Abdomen Clinical Supplement Flashcards
What are the 5 F’s for abdominal protrusions
Fat Fluid Fetus Flatus Feces
Where is the gallbladder
intersection of semilunar line right and 9th intercostal space
Where is the spleen found
under 9th-11th ribs on left midaxillary
Where are the kidneys found
11th ribs along the scapular line
Which kidney is more superior and why
left is more superior due to liver on right
Dermatome of xiphoid process
T6
Dermatome of Umbilicus
T10
Dermatome of inguinal ligament
L1
What is the cremaster reflex
stroking medial aspect of the upper thigh stimulates the ilioinguinal nerve and results in contraction of the cremaster via the genital branch of the genitofemoral nerve, retracts testes
What level of the spinal cord does the cremaster reflex test
L1-L2
What is the abdominal reflex
When you stroke skin of wall from lateral to medial at the level of the umbilicus there should be contraction of abdominal wall muscless ipsilaterally
When the abdominal reflex is absent what is indicated
spinal cord injuries above T5-T6
Direct inguinal hernias are found in which population
commonly found in old men with weak abdominal walls
Where do direct inguinal hernias occur
medial to inferior epigastric vesicles through the Hesselbach triangle
Do direct inguinal hernias go through the deep inguinal ring
no
What are direct inguinal hernias covered by
visceral peritoneum and parietal peritonealium and transversalis fascia
Do direct inguinal hernias enter inguinal canal
no
What are the boundaries of Hesselbach’s triangle
Medial: rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament
How do you fix a direct inguinal hernia
suture the inguinal ligament and conjoint tendon together
What population do indirect inguinal hernias occur in
younger children, males> females
Where do indirect inguinal hernias occur
lateral to the inferior epigastric vessels
Do indirect inguinal hernias enter inguinal canal
yes
What coverings do indirect inguinal hernias have
same as spermatic cord
What is the triangle of pain boundaries
inguinal ligament and testicular vessels
What is the clinical relevance of the triangle of pain
staples should be avoided due to genitofemoral nerve (femoral branch), femoral nerve, and lateral femoral cutaneous nerve are found here
What is the triangle of doom boundaries
vas deferens and testicular vessels
What is the clinical relevance of the triangle of doom
stable should be avoided because it includes external iliac vessels, deep circumflex iliac vessels, and genital branch of genitofemoral
What is an epigastric hernia
in the midline between the xiphoid and umbilicus
What is an esophageal/ hiatal hernia
herniation of the fundus of the stomach through the esophageal hiatus
What is congenital diaphragmatic hernia (bochdalek)
herniation thru left vertebrocostal trigone into pulmonary cavity; can involve gut, spleen, or retroperitoneal structures
What is femoral hernia
protrustion of gut loops through the femoral ring
Where is a femoral hernia found in relationship to pubic tubercle and femoral vein
lateral to pubic tubercle
medial to femoral vein
What is De Garengeot’s Hernia
femoral hernia that involves the appendix
What is an incisional hernia
herniation through a surgical wound
What are the two type of lumbar hernias
Grynfeltt
Petit
What is Grynfeltt’s hernia
herniation at superior lumbar triangle between 12th rib, quadratus lumborum, and internal oblique
What is Petit’s hernia
herniation at inferior lumbar triangle, between latissimus dorsi, external oblique, and iliac crest
What is obturator hernia
herniation of viscera thru the obturator canal
What is supravesical hernia
herniating mass leaves thru the opening in the supravesical fossa between median umbilical ligament (urachus) and remnant of the umbilical artery (medial umbilical ligament)
What does supravesical hernia usually result in
intestinal obstruction
What nerve is at risk with a supravesical hernia repair
iliohypogastric
What is an umbilical hernia
herniation through the umbilicus
What nerves are anesthetized in a vasectomy
ilioinguinal and genital branch of genitofemoral
What layers of fascia are cut in a vasectomy
Skin, Dartos fascia, external spermatic fascia, cremaster’s fascia, internal spermatic fascia
What are neurovascular structures at risk in a vasectomy
testicular vessels, pampiniform plexus
ilioinguinal and genitofemoral nerve
What is torsion of the testes
rotation and twisting of the spermatic cord, along with vascular occlusion
What is torsion of the testes associated with
deficient anchoring of the testicle to the tunica vaginalis and via gubernaculum
What are common S/S of testes torsion
sudden testicular pain and enlargement
nausea/vomiting
abnormal cremaster reflex
