Bates Flashcards
Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or lower esophageal sphincter action. Helicobacter pylori may be present.
process of Gastroesophageal reflux disease (GERD)
location of Gastroesophageal reflux disease (GERD)
Chest or epigastric
what does Gastroesophageal reflux disease (GERD) feel like
Burning (heartburn) Also regurgitation
when does GERD occur
After meals, specifically fatty foods
Lying down, bending over. Physical activity
aggravating factors of GERD
What relieves gerd
Antacids; avoiding alcohol, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers
associated symptoms with GERD
Wheezing, chronic cough, shortness of breath, hoarseness, choking sensation, halitosis, sore throat. Increases risk of Barrett’s esophagus and esophageal cancer
Peptic Ulcer and Dyspepsia
Process
Location
Quality
Timing
Aggravating factors
Relieving factors
Associated symp
Process: Demonstrated ulcer usually in duodenum or stomach; dyspepsia causes similar symptoms but no ulceration. H. pylori infection often present.
Location: Epigastric, may radiate to the back
Quality: Variable: gnawing burning, boring, aching, pressing, or hungerlike
Timing: Intermittent. Duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few weeks, disappears for months, then recurs.
Aggravating factors: Variable
Relieving factors: Food and antacids may bring relief, least commonly in gastric ulcer.
Associated symp: Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer). Dyspepsia is more common in the young (20–29 years), gastric ulcer in those over 50 years, and duodenal ulcer in those 30–60 years.
Cancer of the Stomach
Process
Location
Quality
Timing
Aggravating factors
Relieving factors
Associated symp
Process: Predominantly adenocarcinoma (90%–95%)
Location: Increasingly in “cardia” and GE junction; also in distal stomach
Quality: Variable
Timing: The history of pain is typically shorter than in peptic ulcer. Pain is persistent, slowly progressive.
Aggravating factors: Often food
Relieving factors: Not relieved by food or antacids
Associated symp: Anorexia, nausea, early satiety, weight loss, and sometimes bleeding. Most common in ages 50–70
Acute Appendicitis
Process
Location
Quality
Timing
Aggravating factors
Relieving factors
Associated symp
Process: Acute inflammation of the appendix with distention or obstruction OR Right lower quadrant pain
Location: Poorly localized periumbilical pain, followed usually by OR Right lower quadrant pain
Quality: Mild but increasing, possibly cramping OR Steady and more severe
Timing: Lasts roughly 4–6 hours OR Depends on intervention
Aggravating factors: Movement or cough
Relieving factors: If it subsides temporarily, suspect perforation of the appendix.
Associated symp: Anorexia, nausea, possibly vomiting, which typically follow the onset of pain; low fever
Acute Cholecystitis
Process
Location
Quality
Timing
Aggravating factors
Associated symp
Process: Inflammation of the gallbladder, usually from obstruction of the cystic duct by gallstone
Location: Right upper quadrant or upper abdominal; may radiate to the right scapular area
Quality: Steady, aching
Timing: Gradual onset; course longer than in biliary colic
Aggravating factors: Jarring, deep breathing
Associated symp: Anorexia, nausea, vomiting, fever
Biliary Colic
Process
Location
Quality
Timing
Associated symp
Process: Sudden obstruction of the cystic duct or common bile duct by a gallstone
Location: Epigastric or right upper quadrant; may radiate to the right scapula and shoulder
Quality: Steady, aching; not colicky
Timing: Rapid onset over a few minutes, lasts one to several hours and subsides gradually. Often recurrent
Associated symp: Anorexia, nausea, vomiting, restlessness
Acute Pancreatitis
Process Location Quality Timing Aggravating factors Relieving factors Associated symp
Process: Acute inflammation of the pancreas
Location: Epigastric, may radiate to the back or other parts of the abdomen; may be poorly localized
Quality: Usually steady
Timing: Acute onset, persistent pain
Aggravating factors: Lying supine
Relieving factors: Leaning forward with trunk flexed
Associated symp: Nausea, vomiting, abdominal distention, fever. Often a history of previous attacks and alcohol abuse or gallstones
Chronic Pancreatitis
Process Location Quality Timing Aggravating factors Relieving factors Associated symp
Process: Fibrosis of the pancreas secondary to recurrent inflammation
Location: Epigastric, radiating through to the back
Quality: Steady, deep
Timing: Chronic or recurrent course
Aggravating factors: Alcohol, heavy or fatty meals
Relieving factors: Possibly leaning forward with trunk flexed; often intractable
Associated symp: Pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and diabetes mellitus.
