The Abdomen Flashcards
1
Q
Boundaries of the abdomen
A
The region lying between the thorax above and the pelvic cavity below.
The anterior abdominal wall is bounded by the 7-12th costal cartilages and the xiphoid process of the sternum superiorly, and the inguinal ligaments and pelvic bones inferiorly.
The abdominal cavity is separated from the thoracic cavity by the diaphragm.
2
Q
Abdominal regions
A
Right hypochondrium – Epigastrium – Left hypochondrium
Right lumbar – Umbilical – Left lumbar
Right inguinal – Suprapubic – Left inguinal
3
Q
Physiology of swallowing
A
The swallowing process is controlled by the medulla initially and by an autonomous peristaltic reflex coordinated by the enteric nervous system in the mid- and distal-oesophagus.
This complex process can be divided into 3 phases: oral phase, oro-pharyngeal phase, and oesophageal phase.
4
Q
Physiology of swallowing: oral phase
A
Food enters the oral cavity.
Mastication and bolus formation.
5
Q
Physiology of swallowing: oro-pharyngeal phase
A
Tongue elevates and propels the bolus to the pharynx.
The soft palate elevates to seal the nasopharynx.
The larynx and hyoid bone move anteriorly and cranially.
Epiglottis moves posteriorly and caudally to close the respiratory tract.
Respiration pauses.
Pharynx shortens.
6
Q
Physiology of swallowing: oesophageal phase
A
Upper oesophageal sphincter relaxes. Bolus passes into the oesophagus. Oesophagus contracts sequentially (peristalsis). Lower oesophageal sphincter relaxes. Bolus enters the stomach.
7
Q
Abdominal history: dysphagia overview
A
This is difficulty swallowing, the principal symptom of oesophageal disease. Level of obstruction Onset Time course Solids/liquids Associated symptoms
8
Q
Abdominal history: dysphagia, level of obstruction
A
Where does the patient feel the obstruction?
Patients can often point to a level on the chest although the sensation usually correlates poorly with the actual level of obstruction.
9
Q
Abdominal history: dysphagia, onset
A
How quickly did the symptoms emerge?
Obstruction caused by cancer may progress rapidly over a few months.
Benign peptic stricture may give very long history of GORD with slowly progressive dysphagia.
10
Q
Abdominal history: dysphagia, time course
A
Is the symptom intermittent or constant?
Present for only the first few swallows: lower oesophageal ring, spasm?
Progressive: cancer, stricture, achalasia.
11
Q
Abdominal history: dysphagia, solids/liquids
A
Solids, liquids, or both affected?
Both solids and liquids being affected equally suggests a motor cause (achalasia, spasm).
Solids affected more than liquids suggests some physical obstruction is more likely (e.g. cancer).
12
Q
Abdominal history: dysphagia, associated symptoms
A
Heartburn (leads to oesophageal strictures)
Weight loss
Wasting
Fatigue (perhaps suggestive of cancer)
Coughing and choking suggest pharyngeal dysphagia due to motor dysfunction, e.g. motor neuron disease causing bulbar or pseudobulbar palsy.
13
Q
Types of dysphagia
A
Oropharyngeal
Oesophageal
14
Q
What is oropharyngeal dysphagia?
A
‘High’ dysphagia.
Patients have difficulty initiating a swallow and often feel as though the cervical/neck area is the level of apparent obstruction.
Symptoms relate to both the dysphagia itself and likely underlying causes: difficulty initiating swallow, nasal regurgitation, coughing, nasal speech, diminished cough reflex, choking, dysarthria and diplopia, halitosis.
15
Q
What is oesophageal dysphagia?
A
‘Low’ dysphagia.
Patients find the site of apparent obstruction difficult to localise and may often point to their neck when the obstruction is actually within the distal oesophagus (e.g. in achalasia).
16
Q
Causes of oropharyngeal dysphagia
A
Mechanical and obstructive: infections (e.g. retropharyngeal abscess), enlarged thyroid, lymphadenopathy, Zenker’s diverticulum, reduced muscle compliance (e.g. myositis, fibrosis), malignancy, large cervical osteophytosis.
Neuromuscular: stroke, Parkinson’s disease, bulbar palsy, motor neuron disease, multiple sclerosis, myasthenia graves, muscular dystrophy.
Other: poor dentition, oral ulcers, xerostomia.
17
Q
Causes of oesophageal dysphagia
A
Mucosal disease: peptic stricture, oesophageal rings and webs (e.g. Plummer-Vinson syndrome), oesophageal tumours, chemical injury, radiation injury, infectious oesophagitis, eosinophilic oesphagitis.
Mediastinal disease: tumours, infection (e.g. TB, histoplasmosis), cardiovascular (e.g. vascular compression).
Smooth muscle/ innervation disease: achalasia (e.g. idiopathic, Chagas disease), scleroderma, post-surgical (e.g. post-fundoplication, antireflux devices, gastric banding).
18
Q
Abdominal history: odynophagia
A
This is pain on swallowing and usually reflects a severe inflammatory process involving the oesophageal mucosa or, rarely, the oesophageal musculature.
The character may range from a dull retrosternal ache to a sharp, stabbing pain with radiation through to the back.
Severity can be such that patients feel unable to swallow their own saliva.
19
Q
Abdominal history: odynophagia, causes
A
Chemical irritation: acid, alkali
Drug-induced oesophagitis: antibiotics e.g. doxycycline, potassium chloride, quinidine, iron sulphate, zidovudine, NSAIDs.
Radiation oesophagitis.
Infectious oesophagitis.
Healthy patients: Candida albicans, herpes simplex.
Immunocompromised patients: fungal (Candida, histoplasmosis), viral (herpes simplex, cytomegalovirus, HIV, EBV), Mycobacteria (tuberculosis, avium-complex), protozoan (Cryptosporidium, Pneumocystis jiroveci), idiopathic ulceration.
Severe ulcerative oesophagitis secondary to GORD.
Oesophageal carcinoma.
20
Q
Abdominal history: globus sensation
A
This is the sensation of a ‘lump’ or tightness in the throat and is usually not related to swallowing.
Patients may describe this as a ‘tightness’, ‘choking’, or ‘strangling feeling’ as if something is caught in the throat.
Present between meals.
Swallowing solids or large liquid boluses may give temporary relief.
Exacerbated by emotional stress.
Dysphagia and odynophagia are not present.
21
Q
Abdominal history: globus sensation, causes
A
The cause of globus sensation is often unclear and may be a combination of physiological and psychological factors.
Anxiety, panic disorder, depression, and somatisation are often present.
Physiological tests of oesophageal motility are often normal.
A combination of biological factors, hypochondriacal traits, and learned fear following an episode of choking can increase the symptom.
22
Q
Abdominal history: heartburn and reflux
A
GORD.
Caused by the regurgitation of stomach contents into the oesophagus due to an incompetent anti-reflux mechanism at the gastro-oesophageal junction.
Site: mid-line, retrosternal.
Radiation: to the throat and occasionally the infra-scapular regions.
Nature: ‘burning’.
Aggravating factors: worse after meals and when performing postures which raise the intra-abdominal pressure (bending, stooping, lying supine); pregnancy.
Associated symptoms: acid or bitter taste (acid regurgitation), sudden filling of the mouth with saliva (waterbrash).
Acid reflux may be worsened by certain foods (alcohol, caffeine, chocolate, fatty meals) and some drugs (calcium channel blockers, anticholinergics) which act to reduce the GOJ sphincter pressure.
Hiatus hernia is another important cause of reflux symptoms.
23
Q
Abdominal history: heartburn, causes
A
Decreased lower oesophageal sphincter pressure: foods (fats, sugars, chocolate, onions, coffee, alcohol); cigarette smoking; medication (calcium channel blockers, nitrates, diazepam, theophylline, progesterone, anticholinergics).
Direct mucosal irritation: foods (citrus fruits, tomato-based foods, spicy foods, coffee); medication (aspirin, NSAIDs, tetracycline, quinidine, potassium chloride, iron).