abnormal positioning of epididymis
What is the normal position of the epididymis
head is superior to testicle
body is posterior and lateral
What is hydrocele of the testes
excessive accumulation of fluid in the cavity of the tunica vaginalis
What is a congenital hydrocele
accumulation of fluid in the tunica vaginalis and direct communication with the peritoneal sac via a persistent processus vaginalis
How can hydroceles be diagnosed
with transillumination
What is hematocele of the testis
collection of blood in the cavity of the tunica vaginalis
What causes hematocele
trauma to testicular veins
What is a varicocele
varicose veins involving the pampiniform plexus
Which side do varicoceles most commonly occur on
left side
What are S/S of varicocele
scrotum feels like a bag of worms
hematuria
flank pain
What causes varicocele
entrapment of the left renal vein by the SMA, backing up blood into the left testicular vein that drains into the renal vein
What is a spermatocele
benign, cystic accumulation of sperm in the head of the epididymis
How is a spermatocele identifiable on exam
mass is superior to testicle and is smooth, soft, and well circumscribed
transilluminates
How are the testes drained lymphatically
lumbar/para-aortic nodes
How is the scrotum drained lymphatically
superficial inguinal nodes
What is orchitis
inflammation of the testes
What is the phrenicocolic ligament
tethers the splenic flexure of the colon to the body wall
What does the phrenicocolic ligament restric
the flow of ascites in the abdominal cavity
What is peritonitis
inflammation of the peritoneum
When is peritonitis painful
when it involves parietal peritoneum
What causes peritonitis
infections, perforated ulces, appendicitis, diverticulitis, cirrhosis, cancer
What is Morrison’s pouch
right subhepatic recess
What is important about Morrison’s pouch
fluid can accumulate here in the supine position and can reach the right subphrenic space and irritate the diaphragm and the lesser sac via the epiploic foramen
What are peritoneal adhesions
fusion of parietal and visceral layers
What causes peritoneal adhesion
trauma or inflammation from surgery
What is guarding
reflexive contraction of the abdominal wall musculature to protect inflamed organs
What causes guarding
pain from appendicitis, ulcers, tumor, ectopic pregnancies
What is volvulus
abdominal organs that have a mesentery can twist and block flow of intestinal contents
What does volvulus result in
reduced blood flow and ischemia
What is ascites
accumulation of serous fluid in the peritoneal cavity
What is paracentesis
removal of ascites from the peritoneal sac
How is the patient positioned during paracentesis
supine
Where is paracentesis performed on the patient
t10 dermatome anesthetized and avoid the inferior epigastric artery
What are the layers passed in paracentesis
skin campers fascia scarpas fascia external and internal obliques transverse abdominus transversalis fascia parietal peritoneum
What is culdocentesis
removal of fluid from the recto-uterine pouch
How is culdocentesis performed
entering the peritoneal cavity via the posterior vaginal fornix
Why is the peritoneum used for intraperitoneal delivery of drugs
large surface area permits rapid absorption of fluids within the peritoneal cavity
When is peritoneal dialysis performed
renal failure
Why is the peritoneum used for peritoneal dialysis
large surface area of the peritoneum allows it to be used as a dialysis membrane
What is ventriculoperitoneal shunt
excess CSF can be absorbed thru the peritoneum
What is pneumoperitoneum
gas introduced into the peritoneal cavity
When can pneumoperitoneum arise pathologically
any bowel performation= free subdiaphragmatic air
What is GERD
regurgitation of gastric contents
What are S/S of GERD
heartburn
dysphagia
sore throat
What are 4 physiological mechanisms that normally prevent reflux of stoamch into the esophagus
lower esophageal sphincter
folds of gastric mucosa that seal
angle of cardiac orifice
right crus of diaphragm
What is Barrett’s esophagus
replacement of the stratified squamous esophageal epithelium with simple columnar glandular gastric epithelium from chronic reflux
What is barrett’s esophagus related to clinically
premaligmnant condition, increased risk for esophageal carcinoma
How can gastric cancer spread locally
duodenum, pancreas, posterior body wall
How can gastric cancer spread lymphatically
celiac nodes–> supraclavicular–> periumbilical –> anterior axillary nodes
How can gastric cancer spread venous
liver
What are important nodes in gastric cancer
Virchow’s node
sister Mary Joseph node
Irish node
In gastric cancer, where is Virchow’s node
supraclavicular node on the left
In gastric cancer, where is sister Mary Joseph node
