Exam of Abdomen

What are the two divisions of the abdomen?

Four quadrant and nine region. Four quadrant self explanatory Epigastric, umbilical, hypogastric is middle Right and left hypochondriac, flank, and inguinal are on the sides.

With acute abdomen, what signs indicate peritonitis?

Abdominal distention (protuberance), with tympany on percussion Tenderness to palpation Rebound tenderness Increased or decreased bowel sounds Cutaneous hypersensitivity Rigidity (involuntary spasm of abdominal wall musculature)

Where should the umbilicus be located in a normal individual, without previous surgery or pregnancy? What does hepatomegaly do? What do pelvic tumors and pregnancy do?

Absence of a history of pregnancy or a history of surgery, umbilicus should be located within 1 cm of midpoint between symphisis pubis and xiphoid. Hepatomegaly stretches upper abdominal segment so umbilicus is displaced down. Distance between xiphoid and umbilicus is at least 2 cm longer than distance from umbilicus to symphysis pubis. Pelvic tumors and pregnancy displace umbilicus down. Distance between umbilicus and symphysis pubis is at least 2 cm longer than distance from umbilicus to xiphoid.

Nodularity of lower liver edge occurs in what 2 pathologies?? Pulsatile Liver indicates what (2 things)? What is Riedel's Lobe?

Alcoholic Cirrhosis, metastatic cancer Pulsatile liver indicates tricuspid regurg or constrictive pericarditis (can be in severe tricuspid stenosis) AKA backup of right heart Long tail to the right lobe of the liver that may be palpable many centimeters below right costal margin. Normal anatomic variant, does not mean hepatomegaly.

Describe Anorexia Vomiting Early Satiety Dysphagia Odynophagia Diarrhea Constipation (include things that you don't already know)

Anorexia - loss of appetitie Vomiting - Bright red, or black coffee indicates GI bleeding. Greenish may be bowel obstruction. Early satiety - inability to eat full meal, may be tumor, motility (diabetic neuropathy) or psychological (anorexia). Dysphagia - difficulty swallowing. Structural or motility. May be at risk for aspiration. Odynophagia - pain w/ swallowing. Can occur with ulcerations of esophagus, exposure to caustic agents, infections like herpes, candidiasis of esophagus. ^ these can be considered alarm symptoms Diarrhea - excess of 200g/day. Acute less than two weeks. Chronic over 4. Constipation - is <3 bowel movements per week, with hard stools.

Palpation and Cutaneous hypersensitivity - this may develop on abdominal wall overlying areas of peritoneal irritation: What might cause RLQ CH? What is Boas' sign? What is Kehr's sign? What might early shingles do?

Appendicitis Boas' sign - CH over posterior right lower libs occuring w/ inflammation of gallbladder (acute cholecystitis) Kehr's sign - CH over left shoulder, secondary to diaphragmatic irritation after splenic rupture. Early herpes zoster (shingles) prior to onset of typical rash may cause sever abdominal pain and CH.

What is the scratch test?

Auscultation of liver while scratching parallel to costal margin - used by some to detect lower liver margin when ascites or obesity present. Also not reliable.

Tenderness is term given to pain produced by palpation. What is direct vs indirect tenderness?

Direct - caused by localized inflammation of abdominal wall, peritoneum, or hollow organ. Solid organ may be tender when capsule stretched. Indirect - Develops at location distant to site of pathology as a result of peritoneal irritation. Rovsing's sign (palpate LLQ, causing RLQ pain, is example).

Abdominal lymphadenopathy is usually asymptomatic - but what are some signs and symptoms that result from lymph node enlargement in the abdominal cavity?

Dull, poorly localized abdominal pain, secondary to compression of ANS fibers w/ visceral pain (referred to any internal organs) Backache Ureteral obstruction Peripheral lower extremity edema Constipation/diarrhea These problems dont usually start until nodes are larger than 3-4cm. If large enough, can cause vascular bruits.

What is Grey Turner's Sign?

Ecchymosis in one or both flanks. Occurs in conditions with RETROPERITONEAL AND INTRAPERITONEAL BLEEDING, and blood collecting in subcutaneous fascial planes: Examples including ovarian cyst hemorrhage, hemorrhagic ascites secondary to metastatic cancer, bilateral salpingitis, strangulated bowel with hemorrhage, pancreatitis

What is Costovertebral angle tenderness? What if this same technique is applied at the RUQ/lower ribs?

