Abdomen

ABDOMEN I.

REVIEW

OF

RELATED HISTORY

A.

HISTORY OF PRESENT ILLNESS 1. Abdominal Pain – onset and duration, character (dull, sharp, burning, stabbing, cramping), location, associated symptoms, relationship to: menstrual cycle, urination, defecation, inspiration, body position, food or alcohol intake, stress, recent stool characteristics (color, consistency, odor, frequency), urinary characteristics, therapies to treat 2. Indigestion – character, location, association with: food intake, timing of food intake, discomfort, belching, flatulence, loss of appetite, location, onset, relief agents 3. Nausea / Vomiting – stimuli (odors, activities, time of day), date of last menstrual period, characteristics 4. Constipation – presence of bright blood, black or tarry appearance, pattern 5. Jaundice – onset and duration, color of stools or urine, exposure to hepatitis, use of club/recreational drugs 6. Urinary frequency – change in usual pattern and/or volume, change in urinary stream B.

PAST MEDICAL HISTORY - gastrointestinal disorders, hepatitis or cirrhosis, abdominal or urinary tract surgery or injury, major illnesses (cancer, arthritis, kidney disease, cardiac disease), blood transfusions C.

FAMILY HISTORY - gallbladder disease, kidney disease, malabsorption syndrome (cystic fibrosis), polyposis, colon cancer D.

PERSONAL AND SOCIAL HISTORY - nutrition (24-hr recall, food preferences and dislikes, ethnic foods, religious food restrictions), first day of last menstrual period, alcohol intake, stress, exposure to infectious diseases, trauma, use of club/recreational drugs

II.

EXAMINATION

A.

PREPARATION - need good source of light, full exposure of abdomen - have patient empty bladder and in supine position

AND

FINDINGS

- place small pillow under patient’s head and another under slightly flexed knees - draw imaginary line from sternum to pubis through umbilicus then a second imaginary line perpendicular to first (horizontally across abdomen through umbilicus) dividing abdomen in 4 quadrants - anatomic landmarks are useful in describing location of pain, tenderness, and other findings Quadrants: Rt. Upper (RUQ) Lt. Upper (LUQ) Rt. Lower (RLQ) Lt. Lower (LLQ) - liver & gall bladder - left lobe of liver - part of r. kidney - part of l. kidney - duodenum - spleen - cecum & appendix ovary - rt. renal artery - stomach - rt. iliac artery - lt. iliac artery - aorta, - rt. femoral artery - lt. femoral artery - ovary & tube - sigmoid colon - ureter

-

B.

INSPECTION 1. Surface Characteristics – observe skin color and surface characteristics - skin may be somewhat paler if it has not been exposed to sun - fine venous network is often visible - unexpected findings include generalized color changes such as jaundice or cyanosis; glistening, taut appearance suggesting ascites; bruises and localized discoloration (Cullen sign) suggesting internal bleeding; striae (originally pink or blue, changing to silvery white over time) resulting from pregnancy or weight gain - inspect for lesions, particularly nodules - note any scars and draw their location, configuration, and relative size on illustration of abdomen 2.

Contour – inspect for contour, symmetry, and surface motion - contour is the abdominal profile from the rib margin to pubis - expectations can be described as flat, rounded, or scaphoid - should be evenly rounded with maximum height of convexity at umbilicus - note location and contour of umbilicus

- may be inverted or protrude slightly, but should be free of inflammation, swelling, or bulges that may indicate a hernia - distention may occur as a result of obesity, enlarged organs, and fluid or gas - distention from umbilicus to symphysis can be caused by ovarian tumor, pregnancy, uterine fibroids, or distended bladder - ask patient to take deep breath and hold it and/or lift head from table - contour should remain smooth and symmetric - this maneuver lowers diaphragm and compresses organs of abdominal cavity exposing previously “hidden” objects - hernias will protrude in the area of surgical scars, navel area, and rectus abdomens muscles - most are reducible (contents are easily replaced) - nonreducilble hernia is one that the blood supply to protruded contents is obstructed and requires immediate surgical interventions 3.

Movement – smooth, even movement should occur with respiration - males exhibit primarily abdominal movement with respiration, whereas females show mostly costal movement - limited abdominal motion associated with respiration may indicate peritonitis or disease - marked pulsation may occur as result of increased pulse pressure or abdominal aortic aneurysm C.

