Bates Chapter 11 Abdomen

colicky pain signal

colicky pain signals renal stones, unlike in parietal pain these patients move around until they find a comfortable position. Bending over with cramping signals a renal stone and is a colicky pain signal

prevalence of Upper Abdominal Pain, discomfort and Heartburn

is approximately 25% in US and other Western countries

Heartburn

rising retrosternal burning pain or discomfort occurring weekly or more often and is aggravated by alcohol, chocolate, citrus fruits, coffee, onions and peppermint or positions like bending over, exercising, lifting or lying supine. Angina from inferior wall coronary disease may also be mistaken as heartburn.

which of the three mechanisms of pain is difficult to localize?

visceral pain is difficult to localize. Both parietal pain and referred pain are localized.

Causes of Belching

aerophagia or swelling air.

Increased pulsations in abdominal aorta suggest what?

AAA Abdominal Aortic Aneurysm

Common or Concerning Symptoms of Gastrointestinal Disorders

Abdominal pain Acute and chronic indigestions Nausea Vomitting Vomitting up blood (hematemesis) Loss of appetite Anorexia Early satiety Difficulty swallowing (dysphagia) Painful swallowing (odynophagia) Change in Bowel Function Diarrhea, constipation Jaundice

Barrett Esophagus

About 10% of patients with chronic heartburn have Barrett esophagus in which the squamous cells change to columnar epithelium.

Types of Visceral Pain

Again, this type of pain is caused by dissension, unusual forceful stretching or contracting of hollow abdominal organs and may occur in solid organs as well. Types of visceral pain varies according to the quadrant it is experienced in which is relative to the structures found within those quadrants. Pain from biliary tree and liver: RUQ. Sacral pain from rectum: Suprapubic Epigastric pain from stomach, duodenum or pancreas: mostly LUQ Small intestine, appendix or proximal colon: usually umbilical pain Colon, bladder or uterus: hypogastric pain

If patient claims of abdominal pain but suggests that it is relieved by rest and aggravated by exertion, what does that indicate?

Angina from inferior wall coronary disease may present itself as "indigestion" but is precipitated by exertion and relieved by rest.

Which neuropeptides have been studied to interconnect with symptoms of pain, bowel disfunction and stress?

Neuropeptides such as 5 Hydroxytryptophan and substance P mediate interconnected symptoms of pain, bowel dysfunction and stress.

Which position should a patients arm be

Ask patient to keep arms on the side or over chest as placing arms over head will stretch the abdomen and make it hard to palpate structures

2. Abdomen Auscultation

Auscultate the abdomen before palpation as the palpation maneuver may alter the characteristics of the bowel sound. Listen for bruits, peritoneal inflammation or obstruction (BRUITS suggest VASCULAR OCCLUSIVE DISEASE) Listen for bowel sounds, noting their frequency and character (normal sounds should occur at an estimated frequency of 5-34 per minute) Because bowel sounds are widely transmitted, listening in one area (LRG is usually sufficient). ALTERED BOWEL SOUNDS are common in diarrhea, intestinal obstruction, paralytic ileum (inability of bowel to contract correctly and remove waste from the body), peritonitis. If patient has hypertension, auscultate the epigastrium and in each upper quadrant for bruits. When patient sits up, also listen for CVA's. Bruits with systolic and diastolic features suggest turbulent blood flow from atherosclerotic arterial disease. Auscultate over liver and spleen- listen for friction rubs (present in hepatoma, gonococcal infection around liver, splenic infarction and pancreatic carcinoma).

Mechanisms of Abdominal Pain

Before exploring symptoms, one should explore the mechanisms of abdominal pain. There are three broad categories: Visceral Pain Parietal Pain Referred Pain

Causes of Bloating

Bloating may occur with lactose intolerance, inflammatory bowel disease, ovarian cancer

Can the pancreas be palpated?

No. In healthy people, the pancreas cannot be palpated.

Right Lower Quadrant and explanation

Cecum (a pouch connected to the junction of the small and large intestines), appendix, ascending colon, right ovary, bowel loops In the right lower quadrant are bowel loops and the appendix at the base of the cecum which is at the junction of the small and large intestines. in healthy people, these structures are not palpable.

What are signs of colon cancer?

