NR509 Chapter 19 Abdominal

Right-sided rectal tenderness suggests __________ but may also be caused by an inflamed adnexa or seminal vesicle

Appendicitis

Obstipation defined.

severe constipation with inability to pass both stool and gas

Rome IV criteria

stipulate that constipation should be present for the last 3 months with symptom onset at least 6 months prior to diagnosis and should have at least two of the following conditions: less than three bowel movements per week, ≥25% or more defecations with either straining or sensation of incomplete evacuation, lumpy or hard stools, or manual facilitation.

A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an?

AAA

Common concerning symptoms of the ABD

ABD pain acute and chronic Indigestion, vomiting, hematamesis, loss of appetite, early satiety dysphagia or odynophagia change on bowel function diarrhea constipation juandice

Flank pain, fever, and chills signal?

acute pyelonephritis

Risk factors for AAA

age ≥65 years history of smoking male gender first-degree relative with a history of AAA repair.

Things that aggravate heartburn?

alcohol; chocolate; citrus fruits; coffee; onions; and peppermint; or positions like bending over, exercising, lifting, or lying supine.

In chronic liver disease, finding an enlarged palpable liver edge below the ribs is suggestive of?

an enlarged liver and cirrhosis

Thin, pencil-like stool occurs in?

an obstructing "apple-core" lesion of the distal colon.

Factors that aggravate or alleviate ABD pain?

body position, association with meals, alcohol, medications (including aspirin, NSAIDs, and any over-the-counter medications), stress, and use of antacids

Vomiting and nausea with constipation or obstipation are indicative of?

bowel obstruction and warrants further imaging workup.

A hepatic bruit suggests?

carcinoma of the liver or cirrhosis

Dyspepsia defined.

chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by epigastric pain or burning (or both) and postprandial fullness or early satiety (or both). Note that bloating, nausea, or belching can occur alone but also can accompany other disorders. If these conditions occur alone, they do not meet the criteria for dyspepsia.

Involuntary voiding or lack of awareness suggests?

cognitive or neurosensory deficits.

Gallstones or pancreatic, cholangio-, or duodenal carcinoma may obstruct the?

common bile duct

Peritonitis is marked by?

severe diffuse abdominal pain with guarding and rigidity on examination. Patients may or may not have accompanying abdominal distention. persistent involuntary guarding and rigidity

Common concerning urinary and renal disorders

suprapubic pain, dysuria, urgency or frequency, nocturia or polyuria, urinary incontinence, hematuria flank pain and ureteral colic

Murphy sign

tenderness in the right subcostal area on inspiration, associated with acute cholecystitis

Pain of duodenal or pancreatic origin may be referred to?

the back, pain from the biliary tree, to the right scapular region or the right posterior thorax.

Pain from pleurisy or inferior wall myocardial infarction may be referred to?

the epigastric area.

Ascites reflects?

the increased hydrostatic pressure in cirrhosis (the most common cause of ascites), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It may signal decreased osmotic pressure in nephrotic syndrome, malnutrition, or ovarian cancer.

Carotenemia

the presence of the orange pigment carotene in the blood due to ingestion of carrots, presents as a yellow discoloration of the skin, especially palms and soles, but not the sclera or mucous membranes.

A change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign

this sign is only moderately useful for detecting splenomegaly

Patients who have _________________________ warrant endoscopy to evaluate possible esophagitis, peptic strictures, Barrett esophagus, or esophageal cancer.

uncomplicated GERD who fail empiric therapy, age >55 years, and "alarm symptoms"

Bruits in the epigastrium are suspicious for?

renal artery stenosis or renovascular hypertension

Pink-purple striae are a hallmark of?

Cushing syndrome

Structures of the LLQ

Sigmoid colon, descending colon, and left ovary

Angina from inferior wall coronary artery disease may present as?

"indigestion," but is precipitated by exertion and relieved by rest.

Epigastric pain can occur with?

(GERD), pancreatitis, and perforated duodenal ulcers.

Neuropeptides such as _________ and _____________ mediate interconnected symptoms of pain, bowel dysfunction, and stress.