periumbilical
In gastric cancer, where is Irish node
anterior axillary node
What are gastric ulcers
erosion of gastric mucosa, can erode thru walls and damage adjacent structures
What structures are at risk with a 1st part duodenal ulcer
gastroduodenal artery
common bile duct
portal vein
What structures are at risk with a 2nd part duodenal ulcer
right renal vessels
IVC
What structures are at risk with a 3rd part duodenal ulcer
right ureter, IVC aorta Psoas major gonadal vessels
What structures are at risk with a 4th part duodenal ulcer
left sympathetic trunk
left psoas major
aorta
left renal vessels
What is the consequence of any perforation of the stomach, small intestine, large intestine
intraperiotoneal air
How can intraperitoneal air be identified
free subdiaphragmatic air
What is Wilkie’s SMA syndrome
compression of the 3rd part of the duodenum between the SMA and aorta
What does Wilkie’s SMA syndrome result in
obstruction (nausea, vomiting, abdominal pain, malnutrition)
Who is Wilkie’s SMA syndrome more common in
young, anorexic women
What is Meckel’s diverticulum
persistent vitelline duct
What are symptoms of Meckel’s diverticulum
asymptomatic
hematochezia
periumbilical pain
Where does Meckel’s diverticulum occur
2 feet from ileocecal valve
What can causes Ischemia of the intestine
blood clot can deprive and result in necrosis and severe visceral pain and ileus
What is Chrohn’s disease
chronic inflammatory condition of the intestine, most often the ileum, that leads to fibrosis and obstructive symptoms
What are S/S of Chrohn’s disease
abdominal pain
diarrhea
fistulas and obstruction
WHat are three dispositions of the appendix to infection
Long thin tube that can collect fecal material
narrow lumen, easily blocked
abundant collection of lymphatic tissue
Does the appendicular artery have significant anastomoses
no
What can result if the appendicular artery is compressed
necrosis, gangrene, perforation
What is the most common cause of acute abdomen pain
appendicitis
How does pain occur in appendicitis
vague, dully achy pain around the umbilicus at first
irritation of the parietal peritoneum results in a sharp, well-localized somatic pain in RLQ
What is McBurney’s point
the middle third of a line connecting the ASIS and umbilicus
What is McBurney’s point used for
surgically approximate the appendix
What structures are palpable on a DRE for males
prostate rectal wall bladder seminal vesicles ductus deferens perineal body bulb of penis
What structures are palpable on a DRE for females
vagina, cervix, perineal body
What are S/S of bowel obstruction
pain, nausea, vomiting
constipation
hyperactive bowl sounds
If blood supply is interrupted in bowel obstruction what must occur
surgical emergency
What is diverticular disease
inflammation of diverticula, small pouches extending from the intestinal lumen
Where are diverticula commonly found
large intestine (sigmoid colon–LLQ pain)
What are S/S of diverticular disease
pain, nausea
constipation
peritonitis, bleeding, rupture
What is ulcerative colitis
inflammation of large intestine most commonly in the rectum
What is chronic ulcerative colitis associated with
increased risk of colorectal cancer
What is intussusception
telescoping of one part of the intestine into an adjacent part
What can intussusception result in
ischemia and necrosis
What is the presentation of intussusception
infant is lathargic, vomiting, abdominal pain, palpable mass, currant jelly stool
What are S/S of colorectal carcinoma
bright red bloody stool
weight loss
changes in stool
malaise
How does colorectal carcinoma spread locally
peritoneum, pelvic organs
How does colorectal carcinoma spread lymphatically
drainage to corresponding nodes
How does colorectal carcinoma spread venous
liver, lungs, vertebra, brain
What is colostomy
proximal portion of colon is sutured to an opening along the anterior abdominal wall thru the rectus abdominis where waste products are expelled
What is rectal prolapse
protrusion of the rectal wall into the anal canal or thru the anal opening
What are S/S of rectal prolapse
reddish mucosal mass protrusion into the anal canal
constipation
malnutrition
prior rectal trauma
What is a rectocele
weakness in puborectalis and pubovaginalis muscles that cause bulging of rectal wall into posterior vaginal wall
What are S/S of a rectocele
painful intercourse
sense of fullness
constipation
painful bowel movements
What is considered an upper GI bleed
proximal to the ligament of Treitz
What are S/S of an upper GI bleed
vomiting blood or melena black stool
What are causes of an upper GI bleed
stomach cancer
ulcers
gastritis
esophageal varices
What is considered a lower GI bleed
distal to the liagment of Treitz
