Location of Rectus abdominus
anteriorly prominent muscle of abdomen
Relation of Rectus abdominus to physical exam
prominence when supine pt raises head; relax for exam >> ask pt to bend knees
Location of Internal/external obliques
Location of Linea alba
tendinous band, midline, between rectus abdominis muscles - from xiphoid process to symphysis pubis, contains umbilicus
Location of Inguinal ligament
anterior superior spine of ilium to each side of pubis
Skeletal landmarks important in abdominal exam
xiphoid process, costal margin, iliac crest, anterior superior iliac spine (ASIS), symphysis pubis, pubic tubercle, inguinal ligament (attaches to ASIS, pubic tubercle); promontory (part of sacrum)
Important vascular structures in abdomen
abdominal aorta, common iliac arteries (umbilicus), splenic artery, renal arteries; celiac trunk (blood supply)
liver, gallbladder, small intestine (duodenum, jejunum, ileum), colon (cecum, ascending colon, transverse colon, descending colon, sigmoid colon), spleen, stomach, pancreas; kidneys, adrenal glands, ureters, bladder, uterus, ovaries, fallopian tubes; ,
Shape of stomach
Function of stomach
secretes HCl, digestive enzymes (pepsin - digests proteins, gastric lipase - emulsifies fats); very little absorption
Functional sections of the stomach
3 sections: fundus, body (mid 2/3), pylorus (most distal portion, narrows, terminates in pyloric orifice);
Vascular supply of the stomach
supplied by (gastroduodenal, L gastric, R & L gastro-omental, short gastric)
Size of liver
heaviest organ in body (~3 lbs in adults);
Function of liver
drains into bile duct --> hepatic duct --> cystic duct from GB to form common bile duct
Secretions of liver
liver cells secrete bile
Functional sections of the liver
four lobes - functional units;
Location of the liver
inferior surface touches gallbladder, stomach, duodenum, hepatic flexure of colon;
Vascular supply of the liver
hepatic artery (brings oxygenated blood directly from the aorta), portal vein (brings venous blood rich in products of digestion, absorbed directly from GI tract), venous return (3 hepatic veins carry blood from liver to inferior vena cava
Shape of gallbladder
sac-like, pear-shaped organ;
Size of gallbladder
~4 in long;
Function of gallbladder
concentrate & store bile from liver
Location of the gallbladder
recessed to inferior surface of liver;
Vascular supply of the gallbladder
supplied by cystic artery
Size of small intestine
21 feet long (duodenum = 12 in (1 foot), jejunum = 8 ft, ileum = 12 feet);
Function of small intestine
completes digestion by way of action of pancreatic enzymes, bile, several enzymes; nutrient absorption due to tremendous surface area from circular folds/villi
Functional sections of the small intestine
Duodenum; Jejunum; ileum
Vascular supply of the small intestine
superior mesenteric artery and branches
Size of colon
length 4.5-5 ft, diameter 2.5 in;
Function of colon
live bacteria (decompose undigested food residue, unabsorbed amino acids, cell debris, and dead bacteria --> putrefaction
mucus glands secrete large quantities of alkaline mucus (lubricate intestinal contents, neutralize acids formed by intestinal bacteria)
Functional sections of the colon
Cecum; ascending colon; hepatic flexure; transverse colon; splenic flexure; descending colon; sigmoid colon; rectum; anal canal
Vascular supply of the colon
inferior mesenteric artery and branches
Function of spleen
white pulp (makes up most of spleen, lymphoid tissue, part of reticuloendothelial system - fliters blood and manufactures lymphocytes & monocytes); red pulp (capillary network, venous sinus system, allows for storage and release of blood, permits to accommodate up to several mL at once)
Functional sections of the spleen
White pulp; red pulp
Location of the spleen
LUQ, above left kidney, below diaphragm;
Vascular supply of the spleen
supplied by celiac trunk- splenic artery, and splenic vein
Function of pancreas (exocrine)
exocrine function: acinar cells digest juices containing inactive enzymes for the breakdown of proteins, fats, carbs; pancreatic duct runs length of organ empties into duodenum at duodenal papilla, along common bile duct; in duodenum, digestive enzymes are activated
Function of pancreas (endocrine)
islet cells produce insulin, glucagon; secrete both into blood to regulate blood glucose levels
Secretions of the pancreas
Insulin; glucagon; digestive enzymes
Location of the pancreas
behind/beneath stomach; head resting in curve of duodenum; tip extending across the abodminal cavity to almost touch the spleen
Vascular supply of the pancreas
supplied by superior mesenteric and celiac trunk
Size of kidneys
>1 million nephrons per kidney
Function of kidneys
excretory organs, remove water-soluble waste;
Secretions of the kidneys
endocrine gland (produces renin - controls aldosterone secretion); primary source of erythropoietin; produces biologically active form of vit. D
Location of the kidneys
retroperitoneal space of upper abd; imbedded in fat/fascia; at T12-13; costovertebral angle formed by lower border 12th rib/transverse process of upper lumbar vertebrae; right sits slightly lower than left;
Vascular supply of the kidneys
1/8 cardiac output designated to kidneys via renal artery;
Function of ureters
carry urine to bladder from kidneys via peristolic waves
Vascular supply of the ureters
supplied by renal artery, aorta, gonadal (testicular or ovarian), common iliac, inf. Vesical, superior vesical arteries
Size of bladder
normal adult capacity 400-500ml;
Function of bladder
empties urine from body via urethra;
Location of the bladder
may be palpable above symphysis pubis if distended
Vascular supply of the bladder
supplied by superior and inferior vesical arteries (arise from internal iliac) and drain into internal iliac vein
Location of the uterus/ovaries/fallopian tubes
lower abd/pubic region; not readily palpable;
What is biliary colic?