Elicited by striking soft tissues of costovertebral angle on each side with heel of hand. Tenderness here indicates inflammation of or around kidney (pyelonephritis) Liver tenderness also assessed by striking RUQ and lower ribs with heel of hand. Tenderness found in acute hepatitis or acute cholecystitis

Hepatomegaly - when does this occur? What might alcoholic cirrhosis do, early and late? What might also might reduce liver size?

Fatty liver disease, amyloidosis, neoplastic infiltration, acute inflammation, passive venous congestion due to right heart failure. Alcoholic cirrhosis may cause massively enlarged liver, but end staged cirrhosis will show shrunken liver less than 6 cm in size vertical in MCL. Acute massive hepatocellular necrosis causes reduction in liver size.

Rectal exam: How is this done? What is the retrovesical pouch? Blumers shelf? Stool Guaiac testing?

Finger in distal rectum detects rectal carcinoma, perirectal abscess, tuboovarian abscess, uterine lesions, and appendiceal abcess. Retrovesical pouch of peritoneum lies anterior and superior to examining finger when directed toward navel. Patients w/ metastatic intra abdominal cancer, deposits occur here. Examiner will detect hard shelf (Blumers shelf) on digital exam. Stool guaiac testing can provide important clues to important intraabdominal pathology. Guaiac positive stool present in conditions associated w passage of blood thru GI tract.

What do RLQ masses represent? LLQ? RUQ? LUQ? Epigastric masses? Hypogastric masses? For these, I'll write out the bolded terms, be semi familiar with the non bolded ones.

RLQ: Feces in right colon, ovarian cyst LLQ: Feces in left colon, ovarian cyst, diverticular abcess RUQ: Hepatomegaly, enlarged gallbladder, enlarged kidney LUQ: Enlarged Spleen, enlarged lft kidney Epigastric: Enlarged Left liver lobe, Aortic aneursym Hypogastric: Increased uterine size (pregnancy, enlarged bladder).

Rectal Kidney Ureteral

Rectal pain lies deep within pelvis, poorly localized, often associated with need to defecate. Kidney pain may localize to RUQ, LUQ, left flank, right flank, or costovertebral angles. Fairly constant, moderately sever when due to kidney infection (pyelonephritis). Often presents with systemic signs of infection (fever, chills, malaise) Ureteral pain occurs in LLQ or RLQ and radiates to testicles or labia. Excruciatingly severe when passing renal calculus (kidney stone). Will come in waves until stone is passed. Microscopic hematuria usually means renal calculus

Retroperitoneal nodes consist of which nodes, draining what?

Sacral, internal iliac, external iliac, common iliac, para aortic. These drain rectum, prostate, cervix, uterus, fallopian tubes, bladder, urethra, kidneys, adrenals, AAW, ovaries, testes.

What does a scaphoid abdomen mean? What does a flat abdomen mean? What does a protuberant abdomen mean, and what are the six F's?

Scaphoid is concave, happens in malnourished Flat abdomen typical with non obese adults Protuberant (abdominal distention): Fat Fluid (ascites) Flatus Fetus Feces Fatal Growths

What is a succussion splash? Where is this considered a problem?

Sloshing sound heard through stethoscope during sudden movement of patient, reflecting presence of gas and fluid in an obstructed organ. LUQ or midepigastric splash 2 hours after water or 5 hours after meal indicates delayed gastric emptying. Pyloric channel ulcer can cause gastric outlet to swell, preventing emptying.

Small Intestine pain Appendicitis (McBurney, Rovsing's) Colon

Small intestine presents as crampy periumbilical discomfort. Can be caused by intestinal ischemia. Appendicitis causes nausea, periumbilical pain. Can peak in intensity at 4-6 hours, may subside and reappear in RLQ at Mcburney's point. Rovsing's sign is pain in RLQ when pressure on LLQ. Colon localizes to RLQ and LLQ, pain may be constant or occur in spasms. May be associated w/ or relieved by defecation.

What is a fluid wave?