5-hydroxytryptophan and substance P

Screening for Colorectal Cancer USPSTF

Adults age 50 to 75 yrs—options (grade A recommendation) stool-based tests q1-3 yeras, direct visualization Colonoscopy every 10 yrs Sigmoidoscopy every 5 yrs Flexible sigmoidoscopy every 10 yrs with FIT every 3 yrs Adults age 76 to 85 yrs—individualized decision making (grade C recommendation) Adults older than age 85—do not screen (grade D recommendation)

medication-induced constipation?

Anticholinergic agents, antidepressants, calcium-channel blockers, calcium and iron supplements, and opioids

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for?

Appendicitis in women consider (PID), ruptured ovarian follicle, and ectopic pregnancy.

McBurney Sign

Appendicitis is twice as likely in the presence of RLQ tenderness it is three times more likely if there is McBurney point tenderness (McBurney sign)

Rovsing sign

Pain in the RLQ during left-sided pressure is a positive Rovsing sign with the patient supine, press deeply and evenly in the LLQ. Then quickly withdraw your fingers.

Nonspecific diffuse abdominal pain with abdominal distention, nausea, emesis, and lack of flatus and/or bowel movements is symptomatic of?

Bowel obstruction

Structures of the RLQ

Cecum, appendix, ascending colon, terminal ileum, and right ovary

Pain in the LLQ accompanied by diarrhea in a patient with a history of constipation is suggestive of?

Diverticulitis

A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient?

Do not screen routinely Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years.

A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA?

History of smoking

Obturator sign

Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Internal rotation of the hip

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation?

Functional change in bowel movement Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS).

If patients report heartburn and effortless regurgitation together more than once a week, the accuracy of diagnosing _________is over 90%.

GERD

Regurgitation is a common symptom of?

GERD however, it can also be a presenting symptom of esophageal stricture, Zenker diverticulum, or esophageal or gastric malignancy.

Mechanisms of Jaundice

Increased production of bilirubin Decreased uptake of bilirubin by the hepatocytes Decreased ability of the liver to conjugate bilirubin Decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood

Risk factors for liver disease.

Infectious hepatitis Nonalcoholic steatohepatitis Alcoholic hepatitis or alcoholic cirrhosis Toxic liver damage Gallbladder disease or prior surgery Hereditary disorders

Does the skin itch without other obvious explanation? Why?

Itching or pruritus occurs in cholestatic or obstructive jaundice when bilirubin levels are markedly elevated.

Firmness or hardness of the liver, bluntness or rounding of its edge, and surface irregularity are suspicious for?

Liver disease

A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly?

Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration.

Steatorrhea

Oily residue, sometimes frothy or floating fatty diarrheal stools from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.

Acute Appendicitis

Right lower quadrant signs are typical of acute appendicitis but may be absent early in the course. The typical area of tenderness, McBurney point,

Structures of the RUQ

liver, gallbladder, pylorus, duodenum, hepatic flexure of the colon, and head of the pancreas

An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis?

Ruptured tubal (or ectopic) pregnancy Rationale:The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery.

Acute Cholecystitis

Signs are maximal in the right upper quadrant. Check for Murphy sign

Structures of the LUQ

Spleen, splenic flexure of the colon, stomach, and body and tail of pancreas

Small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in

rectal inflammatory conditions.

"Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding, and rebound in the right lower quadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness. Psoas sign positive."

These findings suggest peritonitis from possible appendicitis.

IBD

Ulcerative colitis (acute) and Crohn's disease(chronic)

acholic stools

When excretion of bile into the intestine is completely obstructed, the stools become gray or light colored, or acholic, without bile. Liver failure

Psoas sign

With the patient supine, place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient's right thigh at the hip. Flexion of the thigh at the hip makes the psoas muscle contract; extension stretches it.

Functional, or non-ulcer, dyspepsia defined.

a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD). Symptoms are usually recurring and present for more than 6 months.

Acute Diverticulitis

a confined inflammatory process, usually in the left lower quadrant, that involves the sigmoid colon. If the sigmoid colon is redundant there may be suprapubic or right-sided pain. Look for localized peritoneal signs and a tender underlying mass. Microperforation, abscess, and obstruction may ensue.

Diagnostic criteria for IBS?

a diagnosis of exclusion and requires 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.