Acute Diverticulitis
Process Location Quality Timing Associated symp
Process: Acute inflammation of a colonic diverticulum, a saclike mucosal outpouching through the colonic muscle
Location: Left lower quadrant
Quality: May be cramping at first, but becomes steady
Timing: Often a gradual onset
Associated symp: Fever, constipation. There may be initial brief diarrhea.
Cancer of the Pancreas
Process
Location
Quality
Timing
Relieving factors
Associated symp
Process: Predominantly adenocarcinoma (95%)
Location: Epigastric and in either upper quadrant; often radiates to the back
Quality: Steady, deep
Timing: Persistent pain; relentlessly progressive illness
Relieving factors: Possibly leaning forward with trunk flexed; often intractable
Associated symp: Anorexia, nausea, vomiting, weight loss, and jaundice; depression
Acute Bowel Obstruction process
Obstruction of the bowel lumen, most commonly caused by (1) adhesions or hernias (small bowel), or (2) cancer or diverticulitis (colon)
acute Bowel obstruction
SMALL BOWEL
Location
Quality
Timing
Associated symp
Location: Small bowel: periumbilical or upper abdominal
Quality: Cramping
Timing: Paroxysmal; may decrease as bowel mobility is impaired
Associated symp: Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction). Obstipation develops.
acute Bowel obstruction
COLON
Location
Quality
Timing
Associated symp
Location: Colon: lower abdominal or generalized
Quality: Cramping
Timing: Paroxysmal, though typically milder
Associated symp: Obstipation early. Vomiting late if at all. Prior symptoms of underlying cause.
Mesenteric Ischemia
Process
Location
Quality
Timing
Associated symp
Process: Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion
Location: May be periumbilical at first, then diffuse
Quality: Cramping at first, then steady
Timing: Usually abrupt in onset, then persistent
Associated symp: Vomiting, diarrhea (sometimes bloody), constipation, shock; older age
Oropharyngeal Dysphagia,
due to motor disorders affecting the pharyngeal muscles
Timing
Factors that aggravate
Associated symptoms and conditions
Timing: Acute or gradual onset and a variable course, depending on the underlying disorder
Factors that aggravate: Attempts to start the swallowing process
Associated symptoms and conditions: Aspiration into the lungs or regurgitation into the nose with attempts to swallow. From stroke, bulbar palsy, or other neuromuscular conditions
Esophageal Dysphagia what are the mechanical narrowing issues (3)
Mucosal rings and webs Esophageal stricture Esophageal cancer
Mucosal rings and webs
timing
aggravating factors
relieving factors associated symp/conditions
timing : Intermittent
aggravating factors: Solid foods
relieving factors: Regurgitation of the bolus of food
associated symp/conditions: none
Esophageal stricture
timing
aggravating factors
relieving factors
associated symp/conditions
timing : Intermittent; may become slowly progressive
aggravating factors: solid foods
relieving factors: Regurgitation of the bolus of food
associated symp/conditions: A long history of heartburn and regurgitation
Esophageal cancer
timing
aggravating factors
relieving factors
associated symp/conditions
timing : May be intermittent at first; progressive over months
aggravating factors: Solid foods, with progression to liquids
relieving factors: Regurgitation of the bolus of food
associated symp/conditions: Pain in the chest and back and weight loss, especially late in the course of illness
Esophageal Dysphagia what are the motor disorders (3)
Diffuse esophageal spasm Scleroderma Achalasia
Scleroderma
timing
aggravating factors
relieving factors
associated symp/conditions
timing : Intermittent; may progress slowly
aggravating factors: Solids or liquids
relieving factors: Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis)
associated symp/conditions: Heartburn; other manifestations of scleroderma Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating
Achalasia
timing
aggravating factors
relieving factors
associated symp/conditions
timing : Intermittent; may progress
aggravating factors: Solids or liquids
relieving factors: Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis)
associated symp/conditions: Heartburn; other manifestations of scleroderma Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating
Diffuse esophageal spasm
timing
aggravating factors
relieving factors
associated symp/conditions
timing : Intermittent
aggravating factors: Solids or liquids
relieving factors: sometimes nitrogylcerin. Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis)
associated symp/conditions: Chest pain that mimics angina pectoris or myocardial infarction and lasts minutes to hours; possibly heartburn
constipation can happen from what 2 types of things
life activities and habits
mechanical obstruction
life activities and habits
Irritable Bowel Syndrome
process
associated symp. and setting
process: Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria.
