ABDOMEN- IM Flashcards
At the end of the lecture, the student must be able to: Describe the basic structures and functions of the abdomen Recognize manifestations of diseases of the abdominal system and correlate this with pathophysiologic processes Demonstrate effectively steps and manoeuvres in examining the abdomen Identify variations in the physical exam techniques and findings in different patient population Enumerate common abdominal diseases and their manifestations. Demonstrate proper technique
Purpose for doing abdominal examination
- Assess the urgency of the case
- Findings in physical examination could point to the diagnosis
- To decide on the laboratory tests to be requested
- To decide on the management
•Symptoms referable to the GI tract
- Dysphagia
- Abdominal pain
- Nausea
- vomiting
- Diarrhea
- Constipation
- GI bleeding
- Weight loss
Gastrointestinal Symptoms
- Location
- Upper GI
- Lower GI
- Others
•Conduct careful history
•timing of the onset
•Determine of life threatening
Cluster several findings
•Patterns and mechanisms
- Visceral pain
- Parietal pain
- Referred pain
•Describe Visceral pain
•hollow abdominal organs contract forcefully or distended or stretched
•Stretching of the capsule can also cause pain
•Ischemia stimulates visceral pain fibers
•Difficult to localize
•Describe Parietal pain
- Inflammation of the parietal peritoneum
- Steady, aching, more severe than visceral, precisely localized
- Aggravated by movement or coughing
•Referred pain
- Felt in more distant sites
- Develops ad the initial pain becomes more intense
For descriptive purposes, the abdomen
is often divided by imaginary
lines crossing at the umbilicus, forming
the__________, _______, _____ and ________
Another
system divides the abdomen
into nine sections. Terms for three of
them are commonly used: epigastric,
umbilical, and hypogastric or suprapubic.
- right upper,
- right lower,
- left upper,
- and left lower quadrants.
Another
system divides the abdomen
into nine sections. Terms for three of
them are commonly used
- : epigastric,
- umbilical,
- and hypogastric or suprapubic.
Examine the abdomen, moving in a
____________;
clockwise rotation
several organs are
often palpable. Exceptions are the
___________, _________ and _______
The abdominal cavity extends
up under the rib cage to the dome of
the diaphragm, placing these organs
in a protected location, beyond the
reach of the palpating hand.
stomach and much of the liver and
spleen.
In the right upper quadrant, the soft
consistency of the liver makes it difficult
to feel through the abdominal
wall.
The lower margin of the_________________, is often palpable at the right costal margin.
liver,
the liver edge
The gallbladder,
which rests against the inferior surface
of the liver, and the more deeply
lying duodenum are generally not palpable.
At a deeper level, the lower pole
of the right kidney may be felt, especially
in___________
thin people with relaxed abdominal
muscles.
Moving medially,
the examiner encounters the rib cage,
which protects the stomach; occasionally
patients misidentify the
stony hard _______________
** in the midline
as a tumor. The abdominal aorta**
often has visible pulsations and is usually
palpable in the upper abdomen
xiphoid process
In the left upper quadrant, the spleen is lateral to and behind the stomach, just above the left kidney in the left midaxillary line. Its upper margin rests against the dome of the diaphragm.
The 9th, 10th, and 11th ribs protect most of the
spleen. The_____________ may be palpable below the left costal margin in a
* *small percentage of adults.**
tip of the spleen
In healthy people the__________cannot be detected.
pancreas
What can be felt In the left lower quadrant, you can often feel the
In the lower midline are the bladder, the sacral promontory, the
bony anterior edge of the S1 vertebra, sometimes mistaken for a tumor, and,
in women, the uterus and ovaries.
- firm, narrow, tubular sigmoid colon.
- Portions of the transverse
- and descending colon may also be palpable.
In the right lower quadrant are___________ near the junction of the small and large intestines. In healthy
people, these are not palpable.
bowel loops and the appendix at the tail of
the cecum
A distended bladder may be palpable above the symphysis pubis.The bladder accommodates roughly 300 ml of urine filtered by the kidneys into the renal pelvis and the ureters.
Bladder expansion stimulates contraction of
bladder smooth muscle, the detrusor muscle, at relatively low pressures.
Rising
pressure in the bladder triggers the conscious urge to void.