sudden obstruction of cystic duct or common bile duct by gallstone
Describe common pain characteristics of biliary stones.
pain in epigastric or RUQ; may radiate to right scapula or shoulder; steady, aching, not colicky; rapid onset over a few min, lasts one to several hrs and subsides gradually, often recurrent
What are associated S/SX of biliary stones?
anorexia, N/V, restlessness
Describe common pain characteristics of ureteral pain.
severe and colicky, originating at CVA and radiating around trunk into lower quadrant of abd, possibly into upper thigh and testicle or labium.
S/SX associated with ureteral pain.
fever, chills, hematuria
Causes of ureteral pain
Results from sudden distention of ureter and associated distention of renal pelvis, often due to sudden obstruction of ureter by renal or urinary stones or blood clots
Know the correct positioning of the patient of the abd exam
supine, well-draped with exposure from just above xiphoid process to symphysis pubis, abd muscles relaxed, knees bent, arms at side, bladder empty
What are the three types of abdominal pain?
parietal, visceral, and referred
What are aggrevating factors of parietal pain?
aggravated by movement/coughing, pt prefers to lie still
9 Regions of abdomen
9 regions: epigastric, R&L hypochondriac, umbilical, R&L lumbar, hypogastric (pubic), R&L inguinal
Quadrants of abdomen
4 abd quadrants: RUQ, LUQ, RLQ, LLQ
Organs in RUQ
liver, gallbladder, pylorus, duodenum, pancreas head, hepatic flexure, ascending colon (portion), transverse colon (portion), upper pole of right kidney, right adrenal gland
Organs in RLQ
cecum, appendix, ascending colon (portion), right iliac artery, lower pole of right kidney, right ureter, right ovary, right fallopian tube, right spermatic cord, uterus (if enlarged), bladder (if enlarged)
Organs in LUQ
left lobe of liver, spleen, stomach, pancreas (body), uppoer pole of left kidney, left adrenal gland, splenic flexure, transverse colon (portion), descending colon (portion)
Organs in LLQ
lower pole of left kidney, sigmoid colon, descending colon (portion), left ovary, left fallopian tube, left ureter, left spermatic cord, uterus (if enlarged), bladder (if enlarged)
Organs in epigastric region
liver, stomach, pancreas, abdominal aorta
Organs in Umbilical region
Transverse colon; tip of pancreas
Organs in hypogastric/suprapubic region
sigmoid colon, urinary bladder, uterus
Which organs are typically palpable?
Palpable: sigmoid colon, portions of transverse and descending colon, lower liver margin (below right costal margin), R kidney, lower pole, abd aorta, iliac arteries, distended bladder, uterus, xiphoid process
Which organs are typically nonpalpable?
NOT easily palpable: liver, stomach, spleen (NL size; 9-11th ribs, mostly posterior to left axillary line behind stomach above kidney, against diaphragm), gallbladder, duodenum, pancreas
loss or lack of appetite; qualify by asking if pt has: intolerance to certain foods, reluctance to eat 2ﾰ anticipated discomfort; ask about associated symptom: N/V, early satiety (related ds: hepatitis, gastric CA, anticholinergic meds, diabetic gastroparesis, gastric outlet obstruction); consider dietary assessment or consult
buring retrosternal pain; caused by abnormal refulx of acid from stomach into esophagus; symptom of GERD; radiate from epigastrium to neck; originates in esophagus; aggravated by certain foods that relax LES (chocolate, alcohol, coffee, peppermint, citrus fruits); aggravated by postural changes (lying supine, bending over)
distress associated with eating; characterized by sense of: fullness, heartburn, discomfort, excessive belching, flatulence, lack of appetite, severe pain; location: localized/general, radiates to arms or shoulders; associated with: food intake, timing of food intake, amount, type; onset of s/sx: day or night, time, sudden vs. gradual; alleviate: meds: Rx or OTC
sensation of unease and discomfort in the stomach associated with an urge to vomit; stimuli: odors, activites, time of day, food intake; for female: date of LMP (pregnant?)