Something generated by tapping one side of abdominal wall while palpating for presence of shock wave on oposite side. High specificity for ascites. Most useful test.

How can Splenic Percussion be used to determine splenomegaly?

Splenic percussion over lowest left intercostal space in anterior axillary line usually makes tympany. During mild enlargment, percussion here produces dullness. Change in percussion note indicates splenomegaly. (positive splenic percussion sign).

What can an enlarged spleen be confused w/ ? What helps to differentiate? What is the difference between a dull and tympanic note here?

Stool or kidney. Repeat exam needed to verify. May be difficult to tell LUQ mass due to enlarged spleen from LUQ mass due to enlarged kidney. Prominent notch on medial side of mass is diagnostic for enlarged spleen. Percussion over mass gives rise to dull note if mass is due to enlarged spleen. More tympanitic note if it is due to enlarged kidney, because kidney lies beneath splenic flexure of colon.

What are the five major mechanisms that produce abdominal pain, and what are their causes/presentations?

Stretching of encapsulated organs (liver, spleen, kidneys). Constant and dull in intensity. RUQ pain secondary to liver congestion in CHF, LUQ pain secondary to spleen issues, flank pain secondary to kidney swelling/inflammation (pyelonephritis) Irritation of mucosal lining of esophagus, stomach, duodenum from ulcer or inflammation. Burning pain, severe. Smooth muscle spasm from IBS or viral gastroenteritis. Crampy or colicky. Very common. Peritoneal irritation from appendicitis, diverticulitis, acute cholecystitis. Sharp stabbing pain w/ tenderness on palpation. Direct splanchnic nerve stimulation from pancreatic cancer or AAA can compress, cause poorly localized pain.

Upon liver examination, what is the normal liver size in the adult male? What does it mean if upper margin is found above 6th rib? Below 8th?

9-12 cm in mid clavicular line. Upper liver at 7th or 8th rib anteriorly. If upper margin of hepatic dullness is higher than 6th rib, liver is probably enlarged. If upper margin of hepatic dullness lower than 8th rib, liver is displaced downward by lungs (emphysema)

How are the kidneys palpated? What is normal? Bilaterally enlarged kidneys suggest what? Unilateral? What if one kidney is enlarged and stony hard?

Ballottement - two handed technique where kidney is trapped between two hands. Palpation of kidneys is usually done too low in flanks. Right kidney 1-2 cm lower than left due to liver, may be palpable in thin people. Left kidney never palpable. Bilaterally enlarged kidneys suggest polycystic kidney disease Unilaterally enlarged kidney due to hydronephrosis (can also cause bilateral). One kidney enlarged and stony hard is cancer.

Describe Large bowel mechanical obstruction (ileus). Causes? How does it appear on X Ray?

Can be caused by tumor (colon cancer, usually sigmoid), or diverticulitis (w/ localized inflammation and matting of lymph nodes, leading to obstruction), Also hernias, volvulus, and intussusception just like small bowel. Appears as loops of bowel dilated laterally. Little or small gas may be seen distal to obstruction and in rectal area.

What is ascites? What will you hear over ascites? What are two common causes for it, and what is commonly associated?

Free fluid in peritoneal cavity. Patients usually get it checked out when it causes abdominal distention. Ascites sinks, but bowel loops with gas rise - the ascites will have dullness, and loops will have tympany. Cirrhosis w/ portal HTN and right sided CHF Often times associated with increase in abdominal girth and ankle edema. Most accurate technique is ultrasound.

Often, pain location is a clue to what area it is in. However, sometimes it is poorly localized, and sometimes the origin is outside of abdomen. Describe pain of: Gallbladder disease Pancreatic disease Esophageal

Gallbladder commonly RUQ/epigastric that can radiate to RIGHT SHOULDER BLADE via phrenic nerve, colicky in nature. Pancreatic commonly mid epigastric and radiates STRAIGHT TO BACK. Esophageal is retrosternal and can be confused with angina. Can also be mid epigastric. Esophageal can be ruled in if it is exacerbated by swallowing and maneuvers that increase intra abdominal pressure like bending over at waist may cause reflux.