Increased intra-abdominal pressure: bending over, lifting, straining at stool, exercise.
Other: lying supine, lying on the right, red wine, high emotion.
24
Q
Abdominal history: nausea
A
A feeling of sickness- the inclination to vomit.
Usually occurs in waves.
May be associated with retching or heaving.
Can last from seconds to days depending on the cause.
25
Abdominal history: vomiting (emesis)
The forceful expulsion of the gastric contents by reflex contractions of the thoracic and abdominal muscles.
Usually follows nausea and autonomic symptoms such as salivation.
26
Abdominal history: nausea and vomiting, onset
Over what time period have the symptoms developed?
Acute: cholecystitis, gastroenteritis, recreational drug use, pancreatitis.
Chronic: metabolic disorders, gastroparesis, GORD, pregnancy, medications.
27
Abdominal history: nausea and vomiting, timing
Be clear on exactly when vomiting tends to occur, particularly its relation to meals.
Before breakfast: alcohol, raised intracranial pressure, pregnancy, uraemia.
During or immediately after eating: psychiatric causes (also peptic ulcer disease, pyloric stenosis).
1-4 hours after a meal: gastric outlet obstruction, gastroparesis.
Continuous: conversion disorder, depression.
Irregular: major depression.
28
Abdominal history: nausea and vomiting, nature of the vomitus
Undigested food: achalasia, oesophageal disorders (e.g. diverticulum, strictures).
Partially digested food: gastric outlet obstruction, gastroparesis.
Bile: proximal small bowel obstruction.
Faeculent/ malodorous: fistula, obstruction.
Large volume: >1.5L in 24hrs, more likely physical than psychiatric.
29
Abdominal history: nausea and vomiting, associated symptoms and their causes
Malignancy: weight loss.
Viral: diarrhoea, myalgia, malaise, headache.
Central neurologic: headache, neck stiffness, vertigo, focal neurological signs/symptoms.
Gastroparesis: early satiety, post-prandial bloating, abdominal discomfort.
Cyclical vomiting syndrome: repetitive migraine headaches, symptoms of IBS.
30
Abdominal history: nausea and vomiting, haematemesis
Presence of blood indicates bleeding in the upper GI tract (oesophagus, stomach, duodenum, above the ligament of Treitz).
The amount of blood and the exact nature of it:
- Large volume of fresh, red blood suggests active bleeding (coincident liver disease and/or heavy alcohol intake may suggest bleeding oesophageal varies, abdominal pain and heartburn may suggest a gastric or oesophageal source such as PUD or GORD).
- Small streaks at the end of prolonged retching may indicate minor oesophageal trauma at the GOJ (Mallory-Weiss tear).
- Coffee-grounds: looking like small brown granules, this blood has been 'altered' by exposure to stomach acid, implying that the bleeding has ceased or is relatively modest.
Previous bleeding episodes, treatment, and outcome (e.g. previous surgery).
Cigarette smoking.
Use of drugs such as aspirin, clopidogrel, NSAIDS, and warfarin.
Ask about weight loss, dysphagia, abdominal pain, and melaena.
31
Abdominal history: causes of upper GI bleeding
```
Peptic ulceration
Oesophagitis
Gastritis/erosions
Erosive duodenitis
Varices
Portal hypertensive gastropathy
Malignancy
Mallory-Weiss tear
Vascular anomalies (e.g. angiodysplasia, AV malformation)
Connective tissue disorders (e.g. Ehlers-Danlos syndrome)
Vasculitis
Bleeding diathesis
```
32
Abdominal history: nausea and vomiting, vomiting bile
Assess the presence or absence of bile.
Bile comes largely in 2 colours- the green pigment (biliverdin) often seen to colour the vomitus in the absence of undigested food; the yellow pigment (bilirubin) appears as orange, often occurring in small lumps.
Undigested food without bile suggests a lack of connection between the stomach and the small intestine (e.g. pyloric obstruction).
33
Abdominal history: abdominal pain, site
Pain from most abdominal organs cannot be felt directly- the sensation is referred to areas of the abdominal wall according to the organ's embryological origin.
Ask the patient to point to the area affected.
Patients often find this challenging and may indicate a wide area.
A very localised pain may originate from the parietal peritoneum, e.g. appendicitis: may begin as umbilical pain then move to the right iliac fossa as the inflammation spreads to the peritoneum overlying the appendix.
Epigastric pain: foregut (stomach, duodenum, liver, pancreas, gallbladder).
Periumbilical pain: midgut (small and large intestines including appendix).
Suprapubic pain: hindgut (rectum and urogenital organs).
34
Abdominal history: abdominal pain, radiation
Ask the patient if the pain is felt elsewhere or if they have any other pains.
Right scapula: gallbladder.
Shoulder-tip: diaphragmatic irritation
Mid-back: pancreas
35
Abdominal history: abdominal pain, character
Ask the patient what sort of pain it is.
Give some examples if they have trouble but be careful not to lead the patient.
Colicky: pain that comes and goes in waves, indicates obstruction of a hollow, muscular-walled organ (intestine, gallbladder, bile duct, ureter).
Burning: may indicate an acid cause, related to the stomach, duodenum, or lower end of the oesophagus.
36
Abdominal history: abdominal pain, exacerbating/relieving factors
Ask the patient what appears to make the pain better or worse, or what they do to get rid of the pain if they suffer from it often.
37
Character of pain: renal colic
Colicky pain at the renal angles and loins, which are tender to touch, radiating to the groins/testicles/labia.
Typically, the patient writhes, unable to find a position that relieves the pain.
38
Character of pain: bladder pain
A diffuse, severe pain in the suprapubic region.
39
Character of pain: prostatic pain
A dull ache which may be felt in the lower abdomen, rectum, perineum, or anterior thighs.
40
Character of pain: urethral pain
Variable in presentation ranging from a 'tickling' discomfort to a severe sharp pain felt at the end of the urethra (tip of the penis in males) and exacerbated by micturition.
Can be so severe that patients attempt to 'hold on' to urine.
41
Character of pain: small bowel obstruction
Colicky central pain associated with vomiting, abdominal distension, and/or constipation.
42
Character of pain: colonic pain
Colicky central pain associated with vomiting, abdominal distension, and/or constipation.
Sometimes relieved by defaecation or passing flatus.
43
Character of pain: biliary pain
Severe, constant, right upper quadrant/epigastric pain that can last hours and is often worse after eating fatty foods.
44
Character of pain: bowel ischaemia
Dull, severe, constant, right upper quadrant/central abdominal pain exacerbated by eating.
45
Character of pain: pancreatic pain
Epigastric, radiating to the back and partly relieved by sitting up and leaning forwards.
46
Character of pain: peptic ulcer pain
Dull, burning pain in the epigastrium.
Typically episodic at night, waking the patient from sleep.
Exacerbated by eating and sometimes relieved by consuming milk or antacids.
47
Abdominal history: bowel habit
How often do you open your bowels?
Has this changed recently?
Blood?
48
Abdominal history: bowel habit, constipation
A disorder that can mean different things to different people.
Normal bowel habit ranges from 3 times a day to once every 3 days.
Constipation is the passage of stool <3 times/week, or stole that area hard or difficult to pass.
Duration of constipation?
Frequency of bowel action?
Stool size and consistency?
Straining, particularly at the end of evacuation?
Associated symptoms (nausea, vomiting, weight loss)?
Pain on defaecation?
Rectal bleeding?
Intercurrent diarrhoea?
Fluid and fibre intake?
Depression, lack of exercise?
DHx (prescription and over the counter)?- codeine, antidepressants, aluminium, and calcium antacids.
Metabolic or endocrine diseases?- thyroid disorders, hypercalcaemia, diabetes, phaeochromocytoma.
Neurological problems?- autonomic neuropathy, spinal cord injury, multiple sclerosis, Hirschprung's disease.
49
Abdominal history: bowel habit, diarrhoea
Defined as an increase in stool volume (>200mL daily) and frequency (3/day).
