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ABDOMEN: Bates Chapter 11 biological
notes
Structures by Quadrant RUQ Liver Gallbladder Duodenum Head of pancreas Right Kidney & Adrenal Hepatic flexure of colon Part of ascending and transverse colon Sections Epigastric
LUQ
Stomach Spleen Left lobe liver Body of pancreas Left Kidney & adrenal Splenic flexure of colon Parts of transverse and Umbilical descending colon RLQ Cecum Appendix Right Ovary/Fallopian Tube Right Ureter *McBurney’s point: 2” from anterior superior spinous process of ilium on a line drawn from that point to the umbilicus.
LLQ
Part of descending colon Sigmoid Colon Left Ovary/Fallopian Hypogastric tube Left Ureter Suprapubic ABD H/HX: Common Concerning Symptoms ABD H/Hx: GU/Renal Disorders Suprapubic pain Difficulty urinating (dysuria) Urinary urgency and Frequency Hesitancy, stream (in males) Polyuria, Nocturia Incontinence (stress, urgency, overflow, urge) Hematuria Flank pain Ureteral Colic *often accompanied by GI sx such as abd pain, N/V (from bates) GI Disorders RED sx highlighted in ppt Abd pain (Acute and Chronic) Indigestion, N/V Hematemesis Anorexia, early satiety Difficulty swallowing (dysphagia) Pain with swallowing (odynophagia) Change in bowel function Diarrhea/Constipation Jaundice Upper GI Sx: Abd pain, heartburn, N/V Lower GI Sx: Diarrhea, constipation, blood in stool, and change in bowel function.
- Pain in ABD: Onset, duration (timing of pain) o Intermittent/Persistent o Acute vs Insidious onset
- Location and movement of pain
- Radiation of pain
- Reproduceable?
- Quality and Severity
- Description – spasm, coliky, steady, dull, tearing, penetrating, sharp.
- Recurrent Pain
- Aggrivating/Relieving Factors. *Ask patient to point to the location and describe sx in their own words * Useful findings in Hx and PE
- Although location of abd pain guides the initial evaluation, associated symptoms are predictive of certain causes/sources of abd pain and can help narrow the DDx. History
- N/V
- Rectal bleeding
- Elimination o Diarrhea/Constipation o Change in color Urine/Stool
- Hemorrhoids
- Voiding difficulty
- Weigh gain/loss
- Type of diet o Pain in relation to meals
- Change in appetite
- Chewing swallowing problems
- Heartburn
- Age, Gender
- Assoc sx: fever, cough, jaundice Pain Visceral pain:
- Poorly localized – occurs often in the epigastrium, periumbilical and lower abdomen.
- Occurs when hollow organs such as the intestines or biliary tree forcefully contract or are distended/stretched. Solid organs such as the liver can cause pain when their capsules are stretched.
- May be difficult to localize.
- Typically pain is palpable near midline and at levels according to the structure involved.
- Ischemia also stimulates visceral pain fibers.
- Visceral pain in RUQ suggests liver distention against its capsule from various causes of hepatitis, including chronic alcoholic hepatitis.
- Visceral periumbilical pain suggests early acute appendicitis from distention and inflamed appendix. It gradually changes to parietal pain in RLQ from inflamed adjacent parietal peritoneum.
Acute Upper Abdominal Pain: pay close attention to body position, association with meals, alcohol, medications, stress and use of antacids. Ask paint to point to the pain.
- Doubling over with cramping, colicky pain signals RENAL STONES
- Sudden knifelike epigastric pain radiating to the back is typical of PACREATITIS
- Epigastric pain happens with GERD, PANCREATITIS & PERFORATED ULCERS
- RUQ Pain and upper abdominal pain common with CHOLECYSTITIS and CHOLANGITIS
- Pain precipitated by exertion consider CAD. Chronic Upper Abdominal Pain:
- Dyspepsia: Chronic or recurrent pain centered in the upper abdomen. Characterized by postprandial fullness, early satiety, and epigastric pain or burning. o Note if bloating, belching and nausea occur alone, these symptoms do not meet the criteria for dyspepsia. o If patient reports heartburn and regurgitation together more than 1 week, the accuracy of dx GERD is more than 90%.
