Abdominal ExaminationTranscribed from the lecture of Dr. NgoSection D 2011 - Mikey Silverman

Surface Anatomy Epigastric/Periumbilical/Suprapubic

Internal Anatomy Based on 9 regions (See Box 17-1 pg 534 Mosby 6th Edition) Hepatic flexure Splenic flexure Head/body/tail of pancreas

Physical Examination of the Abdomen Inspection

Contour Flat, globular

Symmetry Equal contour, shape, bulging effect on left, right, top, bottom

Scars, veins, skin discoloration Can aid you by indentifying past medical histories (appendectomy

scar) Caput medusa Check for scar, hernia, rash, striae

Pulsation Dependent on thickness of abdominal musculature Should be examined based on internal anatomy

Peristalsis Movement of the intestinal structures

Umbilicus Inverted/everted, umbilical herniation

Auscultation – lightly put steth and listen Bowel sounds

Listen for 5 minutes to determine absence of bowel sounds Bruits – sites where u can listen for bruits

Main abdominal aorta Right/left renal artery Right/left iliac arteries

Succusion splash – put steth epigastric or periumbilical, hold steth with both hands, jarring patient left to right to listen for splash (+) splash – there is partial or complete form of gastric obstruction When do you do succusion splash? (inaccurate after meals) after

overnight fasting Friction rub – solid organs if movement with respiration

Percussion – tympanitic (percussion note of abdomen) Measure liver/spleen

normal liver: 6-12 cm (<6 – atrophy) (>12 – hepatomegaly) Spleen – resonant; dullness – splenomegaly (obliterated Traub’s

space 9th ICS) Identify air in the stomach/bowel Identify solid or fluid filled masses

Ascites – water = dullness Shifting dullness – create imaginary line at dullness, shift patient

and determine dullness; area of tympani will change Identify ascetic fluid

Palpation - Parietal side – pain sensitive; initially light palpation, do pain sensitive area last; bimanual examination Tenderness (direct/rebound) – patient will grimace if tender Masses Liver – smooth and nodular/irregular/enlarged liver surface Spleen Kidneys Gallbladder

Rectal examination Left lateral decubitus position (knees flexed) Examine anal opening, any masses, abscesses, hemorrhoids Apply lubricant Go sacral before straight to create comfortable exam Male - Palpate prostate gland Female - Feel for cervix

Clinical Findings Acute Appendicitis Acute Cholecystitis – inflamed gallbladder; Murphy’s sign

Palpable gallbladder – Hydrops Courvoisier’s gallbladder (if gallbladder is palpable)

Costovertebral tenderness (kidney) – one hand on backside, hit lightly Ask patient to flex, if mass is still there abdominal wall mass

Intraabdominal mass will disappear Rebound tenderness – moving back to original position? Psoas sign – ask patient to lie in supine position; lift/flex hip; apply

gentle pressure on thigh (+) = slight tenderness

Obturator sign – lie in supine position; flex at thigh; flex knee, turn thigh laterally, ankle medially Irritate obturator area Acute appendicitis

Abdominal Masses Abdominal wall masses Intraperitoneal Extraperitoneal

Surgical Incisions Right subcostal incision Midline incision Paramedian incision Suprapubic incision Hernia repair Appendectomy scar

History Taking of Patients with GI ComplaintsTranscribed from the lecture of Dr. Ngo

Section D 2011 - Mikey Silverman

Symptoms Abdominal pain Dysphagia Heartburn Nausea, vomiting Altered bowel habits (diarrhea, constipation) GI bleeding Jaundice

Symptom timing can suggest specific etiologies Short duration

Acute infection Toxin exposure Abrupt inflammation or ischemia

Long standing symptoms Underlying chronic inflammatory condition Neoplastic process Functional bowel disorder

Symptom in relation to meals Aggravated

Mechanical obstruction Ischemia Inflammatory bowel disease Functional bowel disorders

Relief Ulcer pain

Pattern & duration may suggest underlying etiologies Intermittent intervals lasting weeks to months

Ulcer pain Sudden onset & lasts up to several hours

Biliary colic Severe pain & persists for days to weeks

Acute inflammation – acute pancreatitis Association of GI symptoms with bowel movement

Meals eliciting diarrhea IBD, IBS

Relief with defecation IBD, IBS

Diarrhea that improves with fasting Malabsorption

Diarrhea that persists with fasting Secretory diarrhea

Symptoms in relation to other factors History of previous abdominal surgeries

Obstructive symptoms Adhesions

Loose stools after gastrectomy Dumping syndrome

Gallbladder excision Post-cholecystectomy diarrhea Enzymes found or produced in gallbladder – cholecystokinin, etc.