forceful expulsion of gastric contents out through mouth; character: nature (color - fresh blood, coffee grounds/blood in stomach/GI, undigested food), quantity, duration, frequency, solids, liquids, both; relationship: previous meal, change in appetite, diarrhea/constipation, weight loss, abd pain, meds, headache, nausea, date of LMP
brownish/black or bright red vomitus; "coffee ground" appearance suggests blood altered by gastric acid - older blood
bright red or maroon colored blood in stool; lower GI bleeds; rapidly bleeding upper GI bleeds (10%); BELOW Ligament of Treitz
black, tarry stools; results from digested blood; upper GI bleed; small bowel, right-sided colonic bleeds; other causes: Bismuth subsalicylate, Iron, spinach, charcoal, licorice, commerical chocolate cookies; ABOVE Ligament of Treitz
difficulty swallowing; sensation of food or liquids sticking or hesitating or "won't go down right;" differentiate if problem with solids or liquids or both; solids - mechanical narrowing; both - motor disorders; ask pt to point to where problem occurs
What is retching?
retching: "heaving," spasmodic movements of chest and diaphragm that force gastric and/or duodenal contents into esophagus but not into pharynx; may proceed vomiting if upper esophageal sphincter (UES) remains closed; if UES is open vomiting occurs; usually caused by a bad smell or chocking
What is regurgitation?
regurgitation: controlled return or flow of stomach contents back into esophagus or mouth; usually without N/V or retching; occurs in GERD, esophageal stricture, and esophageal cancer
What are the different causes of jaundice?
1) intrahepatic or hepatocellular; 2) extrahepatic
What causes intrahepatic/hepatocellular jaundice?
damage to hepatocytes, impaired excretion as a result of damaged hepatocytes or intrahepatic bile ducts
What causes extrahepatic jaundice?
arises from obstruction of extrahepatic bile ducts - cystic duct, common bile duct
What are the s/sx of jaundice?
stool color (gray or light colored - occurs when complete obstruction of excretion of bile into intestine), urine color (tea colored, coca-cola - increased level of conjugated bilirubin (excreted into urine), unconjugated bilirubin (not water soluble, so not excreted in urine)), pruritis, pain
What is jaundice?
(icterus); yellowish discoloration of skin and sclera; result of increased bilirubin levels; MoA: increased production of bilirubin, decreased uptake of bilirubin by hepatocytes, decreased excretion of bilirubin into bile (absorption of conjugated bilirubin back into blood)
What are causes of jaundice?
risk factors for liver disease: Hepatitis A (poor sanitation or in food), Hep B and C (parenteral/mucus membrane exposure to infectious body fluids, shared needles), Alocholic hepatitis/ cirrhosis, toxic liver damage (meds, industrial solvents, environmental toxins), gallbladder disease or surgery (extrahepatic biliary obstruction), hereditary disorders
What history information is needed for CC of jaundice?
onset/duration; color of stools; color of urine; associated with: abd pain, chills, fever; exposure to hepatitis; meds: Rx or OTC (acetaminophen), recreational drug use
Describe visceral pain in the abdomen.
difficult to localize; palpable near midline at levels that vary according to structure involved; quality: gnawing, burning, cramping, aching; associated symptoms: sweating, pallor, N/V, restlessness
Describe parietal pain in the abdomen.
originates in parietal peritoneum, typically associated with inflammation; characteristics of pain: steady, aching, more severe than visceral, more precisely localized over involved structure
Describe referred pain in the abdomen.
felt in more distant sites (innervated at approximately the same spinal levels of the disorded structure, develops as initial pain intensifies, superficial or deep, well localized, may be referred to abd from: chest, spine, pelvis; Right shoulder pain can be referred symptom of cholecystitis. Back pain can result from duodenal or pancreatic origin.
What organs are common causes of visceral pain in the abdomen?
hollow abd organs (intestines or biliary tree) contract unusually forcefully or become distended or stretech; solid organs (ie liver) painful when capsules are stretched
What organs are common causes of referred abdominal pain?
Pain may be referred to abd from chest, spine, pelvis (ex. Pleurisy or inferior wall MI referred to epigastric area)
What organs are common causes of parietal pain in the abdomen?
Later stages of appendicitis due to inflammation of adjacent parietal peritoneum
Know the common organs/ organ types associated with each type of abd pain
RUQ: biliary tree or liver; epigastric: biliary tree, liver, stomach, duodenum or pancreas; periumbilical pain: SI, appendix or proximal colon; hypogastric: colon, bladder, or uterus; suprapubic: rectum
sudden, compelling urge to urinate
difficulty starting or maintaining a urine stream
need to urinate more often than usual
excessive production and discharge of urine
excessive urination during the night
dribbling after the completion of urinating
What are the 4 kinds of incontinence?
1) stress; 2) Urge; 3) Overflow; 4) Total
What is stress incontinence?
a spurt-like leakage of urine during moments of physical activity, such as coughing, sneezing, laughing, jumping, or exercise and with walking, chaning position from sitting to standing, or with sexual activity
What is urge incontinence?
strong, sudden need to urinate due to bladder spasms or contractions
What is overflow incontinence?
Happens to individuals with difficulty passing urine, which causes a permanently full bladder. As urine is continually produced, excess spills out of urethra like a dam overflowing.