Change in bowel habits with mass lesion

Atypical Respiratory Symptoms of GERD

Chest pain, coughing, wheezing, aspiration pneumonia. Some may also complain of pharyngeal symptoms such as hoarseness, chronic sore throat, laryngitis. A total of 30-90% of patients with asthma and 10% with specialty referral for throat have GERD like symptoms.

Right Upper Quadrant Pain and upper abdominal pain are common in what?

Cholecystitis (inflammation of gallbladder as it is present in RUQ) and cholangitis (A serious infection of the liver's bile ducts).

In splenic exam

Continue to examine patient on right side.

Pelvic Cavity

Continuous with abdominal cavity and contains terminal ureters, bladder, pelvic genital organs, loops of large and small intestine. These organs are partially protected by the surrounding pelvis.

Pink stria indicate what

Cushing Disease

Causes of functional or non-ulcer dyspepsia

Delayed gastric emptying (20-40%) gastritis from Heliicobacter pylori (20-60%) peptic ulcer disease irritable bowel movement disease psychosocial factors

Nausea

Described as "feeling sick to my stomach"it may progress to retching and vomiting. Retching describes involuntary spasm of the stomach, diaphragm, and esophagus that proceeds and culminates in vomiting, the forceful expulsion of gastric contents in the mouth.

Diagnosing criterion for GERD

Heartburn, regurgitation mucosal damage on endoscopy Risk factors include reduced salivary flow which slows down acid clearance by dampening action of the bicarbonate buffer present in saliva Obesity resulting in delayed gastric emptying selected medications hiatal hernia (a condition in which a part of the stomach pushes up through the diaphragm)

Asymmetry of abdomen suggests what?

Hernia or enlarged organ

Classification of abdominal masses

Physiological- pregnant uterus Inflammatory- diverticulitis obstructive- distended bladder or dilated loop orbowel

Suprapubic bulge suggests what?

Distended bulge, pregnant uterus ventral femoral or inguinal hernias.

Quadrants of the stomach

Divided into four quadrants at the umbilicus: Upper right, lower right Upper left, lower left

Alarm symptoms of GERD

Dysphagia (difficulty swallowing) Odynophagia (pain with swallowing) Recurrent vomiting Evidence of blood in GI tract Early satiety Weight loss anemia Risk Factors for Gastric Cancer Palpable mass Painless jaundice Patients with alarm symptoms and uncomplicated GERD, age 55 and up warrant endoscopy to evaluate possible esophagitis, peptic strictures (endstage result of chronic reflux esophagitis), Barrett esophagus or esophageal cancer.

Reasons for liver dullness

Enlarged liver Dullness from right pleural effusion or consolidated lung may falsely increase liver size causing dullness Liver dullness may be displaced downwards by the diaphragm in COPD, the span however remains normal.

which areas would you examine last during an abdominal examination?

Examine areas of pain last, have the patient point to these areas.

Neuroregulatory control of bladder

Functions at several levels: In infants: bladder empties by reflex mechanisms into the sacral spinal cord. Voluntary control of bladder is related to higher brain centers and motor and sensory pathways connecting the brain and the reflex arcs of the sacral spinal cord.

Epigastric pain occurs in which conditions?

GERD, pancreatitis, perforated ulcers.

How could liver size be FALSELY decreased?

Gas in the colon may produce tympanic sounds in RUQ, obscure liver dullness and thus falsely decrease liver size.

Bladder

Hollow reservoir with strong smooth muscle walls composed chiefly of detractor muscle (smooth muscle that lines the walls of the bladder) and can accommodate roughly 400-500 ml of Urine filtered by the kidneys. As urine fills the bladder via the ureters of the kidney, bladder expansion stimulates parasympathetic innervation at low pressures resulting in contraction and relaxation (inhibition) of the detrusor muscle. this occurs under AUTONOMIC control. voiding requires relaxation of the external uretheral sphincter which is made up of striated muscles and this occurs under voluntary control. Rising pressure triggers the urge to void but can be controlled by increased intraurethral pressure.

What technique is helpful in palpating the liver (liver edge) in obese patients?

Hooking technique. Stand to the right side of the patient's chest, hook the liver with both hands side by side on the right side below the area of liver dullness. Ask patient to take a deep breath, liver edge should be felt with pads of both fingers as it descends.

Chronic Lower Abdominal Pain

If chronic pain exists in the lower quadrants of the abdomen, ask about change on bowel habits and altering constipation and diarrhea.