associated symp. and setting: Three patterns: diarrhea—predominant, constipation—predominant, or mixed. Symptoms present ≥6 months and abdominal pain for ≥3 months plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance)
life activities and habits
Inadequate Time or Setting for the Defecation Reflex
process
associated symp. and setting
process: Ignoring the sensation of a full rectum inhibits the defecation reflex.
associated symp. and setting: Hectic schedules, unfamiliar surroundings, bed rest
life activities and habits
False Expectations of Bowel Habits
process
associated symp. and setting
process: Expectations of “regularity” or more frequent stools than a person’s norm
associated symp. and setting: Beliefs, treatments, and advertisements that promote the use of laxatives
life activities and habits
Diet Deficient in Fiber
process
associated symp. and setting
process: Decreased fecal bulk
associated symp. and setting: Other factors such as debilitation and constipating drugs may contribute.
Mechanical obstruction
Cancer of the Rectum or Sigmoid Colon
process
associated symp. and setting
process: Progressive narrowing of the bowel lumen from adenocarcinoma
associated symp. and setting: Change in bowel habits; often diarrhea, abdominal pain, bleeding, occult blood in stool. In rectal cancer, tenesmus and pencil-shaped stools. Weight loss.
Mechanical obstruction
Fecal Impaction
process
associated symp. and setting
process: A large, firm, immovable fecal mass, most often in the rectum
associated symp. and setting: Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly patients
Mechanical obstruction
Other Obstructing Lesions (such as diverticulitis, volvulus, intussusception, or hernia)
process
associated symp. and setting
process: Narrowing or complete obstruction of the bowel
associated symp. and setting: Colicky abdominal pain, abdominal distention, and in intussusception, often “currant jelly” stools (red blood and mucus)
Mechanical obstruction
Painful Anal Lesions
process
associated symp. and setting
process: Pain may cause spasm of the external sphincter and voluntary inhibition of the defecation reflex.
associated symp. and setting: Anal fissures, painful hemorrhoids, perirectal abscesses
Mechanical obstruction
Drugs
process
associated symp. and setting
process: A variety of mechanisms
associated symp. and setting: Opiates, anticholinergics, antacids containing calcium or aluminum, and many others
Mechanical obstruction
Depression
process
associated symp. and setting
process: A disorder of mood.
associated symp. and setting: Fatigue, anhedonia, sleep disturbance, weight loss
Mechanical obstruction
Neurologic Disorders
process
associated symp. and setting
process: Interference with the autonomic innervation of the bowel
associated symp. and setting: Spinal cord injuries, multiple sclerosis, Hirschsprung’s disease, and other conditions
Mechanical obstruction
Metabolic Conditions
process
associated symp. and setting
process: Interference with bowel motility
associated symp. and setting: Pregnancy, hypothyroidism, hypercalcemia
less then how many days to be considered acute diarrhea?
≤14 days
what are the three kinds of acute diarrhea
Secretory Infection (non-inflammatory)
Inflammatory Infection
Drug-Induced Diarrhea
Secretory Infection (non-inflammatory)
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Infection by viruses, preformed bacterial toxins (such as S. aureus, B. cereus, C. perfringens, toxigenic E. coli, Vibrio cholerae), cryptosporidium, Giardia lamblia, rotavirus
characteristics of stool: Watery, without blood, pus, or mucus
timing: Duration of a few days, possibly longer. Lactase deficiency may lead to a longer course.
associated symp.: Nausea, vomiting, periumbilical cramping pain. Temperature normal or slightly elevated setting,
persons at risk: Often travel, a common food source, or an epidemic
Inflammatory Infection
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Colonization or invasion of intestinal mucosa (nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica, C. difficile)
characteristics of stool: Loose to watery, often with blood, pus, or mucus
timing: An acute illness of varying duration
associated symp.: Lower abdominal cramping pain and often rectal urgency, tenesmus; fever setting,
persons at risk: Travel, contaminated food or water. Frequent anal intercourse.