- Heartburn: Rising retrosternal burning pain occurring weekly or more often. aggravated by alcohol, chocolate, citrus, coffee, onions; or positions like bending over, exercise or lying supine.
o Some patients with GERD have atypical respiratory symptoms such as chest pain, cough; laryngeal symptoms such as chronic sore throat, laryngitis, and hoarseness. ALARM SYMPTOMS
- Dysphagia
- Odynophagia
- Recurrent emesis
- Evidence of GI bleeding
- Early satiety
- Weight loss
- Anemia
- Risk factors for gastric cancer
- Palpable mass
- Painless jaundice Acute Lower Abdominal Pain:
- Some acute pain, especially in the suprapubic area or radiating form the flank, originates in the GU tract.
- Acute localized to RLQ – assess sharp? Continuous? Intermittent? Cramping? Doubling over?
- RLQ pain that migrates from the periumbilical area, combined with abdominal wall rigidity on palpation is suspicious for appendicitis. In women consider PID, ruptured ovarian follicle, and ectopic pregnancy.
- Combining signs with lab inflammatory markers and CT scans misdiagnosis and unnecessary surgery.
- Acute LLQ pain or diffuse abdominal pain investigate associated sx such as fever and loss of appetite.
- Cramping pain radiating to LLQ or groin may be a renal stone.
- LLQ pain with palpable mass signals diverticulitis
- Diffuse pain with abdominal distention, HYOERACTIVE HIGH PITCHED bowel sounds and tenderness on palpation marks SMALL BOWEL OBSTRUCTION.
- Pain with ABSENT BOWEL SOUNDS, RIGIDITY, PERCUSSION TENDERNESS, & guarding ⟶ PERITONITIS. Chronic Lower Abdominal Pain:
- If there is chronic lower abd pain, ask about change in bowel habits and alternating diarrhea and constipation.
- Change in bowel habits with a mass warns of colon cancer.
- Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery or pellet-like) suggests IBS.
▪ Oily residue, sometimes frothy or floating, occurs with steatorrhea (fatty diarrhea) occurs with malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth. ▪ Explore possible causes: current meds, recent travel, diet habits, immunocompromised.
- Diarrhea common with use of PCN, Macrolides, magnesium antacids, metformin
- If recent hospitalization, consider c-diff.
- Constipation: o Rome III criteria: Constipation should be present for 3 mos with symptom onset at least 6 mos prior to dx and meet 2 of the following criteria: < 3 BM/wk, straining with >25% of defecations, sensation of incomplete evacuation, hard lumpy stools. ▪ Types of primary or functional constipation – normal transit, slow transit, impaired expulsion (pelvic floor disorders), and Constipation predominant IBS. Secondary causes include medications and conditions like DM, and CNS disorders. ▪ Pencil like stool occurs in an obstructing “apple-core’ lesion of the sigmoid colon. ▪ Obstipation signals intestinal obstruction ▪ Melena: Upper GI bleed. ▪ Hematochezia (bright red blood per rectum) usually lower GI bleed. ▪ Blood on surface of TP = hemorrhoids
- Jaundice: 𝖳 level of bilirubin o Mechanisms of Jaundice
- 𝖳 production of bilirubin
- uptake of bilirubin from hepatocytes
- ability of liver to conjugate bilirubin
- excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood. ▪ Unconjugated bilirubin occurs from first 3 mechanisms – hemolytic anemia ▪ Impaired excretion of conjugated bilirubin – viral hepatitis, cirrhosis, primary biliary cirrhosis. o Intrahepatic Jaundice – hepatocellular – from damage to hepatocytes. Or Cholestatic – from impaired secretion as a result from damaged hepatocytes or intrahepatic bile ducts. o Extrahepatic Jaundice – From obstruction of extrahepatic bile ducts, usually common bile ducts. o Ask about color of urine and stools. o Dark urine indicated impaired excretion of bili into the GI tract. o Painless jaundice indicated malignant obstruction of the bile ducts, seen in duodenal or pancreatic cancers.
o Painful jaundice is often r/t infection – Hepatitis A and Cholangitis. o When excretion of bile into the intestine is completely obstructed, the stool becomes gray or light colored, or acholic , without bile. o Acholic stool may occur briefly in viral hepatitis, but they are more common in obstructive jaundice. Urinary Tract:
- Suprapubic pain may be caused by bladder disorders such as bladder infection or bladder distention.