AUSCULTATION - use to assess bowel motility and discover vascular sounds - always precedes percussion and palpation because these maneuvers may alter frequency and intensity of bowel sounds 1. pressure

Bowel Sounds – use diaphragm and hold in place with very light

- listen for bowel sounds and note frequency and character - usually heard as clicks and gurgles that occur irregularly and range from 5 to 35/min - loud prolonged gurgles are stomach growling (borborygmi) - high pitched tinkling sound suggest intestinal fluid and air under pressure - decreased bowel sounds occur with peritonitis and paralytic ileus - absence of bowel sounds is established only after 5 minutes of continuous listening

2. Vascular Sounds – with bell listen to all four quadrants for bruits in aortic, renal, iliac, and femoral arteries - with diaphragm listen for friction rubs over liver and spleen - with bell in epigastric region and around umbilicus, listen for venous hum (soft, low pitched, continuous) - occurs with increased collateral circulation between portal and systemic venous systems D.

PERCUSSION - used to assess size and density of organs and to detect presence of fluid (ascites), air (gastric distention), and fluid-filled or solid masses - percuss all quadrants for sense of overall tympany and dullness - tympany is predominant sound because air is present in stomach and intestines - dullness is over organs and solid masses - distended bladder produces dullness in suprapubic area 1. Additional Liver Assessment – if enlargement is suspected, additional maneuvers are needed - liver dullness is usually detected in 5th to 7th intercostal space 2.

Spleen – percuss spleen just posterior to midaxillary line on left side - may hear a small area of spenic dullness from 6th to 10th rib - large area of dullness suggests enlargement; however, a full stomach or feces filled intestine may mimic dullness - percuss lowest intercostals space in left anterior axillary line before and after patient takes a deep breath - should be tympanic - with enlargement, tympany changes to dullness E.

PALPATION - used to assess organs of abdominal cavity and to detect muscle spasm, masses, fluid, and areas of tenderness - evaluate abdominal organs for size, shape, mobility, consistency, and tension - have patient in supine position with abdominal muscles as relaxed as possible - ticklishness may be a problem - ask patient to perform self-palpation while examiner hands are over patient’s fingers, not quite touching abdomen itself - after time, let fingers drift slowly onto abdomen while still resting primarily on patient’s fingers

- might also use diaphragm as starting point, allowing fingers to drift over edge of diaphragm and palpate without eliciting an excessively ticklish response - applying stimulus to another, less sensitive body part with nonpalpating hand can also decrease ticklish responses 1. Light Palpation – begin with light, systematic palpation of all four quadrants, initially avoiding any areas that have already been identified as problem spots - with palmar surface of fingers, depress abdominal walls no more than 1 cm, using light even pressing motion - avoid short, quick jabs - abdomen should feel smooth with consistent softness - particularly used in identifying muscular resistance and areas of tenderness 2. Moderate Palpation – exerting moderate pressure as intermediate step to gradually approach deep palpation - tenderness not elicited on gentle palpation may become evident with deeper pressure - additional maneuver of moderate palpation is performed with side of hand - palpate during entire respiratory cycle 3. Deep Palpation – necessary to thoroughly delineate abdominal organs and to detect less obvious masses - use palmar surface of extended fingers, pressing deeply and evenly into abdominal wall - palpate all 4 quadrants 4. Masses – identify any masses and note characteristics: location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration - determine if superficial (located in abdominal wall) or intraabdominal - - have patient lift head from table, contracting abdominal muscles - in abdominal wall, masses will continue to be palpable - in abdominal cavity, masses will be more difficult to feel because they are obscured by abdominal musculature 5. herniation)

Umbilical Ring – area should be free of bulges, nodules, and granulation - ring should be round and free of irregularities - note whether incomplete or soft in center (suggests potential for

- umbilicus may be either slightly inverted or everted but should not protrude 6.

Kidneys – assess for tenderness - ask patient to assume sitting position - place palm of hand over right costoverebral angle and strike hand with ulnar surface of fist of opposite hand - patient should perceive blow as thud, but should not cause tenderness or pain - pain is usually performed while examining back rather than abdomen 7.

