Surgery

Abdominal Anatomy (Dr. Mata)

07 February 2008

ABDOMINAL ANATOMY
 Gall Bladder
Abdominal Cavity ▪ detoxifies many substances
 boundaries ▪ stores and concentrates bile
▫ superior: diaphragm ▪ sac located beneath the liver
▫ inferior: pelvis
▫ posterior: lumbar spine  Pancreas
▫ anterior: muscular abdominal wall ▪ endocrine pancreas secrete insulin into the bloodstream
▪ exocrine pancreas secrete digestive enzymes,
Anatomic Landmarks bicarbonate
 quadrants
▫ RUQ, LUQ, LLQ, RLQ  Vermiform Appendix
 anatomic ▪ hollow appendage attached to LI
▫ epigastrium ▪ no physiologic function
▫ umbilical
▫ suprapubic (hypogastrium) MAJOR BLOOD VESSELS
 aorta
Peritoneum  IVC
 abdominal cavity lining
 double-walled structure SOLID ORGANS
▫ visceral  liver, spleen, pancreas, kidney, ovaries (F)
▫ parietal
 separates abdominal cavity into two parts HOLLOW ORGANS
▫ peritoneal cavity  stomach, SI, LI, gall bladder, uterus, urinary bladder,
▫ retroperitoneal space uterus, fallopian tubes, bile ducts

Primary GI Structures RUQ

 liver, gall bladder, duodenum, transverse colon (part),
 Mouth ascending colon (part)
▪ lips, cheeks, gums, teeth, tongue
LUQ
 stomach, liver (part: left lobe), pancreas, spleen,
 Pharynx transverse colon (part), descending colon (part)
▪ portion of airway between nasal cavity and larynx
RLQ
 Esophagus  right ovary, ascending colon, right fallopian tube,
▪ portion of digestive tract between pharynx and stomach vermiform appendix

 Stomach LLQ
▪ hollow digestive organ
▪ receives food from the esophagus
 left ovary, descending colon, left fallopian tube,
sigmoid colon
 Small Intestine
▪ between stomach and cecum
DISORDERS OF THE ALIMENTARY TRACT
▪ composed of duodenum, jejunum, ileum
▪ site of nutrient absorption into the body
Motor (Motility Disorders)
 Large Intestine ▪ achalasia
▪ from ileocecal valve to anus ▪ post vagotomy atony
▪ composed of cecum, colon, rectum ▪ Hirschprung’s disease
▪ recovers water from GI tract secretions
Bleeding
Accessory GI Structures ▪ varices
▪ Mallory-Weiss disease
▪ PUD
 Salivary Glands
▪ cancer
▫ produce, secrete saliva
▪ Meckel’s diverticulum
▫ connect to mouth by ducts
▪ diverticulosis
 Liver
Perforation
▪ large solid organ in RUQ
▪ instrumental
▪ produces, secretes bile
 laparoscopic procedures
▪ produces essential proteins
▪ ulcers
▪ produces clotting factors
▪ obstruction and gangrene
▪ detoxification
 in combination dapat to cause
▪ stores glycogen
perforation
Leu, Brim, Virns – cyempre ang 2D 1 of 7
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▪ diverticulitis  Medications
▫ valproic acid
Obstruction  Allergies
▪ esophagus- cancer, reflux, esophagitis, caustic
 bugs, bites, stings
substances (in suicidal attempt)
EXAMINATION OF THE ACUTE ABDOMEN
▪ pylorus- PUD
▪ small bowel- adhesions, hernia
▪ colon- cancer, volvulus, other  Observe The Patient
 Reasurre  show self-confidence
Inflammations  Auscultate
▪ esophagitis  Percuss And Palpate
▪ gastritis • begin in the quadrant opposite the suspected
▪ regional enteritis pathology
▪ ulcerative colitis • percussion is a very sensitive peritoneal sign
▪ granulomatous colitis  Look
• description of abdominal habitus (scaphoid, flat,
Neoplasia distended)
▪ may occur at any level of the alimentary tract • scars, wounds, erythema, anatomic confines  ano
yung most likely organs involved
 Listen
Abdominal Pain
• with stethoscope  not necessary in all quadrants
• qualitative
 visceral- most common  normal, borborygmus, obstructive, bruit
 somatic • quantitative
 referred  absent, decreased, hyperactive