What are S/S of a lower GI bleed
hematochezia (red stool)
What are causes of a lower GI bleed
diverticular disease hemorrhoids polyps anal fissures cancer IBD
What is ischemic colitis
inflammation of the colon as a result of poor blood flow
What are causes of ischemic colitis
atherosclerosis
hypovolemia
hypoperfusion
sickle cell anemia
What are S/S of ischemic colitis
pain and blood stool
What are important watershed areas in ischemic colitis
Griffith’s point
Sudeck’s point
What is Griffith’s point
splenic flexure: middle colic to left colic artery
What is Sudeck’s point
recto-sigmoidal junction: last sigmoidal to superior rectal artery
What can cause a spleen rupture
ribs 9-11 fracture on the left
What are S/S of a spleen rupture
left shoulder pain when ruptured spleen irritates the diaphragm
What is Kehr’s sign
when spleen irritates the diaphragm and causes left shoulder pain
What are causes of hepatomegaly
heart failure
cancer
alcoholic cirrhosis
What is the lymphatic drainage of the liver
most to hepatic nodes
bare area: phrenic nodes
falciform ligament: parasternal
Round ligament: umbilical nodes
What is the significance of lymphatic drainage of the liver and breast
connections to superficial lymph channels provide a direct route for breast cancer to metastasize to liver
What is Calot’s Triangle
cystic duct, common hepatic duct, and base of the liver
What does Calot’s triangle contain
cystic artery and veins
lymph nodes
autonomic fibers
What is Pringle’s maneuver
clamping vessels of the portal triad at the free edge of the lesser omentum to control bleeding during hepatic procedures
What are 3 causes of jaundice
Pre-hepatic
Hepatic
Obstructive
WHat is pre hepatic jaundice
excessive RBC breakdown
What is hepatic jaundice
disruption of liver function
What is obstructive jaundice
if bile cannot escape gallbladder or biliary tree due to gall stones, it enters blood and causes jaundice
What is liver cirrhosis
hepatocytes are replaced by fatty or fibrous connective tissue which obstructs blood flow through the liver
What does liver cirrhosis result in
hepatomegaly ascites edema jaundice splenomegaly portal hypertension
What is Budd-Chiari syndrome
rare thrombic or non-thrombotic obstruction of hepatic venous outflow, caused by maligancy or hypercoaguable states
What are S/S of Budd-Chiari syndrome
hepatosplenomegaly ascites abdominal pain jaundice edema prominence of collateral veins
What are the 3 portal-caval anastomosis
left gastric-esophageal veins
superior rectal to middle/inferior rectal
paraumbilical to epigastric
What does left gastric –> esophageal veins anastomosis result in
esophageal varices
hematemesis
What does superior rectal–> middle and inferior rectal anastomosis result in
heorrhoids and rectal bleeding
What does paraumbilical–> epigastric anastomosis result in
caput medusa
When is a porto caval shunt performed
in patients with HTN
What is a porto caval shunt
portal vein to IVC
Splenic vein and left renal vein
What is blood flow in the portal vein
right lobe of the liver receives mainly blood from the intestines
left lobe quadrate and caudate lobes receive blood mainly from the stomach and spleen
If cancerous cells from the stomach invade the portal system, which part of the liver will they most likely invade
left lobe
Where are 3 places for gallstones to be commonly lodged
fundus at the neck of the gallbladder
bile duct
hepatopancreatic ampulla
What is cholecystectomy
surgical removal of gallbladder
What needs to be performed in order to do a cholecystectomy
pringle’s maneuver to ligate vessels and find Calot’s triangle to ligate cystic artery
What is cholecystitis
inflammation of the gallbladder
Where does pain from cholecystitis initially show up
in epigastric region
Where does pain from cholecystitis shift to
right hypochondriac region at the 9th costal cartilage junction and linea semilunaris
Where will somatic pain show up from cholecystitis
C3-C5 region of shoulders
What is pancreatitis
inflammation of the pancreas
What can cause pancreatitis
gallstones and retrograde flow of bile into the pancreatic duct
Where does the pancreas drain lymphatically
celiac and superior mesenteric nodes
Where do cancers of the pancreas often spread to
lumbar nodes
What are S/S of pancreatic cancer
obstruction of bile/pancreatic ducts weight loss abdominal and back pain jaundice painless and palpable gallbladder
Where does pancreatic metastasis occur
regional to adjacent organs and any peritoneal surface, local nodes, and liver
What may pancreatic cancer obstruct
portal vein or IVC
What occurs during pancreatic hemorrhage
filling in lesser sac and greater omentum
What is at risk during a splenectomy
tail of the pancreas
What occurs if the tail of the pancreas is damaged