Gastric Duodenal

Gastric is epigastric in location, can radiate to left shoulder. Occurs during gastric tumors and ulcers. Pain from gastric peptic ulcers may get worse with eating, improve with fasting Duodenal pain is also epigastric. Occurs secondary to duodenal peptic ulcer disease. Develops during fasting, relieved with eating. Patients wake up 4-5 AM with pain, eat to relieve it.

Describe bruits due to liver tumors. What does it mean if it doesnt change with patient position? Does change?

Heard in RUQ. Primary systolic, continuous. Can be caused by hepatomas (liver tumor) and vascular tumors. If they dont change with position, usually neoplasia. If heard only over left lobe, decrease with standing, usually means aortic compression via enlarged liver.

Auscultation. What are the only sounds indicative of anything?

High pitched tinkles and rushes of small bowl obstruction, no particular type of other bowel sound is particularly diagnostic, but presence or absence is important to note. Radiate to all quadrants.

What is Murphy's sign?

Hook fingers under right costal margin from above, ask patient to inspire deeply. "Catch" occurs when there is acute cholecystitis. This sign only argues moderately for acute cholecystitis.

Testing for retroperitoneal irritation. What sign is useful for this? What test is useful for this?

Iliopsoas sign - Patient lies on left side, extends straight leg at hip against resistance applied by examiner. If pelvic pain, retroperitoneal inflamation may be due to ureteral calculus, retroperitoneal bleed, tuboovarian abscess, retrocecal appendicitis. Obturator test - perfomed w/ supine patient flexing thigh to 90 degrees while examiner rotates leg internallly and externally at hip by grasping ankle and knee. Presence of pelvic pain due to inflamed obturator internus, indicates retroperitoneal irritation (retrocecal appendicitis)

Arterial Sounds (Bruits) mean what? Which artery produces the most innocent bruits? What are epigastric systolic bruits? Renal artery bruits w/ systolic AND diastolic components?? Common iliac artery bruit location?

Indicate turbulence in dilated, narrowed, or torturous arteries. They occur in 20% of healthy people. Most common INNOCENT source is celiac artery. Epigastric systolic bruits occur in midline between xiphoid and umbilicus. Can happen normally, but also found in <50% of those with AAAs. Renal Artery Bruits are audible on anterior abdomen 2 in above umbilicus, radiating to flank or costovertebral angle. Abdominal bruit with both systolic and diastolic components is completely diagnostic of renal artery stenosis Common iliac arteries occur midway between umbilicus and inguinal ligament.

Abdominal exam. What is the sequence like?

Inspection, Auscultation, percussion, light palpation, deep palpation . The order is changed so that physical manipulation doesnt change bowel sounds.

Complete absence of bowel sounds is characteristic of what? What is one type of this, causes, and how does it appear on X Ray?

Intestinal ileus (Decrease in bowel motility). Can be mechanical: Anatomical (mechanical) obstruction of bowel lumen - Obstructed bowel will dilate, become congested/edematous, and cease peristalsis. Bowel sounds stop. Small bowel mechanical obstruction may happen due to scar tissue, hernia, volvulus (twisting of small bowel on itself), intussusception (small bowel invaginating) or gallstone impaction. Appear as dilated loops of bowel, centrally.

What might produce the same signs as ascites? How can you differentiate from ascites?

Large ovarian cyst. Can cause bulging flanks and even positive fluid wave, with distended abdomen. However: Percussion of abdomen w/ patient supine usually yields anterior dullness and lateral tympany because cyst forces air filled bowel laterally toward flanks. Ascites yields opposite - tympany anteriorly and dullness laterally.

Increased peristaltic sounds are diagnostic of what? What does hyperperistalsis mean? What does early mechanical small bowel obstruction cause? What must happen as it progresses for you to be sure its acute small bowel obstruction?

Little diagnostic significance. Hyperperistalsis can be characteristic of irritated bowel in gastroenteritis or diarrhea, but also occurs at meal time. Early mechanical small bowel obstruction causes increased bowel sounds associated with waves of pain, called Borborygmi. These happen as small bowel forces its contents through obstruction. High pitched tinkles will start to occur as obstruction progresses (between long periods of silence). This, associated with abdominal distention and vomiting suggests diagnosis of acute small bowel obstruction.