Drug-Induced Diarrhea
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives
characteristics of stool timing: Loose to watery
timing.: Acute, recurrent, or chronic
Associated symp: Possibly nausea; usually little if any pain setting,
persons at risk: Prescribed or over-the-counter medications
how many days to be considered chronic diarrhea?
≥30 days
3 types of chronic diarrhea
- diarrheal syndrome
- Inflammatory Bowel Disease
- voluminous Diarrhea (osmotic/secretory diarrhea)
diarrheal syndrome
Irritable bowel syndrome
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Change in frequency and form of bowel movements without chemical or structural abnormality
characteristics of stool: Loose; ~50% with mucus; small to moderate volume. Small, hard stools with constipation. May be mixed pattern.
timing: Worse in the morning; rarely at night.
associated symp.: Crampy lower abdominal pain, abdominal distention, flatulence, nausea. Urgency, pain relieved with defecation. setting,
persons at risk: Young and middle-aged adults, especially women
diarrheal syndrome
Cancer of the sigmoid colon
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process:Partial obstruction by a malignant neoplasm
characteristics of stool: May be blood-streaked
timing: Variable
associated symp.: Change in usual bowel habits, crampy lower abdominal pain, constipation setting,
persons at risk: Middle-aged and older adults, especially older than 55 years
Inflammatory Bowel Disease
Ulcerative colitis
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Inflammation of the mucosa and submucosa of the rectum and colon with ulceration; typically extends proximally from the rectum
characteristics of stool: Soft to watery, often containing blood
timing: Onset ranges from insidious to acute. Typically recurrent; may be persistent. May awaken at night.
associated symp.: Milder cramping, lower or generalized abdominal pain, anorexia, weakness; fever if severe. May include episcleritis, uveitis, arthritis, erythema nodosum. setting,
persons at risk: Often young people. Increases risk of colon cancer.
Inflammatory Bowel Disease
Crohn’s disease of the small bowel (regional enteritis) or colon (granulomatous colitis)
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Chronic transmural inflammation of the bowel wall, in a skip pattern typically involving the terminal ileum and/or proximal colon
characteristics of stool: Small, soft to loose or watery, usually free of gross blood (enteritis) or with less bleeding than ulcerative colitis (colitis)
timing: Insidious onset; chronic or recurrent. Diarrhea may wake the patient at night.
associated symp.: Crampy periumbilical or right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, low fever, and/or weight loss. Perianal or perirectal abscesses and fistulas. May cause small or large bowel obstruction setting,
persons at risk: Often young people, especially in late teens, but also in middle age. More common in people of Jewish descent. Increases risk of colon cancer
Voluminous Diarrhea
Malabsorption syndrome
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Defective membrane transport or absorption of intestinal epithelium (Crohn’s, celiac disease, surgical resection); impaired luminal digestion (pancreatic insufficiency); epithelial defects at brush border (lactose intolerance)
characteristics of stool: Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet
timing: Onset of illness typically insidious
associated symp.: Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein) setting,
persons at risk: Variable, depending on cause
Voluminous Diarrhea - osmotic diarrhea
Lactose intolerance
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Deficiency in intestinal lactase
characteristics of stool: Watery diarrhea of large volume
timing: Follows the ingestion of milk and milk products; relieved by fasting
associated symp.: Crampy abdominal pain, abdominal distention, flatulence setting,
persons at risk: In >50% of African Americans, Asians, Native Americans, Hispanics; in 5%–20% of Caucasians
Voluminous Diarrhea - osmotic diarrhea
Abuse of osmotic purgatives
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Laxative habit, often surreptitious
characteristics of stool: Watery diarrhea of large volume
timing: Variable
associated symp.: Often none setting,
persons at risk:Persons with anorexia nervosa or bulimia nervosa
Voluminous Diarrhea
Secretory diarrhea
process
characteristics of stool
timing
associated symp. setting,
persons at risk
process: Variable: bacterial infection, secreting villous adenoma, fat or bile salt malabsorption, hormone-mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide)
characteristics of stool: Watery diarrhea of large volume
timing: Variable
associated symp.: Weight loss, dehydration, nausea, vomiting, and cramping abdominal pain setting,
persons at risk: Variable depending on cause
Refers to passage of black, tarry (sticky and shiny) stools. Occult blood tests are positive. Involves loss of at least 60 mL of blood into the gastrointestinal tract (less in children), usually from the esophagus, stomach, or duodenum and transit time of 7–14 hours. Less commonly, when transit is slow, blood loss originates in the jejunum, ileum, or ascending colon. In infants, melena may result from swallowing blood during the birth.
