Chapter 14 - Abdominal Flashcards
Which race has the highest incidence of colorectal cancer?
African Americans
Which race has the lowest incidence of colorectal cancer?
Native Americans
The lifetime risk of colonic cancer is 100% for patients with ____
Polyposis coli
What kind of diet puts a person at higher risk for colonic cancer?
Low fiber
High fat
What is the MC type of liver cancer?
Hepatocellular carcinoma
The incidence of liver cancer has been _____
Increasing
Rates of liver cancer are highest in which races?
Asians, Pacific islanders, Hispanics
MC causes of liver cancer in US/western countries
Alcohol-related cirrhosis and fatty liver disease from obesity
MC causes of liver cancer worldwide (outside of US)?
HBV and HCV
What increases the risk of pancreatic cancer?
Smoke and smokeless tobacco
Which organs are located posteriorly in the abdomen (so unlikely to be palpated)?
Kidneys
Duodenum
Pancreas
Why can a child’s kidneys be palpated?
Less developed abdominal muscles
What is dysphagia?
Difficulty swallowing
What is chyme?
Semifluid creamy material produced by gastric digestion of food
Emptying of the stomach is normally complete within:
6 hours of eating
When is the flow of pancreatic juice maximal?
Approx. 2 hours after a meal
What are the 3 enzymes of chyme?
Lipase (fats)
Amylase (starches)
Trypsin (proteins)
Where are bile acids and Vit B12 absorbed?
Ileum
What is the dark color of stool caused by?
Presence of stercobilin (a metabolite of bilirubin)
What are acholic stools?
- No bile
- Pale brown to gray
Most abdominal disease manifests itself with:
Pain!
Abdominal pain can result from:
- Mucosal irritation
- Smooth muscle spasm
- Peritoneal irritation
- Capsular swelling
- Direct nerve stimulation
3 categories of abdominal pain
- Visceral
- Parietal
- Referred
When does visceral pain develop?
Hollow abdominal organs contract forcefully or their walls are stretched
How is visceral pain usually described by the patient?
Gnawing, burning, aching
Difficult for pt to locate specifically
How does parietal pain develop?
Inflammation of peritoneum
- Extremely severe, patient can locate over a specific organ usually
- Movement exacerbates the pain
How does pain vary between gastric and duodenal ulcers?
- Gastric: pain 30 mins to 1 hr after a meal
- Duodenal: pain 2-3 hours after eating or before next meal
Nocturnal pain is a symptom of what abdominal condition?
Duodenal peptic ulcer
What triad of symptoms are found in abdominal angina?
Postprandial pain
Anorexia
Weight loss
What does abdominal angina result from?
Obstructive vascular disease in celiac axis or superior mesenteric artery
Cystitis vs. ureteral pain
- Cystitis: dull pressure a/w burning during urination
- Ureteral: extremely severe and colicky
Vomiting resulting from perforation is commonly ____
NOT massive
Vomiting resulting from obstruction is:
Episodic and at the height of pain
What generally causes persistent vomiting?
Toxins
In acute appendicitis, how do pain and vomiting usually present?
Pain precedes vomiting usually by a few hours
What is feculent vomitus usually caused by?
Intestinal obstruction
_____ is a disease of the colon that produces bloody diarrhea
Shigellosis
-Amebiasis is also a/w bloody diarrhea
Describe diarrhea/constipation in patients with colon cancer or diverticulitis
Diarrhea and constipation frequently alternate
_____ stools may result from malabsorption syndromes
Floating
How does diarrhea classically present in IBS?
More in the morning
“Pencil” diameter stools may result from:
Anal or distal rectal carcinoma
What are black feces a/w?
- Meds like Pepto Bismol, dietary iron supplements
- Foods like black licorice or blueberries
What is hematochezia and what is it a/w?
- Bright red blood per rectum (BRBPR)
- Can occur from colonic tumors, diverticular disease, ulcerative colitis
What is tenesmus?
- Painful ineffective straining at stool
- Caused by inflammation or a space-occupying lesion (e.g. tumor)
What is a common cause of hematochezia?
Hemorrhoidal bleeding
What is melena?
-Black, tarry stool-Results from bleeding above the first section of duodenum w/partial digestion of hemoglobin
Silver-colored stools
- RARE
- Pathognomonic of acholic stools with melena
- Strongly suggestive of cancer of ampulla of Vater in the duodenum
Presence of icterus or jaundice results from:
Decreased excretion of conjugated bilirubin into the bile
Medical jaundice results from:
Intrahepatic biliary obstruction
Surgical jaundice results from:
Extrahepatic biliary obstruction
What condition can be linked to ingestion of raw shellfish?
Hepatitis A
Viral hepatitis is a/w
N/V
Loss of appetite
Aversion to smoking (if in the habit)
What is the MC chronic blood-borne infection in the US?
HCV
What is the MC indication for liver transplantation?
End stage liver disease secondary to HCV infection
How does obstructive jaundice present?
Slowly developing accompanied by pale stools and cola-colored urine
What is suspected if jaundice accompanied by fever and chills?
Cholangitis
Cholangitis may result from:
- Stasis of bile in bile duct (gallstone)
- Cancer of pancreas head
What are the MC occupational exposures known to cause liver disease?
- Carbon tetrachloride
- Vinyl chloride
Abdominal distention may be related to:
- Increased gas in GI tract
- Presence of ascites
What can cause increased gas in the GI tract?
- Malabsorption
- Irritable colon
- Aerophagia
What can cause ascites?
- Cirrhosis
- CHF
- Portal HTN
- Peritonitis
- Neoplasia
What could an abdominal mass be?
