NUR530 - GI

Report of difficulty swallowing from impaired passage of solid foods or liquids from the mouth to the stomach. Food seems to stick or "not go down right," suggesting motility disorders or structural abnormalities.

dysphagia

Visceral periumbilical pain suggests what

early acute appendicitis from distention of an inflamed appendix

Pain from pleurisy or inferior wall MI may be referred to

epigastric area

Pointing to below the sternoclavicular notch as site of dysophagia suggests

esophageal dysphagia

Hematemesis may accompany what

esophageal or gastric varices, Mallory-Weiss tears or PUD

If there is odynophagia consider

esophageal ulceration from indigestion of asa, or nsaid agents, caustic ingestion, radiation, or infection with candida, cytomegalovirus, herpes, HIV

What would endoscopic evaluation be looking for in someone with GERD

esophagitis, peptic strictures, Barrett's esophagus, esophageal cancer (though about 50% have no disease on endoscopy with GERD)

What abdominal structures often are not palpable:

exceptions to palpation are usually liver, spleen, gallbladder, stomach, pancreas, appendix, ovaries, kidneys

Ask if indigestion or discomfort is related to

exertion relieved by rest

Gas in colon may produce tympany in the RUQ, obscure liver dullness and

falsely decrease estimated liver size

Most common cause of protuberant abdomen. Thickens abdominal wall, mesentery and omentum. Umbilicus may appear sunken. A pannus, or apron of fatty tissue may extend below the inguinal ligaments. Lift to look for inflammation in the skin folds or even for a hidden hernia

fat

Rectal fullness, abdominal pain, diarrhea. common in debilitated, bedridden, and often elderly and institutionalized patients

fecal impaction

Where do you feel the infant's aortic pulsation with palpation

felt on deep palpation to left of midline

Obturator sign

flex patient right thigh at the hip with knee bent and rotate leg internally at hip. this maneuver stretches internal obturator muscle right hypogastric pain is positive obturator sign from irritation of the obturator muscle by inflamed appendix

Rare grating sounds with respiratory variation. Indicate inflammation of peritoneal surface of organ as in liver cancer chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. When systolic bruit accompanies a hepatic friction rub, suspect carcinoma of liver

friction rub

This presents as upper abdominal discomfort or pain with 3 mo history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or PUD. Symptoms are usually recurring and present for more than 6 mo

functional, or nonulcer dyspepsia

Any abnormal finding on a stool test, imaging study, or flexible sigmoidoscopy warrants

further eval with colonoscopy

An obstructed, distended _ may merge with the liver, forming a firm oval mass below the liver edge and an area that is dull to percussion

gallbladder

What might cause obstructions to the common bile duct?

gallstones, or pancreatic, cholangio or duodenal carcinoma

Causes of melena

gastritis GERD peptic, gastric, duodenal ulcer esophageal or gastric varices Mallory weiss tear from retching and vomiting

Organic causes of chronic or recurrent abdominal pain in children include

gastritis, ulcer, GERD, constipation, IBS

What might be some causes of an acute abdomen in a child?

gastroenteritis constipation gastrointestinal obstruction appendicitis

An increase in pitch or frequency of bowel sounds is heard in infants with

gastroenteritis or rarely with intestinal obstruction

The sensation of a lump or foreign body in the throat unrelated to swallowing is called _

globus sensation and is NOT true dysphagia

This is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted

guarding

An enlarged, tender liver may be due to what in the infant

heart failure or due to storage disease

DX criteria for GERD

heartburn and regurgitation together more than once a week or mucosal damage on endoscopy

Many patients with chronic upper abdominal discomfort or pain complain of

heartburn, dysphagia, regurgitation

Red or maroon colored stools

hematochezia

Other disease that may produce similar findings are

hemochromatosis, amyloidosis, lymphoma

Predominantly unconjugated bilirubin occurs from the first 3 mechanisms as in

hemolytic anemia (increased production) and gilbert syndrome

Blood on the surface or toilet paper points to

hemorrhoids

If early satiety also consider

hepatitis

In newborns, causes of hepatomegaly may be

hepatitis, storage disease, vascular congestion-CHF, biliary obstruction

Intrahepatic jaundice can be

hepatocellular (from damage to the hepatocytes) or cholestatic (from impaired excretion as a result of damaged hepatocytes or intrahepatic bile ducts)

Enlarged liver that is firm or hard with irregular edge or surface suggests? May or may not be tender

hepatocellular carcinoma

The abdominal examination may reveal classic findings of liver disease such as

hepatosplenomegaly, ascites, or caput medusae (dilated abdominal veins) may also see jaundice, spider angiomas, palmar erythema, dupuytren contractures, asterixis, gynecomastia

Asymmetry suggests

hernia, mass or enlarged organ

Murphy sign

hook left thumb or fingers of right hand under costal margin at point where lateral border of rectus muscle intersects with costal margin. alternatively, palpate in RUQ with fingers of right hand near costal margin and if the liver is enlarged, hook thumb or fingers under liver edge at comparable point, ask patient to take deep breath which forces liver and gallbladder down toward examining fingers, watch breathing and note degree of tenderness a sharp increase in tenderness with inspiratory effort is a positive murphy sign and triples likelihood of acute cholecystitis

Causes of kidney enlargement include

hydronephrosis, cysts, tumors

Dark urine with jaundice indicates what

impaired excretion of bilirubin into GI tract

Is visualizing peristalsis normal?