History of recent travel symptoms in relation to other factors Search for enteric infection (E. Coli – most common traveler’s

diarrhea) Intake of medications or food supplements

May produce pain, altered bowel habits, or GI bleeding Sexual history/Orientation/Practice

Sexually transmitted diseases

Immunodeficiency Past Medical History

GI disorder PUD Polyps Inflammatory bowel disease Intestinal obstruction Pancreatitis

Hepatitis or Cirrhosis (Most common representations: jaundice, abdominal enlargement)

Abdominal surgery (higher frequency to develop adhesions) Major illness

Cancer Metastatic in origin - most common malignancy in liver

Arthritis – joint inflammation Steroids or aspirin

Reasons for ascites Kidney disease Cardiac disease Check for shifting dullness, puddle sign

Blood transfusions, previous surgeries Hep B, Hep C

Hepatitis vaccines Eliminate hepatitis as the cause of jaundice

Colorectal cancer Liver – most common site of metastasis

Other cancers Breast Ovarian Endometrial

Family History Gallbladder disease Kidney disease

Renal stone Polycystic disease Renal tubular acidosis Renal/bladder CA

Familial colorectal cancer syndromes Familial adenomatous polyposis Hereditary non-polyposis colorectal cancer

Colorectal cancer Personal & Social History

Nutrition / Diet Food preference / dislikes Food restrictions / intolerance 24 hour recall of food intake Weight gain or loss

Alcohol intake Frequency Type Usual amount

Significant alcohol intake Female - 60-80 g/day Male - 80-100 g/day

Exposure to infectious diseases Hepatitis Flu Travel history

Use of club/recreational/intravenous drugs Smoking history

Amount Duration Pack years

Significant – 7-10 pack years 20 sticks per pack 10 sticks per day (.5 packs per day) = 4 pack years

Frequency Dysphagia

Difficulty of swallowing A sensation of “sticking” or obstruction of the passage of food through

the mouth, pharynx, or esophagus Types

Oropharyngeal Esophageal

Oropharyngeal dysphagia Results from impairment of the voluntary effort required in bolus

preparation or neuromuscular disorders affecting bolus preparation Impairment of swallowing reflex

Neuromuscular disorders Cortical & suprabulbar disorders Lesions

Esophageal In adults, esophageal lumen can distend up to 4 cm in diameter

If cannot dilate beyond 2.5 cm in diameter, dysphagia to normal solid food can occur

If cannot distend beyond 1.3 cm, dysphagia always present Carcinoma, strictures, esophageal ring

Timing

Acute or gradual Inflammatory process

Intermittent, episodic Esophageal ring

Slowly progressive (over months, years) Carcinoma of esophagus Peptic stricture

Factors that may aggravate Solid Liquid

Factors that relieve Regurgitation of food bolus Maneuvers Response to medications

Associated symptoms & conditions Neurologic disorders Weight loss, anorexia Chest pain, heartburn

Odynophagia Pain during swallowing Usually associated with esophageal mucosal damage

Esophageal ulcer Esophagitis

Heartburn or Pyrosis Substernal warmth in the epigastrium that moves to the neck Symptoms of GERD

Indigestion A nonspecific term that encompasses a variety of upper abdominal

complaints including Nausea Vomiting Heartburn Regurgitation Dyspepsia

Character Fullness Heartburn Belching Flatulence Loss of appetite Severe pain

Location Localized or generalized Radiation

Association Food intake Menstrual period

Onset Day or night Gradual or sudden

Symptom relief By medications Spontaneous resolution Rest Activity

Medications Antacids For other co-morbid medical problems

Nausea Subjective feeling of a need to vomit Association

Relief with vomiting Small bowel obstruction

Particular stimuli Odors Activities Food intake

Menstrual cycle Medications

Antiemetics Vomiting

The oral expulsion of gastrointestinal contents resulting from contractions of gut thoracoabdominal wall musculature

Character Color

Fresh blood or coffee ground Undigested food

Quantity Duration Frequency

Odor Fecaloid in distal small bowel/colonic obstruction

Relationship to Previous meal

Pyloric obstruction within 1 hour of meals Change in appetite Fever, weight loss, abdominal pain Medications, headache