Melena
selected causes of Melena (4)
- Gastritis, GERD, peptic ulcer (gastric or duodenal)
- Gastritis or stress ulcers
- Esophageal or gastric varices
- Reflux esophagitis Mallory-Weiss tear in esophageal mucosa due to retching and vomiting
Usually epigastric discomfort from heartburn, dysmotility; if peptic ulcer, pain after meals (delayed, 2–3 hours if duodenal ulcer). May be silent.
Gastritis, GERD, peptic ulcer (gastric or duodenal)
Recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent bodily trauma, severe burns, surgery, or increased intracranial pressure
Gastritis or stress ulcers
Cirrhosis of the liver or other causes of portal hypertension
Esophageal or gastric varices
Retching, vomiting, often recent ingestion of alcohol
Reflux esophagitis Mallory-Weiss tear in esophageal mucosa due to retching and vomiting
May result from other causes, with negative occult blood tests. These stools have no pathologic significance.
Black, Nonsticky Stools
causes of Black, Nonsticky Stools
Ingestion of iron, bismuth salts, licorice, or even chocolate cookies
Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum. Upper gastrointestinal hemorrhage may also cause red stools; blood loss is then usually large (more than a liter). Rapid transit through the intestinal tract leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin.
Red Blood in the Stools (hematochezia)
causes of Red Blood in the Stools (hematochezia)
- Colon cancer
- Hyperplasia or adenomatous polyps
- Diverticula of the colon
- Inflammatory conditions of the colon and rectum
a. Ulcerative colitis, Crohn’s disease
b. Infectious diarrhea
c. Proctitis (various causes including frequent anal intercourse) - Ischemic colitis
- Hemorrhoids
- Anal fissure
Often a change in bowel habits, weight loss
Colon cancer
Often no symptoms unless inflammation causes diverticulitis
Diverticula of the colon
Rectal urgency, tenesmus
Proctitis (various causes including frequent anal intercourse)
Lower abdominal pain, sometimes fever or shock in older adults. Abdomen typically soft to palpation
Ischemic colitis
Blood on the toilet paper, on the surface of the stool, or dripping into the toilet
Hemorrhoids
Blood on the toilet paper or on the surface of the stool; anal pain
Anal fissure
Ingestion of beets causes
Reddish but Nonbloody Stools
Pink urine, which usually precedes the reddish stool; from poor metabolism of betacyanin
Ingestion of beets
Localized bulges in the abdominal wall include
ventral hernias (defects in the wall through which tissue protrudes) and subcutaneous tumors such as lipomas. The more common ventral hernias are umbilical, incisional, and epigastric. Hernias and a rectus diastasis usually become more evident when the patient raises head and shoulders from a supine position.
2 local bulges in abdominal wall of infant
- Umbilical Hernia
- Diastasis Recti
A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. In infants, it usually closes spontaneously within 1 to 2 years.
Umbilical Hernia
Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge when the patient raises head and shoulders. Often seen in repeated pregnancies, obesity, and chronic lung disease. It has no clinical consequences.
Diastasis Recti
This is a protrusion through an operative scar. Palpate to detect the length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed, has a greater risk for complications than a large defect.
Incisional Hernia
A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With the patient’s head and shoulders raised (or with the patient standing), run your fingerpad down the linea alba to feel it.
Epigastric Hernia
Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including the abdominal wall. Small or large, they are usually soft and often lobulated. Press your finger down on the edge of a lipoma. The tumor typically slips out from under it.