Also a change in consistency to semi-formed or liquid stool.
Establish the time course since acute diarrhoea is suggestive of infection.
Colour, consistency, offensive smell, ease of flushing?
Duration?
Does the diarrhoea disturb the patient's sleep?
Is there any blood, mucus, or pus?
Associated pain or colic?
Is there urgency?
Nausea, vomiting, weight loss?
Any difference if the patient fasts?- no change in 'secretory' diarrhoea, e.g. E. coli, S. aureus; disappears on fasting = 'osmotic' diarrhoea.
Foreign travel?
Recent antibiotics?
50
Abdominal history: bowel habit, causes of constipation
Low fibre diet.
Physical immobility (e.g. stroke, Parkinson's disease).
Functional bowel disease (constipation-predominant IBS).
Drugs (e.g. opiates, iron, antidepressants, aluminium, antacids).
Metabolic and endocrine diseases (e.g. hypothyroidism, hypercalcaemia, hypokalaemia, diabetes mellitus, porphyria, phaeochromocytoma).
Neurological disorders (e.g. autonomic neuropathy, spinal cord injury, multiple sclerosis).
Colonic stricture.
Anorectal disease (e.g. anal fissure- causes pain to the extent that the patient may avoid defaecating altogether).
Habitual neglect.
Depression.
Dementia.
51
Abdominal history: bowel habit, causes of diarrhoea
Malabsorption: may cause steatorrhoea, a fatty, pale stool which is extremely odorous and difficult to flush.
Increased intestinal motility: hyperthyroidism, IBS.
Exudative: inflammation of the bowel causes small volume, frequent stools, often with blood or mucus (e.g. colonic carcinoma, Crohn's disease, ulcerative colitis).
Osmotic: large volume of stool which disappears with fasting; causes include lactose intolerance, gastric surgery.
Secretory: high volume of stool which persists with fasting; no pus, blood, or excessive fat; causes include GI infections, carcinoid syndrome, villous adenoma of the colon, Zollinger-Ellison syndrome, VIP (vasoactive intestinal polypeptide)-secreting tumour.
Other: drugs (especially antibiotics), laxative abuse, constipation and faecal impaction (overflow), small bowel or right colonic resection.
52
Abdominal history: bowel habit, fat malabsorption (steatorrhoea)
A common feature of pancreatic insufficiency.
Also caused by coeliac disease, IBD, blind bowel loops, and short bowel syndrome.
Pale stool.
Offensive smell.
Poorly formed.
Difficult to flush (floats).
53
Abdominal history: bowel habit, rectal bleeding
Amount?- small amounts can appear dramatic, colouring the toilet water red.
Nature of the blood?- red, brown, black.
Is it mixed with the stool or in the stool?
Is it spattered over the pain, with the stool, or only seen on the paper?
Any associated features?- mucus may indicate IBD or colonic cancer.
54
Abdominal history: bowel habit, melaena
This is jet-black, tar-like and pungent-smelling stool representing blood from the upper GI tract (or right side of the large bowel) that has been 'altered' by passage through the gut.
Ask about iron supplementation or bismuth-containing compounds- cause blackened stools but without the melaena smell or consistency.
55
Abdominal history: bowel habit, causes of lower GI bleeding
```
Haemorrhoids.
Anal fissure.
Diverticular disease.
Colorectal carcinoma.
Colorectal polyp.
Angiodysplasia.
IBD.
Ischaemic colitis.
Meckel's diverticulum.
Small bowel disease (e.g. tumour, diverticula, intussusception, Crohn's).
Solitary rectal ulcer.
Haemobilia (bleeding into the biliary tree).
```
56
Abdominal history: bowel habit, mucus
Clear, discoid secretion of the mucous membranes.
Mucus contains epithelial cells, leukocytes, and various salts suspended in water.
Presence of mucus in or on stool may indicate: IBD, solitary rectal ulcer, small or large bowel fistula, colonic villous adenoma, IBS.
57
Abdominal history: bowel habit, flatus
Small amounts of gas frequently escape from the bowel via the mouth (eructation) and anus and the notable excessiveness of this is a common feature of both functional and organic disorders of the GI tract.
Often associated with abdominal bloating and caused by the colonic bacterial fermentation of poorly absorbed carbohydrates.
Excessive flatus is a particular feature of: hiatus hernia, peptic ulceration, chronic gallbladder disease, air-swallowing (aerophagy), high-fibre diet, lactase deficiency and intestinal malabsorption.
58
Abdominal history: bowel habit, tenesmus
This is the feeling of the need to ope the bowels with little or no stool actually passed.
The sensation may be constant or intermittent and is usually accompanied by pain, cramping, and involuntary straining.
Causes include: IBD, anorectal abscess, infective colitis, colorectal tumours/polyps, radiation proctitis, IBS, and thrombosed haemorrhoids.
59
Abdominal history: generalised abdominal swelling, causes
```
Fat
Fluid
Flatus
Faeces
Foetus
Functional
F'ing big tumour
Fibroids
```
60
Abdominal history: ascites in decompensated liver disease
In decompensated cirrhosis, a combination of portal (sinusoidal) hypertension and Na and H2O retention favours the transudation of fluid into the peritoneal cavity (ascites).
The resultant swelling may be unsightly- it can also cause shortness of breath by putting pressure on the diaphragm from below, particularly when supine and may be associated with pleural effusions.
61
Abdominal history: jaundice
Jaundice ('icterus') is a yellow pigmentation of skin, sclera, and mucosae caused by excess bilirubin in the tissue.
Jaundice results from interference in the normal metabolism of bilirubin (including uptake, transport, conjugation, and excretion).
Colour of the urine?- dark in cholestatic jaundice due to renal excretion of conjugated bilirubin.
Colour and consistency of stools?- pale in cholestatic jaundice.
Abdominal pain? e.g. caused by gallstones.
Previous blood transfusions?
Past history of jaundice, hepatitis, pancreatitis, or biliary surgery.
Drugs? e.g. antibiotics, NSAIDs, oral contraceptives, phenothiazines, herbal remedies, anabolic steroids.
IVDU?
Tattoos and body piercing?
Foreign travel and immunisations?
Sexual history?
FHx of liver disease?
Alcohol consumption?
Personal contacts who also have jaundice?
Occupational exposure to hepatotoxins?
62
Abdominal history: jaundice, pre-hepatic causes (unconjugated hyperbilirubinaemia)
Overproduction: haemolysis; ineffective erythropoiesis.
Impaired hepatic uptake: drugs (contrast agents, rifampicin), congestive cardiac failure.
Impaired conjugation: Gilbert's syndrome, Crigler-Najjar syndrome.
63
Abdominal history: jaundice, hepatic causes (conjugated hyperbilirubinaemia)
Infection: viral hepatitis, CMV, liver abscess, septicaemia.
Alcohol and toxins: carbon tetrachloride, fungi (Amanita phalloides).
Drug-induced hepatitis: paracetamol, anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide), statins, sodium valproate, halothane.
Metabolic: haemochromatosis, alpha-1-antitrypsin deficiency, Wilson's disease, Rotor syndrome.
Vascular: Budd-Chiari, right-sided heart failure.
64
Abdominal history: jaundice, post-hepatic causes (conjugated hyperbilirubinaemia)
Luminal: gallstones.
Mural: cholangiocarcinoma, sclerosing cholangitis, primary biliary cirrhosis, choledochal cyst.
Extra-mural: pancreatic cancer, lymph nodes at porta hepatis.
Drugs: antibiotics (flucloxacillin, fusidic acid, coamoxiclav, nitrofurantoin), steroids, sulphonylureas, chlorpromazine, prochlorperazine.
65
Abdominal history: pruritus
This is itching of the skin and may be either localised or generalised.
The mechanism is not fully understood but is likely due to increased bile acid levels secondary to cholestasis.
It has many causes, but is particularly associated with choletatic liver disease (e.g. primary biliary cirrhosis, sclerosing cholangitis).