Accuracy of diagnosing GERD

If patients complain of heartburn or regurgitation more than once a week, the accuracy of diagnosing GERD is more than 90%.

Colicky Pain

In contrast to patients with peritonitis who prefer to lie still, patients with colicky pain suffering from pain as a result of a renal stone move around until they find a position that is comfortable for them.

NonSpecific pain

In emergency rooms, 40-50% of patients have non-specific pain but usually 15-30% need surgery for appendicitis, intestinal obstruction or cholecystitis.

Signs of peritonitis

Inflammation of the parietal peritoneum include: Positive Cough Test- Ask patient to cough and note where the cough produces pain. Then palpate gently in that area starting with one finger and then with the hand. Guarding- voluntary contraction of abdominal wall Rigidity-involuntary contraction of abdominal wall Rebound Tenderness- pain expressed after examiner suddenly removes hand after examination and Percussion Tenderness- same is true for percussion tenderness, when clinician removes stethoscope, it produces pain

1. Abdomen Inspection

Inspection: Observe general appearance of patient (is he or she lying quietly, gripping a side, in pain) Observe surface contours, bulges peristalsis, sit or bend to get a tangential view. Note especially: skin (temperature, color, scars, striae (silver strains form age or stretch marks are normal but pink striae are a hallmark for cushing disease), dilated veins (suggest portal hypertension from cirrhosis or inferior vena cava obstruction), rashes or ecchymosis The umbilicus: contour, inflammation or hernia Contour of Abdomen: is it flat, round protuberant, concave or hollowed. Is it symmetric? Asymmetry suggests hernia or enlarged organ or mass. Lower abdomen mass suggests ovarian or uterine cancer. Bulging flanks suggests ascites, suprapubic bulge suggests distended bladder or pregnant uterus and ventral femoral or inguinal hernias. Check for pulsations: normal pulsations frequently visible in epigastrium. Check for increased pulsations which indicate ABDOMINAL AORTIC ANEURYSM (AAA).

How can you test the integrity of sacral nerves that innervate bladder ?

Integrity of sacral nerves that innervate the bladder can be tested by assessing perirectal and perineal sensations in the S2, S3 and S4 dermatomes.

Irritable Bowel Syndrome

Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet like) linked to luminal and mucosal irritants that alter motility, secretion and pain sensitivity.

What to suspect when pain is disproportionate to the physical findings?

It suggests intestinal mesenteric ischemia.

CVA tenderness is discovered on palpation of which organ?

Kidneys

Diffuse abdominal pain with abdominal dissension, HYPERACTIVE HIGH PITCHED BOWEL SOUNDS, tenderness on palpation marks what?

Large or small bowel obstruction.

4. Palpation

Light Palpation: with gentle dipping motions, with hand and forearm in a horizontal plane, fingers together and flat. Move over all 4 quadrants, gently raising hand off skin as you move. Involuntary rigidity to palpation suggests peritoneal inflammation. Ask patient to breathe and after exhale begin palpation, this helps relax muscles. Patient may also breathe through mouth with jaws wide open. Deep Palpation: Usually done to delineate the liver edge, the kidneys and abdominal masses. Using palmar surfaces, press down with both hands in all 4 quadrants. Identify any masses. Note their location, size, shape, consistency, tenderness, pulsations and any mobility with respiration or pressure from the examining hand. Correlate finding with percussion notes.

Contents of Right Upper Quadrant and Explanation

Liver , gallbladder, pylorus (opening from the stomach to the duodenum), duodenum (first part of the small intestine leading directly into the jejunum), hepatic flexure of (receives blood from superior mesenteric artery) and head of pancreas. The soft consistency of the liver makes it difficult to palpate through the abdominal wall. The lower margin and edge of the liver are often palpable at the right costal margin. The gall bladder which lies at the inferior surface of the liver and more deeply, the duodenum are often not palpable. Medially, the stomach is present near the xiphoid process. The abdominal aorta often has visible pulsations and is often palpable in upper abdomen or epigastrium. At a deeper level, the lower pole of right kidney and tip of 12th floating rib may be palpable especially in children and thin individuals with relaxed abdominal muscles.

Visceral Pain in RUQ Suggests

Liver dissension against its capsule from various causes of hepatitis including alcoholic hepatitis.

