Week 4 - Abdomen Flashcards
Which area of the body is the largest for malpractice?
the abdomen
Boundariers of the Abdomen
-superior: Diaphragm (seprates thoracic from abd cavity)
-inferior: Pelvis (continuous w/ pelvic cavity)
-posterior: veterbreal column + posterior/inferior ribs (lower part of thoracic cage)
-lateral: flank muscles
-anterior: abdominal muscles (rectus abdominus, external oblique, internal oblique, transversus abdominus + fasciae)
Peritoneal Space
organs covered by peritoneal (abdominal) lining
Retroperitoneal Space
organs posterior to the peritoneal lining
-most problematic for injuries (uncovered) + misdiagnosis
-major organ = kidneys (not well protected)
Pelvic Space
organs within the pelvis
Abdominal Wall is made of…
-skin
-superficial fasciae
-deep fascia
-extraperitional fascia
-parietal peritoneum
Abdominal Wall is lined with…
fascial envelope + parietal peritoneum
Rectus Abdominus
(origin, insertion, bloody supply, innervation)
Abd Wall Muscles
joins to 5th rib and sternum (above xiphoid)
-attached by 2 tendons
-origin: pubic symphysis + pubic crest
-insertion: xiphoid process of sternum + costal cartilage of 5, 6, 7th ribs
-bloody supply: inferior + superior epigastric
-innervation: thoracoabdominal nerves (anterior divisoons of 7th-11th lower intercostal nerves)
vertical midline of abdominal wall
External Oblique
(origin, insertion, action)
Abd Wall Muscles
-origin: external surfaces of ribs 5-12
-insertion: anterior iliac crest + fan shaped distribution to abdominal aponeurosis to Linea alba
-action: flexion of vertebral column (draws thorax down), rotates vertebral column, laterally flexes vertebral column
“hands in pocket” superior abd wall muscle
Internal Oblique
(origin, insertion)
Abd Wall Muscles
fibers perpendicular to external oblique
-origin: anterior iliac crest, lateral half of inguinal ligament, thoracocolumbar fascia
-insertion: costal cartilages of ribs 8-12, abdominal aponeurosis to Linea alba
intermediate abd wall muscle
Transversus Abdominus
(origin, insertion, trauma)
Abd Wall Muscles
deepest layer of abdominal muscle
-origins: costal cartilages/ribs 7-12, thoracolumbar fascia, front 2/3 of iliac crest (top border of pelvic bone), lateral 1/3 of inguinal ligament
-insertions: Linea alba, pubic symphysis, xiphoid process
-trauma: rigidity, fractured xiphoid/sternum, internal bleeding
sits below internal/external obliques + rectus abdominus
Origin
proximal attachment
Insertion
distal attachment
Thoracolumbar Fasciae
large diamond shaped sheet of connective tissue located at lower back
Inguinal Ligament
band of connective tissue extends diagnoally down from pelvis
Linea Alba
fibrous band of connective tissue runs down the front of abdominal wall
Pubic Symphysis
connective tissue joining R + L sides of lower pubic bone
Innervation of Transversus Abdominus
-lower 5 intercostal nerves: originate from T1-T11 nerves of spinal cord
-subcostal nerve: originate from T12 nerves of spinal cord
-Iliohypogastric nerve (lumbar plexus in lower back): originate from L1 of spinal cord
-Ilioinguinal nerve: lumbar plexus branch originating from L1 of spinal cord
Blood Supply of Skin Near the Midline:
-superior epigastric artery (branch of internal thoracic artery)
-inferior epigastric artery (branch of external iliac artery)
Blood Supply of Skin of the Flanks:
branches of intercostal, lumbar + deep circumflex arteries
Muscles of Lower Posterior Abdomen
(starting at 12th rib)
-quadratus lumborum
-psoas minor
-iliopsoas (psoas major + iliacus)
-tensor fasciae latae
-sartorius
-pectineus
-adductor longus
-gracilis
-adductor magnus
-quadriceps femoris (rectus femoris, vastus lateralis, vastus medialis)
Abdominal Venous Drainage
collected into a network of veins that radiate from the umbilicus
Drained above via axillary vein via…
Venous Drainage