66
Abdominal history: appetite and weight loss, triggers for concern
Poor intake for longer than 1-2 weeks.
| Weight loss of >10%.
67
Abdominal history: appetite and weight loss
Ask the patient about their eating habit and average daily diet.
When was the symptom first noticed?
Quantify the problem- how much weight lost, over what time period?
Cause of the anorexia?- does eating make the patient feel sick?
Does eating cause pain? e.g. gastric ulcer, mesenteric angina, pancreatitis.
Any accompanying symptoms?- abdominal pain, nausea, vomiting, fever, menstrual irregularities, low mood.
Colour and consistency of stools? e.g. steatorrhoea.
Urinary symptoms?
Recent change in temperature tolerance?
68
Abdominal history: lower urinary tract symptoms
```
Urinary frequency
Urgency
Nocturia
Urinary incontinence
Terminal dribbling
Hesitancy
Dysuria
Haematuria
Incomplete emptying
Intermittency
Oliguria
Anuria
Polyuria
```
69
Abdominal history: lower urinary tract symptoms, urinary frequency
This is the passing of urine more often than is normal for the patient.
How many times in a day?
How much urine is passed each time?
Are they producing more urine than normal or simply feeling the urge to urinate more than normal?
70
Abdominal history: lower urinary tract symptoms, urgency
This is the sudden need to urinate, a feeling that the patient may not be able to make it to the toilet in time.
Ask about the volume expelled.
71
Abdominal history: lower urinary tract symptoms, nocturia
Urination during the night.
Does the patient wake from sleep to urinate?
How many times a night?
How much urine is expelled each time?
72
Abdominal history: lower urinary tract symptoms, urinary incontinence
The loss of voluntary control of bladder emptying.
Patients may be hesitant to talk about this.
"Have you ever not made it in time?"
True: total lack of control of urinary excretion, suggestive of a fistula between the urinary tract and the exterior, or a neurological condition.
Giggle: incontinence during bouts of laughter, common in young girls.
Stress: leakage associated with a sudden increase in intra-abdominal pressure of any cause, e.g. coughing, laughing, sneezing.
Urge: intense urge to urinate such that the patient is unable to get to the toilet in time; causes include overactivity of the detrusor muscle, urinary infection, bladder stones, and bladder cancer.
Dribbling or overflow: continual loss of urine from a chronically distended bladder, typically in elderly males with prostate disease.
73
Abdominal history: lower urinary tract symptoms, terminal dribbling
A male complaint usually indicative of prostate disease.
This is a dripping of urine from the urethra at the end of micturition, requiring an abnormally protracted shake of the penis, and may cause embarrassing staining of clothing.
74
Abdominal history: lower urinary tract symptoms, hesitancy
Difficulty in starting to micturate.
The patient describes standing and waiting for the urine to start flowing.
Usually due to bladder outflow obstruction caused by prostatic disease or strictures.
75
Abdominal history: lower urinary tract symptoms, haematuria
The passage of blood in urine.
Always an abnormal finding.
'Microscopic haematuria' will be undetectable to the patient, only showing on dip-testing.
76
Abdominal history: lower urinary tract symptoms, incomplete emptying
This is the sensation that there is more urine left to expel at the end of micturition.
Suggests detrusor dysfunction or prostatic disease.
77
Abdominal history: lower urinary tract symptoms, dysuria
'Pain on micturition' usually described by the patient as 'burning' or 'stinging' and felt at the urethral meatus.
Ask whether it is throughout or only at the end (terminal dysuria).
78
Abdominal history: lower urinary tract symptoms, intermittency
The disruption of urine flow in a stop-start manner.
| Causes include prostatic hypertrophy, bladder stones, and ureterocoeles.
79
Abdominal history: lower urinary tract symptoms, oliguria
Oliguria is a scanty or low-volume urination and is defined as the excretion of <400mL urine in 24 hours.
Causes can be physiological (dehydration) or pathological (intrinsic renal disease, shock, or obstruction).
80
Abdominal history: lower urinary tract symptoms, polyuria
This is excessive excretion of large volumes of urine and must be carefully differentiated from urinary frequency (the frequent passage of small amounts of urine).
Causes vary widely but include the ingestion of large volumes of water (including hysterical polydipsia), diabetes mellitus (the osmotic effect of glucose in the tubules encourages more urine to be made), failure of action of ADH at the renal tubule (as in diabetes insipidus), and defective renal concentrating ability (e.g. chronic renal failure).
Ask about the use of diuretic medication.
81
Abdominal history: lower urinary tract symptoms, anuria
Anuria is the absence of urine formation and you should attempt to rule out urinary tract obstruction as a matter of urgency.
Other causes include severe intrinsic renal dysfunction and shock.
82
Urinary history: causes of loin pain
Urinary calculi.
Urinary retention.
Pyelonephritis.
Renal tumours.
83
Urinary history: cause of back pain
Bone metastases from prostate cancer.
84
Urinary history: systemic symptoms of acute kidney injury or chronic renal failure
```
Anorexia.
Vomiting.
Fatigue.
Pruritus.
Peripheral oedema.
```
85
Urinary history: past medical history
Neurologic diseases causing bladder dysfunction.
| Previous abdominal or pelvic surgery causing bladder denervation.
86
Urinary history: drug history
Nephrotoxins.
87
Urinary history: family history
Renal failure.
| Polycystic kidney disease.
88
Urinary history: occupational history
Industrial carcinogens causing bladder cancer.
89
Urinary history: foreign travel
Exposure to schistosomiasis.
90
Abdominal history: past medical history
Previous surgical procedures including peri- and post-operative complications and anaesthetic complications.
Chronic bowel disease (e.g. IBD including recent flare-ups and treatment to date).
Possible associated conditions (e.g. diabetes with haemochromatosis).
91
Abdominal history: smoking
Smokers are at increased risk of peptic ulceration, oesophageal cancer, and colorectal cancer.
Smoking may also have a detrimental outcome on the natural history of Crohn's disease.
92
Abdominal history: family history
Ask especially about a history of IBD, coeliac disease, PUD, hereditary liver diseases (e.g. Wilson's, haemochromatosis), bowel cancer, jaundice, anaemia, splenectomy, and cholecystectomy.
93
Abdominal history: social history
Risks of exposure to hepatotoxins and hepatitis through occupation.
Tattoos.
Illicit drug use (especially sharing needles).
Social contacts with a similar disease (particularly relevant to jaundice).
Recent foreign travel.
94
Abdominal history: dietary history
Amount of fruit, vegetables, and fibre in the diet.
Evidence of lactose intolerance.
Change in symptoms related to eating certain food groups.
Sensitivities to wheat, fat, caffeine, gluten.
95
Abdominal examination: introductions
Ensure adequate privacy.
Ideally the patient should be lying flat with the head propped on a single pillow, arms lying at the sides.
The abdomen should be exposed from at least the bottom of the sternum to the symphysis pubis- preferably nipples to knees.
96
Abdominal examination: framework
```
General inspection
Hands
Arms
Axillae
Face
Chest
Inspect abdomen
Palpate abdomen: light, deep, specific organs, examine hernial orifices, examine external gentialia.
Percussion (± examination of ascites).
Auscultation.
DRE.
```
97
Abdominal examination: general inspection
```
Look at the patient from the end of the bed to assess their general health and look for any obvious abnormalities.
High or low body mass.
State of hydration.
Fever.
Distress.
Pain.
Muscle wasting.
Peripheral oedema.
Jaundice.
Anaemia.
```
98
Abdominal examination: inspection, hands, nails
```
Leukonychia
Koilonychia
Muehrcke's lines
Digital clubbing
Blue lunulae
```
99
Abdominal examination: What is leukonychia?
Whitening of the nail bed due to hypoalbuminaemia (e.g. malnutrition, malabsorption, hepatic disease, nephritic syndrome).
100
Abdominal examination: What is koilonychia?
'Spooning' of the nails making a concave shape instead of the normal convexity.
Causes include congenital and chronic iron deficiency.
101
Abdominal examination: What are Muerhcke's lines?