Intraabdominal nodes ?

Located along lesser and greater omentum, gastrosplenic ligament, mesentery, root of large visceral branches of aorta. Drain lower esophagus, stomach, gallbladder, liver, spleen, pancreas, intestines.

What is shifting dullness? Absence of this means what?

Maneuver assessed by percussing abdomen from above to laterally in a supine patient, noting changes from tympany to dullness. When area of dullness shifts to more dependent side (when tympany area shifts towards top) shifting dullness is present. In patient w/out ascites, there is usually no shift in border between tympany and dullness when doing this maneuver. Must have over 500 cc of free fluid. Absence is very useful finding for ruling out ascites as cause for abdominal distention.

What causes splenic enlargement? w/ Jaundice w/ Pallor W/ Lymphadenopathy

Many causes. Splenomegaly w/ jaundice points to hepatic disease w/ portal HTN like in cirrhosis. Splenomegaly and pallor points to leukemia/lymphoma. Splenomegaly w/ lymphadenopathy suggests lymphoma, sarcoidosis, or mono.

Lymph nodes surrounding umbilicus are common site of what? What is Sister Mary Joseph's Nodule?

Metastatic spread from cancers involving intra pelvic and intra abdominal organs Periumbilical nodule or exfoliative mass within or replacing umbilicus called Sister Mary Joseph's nodule is external manifestation of internal malignancy. Sources of malignancy usually stomach, colon, ovary, or pancreas.

Is the spleen typically palpable in the adult? Why shouldnt you do splenic palpation in at risk patients?

No. Splenic enlargment detected by combination of percussion and palpation. Splenic size determination NOT reliable, but if it is palpable, argues STRONGLY for splenomegaly. Splenic palpation is recommended against because of possibility of splenic rupture in patients with mono.

Palpation of internal organs. What organs are normally palpable? Which are not?

Palpable: Liver, lower pole of right kidney, pulsations of AA, descending/sigmoid/ascending colon, cecum, urinary bladder (w/ urine). Not: Gallbladder, pancreas stomach, small bowel, transverse colon, left kidney, spleen.

What is the other cause of Ileus? Causes? X Ray? What will be seen along with it? What rules against diagnosis of bowel obstruction? How long must you listen to determine bowel sounds are absent?

Paralytic Ileus: Conditions that inhibit normal smooth muscle contraction in small and large intestine. Inflammation of bowel, ischemia of bowel, medications, and electrolyte abnormalities. Adynamic ileus can happen after bowel surgery due to maniplation of bowel. Abdominal distention will be seen, and air will be seen on X ray throughout bowel and into rectum. Presence of bowel sounds argues against abdominal obstruction. Before concluding sounds truly absent, examiner must auscultate for at least 5 min. Sometimes in mechanical ileus, 20 min is needed.

Most common cause for a peritoneal friction rub heard in the LUQ? RUQ? What does it mean if there is a RUQ rub w/ systolic bruit?

Peritoneal friction rubs usually spleen or liver. Most common: Splenic infarction. Rub best heard in LUQ, can be caused by splenic abscess and metastatic tumors. RUQ is from the liver. Most commonly from metastatic tumors of the liver, and sometimes liver abscess and hepatitis. Hepatomas can also cause. RUQ rub w/ systolic bruit is considered neoplastic until proven otherwise.

Cullen's sign?

Periumbilical ecchymosis also representing RETROPERITONEAL OR INTRAPERITONEAL BLEEDING. (was first described in ruptured ectopic pregnancy). Blood travels through periumbilical area through falciform ligament.

What is Courvoisier's sign? While not always reliable for its initial purpose, what does it argue strongly for?

Presence of palpably enlarged gallbladder in patient with jaundice. Indicates obstruction of biliary tract w/ cancer. (chronically inflammed gallbladder scarred, cant dilate, but cancer obstruction still can) However not very reliable for biliary tract obstruction. Enlarged gallbladder in jaundice patient argues strongly for extrahepatic obstruction as oppposed to hepatocellular disease (intrahepatic) as cause for jaundice.

What are striae? What about w/ Cushing's syndrome?