in very thin people it can be normal to see peristalsis

This is a protrusion through an operative scar. Palpate to detect length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed has greater risk for complications than large defect

incisional hernia

Ascites reflects the

increased hydrostatic pressure in cirrhosis, heart failure, constrictive pericarditis, inferior vena cava or hepatic vein obstruction

Strongest risk factors for colorectal cancer

increasing age personal hx of colorectal cancer adenamatous polyps long standing inflammatory bowel disease family hx of colorectal neoplasia (particularly those with affected multiple first degree relatives, single first degree relative dx before age 60, hereditary colorectal cancer syndrome)

This is a general term for distress associated with eating that can have many meanings

indigestion

Acute diarrhea, especially foodborne is caused by

infection

Various diseases can cause splenomegaly in children including

infection hematologic disorders such as hemolytic anemias infiltratve disorders inflammatory or autoimmune diseases congestion from portal HTN

Several diseases can cause splenomegaly in infants including

infections hemolytic anemias infiltrative disorders inflammatory or autoimmune disease portal hypertension

Hepatomegaly in teens may be from

infections hepatitis mono inflammatory bowel disease tumor

Painful jaundice points to

infectious in origin-hepatitis A or cholangitis

Right sided rectal tenderness may also be cased by an

inflamed adnexa or seminal vesicle

Enlarged liver with smooth tender edge suggests what and may be from

inflammation; hepatitis, venous congestion in RCHF

Pink urine followed by reddish stool

ingestion of beets

Crohn's vs UC onset

insidious and chronic/recurrent; typically abrupt onset often recurrent and persists, awakens at night

Order of assessing abdomen

inspection, auscultation, percussion, palpation

High pitched tinkling sounds suggest

intestinal fluid and air under tension in dilated bowel

For pain disproportionate to physical findings, suspect what

intestinal mesenteric ischemia

Inspect for increased peristaltic waves of

intestinal obstruction

Rushes of high pitched sounds coinciding with an abdominal cramp signal

intestinal obstruction

Anorexia, nausea and vomiting accompany many GI disorders including

pregnancy, DKA, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions

Dull areas characterize

pregnant uterus, distended bladder, large liver or spllen

In order to be characterized as IBS, sx

present for >6 mo and abdominal pain for >3 mo plus at least 2 of 3 other features: improvement with defecation onset with change in stool frequency onset with change in stool form and appearance

RLQ pain or pain that migrates from the peribumbilical region, combined with abdominal wall rigidity on palpation is suspicious for

appendicitis (in women also consider PID, ruptured ovarian follicle or ectopic pregnancy)

Causes of pertonitis include

appendicitis, cholecystitis, perforation of bowel wall

Majority of those with Hep C

are unaware of being infected

A protuberant abdomen with bulging flanks is suspicious for

ascites

This seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. Umbilicus may protrude. Turn patient onto one side to detect the shift in position of level

ascitic fluid

Testing for fluid wave

ask patient or assistant to press edges of both hands firmly down midline of abdomen. this pressure helps to stop the transmission wave through fat. while you tap one flank sharply with your fingertips, feel on opposite flank for impulse transmitted through fluid. unfortunately this sign is often negative until ascites is obvious and is sometimes positive in people without ascites

When asking about location of pain, what is also important to get the most information?

ask patient to point to pain

When patient reports acute pain in the LLQ or diffuse abdominal pain, investigate how?

associated sx such as fever, loss of appetite

Most people with chronic infection of Hep B present how?

asx until onset of advanced liver disease

Aside from age, people without any strong risk factors are considered to be

average risk for colorectal cancer

Some GERD patients may have "alarm" symptoms like

difficulty swallowing (dysphagia) pain with swallowing (odynophagia) recurrent vomiting evidence of GI bleeding early satiety weight loss anemia risk factors for gastric cancer palpable mass painless jaundice

Severity of pain-sensitivity varies widely and tends to have what pattern in older adults?

diminish

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

discomfort

How can you combat ticklishness during a child's abdominal assessment?

distraction place whole hand flush on abdominal surface for few moments without probing place child's hand under yours and then remove theirs later flex child's knees and hips

If painful or ticklish, what are some techniques you could use?

distraction; place patient's hand under yours at first until comfortable

LLQ pain, especially with palpable mass signals

diverticulitis

A palpable liver edge

does not reliably indicate hepatomegaly (percussion however is pretty accurate)

This is defined as painless, loose or watery stools during >75% of defecations for the prior 3 mo with symptom onset at least 6 mo prior to diagnosis. Stool volume may increase >200g in 24 hours

diarrhea

IBS has 3 patterns:

diarrhea predominant constipation predominant mixed

Bowel sounds may be increased with

diarrhea, early intestinal obstruction

Altered bowel sounds are common in

diarrhea, intestinal obstruction, paralytic ileus and peritonitis

Indicators of oropharyngeal dysphagia include

drooling, nasopharyngeal regurgitation, cough from aspiration

This involves separation of 2 rectus abdominis muscles, causing midline ridge most apparent when infant contracts abdominal muscles. A benign condition in most cases, and resolves during early childhood

diastasis recti

Bulge of hernia should not be confused with what

diastasis recti which is a benign 2-3 cm gap in the rectus muscles often seen in obese and postpartum patients

Patient with complaints of abdominal fullness or early satiety:

dietary assessment warranted

Because ascitic fluid characterisitically sinks with gravity whereas gas filled loops of bowel rise, _ appears in the dependent areas of the abdomen

dullness

_ to percussion of the spleen indicates enlargment

dullness

Duodenal vs peptic ulcer

duodenal ulcer pain relieved by food and recurrs 2-3 hours after, awakens at night, peptic-pain after meals