What is total incontinence?
Continuous leakage of urine due to complete and total loss of urinary control.
S/SX of flank pain
pain in the CVA region
S/SX of suprapubic pain
pain located superior to pubic tubercle
Know the order of abdominal examination
inspection, auscultation, percussion, palpation (light, deep)
Know what to evaluate with abd inspections and what each possible finding indicates
surface, contours, movements of abd-peristalsis, symmetry; scars; dilated veins; striae; rashes; ecchymoses; color changes; umbilicus location, contour, inflammation, bulges; flanks bulge; local bulges; inguinal/femoral areas observed; visible masses or organs
What color are new abdominal striae? What do they indicate?
Pink - new mass, Cushing's syndrome/disease, pregnancy
What conditions are suspected when extensive dilated veins are observed on abdomen?
hepatic cirrhosis, inferior vena cava obstruction
What information should be recorded about scars?
What do scars on the abdomen indicate?
previous surgery cound indicate adhesions or hernia
What conditions are suspected when abdominal color changes are observed?
jaundice, periumbilical disocloration may be sign of intraabdominal bleeding
What characteristics of the umbilicus should be inspected?
Contour (inverted or everted); Location; Inflammation; Bulges
Describe frequently observed abdominal contours.
NL - rounded with max height of convexity at umbilicus, Flat - well-muscled, athletic Rounded - young children, adults with subQ fat, poor muscle tone from inadequate exercise Scaphoid - concave (in very thin adults)
Which organs may have visible masses or boundaries on the abdomen, especially in pathology?
Liver, spleen, uterus, bladder
How peristalsis inspected on the abdominal surface?
tangential lighting will illuminate contour and visible peristalsis, observe for several minutes (increases in obstruction, visible in extremely thin people); pulsations: aortic pulsations are normally visible in epigastrium, abnormally large pulsatoins could be aortic aneurysm
When should the abdomen be auscultated? Why?
Auscultate BEFORE palpation and percussion or bowel sounds will be increased and falsely altered
What sounds are normal in the abdomen?
Bowel sounds (gurgling); Borborygmi (long, prolonged, low-pitched rumbles of stomach growling or the movement of gas through the intestines); gastic bubbles
What are some abnormal sounds in the abdomen?
Bruits, splenic, hepatic, or gastric friction rubs,
What bruits may be heard in the abdomen?
aorta, iliac artery bilaterally, femoral artery bilat, commonly systolic, in supine position listen (epigastrium, each quadrant), hepatic bruit (CA/hepatitis)
What can a hepatic or splenic rub indicate?
iver tumor, gonococcal/chlamydial perihepatitis, recent liver biopsy, splenic infarct
Describe the frequency and character of normal bowel sounds.
frequency: 5-34/min (every 3-5 sec); character: high-pitched gurgles, clicks; auscultate in 4 quadrants
Describe conditions that are indicated by increased bowel sounds.
diarrhea, early intestinal obstruction
Describe conditions that are indicated by decreased/absent bowel sounds.
adynamic ileus, peritonitis
Describe abnormal bowel sounds.
high-pitched tinkling with cramp; rushes of high-pitched sounds with cramping; absent bs
What causes high-pitched tinkling with cramps in the abdomen?
intestinal fluid, air under tension in dilated bowel
What causes rushes of high-pitched sounds with cramping?
How long should you listen for absent bowel sounds?
at least 2 min
Two types of abdominal palpation
Light, then deep
Purpose of light abdominal palpation
useful to ID - abd tenderness, muscular resistance (involuntary rigidity - peritoneal inflammation), some superficial organs/masses; reassures and relaxes pt
How can you differentiate between superficial and intraabdominal (deep) masses?
Ask patient to do a crunch. Masses felt while patient contracts muscles are superficial. Masses that cannot be palpated are deep.
Purpose of deep abdominal palpation
delineate abd organs, detect less obvious masses. In 4 quadrants ID any masses:
When is tenderness to deep palpation normal?
deep palpation may percipitate tenderness in a healthy person over the: cecum, sigomid colon, aorta, midline near xiphoid process
What normal findings of deep palpation are often mistaken for masses?
feces within colon (soft, rounded, boggy mass in cecum, ascending, descending or sigmoid colon), lateral borders of rectus abdominis muscles, uterus, aorta, sacral promontory, common iliac artery
What should be noted about abdominal masses?
Quadrant or region; location, size, shape, consistency, tenderness, pulsations, mobility, movement with respiration or examiner's hand; correlation with percussion
Tips for palpating abdomen
Ways to relax abdomen - pt bends knees, mouth breathes reasons pt tightens abd - provider's hands cold, ticklish, inflammation If you know of a problem area palpate that last!
What percussion notes may be heard in the abdomen?