- Flank pain and ureteral Colic: o Kidney pain is visceral pain produced by distention of the renal capsule. ▪ Flank pain, fever and chills signal acute pyelonephritis o Ureteral colic is severe colicky pain that radiates around the trunk into the lower ABD and groin. ▪ Renal or ureteral colic is caused by sudden obstruction of a ureter from renal or urinary stones, or blood clots.
▪ Weakness of the detrusor muscle associated with peripheral nerve disese ar S2-4. Symptoms : force of urinary stream. ▪ Impaired bladder sensation that interrupts arc reflex as in Diabetic Neuropathy. Symptoms: sx of partial urinary obstruction
- Functional Incontinence: The patient is physically unable to make it to the toilet in time r/t impaired health or environmental conditions. o Mechanisms: Problems with mobility from weakness, poor vision etc. Environmental factors such as unfamiliar settings or bathroom too far away. o Symptoms: incontinence on the way to the bathroom**. Health Promotion:
- Colorecteal Cancer:**
- 3 rd^ most frequently diagnosed cancer
- 3 rd^ leading cause of death in the US
- 5% risk of being diagnosed, 2% lifetime risk of dying from colorectal cancer
- Risk factors
- Strong: increasing age, personal hx of colorectal cancer, polyps, longstanding IBD, family hx
- Weak: Male sex, AA, tobacco use, excessive alcohol use, red meat consumption, obesity
- Prevention : Screening and removal of pre-cancerous polyps
- Screening tests:
- Occult fecal blood stool tests
- Colonoscopy
- Any abnormal finding on stool test, imaging study, or flexible sigmoidoscopy warrants further evaluation with colonoscopy
- Adults 50-75: 1) High sensitivity FOBT annually 2) sigmoidoscopy every 5 years with FOBT every 3 years 3) screening colonoscopy every 10 years
- Adults 76-85: Do not screen routinely
- Adults older than 85 years: Do not screen
- High risk persons: personal hx of colorectal CA, or long-standing IBD, start earlier
Techniques of Examination
- Inspection: o Asymmetry suggests hernia, an enlarged organ, or a mass. o Inspect lower abdominal mass of an ovarian or uterine cancer o Inspect for 𝖳 peristaltic waves of intestinal obstruction. o Inspect for 𝖳 pulsations of an AAA or increased pulse pressure. ▪ Table 11.8 pg 499 Bulges in ABD wall - Umbilical Hernia - Diastasis Recti – separation of the 2 rectus abdominus muscles, through which ABD contents form a midline ridge – only seen when the patient laying flat and rises head and shoulders. Often seen in patients with repeated pregnancies – Clinically benign. - Lipoma – fatty tumors - Incisional Hernia - Epigastric hernia
- Auscultation: o Auscultate the ABD before performing percussion or palpation, will change the characteristics of bowel sounds. o Normal: clicks and gurgles, 5-34 minute o Borborygmi: rumbling of bowel sounds (bor-bor-ig-my) o If a patient has HTN, auscultate the epigastrium for as well as the CVAs for bruits. Bruits suggest vascular occlusive disease. A bruit in one of these areas that has a systolic and diastolic component strongly suggests renal artery stenosis as the cause of HTN. o Bruits with both systolic and diastolic components suggest turbulent blood flow from atherosclerotic artery disease. o Auscultate over the liver and spleen for friction rubs. Friction rubs are present in hepatoma, gonococcal infection around the liver, selenic infarction, and pancreatic cancer.