Striae - stretch marks that occur as a result of rupture of elastic fibers in reticular layer of skin, caused by chronic stretching. Secondary to obesity, pregnancy, ascites, and expanding tumors. Recent stretch marks - pink. Older, silvery. When associated with Cushing's syndrome (chronic excess cortisol production), straie have purplish hue secondary to erythrocytosis from overproduction of adrenal androgens.

What is "acute abdomen" and what are some causes?

Sudden onset of severe abdominal pain. Indicates urgent need for surgical intervention. Etiologies: Peritonitis Bowel Infarct Perforation of hollow organ (ulcer, appendix) Ruptured AA

What is rebound tenderness/Blumbergs sign?? What is direct vs indirect rebound tenderness? What is the cough test? Positive cough + rigidity + guarding =

Transient, sharp, knife like pain that results when pressure is suddenly released during deep palpation due to peritoneal irritation. Is of little diagnostic value compared to regular palpation for detection of peritonitis (often avoided as a technique). Pain may occur beneath site of pressure (direct rebound) in localized peritoneal inflammation, and at sites remote from involved area (indirect rebound) w/ generalized peritoneal inflammation. Cough test - coughing produces sharp abdominal pain - is a more compassionate way of identifying peritoneal inflammation. Positive cough test, rigidity, and guarding all together argue strongly for peritonitis.

Moving to percussion. Ranges from Dull to Tympanic. When is tympany normal? Pathologic? When will you hear dullness normal? Pathologic?

Tympany is normal over gastric air bubble in LUQ. Generalized tympany will be present in mechanical and paralytic ileus and in the presence of a perforated hollow organ. Dullness to percussion occurs over solid organs, fecal filled bowel, and laterally over flanks in abdominal distention due to ascites.

Describe how hernias look on inspection. Umbilical Hernia Spigelian Hernia Diastasis Rectus

Umbilical hernia - navel protrudes during straining or relaxation. Common in childhood, resolves at 4. In adults- occurs with ascites, pregnancy, emphysema. Spigelial Hernia - presents as tender mass in abdominal wall 3-5 cm above inguinal ligaments Diastasis Rectus - not a true hernia. Separation of rectus muscles results in linear midline bulge with increased intraabdominal rpessure. Often be caused by pregnancy or obesity. Finding shows when supine patient lifts his/her head off exam table. Benign, doesnt require attention.

Light Palpation: What is this usually used to assess? How can you tell if a mass is intramural (in abdominal wall) or intra-abdominal?

Used to look for intramural masses, evaluate areas of tenderness prior to deep palpation, and cutaneous hypersensitivity. If palpable mass becomes more prominent when head is raised, mass is intramural (hernias, diastasis rectus) If palpable mass becomes less prominent when head is raised, then mass is intraabdominal.

What about "venous pattern"? Describe normal SVC obstruction IVC obstruction Intrahepatic portal vein obstruction (portal HTN, cirrhosis)

Usually, veins in abdominal wall are barely visible. Above umbilicus, blood flow in abdominal veins usually upward ( cephalad). Below, usually down (caudad). In SVC obstruction, blood flow directon switches to down across whole abdmen IVC obstruction, blood flow in entire abdomen is upward, w/ collateral veins prominent in flanks. Intrahepatic portal vein obstruction (cirrhosis) veins will radiate outward from umbilicus (CAPUT MEDUSA). So its basically flip flopped

What is visible peristalsis and when does it happen? What does the abominal aorta show during inspection?

VP occurs when peristaltic waves are increased in amplitude to degree that they are visible moving across abdominal wall - occurs early in mechanical bowel obstruction AA usually produces slight visible pulsation. Amplitude increased with wide pulse pressure, tortuosity of aorta, or AAA.

Deep Palpation: What is guarding? What is the alternative?

When assessing muscle tone of abdominal wall, contraction may be voluntary or involuntary. Voluntary tensing of wall muscles by patient for fear, anticipation, tickles, cold hands, etc is guarding AKA VOLUNTARY RIGIDITY. Always BILATERAL. Rigidity is INVOLUNTARY reflex muscle spasm of abdominal wall caused by peritoneal irritation. Abdominal wall will not move with respiration. AKA INVOLUNTARY RIGIDITY. May be unilateral OR bilateral depending on pathology.