Tympany, hyperresonance; resonance; dullness
musical note of higher pitch than resonance (over air-filled viscera)
hyperresonance - pitch between tympany & resonance (heard at base of left lung)
sustained note of moderate pitch (over lung tissue, sometimes over abd)
short, high-pitched note with little resonance (over solid filled organs adjacent to air-filled structures)
What percussive sound is predominant in the abdomen? Why?
tympany predominates due to air in stomach and intestines
When or where is dullness heard in the abdomen?
Scattered areas of dullness typically from fluid of ascites, feces, organs/solid masses
Why should dull areas be noted?
Often indicative of underlying masses, enlarged organs; abnormal percussion findings guide palpation (pay special attention to those areas); protuberant abd (note tympany that changes to dullness bilaterally - ascites)
How is the liver edge palpated?
Hooking technique or direct palpation, ask pt to take deep breath (with abd not chest) in and feel for liver edge as it comes down to meet your fingertips (~3 cm below right costal margin in MCL)
What is a normal finding for the liver edge?
NL is soft, sharp, regluar and smooth
What does an abnormal liver edge feel like?
firmness or hardness, bluntness or rounding of edge, irregular contour.
Describe the typical locations of the superior and inferior liver borders.
upper border usually 5-7th ICS
Why is the liver percussed?
To test for hepatomegaly or liver atrophy
How is the vertical span of the liver measured? What is the normal range?
Percuss inferior border to point of dullness; then the superior border to the point of dullness. vertical span is 4-8 cm midsternal line; 6-12 cm in right MCL; typically underestimates actual size but most accurate clinical method.
Describe liver size in relation to gender and height.
NL liver size: men > women, taller > shorter
What does downward displacement of the liver suggest?
What does upward displacementof the liver suggest?
abd fluid or masses
How is the spleen palpated?
palpation with left hand reaching over and around pt to support and press forward lower left rib cage and adj soft tissue and right hand below left costal margin pressing in toward spleen - may be palpable below costal margin
Describe percussion of the spleen.
replaces tympany of stomach & colon with dullness; enlarges (expands anteriorly, downward & medially)
What should be noted about splenic palpation?
tenderness, splenic contour, measure distance between spleen's lowest point and left costal margin, tip of spleen palpable in small % NL adults
How can splenomegaly be detected?
2 techniques to detect splenomegaly: 1) percuss left lower anterior chest wall (Traube's space) and if tympany prominent (esp laterally) then splenomegaly unlikely 2) check for splenic percussion sign by percussing lowest ICS in L anterior axillary line (tympanic) then ask pt to take deep breath and percuss again
What is a positive sign of splenomegaly during percussion?
change in percussion note from tympany to dullness on inspiration (splenomegaly)
What is a normal (negative) sign of spleen size during palpation?
NL spleen percussion note remains tympanic when percussed with inspiration
Are the kidneys always palpable?
No. They are retroperitoneal organs that are largely protected by ribs. Inferior pole of right kidney will be most likely palpable because it is lower in the abdomen due to the liver.
If kidneys are palpable, what should be noted?
size, contour, tenderness
Describe the how to capture a kidney.
1) Stand on pt's side; 2) place your opposite hand (ex. right hand if on the left side) behind pt just below and parallel to 12th rib with fingertips just at CVA; 3) lift to displace kidney anteriorly; 4) gently place your hand (left if on left side) in LUQ lateral and parallel to rectus muscle; 5) ask pt to take deep breath in; 6) at peak of inspiration press your left hand firmly/deeply into LUQ just below costal margin, "capture" kidney; 7) ask pt to exhale then stop breathing briefly; 8) slowly release pressure of top hand to feel for kidney to slide back into expiratory position
What are some causes resulting in positive CVA tenderness?
pain with pressure of fist percussion: Pyelonephritis, musculoskeletal cause
How is CVA tenderness evaluated?
try pressure from your fingertips first, but may not elicit pain, then use fist percussion, use enough force to cuase a perceptible but painless jar or thud in NL person
What does CVA tenderness evaluate?
Know how to palpate and measure the aorta, which pt population is this most appropriate in
firmly press deep in the upper abdomen, slightly to left on midline; identify aortic pulsations. Assess width of aorta by pressing deeply in upper abd with one hand on each side of aorta;
In which patient population should the aortic width be measured?
in pts >50 yo NL is no larger than 3 cm
What pathologic conditions are screened by aortic palpation?
aortic aneurysm: pathological dilation of aorta, due to arteriosclerosis, usually painless, hearld of dreaded/frequent complication (rupture of aorta); torturous abd aorta: difficult to distinguish from aneurysm clinically. Apparent enlargement indicates urgent ultrasound evaluation!
What conditions are associated with muscle rigidity?
early voluntary guarding becomes involuntary muscular rigiditiy in appendicitis; Also associated with perforated gastric or duodenal ulcer
What is muscle rigidity?
involuntary (muscle spasm), indicates peritoneal inflammation
What conditions are associated with symmetric abdominal distension?
obesity, organomegaly, fluid or gas
A distended upper 1/2 of abdomen is a sign of what conditions?
carcinoma, pancreatic cyst, gastric dilation, epigastric hernia
If the abdomen is distended from the umbilicus to symphysis, it can be indicative of what conditions?
ovarian tumor, pregnancy, uterine fibroids, bladder distention
Asymmetric abdominal distention is a sign of what conditions?
hernia, tumor, cysts, bowel obstruction, abd organomegaly, abd aortic aneurysm (AAA), lipoma
What is Row-Howship sign?
pain down medial aspect of thigh to the knees with internal rotation of the hip
What condition is associated with the Row-Howship sign?
