Anatomy Clinical Abdomen

Gross Anatomy

Clinical Correlations

Abdomen

1. Abdominal surgical incisions a. Incisions should be made (if possible) at lines of cleavage i. Collagen fibers in dermis are parallel ii. More narrow scar b. Incision away from nerves i. Muscle atrophy if nerve cut c. Shorter healing time 2. Palpation of the abdomen a. Soft and pliable b. Inward and outward excursion with respiration c. Contour depends on tone and fat d. Looking for enlarged organs, such as liver (mononucleosis) 3. Hydrocele a. Persistent processus vaginalis (congenital) b. Fluid-filled sac surrounds testicle c. 1 in 10 male infants at birth d. Typically not painful or harmful

e. 4. Varicocele a. Pampiniform plexus (testicles) becomes dilated b. Common in adolescents c. Mostly left side due to connection with renal vein vs. right side, which joins with IVC d. Could be caused by primary kidney disease e. Presents with infertility (plexus not cooling) 5. Testicular cancer a. Spreads upward via lumbar lymph to L1 b. Later spreads locally to superficial inguinal lymph 6. Torsion of the Testicle a. Rotation around spermatic cord b. Often associated with excessively large tunica vaginalis c. Active young men and children

Version: 09Apr2009

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Gross Anatomy

Clinical Correlations

Abdomen

d. Severe pain, could lead to testicular necrosis 7. Palpation of the superficial inguinal ring a. Looking for indirect hernia b. Male: Palpate spermatic cord in upper part of the scrotum c. Firm cordlike structure (posterior part) is vas deferens d. Patient coughs to increase intraabdominal pressure e. Female: smaller and difficult to palpate f. Transmits round ligament 8. Peritonitis a. Inflamed parietal peritoneum is extremely sensitive to stretching b. Pressure applied to abdominal wall with one finger c. Rebound tenderness

d. 9. Peritoneal adhesions a. Associated with peritonitis b. Post-surgical (gynecological and general abdominal) as well c. Adhesion occur >90% of the patients following major abdominal surgery and in 55-100% of the women undergoing pelvic surgery d. Small-bowel obstruction, infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery are the most common consequences 10. Ascites and Paracentesis a. Excessive accumulation of peritoneal fluid b. Thin patient needs 1.5L before clinically recognizable c. Local anesthesia, needle through abdominal wall d. Skin, superficial fascia, deep fascia (very thin), aponeurosis or muscle of external oblique, internal oblique muscle, transversus abdominis muscle, fascia transversalis, extraperitoneal connective tissue (fatty), and parietal peritoneum

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Gross Anatomy

Clinical Correlations

Abdomen

e. 11. Partial gastrectomy a. Gastric cancer b. Gastric ulcer i. Reduce acid by sectioning the vagus nerves (vagotomy) ii. Else remove gastrin-bearing mucosa (antrum, gastrectomy)

iii. (red area is gastrin-bearing) 12. Duodenal (Peptic) ulcers a. An ulcer of the posterior wall of the first part of the duodenum may penetrate the wall and erode the relatively large gastroduodenal artery, causing a severe hemorrhage

b. c. As the stomach empties its contents into the duodenum, the acid chyme is squirted against the anterolateral wall of the first part of the duodenum 13. Appendicitis a. Afferent pain fibers enter the spinal cord at the level of the 10th thoracic segment, and a vague referred pain is felt in the region of the umbilicus b. Later, the pain shifts to where the inflamed appendix irritates the parietal peritoneum. Here the pain is precise, severe, and localized 14. Colitis

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Gross Anatomy

Clinical Correlations

Abdomen

a. Pain, tenderness in the abdomen, fever, swelling of the colon tissue, bleeding, erythema (redness) of the surface of the colon, rectal bleeding, and ulcerations of the colon b. Associated with Crone’s disease

c. 15. Colectomy a. Cancer of the large bowel b. Minimally invasive laparoscopic surgery c. Lymph vessels and nodes removed too 16. Ileostomy a. Small intestine brought out to skin; collected in pouch b. Usually done in groin on right side c. Ulcerative colitis; Hirschprung's disease (megacolon) 17. Colonoscopy a. Colorectal cancer is a leading cause of death in the Western world b. Bowels washed, patient sedated, tube inserted

c. 18. Rupture of spleen a. Associated with mononucleosis b. Requires immediate medical and surgical attention c. Severe blood loss (shock)

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Gross Anatomy

Clinical Correlations

Abdomen

d. Left side, T9-T11 e. Removed rather than repaired 19. Pancreatic cancer a. Near head of bile duct; obstructive jaundice (yellow skin tint) b. Whipple procedure (pancreatoduodenectomy) c. Could do stents as well 20. Cirrhosis of liver a. Scarring of liver tissue as hepatocytes die off b. Associated with chronic alcoholism and hepatitis c. Portal hypertension develops 21. Impaction of gallstones a. Usually asymptomatic b. Sometimes very painful i. Eating fatty foods contracts gallbladder against stones c. May result in infected bile into the pancreatic duct i. Pancreatitis d. Gallbladder removed 22. Portal hypertension a. Anastomotic backup of surrounding veins i. Gastroesophogeal, Anorectal, Paraumbilical, Retroperitoneal b. Ascities c. Can insert a shunt from the portal vein back to IVC i. Blood flow through sinusoids impeded ii. Caput medusae

iii. James Lamberg 23. Renal and Ureteric Calculi (stones) a. Consolidation of dissolved minerals in urine b. Episodic flank pain and hematuria c. Most pass with time d. Surgical navigation removal e. Extracorporeal Shock Wave Lithotripsy (ESWL) 24. Abdominal aortic aneurysm a. Localized enlargement of the aorta as a result of congenital or acquired weakness b. Pulsations can be detected left of midline c. Common site is just above the bifurcation of the aorta to common iliac arteries d. Unrecognized rupture of an aneurysm has a 90% mortality rate Version: 09Apr2009

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