 Visceral Pain Bowel Tones

▪ stretching of peritoneum or organ capsules by
distention or edema Pathologic
▪ diffuse  obstruction
▪ poorly localized ▫ hollow
▪ may be perceived at remote locations related to organ’s ▫ air-fluid interface
sensory innervation ▫ like a pebble dropped into a partially filled barrel
▫ tinkles and rushes
Pain Vs Tenderness
 Distinction is critical in diagnosis Percussion
 Be precise • abdomen- tympanitic gas, dull fluid (ascites or blood)
o Conceptually • bladder, uterus- rising out of the pelvis
o Verbally • liver span - midclavicular line by convention
o Written documentation • percussion is also a very sensitive sign of peritonitis
 PAIN- is a subjective symptom
Palpation
 TENDERNESS- objective sign  Prepare The Patient
▪ warn them
Acute Abdomen ▪ make them comfortable
▪ take tension of the abdomen (pillow/bend the knees)
STABLE OR UNSTABLE resuscitative measures ▪ expose the entire abdomen (xiphoid to pubis)
 considerations  After Percussion
▫ precipitating factors/ alleviating factors ▪ softly at first
▫ quality- bright, sharp, dull, achy ▪ deeper
▫ radiation- scapula, inguinal, supraclavicular ▫ LUQ, RUQ, note liver edge
▫ severity- 1 to 10 scale ▫ then LLQ, RLQ
▫ timing- sudden, insidious, crampy/continuous ▪ watch their eyes as you touch them
▪ Note px’s attitude
HPI
 Past Surgical History EXAMINATION OF ACUTE ABDOMEN II
▫ previous abdominal or pelvic operation
▫ prior work-up for abdominal pain Guards
 PMI  Voluntary
▪ Insulin Dependent DM  Involuntary
▪ Aterosclerotic CerebroVascular Disease (ASCVD)
 Common Abdominal Conditions Peritoneal Signs
▪ ileus from narcotics  Rebound
▪ constipation/obstipation  Percussion Tenderness
▪ appendicitis  Peritoneal Tenderness
▪ pancreatitis
▪ perforated PUD Associated Findings
▪ small bowel obstruction  Eyes Dilate
▪ cholecystitis/biliary colic  Electric-Shock Like
PMH  Bright Tenderness
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EXAMINATION OF THE PAINFUL ABDOMEN  Type And Cross  if there’s blood loss

Advanced Palpation Tricks
▪ Sneak Up On Them
▪ Distract With Converstion
▪ Watch Their Eyes
▪ Palpate With Stethoscope
▪ Bump The Stretcher

Advanced and Adjuvant Exams

▪ Shifting Dullness
▪ Listen To Lower Lung Fields
▪ CVA Tenderness
▪ Digital Rectal Exam  mortal sin if not done!
▪ Bimanual Pelvic Exam

EXAMINATION FOR ASCITES

 Fluid Wave
 Shifting Dullness
 Associated Findings
▫ caput medusa
▫ spider angioma

DERMATOMAL PAIN SYNDROME

 due to poorly localizing visceral innervation, disease can
present in vague confusing manner
▪ pneumonia
▪ hepatitis
▪ pancreatitis
▪ PUD
▪ biliary colic
▪ acute MI
▪ GERD

Diagnostic Approach
Essential Questions
▫ stable/unstable?
▫ do I need a surgeon now?
▫ is it obvious that they need an operation?
What is your Clinical Diagnosis?
 Options
▫ upright CXR and abd KUB (kidney, ureter, bladder)
▫ CT + IV or PO contrast
▫ ultrasound
▫ nothing

Diagnostic Modalities
 CT- 15-20% false neg for acute perforation
▫ poor study of gall stones
▫ contrast obscures kidney stones

