Abdomen Flashcards Preview

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Flashcards in Abdomen Deck (155):
1

Presenting GI complaints

 

  • Abdominal pain, acute and chronic
  • Indigestion, nausea, vomiting including blood,  loss of appetite, early satiety
  • Dysphagia +/or odynophagia
  • Change in bowel pattern
  • Diarrhea, constipation
  • Jaundice
  • Weight loss (unintentional)
     

2

Abdomen: quadrants

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3

9 sections of abdomen

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4

Location of spleen

lateral to and behind stomach, just above left kidney in left midaxillary line.

upper margin rests against dome of diaphragm. 

 

5

Which ribs protect most of the spleen?

9, 10, 11

6

Presenting urinary and renal sx

  • Suprapubic pain
  • Dysuria, urgency, or frequency
  • Hesitancy, decreased stream
  • Polyuria or nocturia
  • Urinary incontinence
  • Hematuria
  • Kidney or flank pain
  • Ureteral colic

7

Types of abdominal pain

  • Visceral Pain: organ pain, often in hollow organs – intestine, biliary tree. Also liver. Dull & achy, difficult to localize
  • Parietal Pain: often caused by peritoneum. Often sharp, can be localized and very severe. Aggravated by movement/coughing
  • Referred Pain: occurs elsewhere - sites innervated at approximately same spinal levels as disordered structures. Radiating. Superficial or deep but usually localized. E.g. shoulder in cholecystitis

8

Types of visceral pain

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Visceral pain: RUQ/epigastric

biliary tree & liver

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10

Visceral pain: epigastric

stomach, duodenum, pancreas

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11

Visceral pain: periumbilical

small intestine, appendix, proximal colon

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12

Visceral pain: suprapubic or sacral

rectum

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13

Visceral pain: hypogastric

colon, bladder, uterus 

colonic pain may be more diffuse than illustrated

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14

Referred pain: duodenal or pancreatic origin

to the back

15

Referred pain: biliary tree

right shoulder or right posterior chest

16

Referred pain: plueurisy or inferior wall MI

epigastric area

17

Possible movement of pain from appendicitis, visceral & parietal

visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix

Gradually changes to parietal pain in RLQ from inflammation of adjacent parietal peritoneum

18

Doubling over w/cramping colicky pain indicates...

renal stone

19

Sudden knifelike epigastric pain indicates...

gallstone pancreatitis

20

Epigastric pain commonly... 

gastritis and GERD

21

RUQ pain and upper abdominal pain, think first of....

cholecystitis 

22

Dyspepsia

chronic or recurrent discomfort or pain centered in upper abdomen

23

Discomfort

subjective negative feeling that is nonpainful, can include bloating, nausea, upper abdominal fullness, heartburn, etc.

24

Do bloating, nausea, or belching alone meet the criteria for dyspepsia?

No. Can be seen w/other d/os.

E.g., bloating w/IBD and belching w/aerophagia (swallowing air)

25

Functional / nonulcer dyspepsia: what is it?

3 month history of nonspecific upper abdominal discomfort or nausea not attibutable to structural abnormalities or PUD. Sx usually recurring and present >6mths

26

dyspepsia: causes

multifactorial, including delayed gastric emptying, gastritis from H. pylori, PUD, psychosocial factors

27

Diagnostic criteria for GERD 

  • chronic abdominal discomfort/pain w/primary symptoms of heartburn, acid reflux, regurgitation >once/week

OR

  • mucosal damage on endoscopy

28

Risk factors GERD

  • reduced salivary flow - prolongs acid clearance by damping action of bicarbonate buffer
  • delayed gastric emptying
  • selected medications
  • hiatal hernia

29

Foods and positions that aggravate heartburn

etoh, chocolate, citrus, coffee, onions, peppermint

bending over, exercising, lifting, lying supine

30

atypical respiratory symptoms of GERD

cough, wheezing, aspiration pneumonia

pharyngeal symptoms: hoarseness, chronic sore throat, laryngitis

31

What factors indicate ordering an endoscopy (GERD)?