Upper GI tract
•Chronic upper abdominal pain or discomfort
Dyspepsia
Upper GI tract
Alarm symptoms
- Alarm symptoms
- Dysphagia
- Odynophagia
- Recurrent vomiting
- Evidence of GI bleeding
- Weight loss
- Anemia
- Risk factors for gastric cancer, palpable mass or jaundice
Lower GI tract
•Acute lower GI pain
•
Localized to the right lower quadrant or left lower quadrant
- Chronic lower GI pain
- Ask about change in bowel habits and alternating diarrhea and constipation
- Diarrhea
- Duration
- Acute: 2 weeks
- Chronic ≥ 4 weeks
- Characteristic of the stool, volume, frequency, consistency
- Presence of pus, mucus, blood
- Associated tenesmus
- Constipation
- Present for at least 12 weeks of the prior 6 months with at least 2 of the following conditions:
fewer than 3 bowel movements per week;
25% or more defecation with either straining or sensation of incomplete evacuation; lumpy or hard stools; manual facilitation
Urinary tract
- Suprapubic pain
- Dysuria, urgency or frequency
- Polyuria or nocturia
- Bladder disorders cause this pain
- Bladder infection is typically dull and pressure like
•Suprapubic pain
- Dysuria, urgency or frequency
- Pain on urination
__________is an unusually intense desire to void
•Frequent voiding may occur
•Related symptoms such as blood and fever
•Urgency
•Polyuria or nocturia
– increase in 24-hour urine volume exceeding 3L
•Polyuria
__________ – urinary frequency at night awakening the patient more than once
•Nocturia
•Involuntary loss of urine typical in elderly
•Urinary incontinence
When voiding is inconvenient, higher centers in the brain
can inhibit detrusor contractions until the capacity of the bladder, approximately
____________ is exceeded
400 to 500 ml,
The integrity of the sacral nerves that
innervate the bladder can be tested by assessing perirectal and perineal sensation
in the__________
S2, S3, and S4 dermatome
The kidneys are posterior organs. The ribs protect their upper poles. The costovertebral angle, formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae, defines where to examine for kidney tenderness, termed ________________
costovertebral angle tenderness, or CVAT.
Common concern symptoms in GIT
◗◗ Abdominal pain, acute and
chronic
◗◗ Indigestion, nausea, vomiting including blood, loss of appetite,
early satiety
◗◗ Dysphagia and/or odynophagia
◗◗ Change in bowel function
◗◗ Diarrhea, constipation
Common concerning do in renal
Suprapubic pain
◗◗ Dysuria, urgency, or frequency
◗◗ Hesitancy, decreased streamin males
◗◗ Polyuria or nocturia
◗◗ Urinary incontinence
◗◗ Hematuria
◗◗ Kidney or flank pain
◗◗ Ureteral colic
Before exploring gastrointestinal
and genitourinary symptoms, review the mechanisms and clinical
patterns of abdominal pain. Be familiar with three broad categories of
abdominal pain:
- Visceral
- Parietal
- Referred
________________- occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched.
Visceral pain
Solid organs such as the liver can also become painful when their capsules are stretched. Visceral pain may be difficult to localize. It is typically palpable near the midline at levels that vary according to the structure involved,as illustrated on the next page. Ischemia also stimulates visceral pain fibers
Visceral pain in the right upper
quadrant may result from _________against its capsule in
alcoholic hepatitis.
liver
distention
Visceral pain varies in quality and may be __________, ___________, __________When it becomes severe, it may be associated with sweating, pallor,
nausea, vomiting, and restlessness.
:gnawing, burning, cramping, or
aching.
Visceral_______________may
signify early acute appendicitis from
distention of an inflamed appendix.
It gradually changes to parietal pain
in the right lower quadrant from
inflammation of the adjacent
parietal peritoneum.
periumbilical pain
Pain of _____________
origin may be referred to the back;
pain from the biliary tree, to the
right shoulder or the right posterior
chest.
duodenal or pancreatic
Studies suggest that neuropeptides,
such as_____________ and_______ mediate interconnected
symptoms of pain, bowel
dysfunction, and stress
5-hydroxytryptophan and
substance P,
In emergency rooms, 40% to 45% of
patients ___________but
have nonspecific pain,
15% to 30% need surgery, usually
for___________ , ____________ and ________
appendicitis, intestinal obstruction,
or cholecystitis.
