Abdomen

Question 1

Acute Abdomen

Answer 1

Intra-abdominal process that causes sudden, severe pain and requires surgery to prevent significant complications
- caused by bowel obstruction or peritonitis

Question 2

Bowel Obstruction

Answer 2

partial or complete blockage of the bowel that results in failure of the intestinal contents to pass through

Question 3

Peritonitis

Answer 3

Inflammation/infection of peritoneum

Question 4

Peritoneum

Answer 4

silk-like membrane that lines the inner abdominal wall and covers the organs within the abdomen

Question 5

Perforation

Answer 5

• perforated viscus
• Abnormal opening in a hollow organ (intestines)
• can result from inflammation/abscess
  Examples:
  untreated appendicitis, diverticulitis (or any hollow organ itits) can perforate
• Serious and can be life threatening

Question 6

Diverticulum

Answer 6

Abnormal sac or pouch formed at a weak point in the wall of the alimentary tract.

• LLQ is a common site for pain
• ex: infected diverticulum of the colon

Question 7

Visceral Abdominal Pain

Answer 7

• occurs when organs such as the intestine or biliary tree contract forcefully or distend to stretch abdominally
• May be difficult to localize
• Varies in quality - may be gnawing, burning, cramping, aching
• When severe, can be associated with sweating, pallor, nausea, vomiting and restlessness

Question 8

Parietal

Answer 8

• originates from inflammation of the parietal peritoneum (peritonitis)
• steady, aching pain usually more severe than visceral pain
• more precisely located over involved structure
• exacerbated by movement or cough
• patient attempts to remain still

Question 9

Referred Pain

Answer 9

• felt in more distant sites that are innervated at approx,. the same spinal levels as the affected structures
• often develops as the initial pain, so pain may seem to travel
• may be felt superficially or deeply but is well-localized
• Pain of Ulcer, pancreas or gallbladder referred to back
• Pain of gallbladder/biliary tree may be referred to right shoulder or scapula.
• Pain from pleurisy or acute MI may be referred to epigastric area.

Question 10

Cirrhosis

Answer 10

Liver scarring resulting in poor liver function

Question 11

Portal Hypertension

Answer 11

high blood pressure in the portal vein

• due to liver disease
• resistance to flow in the portal system causes blood to back up and flow down alternate channels.

Question 12

Ascites

Answer 12

Abnormal collection of fluid within the peritoneal cavity (intraperitoneal fluid)
Usu. due to cirrhosis
Pathophysiology not completely understood (“overflow”)
Ascites: free intra-abdominal fluid
Free fluid goes to the dependent part of the abdominal cavity
Gas-filled loops of bowel float to the top and the percussion sound is tympanitic until the fluid level is reached during percussion

Question 13

Jaundice

Answer 13

Results from increased levels of bilirubin (aka hyperbilirubinenia)
(Bilirubin produced when rbc’s breakdown)
Normally the liver removes old rbc’s, conjugates bilirubin – then conjugated bilirubin is excreted in bile (byproduct of the liver that functions in digestion) into the small intestine into the stool
Liver cells secrete bile →
bile collected by system of hepatic ducts →
drain into common hepatic duct →
common hepatic duct joins with cystic duct from the gallbladder to form the common bile duct →
common bile duct transports bile into the duodenum (small intestine)
(Unconjugated hyperbilirubinemia)
E.g. Excessive # of dying rbc’s (Hemolytic jaundice, rare)
(Conjugated hyperbilirubinemia)
The liver is overloaded or damaged (Hepatic jaundice)
E.g. Hepatitis
Bilirubin from the liver is unable to move through the digestive tract properly (Biliary obstruction)
E.g. Bile duct obstruction

Question 14

Bile Pathway

Answer 14

Liver cells secrete bile →
bile collected by hepatic ducts →
drain into common hepatic duct →
common hepatic duct joins with cystic duct from the gallbladder to form the common bile duct →
common bile duct transports bile into the duodenum (small intestine)

Question 15

Unconjugated hyperbilirubinemia

Answer 15

Excessive # of dying rbc’s (Hemolytic jaundice, rare)

Question 16

Conjugated hyperbilirubinemia

Answer 16

The liver is overloaded or damaged (Hepatic jaundice)

E.g. Hepatitis

Question 17

Biliary Obstruction

Answer 17

Bilirubin from the liver is unable to move through the digestive tract properly (Biliary obstruction)
E.g. Bile duct obstruction

Question 18

Preferred order for abdomen examination?

