Lecture 19: Clinical abdomen Flashcards
Characteristics of inguinal hernia
Bulge appearing in groin
Pain in the area, increased by lifting heavy objects or strain during bowel movement
Bulge increases in volume when patient coughs
Bulge disappears when patient is supine
If you insert your finger into the superficial inguinal ring and ask patient to cough, you feel a mass pressing against your finger
What is an inguinal hernia?
Displacement of intra-abdominal structures such as small intestine or greater omentum through a weak area of the abdominal wall in the inguinal region.
What are the muscles of the anterolateral abdominal wall and inguinal canal?
External oblique
Internal oblique
Transverse abdominus
Transversalis fascia
Where does the spermatic cord travel in the abdomen?
Spermatic cord enters at the deep inguinal ring, travels down the inguinal canal, and enters the scrotum at the superficial inguinal ring
Borders of the inguinal triangle
aka Hesselbach’s triangle
Medial = lateral edge of rectus abdominis (1)
Lateral = inferior epigastric
artery and vein (2)
Inferior = Inguinal ligament (3)
See figure
What is the most common type of hernia?
Indirect inguinal hernia
Who gets indirect inguinal hernias most often?
Are often congenital (most hernias of this type close spontaneously by 1 year of age)
Who gets indirect inguinal hernias most frequently?
More common in males than females
Where does the indirect inguinal hernia occur?
LATERAL to the inferior epigastric artery
Who gets the direct inguinal hernia most frequently?
Mostly seen in adults and almost exclusively in males
What is the cause of a direct inguinal hernia?
weakness of the transversalis fascia at inguinal (Hesselbach’s) triangle
Where do direct inguinal hernias occur?
MEDIAL to the inferior epigastric artery
Typical presentation of appendicitis
Abdominal pain in the region of the umbilicus.
Pain gradually became more severe and moved to the lower right quadrant of the abdomen.
Accompanied by fever, vomiting, and nausea.
Upon palpating the abdomen, they noted tenderness over McBurney’s point.
What is appendicitis?
Inflammation of the vermiform appendix (narrow, blind-ending tube)
Appendix contains bacteria
Blockage of the appendix
(usually by fecal matter) causes the bacteria to grow and build up, leading to infection and inflammation
If not treated, the appendix can rupture, leading to peritonitis
Where is McBurney’s point?
Found 1/3 of the distance along a straight line from the pelvis (anterior superior iliac spine) to the umbilicus
Tenderness over this point is a classic sign of appendicitis, but remember that the appendix can move around!
See figure
What else might cause tenderness in McBurney’s point?
Ruptured ovarian cyst
Ectopic pregnancy
Referred pain in appendicitis
The appendix is innervated by nerves originating at T10
Pain is “referred” to the area of skin innervated by T10 – around the umbilicus
Pain moves to right lower abdomen after 24 hours
See figure
How is the appendicitis removed?
Appendectomy
Mesoappendix must be cut, and the appendicular artery and vein must be ligated
See figure
Common presentation of cirrhosis of the liver
Eyes yellow
Jaundice in skin
Distended abdomen, spiderweb pattern of veins running across it (secondary portal hypertension)
Alcoholic
Causes of liver cirrhosis
Several possible causes: congenital conditions, hepatitis, chronic alcohol abuse
The liver has a tremendous regenerative capacity, but chronic conditions like
these cause the liver cells to die and they are gradually replaced by scar tissue
Cause of portal hypertension
Elevated blood pressure in the portal venous system
Pre-hepatic: Portal vein or splenic vein thrombosis
Intra-hepatic: Cirrhosis
What are the physical signs of portal hypertension?
Ascites – elevated pressure causes fluid to be squeezed out of the veins and collect in the abdominal cavity
Caput medusae – “Medusa’s head”
See figure
What is the function of the portal-systemic anastomoses? Pathological?
Sites of communication between the portal and systemic circulation
Provide routes for collateral circulation in portal hypertension
Veins will become dilated and often form new branches (collaterals) in these areas
Where are the portal-systemic anastomoses found?
Esophagus
Umbilicus
Rectum
Colon
Complications in the portal-systemic anastomoses in the umbilicus
Paraumbilical veins (portal) anastomose with epigastric veins (systemic)
Dilation/collaterals of the paraumbilical veins = caput medusae
Complications in the portal-systemic anastomoses in the rectum
Superior rectal vein (portal) anastomoses with the inferior rectal vein (systemic)
Dilation/collaterals of the rectal veins = hemorrhoids
Complications in the portal-systemic anastomoses in the esophagus
Esophagus: branches of the left gastric vein (portal) anastomose with esophageal veins (systemic)
Dilation/collaterals of these small gastric vein branches = esophageal varices
Extremely dangerous! Bleeding from esophageal varices can be fatal!
Common presentation of gastric ulcer
Abdominal pain, nausea (several months)
Dyspnea
Pain radiating into chest
Patient is ashen, cold-sweating
Respiratory distress
Pain concentrated in the epigastric region, accompanied by abdominal rigidity
What do gastric glands produce?
HCl
Gastrin (stimulates HCl production)
Mucous
Pepsinogen: (protein digestion)
Intrinsic factor (Vitamin B12 absorption)
Stomach environment
Highly acidic
pH 1-2
Requires mucous barrier
What causes gastric ulcers?
H. pylori
NSAIDS (also increase
bleeding risk)
Complications that arise with perforated gastric ulcers
Allows gastric juices to leak out, causing peritonitis
Juices can erode the pancreas (pancreatitis) or the splenic artery (hemorrhage)