- Neoplasm
- Hernia
What is the MC complaint of an abdominal hernia?
Swelling (may or may not be painful)
When is a hernia termed “reducible”?
When it can be emptied of its contents by pressure or a change in posture
What does a pulsatile abdominal mass indicate?
Possible aortic aneurysm!
What is pruritus ani?
Localized itching of anal skin
*Cleanliness is almost never a factor
How are bowel movements characterized in IBD?
10-30 watery or blood BMs a day
What do patients develop from IBD due to malabsorption?
Osteopenia/osteoporosis
What is the most reported characteristic of patients with IBD?
Dependency
also obsessive-compulsive
Is denial an issue with IBD patients?
No - typically they are obsessed with the details of their condition
How does sexual activity present in patients with IBD?
- Low level
- Many prefer to be fondled like a child
- Many reject any genital contact
- Many view sex as “dirty”, “unclean”
What may be the basis of depression in IBD patients?
Fear of cancer
What is an unappreciated major complication of IBD?
Substance abuse
Which side should the examiner stand on for abdominal examination?
Patient’s right side
How should you examine abdominal pain?
Examine that area last! Otherwise, abdominal muscles will tighten
How do patients present in renal/biliary colic vs. peritonitis?
- Renal/biliary colic writhe in bed, can’t find comfortable position
- Peritonitis have intense pain on movement so they lay very still in bed
How should you evaluate for jaundice?
In natural light if possible
When does jaundice become apparent?
When serum bilirubin exceeds 2.5 mg/dL in adults (above 6 mg/dL in neonates)
What can spider angiomas indicate?
Sensitive for alcoholic cirrhosis but non-specific (can occur in pregnancy and collagen vascular disorders)
Pyoderma gangrenosum
- Tender ulcerations commonly on lower extremities
- A/w IBD, especially ulcerative colitis
Half and half nails can indicate:
Cirrhosis
Lindsay’s nails
Peutz-Jeghers syndrome
- Melanin deposition around and in oral cavity
- Genetic disorder causing GI and mucocutaneous pigmentation
- Benign polyps in jejunum (rarely become malignant)
Osler-Weber-Rendu syndrome
- Multiple telangiectases of lips, tongue, GI tract
- May bleed insidiously causing anemia
How does Cushing’s syndrome present in the abdominal/GI system?
Obesity (90% pts)
Scaphoid abdomen and what it can be a/w
- Concave
- May be a/w cachexia
Protuberant abdomen may result from:
- Gaseous distention of intestines
- Ascites
- Massive splenomegaly
- Obesity
When a patient with ascites lays supine:
Fluid bulges in the flanks
What are silver striae vs. pinkish-purple striae?
- Silver are consistent with weight loss
- Purple are a/w Cushing’s
What does an everted umbilicus often indicate?
Increased abdominal pressure usually from ascites or a large mass
What is Grey Turner’s sign?
- Massive ecchymoses on abdomen or flanks (SC purpura)
- Result of hemorrhagic pancreatitis or strangulated bowel
What is Cullen’s sign?
Bluish discoloration of the umbilicus resulting from hemoperitoneum of any cause
What is caput medusae?
- Dilated veins that appear to radiate from the umbilicus
- Seen in pts with portal HTN
What are borborygmi and what are they a/w?
- Low pitched rumbling bowel sounds
- A/w hyperperistalsis
- Common in early acute intestinal obstruction
When could a peritoneal friction rub be heard?
Hepatic or splenic inflammation
What is the MC percussion note in the abdomen?
Tympany
- Caused by presence of gas in stomach, SI, colon
- Suprapubic area may sound dull if bladder is distended or a woman’s uterus enlarged
Percussion note over the liver
Dull until colon (tympanic)
What is Traube’s space?
- Where spleen is found in normal individuals
- Within rib cage against posterolateral wall
What is the most sensitive sign for ascites?
Shifting dullness
What is the most specific sign for ascites?
Prominent fluid wave
With patients who are ticklish, what may be useful to assist in palpation of the abdomen?
Sandwich their hand between your hands
Describe rigidity vs. guarding in abdominal exam
- Rigidity is involuntary spasm of abdominal muscles
- Guarding is voluntary spasm of abdominal muscles
Murphy’s sign
- Pain is elicited in LUQ on inspiration
- Suggestive of acute cholecystitis
What is Sims’ position?
- Left lateral prone
- Used for DRE in pts who are weak and confined to bed
What is a sessile polyp?
Attached by a base
What is a pedunculated polyp?
Attached by a stalk
What is Blumer’s shelf?
Shelflike structure that projects into rectum as a result of infiltration of Douglas’ pouch with neoplastic cells
What do the guaiac or benzidine tests assess?
Occult blood in the stool
What are tests that find colorectal polyps and cancer?
- Flexible sigmoidoscopy every 5 years
- Colonoscopy every 10 years
- Double contrast barium enema every 5 years
- CT colonography every 5 years
What are tests that primarily find colorectal cancer?
- FOBT (fecal occult blood test) yearly
- Fecal immunochemical test yearly
Anal cancer is ____ in both men and women _____
Increasing
worldwide
Which populations have higher risk for anal cancer?
- MSM
- HIV positive
- Transplant recipients
- Women with cervical neoplasia
What is the leading cancer diagnosed among men in the US?
Prostate
What population has the highest rates of prostate cancer in the world?
African Americans in the US
Describe PSA
- Produced by prostate
- Mostly found in semen, but also blood
- When cancer develops, PSA rises
- Many false positives for cancer