  • uncomplicated symptoms of GERD but not responding to empiric therapy
  • >55yo
  • alarm Sx: dysphagia, odynophagia, recurrent vomiting, evidence of GI bleed, weight loss, anemia, risk factors for gastric cancer, palpable mass, jaundice

32

What are you worried about when ordering an endoscopy (GERD)?

esophagitis, peptic strictures, Barrett's esophagus

33

Barrett's esophagus

squamocolumnar junction is sisplaced proximally and replaced by intestinal metaplasia

30-fold increased risk of esophageal adenocarcinoma

34

RLQ pain or pain that migrates from periumbilical region, combined w/abdominal wall rigidity on palpation 

most likely appendicitis

in women, consider PID, ruptured ovarial follicle, ectopic pregnancy

35

cramping pain radiating to right or LLQ

may be renal stone

36

LLQ w/palpable mass may be...

diverticulitis

37

Diffuse abdominal pain w/absent bowel sounds and firmness, guarding, or rebound on palpation may be...

small or large bowel obstruction

38

Chronic discomfort

change in bowel patterns w/mass lesion indicates ...

colon cancer

39

IBS symptoms 

Chronic discomfort

Intermittent pain for 12 weeks of preceding 12 months with relief from defecation, change in frequency of bowel movement, or change in form of stool (loose, watery, pellet-like), w/o structural or biochemical abnormalities

40

retching vs vomiting

retching = involuntary spasm of stomach, diaphragm, esophagus  - precedes and culminates in vomiting (forceful expulsion of gastric contents out of mouth)

41

Regurgitation occurs in...

GERD, esophageal stricture, esophageal cancer

42

Fecal odor in vomitus/regurgitated contents indicates...

small bowel obstruction or gastrocolic fistula

43

Hematemesis may indicate...

esophageal or gastric varices, gastritis, or PUD

44

How much blood loss before lightheadedness, syncope 

Typically >500mL

45

Abdominal fullness or early satiety, consider...

diabetic gastroparesis, anitcholinergic medications, gastric outlet obstruction, gastric cancer 

early satiety in hepatitis

46

dysphagia - structural vs motility d/o

solid foods - more structural (e.g., esophageal stricture, web or schatzki's ring, neoplasm)

solids & liquids: motility d/o more likely

47

odynophagia (pain on swallowing), consider...

esophageal ulceration from radiation, caustic indigestion, infection from candida, CMV, herpes simplex, HIV

can also be pill-induced from aspirin or NSAIDs

48

Excessive flatus, consider...

aerophagia, legumes or other gas-producing foods, intestinal lactase deficiency, IBS

49

Diarrhea defined

increased water content in stool, volume >200g in 24 hours

50

acute vs chronic diarrhea

acute: 2 weeks

chronic: 4+ weeks

51

quality of diarrhea from small intestine

high-volume, frequent watery stools

52

small-volume stools w/tenesmus, or diarrhea with mucus, pus, or blood occur in...

rectal inflammatory conditions

53

Significance of nocturnal diarrhea

usually pathologic

54

oily, sometimes frothy or floating diarrhea

steatorrhea - from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth

55

Medications commonly assoc w/diarrhea

PCN and macrolides, magnesium-based antacids, metformin, herbal and alternative meds

56

constipation defined

at least 12 weeks of prior 6 mths w/at least 2 of following:

  • fewer than 3 bms/week
  • 25% or more defecations w/either straining or sensation of incomplete evacuation
  • lumpy or hard stools
  • manual facilitation