How much fluid is typically retained by women? By men?
healthy women have up to 20ml, healthy men have almost none
What is ascites?
pathologic accumulation of fluid in peritoneal cavity
What is the cause of ascites in the majority of patients? What is the percentage associated with this?
>80% pts with ascites from portal HTN secondary to chronic liver disease
What are other causes of ascites?
peritonitis, intra-abdominal malignancy, hypoalbuminemia, and ductal disruptions
What are S/SX of ascites?
non-specific abd discomfort, weight loss associated with increased abd girth, N/V;
What history information is important when ascites is present?
EtOH use, weight loss
How do you elicit rebound tenderness?
palpate deeply and slowly in abd area away from suspected area of local inflammation, then quickly remove palpating hand; Ask pt "which hurts more, now (while pressing) or now (during release)?"
Describe positive rebound tenderness. What does this suggest?
the sensation of pain on the side of inflammation that occurs on release of pressure suggests inflammation; if tenderness is felt elsewhere - that area may be the 'real' source of the problem.
What is a Blumberg sign?
rebound tenderness - associated with peritoneal irritation, appendicitis
What conditions are associated with rebound tenderness?
Appendicitis (RLQ pain due to peritoneal inflammation); perforated gastric or duodenal ulcer; acute pancreatitis; peritonitis
What does the shifting dullness test assess?
Describe the shifting dullness test.
Map borders of tympany and dullness with pt in supine, ask pt to turn onto on 1 side.
What are normal (negative) results of a shifting dullness test? What are abnormal (positive)?
Negative - No ascites if tympany and dullness are constant. Positive - ascites if dullness shifts to more dependent side and tympany shifts to the top.
What signs are suggestive of ascites during inspection?
protuberant abd with bulging flanks (ascitic fluid sinks with gravity)
Describe the fluid wave test for ascites.
requires 3 hands, pt in supine, ask pt to press edge of hand and forearm firmly along vertical midline of abd, place both of your hands on each side of the abd and tap one flank (sharply, with fingertips); feel on opposite flank for an impuse transmitted through the fluid;
What findings may result from the fluid wave test?
Positive - fluid wave hits opposite hand due to fluid accumulation; False negative - often occurs until ascites is obvious; False positive - due to obesity
What is the most common emergency surgery among people 10-30 years old? What percentage of the popuation is affected?
Appendectomy; 7% population
What is appendicitis?
acute inflammation of the appendix from obstruction
What are the potential causes of appendicitis?
may be fecalith, foreign body or neoplasm;
Describe the classic pain/presentation of appendicitis.
mild crampy colicky pain beginning periumbilical or epigastric; shifts to RLQ within 12 hrs, often at McBurney point; becomes steady ache that worsens with walking or coughing
What are some associated S/SX of appendicitis?
anorexia, N/V, low-grade fever; high fever or rigors suggest perforation
List specific physical examination tests used in evaluating for appendicitis.
Cutaneous hypersthesia; Rovsing's sign; Psoas sign; obturator sign; Markle sign; McBurney; rectal exam (right-sided rectal tenderness)
Describe general physical examination techniques/finding suggesting appendicitis.
ask pt to point to: where pain began, where it is now; ask pt to cough (increases RLQ pain, younger pts > older pts); localized tenderness (in any part of RLQ); muscular rigidity.
Describe cutaneous hyperesthesia.
perform at a series of points down the abd wall; gently pick up a fold of skin between your thumb and index finger, without pinching it; normal: not painful; abnormal: localized pain in RLQ may accompany appendicitis
Describe how to elicit Markle sign.
pt stands with straightened knees, raises up on toes, relaxes and allows heels to hit floor and jar body. Positive Markle sign = positive abd pain. Alternative: heel strike. Markle sign associated with peritoneal irritation, appendicitis
What conditions may elicit right sided rectal tenderness during a rectal exam?
appendicitis, inflamed adnexa, seminal vesicle
What is acute choleocystitis?
inflammation of the gallbladder
What causes acute choleocystitis?
>90% from obstruction of the cystic duct by gallstone
What S/SX are associated with acalculous choleocystitis?
RUQ pain and fever within 2-4 weeks of sx
What are usual pain characteristics for acute cholecystitis?
steady, aching pain in RUQ or epigastric area; pain may radiate to right scapular area; acute onset which subsides over minutes to hours then returns
What are some possible associated findings when acute choleocystitis is present?
RUQ tenderness, + Murphy sign (see below), palpable gallbladder, anorexia, N/V, fever, possible jaundice
What is PUD?
ulcer in stomach or duodenum;
What are S/SX of PUD?
dyspepsia similar s/sx without ulcer; involves both anterior & posterior walls (abd tenderness on palpation suggests anterior wall ulcers)
What are possible causes of PUD?