This is defined as chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by post prandial fullness, early satiety, and epigastric pain or burning

dyspepsia

An abdominal mass felt on palpation in the child may represent

stool from constipation or tumor

If solid foods provoke dysphagia, consider

structural causes like esophageal stricture, webbing or Schatzki ring, and neoplasm

Inspect the abdomen of the infant in what position

supine and optimally asleep

Melena in infants may result from

swallowing blood during birth

When looking for appendicitis, palpate for what?

tenderness, rebound tenderness, guarding, rigidity

This is a constant urge to defecate, accompanied by pain, cramping and involuntary straining

tenesmus

In patients with jaundice, pay special attention to

the associated sx and setting in which it occurred (color of urine?-when the level of conjugated bilirubin increases in the blood, it may be excreted into the urine, turning the urine a dark yellowish brown or tea color. unconjugated bilirubin is not water soluble so it is not excreted into urine

Can you palpate the intestines of the infant

the descending colon is a sausage like mass in the LLQ

When a spleen enlarges, it expands anteriorly, downward and medially, often replacing the tympany of the stomach and colon with

the dullness of solid organ

Abdominal abdominal massess in infants can be associated with

the kidney (hydronephrosis) bladder (urethral obstruction) bowel (Hirschsprung disease or intussusception) tumors

Occasionally, the right kidney is more anterior and should be distinguished from

the liver; lower pole of kidney is rounded and liver edge if palpable tends to be sharper and extends farther medially and laterally. The liver itself cannot be captured

How do you assess an obese child's abdomen

the same

High volume frequent watery stools are usually from

the small intestine

Suspect splenomegaly with left flank mass if

there is a palpable notch on medial border, edge extends beyond midline, percussion is dull, and fingers can probe deep to the medial and lateral borders but NOT between the mass and costal margin. Confirm findings with further evaluation

The span of liver dullness is decreased when

there is free air below the diaphragm from perforated bowel or hollow viscus, resolution of hepatitis or heart failure

Can you palpate the kidneys in the infant?

you may be able to palpate the kidneys in an infant by carefully placing fingers of one hand in front of and those of the other behind each kidney

You notice pulsations in the infant's/child's abdomen; what do you make of this

you will commonly note pulsations in the epigastrium caused by the aorta

Screening recommendations for colorectal cancer in higher risk persons (personal hx colorectal neoplasia or longstanding IBD, family hx)

should begin screening at younger age, usually with colonoscopy, and get more frequent testing than average risk adults

Structures of left lower quadrant

sigmoid colon descending colon left ovary

Technique for assessing liver size in infants

simultaneous percussion and auscultation, noting change in sound, can do scratch test

Normally, the liver is

slightly tender

Vomiting and pain indicate

small bowel obstruction

Fecal odor occurs with

small bowel obstruction and gastrocolic fistula

Diffuse abdominal pain with abdominal distention, hyperactive high pitched bowel sounds and tenderness on palpation marks

small or large bowel obstruction

What will the spleen feel like in infants and children? Where is it palpated?

soft with sharp edge and projects downward like tongue from under left costal margin; it is moveable and rarely extends more than 1-2 cm below left costal margin

What is Riedel lobe?

some individuals have elongated and easily palpable right lobe of liver and projects downward toward iliac crest. Represents variation in shape, not increase in liver volume or size

What other organ can be easily felt in the abdomen of most infants?

spleen

Structures of left upper quadrant

spleen splenic flexure of colon stomach body and tail of pancreas transverse colon

A left flank mass can represent either

splenomegaly or enlarged left kidney

If dull in Traube space,

splenomegaly, but this can also result from fluids or solids in the stomach or colon

Process of palpating infant's abdomen and why

start gently in low abdomen moving upward with fingers; helps to identify an enlarged liver that extends down into pelvis-can feel liver edge in most infants, 1-3 cm below right costal margin

Oily residue, sometimes frothy or floating occurs with and is from what

steatorrhea (fatty diarrheal stools) from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth

When patient raises head and shoulder, this tenderness persists whereas tenderness from deeper lesion (protected by tightened muscles) decreases

Abdominal wall tenderness

Local causes of peritoneal inflammation include

Acute cholecystitis Acute pancreatitis Acute appendicitis Acute diverticulitis

Frequently bilateral, tenderness is usually maximal just above inguinal ligaments. Rebound tenderness and rigidity may be present. On pelvic examination, motion of cervix and uterus causes pain

Acute salpingitis

Constipation may occur with what conditions?

DM, hypothyroidism, hypercalcemia, MS, Parkinson's, systemic sclerosis

Separation of the 2 rectus abdominis muscles, through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when the patient raises the head and shoulders. Often present in patients with repeated pregnancies, obesity, and chronic lung disease. Clinically benign

Diastasis recti

A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With patient coughing or performing a valsalva meneuver, palate by running your fingerpad down the linea alba

Epigastric hernia

Rovsing sign

Press deeply and evenly in LLQ and quickly withdraw your fingers-pain in RLQ during left sided pressure is positive rovsing

Because bowel sounds are widely transmitted through the abdomen, listening in what spots are recommended?

RLQ is sufficient

Appendicitis is likely with presence of

RLQ tenderness, Rovsing sign and psoas sign, 3 times more likely with McBurney point tenderness

Types of visceral pain

RUQ or epigastric pain from biliary tree and liver Epigastric pain from stomach, duodenum, pancreas Periumbilical pain from small intestine, appendix, proximal colon Suprapubic or sacral pain from rectum Hypogastric pan from colon, bladder or uterus. colon pain may be more diffuse than illustrated

This pain is felt in more distant sites which are innervated at approximately the same spinal levels as the disordered structures.