57

thin, pencil like stools

possibly an obstrucing "apple-core" lesion of the sigmoid colon

58

Medications assoc w/constipation

anti-cholinergics, CCBs, iron supplements, opiates

59

diseases assoc w/constipation

diabetes, hypothyroidism, hypercalcemia, MS, Parkinson's, systemic sclerosis

60

obstipation

no passage of feces or gas - indicates intestinal obstruction

61

melena

black tarry stools - upper GI bleeding

may occur w/as little as 100mL blood

62

hematochezia

stools that are red or maroon colored - 

indicates >1000 mL blood, usually d/t lower GI bleed

63

mechanisms of jaundice

  • increased production of bilirubin
  • decreased uptake of bilirubin by hepatocytes
  • decreased ability of liver to conjugate bilirubin
  • decreased excretion of bilirubin into bile, resulting in absorption of conjugated bilirubin back into blood

first 3 result in predominately unconjugated bilirubin

64

conditions resulting in jaundice

predominately unconjugated bilirubin: e.g., hemolytic anemia (increased production), Gilbert's syndrome

impaired excretion of conjugated bilirubin: viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis, as from OCs, methyl testosterone, chlorpromazine

65

What to ask about if see jaundice?

  • Urine color: dark indicates impaired excretion of bilirubin into GI tract (only conjugated ends up in urine)
  • Stool color: excretion of bile into intestine is completely obstructed, so stools are acholic (w/o bile). Occurs briefly in viral hepatitis, common in obstructive jaundice.
  • Pruritis
  • Risk factors for liver Dz

 

66

Risk factors for liver Dz

  • hepatitis: A (ass), B (body fluids, IV drugs), C (IV drugs, blood transfusion)
  • Alcoholic hepatitis/cirrhosis: 
  • Toxic liver damage: meds, industrial solvents, environmental toxin, some anesthetic agents
  • Gallbladder dz or surgery: may result in extrahepatic biliary obstruction
  • hereditary d/os: in family Hx

67

Pruritis in jaundice indicates...

cholestatic or obstructive jaundice

68

pain in skin w/jaundice indicates...

distended liver capsule, biliary colic, pancreatic cancer

69

Symptoms of BPH or urethral stricture

Trouble starting, stand close to toilet to void, change in force/size of stream, straining to void, hesitate or stop in middle of voiding, dribbling when finished

70

Men: prostatic pain vs urinary infection pain

infection: burning proximal to glans penis

prostatic pain: in perineum and occasionally in rectum

71

Painful urination occurs in...

cystitis, urethritis, UTI

72

Dysuria, consider...

bladder stones, foreign bodies, tumors, acute prostatitis

73

burning on urination in women

internal: urethritis

External: vulvovaginitis

74

urgency in urination suggests...

bladder infection or irritation

75

in men, painful urination w/o frequency or urgency suggests...

urethritis

76

Urinary frequency: polyuria vs frequency w/small amts

polyuria - large amounts

frequency w/o polyuria - bladder d/o, impairment to flow at or below bladder neck

77

Types of incontinence

  • Stress: increased abdominal pressure, d/t poor urethral sphincter tone or poor support of bladder neck
  • urge: urgency then immediate leakage d/t uncontrolled detrusor contractions that overcome urethral resistance
  • overflow: neurologic d/o or anatomic obstruction limits emptying until overflow
  • functional: d/t impaired cognition, musculoskeletal problems, immobility

78

Sx acute pyelonephritis

kidney pain, fever, chills

typically dull, aching, steady

79

Sx sudden obstruction to ureter, e.g., d/t renal or urinary stones or blood clots

Renal or ureteral colic - severe, originates at CVA and radiates around trunk into lower quadrant of abdomen, possibly into upper thigh and testicle or labium. Ask about fever, chills, hematuria

80

Classic signs of alcoholism

hepatosplenomegaly, ascites, caput medusa, spider angiomas, palmar erythema, peripheral edema

81

caput medusa

collateral pathway of recanalized umbilical veins radiating up the abdomen that decompresses portal vein hypertension

82

Inspection: striae

silver normal

Purple -- think Cushing's syndrome

83

Inspection: dilated veins

can be indicative of hepatic cirrhosis or IVC obstruction

84

Inspection: ecchymosis of abdominal wall

intraperitoneal or retroperitoneal bleeding

85

Contour of abdomen: possibilities

flat, rounded, protuberant, scaphoid (markedly concave or hollowed)