Transverse white lines on the nails.
| Seen in hypoalbuminaemic states including severe liver cirrhosis.
102
Abdominal examination: causes of digital clubbing
Cirrhosis
IBD
Coeliac disease
103
Abdominal examination: What are blue lunulae?
A bluish discolouration of the normal nail lunulae, seen in Wilson's disease.
104
Abdominal examination: inspection, hands, palms
Palmar erythema
Duputryen's contracture
Anaemia
105
Abdominal examination: What is palmar erythema?
'Liver palms'.
A blotchy reddening of the palms of the hands, especially affecting the thenar eminence and hypothenar eminences.
Can also affect the soles of the feet.
Associated with chronic liver disease, pregnancy, thyrotoxicosis, rheumatoid arthritis, polycythaemia, and rarely chronic leukaemia.
It can also be a normal finding.
106
Abdominal examination: What is Dupuytren's contracture?
This is thickening and fibrous contraction of the palmar fascia.
In early stages, palpable irregular thickening of the fascia is seen, especially that overlying the 4th or 5th metacarpals.
Can progress to a fixed flexion deformity of the fingers starting at the 5th and working across to the 3rd or 2nd.
Often bilateral, it may also affect the feet.
Seen especially in alcoholic liver disease but may also be seen in manual workers (or may be familial).
107
Abdominal examination: anaemia in the hands
Pallor in the palmar creases suggests significant anaemia.
108
Abdominal examination: inspection, upper limbs
```
Bruising
Petechiae
Muscle wasting
Scratch marks (excoriations)
Iatrogenic features
```
109
Abdominal examination: inspection, upper limbs, bruising
Hepatocellular damage and the resulting coagulation disorder.
Thrombocytopaenia due to hypersplenism.
Marrow suppression with alcohol.
110
Abdominal examination: inspection, upper limbs, petechiae
Pin-prick bleeds which do not blanch with pressure.
| Possibly a sign of thrombocytopenia.
111
Abdominal examination: inspection, upper limbs, muscle wasting
Seen as a decrease in muscle mass, possibly with overlying skin hanging loosely.
A late manifestation of malnutrition and often seen in patients with chronic alcoholic liver disease.
112
Abdominal examination: inspection, upper limbs, excoriations
Suggests pruritus (itch) is present and may be the only visible feature of early cholestasis.
113
Abdominal examination: inspection, upper limbs, iatrogenic features
Be careful not to miss AV fistulae or haemodialysis catheters.
114
Abdominal examination: inspection, upper limbs, liver flap
Characteristic of encephalopathy due to liver failure.
Identical to the flap seen in hypercapnic states.
Ask the patient to stretch their hands out in front of them with the hands dorsiflexed at the wrists and the fingers outstretched and separated.
The patient should hold this position for at least 15 seconds.
If asterixis is present, the patient's hands will move in a jerky, irregular flexion/extension at the wrist and MCP joints.
The flap is nearly always bilateral, may be subtle and intermittent.
Hepatic encephalopathy in a patient with previously compensated liver disease may have been precipitated by infection, diuretic medication, electrolyte imbalance, diarrhoea or constipation, vomiting, centrally acting drugs, upper GI bleeding, abdominal paracentesis, or surgery.
115
Abdominal examination: inspection, upper limbs, axillae
Examine carefully for lymphadenopathy and acanthosis nigricans (a thickened blackening of the skin, velvety in appearance, may be associated with intra-abdominal malignancy).
116
Abdominal examination: inspection, face, eyes
Ask the patient to look ahead whilst you look at their eyes and orbits.
Ask the patient to look up whilst you gently retract the lower lid with a finger, looking at the sclera and conjunctiva.
Jaundice? scleral icterus.
Anaemia? conjunctival pallor.
Kayser-Fleischer rings? best seen with a slit-lamp in ophthalmology clinic, a greenish-yellow pigmented ring just inside the cornea-scleral margin due to copper deposition, seen in Wilson's disease.
Xanthelasma? raised yellow lesions caused by a build-up of lipids beneath the skin- especially at the nasal side of the orbit.
117
Abdominal examination: inspection, face, mouth
```
Ask the patient to show you their teeth then 'open wide', and look carefully at the state of the teeth, the tongue and the inner surface of the cheeks.
Angular stomatitis
Circumoral pigmentation
Dentition
Telangiectasia
Gums
Breath
Tongue
```
118
Abdominal examination: inspection, face, mouth, angular stomatitis
A reddening and inflammation at the corners of the mouth.
| A sign of thiamine, vitamin B12, and iron deficiencies.
119
Abdominal examination: inspection, face, mouth, circumoral pigmentation
Hyperpigmented areas surrounding the mouth.
| Seen in Peutz-Jegher's syndrome.
120
Abdominal examination: inspection, face, mouth, dentition
Note false teeth or if there is evidence of tooth decay.
121
Abdominal examination: inspection, face, mouth, telangiectasia
Dilatation of the small vessels on the gums and buccal mucosa.
Seen in Osler-Weber-Rendu syndrome.
122
Abdominal examination: inspection, face, mouth, gums
Look especially for ulcers (causes include coeliac disease, IBD, Behcet's disease, and Reiter's syndrome) and hypertrophy (caused by pregnancy, phenytoin use, leukaemia, scurvy, or inflammation- gingivitis).
123
Abdominal examination: inspection, face, mouth, breath
Fetor hepaticus: a sweet-smelling breath.
Ketosis: sickly sweet 'pear-drop' smelling breath.
Uraemia: a fishy smell.
124
Abdominal examination: inspection, face, mouth, tongue
Glossitis: smooth, erythematous swelling of the tongue; causes include deficiencies of iron, B12, and folate.
Macroglossia: enlarged tongue; causes include amyloidosis, hypothyroidism, acromegaly, Down's syndrome, neoplasia.
Leukoplakia: a white thickening of the tongue and mucous membranes; a premalignant condition caused by smoking, poor dental hygiene, alcohol, sepsis, and syphilis.
Geographical tongue: painless red rings and lines on the surface of the tongue looking like a map; can be caused by vitamin B12 deficiency or may be a normal variant.
Candidiasis: 'thrush'; a fungal infection of the oral membranes seen as creamy white curd-like patches which can be scraped off revealing erythematous mucosa below; causes include immunosuppression, antibiotic use, poor oral hygiene, iron deficiency, diabetes.
125
Abdominal examination: inspection, neck
Examine the cervical and supraclavicular lymph nodes.
Look especially for a supraclavicular node on the left side which, when enlarge, is Virchow's node (Troisier's sign, suggestive of gastric malignancy).
126
Abdominal examination: inspection, chest
Look at the anterior chest.
Spider naevi: telangiectatic capillary lesions.
Gynaecomastia: the excessive development of male mammary glands due to ductal proliferation such that they resemble post-pubertal female breasts.
127
Abdominal examination: inspection, chest, spider naevi
Telangiectatic capillary lesions.
A central red area with engorged capillaries spreading out from it in a 'spidery' manner.
Caused by engorgement of capillaries from a central 'feeder' vessel.
If the lesion is truly a spider naevus, it will be completely eliminated by pressure at the centre using a pen-point or similar and will fill outwards when the pressure is released.
Can range in size from those that are only just visible up to 5-6mm in diameter.
Found in the distribution of the superior vena cava.
A normal adult is 'allowed' up to 5 spider naevi.
Causes include chronic liver disease and oestrogen excess.
128
Abdominal examination: inspection, chest, gynaecomastia
The excessive development of male mammary glands due to ductal proliferation such that they resemble post-pubertal female breasts.
This is often embarrassing for the patient so be sensitive.
Caused by alcoholic liver disease, congenital adrenal hyperplasia, and several commonly used drugs including spironolactone, digoxin, and cimetidine.
Can also be seen during puberty in the normal male.
