Chapter 22: Abdomen Physical Examination and Anatomy

Vocabulary practice flashcards covering abdominal anatomy, examination techniques, surface landmarks, bowel/vascular sounds, diagnostic signs, and physiological changes across the lifespan.

Viscera

All internal organs contained inside the abdominal cavity.

Parietal Peritoneum

The serous membrane layer that lines the internal abdominal wall ( parietal) and covers surface ( visceral) or most organs .

Visceral Peritoneum

The serous membrane layer that covers the external surface of most abdominal organs.

Solid Viscera

Abdominal organs that maintain a characteristic shape, including the liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus.

Hollow Viscera

Abdominal organs whose shape depends on their contents, including the stomach, gallbladder, small intestine, colon, and bladder.

midline organs

aorta and uterus if enlarged and bladder if distended

Right Upper Quadrant (RUQ)

Anatomical region containing the liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic flexure of colon, and parts of the ascending and transverse colon.

Left Upper Quadrant (LUQ)

Anatomical region containing the stomach, spleen, aorta, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure of colon, and parts of the transverse and descending colon.

Right Lower Quadrant (RLQ)

Anatomical region containing the cecum, appendix, right ovary and tube, right ureter, and right spermatic cord.

Left Lower Quadrant (LLQ)

Anatomical region containing part of the descending colon, sigmoid colon, left ovary and tube, left ureter, and left spermatic cord.

Age-Related GI Changes

Gastrointestinal physiological shifts in older adults including decreased salivation, delayed esophageal emptying and gastric acid secretion, increased incidence of gallstones, impaired drug metabolism due to reduced liver size, and frequent constipation.

gallstones

hard, pebble like deposits of digestive fluid that can form in the gallbladder.

because it chemically unbalanced or doesn’t empty properly , with too much cholesterol in bile from liver thought bile duct become stones

many with no symptoms

pain in upper right our middle abdomen when eating fatty foods

sever or persistent pain fever yellow skin or wyes or repeated vomiting

would have to get the removed or pass it thought

liver decrease

normal for again adults

the hepatocytes because smaller and fewer causes that, less fibrous/ connective tissue, ability to regenerate declines too

drug metabolism is impaired

slower or less effective breaking down drugs

increase drug toxicity, and altered drug responses, increasing the risk of adverse effects, falls, confusion,

regularly reported by again adults

constipation

decrease movement of still In digestive system, less active , medications, reduce sensation, changes in pelvis floor

common causes of constipation

• Decreased physical activity

• Inadequate intake of water

• Low-fiber diet

• Side effects of medications

• Irritable bowel syndrome

• Bowel obstruction

• Hypothyroidism

• Inadequate toilet facilities, that is, difficulty ambulating to toilet may cause a person to deliberately retain stool until it becomes hard and difficult to pass

Lactose Intolerance

A condition resulting from a deficiency in lactase, causing abdominal pain, bloating, and flatulence when consuming milk sugar; affects $20\text{\% to }30\text{\%}$ of whites, $70\text{\%}$ of Mexican Americans, $80\text{\%}$ of blacks, and $100\text{\%}$ of American Indians.

Celiac Disease

An autoimmune disorder affecting less than $1\text{\%}$ of the population characterized by intolerance to gluten, leading to intestinal inflammation, mucosal damage, and malabsorption.

subjective data

• Appetite: change or weight loss and time period

• Dysphagia: any difficulty swallowing, onset or associated symptoms

• Food intolerance: type of food reaction and use of rx or etc , frequency

• Abdominal pain: onset duration severity quality pattern, w eating, worse or better, other symptoms, alleviating factors or aggravating factors , treatment: rx or otc

• Nausea and vomiting: onset frequency, type amount, associated symptoms and triggers, recent foods and travel habits

• Bowel habits: frequency color consistency diarrhea or constipation, any recent changes, laxative uses:type amount frequency

• Past abdominal history: Gi disease/ pathology , diagnostic procedure, surgeries and clinical response

• Medications: rx, otc, type amount frequency smoking history

• Nutritional assessment

Dysphagia

Difficulty in swallowing.

Additional History for Aging Adults

• ccess to groceries and food preparation.

• shared meals or eats alone.

• 24 hour dietary recall. 

• swallowing or feeding difficulties.

• activities done following mealtimes. 

• bowel health—frequency, constipation, fiber in your diet, use of laxatives. 

• medications—Rx and OTC.

object data, assessment

• Preparation

  • Adequate lighting

  • Expose abdomen so that it is fully visible; drape genitalia and female breasts.