86

Inspection: Bulging of flanks indicates...

ascites

87

Inspection: suprapubic bulge indicates

distended bladder or pregnant uterus

88

Inspection: lower abdominal mass indicates

ovarian or uterine cancer

89

Inspection: assymetrical abdomen suggests

enlarged organ or mass

90

Inspection: increased peristalsis indicates

intestinal obstruction

91

Normal bowel sounds

clicks and gurgles, 5-34/minute

occasionally borborygmi

92

borborygmi

prolonged gurgles of hyperperistalsis, "stomach growling"

93

Auscultation: what indicates renal artery stenosis?

bruit in one of the upper quadrants, w/both systolic & diastolic component

(4-20% of healthy individuals have abdominal bruits)

94

Friction rub over liver or spleen indicates...

hepatoma, gonococcal infection around liver, splenic infarction, pancreatic carcinoma

95

protuberant abdomen tympanitic throughout suggests...

intestinal obstruction

96

Percussion: Why might you find an air bubble on the right and dullness on the left of the abdomen

rare condition - situs inversus, organs are reversed

97

How to categorize abdominal masses

  • physiologic: pregnant uterus
  • inflammatory: diverticulitis of colon
  • vascular: AAA
  • neoplastic: colon cancer
  • obstructive: distended bladder or dilated loop of bowel

98

Palpating the liver

left hand behind pt, parallel to and supporting right 11th and 12th ribs and adjacent to soft tissues below. Remind pt to relax on hand if necessary.

Right hand lateral to rectus muscle, fingertips well below lower border of liver dullness, press gently in and up as pt takes deep breath

99

How does the liver feel in your hands?

may not feel it, but if you do, normal liver is soft, sharp, regular, w/smooth surface

may be slightly tender

 

100

Tenderness over liver suggests...

inflammation, as in hepatitis

or congestion, as in heart failure

101

Percussion of spleen

Percuss left lower anterior chest wall roughtly from border of cardiac dullness at 6th rib to anterior axillary line and down to costal margin (Traube's space)

if dullness, palpation correctly detects 80% of time

102

Splenic percussion sign

Percuss lowest interspace of left anterior axillary line. Percuss w/deep breath. Should be tympanitic on both.

103

Causes of splenomegaly

portal hypertension, hematologic malignancies, HIV, splenic infarct or hematoma

104

2 positions to check for splenomegaly

  • 1st, supine. Left hand supports and presses forward lower left rib cage (from below), right hand below Rt costal margin, palpation on inspiration
  • 2nd: right lateral, legs somewhat flexed at hips and knees

105

splenomegaly vs enlarged left kidney

if both in left flank, suspect splenomegaly if notch is palpated on medial border, the edge extends beyond midline, percussion is dull, fingers can probe deep into medial and lateral borders, but NOT between mass and costal margin

106

palpate kidney

Left from left side

  • right hand behind pt, just below and parallel to 12th rib, fingertips just reaching CVA.
  • Lift.
  • Place left hand on LUQ, lateral and parallel to rectus muscle.
  • On deep inspiration, press left hand firmly and deeply down into LUQ, trying to capture kidney.
  • Ask pt to breathe out then stop breathing briefly. Slowly release pressure as you feel for it to move back into position

OR similar to spleen, from right side

Right kidney: from right side, same method

107

causes of kidney enlargement

hydronephrosis, cysts,tumors

bilateral: PKD

108

CVA tenderness indicates

pylenephritis or musculoskeletal cause

109

How much bladder volume before dullness?

