ABDOMEN

I. REVIEW OF RELATED HISTORYA. 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, pattern5. Jaundice – onset and duration, color of stools or urine, exposure to hepatitis, use of club/recreational

drugs6. 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 AND FINDINGSA. PREPARATION

- need good source of light, full exposure of abdomen- have patient empty bladder and in supine position- 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. Bowel Sounds – use diaphragm and hold in place with very light pressure- 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 non-palpating 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. 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 herniation)- 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 ProceduresAscites 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 VARIATIONSA. 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 ABNORMALITIESGASTROESOPHAGEAL 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 chronicacute = 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