129
Abdominal examination: inspection, abdomen
```
Abdominal distension
Focal swellings
Divarication of the recti
Prominent vasculature
Peristaltic waves
Striae
Skin discolouration
```
130
Abdominal examination: inspection, abdomen, abdominal distension
Does the abdomen look swollen?
| Consider the 5 Fs and note the state of the umbilicus (everted? deep?).
131
Abdominal examination: inspection, abdomen, focal swellings
Treat and abdominal swelling as you would do any other lump and bear in mind the underlying anatomy and possible organ involvement.
132
Abdominal examination: inspection, abdomen, divarication of the recti
Particularly in the elderly and in patients who have had abdominal surgery, the twin rectus abdominis muscles may separate laterally on contraction, causing a bulge through the resultant mid-line gap.
Ask the patient to lift their head off the bed or to sit up slightly and watch for the appearance of a longitudinal midline bulge.
133
Abdominal examination: inspection, abdomen, prominent vasculature
If veins are seen coursing over the abdomen, note their exact location.
Attempt to map the direction of blood flow within them.
Place 2 fingers at one end of the vein and apply occlusive pressure.
Move 1 finger along the vein, emptying it in a 'milking' action.
Release the pressure from 1 finger and watch for flow of blood.
Repeat, emptying blood in the other direction.
Due to the venous valves, should be able to determine the direction of blood flow in that vein.
Inferior flow of blood suggests superior vena cava obstruction.
Superior flow of blood suggests inferior vena cava obstruction.
Flow radiating out from the umbilicus ('caput medusae') indicates portal vein hypertension (porto-systemic shunting occurs through the umbilical veins which become engorged).
134
Abdominal examination: inspection, abdomen, peristaltic waves
Usually only seen in thin, fit, young individuals.
| A very obvious bowel peristalsis is seen as rippling movements beneath the skin and may indicate intestinal obstruction.
135
Abdominal examination: inspection, abdomen, striae
'Stretch marks' are pink or white streaky lines caused by changes in the tension of the abdominal wall.
These may be normal in rapidly growing pubescent teens.
Also seen in obesity, pregnancy ('striae gravidarum'), ascites, and following rapid weight loss or abdominal paracentesis.
136
Abdominal examination: inspection, abdomen, skin discolouration
There are 2 classical patterns of bruising/discolouration indicating the presence of retroperitoneal blood (seen especially in pancreatitis).
Cullen's sign: discolouration at the umbilicus and surrounding skin.
Grey Turner's sign: discolouration at the flanks.
137
Abdominal examination: What is Cullen's sign?
Discolouration at the umbilicus and surrounding skin.
| Pattern of bruising/discolouration indicating the presence of retroperitoneal blood (seen especially in pancreatitis)
138
Abdominal examination: What is Grey Turner's sign?
Discolouration at the flanks.
| Pattern of bruising/discolouration indicating the presence of retroperitoneal blood (seen especially in pancreatitis)
139
Abdominal examination: stomas, inspection
Site?
Bag covering?
Appearance: healthy mucous lining? what colour? spouted or flush to skin? one orifice (end) or two (loop)?
Content? e.g. urine, formed stool, semi-formed or liquid stool?
Any other abdominal scars?
Any drains or healed stoma sites?
Look for evidence of complications: early = necrosis (black/brown discolouration), infection; late = parastomal hernia, prolapse, stenosis, retraction, obstruction, skin erosions, bleeding.
140
Abdominal examination: common types of stoma
Ileostomy
Colostomy
Urostomy/ileal conduit
Gastrostomy/duodenostomy/jejunostomy
141
Abdominal examination: What is an ileostomy?
May be loop or end.
End = total/partial colectomy (e.g. IBD, familial adenomatous polyposis, total colonic Hirschprung's disease).
Loop = to protect distal anastomosis (e.g. partial colectomy, formation or ileorectal pouch.
142
Abdominal examination: What is a colostomy?
May be loop or end.
End = Hartmann's procedure, abdominoperitoneal resection.
Loop = rectal trauma, colovaginal or perianal fistula.
143
Abdominal examination: What is a urostomy/ileal conduit?
One or both ureters are diverted to a short length of ileum which is disconnected and brought to the skin (usually follows radical lower urinary tract surgery).
Spouted, prominent mucosal folds, dark pink/red, right-sided.
Indistinguishable from ileostomy unless the output is seen.
144
Abdominal examination: What is a gastrostomy/duodenostomy/jejunostomy?
Surgically or endoscopically created connection between the stomach/duodenum/jejunum and the anterior abdominal wall.
For feeding and/or drainage (stomach).
Narrow calibre, flush to skin with little visible mucosa, usually at left upper quadrant.
Fitted with indwelling tubes or access devices.
145
Abdominal examination: palpation, general
The patient should be positioned lying supine with the head supported by a single pillow and arms at their sides.
Squat by the side of the bed or couch so that the patient's abdomen is at your eye level.
Each of the 4 quadrants or 9 regions should be examined in turn with light and then deep palpation before focusing on specific organs.
Ask the patient if there is any area of tenderness and remember to examine this part last.
Before you begin, ask the patient to let you know if you cause any discomfort.
You should be able to examine the abdomen without looking at it closely- instead, watch the patient's face for signs of pain.
146
Abdominal examination: light palpation
Use the finger tips and palmar aspects of the fingers.
Lay your right hand on the patient's abdomen and gently press in by flexing at the metacarpo-phalangeal joints.
If there is pain on light palpation, attempt to determine whether the pain is worse when you press down or when you release the pressure (rebound tenderness).
If the abdominal muscles seem tense, determine whether it is localised or generalised. Ensure the patient is relaxed. If necessary they can slightly bend their knees.
An involuntary tension in the abdominal muscles, apparently protecting the underlying organs, is guarding.
147
Abdominal examination: deep palpation
Once all 4 quadrants/ 9 regions are lightly palpate, re-examine using more pressure.
This should enable you to feel any masses or structural abnormalities.
If a mass is felt, treat it as you would any other lump.
It is often possible to detect the putty-like consistency of stool in the sigmoid colon.
148
Abdominal examination: palpation, aorta
The abdominal aorta may be palpated in the midline above the umbilicus, particularly in thin people.
Place each hand either side of the outermost palpable margins.
Measure the distance between your fingers. Normal = 2-3cm.
Is it pulsatile/expansile in itself (in which case your fingers will move outwards) or is the pulsation transmitted through other tissue (in which case your fingers will move upwards).
149
Abdominal examination: palpation, liver
The normal liver extends from the 5th intercostal space on the right of the midline to the costal margin, duding under the ribs so it is often not normally palpable- don't worry if you can't feel it.
Using the flat of your right hand, start palpation from the right iliac fossa.
You should angle your hand such that the index finger is aligned with the costal margin.
Exert gentle pressure and ask the patient to take a deep breath.
With each inward breath, your fingers should drift slightly superiorly as the liver moves inferiorly with the diaphragm.
Relax the pressure on your hand slightly at the height of inspiration.
If the liver is just above the position of your hand, the lateral surface of your index finger will strike the liver edge and glide over it with a palpable 'step'.
If the liver is not felt, move your hand 1-2cm superiorly and feel again.
Repeat the process, moving towards the ribs until the liver is felt.
150
Abdominal examination: palpation, gallbladder
Lies at the right costal margin at the tip of the 9th rib, at the lateral border of the rectus abdominis.
Normally only palpable when enlarged due to biliary obstruction or acute cholecystitis.
Felt as a bulbous, focal, rounded mass which moves with inspiration.
Position the right hand perpendicular to the costal margin and palpate in a medial to lateral direction.
151
Abdominal examination: gallbladder signs
Murphy's sign.
| Courvoisier's law.
152
Abdominal examination: What is Murphy's sign?
A sign of cholecystitis- pain on palpation over the gallbladder during deep inspiration.
Only positive if there is no pain on the left at the same position.
153
Abdominal examination: What is Courvoisier's law?
In the presence of jaundice, a palpable gallbladder is probably not caused by gallstones.
154
Abdominal examination: palpation, liver, liver edge felt
How far below the costal margin does it extend in finger-breadths or cm and record the number carefully.
