Abdominal Examination

Transcribed from the lecture of Dr. Ngo

Section 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 Traubs 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; Murphys sign
Palpable gallbladder Hydrops Courvoisiers 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

Complaints
Transcribed 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
travelers 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 Pain

Transcribed 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)