  • Position for comfort to enhance abdominal wall relaxation.

    • Empty bladder prior to examination with specimen saved if needed.

    • Warm stethoscope and examine areas identified as painful last so as to prevent guarding.

  • Auscultate prior to palpation and percussion.  

    • Use distraction to keep patient relaxed and facilitate muscle relaxation.

• Equipment

  • Stethoscope, small centimeter ruler, and skin-marking pen 

  • Alcohol wipe to clean endpiece

Abdominal Examination Order

The clinical sequence of techniques used for assessing the abdomen: Inspection, Auscultation, Percussion, and Palpation (auscultation is performed before percussion and palpation to avoid false stimulation of bowel sounds).

Abdominal Contour

The profile of the abdomen evaluated from the rib margin to the pubic bone, which reflects nutritional state and normally ranges from flat to rounded.

symmetry

abdomen should be symmetric

inspection characteristics

flat: flat stomach

scaphoid: sucken

rounded: round

protuberant: sticking out

umbilicus

normally it is midline and inverted with no sign of discoloration inflammation or hernia

Skin

• Surface smooth and even, with homogeneous color; assess skin turgor 

• Inspect for pigment change and presence of lesions or scars.

inspection of the abdomen

pulsation or movement

hair distribution: females inverted triangle , men diamond

demonear

Bowel Sounds

High-pitched, gurgling, cascading noises originating from air and fluid movement through the small intestine, normally occurring irregularly between $5\text{ to }30\text{ times per minute}$.

use diaphragm , hold lightly , listen in all four quadrants, note character and frequency

Hypoactive Bowel Sounds

Decreased bowel motility sounds occurring at approximately $3\text{ per minute}$, which can follow abdominal surgery or inflammation.

hyperactive

loud high pitch signal increased motility

Borborygmus

Hyperactive bowel sound produced by hyperperistalsis, commonly described as stomach growling.

Silent Abdomen

The clinical determination of completely absent bowel sounds, requiring continuous listening with a stethoscope for $5\text{ minutes}$ by the watch.

vascular sounds

listen with the bell, some may have bruit

• Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension.

• Do not use auscultation for initial placement of nasogastric tube insertion. 

  • Evidence-based practice (EBP) confirming initial placement by imaging study and continued assessment by external tube length and pH of stomach aspirate

percussion of tympana

• Percuss general tympany, liver, and splenic dullness.

  • To assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses

  • General tympany

    • First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness in clockwise manner.

Costovertebral Angle Tenderness

A sharp tenderness elicited by indirect fist percussion over the 12th rib at the costovertebral angle on the back, indicating kidney inflammation person sitting up

Light Palpation

An abdominal palpation technique using one hand depressed lightly into the abdominal wall to evaluate overall muscle tone, surface characteristics, and initial tenderness.

Deep Palpation

An abdominal palpation technique using two hands (one stacked over the other) to delineate deep organ boundaries, consistency, and abnormal masses.

Normally Palpable Structures

Structures that can normally be detected during deep abdominal palpation, including the xiphoid process, normal liver edge, lower pole of right kidney, pulsatile aorta, rectus muscle borders, sacral promontory, cecum, ascending colon, sigmoid colon, gravid uterus, and full bladder.

Identification of a Mass

• If you identify a mass, then note the following:

  • Location

  • Size

  • Shape

  • Consistency: soft, firm, hard

  • Surface: smooth, nodular

  • Mobility, including movement with respirations

  • Pulsatility

  • Tenderness

palpation of liver

• Place your left hand under a person’s back parallel to 11th and 12th ribs and lift up to support abdominal contents.

• Place your right hand on RUQ, with fingers parallel to midline.

  • Push deeply down and under right costal margin.

  • Ask the person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation.

  • It feels like a firm regular ridge; often liver is not palpable.

• Hooking technique 

  • Alternative method used to palpate liver.

palpation of spleen 1

• Normally spleen is not palpable and must be enlarged three times its normal size to be felt.

• To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs. 

• Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just inferior to rib margin.

• Push your hand deeply down and under left costal margin, and ask the person to take deep breath.

• You should feel nothing firm.

  • Enlargement seen with:

    • Mononucleosis, leukemia and lymphomas, portal HTN and HIV infection

• Do not continue to palpate if enlarged as it could rupture.

palpation of spleen enlargement

• Mononucleosis, leukemia and lymphomas, portal HTN and HIV infection

• Normally spleen is not palpable and must be enlarged three times its normal size to be felt.