400-600mL

110

how to palpate aorta

press firmly deep in upper abdomen, slightly to left of midline. If >50, assess width

Normal is

111

Risk factors for AAA

>65yo, hx smoking, male, 1st degree relative w/hx of AAA repair

112

Distinguishing mass of abdominal wall from abdominal mass

abdominal wall: remains palpable if does half sit up or bears down

intra-abdominal: obscured by muscle contraction

113

history taking: significance of aspirin, steroids, PPIs

  • Aspirin : increased risk of bleeding, assoc w/gastric ulcers
  • Steroids: increase risk bleeding & ulceration
  • PPIs treat reflux dz

114

Pain and structures: epigastric

Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen

115

Pain and structures: upper right corner

Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen

116

Pain and structures: upper left corner

Esophagus, stomach, duodenum, liver, gallbladder, pancreas, spleen

117

Pain and structures: periumbilical

jejunum, ileum, appendix, ascending colon

118

Pain and structures: lower abdomen

GU structures: bladder, prostate, uterus
 

119

Pain and structures: Right lower quadrant

appendix, fallopian tube, ovary
 

120

Pain and structures: Left lower quadrant

 sigmoid colon, fallopian tube, ovary
 

121

Pain and structures: Flanks

kidneys

122

Differential Dx: pain in RUQ

 

  • Duodenal ulcer
  • Hepatitis
  • Hepatomegaly
  • Pneumonia
  • Cholecystitis

 

123

Differential Dx: Pain in RLQ

  • Appendicitis
  • Salpingitis
  • Ovarian cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Diverticulitis
  • Regional ileitis
  • Perforated Cecum

124

Differential Dx:​ pain in LUQ

  • Ruptured spleen
  • Gastric ulcer
  • Aortic aneurysm
  • Perforated colon
  • Pneumonia
  • Pyelonephritis

125

Differential Dx:​ pain in LLQ

  • Sigmoid diverticulitis
  • Salpingitis
  • Ovarian cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Perforated colon
  • Regional ileitis
  • Ulcerative colitis

126

Differential Dx: periumbilical pain

  • Intestinal Obstruction
  • Acute pancreatitis
  • Early appendicitis
  • Mesenteric thrombosis
  • Aortic aneurysm
  • Diverticulitis

127

Differential Dx: Pelvic pain

  • Bladder
    • Distension
    • Infection
    • Stones
  • Prostatitis
  • Uterus
  • Urethritis, vulvovaginitis, 

128

Preparation for abdominal exam

  • Empty bladder
  • Ask patient to point to painful areas
  • Distract patient with conversation – esp when beginning palpation.
  • Ensure proper draping
  • Position properly
    • Pillow under head
    • Pillow under knees
    • Arms at sides or cross chest

129

Linea nigra

black line down abdomen, normal in pregnancy

130

bruits: bell or diaphragm?

bell

131

friction rubs & venous hums: bell or diaphragm?

diaphragm

132

Abdomen: what to percuss

  • 4 Quadrants for masses, fluid or gas
  • Liver
  • Spleen
  • Costovertebral angle

133

Characteristics of tympany

  • High pitch note
  • Predominates due to gas in the intestines
  • Protuberant abdomen with tympany may be intestinal obstruction

134

Characteristics of dullness

  • Short, no resonance
  • Scattered: feces

135

Dullness over large areas may be...

  • Organ
    • Enlarged liver
    • Distended bladder
  • Mass: ovarian tumor
  • Pregnancy

 

136

Dulness at flanks may be...

 

Ascites

137

normal vertical span of liver

Adult:

6-12 cm in MRCL
4-8 cm at midsternal line

138

Image - location of abdominal pain and etiology

A image thumb
139

Fluid Wave test

  • For ascites

 

  • Patient or assistant presses edges of both hands down midline of abdomen
  • Hold your hand on one flank, tap opposite side with other hand

140

Shifting dullness

  • for ascites
  • Percuss border of tympany and dullness with patient supine
  • Ask patient to rotate to side and repeat
  • In ascites, dullness shifts

141

Mc Burneys point

test for appendicitis

2 inches from anterior superior spinous process of ilium (1/3 way between ASIS & umbilicus) - pain w/pressure

 

142

Rovsing’s sign

 

test for appendicitis

Press gently on LLQ elicits pain in RLQ

143

Rebound tenderness

test for appendicitis

Quickly withdraw hand elicits increase in RLQ pain

144

Psoas sign

test for appendicitis

  • Place hand above right knee
    • Ask patient to raise leg
  • Or patient turned on left side, extend right leg at hip