Referred pain

This type of pain often develops as the initial pain becomes more intense and seems to radiate or travel from the initial site. It may be palpated superficially or deeply but is usually localized

Referred pain

Percuss the abdomen where and what should you hear?

all 4 quadrants, liver (midclavicular line from umbilicus and nipple line) and splenic (lowest interspace, anterior axillary line) margins; should hear mostly tympany due to gas in the GI tract but scattered areas of dullness from fluid and feces are common. Dullness over liver, tympany over spleen

Screening recommendations for risky or hazardous alcohol use

all adults in primary care settings, including pregnant women and brief behavioral counseling interventions recommended

Percussion helps assess what

amount and distribution of gas in abdomen, viscera, masses that are solid or fluid filled and the size of the liver and spleen

Inflammation of the parietal peritoneum or peritonitis signals

an acute abdomen

Thin, pencil like stool occurs in

an obstructing "apple core" lesion of the sigmoid colon

This may present as indigestion precipitated by exertion and relieved by rest

angina from inferior wall coronary artery disease

What might also present like heartburn?

angina from inferior wall coronary ischemia along the diagphragm

This is a loss of or lack of appetite

anorexia

Induced vomiting without nausea is more indicative of what

anorexia/bulimia

What medications may contribute to constipation?

anticholinergics, calcium channel blockers, iron supplements, opiates

Localized tenderness anywhere in the RLQ even in the right flank suggests what

appendicitis

RLQ signs are typical of this but may be absent early in course. typical area of tenderness at McBurney Point. Examine other areas of RLQ as well as right flank

appendicitis

Gentle palpation aids in

detection of abdominal tenderness, muscular resistance and some superficial organs and masses. it also reassures and relaxes the patient

If fullness or early satiety, consider

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

Listen for bowel sounds with what part of the stethoscope

diaphragm

How wide should the aorta be in adults over 50 years old

no more than 3cm wide

Obstipation signifies

no passage or feces or gas; intestinal obstruction

Do most people who have colorectal cancer dx have family hx?

no; 75% of those dx do not

Chronic diarrhea is typically

noninfectious in origin and may be from Crohn's disease or UC

Types of primary or functional constipation are

normal transit, slow transit, impaired expulsion (from pelvic floor disorders), and constipation predominant IBS

Suspect an enlarged kidney if there is

normal tympany in the LUQ and you can probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders

Recommendations on hormone replacement (in prevention of colorectal cancer)

not advised; more likely to present with advanced cancers and higher risk of mortality also increased risk breast cancer, cardiovascular events and venous thromboembolism-risk outweigh benefits

Digital rectal examination for colorectal screening

not recommended

Extrahepatic jaundice arises from

obstruction of the extrahepatic bile ducts, most commonly the common bile ducts

Which sign has the lowest sensitivity and is the least helpful

obturator

Infection of the umbilical stump can be serious and is characterized by periumbilical edema and erythema

omphalitis

What drugs might cause constipation?

opiates anticholinergics antacids

What causes drug induced cholestasis?

oral contraceptives, methyl testosterone, chlorpromazine

Situs inversus?

organs reversed-air bubble and tympany on the right and liver dullness on left

How to percuss for ascites

outward in several directions from central area of tympany

Auscultate for friction rubs where? When are these present?

over liver and spleen; hepatoma, gonococcal infection around liver, splenic infection, pancreatic carcinoma

Normal liver size in healthy term newborns

palpation and percussion-6 plus or minus 1 projection below costal margin- 2.5 plus or minus 1

Epigastric tenderness and rebound tenderness usually present but abdominal wall may be soft

pancreatitis

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

pancreatitis

Bowel sounds may be decreased then absent with

paralytic ileus or peritonitis

Arterial bruits with both systolic and diastolic components suggest

partial occlusion of the aorta or large arteries in epigastrium: renal artery stenosis or renovascular hypertension

Nocturnal diarrhea is usually

pathologic

The accuracy of dx GERD is over 90% if:

patient reports heartburn and regurgitation together more than once a week

When observing for pain, watch what?

patient's face

Diarrhea is common with what medications

penicillins and macrolides, magnesium based antacids, metformin, and herbal and alternative medicines

Why is it important to auscultate first?

percussion and palpation maneuvers may alter characteristics of bowel sounds

Complications of colonoscopy

perforation and bleeding

Involuntary rigidity typically persists despite these maneuvers, suggesting

peritoneal inflammation

A silent, tympanitic, distended and tender abdomen in the infant suggests

peritonitis

Pain with absent bowel sounds, rigidity, percussion tenderness and guarding points to

peritonitis

What is associated with decreased risk of colorectal cancer

physical activity, ASA, NSAIDs, post menopausal combined hormone replacement therapy

Abdominal masses may be categorized in several ways

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

Psoas sign

place hand just above patients right knee and ask patient to raise that thigh against your hand increased abdominal pain is positive psoas sign suggesting irritation of the psoas muscle by inflamed appendix

Ask the patient what in terms of dysphagia

point to where it occurs, what provokes it

Bilateral kidney enlargement suggests

polycystic kidney disease

Causes of splenomegaly include

portal HTN, hematologic malignancies, HIV infection, infiltrative disease like amyloidosis and splenic infarct or hematoma

If hepatomegaly is accompanied by splenomegaly in children

portal HTN, storage diseases, chronic infections, malignancy

Dilated veins suggest what

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

Signs of peritonitis include

positive cough test, guarding, rigidity, rebound tenderness, percussion tenderness

