Lecture 1: GI and Renal Systems

Right Hypochondrium Region

Epigastric Region

Left Hypochondrium Region

Right Lumbar Region

Umbilical Region

Left Lumbar Region

Right Inguinal Region

Suprapubic Region

Left Inguinal Region

RUQ

Quadrant that contains:

Liver, GB, pylorus, duodenum, pancreas head, R adrenal, R kidney upper pole, end of ascending colon, beg of transverse colon

LUQ

Quadrant that contains:

Liver L lobe, spleen, stomach, pancreas body, L adrenal, L kidney upper pole, end of transverse and beg of descending colon

LLQ

Quadrant that contains:

L kidney lower pole, sigmoid colon, end of descending colon, L ureter, L ovary, L fallopian tube, L spermatic cord, uterus if enlarged, bladder if enlarged

RLQ

Quadrant that contains:

R kidney lower pole, cecum, appendix, beg of ascending colon, R ureter, R ovary, R fallopian tube, R spermatic cord, uterus if enlarged, bladder if enlarged

Substernal

Where would the pain be?

-esophagus is affected

-ex: esophagitis

Shoulder

Where would the pain be?

-Diaphragm is affected

-ex: Sub-phrenic abscess

Epigastric Region

Where would the pain be?

-Stomach, Duodenum, or gallbladder is affected

-ex: Gastric ulcer, Duodenal Ulcer, Cholecystitis

Epigastric Region

Where would the pain be?

-Liver or pancreas is affected

-ex: Hepatitis or pancreatitis

Right Scapula

Where would the pain be?

-biliary tract is affected

-ex: biliary colic

Midback

Where would the pain be?

-Aorta or Pancreas is affected

-ex: pancreatitis or aortic dissection

Periumbilical

Where would the pain be?

-Small Intestine is affected

-ex: obstruction

Hypogastrium

Where would the pain be?

-colon is affected

-ex: Diverticulitis or Ulcerative colitis

Sacrum

Where would the pain be?

-Rectum is affected

-ex: proctitis or abscess

Meniere's Disease

Emesis with hearing loss and tinnitus may be seen with ________________________

Gastric Ulcer

dark, tarry stools indicate a what?

Absence of bile (Gallbladder disease)

what do pale stools indicate?

Morning

in IBS, when is the patient most likely to be affected?

Malabsorption

floating stool indicates what?

Left

Loose stools indicate diseases of the ________ colon

Hematochezia

-bright red blood

-assoc with tumors, diverticular disease, and ulcerative colitits

Melena

-black tarry stools

-due to bleeding from above the small bowel caused by stomach tumors or ulcer disease

Acholic Stools

-silver colored stools

-assoc with duodenal cancer with sloughing off of tissue

Tenesmus

painful, continued straining during stooling, caused by lesion in distal rectum or anus

Decreased Excreiton of conjugated bilirubin into bile

what causes jaundice?

Hepatitis C

-Pt is jaundiced

-pt has hx of transfusion, IV Drug use, and tattoos

Hepatitis A

-Pt is jaundiced

-pt has recently traveled abroad or ingested raw seafood

Hepatitis B

-Pt is jaundiced

-pt has occupational exposure to carbon tetrachloride and vinyl chloride

Bile Obstruction w/ Stones or Cancer

what does slowing, developing jaundice with pale stools indicate?

Liver disease

what does rapid jaundice with nausea and loss of appetite indicate?

Liver Toxicity

what does liver enlargement without pain to palpation indicate?

Appendicitis

• Diffuse periumbilical pain and anorexia early

• Pain localizes to RLQ as peritonitis develops

• Low grade fever, nausea, and vomiting may not be present

• X-rays and other tests are often negative

Acute Cholecystitis

• Localized or diffuse RUQ pain

• Radiation to right scapula

• Vomiting, constipation, low grade fever

Acute Renal Colic

• Severe flank pain

• Radiation to groin

• Vomiting and urinary symptoms

• Blood in the urine

• Diabetes

• MI

• HTN

• CAD

• Stroke

• CKD

• TB

• Cancers

• Bleeding disorders

• Anemia

• Asthma

• Allergies

• Alcoholism

• Drug addiction

• Mental illness

Family Hx Red Flags

Name, dose, route, frequency, duration, compliance

what all do you need to know about the Patient's medications?

Caput Medusae

-dilation of veins at the umbilicus

-backflow thru veins in the falciform ligament

Grey Turner's Sign

-Massive ecchymosis noted on the flanks

-due to pancreatitis

Cullen's Sign

-Bluish discoloration of the umbilicus

-from hemoperitoneum

Sister Mary Joseph Nodule

-Cutaneous matastasis localized to the umbilicus

Ascites

abnormal accumulation of fluid in the abdomen

Up to 2 min or until bowel sounds are heard

how long should you listen to bowel sounds?