Lipoma
Protuberant Abdomens causes (5)
- Fat
- Gas
- Tumor
- Pregnancy
- Ascitic Fluid
is the most common cause of a protuberant abdomen. thickens the abdominal wall, the mesentery, and omentum. The umbilicus may appear sunken. A pannus, or apron of fatty tissue, may extend below the inguinal ligaments. Lift it to look for inflammation in the skin folds or even for a hidden hernia.
Fat
_____ distention may be localized or generalized. It causes a tympanitic percussion note. Increased production from certain foods may cause mild distention. More serious are intestinal obstruction and adynamic (paralytic) ileus. Note the location of the distention. Distention becomes more marked in colonic than in small bowel obstruction.
Gas
A large, solid _______, usually rising out of the pelvis, is dull to percussion. Air-filled bowel is displaced to the periphery. Causes include ovarian tumors and uterine myomata. Occasionally a markedly distended bladder may be mistaken for such a tumor.
Tumor
is a common cause of a pelvic “mass.” Listen for the fetal heart
Pregnancy
seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness)
Ascitic Fluid
Bowel Sounds Bowel sounds may be: Increased:
as in diarrhea or early intestinal obstruction
Bowel Sounds Bowel sounds may be: decreased:
Decreased, then absent, as in adynamic ileus and peritonitis. Before deciding that bowel sounds are absent, sit down and listen where shown for 2 minutes or even longer.
High-pitched tinkling sounds suggest
intestinal fluid and air under tension in a dilated bowel
Rushes of high-pitched sounds coinciding with an abdominal cramp indicate
intestinal obstruction.
suggests carcinoma of the liver or alcoholic hepatitis.
hepatic bruit
with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries.
Arterial bruits
Partial occlusion of a renal artery may explain
hypertension
is rare. It is a soft humming noise with both systolic and diastolic components. It indicates increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.
Venous Hum
are rare. They are grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct.
Friction Rubs
When a systolic bruit accompanies a hepatic friction rub, suspect
carcinoma of the liver.
2 Types of Tender Abdomens
- abdominal wall tenderness
- Visceral Tenderness
When the patient raises the head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases.
Abdominal wall Tenderness
The structures (enlarges liver, normal aorta, normal cecum, normal or spastic sigmoid colon) may be tender to deep palpation. Usually the discomfort is dull with no muscular rigidity or rebound tenderness. A reassuring explanation to the patient may prove quite helpful.
Visceral Tenderness
Tenderness From Disease in the Chest and Pelvis 2 types
- Acute Pleurisy
- Acute Salpingitis
Abdominal pain and tenderness may result from acute pleural inflammation. When unilateral, it may mimic acute cholecystitis or appendicitis. Rebound tenderness and rigidity are less common; chest signs are usually present.
Acute Pleurisy
Frequently bilateral, the tenderness of ____________ (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments. Rebound tenderness and rigidity may be present. On pelvic examination, motion of the uterus causes pain.
Acute Salpingitis
is more severe than visceral tenderness. Muscular rigidity and rebound tenderness are frequently but not necessarily present. Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with boardlike muscular rigidity. These signs on palpation, especially abdominal rigidity, double the likelihood of peritonitis
Tenderness of Peritoneal Inflammation
Local causes of peritoneal inflammation include:
- Acute Cholecystitis
- Acute Pancreatitis
- Acute Appendicitis
- Acute Diverticulitis
Signs are maximal in the right upper quadrant. Check for Murphy’s sign
Acute Cholecystitis
epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft.
Acute Pancreatitis
Right lower quadrant signs are typical of acute appendicitis but may be absent early in the course (McBurney’s point). Explore other portions of the right lower quadrant as well as the right flank.
Acute Appendicitis
most often involves the sigmoid colon and then resembles a left-sided appendicitis.
Acute Diverticulitis
T OR F
A palpable liver does not necessarily indicate hepatomegaly (an enlarged liver), but more often results from a change in consistency—from the normal softness to an abnormal firmness or hardness, as in cirrhosis.
TRUE
Clinical estimates of liver size should be based on both ______ AND _______ although even these techniques are far from perfect
percussion and palpation
This finding is common when the diaphragm is low (e.g., in COPD). The liver edge may be palpable well below the costal margin. Percussion, however, reveals a low upper edge, and the vertical span of the liver is normal.