Doubling over with cramping colicky
pain indicates __________.
renal stone
Sudden
knifelike epigastric pain occurs
in____________.6,7
gallstone pancreatitis
_____________occurs with gastritis
and gastroesophageal reflex disease
(GERD).\
Epigastric pain
_______________ are common
in cholecystitis.
Right upper quadrant
and upper abdominal pain
Note that angina from inferior wall
coronary artery disease may present
as “__________ but is precipitated
by exertion and relieved by
rest.
indigestion,”
Chronic Upper Abdominal Discomfort or Pain.
Dyspepsia
Discomfort
____________- is defined as
chronic or recurrent discomfort or pain centered in the upper abdomen.
Dyspepsia
____________t is defined as a subjective negative feeling that is nonpainful. can include various symptoms such as bloating, nausea, upper abdominal
fullness, and heartburn.
Discomfort
Note that ______________can occur alone and can be seen
in other disorders.
When these conditions occur alone, they do not meet
the criteria for dyspepsia.
bloating, nausea, or belching
Bloating may occur with _____________
inflammatory
bowel disease;
belching from
________________________
aerophagia, or swallowing air.
Many patients with upper abdominal discomfort or pain will have _____________ , ____________** **defined as a 3-month history of nonspecific
upper abdominal discomfort or nausea not attributable to structural
abnormalities or peptic ulcer disease.
Symptoms are usually recurring and
typically present for more than 6 months.3
functional,
or nonulcer, dyspepsia,
Multifactorial causes include
delayed gastric emptying
(20%–40%),
gastritis from H. pylori
(20%–60%)
, peptic ulcer disease
(up to 15% if H. pylori is present),
and psychosocial factors.3
Many patients with chronic upper abdominal discomfort or pain complain
primarily of _________, _______ and ___________\
. If patients report these
symptoms more than once a week, they are likely to have gastroesophageal
reflux disease (GERD) unless proven otherwise.3,9
heartburn, acid reflux, or regurgitation
Heartburn is a rising retrosternal burning pain or discomfort occurring** weekly or more ofte**n. It is typically aggravated by food such as alcohol,
chocolate, citrus fruits, coffee, onions, and peppermint; or positionslike
bending over, exercising, lifting, or lying supine.
Thirty percent to 90% of patients
with_________ and 10% with specialty
referral for throat conditions have
GERD-like symptoms.
asthma
Some patients may have “alarm symptoms,such as __________________, evidence
of gastrointestinal bleeding, weight loss, anemia, or risk factors for
gastric cancer, a palpable mass, or jaundice.
- difficulty swallowing(dysphagia),
- pain with swallowing (odynophagia),
- recurrent vomiting
These symptoms or mucosal damage
on endoscopy are the diagnostic
criteria for GERD.
Risk factors
include reduced salivary flow, which
prolongs acid clearance by damping
action of the bicarbonate buffer;
delayed gastric emptying; selected
medications; and hiatal hernia.
Note that__________ from inferior wall
coronary ischemia along the diaphragm
may present as heartburn.
angina
Thirty percent to 90% of patients
with___________- and 10% with specialty
referral for throat conditions have
GERD-like symptoms.
asthma
Patients with uncomplicated GERD
who do not respond to empiric
therapy, patientsolder than 55
years, and those with “alarm symptoms”
warrant _____________to detect
esophagitis, peptic strictures, or Barrett’s
esophagus.
In this condition,
the squamocolumnar junction is
displaced proximally and replaced
by intestinal metaplasia, increasing
the risk of esophageal adenocarcinoma
30-fold.9,11–14 Approximately
50% of patients with GERD will have
no disease on endoscop
**endoscopy **
abdominal pain and discomfort may be _________Asking the patient
to point to the pain and characterize all its features, combined with findings
on the physical examination, will help you identify possible causes.
Some
acute pain, especially in the suprapubic area or radiating from the flank,
originates in the genitourinary tract
acute or chronic.
Acute Lower Abdominal Pain.
Patients may complain of acute pain
localized to the right lower quadrant. Find out if it is sharp and continuous,
or intermittent and cramping, causing them to double over.