Less common pelvic "mass."

pregnancy

Pain of aorta on palpation may signal what

rupture

The most effective prevention strategy for colorectal cancer is

screen for and remove pre cancerous adenomatous polyps

An easily palpable impulse suggests ascites which is even more likely when combined with

shifting dullness and peripheral edema

Colicky abdominal pain, abdominal distention, "currant jelly" stools (red blood and mucus)

"other obstructing lesions" such as diverticulitis, volvulus, intussusception, hernia

Screening Recommendations for colorectal cancer

-Adults ages 50-75 years --high sensitivity fecal occult blood testing (FOBT) annually, either a guaiac based or fecal immunochemical test --sigmoidoscopy every 5 years with FOBT every 3 years --double contrast barium enema or CT colonography every 5 years as well as fecal DNA test --screening colonoscopy every 10 years -Adults ages 76-85 years --do not screen routinely (benefits are small in comparison to risks) -Adults older than 85 --do not screen (competing causes of mortality preclude a mortality benefit that outweighs harms)

CDC recommendations for Hepatitis A Vaccination

-All children at 1 year -Individuals with chronic liver disease -Groups at increased risk-travelers to poor sanitation areas, men that have sex with men, injection and illicit drug use, work with nonhuman primates, clotting factor disorders (vaccine can be given prior to travel)

Screening recommendations for Hep B

1. those at high risk of infection (those born in countries with high rates infection, HIV, IV drug users, men who have sex with men, household contacts, or sexual contacts with infected persons, fluid exposure, dialysis, correctional facilities 2. all pregnant women ideally in first trimester 3. universal vaccination for all infants beginning at birth

Standard drink equivalents

12 oz beer or wine cooler, 8 oz malt liquor, 5 oz wine, 1.5 oz spirits

Before deciding if bowel sounds are absent, how long should you listen and where

2 min, RLQ

Acute diarrhea lasts up to

2 weeks

Chronic diarrhea is defined as lasting

4 weeks or more

Normal measure of liver span

4-8 cm midsternal line, 6-12 cm midclavicular line

Symptoms of blood loss such as lightheadedness or syncope depend on the rate and volume of bleeding and are rate until blood loss exceeds

500cm3

Weaker risk factors for colorectal cancer

AA male tobacco alcohol red meat consumption obesity

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

AAA

This is a metastatic change in the esophageal lining from normal squamous to columnar epithelium (dysplasia)

Barrett's esophagus

If diarrhea after recent hospitalization, consider

CDiff

What might cause downward displacement of liver by low diaphragm

COPD

Liver dullness may be displaced downward by the low diaphragm of

COPD, but span remains normal

Functional disorders causing abdominal pain in children include

IBS, functional dyspepsia, childhood functional abdominal pain syndrome

Chronic transmural inflammation of the bowel wall with skip pattern involving terminal ileum and or proximal colon and rectal sparing; may cause strictures

Crohn's disease

Pink-purple striae are a hallmark of

Cushing syndrome

Regurgitation occurs with

GERD, esophageal stricture, esophageal cancer

Gurgling or regurgitation of undigested foods occurs in

GERD, motility disorders, and structural disorders like esophageal stricture and Zenker diverticulum

Epigastric pain occurs with

GERD, pancreatitis, perforated ulcers

Distention may be localized or generalized. Causes tympanitic percussion note. Selected foods may cause mild distention from increased intestinal production of this. More serious causes are intestinal obstruction and paralytic ileus. Note location of distention. If more marked, obstruction in colon more likely vs small bowel.

Gas

Postexposure prophylaxis Hepatitis A

Healthy unvaccinated should receive Hep A vaccine or single dose immune globulin (preferred for age >40) within 2 weeks of exposure (applies to close personal contact of those with confirmed dx)

This is a rising retrosternal burning pain or discomfort occuring weekly or more often. It is typically aggravated by foods such as alcohol, chocolate, citrus fruits, coffee, onions, peppermint, or positions like bending over, exercising, lifting or lying supine

Heartburn

There are vaccines for which Hepatitis viruses?

Hep A and B

What types of hepatitis can cause chronic hepatitis, cirrhosis and liver cancer?

Hep B and C

Risk factors for liver disease

Hepatitis (poor sanitation, travel, contaminated food or water, contact with infected person/infected persons' fluids) Alcoholic hepatitis or cirrohosis-screen carefully for alcohol use Toxic liver damage - medications, industrial solvents, environmental toxins, anesthetic agents Gallbladder disease or surgery - may result in extrahepatic biliary obstruction Hereditary disorders- family hx

Acholic stools may occur briefly in

Hepatitis A and are common in obstructive jaundice

Which Hepatitis viruses can be transmitted through sex?

Hepatitis B (Hepatitis C is rare)

Screening recommendations for Hep C

High risk groups (IV drug users, organ transplant or transfusion before 1992, transfusion with clotting factors before 1987, hemodialysis, health care workers with needle stick injury or mucosal exposure to positive blood, HIV, or birth from positive mother)

Initial alcohol screening question

How many times in the past year have you had 4 or more drinks/day (women,) or 5 or more drinks a day (men)

Intermittent pain for 12 weeks of the preceding 12 mo with relief from defecation, or 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 suggests

IBS

Tenderness over the liver suggests

Inflammation (as in hepatitis) or congestion (as in heart failure)

Assess carefully for peritoneal signs of acute abdomen:

McBurney's point, Rovsing, psoas, obturator

Definitions of drinking levels for adults

Moderate drinking: Women- <1 drink/d, Men <2 drink/d Unsafe drinking levels (increased risk for developing an alcohol use disorder: Women- >3 drinks/d and >7drinks/w Men- >4 drinks/d and >14 drinks/w Binge drinking: Women: >4 drinks one occasion Men: >5 drinks one occasion

When RUQ pain and tenderness suggest cholecystitis, assess for what sign

Murphy

This is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patients typically prefer to lie still.