What is the nature of the liver edge? smooth or irregular surface?
Is there any tenderness?
Is the liver pulsatile?
155
Abdominal examination: palpation, liver, findings
It is often possible to palpate the liver just below the costal margin at the heigh of inspiration in normal, healthy, thin people.
An enlarge liver has many causes.
A normal liver may be palpable in patients with COPD or asthma in whom the chest is hyper-expanded or in patients with a sub-diaphragmatic collection.
The liver may also be palpable in the presence of 'Riedel's lobe'- a normal variant in which a projection of the liver arises from the inferior surface of the right lobe- more common in females, commonly mistaken for a right kidney or enlarged gallbladder.
156
Abdominal examination: palpation, spleen, overview
The largest lymphatic organ which varies in size and shape between individuals- roughly the size of a clenched fist.
Normally hidden beneath the left costal cartilages and impalpable.
Enlargement of the spleen occurs in a downward direction, extending into the left upper quadrant (and even the left lower quadrant) across towards the right iliac fossa.
157
Abdominal examination: palpation, spleen, technique
Palpated using a similar technique to that used to examine the liver.
Your left hand should be used to support the left of the ribcage posterolaterally.
Your right hand should be aligned with the fingertips parallel to the left costal margin.
Start palpation just below the umbilicus in the midline and work towards the left costal margin asking the patient to take a deep breath in and feeling for the movement of the spleen under your fingers- much like for the liver.
The inferior edge of the spleen may have a palpable 'notch' centrally which will help you differentiate it from any other abdominal mass.
If a spleen is felt, measure the distance to the costal border in finger-breadths or cm.
158
Abdominal examination: causes of splenomegaly
Infection: EBV, CMV, HIV, viral hepatitis, any cause of septicaemia, subacute bacterial endocarditis, typhoid, brucellosis, tuberculosis, leptospirosis, histoplasmosis, malaria, leishmaniasis, trypanosomiasis.
Haematological: myeloid and lymphatic leukaemia, lymphoma, spherocytosis, thalassaemia, sickle cell (splenic infarcts may cause a small spleen in late disease), autoimmune haemolytic anaemia, idiopathic thrombocytopaenic purpura.
Infiltration: glycogen storage diseases, Gaucher's disease.
Congestive: hepatic cirrhosis, congestive heart failure, portal vein thrombosis, splenic vein thrombosis, Budd-Chiari syndrome.
Other: amyloidosis, cysts, hamartomas, connective tissu disorders (e.g. RA, SLE, sarcoidosis).
159
Abdominal examination: causes of hepatosplenomegaly
Hepatic: chronic liver disease with portal hypertension (if cirrhotic, liver may be impalpable).
Infection: EBV, CMV, viral hepatitis, infective endocarditis.
Infiltration: amyloidosis, Gaucher's disease.
Haematological: lymphoma, leukaemia, pernicious anaemia, myeloproliferative disease.
Endocrine: acromegaly, thyrotoxicosis.
Granulomatous conditions: tuberculosis, sarcoidosis, Wegener's granulomatosis.
Other causes: malaria, kala-azar, schistosomiasis.
160
Abdominal examination: causes of hepatomegaly
Cirrhosis.
Congestive cardiac failure.
Neoplastic: secondary and primary (e.g. hepatoma).
Infective: acute viral hepatitis, liver abscess, hydatid cyst.
Polycystic disease.
Tricuspid regurgitation (pulsatile hepatomegaly).
Budd-Chiari syndrome.
Haemochromatosis.
Infiltrative: amyloidosis, sarcoidosis.
161
Abdominal examination: palpation, kidneys, overview
The kidneys are retroperitoneal, ling on the posterior abdominal wall either side of the vertebral column between T12 and L3 vertebrae.
They move slightly inferiorly with inspiration.
The right kidney lies a little lower than the left (displaced by the liver).
Palpation is bimanual (both hands).
You may be able to feel the lower pole of the right kidney in normal, thin people.
Take care not to mistake splenomegaly for an enlarged kidney.
162
Abdominal examination: palpation, bladder
The urinary bladder is not palpable when empty.
As it fills, it expands superiorly and may reach as high as the umbilicus if very full.
It may be difficult to differentiate it from an enlarged uterus or ovarian cyst.
The full bladder will be: a palpable, rounded mass arising fro behind the pubic symphysis; dull to percussion; unable to feel below it; pressure will make the patient feel the need to urinate.
163
Abdominal examination: palpation, kidneys, technique
Place your left hand behind the patient at the right loin.
Place your right hand below the right costal margin at the lateral border of the rectus abdominis.
Keeping the fingers of your right hand together, flex them at the metacarpo-phalangeal joints, pushing deep into the abdomen.
Ask the patient to take a deep breath- you may be able to feel the rounded lower pole of the kidney between your hands, slipping away when the patient exhales.
This technique is balloting.
Repeat for the left kidney, leaning over and placing your left hand behind the patient's left loin.
164
Abdominal examination: palpation, kidneys, findings and causes
Unilateral palpable kidney: hydronephrosis, polycystic kidney disease, renal cell carcinoma, acute renal vein thrombosis, renal abscess, acute pyelonephritis.
Bilateral palpable kidneys: bilateral hydronephrosis, bilateral renal cell carcinoma, polycystic kidney disease, nephrotic syndrome, amyloidosis, lymphoma, acromegaly.
165
Abdominal examination: hernias, overview
A hernia is an abnormal protrusion of a structure, organ, or part of an organ out of the cavity in which it belongs. A hernia can usually be 'reduced' i.e. its contents returned to the original cavity either spontaneously or by manipulation.
Abdominal hernias are usually caused by portions of bowel protruding through weakened areas of the abdominal wall.
In the abdomen, hernias usually occur at natural openings or weak spots such as surgical scars.
Most abdominal hernias have an expansile cough impulse.
Strangulation: hernias that cannot be reduced may become fixed and swollen as their blood supply is occluded, causing ischaemia and necrosis of the herniated organ.
166
Abdominal examination: an approach to hernias
Determine the characteristics as you would any lump, including position, temperature, tenderness, shape, size, tension, and composition.
Make not of the characteristics of the overlying skin.
Palpate the hernia and feel for a cough impulse.
Attempt reduction of the hernia.
Percuss and auscultate the hernia (listening for bowel sounds or bruits).
Always remember to examine the same site on the opposite side.
167
Abdominal examination: examining an inguinal hernia, inspection
Look for visible swelling at both groins.
Ask the patient to cough and watch for swellings.
Look for scars in relation to previous open repair (groin) and laparoscopic repair (around umbilicus).
168
Abdominal examination: examining an inguinal hernia, palpation
Ask the patient if there is any pain.
Examine the scrotum and its content.
Examine any lump carefully.
Ask patient to cough and feel for an expansile cough impulse.
Ask if the lump is normally reducible. Lie the patient down on couch to allow gravity to help reduction. Try to reduce the hernia or ask patient to reduce it for you.
169
Abdominal examination: examining a hernia, relate the swelling to the bony landmarks
Place a finger on the pubic tubercle and ask patient to cough. Inguinal hernias will be superior and medial to your finger. Femoral hernias will be inferior and lateral to your finger.
Place 2 fingers at the midpoint between ASIS and pubic tubercle (internal ring). Ask patient to cough. This will prevent an indirect inguinal hernia appearing, whereas a direct inguinal hernia will appear.
170
Abdominal examination: examining an inguinal hernia, auscultation
Listen over any swelling for bowel sounds.
171
Abdominal examination: examining an inguinal hernia, anatomy and overview
The inguinal canal extends from the pubic tubercle to the ASIS.
In the male, it carries the spermatic cord (vas deferens, blood vessels, and nerves).
In the female, it is much smaller and carries the round ligament of the uterus.
The internal ring is an opening in the transversals fascia lying at the mid-inguinal point, halfway between the ASIS and the pubic symphysis (about 1.5cm above femoral pulse).
The external ring is an opening of the external oblique aponeurosis and is immediately above and medial to the pubic tubercle.