Additional Procedures Ascites Assessment – suspected in patients who have protuberant abdomens or flanks that bulge in supine position - percuss for areas of dullness and resonance with patient supine - gravity settles fluid: expect to hear dullness in dependent parts and tympany in upper parts Shifting Dullness – without ascites, borders will remain relatively constant - with ascites, border of dullness shifts to dependent side (approaches midline) as gravity settles fluid Fluid Wave – will need assistance - with patient supine, press edge of hand and forearm firmly along vertical midline of abdomen which stops the transmission of a wave - detected fluid wave suggests ascites, but findings are not conclusive Pain Assessment – rate the pain, is there an underlying physical cause?, has there been recent trauma? - pain severe enough to make patient unwilling to move, is accompanied by nausea and vomiting and marked by areas of localized tenderness generally with underlying cause - patients may give a “touch-me-not” warning - - do not touch in particular areas - patients with organic cause for abdominal pain are generally not hungry - ask patient to point finger to location - if not directed to navel but goes to fixed point, great likelihood of significant physical importance

- farther from navel, more likely it will be organic in origin - patients with nonspecific abdominal pain keep eyes closed, those with organic disease keep eyes open - ask patient to cough or take deep breath - asses patient’s willingness to jump or to walk - careful assessment of quality and location of pain can usually narrow possible causes Common Conditions: Appendicitis – becomes localized to RLQ - guarding, tenderness, iliopsoas and obturator signs, RLQ skin hyperesthesia; anorexia, nausea, or vomiting after onset of pain; low-grade fever Cholecystitis – severe, unrelenting RUQ or epigastric pain; may be referred to right subscapular area - RUQ tenderness and rigidity, palpable gallbladder, anorexia, vomiting, fever, possible jaundice Pancreatitis – dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks; may be referred to left shoulder - epigastric tenderness, vomiting, fever, shock; Cullen sign; signs occur 2 - 3 after onset Perforated Gastric or Duodenal Ulcer – abrupt RUQ; may be referred to shoulders - abdominal free air and distention with increased resonance over liver; tenderness in epigastrium or RUQ; rigid abdominal wall, rebound tenderness Diverticulitis – epigastric, radiating down left side of abdomen especially after eating; may be referred to back - flatulence, borborygmius, diarrhea, dysuria, tenderness on palpation Intestinal Obstruction – abrupt, severe, spasmodic; referred to epigastrium, umbilicus - distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis; bowel sounds absent (with paralytic obstruction) or hyperactive high pitched (with mechanical obstruction)

III.

DEVELOPMENTAL VARIATIONS

A.

INFANTS AND CHILDREN - if possible, should be examined during a time of relaxation and quiet - sucking a bottle or pacifier may help - parent’s lap makes best exam surface 1.

Inspection – noting shape, contour, and movement with respiration - should be rounded and dome-shaped - note any localized fullness - note whether abdomen protrudes above level of chest or is scaphoid (shaped like a boat) - pulsations are common - superficial veins are usually visible in thin infant; however, distended veins across abdomen are unexpected finding - inspect umbilical cord, counting number of vessels (2 arteries, 1 vein) - umbilical stump should be dry and odorless - inspect for discharge, redness, induration, and skin warmth - note any protrusion through umbilicus or rectus abdominis muscles when infant strains - umbilicus is usually inverted - umbilical hernia is common - umbilicus often everts with increased abdominal pressure - herniation through rectus abdominis muscles is a problem 2. Auscultation and Percussion – peristalsis is detected when metallic tinkling is heard every 10 to 30 seconds - bowel sounds should be present within 1 to 2 hrs after birth - auscultate chest for bowel sounds - no bruits or venous hums should be detected - bruit of stenosis has high frequency and is soft - bruit of arteriovenous fistula is continuous - abdomen may produce more tympany on percussion than found in adults - tympany is usually result of gas whereas dullness may indicate fluid or solid mass - before 2 yrs old, females have slightly larger liver span than males 3. Palpation - palpate with infant’s feet slightly elevated and knees flexed to promote relaxation - begin with superficial palpation a.