Barrett's esophagus

a metaplastic change in the esophageal lining from normal squamous to columnar epithelium. In those affected, dysplasia on endoscopy increases the risk of esophageal cancer from 0.1% to 0.5% (no dysplasia) to 6% to 19% per patient year (high-grade dysplasia).

Discomfort defined as

a subjective negative feeling that is nonpainful. It can include various symptoms such as bloating, nausea, upper abdominal fullness, and heartburn.

jaundice or icterus

a yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. Jaundice is usually apparent when plasma bilirubin is >3 mg/dL. The yellow color may have a greenish tinge in patients with longstanding jaundice, due to oxidation of bilirubin to biliverdin.

If fullness or early satiety, consider?

diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, and gastric cancer.

Alarm symptoms of GERD

dysphagia, odynophagia, recurrent vomiting, GI bleeding, early satiety, weight loss, anemia, risk factors for GI cancer, palpable mass, painless jaundice 50-80% have no disease.

Visceral periumbilical pain can be suggestive of?

early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum.

Acute Pancreatitis

epigastric tenderness and rebound tenderness and localized guarding are usually present, but the abdominal wall may be soft.

Hematemesis may accompany?

esophageal or gastric varices, Mallory-Weiss tears, or PUD

Angina from inferior wall coronary ischemia along the diaphragm may also present as?

heartburn

Painful jaundice is commonly infectious in

hepatitis A and cholangitis

Friction rubs found on abdominal examination?

hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma.

For pain disproportionate to physical findings, suspect?

intestinal mesenteric ischemia.

A protuberant abdomen that is tympanitic throughout suggests?

intestinal obstruction or paralytic ileus.

Ecchymosis of the abdominal wall is seen in?

intraperitoneal or retroperitoneal hemorrhage

Bloating may occur with?

lactose intolerance, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and GERD, to early presentation of malignancies.

Change in bowel habits with a palpable mass warns of?

late-stage colon cancer.

Visceral pain in the RUQ suggests?

liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis or biliary pathology.

Painless jaundice points to?

malignant obstruction of the bile ducts, seen in duodenal or pancreatic carcinoma;

Tenderness of Peritoneal Inflammation

more severe than visceral tenderness. Muscular rigidity and rebound tenderness are frequently but not necessarily present. Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with board-like muscular rigidity. These signs on palpation, especially abdominal rigidity, double the likelihood of peritonitis.

Cramping pain radiating to the flank or groin accompanied by urinary symptoms may be suggestive of?

nephrolithiasis (renal stone).

Visceral pain

occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. Nonspecific and difficult to localize. Ischemia stimulates visceral pain fibers. gnawing, cramping or aching

referred pain

often develops as the initial pain becomes more intense and seems to radiate or travel from the initial site. Palpation at the site of referred pain often does not result in tenderness.

Abdominal pain key information

onset location: where in the viscera character: visceral or somatic radiation: presence or absence palliative, provoking, or associated factors: relief with vomit, increased pain with eating, anorexia, fever, diarrhea and constipation PMH, surgical and social: hx of previous ABD surgery, smoking, elicit drug use, STI, and infertility

Causes of bladder distention

outlet obstruction from a urethral stricture or prostatic hyperplasia; medication side effects; and neurologic disorders, such as stroke and multiple sclerosis.

somatic or parietal pain

pain originates from inflammation of the parietal peritoneum, called peritonitis, which can be localized or diffuse. steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. aggravated by movement or coughing prefer to lie still

Arterial bruits with both systolic and diastolic components suggest?

partial occlusion of the aorta or large arteries.

Diarrhea is common with use of?

penicillin and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines.

Patients who have _________ require surgical evaluation urgently.

peritonitis

Abdominal masses may be categorized in these ways:

physiologic (pregnant uterus) inflammatory (diverticulitis) vascular (an AAA) neoplastic (colon cancer) obstructive (a distended bladder or dilated loop of bowel)

Dilated veins on inspection of the abdomen suggest?

portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction.

Causes of splenomegaly

portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma.

Signs of peritonitis

positive cough test involuntary guarding rigidity (4x more likely) rebound tenderness percussion tenderness.

Anorexia, nausea, and vomiting accompany many disorders ranging from benign to more insidious, including?

pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, and adverse drug reactions. Induced vomiting without nausea is more indicative of bulimia.