Right lower quadrant pain or pain
that migrates from the periumbilical
region, combined withabdominal
wall rigidity on palpation, is most
likely to predict _________
In
women, consider pelvic inflammatory
disease, ruptured ovarian follicle,
and ectopic pregnancy.16
appendicitis.
Cramping pain radiating to the right
or left lower quadrantmay be a
_____________.
renal stone
When patients report acute pain in the left lower quadrant or diffuse
abdominal pain, investigate associated symptoms such as ______________
fever and loss of
appetite.
Left lower quadrant pain with a
palpable mass may be____________
diverticulitis.
Diffuse abdominal pain with absent
bowel sounds and firmness, guarding,
or rebound on palpation is seen
in _______________________
small or large bowel obstruction
If there is chronic pain in the quadrants
of the lower abdomen, ask about ____________________
change in bowel habits and alternating
diarrhea and constipation.
Change in bowel habits with mass
lesion indicates_____________.
colon cancer
Intermittent
pain for 12 weeks of the preceding
12 monthswithrelief from
defecation,change in frequency
of bowel movements, or change in
form of stool (loose, watery, pelletlike),
without structural or biochemical
abnormalities are symptoms of
__________________
irritable bowel syndrome
Gastrointestinal Symptoms Associated With Abdominal Pain. Patients often experience abdominal pain in conjunction with other symptoms.
_______________ is a good starting question that may lead to other concerns like indigestion, nausea, vomiting, and anorexia.
“How is your appetite?”
_______________ is a
general term for distress associated with eating that can have many meanings.
Urge your patient to be more specific.
Indigestion
Gastrointestinal Symptoms Associated With Abdominal Pain
Nausea,
Anorexia
Nausea, often described as “feeling sick to my stomach,” may progress to retching and vomiting.
_______________ describes involuntary spasm of the stomach,
diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.
Retching
____________, _________ and ____________
accompany many gastrointestinal
disorders; these are all seen in
pregnancy, diabetic ketoacidosis,
adrenal insufficiency,hypercalcemia,
uremia, liver disease, emotional
states,adverse drug reactions, and
other conditions
Anorexia, nausea, and vomiting
. Induced vomiting
without nausea is more indicative of
______________
anorexia/bulimia.
Some patients may not actually vomit but raise esophageal or gastric contents
without nausea or retching, called ____________
regurgitation.
Regurgitation occurs in________________
GERD,
esophageal stricture,
and esophageal
cancer.
Vomiting and pain indicate_____________
small
bowel obstruction
. Fecal odor occurs
with_________________
small bowel obstruction or gastrocolic
fistula.
Coffee-grounds emesis or red blood is termed __________
hematemesis.
Hematemesis may accompany
_________________
- esophageal or gastric varices,
- gastritis, or peptic ulcer disease.
Symptoms of blood loss such
as______________
depend on the rate and volume of
bleeding and are rare until blood
loss exceeds 500 ml.
lightheadedness or syncope
______________ is loss or lack of appetite.
Find out if it arises from intolerance
to certain foods or reluctance to eat because of anticipated discomfort.
Check for associated symptoms of nausea and vomiting
Anorexia
moderate meals, or early satiety, the inability to eat a full meal. A dietary
assessment or recall may be warranted
Patients may complain of unpleasant abdominal fullness after light or
moderate meals, or early satiety, the inability to eat a full meal.
Consider diabetic gastroparesis,
anticholinergic medications, gastric
outlet obstruction, gastric cancer;
early satiety in hepatitis.
The sensation of a lump in the throat or the retrosternal area unassociated
with swallowing is not true dysphagia.
Food seems to stick, hesitate, or
“not go down right,”_______________
suggesting motility disorders or structural anomalies.
Indicators of oropharyngeal dysphagia
include__________________
drooling, nasopharyngeal
regurgitation, and cough
from aspiration in neuromuscular
disorders affecting motility such as
stroke or Parkinson’s disease; gurgling
or regurgitation of undigested
food occur in structural conditions
like Zenker’s diverticulum.
Pointing to below the sternoclavicular
notch indicates________________
esophageal
dysphagia.