lateral thoracic vein
Drained below via femoral vein via…
Venous Drainage
superficial epigastric + great sapphenous vein
Paraumbilicus Veins
Venous Drainage
form clincially important portal system venous anastomosis
Caput Medusae
superficial veins aorund umbilicus + paraumbilical veins connecting them to portal vein become distended
-portal vein obstruction
-distended veins radiate out from umbilicus
-occurs with: any blockage, liver problems, alcoholism, difficulty defecating, cancer
-leads to backup -> compression -> distension (could be a tumor)
Abdominal Nerves
supply skin, muscles + parietal peritoneum
-derived from: anterior rami of lower 6 thoracic nerves + L1 nerves
Inflammation of Parietal Peritoneum
causes pain in overlying skin + increase reflex in tone of abdominal musculature of the same area
Lymphatic drainage of skin above the umbilicus:
drains upwards to anterior axillary nodes (pectoral group of nodes)
Lymphatic drainage of skin below the umbilicus:
drains downward/laterally to superficial inguinal nodes
Swelling of groin possibly due to:
enlarged superificial inguinal node
Rectus Sheath
formed by aponeurosis of 3 lateral abdominal muslces (internal oblique, external oblique, transverse abdominus)
-long fibrous sheath enclosing the rectus abdominus + pyramidalis
-contains anterior rami of lower 6 thoracic nerves
-contains superior/inferior epigastric + lymphatic vessels
Anterior Wall of Rectus Sheath
Rectus Sheath
formed by aponeurosis of external oblique (in front of the muscle)
-firmly attached to rectus abdominus by tendinous intersections
Posterior Wall of Rectus Sheath
Rectus Sheath
formed by thoracic wall of 5th, 6th, 7th costal cartilages + intercostal spaces
-is NOT attached to rectus abdominus
Transversus Abdominus Aponeurosis
Rectus Sheath
behind the muscle
Esophagus
carries food + liquid to the stomach
Small Intestine
duodenum, jejunum, ileum
Large Intestine
cecum, ascending colon, transverse colon, descending colon sigmoid colon
Abdominal Cavity
separated form the throax by the diaphragm
-lined with peritoneum
Pelvic Cavity
lower portional of abdominal cavity
-“pelvic region”
-pelvis, vertebrae, sacrum
Cholecystitis
inflammation of gallbladder
-common in young women especially after pregnancy
Pelvic Inflammation
diffused tenderness
-may be ectopic pregnancy or ovarian cyst
Referred Pain: RUQ Organs
-liver: cholecystitis or liver lac
-kidney
-gallbladder: pain w/o trauma = gallbladder disease
-pancreas
-lung
Referred Pain: LUQ Organs
-heart
-lung
-spleen: rigidity under lower ribs
-kidney
-stomach
Referred Pain: RLQ Organs
-appendix: rebound tenderness = appendicitis
-ureter
-bladder
-colon: colitis or diverticulitis
-gonads
Referred Pain: LLQ Organs
-ureter
-bladder
-colon: colitis or diverticulitis
-gonads
RUQ Pain + Associated Conditions
-acute cholcystitis
-acute hepatitis
-hepatic abscess
-hepatomegaly
-perforated duodenal ulcer
-acute pancreatitis
-retrocecal appendicitis
-herpes zoster
-myocardial ischemia
-RLL pneumonia
RLQ Pain + Associated Conditions
-appendicitis
-regional enteritis
-diverticulitis
-leaking aneurysm
-abd. wall hematoma
-ruptured ectopic pregnancy
-ovarian cyst
-PID
-endometriosis
-kidney stones
-groin hernia
LUQ Pain + Associated Conditions
-gastritis
-acute pancreatitis
-splenic enlargement, rupture, aneurysm
-myocardial ischemia
-LLL pneumonia
LLQ Pain + Associated Conditions
-sigmoid diverticulitis
-leaking aneurysm
-ruptured ectopic pregnancy
-PID
-endometriosis
-seminal vesiculitis
-enteritis
Diffused Mid-Abdominal Pain + Associated Conditions
-peritonitis
-acute pancreatitis
-early appendicitis
-gastroenteritis
-dissecting/rupturing aneurysm
-intestinal obstruction
-diabetes mellitus
Visceral Pain
stretching of hollow organs or capsule of solid viscus, leading to poorly localized/characterized pain