Deep Palpation – perform in all quadrants - note location, size, shape, tenderness, and consistency of

any masses - use transillumination to distinguish cystic masses from solid masses

- if any suspicion of neoplasm exists, limit palpation of mass because manipulation may cause injury or spread of malignancy - distended bladder, felt as firm, central dome-shaped structure in lower abdomen, may indicate urethral obstruction or central nervous system defects - tenderness or pain on palpation may be difficult to detect - pain and tenderness are assessed by change in pitch of crying, facial grimacing, rejection of opportunity to suck, and drawing the knees to the abdomen with palpation - after age 5, contour, when supine, may become convex and will not extend above imaginary line drawn from xiphoid process to symphysis pubis - respirations continue to be abdominal until 6 or 7 yrs old B.

ADOLESCENTS - techniques are the same as those for adults

C.

PREGNANT WOMEN - bowel sounds will be diminished as a result of decreased peristaltic activity - striae and midline band of pigmentation (linea nigra) may be present - constipation is common and hemorrhoids often develop later D.

OLDER ADULTS - abdominal wall becomes thinner and less firm as result of loss of connective tissue and muscle mass - palpation may be relatively easier and yield more accurate findings - pulsating abdominal aortic aneurysm may be more readily palpable - abdominal contour is often rounded as result of loss of muscle tone - use judgment in determining whether a patient is able to assume a particular position - be aware that respiratory changes can produce corresponding findings in exam - intestinal disorders are common, particularly sensitive to patient complaints and related findings - constipation is common - fecal impaction is common - gastrointestinal cancer increases with age - various symptoms depend on site of tumor - symptoms range from dysphagia to nausea, vomiting, anorexia, and meatemesis; can include changes in stool frequency, size, consistency, or color

IV.

COMMON ABNORMALITIES

GASTROESOPHAGEAL REFLUX DISEASE – relaxation of incompetence of lower esophagus produces gastroesophgeal reflux - backward flow of acid from stomach up into esophagus - patients experience heartburn (acid indigestion) - common among elderly and pregnant women - symptoms in infants and children include regurgitation and vomiting IRRITABLE BOWEL SYNDROME – functional disorder of intestine that produces cluster of symptoms, consisting most commonly of abdominal pain, bloating, constipation, and diarrhea - no sign of disease that can be seen or measured, but intestine is not functioning normally - more common in women HIATAL HERNIA WITH ESOPHAGITIS – occurs when a part of stomach has passed through esophageal hiatus in diaphragm into chest cavity - very common and occurs more in women and older adults - associated with obesity, pregnancy, ascites, and use of tight-fitting belts and clothes - clinically significant when accompanied by acid reflux, producing esophagitis DUODENAL ULCER (DUODENAL PEPTIC ULCER DISEASE) – most common form of peptic ulcer disease, duodenal ulcer is a chronic circumscribed break in duodenal mucosa that scars with healing - occurs twice as often in men as in women - occurs on both anterior and posterior walls - perforation of duodenum is life-threatening, requires immediate surgical intervention - posterior ulcers are more likely to bleed CROHN DISEASE – chronic inflammatory disorder of gastrointestinal tract that produces ulceration, fibrosis, and malabsorption - terminal ileum and colon are most common sites - mucosa has characteristic cobblestone appearance - patient exhibits chronic diarrhea, compromised nutritional status and often other systemic manifestations such as arthritis, iritis, and erythema nodosum ULCERATIVE COLITIS – chronic inflammatory disorder of colon and rectum that produces mucosal friability and areas of ulceration; fibrosis is minimal - characterized by bloody, frequent, watery diarrhea (as many as 20 or 30/day) - patients exhibit weight loss, fatigue, and general debilitation STOMACH CANCER – most commonly found in lower half of stomach