If solid foods, consider structural
esophageal conditions like__________________
esophageal
stricture, web or Schatzki’s ring,
neoplasm
if solids and liquids, a
________________is more likely.
motility disorder
Consider esophageal ulceration
from radiation, caustic ingestion,
or infection from Candida, cytomegalovirus,
herpes simplex, or HIV.
________________ can be pill-induced
from aspirin or non-steroidal antiinflammatory
agents.
Odynophagia
Greek roots odyno-, pain + -phagia, from phagein, to eat)
Change in Bowel Function. You will frequently need to assess bowel
function. Start with open-ended questions:
“How are your bowel movements?”
“How frequent are they?”
“Do you have any difficulties?”
“Have
you noticed any change?” The range of normal is broad. Current parameters
suggest a minimum may be as low as two bowel movements per week.
Some patients may complain of passing excessive gas, or flatus, normally
about 600 ml/day
Consider aerophagia, legumes or
other gas-producing foods, intestinal
lactase deficiency, or irritable
bowel syndrome.
Patients vary widely in their views of diarrhea
and constipation.
Increased water content of the stool results in diarrhea,
or stool volume ______________
. Patients, however, usually focus
on the change to loose watery stools or increased frequency
>200 g in 24 hours
Ask about the duration.
Acute diarrhea lasts up to 2 weeks.
Chronic diarrhea
is defined as lasting 4 weeks or more.
Acute diarrhea, especially foodborne,
is usually caused by__________________;
19,20
infection
chronic diarrhea is typically
__________________ in origin, as in Crohn’s
disease and ulcerative colitis.
noninfectious
High-volume, frequent watery
stools usually are from the_______________;
small
intestine
small-volume stools with
tenesmus, or diarrhea with mucus,
pus, or blood occur in rectal inflammatory
conditions.
_____________ usually has
pathologic significance.
Nocturnal diarrhea
Oily residue, sometimes frothy or
floating, occurs with steatorrhea,
or fatty diarrheal stools, from _____________________
malabsorption
in celiac sprue, pancreatic
insufficiency, and small bowel bacterial
overgrowth.
Diarrhea is common with use of penicillins
and macrolides, magnesiumbased
antacids, metformin, and
herbal and alternative medicines.
Another common symptom is constipation.
Recent definitions stipulate that
constipation should be present for at least 12 weeks of the prior 6 months
with at least two of the following conditions:
fewer than 3 bowel movements
per week;
25% or more defecations with either straining or sensation
of incomplete evacuation; lumpy or hard stools; or manual facilitation.
Thin, pencil-like stool occurs in an
obstructing “apple-core” lesion of
the ___________
sigmoid colon.
Consider medications such as anticholinergic
agents, calcium-channel
blockers, iron supplements, and
opiates. Constipation also occurs
with diabetes, hypothyroidism, hypercalcemia,
multiple sclerosis, Parkinson’s
disease, and systemic sclerosis
____________may appear with as little as
100 mLof blood fromupper gastrointestinal
bleeding;
Melena
__________ if
more than 1,000 mL of blood, usually
from lower gastrointestinal bleeding.
hematochezia
Blood on the surface or toilet paper
may occur with hemorrhoids.
Mechanisms of Jaundice
◗◗ Increased production of bilirubin
◗◗ Decreased uptake of bilirubin by the hepatocytes
◗◗ Decreased ability of the liver to conjugate bilirubin
◗◗ Decreased excretion of bilirubin into the bile, resulting in absorption of
conjugated bilirubin back into the blood.
Predominantly__________ occurs from the first three
mechanisms, as in hemolytic anemia
(increased production) and Gilbert’s
syndrome.
unconjugated
bilirubin
Impaired excretion of conjugated
bilirubin is seen in viral hepatitis, cirrhosis,
primary biliary cirrhosis, and
drug-induced cholestasis, as from
oral contraceptives, methyl testosterone,
and chlorpromazine.
Gallstones or pancreatic carcinoma
may obstruct the________
common bile duct.
Dark urine from bilirubin indicates
_____________ into
the gastrointestinal tract.
impaired excretion of bilirubin
____________—when increased
abdominal pressure causes bladder
pressure to exceed urethral resistance
due to poor urethral sphincter
tone or poor support of bladder
neck;
Stress incontinence