145

Oburator sign

test for appendicitis

  • Flex patients right thigh at hip
  • Knee bent
  • Rotate leg medially and laterally 

146

Special test for cholecystitis

Murphy’s sign

  • Ask pt take deep breath out. When in full expiration, Hook left thumb and fingers of right hand under costal margin.  Then ask to take deep breath in.
  • A sharp increase in tenderness with sudden stop in inspiratory effort is positive sign
  • Acute cholecystitis

147

Red alerts for abdominal emergency: subjective

  • Progressive intractable vomiting
  • Lightheadedness on standing (bleeding)
  • Acute onset of pain
  • Pain that progresses in intensity over hours

148

red alerts for abdominal emergency: objective

  • Involuntary guarding
  • Progressive abdominal distension
  • Orthostatic hypotension
  • Fever
  • Leukocytosis (elevated WBC)
  • Decrease urine output

149

Potential surgical emergencies

  • Perforation:  look for signs of peritonitis (generalized pain, fever, elevated WBC)
  • Ectopic pregnancy: in any woman of childbearing years (positive pregnancy test, vag bleeding, abd pain)
  • Appendicitis: RLQ pain (mean age, 22 – increases teenage years, starts to decline)
  • Obstruction: elderly (tendency, +meds that cause. Hyperactive BSs above obstruction, diminished or absent below, + nausea, vomiting)
  • Ruptured abdominal aortic aneurysm: when back pain is present (severe sharp back pain, can be fatal)
  • Intussusception: in infants (telescoping of intestine onto self. Currant jelly stool, vomiting or lump in abdomen)
  • Malrotation: infants < 1 month old (congenital abnormality; organs displaced w/in abdomen)

150

RED ALERTS:  Peritonitis

  • Pain: front, back, sides
  • Electrolytes full-shock ensues
  • Rigidity or rebound of anterior abdominal walls
  • Immobile abdomen and patient
  • Tenderness with involuntary guarding
  • Obstruction
  • Nausea and vomiting
  • Increasing pulse rate, decreasing blood pressure
  • Temperature falls and then rises, tachypnea
  • Increasing girth of abdomen
  • Silent abdomen: no bowel sounds

151

Lab Tests - abdomen

  • Complete blood count with diff (leukocytosis)
  • Qualitative urine (hCG)
  • Erythrocyte Sedimentation Rate (inflammation marker)
  • Urinalysis (urinary Sx, or older adults w/vague Sx)
  • Urine C&S (for antibiotics)
  • Cultures of STDs
  • Fecal Occult Blood Tests
  • LFT’s (e.g., if hepatomegaly)
  • Amylase and Lipase (pancreatitis)
  • Cardiac Enzymes (esp in women, who present w/MIs differently)

152

Diagnostic tests, abdomen

  • Electrocardiogram (suspect MI)
  • Radiography
  • Anteriorposterior
  • Abdominal/pelvic ultrasound (appendicitis, esp kids when don’t want to subject to radiation)
  • Computed Tomography/ MRI
  • Colonoscopy

153

Screening for ETOH abuse: who and how

US Preventive Services Task Force (USPSTF) recommend screening for all adults

CAGE
AUDIT

154

Screening for colon cancer: who and how

assess for risk beginning at age 20 and if high risk, refer for complex mgmt

If avg risk, offer screening options at 50yo

  • High-sensitivity fecal occult blood test (annually)
  • Sigmoidoscopy every 5 years w/ FOBT every 3 yr
  • Screening colonoscopy every 10 years.

 

155

Life of bilirubin

  • bile pigment derived chiefly from breakdown of hemoglobin
  • Hepatocytes conjugate bilirubin (combine unconjugated bili w/other substances) so that it is water soluble, then excrete into bile. 
  • Bile passes through cystic duct into common bile duct, which also drains extrahepatic ducts from liver. 
  • More distally, common bile duct and pacncreatic ducts empty into duodenum at ampulla of Vater