Parietal pain

This type of pain originates from inflammation of the parietal peritoneum, called peritonitis

Parietal pain

Explain the progression of appendicitis pain

Periumbilical pain from distention of an inflamed appendix which gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum

Tenderness associated with this is more severe than visceral tenderness. Muscular rigidity and rebound tenderness are frequently but not necessarily present. If generalized causes exquisite tenderness throughout the abdomen, together with board like muscular rigidity. Signs on palpation especially abdominal rigidity double likelihood of this

Tenderness of peritoneal inflammation

Mucosal inflammation typically extending proximally from the rectum (proctitis) to varying lengths of the colon (colitis to pancolitis) with microulcerations and if chronic inflammatory polyps

UC

Cramping with urgency, tenesmus fever, fatigue, weakness, abdominal pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema nodosum VS Cramping periumbilical right lower quadrant or diffuse pain with anorexia, fever, and or weight loss, perianal or peri rectal abscess and fistulas may cause small or large bowel obstruction

UC; Crohn's

Which inflammatory bowel disease will cause frequent watery and bloody stools vs small soft to loose or watery stools with bleeding or obstructive sx

UC; Crohns

Best method for determining hepatomegaly

US

Acute abdominal processes in the older adult as far as signs and sx

aging often blunts manifestations of acute abdominal disease. pain may be less severe, fever often less pronounced, signs of peritoneal inflammation such as guarding and rebound tenderness may be diminished or even absent

When does a GERD patient warrant endoscopic evaluation

Uncomplicated GERD that fails empiric therapy, age >55 years, and "alarm" sx

Ischemia stimulates this pain

Visceral pain

This pain occurs when hollow abdominal organs such as intestine or biliary tree contract unusually forcefully or are distended or stretched. Solid organs such as the liver can also become painful when their capsules are stretched. This pain may be difficult to localize. It is typically palpable near the midline at levels that vary according to structure involved.

Visceral pain

This type of pain varies in quality and may be gnawing, burning, cramping, or aching. When it becomes severe, sweating, pallor, nausea, vomiting and restlessness may follow

Visceral pain

Usually this discomfort is dull with no muscular rigidity or rebound tenderness

Visceral tenderness

Why is it important to ask about the color of stool with jaundice?

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

Abdominal changes in the older adult

abdominal muscles tend to weaken decreased activity of lipoprotein lipase and fat may accumulate in lower abdomen and near hips even if weight stable-this change in abdominal fat distribution increases risk of CVD. changes often produce softer more protruding abdomen which patients may interpret as fluid or evidence of disease

Confined inflammatory process usually in LLQ that involves sigmoid colon. If sigmoid colon is redundant, there may be suprapubic or right sided pain. Look for peritoneal signs and a tender underlying mass. microperforation abscess and obstruction may ensue

acute diverticulitis

LLQ pain with cramping, steady pain with gradual onset. May have associated fever, constipation, nausea, vomiting, abdominal mass with rebound tenderness

acute diverticulitis

May children present with abdominal pain from ? Despite pain,physical exam is relatively normal except for increased bowel sounds on auscultation and mild tenderness on palpation

acute gastroenteritis

Abdominal pain and tenderness may result from this. When unilateral, can mimic acute cholecystitis or appendicitis. Rebound tenderness and rigidity are less common; chest signs usually present

acute pleurisy

Causes of flatus include

aerophagia, ingestion of legumes or other gas producing foods, intestinal lactase deficiency, and IBS

Belching may result from

aerophagia-swallowing air

Risk factors for AAA are

age <65 history of smoking male gender first degree relative with history of AAA repair

How to identify an organ or mass in an ascitic abdomen

ballotte-straighten and stiffen fingers of one hand together, place them on abdominal surface and make brief jabbing movement directly toward anticipated structure. this quick movement often displaces the fluid so that your fingertips can briefly touch the surface of the structure through the abdominal wall

How do you conduct a cough test?

before palpation, ask patient to cough and identify where it produces pain

Brownish or blackish vomitus with "coffee ground" appearance suggests

blood altered by gastric acid; (coffee ground emesis or red blood is called hematemesis)

As you explore factors that aggravate or relieve pain, pay special attention to:

body position association with meals alcohol medications (asa, antacids) stress

If the patient has HTN, auscultate the epigastrium and in each upper quadrant for

bruits

Change in bowel habits often diarrhea, abdominal pain bleeding, occult blood in stool, tenesmus and pencil shaped stools, weight loss

cancer of rectum or sigmoid colon

A hepatic bruit suggests

carcinoma of liver or cirrhosis

Structures of right lower quadrant

cecum appendix ascending colon right ovary

If there is chronic pain in the quadrants of the lower abdomen, ask about

change in bowel habits and alternating diarrhea or constipation

Pain may be referred to the abdomen from where?

chest, spine, pelvis

Signs are maximal in RUQ

cholecystitis

RUQ and upper abdominal pain are common in

cholecystitis and cholangitis

Most common cause of ascites

cirrhosis

This may produce enlarged liver with firm nontender edge. May be scarred and contracted.

cirrhosis

Gastric juice is

clear and mucoid; small amounts of yellowish or greenish bile are common and have no special significance