Regurgitation Effortless passage of gastric contents into the mouth

Diarrhea Passage of abnormally liquid or unformed stools at an increased

frequency Stool weight > 200 g/day

Acute - < 2 weeks Persistent - 2-4 weeks Chronic - > 4 weeks

Acute > 90% of cases are caused by infectious agents Accompanied by fever, vomiting & abdominal pain

Remaining 10% caused by Medications Toxic ingestions Ischemia Other conditions

Character Watery

Copious, explosive Color

Bloody Mucoid Undigested food Oil, fat

Odor Frequency Duration

Associated symptoms Chills Fever Thirst Weight loss Abdominal pain or cramping Fecal incontinence

Relationship to Food intake Stress

Travel history Medications

Laxatives or stool softeners Antidiarrheals Alternative therapies

Constipation A common complaint in clinical practice Usually refers to persistent, difficult, infrequent, or seemingly

incomplete defecation Less than 3 bowel movements per week Character

Change in caliber, scyballous Diarrhea alternating with constipation Associated symptoms

Abdominal pain or discomfort Weight loss Hematochezia

Pattern Last bowel movement Pain with passage of stool Change in caliber of stool

Diet Fluid intake High fiber food Anorexia, loss of appetite

GI Bleeding Presentation

Hematemesis Vomitus of red blood or coffee ground material

Melena Black, tarry, foul smelling stool

Hematochezia Passage of bright red or maroon blood from the rectum

Presentation Occult GI bleeding

Identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency

Symptoms of blood loss or anemia Patient may present with lightheadedness, syncope, angina or

dyspnea Upper

Indicates that the source of bleeding is above the Ligament of Treitz Melena indicates blood has been present in the GI tract for at least 14

hours Lower

Bleeding is distal to the Ligament of Treitz Determine if bleeding is upper or lower Medication history

NSAIDs Aspirin Steroids

History of liver disease Significant alcohol intake Cirrhosis

Abdominal PainTranscribed from the lecture of Dr. Ngo

Section D 2011 - Mikey Silverman

Types of Abdominal Pain Visceral Somatic/Parietal Referred

Visceral Pain Stimulus

Mechanical Stretching of hollow viscus: rapid distention forceful muscular

contraction Stretching of solid porgan serosa or capsule torsion or traction of the mesentery

Chemical from substances released due to mechanical injury, inflammation,

issue ischemia and necrosis noxious thermal or radiation injury

Dull ache, gnawing or crampy/colicky Writhes or double up Poorly localized Midline in location May radiate to specific sites Accompanied by nonspecific symptoms of anorexia, nausea, vomiting,

pallor, sweating Somatic/Parietal Pain

Result of inflammation of the parietal peritoneum Sharp Well localized Lateral in location/area of inflammation Aggravated by movement Tenderness, guarding

Referred pain Occurs when visceral noxious stimuli becomes more intense Felt in areas remote from the diseased organ Well localized Pain felt in the corresponding segmental skin area

Clinical Appraisal of Pain Location and radiation Onset Character and severity Temporal relation Duration and recurrence Aggravating and relieving factors Associated symptoms

Character Cutaneous

Pricking Burning, itching Sharply localized

Esophageal, lower Burning

Motor dysfunction Gastric

Gnawing, burning Hunger sensation, dull ache

Peptic ulcer disease Biliary Colic/Renal Colic

Mild onset Becomes intense until it reaches a high plateau of severity Pain relief with antispasmodics or an opiate

Intestinal Spasm True colicky pain Rhythmically intermittent Periods of intense pain of several seconds followed by longer interval

of remission Severity

Opiates have been required Patients awakened by pain from sleep Discontinuance of work or other activities Pain assessment scales

Temporal relation Food

Pain relief after eating or intake of alkali with recurrence 1-4 hours after food ingestion E.g. peptic ulcer disease

Postcibal pain, known cardiac patient E.g. intestinal angina

Pain 3-5 hours after ingestion of heavy evening meal

E.g. biliary colic Pain few minutes after eating with relief after belching of gas

E.g. functional GI disorder (non-ulcer dyspepsia) Defecation/flatus Rides (car, horse, farm wagon) Emotional upset

Duration and Recurrence Periodicity and rhythmicity

Occurrence day after day, weeks r months E.g. peptic ulcer disease

Constant Weeks or months

E.g. malignancy, chronic inflammation Weeks or month, no relationship to physiologic function

Aggravating and relieving factors Associated symptoms

Esophagus : chest pain, heartburn, dysphagia, odynophagia Stomach : vomiting, GI bleeding, anemia Intestines : change in bowel habits, vomiting, GI bleeding Hepatobiliary : jaundice Renal : hematuria, dysuria Reproductive organs : change in menstrual cycle, vaginal discharge Constitutional symptoms : fever, anorexia, weight loss

Questions to ask Describe the location, character and radiation of the pain Has the pain been present for hours, days, weeks, months or years? Is the pain constant or intermittent? Have you noticed specific aggravating or relieving factors? Is the pain affected by eating or defecation? Does the pain awaken you from sleep? Is there associated nausea or vomiting? Has there been associated weight loss? Is there a history of intake of drugs? Has there been a change in bowel habit?