Answer 18

inspection, auscultation, percussion, palpation

Question 19

Striae

Answer 19

Large normal-colored stretch marks 
Pregnancy
Weight gain
Rapid growth
Large purple-colored stretch marks
Seen in Cushing’s disease and steroid use

Question 20

Cullen’s Sign

Answer 20

ecchymosis over the umbilicus
Both late signs suggesting intra-abdominal bleeding
Assoc. with severe, life-threatening acute pancreatitis

Question 21

Grey Turner’s Sign

Answer 21

ecchymosis over the flanks
Both late signs suggesting intra-abdominal bleeding
Assoc. with severe, life-threatening acute pancreatitis

Question 22

Normal Venous Flow

Answer 22

Normal venous flow above the umbilicus is upward
Normal venous flow below the umbilicus is downward
Normally, veins of the abdominal wall are scarcely visible
May be visible during normal pregnancy

Question 23

Caput medusae

Answer 23

visible radiating veins from the umbilicus – may result from portal venous hypertension with ascites (due to collateral circulation)

Question 24

diastasis recti

Answer 24

Separation of rectus abdominus muscles
Obvious with flexion of neck (flex abd muscles)
“Please lift your head up”

Question 25

Increased Peristaltic activity

Answer 25

Visible waves of movement seen beneath the skin | May be seen with bowel obstruction or gastroenteritis (can be normal)

Question 26

Borborygmi

Answer 26

hyperactive bowel sounds heard at auscultation

Question 27

Hyperactive bowel sounds

Answer 27

Gastroenteritis Early intestinal obstruction Peritonitis (early) Borborygmi – loud, active sounds

Question 28

High pitched, tinkling bowel sounds

Answer 28

Early bowel obstruction (“mechanical SBO”) | Intestinal fluid under pressure, with rushes of fluid moving through bowel

Question 29

Hypoactive

Answer 29

Are BS quiet or absent? Listen for ≈ 5 min before determining BS are absent Ileus – little to no bowel activity Peritonitis – BS may be hyperactive initially, but eventually become hypoactive due to progressively severe inflammation; may progress to an “ileus”

Question 30

Hepatomegaly may be due to

Answer 30

``` Congestive heart failure Cirrhosis Hepatitis Abscess Tumor Cysts ```

Question 31

Shifting Dullness specialized exam

Answer 31

With patient supine, percuss the border of tympany & dullness Have patient roll onto his/her side, then percuss the border again An obvious shift in the location of the border suggests ascites is present

Question 32

Splenomegaly may be due to

Answer 32

Mononucleosis (tender, fragile spleen) Other viral, parasitic, or bacterial infections Hematologic disorders Lymphomas, some leukemias, hemolytic disease Cirrhosis with portal hypertension Cysts

Question 33

Test for ascites

Answer 33

Shifting dullness Fluid wave Patient or assistant applies pressure down middle of abdomen to stop transmission of impulse through fat Tapping on one side, assess for wave or vibration of fluid on other side If present, indicates ascites

Question 34

Test for peritoneal signs

Answer 34

Rebound tenderness | Rectal tenderness

Question 35

Test for peritoneal signs associated with appendicitis

Answer 35

Rosving’s sign Psoas sign Obturator sign

Question 36

Test for GB inflammation

Answer 36

Murphy’s sign

Question 37

Succussion Splash

Answer 37

Infrequently done “Shaking” the abdomen with the examiner’s hands or a brief thrust with one hand to create a “splash” sound May be heard with or without a stethoscope May indicate bowel obstruction or ascites

Question 38

Evaluating for Peritoneal Signs

Answer 38

Evaluating for peritoneal signs – assessing for an “acute abdomen” Guarding – tensing of the abdominal wall muscles to guard inflamed organs Voluntary – distract patient Involuntary – (involuntary guarding = rigidity) Rebound tenderness Note – part of evaluating for appendicitis involves evaluating for peritoneal signs There are also specialized exams specific to appendicitis

Question 39

Rebound Tenderness

Answer 39

A classic finding with peritonitis, but may be unnecessary Technique – over site of most tenderness, press in, then suddenly release – observe! Often part of evaluation for appendicitis (which causes peritonitis)

Question 40

Rectal Exam

Answer 40

A digital rectal exam with fingertip palpation of the RLQ and LLQ may be helpful Pain with RLQ rectal palpation suggests appendiceal inflammation (i.e. appendicitis)

Question 41

Rovsing's sign

Answer 41

Note – appendicitis causes peritonitis So, patient may be guarding & may have rebound tenderness Rosving’s sign tests for referred rebound tenderness Press deeply and evenly in the LLQ, then quickly withdraw your fingers Sudden pain in the RLQ is a positive Rovsing’s sign – suggests appendicitis

Question 42

Psoas Sign

Answer 42

``` 2 acceptable techniques: 1. Place your hand above patient’s right knee and ask him/her to raise his/her thigh against resistance 2. With pt on his/her left side, gently hyperextend his thigh at the hip Maneuver #1 tenses the iliopsoas muscle; maneuver #2 stretches the iliopsoas muscle Both cause pain if there is irritation from appendeceal inflammation (ie. appendicitis) ```

Question 43

Obturator Sign

Answer 43

With patient supine and R knee bent, internally rotate the right leg at the hip This stretches the internal obturator muscle – produces RLQ pain from obturator muscle irritation due to an inflamed appendix (ie. appendicitis)

Question 44

Murphy's Sign

Answer 44

Used to test for GB or liver inflammation – various techniques Position fingers of R. hand or thumb of L. hand under R. costal margin & ask patient to take a deep breath Sudden pain & abrupt cessation of inspiration suggests GB inflammation (cholecystitis) or liver inflammation

Question 45

Alternate Murphy's Sign

Answer 45

Lay left hand flat against liver; use fist to percuss (Murphy’s punch)