Downward Displacement of the Liver by a Low Diaphragm
In some people, especially those with a lanky build, the liver tends to be elongated so that its right lobe is easily palpable as it projects downward toward the iliac crest. Such an elongation, sometimes called Riedel’s lobe, represents a variation in shape, not an increase in liver volume or size. Examiners can only estimate the upper and lower borders of an organ with three dimensions and differing shapes. Some error is unavoidable.
Normal Variations in Liver Shape
Cirrhosis may produce an enlarged liver with a firm, nontender edge. The cirrhotic liver may also be scarred and contracted. Many other diseases may produce similar findings such as hemochromatosis, amyloidosis, and lymphoma. An enlarged liver with a ________ tender edge suggests inflammation, as in hepatitis, or venous congestion, as in right-sided heart failure.
Smooth Large Liver
blank line is: SMOOTH
An enlarged liver that is firm or hard and has an ______ edge or surface suggests hepatocellular carcinoma. There may be one or more nodules. The liver may or may not be tender.
Irregular Large Liver
blank line is: IRREGULAR
Screening for colorectal cancer assess risk:
Begin screening at age 20 years.
If high risk, refer for more complex management.
If average risk at age 50 (high-risk conditions absent), offer the screening options listed in the next cards
Personal history of colorectal cancer or adenoma
First-degree relative with colorectal cancer or adenomatous polyps
Personal history of breast, ovarian, or endometrial cancer
Personal history of ulcerative or Crohn’s colitis
Common high-risk conditions (25% of colorectal cancers)
Familial adenomatous polyposis
Hereditary nonpolyposis colorectal cancer
Hereditary high-risk conditions (6% of colorectal cancers)
COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008
Adults age 50 to 75 years—options:
High-sensitivity fecal occult blood testing (FOBT) annually
Sigmoidoscopy every 5 years with FOBT every 3 years
Screening colonoscopy every 10 years
COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008
Adults age 76 to 85 years
do not screen routinely, as gain in life-years is small compared to colonoscopy risks, and screening benefits not seen for 7 years; use individual decision making if screening for the first time
COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008
Adults older than age 85
do not screen, as “competing causes of mortality preclude a mortality benefit that outweighs harms”
third most common cancer in both men and women, and it causes almost 10% of deaths from cancer.
Colorectal cancer
More than ______% of cases occur after age 50, primarily from neoplastic changes in adenomatous polyps; only about a third of cases have identifiable high-risk factors.
90%
Incidence rates are ___________, except in adults younger than 50 years who fall outside the current age threshold for screening.
decreasing
mortality rates in ____________ are double those of other ethnic groups.
african americans
order of abdomen exam
- inspection
- Auscultation
- Percussion
- Palpation (light then deep)
increased peristaltic waves
intestinal obstruction
bruits suggest
vascular occlusion
Bruits with both systolic and diastolic components suggest
the turbulent blood flow from atherosclerotic arterial disease.
A protuberant abdomen that is tympanitic throughout suggests
intestinal obstruction
Dull areas can indicate
a pregnant uterus, an ovarian tumor, a distended bladder, or a large liver or spleen.
Dullness in both flanks prompts further assessment for
ascites
rare condition organs are reversed—air bubble on the right, liver dullness on the left.
Situs inversus
Involuntary rigidity (muscular spasm) typically persists despite these maneuvers, suggesting
Peritoneal inflammation
Abdominal masses may be categorized in several ways: (5)
- physiologic (pregnant uterus)
- inflammatory (diverticulitis of the colon)
- vascular (an abdominal aortic aneurysm)
- neoplastic (colon cancer)
- obstructive (a distended bladder or dilated loop of bowel) .
is twice as likely in the presence of guarding, Rosving’s sign, and the psoas sign; it is three times more likely if rigidity and McBurney’s point tenderness are present
Appendicitis
begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it. Older patients report this pattern less frequently than younger ones.
Appendicitis
Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate
appendicitis
Pain in the right lower quadrant during left-sided pressure is a positive
Rovsing’s sign.
Increased abdominal pain on either maneuver constitutes a positive _________, suggesting irritation of the psoas muscle by an inflamed appendix.
psoas sign
Right hypogastric pain constitutes a positive _________, from irritation of the obturator muscle by an inflamed appendix.
obturator sign
A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive ___________ of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.
Murphy’s sign