Cramping Pain radiating to right lower quadrant or Left Lower Quadrant or groin

May be a renal stone

The Liver- Percussion

Measure vertical span of liver using the following steps: 1. In order to measure span of liver dullness in right mid clavicular line, carefully locate the midclavicular line. Use light to moderate percussion strike as a heavy strike will lead to underestimating liver size. Start below the umbilicus in an area of tympani, not dullness, percuss upward toward the liver. Identify lower border in midclavicular line. 2. In order to measure dullness in upper border of liver, start at nipple line (in an area of tympany) and percuss downward toward the midclavicular line until it becomes dull. Outline the upper border. Normal is about 6-12 cm in midclavicular line and 4-8 cm in midsternal line

What is intraurethral pressure related to?

Note: urethra comes out bladder and ureters exit the kidneys and enter the bladder. Intraurethral pressure is related to smooth muscle tone in the internal urethral sphincter , thickens of urethral mucosa and in women, sufficient support to the bladder and proximal urethra from pelvic muscles and ligaments to maintain proper anatomical relationships.

Visceral Pain

Occurs when hollow abdominal organs such as intestines and biliary tree are distended or contract unusually forcefully or stretched. Solid organs such as the liver may also become painful when their capsules are stretched. Visceral pain may be difficult to localize. It is typically palpable at the midline but depends on which structures are involved. Ischemia also stimulates visceral pain fibers. Visceral pain varies in quality and may be gnawing, burning, cramping or aching. When it becomes severe, sweating, pallor, nausea, vomiting and restlessness may follow.

On inspiration, how far is the liver palpable and where?

On inspiration, liver is palpable about 3 cm below the right costal margin in the midclavicular line.

Parietal Pain

Originates from inflammation of the parietal peritoneum (portion that lines abdominal and pelvic cavities) known as peritonitis. Steady aching pain, usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by coughing or moving and patients with parietal pain usually prefer to lie still.

Examples of referred pain

Pain from pleurisy (inflammation of the tissues that line the lung and chest cavity) and MI may be referred to the epigastric area masked as abdominal pain.

Lower Abdominal Pain and Discomfort

Pain may be acute or chronic. Ask patients to point to the pain. Acute Lower Abdominal Pain Patients may complain of acute pain localized in the Right Lower Quadrant. Find out if it is sharp and continuous or intermittent, cramping causing them to double over.

Abdominal Pain and Associated Gastrointestinal Symptoms

Patients often experience abdominal pain in conjunction with other symptoms such. Ask "How is your appetite?" then pursue symptoms such as nausea, vomiting, anorexia.

Patients with which type of pain prefer to stay still and even coughing or movement causes them pain?

Patients with parietal pain.

How to assess percussion of non-palpable liver

Place left hand on lower right rib cage and gently strike hand with lunar surface of right fist. Ask patient to compare sensation with that produced by a smiliar stroke on the opposite side.

2. Palpation

Place your left hand below the 11th and 12th rib of the patient. Remind the patient to relax again on that hand. This hand should be placed parallel to the point where you will examine the liver (right upper quadrant). Start lateral to rectus muscle with fingers well below the border of liver dullness. Some prefer to point the fingers up to patients head, others observe a more oblique angle. Ask patient to take in a deep breath , try to feel liver edge as it slides down to meet your finger. (Normal liver is soft, sharp and regular with smooth surface). Note tenderness (normal liver may be slightly tender) FIRMNESS OR ROUNDNESS OF ITS EDGE and surface irregularities are signs of liver disease,

Gastrointestinal Complaints

Rank high among reasons for office and emergency room visits. You will encounter a wide variety of upper GI symptoms including abdominal pain, nausea, heartburn, vomiting stomach content or blood, difficulty or pain with swallowing, loss of appetite and jaundice. Abdominal pain alone accounted for more than 1.5 million outpatient visits and 11 million emergency room visits in 2011. Lower GI complaints include diarrhea, constipation, change in bowel habits and blood in stool often describes as either bright red or dark and tarry.

Questions you should ask patients with symptoms of upper abdominal pain.

Remember that causes range from being benign to life threatening! Determine TIMING of pain: Is it acute or chronic? Did the pain start suddenly or gradually? when did it begin and how long does it last? What is the pattern over 24 hours? Over weeks or months? Ask patient to describe pain in their own words (if they can't throw out words like gnawing, burning, burning). Ask patient to point to pain (often helpful in identifying the quadrant pain is in and thus the underlying organs that may be involved. If they have clothes on repeat this step as part of the physical examination). Ask patient to rank severity of pain but keep in mind that pain threshold varies from individual to individual. Play important attention to factors that aggravate or alleviate pain especially body positions, associations with meals, alcohol, medications including aspirin and aspirin like products, stress and use of antacids. Ask if indigestion or discomfort is relieved by rest.