- metastases, local and distant are common - symptoms may be vague and nonspecific, and include loss of appetite, feeling of fullness, weight loss, dysphagia, and persistent epigastric pain - physical exam may reveal tenderness, enlarged liver, positive supraclavicular nodes, and ascites DIVERTICULOSIS – inflammation of existing diverticula produces left quadrant pain, anorexia, nausea, vomiting, and altered bowel habits (usually constipation) - abdomen may be distened and tympanic with decreased bowel sounds and localized tenderness COLON CANCER (COLORECTAL CANCER) – carcinoma of colon usually occurs in rectum, sigmoid, and lower descending colon; may appear in proximal colon - earliest sign is occult blood in stool detectable by fecal occult blood testing - history of frequency and character of stools HEPATITIS – inflammatory process of liver characterized by diffuse or patchy hepatocellular necrosis - most commonly caused by viral infection, alcohol, drugs, or toxins - symptoms include jaundice, hepatomegaly, anorexia, abdominal and gastric discomfort, clay-colored stools, and tea-colored urine CIRRHOSIS – characterized by destruction of liver parenchyma - liver is initially enlarged with firm, nontender border on palpation; but as scarring progresses, liver mass is reduced, and generally cannot be palpated - associated symptoms include ascites, jaundice, prominent abdominal vasculature, cutaneous spider angiomas, dark urine, light-colored stools, and spleen enlargement - patient complains of fatigue, and in late stages muscle wasting may be evident CHOLELITHIASIS – stone formation in gallbladder - symptoms of indigestion, colic, and mild transient jaundice are common - commonly produces episodes of acute cholecystitis and pancreatitis GALLBLADDER CANCER – invasion of gallbladder by malignant cells results in abdominal pain, jaundice, and weight loss - mass may be palpable in upper abdomen CHOLECYSTITIS – inflammatory process of gallbladder that may be either acute or chronic acute = associated stone formation in 90% of all cases, causing obstruction and inflammation - symptoms include pain in right upper quadrant with radiation around midtorso to right scapular region

- pain is abrupt and severe, lasting from 2 to 4 hours chronic = repeated attacks of acute in gallbladder that is scarred and contracted - patients exhibit fat intolerance, flatulence, nausea, anorexia, and nonspecific abdominal pain and tenderness of right hypochondriac region CHRONIC PANCREATITIS – chronic inflammation of pancreas produces constant, unremitting abdominal pain, epigastric tenderness, weight loss, steatorrhea, and glucose intolerance PANCREATIC CANCER – malignant degeneration results in abdominal pain that radiates from epigastrium to upper quadrants or back, weight loss, anorexia, and jaundice SPLEEN RUPTURE – most commonly injured in abdominal trauma because of its anatomic location - mechanism of injury can be either blunt (most common) or penetrating - symptoms are pain in left upper quadrant with radiation to left shoulder, hypovolemia, and peritoneal irritation - diagnosis is made by positive paracentesis or splenic scan - surgical intervention may be required GLOMERULONEPHRITIS – inflammation of capillary loops of renal glomeruli usually producing nonspecific symptoms - patient complains of nausea, malaise, and arthralgias - hematuria may occur and pulmonary infiltrates may be present PYELONEPHRITIS – infection of kidney and renal pelvis characterized by flank pain, bacteriuria, pyuria, dysuria, nocturia, and frequency - costovertebral angle tenderness may be evident ACUTE RENAL FAILURE – sudden, severe impairment of renal function causing acute uremic episode - urine output may be normal, decreased, or absent - patient may show signs of either fluid overload or deficit CHRONIC RENAL FAILURE – slow, insidious, and irreversible impairment of renal function - uremia develops gradually - patient may experience oliguria (slight or infrequent urination) or anuria (absence of urine formation) and have signs of fluid overload Intussusception – prolapse of one segment of intestine into another causing intestinal obstruction - commonly occurs between 3 and 12 mos. old - cause is unknown - symptoms include acute intermittent abdominal pain, abdominal distention, vomiting, and passage at first of

normal brown stool - subsequent stools may be mixed with blood and mucus with a red currant jelly appearance - mass may be palpated in right or left upper quadrant, whereas lower quadrant feels empty - child is inconsolable, sometimes doubling up with pain Urinary Incontinence – most common types are stress – leakage of urine due to increased intraabdominal pressure that can occur from coughing, laughing, exercise, or lifting heavy things - causes include weakness of bladder neck supports and anatomic damage to urethral sphincter urge – inability to hold urine once the urge to void occurs - causes can be local genitourinary (genital organ functions) conditions, or central nervous system disorders (stroke) overflow – mechanical dysfunction resulting from overdistended bladder - causes include anatomic obstruction by prostatic hypertrophy and strictures; neurologic abnormalities that impair detrusor contractility (multiple sclerosis); or spinal lesions functional – intact urinary tract, but other factors such as cognitive abilities, immobility, or musculoskeletal impairments lead to incontinence