digestive enzymes are relased into the abdominal cavity
What is an abdominal aortic aneurysm
congenital or acquired dilation of the wall of the aorta, palpated left of the midline; fatal if it ruptures
What is aortic dissection
tear in the intimal layer of the aorta and hemorrhage between the layers of the vessel
What are S/S of aortic dissection
acute onset of chest/back pain
lower extremity ischemia and neuropathy
pulse defacit in lower extremities
What is obliteration of the abdominal aorta
gradual build-up of plaque in the abdominal aorta at the bifurcation
What can obliteraltion of the abdominal aorta cause
claudication
impotence
Leriche Syndrome
What are 4 aorta-aorta anastomoses
- Intercostals, subcostal, lumbar–> iliolumbar, superior gluteal, internal iliac
- intercostals, subcostal, lumbar–> circumflex iliac–> external iliac
- IMA–> middle/inferior rectals–> internal iliac
- Subclavian–> internal thoracic–> superior epigastric–>inferior epigastric–> external iliac
How can the IVC be obstructed
abdominal masses or build up of clots around an IVC filter
What are caval-caval anstomoses
- Inferior–> superior epigastric
- Superficial epigastric–> lateral thoracic
- vertebral/lumbar veins and Batson’s plexus–> azygos system
How can we treat recurring blood clots arising from the lower extremity
placing a filter/screen in the IVC
What is psoas major covered by
investing fascia
How may an infection spread to the psoas muscle
from vertebra thru the investing fascia of the psoas major muscle
How can an infection spread from the psoas muscle
underneath the sheath deep to the inguinal ligament
What is the relevance of the Psoas test/sign
inflammation of viscera can affect function of the iliopsoas muscle
What can impact function of right psoas major muscle
inflamed retrocecal appendix
How is the psoas test/sign performed
ask patient to actively flex the thigh at the hip
abdominal pain=positive test
What is the thomas test used for
diagnose dysfunction/contracture of the psoas major muscle
How is the Thomas test performed
patient lays on their back and examiner flexes the unaffected hip towards the chest while the affected hip remains flat on the table
What is a positive Thomas test
dysfunction indicated when the test reveals flexion of the contralateral hip
When do we see iliohypogastric nerve injury
inguinal hernia surgery hysterectomy appendectomy pregnancy abdominal muscle tears
When do we see ilioinguinal nerve injury
inguinal hernia surgery
abdominal surgery
pregnancy
placement of femoral catheter
When do we see genitofemoral nerve injury
hernia repair
appendectomy
retroperitoneal hematoma
When do we see lateral femoral cutaneous nerve injury
entrapment in sartorius or inguinal ligament
What is meralgia paresthetica
entrapment of the lateral femoral cutaneous nerve
What are renal cysts
large, fluid-filled cysts, commo in older individuals
Multiple renal cysts may lead to what
renal failure
What does renal carcinoma metastasis spread locally
adrenal gland
posterior abdominal wall
Where does renal carcinoma metastasis spread lymphatically
lumbar nodes
Where does renal carcinoma spread venous
bone, brain, liver, lung
Where does renal carcinoma arise from
tubular epithelium
What is renal carcinoma associated with
hematuria and back pain
What is renal hypertension
stenosis of a renal artery or supra-renal artery reduces blood flow to the kidney
What does renal hypertension result in
humoral response for the kidney in an attempt to raise normal blood pressure
WHat are accessory renal arteries
end arteries that do not anastomose with branches from the renal arteries
What can blockage of renal arteries lead to
renal infarct
Which kidney is used for transplantation and why
left kidney
renal vein is longer
Where are transplanted kidneys placed
iliac fossa
Where are transplanted kidneys placed arterial
internal iliac artery
What is nephroptosis
inferior displacement of the kidney due to insufficient peri-renal adipose tissue
What may nephroptosis causes symptom wise
flank or groin pain
hematuria
Where are 4 places the ureters are contricted and a stone can become lodged
renal pelvis and ureter
crossing pelvic inlet
passage thru the wall of the bladder
testicular/ovarian vessels cross the ureter
What are consequences of urinary obstruction
hydronephrosis
What is hydronephrosis
enlargement of the ureter, renal pelvis, and or calyces
What can hydronephrosis lead to
renal failure
What are causes of hydronephrosis
stones, tumors, prostatic hypertrophy
What are S/S of kidney stones
flank to groin pain
nausea
vomiting
hematuria
What is the arterial supply to the abdominal ureter
medial side
What is the arterial side to the pelvic ureter
lateral side