-dull, cramping, aching
-can be localized to sensory cortex to an approximate spinal cord level (determined by embryologic origin of organ involved)
lining of the organ; deep pain
Foregut Organs
Visceral Pain
produce pain in epigastric region
-stomach, duodenum, biliary tract
Midgut organs
Visceral Pain
produce periumbilical pain
-small bowel, appendix, cecum
Hindgut Organs
Visceral Pain
produce suprapubic or hypogastric pain
-colon (including sigmoid), intraperitoneal portions of genitourinary tract
Parietal Pain
caused by irritation of fibers that innervate the parietal peritoneum
-can be localized to dermatome superficial to site of painful stimulus
With any disease progression, viseceral pain will lead to
parietal pain, causing tenderness
Localized peritonitis leads to:
rigidity and rebound tenderness
Referred Pain
pain or discomfort perceived at a site distant from affected organ because of overlapping transmission pathways
Rebound Tenderness
press slowly + let go quickly; produces pain once pressure is removed
Sub-diaphragmatic Irritation
Referred Pain
ipsilateral supraclavicular or shoulder pain
Gynecologic pathology
Referred Pain
back or lower extremity pain
Biliary Tract Disease
Referred Pain
R infrascapular pain
Myocardia Ischemia
Referred Pain
mid-epigastric, neck, jaw or L extremity pain
Ureteral Obstruction
Referred Pain
ipsilateral testicular pain
Hollow Organs
allow materials to pass through; act as “holding tanks”
-decreased risk of injury when organ is empty
-air is present (soft, resonant sound - same sound as solid organ when it’s full ex. fluid in abdomen or pneumonia)
-full = increased pressure = increased chance of rupture
stomach, large intestine, small intestine pancreas
Solid Organs
significant blood supply; no air present + hard/echo sound
-increased risk of injury (bruising, tearing - hematuria)
liver, spleen, pancreas, kidney, ovaries, testes
Spleen
Palpation
palpate for enlarged spleen under L ribcage
-have pt raise arms above head
Liver
Palpation
press firmly below costal margin
-ask pt to take a deep breath
-may feel liver slide against your hand
-normal liver is not tender
Kidneys
Palpation
under posterolateral portion of ribcage
-R kidney rests more inferior than L
-bruising, pooling of blood, swelling
Abdominal Rigidity
Palpation
occurs secondary to muscle guarding or blood accumulation (indication of internal injury)
-check for rebound tenderness
-normal percussion findings: solid organs have dull thump resonant sound
-positive/abnormal finding: hard, solid echo over area that should sound shallow
Hernia
protrusion of organ through defect in the wall of the cavity
Classifications of Hernias
-reducible: easily manipulated back in place
-irreducible/incarcerated: cannot be reduced due to adhesions in hernia sac
-strangulated: herniated intestine becomes twisted or edematous
Inguinal Hernia
pressure in the abdominal wall finds a weak spot, intestine passes through
-bilateral in 20% of cases
-R side more frequent than L side
Direct Hernia
Inguinal Hernia
herniation through muscle weakness in inguinal canal
-acquired
-25% common
-increased abdominal pressure weakens fascia
-can be caused by constipation, coughing, straining, heavy lifting, prostate enlargement
Indirect Hernia
Inguinal Hernia
herniation through inguinal ring
-congenital
-75% common, 3x more likely in males
-can develop at any age but prevalent in infants less than 1 y/old
Femoral Hernia
through femoral canal
-4% incidence
-common in elderly women
-female prediposition (3:1)
-increased abd pressure
-hernia sac bulges into femoral canal (medial to femoral vein)
Bilateral Hernia
R + L inguinal hernia (simultaneous)
-L hernia present = 25% risk of occult R inguinal hernia
-common in children + elderly men
-L hernia present -> check for R side
Incisional Hernia