Normal bowel sounds consist of

clicks and gurgles, 5-34/min may hear occasional prolonged gurgles of hyperperistalsis from "stomach growling" called borborygmi

Change in bowel habits with a mass lesion warns of

colon cancer

Gold standard diagnostic test for colorectal screening

colonoscopy

What markedly reduces misdiagnosis and unnecessary surgery related to appendicitis?

combination of signs, inflammatory markers and CT scans

Chronic or recurrent abodminal pain in children

common and may be from both functional or organic disorders

A single umbilical artery may be associated with

congenital anomalies or isolated anomaly

In someone without ascites, the border between tympany and dullness usually stays relatively

constant

Screening by palpation followed by ultrasound for AAA does what

decreases mortality esp in male smokers >65

Multifactorial causes of dyspepsia include

delayed gastric emptying, gastritis from H.Pylori, IBS, psychosocial

What non GI causes can be linked to constipation?

depression, neurologic, metabolic

A protuberant abdomen that is tympanitis throughout suggests

intestinal obstruction or paralytic ileus

Find out if anorexia is from

intolerance to certain foods-food fear and fear of abdominal discomfort or distortions of self image; check for associated nausea or vomiting

Ecchymosis of the abdominal wall is seen in

intraperitoneal or retroperitoneal hemorrhage

In a child with an acute abdomen, check for

involuntary rigidity, rebound tenderness, Rovsing sign, positive psoas or obturator

What non pathologic causes may turn stool black?

iron, pepto, licorice, chocolate cookies

Is it normal to see aortic pulsation?

it is frequently visible in epigastrium

What skin sx might you see with cholestatic or obstructive jaundice?

itching

This is a strikingly yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. Normally hepatocytes conjugate unconjugated bilirubin with other substances making the bile water solube, and then excrete the conjugated bilirubin into the common bile duct which also drains the extrahepatic ducts from the liver. More distally, the common bile duct and the pancreatic ducts empty into the duodenum at the ampulla of vater.

jaundice or icterus

Bloating may occur with

lactose intolerance, inflammatory bowel disease, ovarian cancer

Before you begin examination, ask patient to point to any areas of pain so that you can examine these areas

last

Is a normal right kidney palpable? Is a normal left kidney palpable?

left kidney normall not palpable; right kidney may be palpable especially when patient is thin and abdominal muscles are relaxed

McBurney Point

lies 2 inches from anterior superior spinous process of ilium on a line drawn from that process to the umbilicus

Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including abdominal wall. small or large, they are usually soft and often lobulated. press your finger down on the edge of a lipoma. tumor typically slips out from under your finger and is well demarcated, nonreducible and usually nontender

lipoma

Structures in right upper quadrant

liver gallbladder pylorus duodenum hepatic flexure of colon head of pancreas

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

liver disease

Visceral pain in RUQ suggests what?

liver distention against its capsule from various causes of hepatitis, including alcoholic hepatitis

The umbilicus of the newborn will have what 2 portions

long cutaneous portion (umbilicus cutis) which is covered with skin and retracts to be flush with abdominal wall amniotic portion (umbilicus amnioticus) which is covered by firm gelatinous substance and dries up and falls off within 2 weeks

Painless jaundice points to

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

When percussing an infant's abdomen, what might you hear? Why?

may note greater tympanitic sounds because of infants propensity to swallow

Causes of dysphagia

mechanical/obstructive in younger adults neurologic/muscular in older adults

Secondary causes of constipation include

medications and conditions like amyloidosis, diabetes, CNS disorders

Black tarry stools

melena

"food fear" with abdominal pain and a slightly distended soft nontender abdomen are hallmarks of

mesenteric ischemia

Hematochezia may signify blood from

more than 1000 mL lower GI, but if massive can have upper GI source as well

If solid and liquids provoke dysphagia, consider

motility disorder like achalasia

In contrast to peritonitis, patients with colicky pain from renal stone present how?

move around frequently trying to find comfortable position

Normal bowel sounds in infant

musical tingling bowel sounds

This is often described as "feeling sick to my stomach," may progress to retching and vomiting

nausea

The pain of appendicitis classically begins where and then migrates where

near umbilicus and then migrates to RLQ (older adults less likely to report this pattern)

When may ascites signal decreased osmotic pressure?

nephrotic syndrome, malnutrition or ovarian cancer

Studies suggest that symptoms of pain, bowel dysfunction, and stress of the gut are mediated by what?

neuropeptides like 5-hydroxytryptophan and substance P

Recommendations on diet and supplement use in prevention of colorectal cancer

no convincing evidence

Ask about stool characteristics identified by the Rome III criteria, which stipulate that constipation should be

present for the last 3 mo with sx onset at least 6 mo prior to dx and meet at least 2 of following conditions: fewer than 3 BMs per week 25% or more defecations with either straining or sensation of incomplete evacuation lumpy or hard stools manual facilitation

How to assess width of aorta in adults over 50 years

press deepy in upper abdomen with one hand on each side of aorta

How to feel aortic pulsation

press firmly in epigastrium slightly left of midline

Dullness in both flanks?

prompts further assessment for ascites

An exaggerated "pot belly appearance" may indicate what in kids?

protuberant abdomen in toddlers and young children normally, but exaggerated may indicate malabsorption from celiac disease, CF or constipation, aerophagia

The infants abdomen normally appears _ ---why?

protuberant as a result of poorly developed abdominal musculature

Pain with pressure of first percussion supports

pyelonephritis if associated with fever and dysuria but may also be musculoskeletal