Left Lower Quadrant Contents and explanation

Sigmoid colon (is the part of the large intestine that is closest to the rectum and anus), descending colon, left ovary In the left lower quadrant you can often palpate the firm sigmoid colon, the portions of the transverse and descending colon especially if a stool is present. In the lower midline are the bladder, sacral promontory consisting of the bony anterior edge of S1 and in women the uterus and ovaries.

Left Lower Quadrant (LLQ Pain) especially with palpable mass

Signals Diverticulitis (An inflammation or infection in one or more small pouches in the digestive tract).

If the there is inflammation of the peritoneum in the right upper quadrant, what organ do you suspect is causing it.

Since parietal pain is localized, generally over the area causing it, in this case it will be one or more of the organs in the right upper quadrant (example: spleen).

Regurgitation

Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching, called regurgitation. It occurs in GERD, esophageal stricture (is a narrowing of the esophagus) and esophageal cancer.

The spleen and its enlargement

Spleen enlarges and moves, anteriorly and downward medially below the costal margins.It creates dullness on percussion of the stomach suggesting enlargement, however, dullness may be absent if enlarged spleen lies above costal margins.

Left upper quadrant contents and explanation

Spleen, splenic flexure of colon (is a watershed region as it receives dual blood supply from the terminal branches of the superior mesenteric artery and the inferior mesenteric artery, thus making it prone to ischemic damage in cases of low blood pressure because it does not have its own primary source of blood), stomach, body and tail of pancreas, transverse colon The spleen lies lateral to and behind the stomach just above the left kidney in the left midaxillary line. Its upper portion lies in the dome of the diaphragms. The 9th, 10th and 11th ribs protect the spleen. The tip of the spleen is palpable below the left costal margin in a small percentage of people. Only unhealthy people with enlarged spleens (splenomegaly) can the spleen be palpated. In healthy people, pancreas cannot be palpated.

Organs not palpable by hand in abdomen region

Stomach, spleen, much of the liver. These organs lie high in the abdomen cavity close to the diaphragm where they are protected by the thoracic ribs beyond the reach of the palpating hand. The dome of the diaphragm lies at about the 5th anterior intercostal space.

Landmarks of Abdomen

Xiphoid process costal margin: cartilage that attach the ribs to sternum Rectus Abdominis Midline overlying linea alba Umbilicus: right over belly button Iliac Crest Anterior superior iliac spine (more anterior) Inguinal ligament Pubic tubercle Pubic symphysis

Discomfort

Subjective negative feeling that is non-painful and can include various symptoms such as bloating, nausea, upper abdominal fullness and heartburn

Pancreatic pain signal

Sudden knife like epigastric pain often radiating to the back is typical of pancreatitis.

Visceral Periumbilical Pain

Suggests acute appendicitis from distension of an inflamed appendix. It gradually changes to parietal pain in the Right Lower quadrant (RLQ) from inflammation of the adjacent parietal peritoneum.

Which region describes the location of the bladder the best?

Suprapubic or hypogastric

Urinary and Renal Disorders

Suprapubic pain Difficulty urinating (dysuria), urgency, frequency Hesitancy, reduced stream in males Excessive urination (polyuria) Excessive urination at night (nocturia) Urinary incontinence Blood in uric hematuria Flank pain in ureteral colic (usually from stones or infection)

Right Lower Quadrant Pain migrating from Umbilicus

Suspicious of appendicitis, combined with abdominal wall rigidity on palpation. In women, for RLQ pain, you must consider pelvic inflammatory disease, ruptured ovarian follicle and ectopic pregnancy . combining the signs with laboratory markers and CT scans avoids unnecessary survey and misdiagnosis.

What does tenderness OVER liver suggest?

Tenderness over liver suggests inflammation due to CHF AND/OR HEPATITIS

Location of abdomen or abdominopelvic cavity

The abdomen or abdominopelvic cavity lies between the thoracic and pelvic cavity and contains two continuous cavities, the abdominal cavity and the pelvic cavity enclosed by a flexible multilayered wall of muscles and sheet like tendons. This extended cavity houses most of the digestive organs, the spleen and parts of the urogenital system. Lining this cavity and folding over viscera such as the stomach and intestines are the parietal and visceral peritoneum.