Direct inguinal hernia: herniation at the site of the external ring.
Indirect inguinal hernia: the most common site (85% of all hernias), more likely to strangulate than direct inguinal hernias.
172
Abdominal examination: examining a femoral hernia, anatomy and overview
The femoral canal is the small component of the femoral sheath medial to the femoral vessels and contains loose connective tissue, lymphatic vessels, and lymph nodes.
It is bordered anteriorly by the inguinal ligament, the pectineal ligament posteriorly, the femoral vein laterally, and the lacunar ligament medially.
Femoral hernias are protrusions of bowel or momentum through this space.
They are more common in middle-aged and elderly women and can easily strangulate due to the small, rigid opening they pass through.
173
Abdominal examination: examining a femoral hernia, inspection
Lump in the groin: below and lateral to the pubic tubercle, medial to the femoral artery (palpate for the pulsation).
Flattening/obliteration of the inguinal skin crease.
Overlying skin appears normal in colour/texture.
174
Abdominal examination: examining a femoral hernia, palpation
Firm smooth, spherical lump, tender if strangulated.
Non-reducible.
Often no cough-impulse.
175
Abdominal examination: examining a femoral hernia, percussion and auscultation
A resonant percussion note and active bowel sounds imply strangulated bowel.
Femoral hernias commonly contain greater omentum.
176
Abdominal examination: examining an incisional hernia, overview
Be sure to examine the patient standing and lying supine.
Incisional hernias account for 10-15% of all hernias.
Peak incidence is at 5 years post-surgery.
177
Abdominal examination: examining an incisional hernia, inspection
A lump arising from the site of a previous incision.
178
Abdominal examination: examining an incisional hernia, palpation
A positive cough impulse is present.
Note the size, site, shape, and constituents.
Assess whether the hernia is reducible, if so palpate the edges to quantify the defect's size.
If irreducible, the lump may be an incarcerated or strangulated hernia.
179
Abdominal examination: examining an incisional hernia, auscultation
Active bowel sounds point to bowel in the hernial sac.
180
Abdominal examination: examining an incisional hernia, completion
A full abdominal examination should be conducted, looking for signs of deep infection and for a cause of raised intra-abdominal pressure.
181
Abdominal examination: examining a paraumbilical hernia, overview
A hernia in the linea alba, just superior or inferior to the umbilicus.
Male:female ratio 1:5.
Risk factors include obesity, multiparity, and advancing age.
182
Abdominal examination: examining a paraumbilical hernia, inspection
Bulge beside the umbilicus.
| The umbilicus is often distorted into a crescent shape.
183
Abdominal examination: examining a paraumbilical hernia, palpation
The lump is separate from the umbilicus and should be reducible.
Examine the patient standing and make careful note of the size, site, shape and constituents of the lump.
A positive cough impulse may be present.
Absence of a cough impulse does not exclude a hernia.
Now examine the patient lying supine.
Assess if the hernia is reducible; if so, palpate the edges to quantify the defect's size.
184
Abdominal examination: examining a paraumbilical hernia, percussion
Resonance to percussion implies bowel is present in the hernia sac.
185
Abdominal examination: examining a paraumbilical hernia, auscultation
Active bowel sounds point to bowel in the hernia sac.
186
Abdominal examination: examining a paraumbilical hernia, completion
A full abdominal examination should be conducted, looking for causes of raised intra-abdominal pressure.
187
Abdominal examination: percussion, overview
In the examination of the abdomen, percussion is useful for determining the size and nature of enlarged organs or masses, detecting shifting dullness, and eliciting rebound tenderness.
Organs or masses will appear as dullness whereas a bowel full of gas will seem abnormally resonant.
188
Abdominal examination: percussion, examining for ascites, overview
If fluid is present in the peritoneal cavity (ascites), gravity will cause it to collect in the flanks when the patient is lying flat.
This will give dullness to percussion laterally with central resonance as the bowel floats.
Ascites will give a distended abdomen, often with an everted umbilicus.
If you suspect the presence of ascites, percuss centrally to laterally with the fingers spread and positioned longitudinally, and listen (and feel) for a definite change to a dull note.
There are then 2 specific tests to perform: shifting dullness and fluid thrill.
189
Abdominal examination: percussion, shifting dullness
Percuss centrally to laterally until dullness is detected.
This marks the air-fluid level in the abdomen.
Keep your finger pressed there as you:
- ask the patient to roll onto the opposite side (usually away from you; if dullness is detected on the right, roll the patient onto their left-hand side, and vice versa)
- ask the patient to hold the new position for half a minute
- repeat percussion moving laterally to central over your mark.
If the dullness truly was an air-fluid level, the fluid will now be moved by gravity away from the marked spot and the previously dull area will be resonant.
190
Abdominal examination: percussion, fluid thrill
In this test, you are attempting to detect a wave transmitted across the peritoneal fluid.
This is only really possible with massive ascites.
You need an assistant for this test (you can ask the patient to help).
Ask your assistant to place the ulnar edge of one of their hands in the midline of the abdomen.
Place your left hand on one side of the abdomen, about level with the midclavicular line.
With your right hand, flick the opposite side of the patient's abdomen.
If a 'fluid thrill' can be detected, you will feel the ripple from the flick transmitted as a tap to your left hand.
The assistant's hand is important- it prevents transmission of the impulse across the surface of the abdominal wall.
191
Abdominal examination: percussion, liver
Percuss to map the upper and lower borders of the liver- note the length, in cm, at the midclavicular line.
192
Abdominal examination: percussion, spleen
Percussion from the left costal margin towards the midaxillary line and the lower left ribs may reveal dullness suggestive of splenic enlargement that could not normally be palpated.
193
Abdominal examination: percussion, kidneys
Useful in differentiating an enlarged kidney from an enlarged spleen or liver.
The kidneys lie deep in the abdomen and are surrounded by perinephric fat which makes them resonant to percussion.
Splenomegaly or hepatomegaly will appear dull.
194
Abdominal examination: percussion, bladder
Dullness to percussion in the suprapubic region may be helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant).
195
Abdominal examination: auscultation, bowel sounds
These are low-pitched gurgling sounds produced by normal gut peristalsis.
They are intermittent but will vary in timing depending on when the last meal was eaten.
Listen with the diaphragm of the stethoscope in the right iliac fossa.
Normal: low-pitched gurgling, intermittent.
High-pitched: 'tinkling', suggestive of partial or total bowel obstruction.
Borborygmus: loud low-pitched gurgling that can even be heard without a stethoscope, typically of diarrhoeal states or abnormal peristalsis.
Absent sounds: if no sounds are heard for 2 minutes, there may be a complete lack of peristalsis, i.e. a paralytic ileus or peritonitis.
196
Abdominal examination: auscultation, bruits
These are sounds produced by the turbulent flow of blood through a vessel, similar in sound to heart murmurs.
Listen with the diaphragm of the stethoscope.
Bruits may occur in normal adults but raise the suspicion of pathological stenosis (narrowing) when heard throughout both systole and diastole.
There are several areas you should listen at on the abdomen:
1) Just above the umbilicus over the aorta (abdominal aortic aneurysm).
2) Either side of the midline just above the umbilicus (renal artery stenosis).
3) At the epigastrium (mesenteric stenosis).
4) Over the liver (AV malformations, acute alcoholic hepatitis, hepatocellular carcinoma).
197
Abdominal examination: auscultation, friction rubs
These are creaking sounds like that of a pleural rub, heard when inflamed peritoneal surfaces move against each other with respiration.
Listen over the liver and the spleen in the right and left upper quadrants respectively.
Causes include hepatocellular carcinoma, liver abscesses, recent percutaneous liver biopsy, liver or splenic infarction and STD-associated perihepatitis (Fitz-Hugh-Curtis syndrome).
198
Abdominal examination: auscultation, venous hums
Rarely, it is possible to hear the hum of venous blood flow in the upper abdomen over a caput medusa secondary to porto-systemic shunting of blood.