When To Call A Surgeon?

 unstable vs call –immediately ( hypotension, ↓pulse
pressure, ↓RR)
 obvious peritonitis
 work up complete in stable, less obvious
▫ CBCs, coags, blood gases, lytes, amylase, bilirubins,
LFTs(liver fxn tests), imaging

Chores in the Interim

 ABCs
▫ does this patient need intubation?
▫ IVS- 2 large bore if unstable
◦ Resuscitation NS(normal saline) vs LR
(lactated ringer)
▫ bolus therapy- 20cc/kg repeat if necessary
▫ foley catheter  to monitor urine output
▫ ? central line
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 Antibiotics- gram neg and anaerobic WHEN NOT TO OPERATE?

▫ ciprofloxacin/ flagyl
▫ piperazin, tazobactam –Pip- Tazo ▪ cholangitis
▫ cefotetan ▪ appendiceal abscess
▪ pain medication?  not sure coz if there’s abdominal ▪ acute diverticulitis + abscess
pain you can’t just give analgesic dapat alam mu ▪ acute hepatitis/pancreatitis
muna yung diagnosis ▪ ruptured ovarian cyst
▪ long standing perforated ulcer
Common Pitfalls
▪ acute mesenteric ischemia Non Surgical Causes
▪ intestinal volvulus o Rectus Muscel Hematoma
▪ gallstone ileus o Acute Salphingitis
▪ aortic abdominal aneurysm/back pains o Acute Porphyria
▪ “it’s just gastroenteritis” o DKA, Acute Adrenal Insufficiency
o GE Reflux, Hepatitis
EVALUATION OF THE ABDOMINAL PATIENT (SUMMARY)
o Pulmonary Nodule, Pulmonary Infarction
▪ patient condition guides the urgency o MI, Acute Pericarditis
▪ clinical diagnosis is the first step o Pyelonephritis
▪ imaging studies depend on clinical diagnosis o Sickle Cell Crisis
▪ patient preparation is crucial to outcome
Approach In Patients With Jaundice
Lab Tests  Check For Signs Of The Underlying Disease For
▪ WBC and differential Examination
Example cirrhosis
Diagnostic Imaging • Spider Nevi, Liver Palm
 Plain Films • Flapping Tremor
▪ upright CXR- free air (pneumoperitoneum) • Splenomegaly
▪ KUB
• Finger Clubbing
▫ calcification
• Ascites
▫ foreign bodies  whee. Santol seeds!
• Leg Edema
▫ reactive bowel patterns
▫ fluid/ air levels • TB
 Lateral Decubitus Film  Investigations (Jaundice)
 Ultrasound Initial
▪ rapid, safe, low cost, always available • checking urinary bilirubin and urobilinogen
▫ operation dependent • checking liver function tests
▪ fluid, inflammation, air in walls, masses  either cystic • ultrasound, CT, MRI
or solid • liver biopsy
▪ liver, GB, CBD, spleen, pancreas, appendix, kidneys, • laparoscopy
ovaries, uterus
 CT Scan Nausea & Vomiting Causes
▪ better than plain films and US for evaluation of solid and o Viral Infections
hollow organs o Medications
▫ IV contrast o Motion Sickness/ Sea sickness
▫ oral contrast
o Migraine Headaches
▫ per rectal contrast
o Morning Sickness During Pregnancy
▪ use in appendicitis, diverticulitis, abscess,
o Food Poisoning
pancreatitis
o Allergies
WHEN TO OPERATE? o Chemotherapy  in CA patients
o Alcoholism
▪ peritonitis (excluding primary peritonitis) o Brain Tumors
▪ abdominal pain/tenderness + sepsis
▪ make sure pancreatitis is excluded Constipation
▪ pneumoperitoneum  a decrease in frequency of bowel movements compared to
▪ acute interstitial ischemia a child’s usual pattern ( some physicians define
constipation as fewer than 3 bowel movements per week)
WHAT IF ITS NOT CLEAR?  the passage of hard, oftentimes large caliber, dry bowel
movements
Challenging Patients  bowel movements that are difficult or painful to push out
▪ neurologically compromised  Obstipation- severe constipation
▪ intoxicated
▪ steroids Causes of Constipation
▪ immunosuppressed o diet
If signs and symptoms are equivocal o lack of exercise
▪ serial exams (same person) o busy children
▪ imaging o emotional
▪ serial labs o physical problems that can cause constipation
▪ keep off antibiotics
(abnormalities of intestinal tract, rectum, anus,
▪ tincture of time
problems of the nervous system  like cerebral palsy)
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o endocrine problems (hyperthyroidism) SIGNS AND SYMPTOMS OF INTESTINAL OBSTRUCTION