Approach to a patient with abdominal pain History Physical Examination Laboratory Examination Radiographic Exam Endoscopic exam Surgery

Acute Abdomen Abdominal pain of great severity Sudden in onset Maybe medical or surgical Symptoms and signs of acute peritonitis Natural history of disease process result in disruption of the organ

system involved Occurrence of spreading infection Bleeding Life threatening Examples

Perforated peptic ulcer disease Acute appendicitis Abdominal aneurysm, dissecting/rupture Acute cholecystitis with rupture/empyema Severe acute pancreatitis Ovarian cyst, twisted

Can lead to acute abdomen Ectopic pregnancy Mesenteric occlusion Embolism at the aortic bifurcation Intestinal infarction

Abdominal Enlargement (See Mosby table) Flatus (Gas) (Intestinal Obstruction) Fatal Tumors Fat Fluid (Ascites) Feces Fetus Facts about intestinal gas

Intestines of normal subjects <200 mL

Rate of gas excretion/rectum 500-1500 mL/day

Number of passages /rectum 13.6/day

Composed of N2, O2, CO2, H2, CH4 N2-predominant, O2-least

Intestinal obstruction – caused by the accumulation of gas and fluid proximal and within the obstructed segment Mechanical obstruction

Extrinsic – adhesions, internal and external hernias Intrinsic – diverticulitis, carcinoma Obturation of the lumen – gallstone obstruction, intussusceptions

Adhesions and external hernias are the most common causes of obstruction of the small intestines

Carcinoma, diverticulitis, volvulus (large intestinal twisting) are the most common causes of obstruction of the large intestines

Non-mechanical obstruction Adynamic ileus – absence of aboral peristalsis; most common overall

cause of obstruction – peritoneal insult, abdominal operation, electrolyte imbalance (dec. K), intestinal ischemia

Spastic ileus – very uncommon; due to extreme and prolonged contraction of the intestines

Subjective Data Paroxysms of poorly localized, crampy mid-abdominal pain (becomes

localized when peritonitis occurs) Vomiting is the hallmark

Vomitus is bile and mucus in proximal obstruction feculent in distal obstruction

Obstipation (failure or inability to pass gas) and failure to pass gas Alteration in bowel habits, hematochezia

Objective Data Abdominal distention is the hallmark

Least in proximal obstruction and marked in colonic obstruction Fever Tenderness and rigidity of the abdomen Loud, high pitched, borborygmi

Ascites (askos, Greek) – bag or sack Pathologic accumulation of fluid in the peritoneal cavity Causes

Cirrhosis – 75% (EtOH, chronic Hep B/C, NAFLD)

Non-cirrhotic -25% Malignancy – 10% Cardiac failure – 3% TB – 2% Pancreatitis – 1% Others – 9%

Subjective data Increase in abdominal girth is the hallmark-noticed because of

increasing belt and clothing size Sensation of “pulling” or “stretching of the flanks” Pain depends on abdominal organ involvement Heartburn Dyspnea, orthopnea, tachypnea from elevation of the diaphragm Important to gather historical information about alcohol intake, blood

transfusion, change in bowel habits, CHF or nephrosis Objective data

Distended abdomen, bulging flanks, everted umbilicus, periumbilical veins (caput medusa)

Bruit over an enlarged liver, friction rub, venous hum at umbilicus (+) fluid wave, shifting dullness, decreased liver span Splenomegaly, palpable masses, peri-umbilical nodules (Sister Mary

Joseph nodes) Rectal exam – palpable masses, frozen pelvis

Abdominal Tumors May involve any of the peritoneal/retroperitoneal structures

(benign/malignant) Maybe a site of metastatic lesions from other primaries Subjective data – manifestations related to organs involved Objective data – palpable mass is the hallmark (location, size, shape,

surface, borders, consistency, tenderness, mobility, pulsatility)