- Bruits: o A hepatic Bruit suggests carcinoma of the liver or cirrhosis. o Arterial Bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries o Bruits in the epigastrium suggest renal artery stenosis or renovascular HTN. Bruit
- Venous Hum: o Rare soft humming noise with both systolic and diastolic components. o It points to collateral circulation between the portal and venous systems, as in hepatic cirrhosis. Venous Hum
- Friction Rubs: o Rare grating sounds with respiratory varitations. o Indicate an inflamed peritoneal surface of an organ, as in liver cancer, recent liver bx, or splenic infarct. o When a systolic bruit accompanied a friction rub, suspect liver cancer Friction Rubs
- Percussion: o A protuberant abdomen with tympanic sounds throughout suggests intestinal obstruction or paralytic ileus. o Dull areas characterize a pregnant woman, an ovarian tumor, distended bladder, or a large liver or spleen. o Dullness in both flanks prompts further assessment for ascites. o Percuss the lower border of liver by starting at the level well below the umbilicus in the RLQ midclavicular line, percuss upward toward the liver until sounds go from tympani to dull and mark that spot. Then percuss the upper border of liver by starting at nipple line and midclavicular line and percuss down until sounds change from resonant to dull and mark that spot. Measure the distance between the 2. Normal 6-12 cm. greater than 12 indicated enlarged liver. o Kidney percussion: CVAT supports pyelonephritis if associated with fever and dysuria. May also be MSK.
▪ Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis. ▪ Classically the McBurney point lies 2” from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus. ▪ Palpate the tender area for guarding, rigidity, or rebound tenderness ▪ Palpate for the Rovsing sign and referred rebound tenderness. Press deeply and evenly in the LLQ, then quickly withdraw your fingers. Positive signs will cause pain in the RLQ during left-sided pressure. ▪ Assess the psoas sign: place your hand just above the patient right knee and ask them to raise that thigh against your pressure. Alternatively ask the patient to turn on to the left side. Then extend the patients right leg at the hip. Flexion of the leg at the hip mix the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver is a positive psoas sign suggesting irritation of the psoas muscle by an inflamed appendix. ▪ Assess the obturator sign. Flex the patient’s right thigh at the hip, with an event, and rotate the lake internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle buying inflamed appendix.
- Mass in the abdominal wall o Occasionally there are masses in the abdominal wall rather than inside the abdominal cavity. o Ask the patient either to raise the head and shoulders or strain down, thus tightening the down low muscles. Feel for the mass again. o A mass in the abdominal wall remains palpable; intra-abdominal Mass isn’t secured by muscular contraction. Psoas Sign: Appendicitis Obturator Sign: Appendicitis Rebound Tenderness: Appendicitis Rovsing Sign: Appendicitis McBurney Point of Tenderness: Appendicitis Murphy Sign: Acute cholecystitis Problem Location Quality/Type of pain Assoc sx GERD Chest or epigastric Heartburn, regurgitation (Visceral Pain) Wheezing, cough, hoarseness, SOB, dysphagia, choking sensation, regurgitation, halitosis. Peptic Ulcer Disease Epigastric, may radiate to the back Variable, epigastric gnawing or burning, may also be boring, aching or hunger- like. (Visceral pain) N/V, belching, bloating, heartburn, weight loss, dyspepsia Acute appendicitis Poorly localized periumbilical pain, usually migrates to RLQ Mild but increasing, possible cramping. Steady and more severe. (visceral pain) Anorexia, nausea, possible emesis w/pain and low fever Acute Cholecystitis RUQ or epigastrium, may radiate to right shoulder or interscapular area Steady Aching (Visceral Pain) Anorexia, N/V, fever, no jaundice, Biliary Colic Epigastric or RUQ, may radiate to right scapula and shoulder Steady, Aching, not colicky, Usually last longer than 3 hrs. Anorexia, N/V, restlessness
Acute Pancreatitis Epigastric radiating to the back Usually Steady N/V, ABD distention, fever, often recurrent with hx of alcohol abuse or gallstones. Acute Diverticulitis LLQ May be cramping at first and then steady Fever, constipation. N/V, abdominal mass with rebound tenderness Acute Bowel Obstruction Small bowel: periumbilical or upper abdominal. Colon: Lower abdominal or generalized Cramping Cramping Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction); Constipation develops early; vomiting late if at all; prior symptoms of underlying cause.