Costovertebral angle tenderness

The costovertebral angle is formed between the inferior border of the 12th rib and the transverse process of upper lumbar vertebrae. This angle determines the point where you should check for kidney tenderness.

Where does the dome of the thoracic diaphragm lie?

The dome of the diaphragm lies at the 5th anterior intercostal space.

Kidneys

The kidneys are retro peritoneal (posterior to the peritoneal) organs. The ribs cover their upper poles. The costovertebral angle formed by the inferior border of the 12th vertebrae and the transverse process of upper lumbar vertebrae defines where to examine for kidney tenderness, called costovertebral angle tenderness.

Traube space

The space in which the spleen lies: border of cardiac dullness from 6th rib to anterior axillary line and down costal margin. As you percuss these areas, note the lateral extend of tympani.

Can spleen be palpated?

The spleen is part of the left upper quadrant and lies lateral to and posterior to the stomach in the left axillary line above the left kidney. It is protected by the 9th, 10th and 11th ribs. Only its tip can be palpated in a small percentage of people.

3. Abdomen Percussion

This step helps you assess the amount of air/gas distribution in abdomen. Percuss abdomen lightly in all quadrants to determine distribution of tympani and dullness. Briefly percuss lower anterior chest: on right you will find dullness from liver and on left the gastric air bubble that overlies the splenic flexure of colon. In rare case of situs invertus, spleen (air filled area) is on left and liver is on right (area of dullness). A protuberant abdomen that is tympanic throughout suggest intestinal obstruction or paralytic ileus. Dull areas characterize a pregnant uterus, ovarian tumor, distended bladder, large liver or spleen. Dullness in both areas (flanks) also prompts assessment for ascites which are causing fluid to fill in this area.

Functional or non ulcer dyspepsia

To make the diagnosis for non-ulcer dyspepsia, patients need to have non-specific symptoms of abdominal discomfort or nausea that do not attribute to structural abnormalities or peptic ulcers for at least 3 months. Symptoms are usually present and recurring for more than 6 months.

Sections of abdomen

Usually divided into 9 sections, of these 3 are as follows: Abdominal space, umbilical space, hypogastric or suprapubic space

Voluntary control of voiding

When a person needs to hold their void, such as when they are not able to find a place to go, the higher centers of the brain can inhibit detrusor contractions until the capacity of the bladder exceeds 400-500ml.

When is it not good to suggest dyspepsia?

When conditions of discomfort such as bloating, belching, and nausea occur alone, they do not meet the criterion of dyspepsia.

When is liver span decreased?

When liver is small, air below diaphragm as from perforated bowel or hollow visceral, hepatitis, hear failure, and less commonly with progression of fulminant hepatitis ( massive necrosis of liver parenchyma and a decrease in liver size).

How could liver size be FALSELY increased?

When there is pleural effusion or consolidated lung, this may increase liver dullness and hence falsely increase its size.

Obstructed Distended gallbladder

may merge with the liver on palpation (its is a firmly oval mass below liver edge and may be dull in the area)

Lower abdomen mass suggests what?

ovarian or uterine cancer

Referred Pain

pain experienced at distant sites which are innervated at approximately the same spinal levels as the disordered structures. Referred pain develops as the initial pain becomes more intense and begins to radiate or travel from the initial site. It may be palpated superficially or deeply but it is usually localized. Pain may also be referred to the abdomen from the chest, pelvis and/or spine making this a very complicated assessment.

Dyspepsia

pain or discomfort in digestion; also known as indigestion. It is defined as chronic or recurrent discomfort or pain centered in the upper abdomen characterized by postprandial fullness, early satiety and epigastric pain or burning. Characterized by various symptoms such as bloating, nausea, upper abdominal fullness and heartburn

Pain with ABSENT BOWEL SOUNDS, rigidity, percussion tenderness and guarding points to

peritonitis (inflammation of the peritoneum-the membrane lining the abdominal wall and covering the abdominal organs.) Decreased then absent sounds may also be present in dynamic ilues (is the failure of passage of enteric contents through the small bowel and colon that are not mechanically obstructed. Essentially it represents the paralysis of intestinal motility).

What is the abdominopelvic cavity lined by?

the parietal and visceral peritoneum