5-10 seconds and high pitched

describe normal bowel sounds

Borborygmi

low pitched rumbling bowel sounds

Succussion Splash

• While moving patient side to side a sloshing sound is heard

• Distention of stomach or colon

• Start mid-clavicular and go downward

• Over the liver is dull and over colon more tympanic

• Average length of liver is 10cm

describe percussion of the liver

Traube's Space

-6th rib superiorly

-axillary line laterally

-costal margin inferiorly

Fluid Wave

-indentifies a shifting dullness

-detects ascites

-may see false positive in obese pts

-may cause bulging flanks

Rigidity

-involuntary spasm of abdominal wall

-does not relax with experiation

-indicates diffuse or localized peritoneal irritation

Hyperesthesia

-an area of increased sensitivity that mat be noted with a light stroking of the abdomen

Right Side, C1-C2

What parasympathetic innervations? (region and side)

-pancreas

-liver

-gallbladder

-small intestine

-ascending colon

-Right half of transverse colon

Left Side, C1-C2

What parasympathetic innervations? (region and side)

-esophagus

-stomach

-duodenum

S2-S4 (both sides)

What parasympathetic innervations? (region and side)

-left half of transverse colon

-descending colon

-sigmoid colon

-rectum

Sacral Plexus (S2-S4)

parasympathetic innervation for all viscera from descending colon to rectum

Vagus Nerve (CN X)

parasympathetic innervation for all viscera from pharynx to splenic flexure

Right Side, T3-T6

What Sympathetic innervations? (region and side)

-Esophagus

Left Side, T5-T10

What Sympathetic innervations? (region and side)

-Stomach

Right Side, T6-T8

What Sympathetic innervations? (region and side)

-Duodenum

Bilateral, T5-T9

What Sympathetic innervations? (region and side)

-pancreas

Right side, T5-T10

What Sympathetic innervations? (region and side)

-Gallbladder

Bilateral, T8-T10

What Sympathetic innervations? (region and side)

-Small Intestine

Right side, T9-T12

What Sympathetic innervations? (region and side)

-Appendix

Right side, T11-L1

What Sympathetic innervations? (region and side)

-Cecum and Ascending colon

Left side, L1-L3

What Sympathetic innervations? (region and side)

-Descending colon

Celiac Ganglion

autonomic innervation of the foregut

Superior mesenteric ganglion

autonomic innervation of the midgut

Inferior mesenteric ganglion

autonomic innervation of the hindgut

Celiac Ganglion

• Receives fibers from T5-9

• Feeds: distal esophagus, stomach, proximal duodenum, liver, gallbladder, spleen, portions of pancreas

-Location: mid epigastric below xiphoid process

Superior Mesenteric Ganglion

• Receives fibers from T8-12

• Feeds: distal duodenum, portions of pancreas, jejunum, ileum, ascending colon, proximal 2/3rds of the transverse colon

• Location: Midline along linea alba above umbilicus

Inferior Mesenteric Ganglion

• Receives fibers from T10- L2, via the 3 lumbar splanchnic nerves

• Feeds: distal 1/3 of the transverse colon, descending colon, sigmoid colon, rectum

• Location: Midline along linea alba above umbilicus but below superior mesenteric

Rebound Tenderness

-peritoneal irrritation caused by palpating deepuly and slowely in an area away from the suspected area of inflammation

-palpating hand is removed quickly, and a sensation of pain is felt at area of inflammation

Rovsing's Sign

Pain produced in RLQ when palpating the LLQ

Scratch Test

Listen with stethoscope and use index finger to scratch, as index finger scratches over liver there will be a marked intensity in sound

Hooking

placing both hands at area of dullness and lifting inward and upward while pt inhales

Liver Tap

• Place L hand in RUQ and hit with fist of R hand

• Pain may be felt with inflammatory processes of liver and GB

Murphy's Sign

Pain elicited while palpating liver during inspiration, causing it to halt

Abdominal Aortic Aneurysm (AAA)

• A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more wide

• Sensitivity of palpation increases as it enlarges

McBurney's Point

• Pain produced at a point 1/3 the distance from the ASIS to the umbilicus

• 2/3 the distance from the umbilicus to the ASIS

Iliopsoas test

• Patient lies on the unaffected side and extends the other leg against examiner's hand

• A positive test is pain with this maneuver (intra-abdominal irritation)

Obturator test

• Patient is supine and examiner flexes the patient's thigh at the hip with the knee bent and rotates the leg internally and externally at the hip

• Pain is felt if there is inflammation adjacent to the muscle

Digital Rectal Exam

• Patient in standing/bent over table, left lateral recumbent, SIMS, or supine positions

• Patient is asked to relax at first and then strain to examine for hemorrhoids

• Use one hand to hold buttocks and place GLOVED and lubricated index finger of other hand in anal canal

• Allow sphincter to relax and place index finger in entire length

• Examine the entire circumference

Blumer's Shelf

• Intraperitoneal masses may be felt on examination of anterior rectal area

• These tumors may be felt as shelf-like hard projections from the infiltration of Douglas' pouch with neoplastic cells