o medications (iron preparation, narcotics such as
codeine) ▪ crampy abdominal pain that comes and goes (intermittent)
▪ nausea
▪ vomiting
▪ inability to have bowel movement/pass gas
▪ swelling of abdomen (distention)
▪ abdominal tenderness

Mechanical Obstruction of the SI

Common causes include the ff:
o Intestinal Adhesions
o Hernias
o Tumors
o Telescoping Of A Portion Of The Intestines
( intussusception)
o Volvulus (Twisting Of Intestine)
o Narrowing Of The Outlet From Stomach (Stricture)

Colon
Most Common Causes Of Colonic Obstruction
o Cancer
o Diverticulitis
o Volvulus
Less Common
o Impacted Feces
o Intussusception
o Stricture
o Foreign Bodies/swallowed object that block the colon

WAITING FOR A BUS...

You know, love is just like someone waiting for a bus. When the bus comes,
you look at it and you say to yourself "eeee...so full.... cannot sit down. Ill wait
for the next one". So you let the bus go and waited for the second bus. Then
the second bus came, you looked at it you say,"eeee...this bus is so old...so
shabby!" So you let the bus go and again, decided to wait for the next bus.
After a while another bus came, it's not crowded, not old but you said, "eeee...
not air-conditioned ...better wait for the next one. So again you let the bus go
and decided to wait for the next bus. Then the sky started to get dark as it is
getting late. You panicked and jumped immediately inside the next bus. It is
not until much later that you found out that you had boarded the wrong bus!
So you wasted your time and money waiting for what you want! Even if an
air-conditioned bus comes, you can't ensure that their-conditioned bus won't
break down or whether or not the airconditioner will be too cold for you. So
people... wanting to get what you want is not wrong. But it wouldn't hurt to
give other person a chance, right? If you find that the "bus" doesn't suit you
just press the red button and get off the bus! (as simple as that!) Hey who
said life is fair??? The best thing to do is be observant and open while you
scrutinize the bus. If it doesn't suit you, get off. But you must always have an
extra something, which you could use for the next bus that comes. But wait...
I'm sure you have this experience before...You saw a bus coming (the bus you
want, of course) you flagged it but the driver acted as if he did not see you and
zoomed pass you! It just wasnt meant for you! The bottom line is, being loved
is like waiting for a bus you want. Getting on the bus and appreciating the bus
by giving it a chance depends totally on you. If you haven't made any choice,
WALK! Walking is like being out of love. The good side of it is you can still
choose any bus you want... the rest who couldnt afford another ride would
just have to be content with the bus they rode on, ugly or not. One more
thing.... sometimes its better to choose a bus you are already familiar with
rather than gamble with a bus that
is unfamiliar to you. But then again, life wouldn't be complete without the
risks involved.
BUT THERE'S ONE BUS THAT I FORGOT TO TELL YOU ABOUT - THE
BUS THAT YOU DON'T HAVE TO WAIT FOR... IT WILL JUST STOP ON
ITS OWN AND WILL ASK YOU TO COME INSIDE AND TAKE A FREE
RIDE FOR THE REST OF YOUR LIFE…

You Never Lose By Loving

You Always Lose By Holding Back

Yay! mush mush. valentines na kasi.. tsk tsk. ;)

Special thanks sa 2D for the notes.. complete na to’.. wl some

notes yung nkaitalicized 9as if it helps..).. haha.
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--brim