Deep palpation in the RUQ or midline can reveal an "olive" or 2cm firm mass. While feeding, some infants with this condition will have visible peristaltic waves that pass across their abdomen, followed by projectile vomiting. Infants present at about 4-6 weeks of age

pyloric stenosis

If you suspect but do not see an umbilical or ventral hernia, ask patient to do what

raise both head and shoulders off table bulge of hernia will appear with this action

If you're trying to distinguish between a mass in the abdominal wall vs in the abdominal cavity, have patient do what

raise head and shoulders or strain down thus tightening abdominal muscles mass in abdominal wall will remain palpable whereas an intra abdominal mass will be obscured by muscular contraction

This refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly remove the hand. Positive if withdrawal of pressure causes pain. Withdraw pressure quickly.

rebound tenderness

Recommendations on use of NSAIDs (in prevention of colorectal cancer)

recommends against regular use for prevention in average risk persons because of potential harms including GI bleed, hemorrhagic stroke and renal impairment (risks outweigh benefits)

When assessing for appendicitis, you should also perform examination of what?

rectal exam and in women, pelvic exam they have low sensitivity by may identify an inflamed appendix atypically located within the pelvic cavity or other causes of abdominal pain

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

rectal inflammatory conditions

Risk factors for GERD

reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer obesity delayed gastric emptying selected medications hiatal hernia

Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching called

regurgitation

If resistance is present on palpation, try to distinguish voluntary guarding from involuntary rigidity or muscular spasm. Voluntary guarding decreases with what techniques

relaxation, palpate after asking patient to exhale, ask patient to mouth breathe with jaws wide open

A bruit in one of the areas of epigastrium, upper quadrants or CVAs that has both systolic and diastolic components strongly suggests

renal artery stenosis as the cause of HTN

Cramping pain radiating to the RLQ or LLQ or groin may be?

renal stone

doubling over with cramping colicky pain indicates

renal stone

Some patients with GERD may also have what type of symptoms manifesting from another body system?

respiratory symptoms such as chest pain, cough, wheezing, aspiration PNA, pharyngeal sx like hoarseness, chronic sore throat, laryngitis

This describes involuntary spasm of the stomach, diagphragm and esophagus that precedes and culminates in vomiting

retching

This is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations

rigidity

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

these findings suggest peritonitis from possible appendicitis

Are kidneys normally palpable?

they are retroperitoneal and usually not palpable

Why is it easy to palpate an infant's abdomen?

they like being touched

You see abdominal wall blood vessels and intestinal peristalsis in the infant. What do you make of this?

this is normal due to poorly developed abdominal musculature

Deep palpation is usually required for what

to delineate the liver edge, kidneys, abdominal masses

What is a good technique to use to palpate an infant's abdomen?

to relax infant-hold legs in flexed position at knees and hips with one hand and palpate abdomen with other, pacifier may quiet infant in this position as well

Pain of duodenal or pancreatic origin may be referred where?

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

In ascites, dullness shifts

to the more dependent side whereas tympany shifts to the top

Common mistake with palpation of spleen or liver

too close to costal margin

Large, solid and usually rising out of pelvis. Dull to percussion. Air filled bowel is displaced to the periphery. Causes include ovarian etiology or uterine etiology. Occasionally, markedly distended bladder is mistaken for this

tumor

Bruits over aorta, iliac arteries and femoral arteries with both systolic and diastolic components suggest

turbulent blood flow from atherosclerotic arterial disease

What should the umbilical cord look like?

two thick walled umbilical arteries and one larger but thin walled umbilical vein which is usually located at the 12 o clock position

How should a child's abdomen sound on percussion?

tympanitic

USPSTF recommendations for AAA screening

ultrasound screening for men over 65 years who have "ever smoked"

This forms at the base of the navel and is the development of pink granulation tissue formed during healing process

umbilical granuloma

A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. in infants, usually closes spontaneously in 1-2 years

umbilical hernia

Detectable by few weeks of age and most disappear by 1 year, nearly all by 5 years. Caused by defect in abdominal wall and can be quite protuberant with increased intra abdominal pressure (crying)

umbilical hernias

Antiviral therapy for Hep C

undetectable RNA 24 wks after completing tx ranges from 40-90% depending on viral phenotype and drugs used so recommendations for screening is of moderate benefit for persons at high risk of infection as well as those born between 1945 and 1965

Hepatomegaly in young children

unusual may be fromCF, protein malabsorption, parasites, fatty liver, tumor

Melena may signify blood from

upper GI (as little as 100 mL)

Scratch test

used to determine lower border of liver. place diaphragm of stethoscope just above right costal margin at midclavicular line. with fingernail, lightly scratch skin of abdomen along midclavicular line moving from below the umbilicus toward costal margin. when your scratching finger reaches liver's edge you will hear a change in the scratching sound as it passes through the liver to your stethoscope. accuracy not well studied

Patient education prior to colonoscopy

usually sedated, may be averse to extensive bowel prep required

Bruits suggest

vascular occlusive disease

Rare soft humming noise with both systolic and diastolic components. Points to increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis

venous hum

Impaired excretion of conjugated bilirubin is seen in

viral hepatitis, cirrhosis, primary biliary cirrhosis, drug induced cholestasis

Flexible sigmoidoscopy does what

visualizes distal 60 cm of bowel

Colonoscopy does what

visualizes entire colon and can remove polyps

This is the forceful expulsion of gastric contents of the mouth

vomiting

What does NOT need the criteria for dyspepsia?

when bloating, nausea or belching occur alone

Do you percuss the infant's abdomen?

you can as you would an adults; will be useful for determining size of organs and abdominal masses