate?
is a sign of congestion, may indicate congestive heart failure
106
What other liver presentations are abnormal?
a hard or nodular liver edge
107
Following the liver, what organ structure is then palpated for on the left side of the abdomen?
the spleen
108
What is typical of spleen palpation?
the tip of the spleen may be felt, but in many cases, is not palpable at all
109
What might indicate an enlarged spleen and warrant further investigation?
a spleen that is palpable more than 1cm below the costal margin
110
What is complete situs inversus?
reversal position of all the thoracic and abdominal organs
111
What is partial situs inversus?
the reversal position of some but not all of the abdominal organs
112
Situs inversus is associated with congenital anomalies of what other organ system?
CV, but such defects are more common in partial situs inversus
113
When are the kidneys most easily palpated?
When done early, before the infant has eaten or begun prolonged crying
114
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
115
How large is the normal newborn kidney?
4.5-5cm from the upper to the lower pole
116
Where is the right kidney typically positioned in relation to the left?
the right kidney is normally situated slightly lower than the left
117
What does a very easily palpated kidney indicate?
the kidney is usually enlarged and indicative of hydronephrosis or a cystic kidney
118
What consistency should a kidney feel like?
smooth and firm; similar to a large, ripe olive
119
Where is the bladder situated?
from 1-4cm above the symphysis pubis
120
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
121
If percussed, what does a dull sound indicate?
the presence of urine in the bladder
122
What does continuous bladder distention suggest?
a urinary tract obstruction or CNS abnormality
123
Once the abdominal organs have been located and palpated, what should the entire abdomen be assessed for?
the presence of masses
124
What are normal findings on abdominal palpation?
stool in the colon (sausage shape in the right and left lower quads) and gaseous distention
125
How can normal stool in colon that progresses be differentiated from an abnormal fixed mass?
serial examinations
126
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
127
What are the majority of abdominal masses palpated in the newborn?
involve the urinary tract and are cystic or solid on examination
128
How common is neoplasia in the newborn?
very rare
129
What is the final step in the abdominal assessment?
the groin and femoral region should be inspected and palpated
130
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
131
An absent or weak femoral pulse is consistent with what congenital cardiac malformations?
COA or interrupted aortic arch
132
Full or bounding femoral pulses are consistent with what cardiac condition?
PDA
133
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
134
What might a bulge in the labia majora indicate?
a hernia or an abnormal gonad
135
When is the presence of a hernia most easily evaluated?
when the infant is crying because intra-abdominal pressure increases
136
In what population are inguinal hernias most common?
M>F; more common in extremely preterm
137
What are typical features of a normally presenting hernia?
should be soft and capable of being pushed back into the body cavity without difficulty
138
When is surgical intervention required for inguinal hernias?
for all inguinal hernias; emergently if any evidence of strangulation is noted
139
What is a femoral hernia?
a small bulge adjacent and medial to the femoral artery
140
In what population do femoral hernias most commonly present?
an uncommon finding; F>M