Helicobacter pylori may be present;
What are pain characteristics associated with PUD?
variable gnawing, burning, boring, aching, pressing or hungerlike; epigastric pain that may radiate to back
Does PUD occur more often in women or men? What is the associated ratio?
What is a diverticulum?
a saclike mucosal outpouching through the colonic muscle; most are asymptomatic
What is diverticulitis?
What causes diverticulum?
pouches may form when high pressure pushes against weak spots in the colon where blood vessels pass though muscle layer of the bowel wall to supply blood to the inner wall; usually due to a low fiber diet
What portion of the colon is most susceptible to formation of diverticulum?
most often involves sigmoid colon
What are common pain characteristics associated with diverticulitis?
crampy then steady ache in LLQ; mild to severe dx with perforation/peritonitis
What are other S/SX and history associated with diverticulitis?
other s/sx include: N/V, fever, loose stool or constipation, Hx of chronic constipation and low fiber diet, stool occult blood common
What is acute pancreatitis?
acute inflammation of the pancreas
What are pain characteristics associated with acute pancreatitis?
abrupt onset of steady deep and boring epigastric pain that may be severe; often radiates to back or left shoulder; lying supine and walking increases pain; sitting and leaning forward with flexed trunk may help
What are other S/SX and history associated with acute pancreatitis?
N/V, weakness, sweating, abd pain/distention, fever, shock; pertinent Hx includes: previous attacks, alcohol abuse, gallstones, celiac dx, obesity, smoking
What physical exam findings are likely with acute pancreatitis?
epigastric tenderness, rebound tenderness, upper abd mass due to enlarged pancreas, distened abd, jaundice if related to biliary dx, positive grey turner sign/cullen's sign
What is an acute bowel obstruction?
obstruction of bowel lumen
What are common causes of acute bowel obstructions?
adhesions, hernias, cancer, diverticulitis; types: strangulated, volvulus, intussusception
What are usual pain characteristics for acute bowel obstructions?
abrupt, crampy, severe, spasmodic, referred to epigastrium & umbilicus
What are possible associated S/SX and history for acute bowel obstructions?
possible associated s/sx include: distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis, absence of flatulence, bowel sounds (absent with paralytic obstruction, hyperactive high-pitched with mechanical obstruction)
What is the Dance sign? What condition is it associated with?
absence of bowel sounds in RLQ - associated with intussusception resulting in acute bowel obstruction
What is intussusception?
the slipping of a length of intestine into an adjacent portion usually producing obstruction
What are common S/SX of GERD?
heartburn, acid reflux, regurgitation (waterbrash - bitter or sour taste of acid in back of throat), cough, chronic ST, laryngitis for >1 wk
What is GERD?
Gastroesophageal reflux disease - relaxation or incompetence of LES which results in backwards flow of acid from stomach up into esophagus
In which populations is GERD most prevalent?
pregnant women; elderly, and obese people
What are less severe complications associated with GERD?
respiratory problems (chronic cough, sore throat, asthma, chronic laryngitis, noncardiac chest pain), esophageal bleeding, dysphagia
What are more severe complications associated with GERD?
Barrett esophagus: seen in up to 10% of pt with chronic reflux; most pts present with long hx of reflux; precursor to esophageal adenocarcinoma
What is Barrett espophagus?
chronic reflux injures the esophageal squamous epithelium;
What are alarm symptoms for GERD?
dysphagia, odynophagia, recurrent vomiting, GI bleed, wt loss, anemia; risk fx for gastric CA, palpable mass, or jaundice;
When should endoscopy be performed in GERD patients?
failed empiric therapy, pts >55, and those with alarm symptoms warrant endoscopy
5% pts with GERD develop stricture formation secondary to scarring; s/sx gradual development of solid food dysphagia; may have reduction in heartburn as stricture acts as barrier to reflux
What are typical pain characteristics of a perforated gastric or duodenal ulcer?
abrupt RUQ, may be referred to shoulders;
What are possible associated findings for a perforated ulcer?
abd free air & distension with increased resonance over liver, tenderness in epigastrium or RUQ, rigid abd wall, rebound tenderness
What is peritonitis?
inflammation of the peritoneum;
What are causes of peritonitis?
most common cause is perforation of GI tract; other causes include appendicits/cholecystitis;
What are the pain characteristics of peritonitis?
pain may be (sudden or gradual onset, generalized or localized, dull to severe/unrelenting)
What are S/SX of peritonitis?
s/sx include: positive cough test, guarding (voluntary contraction), rigidity (persistent involuntary reflex contration - makes peritonitis 4x more likely, abd rigidity diffuse in generalized peritonitis), rebound and percussion tenderness, nausea with loss of appetitie very common, reduced bowel sounds
What tests may be positive if peritonitis is present?