• An alternative position is to roll a person onto his or her right side to displace spleen more forward and downward. 

• If palpable, do not continue to palpate as it is friable and can rupture. 

palpation kidney

• ou can elect to palpate either the right or the left kidney.

  • Patient must take a deep breath prior to examination.

  • Right kidney

    • Feel no change or feel smooth muscle mass 

    • Either is normal 

  • Left kidney

    • Feel no change with inhalation

    • Not normally palpable 

    • 1 cm higher than right kidney

Aortic Pulsation Width

The normal anterior pulsation width of the abdominal aorta in adults, measuring $2.5\text{ to }4\text{ cm}$ wide in the upper abdomen slightly left of midline.

Widened in the presence of abdominal aortic aneurysm

thumb and finger

Ascites

The presence of free fluid in the peritoneal cavity causing abdominal distention, bulging flanks, and an inverted/protruding umbilicus displaced downward, confirmed by fluid wave and shifting dullness tests.

fluid wave test

• The patient lies on their back.

• The examiner taps one side of the abdomen while feeling for a wave on the opposite side.

• Positive test: a wave of fluid is felt on the other side.

• feel

shifting dullness test

• areas of dullness caused by fluid.

• The patient then turns onto their side.

• Positive test: the area of dullness shifts because the fluid moves with gravity

• hear

Blumberg's Sign

Rebound tenderness evaluated during abdominal release, indicating peritoneal inflammation or acute appendicitis.

when patients feels more pain when pressure is released

Murphy's Sign

Inspiratory arrest triggered during right upper quadrant deep palpation beneath the costal margin, indicating acute cholecystitis (gallbladder inflammation).

when patients stops or inhabits their breath because of pain

other special test for appendicitis

• McBurney’s point tenderness: lower abdominal between belly button and right hip, tenderness when palpated , RLQ tenderness

• Iliopsoas muscle test: raise the right thigh against resistance or extends the right hip while the patient is lying down, RLQ/ hip pain

• Obturator test: right hip and knee are flexed, and the examiner rotates the hip inward and outward, RLQ pain irritation near obturator muscle can lead to inflammation appendix located in the pelvis

• The Alvarado score (MANTRELS score) evaluation of RLQ pain acute appendicitis: Migration of pain to RLQ, anorexia , n/v, tenderness in RLQ, round tenderness, fever, leukocytes high WBC , shift to left

Developmental Competence:
The Aging Adult

• On inspection, you may note increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities.

• Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may note peristalsis.

  • Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesity.

• Liver and kidneys are easier to palpate.

  • With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin with inhalation.

Referred Abdominal Pain

Pain perceived at a location distant from its organ origin, such as shoulder pain from a perforated duodenal ulcer or midscapular pain from pancreatitis.

common sites of referred abdominal pain

Liver—RUQ

Esophagus—behind lower sternum

Ulcer—shoulder

Gallbladder—RUQ

Appendix—RLQ

Pancreas—Midscapular

Kidney—flank pain

Small intestine—diffuse

Colon—colicky pain and bloating 

Abnormal Findings (1 of 3)
Abdominal Distention

• Obesity

• Air or gas

• Ascites

• Ovarian cyst

• Pregnancy

• Feces

• Tumor

inspection of abnormal findings

• inspection

  • Umbilical hernia: bludgeoned around belly button, weak area, noticeable with coughing and straining

  • Epigastric hernia: upper middle between breast bone and belly button weakness in walls

  • Incisional hernia: bulge in previous surgical incisions weak spot

• Abnormal bowel sounds

  • Succussion splash: increased air in fluid in stomach commons in infant

  • Marked peristalsis: hearing or visible or strong intestinal movement and intestinal obstruction

  • Hypoactive bowel sounds: less frequent , ileum, after surgery , with peritonitis

  • Hyperactive bowel sounds: more frequent , diarrhea, gastroenteritis, or early intestinal obstruction

Abnormal Findings

• Friction rubs and vascular sounds

  • Peritoneal friction rub

  • Arterial bruit

  • Venous hum

• On palpation of enlarged organs

  • Enlarged liver

  • Enlarged nodular liver

  • Enlarged gallbladder

  • Enlarged spleen

  • Enlarged kidney

  • Aortic aneurysm

Summary Checklist: Abdomen Examination

• Inspection

  • Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor

• Auscultation

  • Bowel sounds; note any vascular sounds

• Percussion

  • All four quadrants and borders of liver and spleen

• Palpation

  • Light and deep palpation in all four quadrants, and palpate for liver and spleen