type of ventral hernia; develops in scar of prior laparotomy or drain site
-risks include:
1. vertical scar
2. wound infection (wound opens up)
3. wound dehiscence (getting surgical site wet)
4. malnutrition
5. obesity
6. tobacco use (decreased vascularization)
bacteria degrades sutures -> infection
Complications of Hernia
-bowel incarceration: trapping abdominal contents within hernia
-strangulation: pressure compromises blood supply (decreased venous pressure), ischemia, necrosis (gangrene)
-small bowel obstruction
HIDA Scan
hepatobiliary iminodiacetic acid scan of liver function
Cholecystitis
(Manifestation)
stone in cystic duct -> bile still produced -> flow is blocked -> inflamed gallbladder (cholecystitis)
Pancreatic Cancer
(Manifestation)
tumor compresses CHD -> backup of bile + buildup of bilirubin -> jaundice + pain from swelling
(painless jaundice)
R Hepatic Artery
branches off to cystic artery, supplies gallbladder
Gallbladder
responsible for concentrating + storing bile
-sits under the liver in RUQ
-hollow organ of smooth muscle (does not relax or empty well)
-lies in shallow depression on interiro ruface of the liver
-capacity = 30-50 mL of bile
-connected to CHD by cystic duct
-blood supply = cystic artery (originating from RHA)
Bile
responsible for helping the body to digest fats
-golden color
-1/4 -1 1/4 L bile produced daily
Bile Composition
-water
-electrolytes (Na+, K+, Ca2+, Cl-, HCO3)
-fatty acids
-cholesterol
-bilirubin
-bile salts
Increased production of bile leads to…
production of gallstones when gallbladder is non-functional
Factors associated w/ increased risk of gallstone development
-obesity (increased abd pressure)
-pregnancy (very common, increased pressure)
-Crohn’s Disease
-terminal ileal resection
-gastric surgery
-Sickle Cell Disease
Murphy’s Sign
RUQ pain upon palpation causes cessation of breathing
-indicates cholecystitis
Gallstone Disease
revealed by ultrasound
-3 stages:
1. cholesterol supersaturation in bile
2. crystal nucleation
3. stone growth
Symptomatic Cholelithiasis
pain occurs due to stone obstructing cystic duct
-increased wall tension
-pain resolves when stone passes
-pain 1-5 hours (rarely >24 hours)
-can cause acute/chronic cholecystitis
-epigastric/RUQ pain, no fever/WBC
Acute Cholecystitis
acute GB inflammation due to cystic duct obstruction
-persistent RUQ pain
-incr. WBC
- + Murphy’s sign
Chronic Cholecystitis
recurrent bouts of cholecystitis leading to chronic GB wall inflammation/fibrosis
-no fever/WBC
Chronic Calculous Cholecystitis
Symptomatic Cholelithiasis
recurrent inflammatory process due to recurrent cystic duct obstruction
-90% lead to gallstones
-leads to scarring/wall thickening
-scar tissue does not function well
-treatment: laparotic cholecystectomy
Acute Calculous Cholecystitis
Symptomatic Cholelithiasis
persistent cystuc duct obstruction
-GB distension, edema
-pain persists >24 hours
-palpable tender RUQ mass
-sonography for inital imaging
Acute Acalculous Cholecystitis
caused by GB / biliary stasis from lack of enteral stimulation by cholecystokinin
-5-10% of acute cholecystitis cases
-seen in critically ill pts or prolonged TPN
-likely to progress to gangrene
Cholangitis
infection of bile ducts due to CBD obstruction secondary to stones/strictures
-Charcot’s triad + Raynaud’s Pentad
-may lead to life threatening sepsis
Charcot’s Triad
Cholangitis
jaundice, fever + RUQ pain
-70% of pts
Raynaud’s Pentad
Cholangitis
collection of signs + symptoms suggesting obstructive ascending cholangitis
-combination of Charcot’s Traid w/ shock + AMS
Complications of Acute Cholecystitis
-empyema of GB: pus filled GB due to bacterial proliferation in obstructed GB (high fever)
-emphysematous cholecystitis: severe RUQ pain + sepsis (common in men + diabetics, air in GB wall)
-perforated GB: contained abscess in RUQ occuring in 10% of pts