Blumberg; Markle; Balance; Obturator; Iliopsoas
What is the Balance sign?
dull percussion in both flanks; constant on left, but shifts on right with positional change; due to coagulated blood on left/liquid blood on right - associated with ruptured spleen
What symptoms have an acute onset when a UTI is present?
dysuria, frequency, urgency, nocturia; hematuria;
What PE findings are common with a UTI?
suprapubic tenderness, CVA tenderness, or both
What DDX should be considered in a female UTI?
vaginitis, STD urethritis, urethral syndrome (symptoms of UTI without infection), interstitial cystitis (what is usually referred to as an UTI, typically E. coli)
What DDX should be considered in a male UTI?
bladder stones/tumors, prostatitis, prostatodynia, urethritis (gonoccocal, nongonococcal, bacterial), epididymitis (intrascrotal infection)
What is pyelonephritis?
infection of kidney & renal pelvis (progression from untreated UTI)
What pain characteristics are common with pyelonephritis?
dull, achy, steady pain; may radiate anteriorly towards umbilicus
What are associated S/SX of pyelonephritis?
flank pain, frequency, dysuria, nocturia, fever, CVA tenderness, bacteriuria, pyuria, N/V, pregnancy
What are possible associated findings related to renal calculi?
fever, N/V, hematuria, + Kehr sign
What are usual pain characteristics associated with renal calculi?
intense pain with sudden onset localized to flank; as stone moves down ureter, pain may radiate around abd to groin and into ipsilateral testis or labium; may be episodic; pt can't sit still; no sign of infection
What S/SX are associated with PUD?
upper GI bleeding can occur as a result of ulceration (hematemesis, melana, dizziness, syncope, decreased BP, increased pulse, decreased hematocrit);
When is PUD a medical emergency?
When an ulcer perforates
What ulcer location is most likely to perforate?
What ulcer location is most likely to bleed?
What are common findings of duodenal and gastric ulcers?
most common; more likely than gastric ulcers to: waken pt at night, cause intermittent pain, disappear for months then reoccur, be relieved by food and antacids, reoccur 2-3 hrs postprandial or before the next meal, be seen in 30-60 yr olds, high stress environments
What is a Cullen sign?
ecchymoses around umbilicus
What conditions may elicit a positive Cullen sign?
Peritoneal irriation; pancreatitis; ectopic pregnancy
What should be suspected if positive Grey-Turner and Cullen signs are present? When would these present?
pancreatic necrosis with retroperitoneal or intraabdominal bleeding; both signs may occur 2-3 days after onset of pain
What is the Grey-Turner sign?
bruising of the flanks (hemorrhaging)
What conditions are associated with a positive Grey-Turner sign?
How long does it take for a positive Grey-Turner sign to appear?
sign takes 24-48 hrs to appear
Why is a positive Grey-Turner sign concerning?
predicts a severe attack of acute pancreatitis with mortaility rising from 8-10% to 40%
What is a positive Kehr sign?
classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the clavicle; more specifically, abd pain radiates to left shoulder
What conditions are associated with a positive Kehr sign?
Renal calculi; splenic rupture; ectopic pregnancy
What is a positive McBurney sign?
rebound tenderness & sharp pain with palpation of McBurney point (located approximately over the appendix in RLQ)
What condition is most typically associated with a positive McBurney sign?
What is a positive Aaron sign? What condition is it associated with?
referred pain in epigastrium with palpation at McBurney's point - associated with appendicitis
How is Murphy's sign evaluated?
place right hand under costal margin (over gallbladder), ask pt to take a deep breath and press upward.
What indicates a positive Murphy's sign?
a sharp increase in tenderness with sudden stop in inspiratory effort
What condition is associated with a positive Murphy's sign?
How is the obturator sign evaluated?
pt lies on back with right hip flexed at 90ﾰ; examiner then holds pt's right ankle in right hand; with left hand the examiner externally rotates the hip by pulling the right knee to and away from the pt's body.
What is a positive obturator sign?
right hypogastric pain
What test uses the "Figure 4"?
How does the process of eliciting an obturator sign work?
stretching obturator internus muscle contracts an inflamed and enlarged appendix; pain is elicited for positive obturator sign
What condition is associated with a positive obturator sign?
What condition is associated with a positive psoas sign?
How does the process of eliciting an psoas sign work?
pain results because iliopsoas muscle borders peritoneal cavity; stretching the muscle by hyperextending the hip or contraction by flexion of the hip causes friction against nearby inflamed tissues
Describe the process of eliciting the psoas sign.
1st method: passively extending thigh of a pt lying on their side with knees extended. If abd pain results, it is a "positive psoas sign". 2nd method: place your hand just above pts right knee; ask pt to raise right thigh against your hand. Pain with flexion is positive psoas sign.
What conditions are associated with positive Rovsing's sign?
peritoneal irritation, apppendicitis
Describe the process of eliciting the Rovsing's sign.
press deeply/evenly in LLQ; quickly withdraw fingers;
What is a positive Rovsing's sign?
Pain in RLQ during left-sided pressure suggests appendicitis