Abdomen (BITGUE)

abdomen

bordered superiorly by the costal margins,
inferiorly by the symphysis pubis and inguinal canals, and
laterally by the flanks.

right upper quadrant (RUQ), right lower quadrant (RLQ), left lower quadrant (LLQ), and left upper quadrant (LUQ)

the abdomen can be
described as having four quadrants:

midline, xiphoid, umbilicus, symphysis pubis

The quadrants are determined by an imaginary vertical line _____ extending from the tip of the sternum _____through
the _____ to the _____

epigastric, umbilical, and hypogastric
or suprapubic.

Another method divides the abdomen into nine regions. Three of these regions are still commonly used to describe abdominal findings:

abdominal wall musculature

The abdominal contents are enclosed externally by the_____, which includes three layers of muscle extending from the back, around the flanks, to the front.

external abdominal oblique

outermost layer of abdominal wall muscles

internal abdominal oblique

middle layer of abdominal wall muscles

transverse abdominis

innermost layer of abdominal wall muscles

rectus abdominis

Connective tissue
from these muscles extends forward to encase a vertical muscle
of the anterior abdominal wall called the

aponeuroses

The fibers and connective tissue extensions of these muscles _____ diverge in a characteristic plywood-like pattern (several
thin layers arranged at right angles to each other), which
provides strength to the abdominal wall.

linea alba

The joining of these
muscle fibers and aponeuroses at the midline of the abdomen
forms a white line called the _____, which extends vertically from the xiphoid process of the sternum to the symphysis
pubis.

peritoneum, parietal peritoneum, visceral peritoneum

A thin, shiny, serous membrane called the _____ lines the abdominal cavity _____ and also provides a protective covering for most of the internal abdominal organs _____.

gastrointestinal, reproductive (female), lymphatic, and urinary

Within the abdominal cavity are structures
of several different body systems

Solid viscera

are those organs that maintain their shape
consistently: liver, pancreas, spleen, adrenal glands, kidneys,
ovaries, and uterus

hollow viscera

consist of structures that
change shape depending on their contents. These include the stomach, gallbladder, small intestine, colon, and bladder.

liver

the largest solid organ in the body. It is located below the diaphragm in the RUQ of the abdomen. It is composed of four lobes that fill most of the RUQ and extend to the left midclavicular
line.

Right Upper Quadrant (RUQ)

Ascending and transverse colon
Duodenum
Gallbladder
Hepatic flexure of colon
Liver
Pancreas (head)
Pylorus (the small bowel—or ileum— traverses all quadrants)
Right adrenal gland
Right kidney (upper pole)
Right ureter

Right Lower Quadrant (RLQ)

Appendix
Ascending colon
Cecum
Right kidney (lower pole)
Right ovary and tube
Right ureter
Right spermatic cord

Left Upper Quadrant (LUQ)

Left kidney (upper pole)
Left ureter
Pancreas (body and tail)
Spleen
Splenic flexure of colon
Stomach
Transverse descending colon

Left Lower Quadrant (LLQ)

Left kidney (lower pole)
Left ovary and tube
Left ureter
Left spermatic cord
Descending and sigmoid colon

Midline

Bladder
Uterus
Prostate gland

pancreas

located mostly behind the stomach deep in
the upper abdomen, is normally not palpable. It is a long gland
extending across the abdomen from the RUQ to the LUQ.

an endocrine gland and an accessory organ of digestion

The pancreas has two functions:

spleen

approximately 7 cm wide and is located above the left kidney just below the
diaphragm at the level of the ninth, tenth, and eleventh ribs. It
is posterior to the left mid-axillary line and posterior and lateral
to the stomach. This soft, flat structure is normally not palpable.

spleen

functions primarily to filter the blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver.

kidneys

are located high and deep under the diaphragm. These glandular, bean-shaped organs measuring
approximately 10 × 5 × 2.5 cm are considered posterior organs
and approximate with the level of the T12 to L3 vertebrae

filtration and elimination of metabolic waste products.

primary function of the kidney

kidney

also play a role in blood pressure control and maintenance of water, salt, and electrolyte balances. In addition, they function as endocrine glands by secreting hormones.

pregnant uterus

may be palpated above the level of the symphysis pubis in the midline

ovaries

are located in the RLQ and LLQ, and are normally palpated only during a bimanual examination of the internal genitalia

stomach

It is a distensible,
flask-like organ located in the LUQ just below the
diaphragm and between the liver and spleen. The stomach is not usually palpable.

store, churn, and digest food.

The stomach's main function is to

gallbladder

a muscular sac approximately 10 cm long, functions primarily to concentrate and store the bile needed to digest fat. It is located near the posterior surface of the liver
lateral to the mid-clavicular line.

small intestine

the longest portion of the digestive tract (approximately 7.0 m long) but is named for its
small diameter (approximately 2.5 cm).

digestion and absorption of nutrients

Two major functions
of the small intestine are

colon, or large intestine

a wider diameter than the small intestine (approximately 6.0 cm) and is approximately
1.4 m long. It originates in the RLQ, where it attaches to the
small intestine at the ileocecal valve.

ascending, transverse, and descending

The colon is composed
of three major sections:

ascending colon

extends up along the right side of
the abdomen.

transverse colon

At the junction of the liver in the RUQ, it flexes
at a right angle and becomes the

descending colon

In the LUQ near
the spleen, the colon forms another right angle then extends
downward along the left side of the abdomen as the

sigmoid colon

often felt as a firm structure on palpation,

colon

functions primarily to secrete large amounts
of alkaline mucus to lubricate the intestine and neutralize
acids formed by the intestinal bacteria. Water is also absorbed
through the large intestine, leaving waste products to be eliminated
in stool.

arterial blood

The abdominal organs are supplied with _____ by the abdominal aorta and its major branches

PREGNANCY (NORMAL
FINDING)

Pregnancy is included here so that the examiner may differentiate it from
abnormal findings.
It causes a generalized protuberant abdomen, protuberant umbilicus, a
fetal heart beat that can be heard on auscultation, percussible tympany over the
intestines, and dullness over the uterus.

FECES

Hard stools in the colon appear as a localized distention. Percussion over the area discloses dullness

FLATUS

The abdomen distended with gas may appear as a generalized protuberance
(as shown), or it may appear more localized. Tympany is the percussion tone over the area

FAT

Obesity accounts for most uniformly
protuberant abdomens. The abdominal
wall is thick, and tympany is the
percussion tone elicited. The umbilicus
usually appears sunken.

FIBROIDS AND OTHER
MASSES

A large ovarian cyst or fibroid tumor
appears as generalized distention in
the lower abdomen. The mass displaces
bowel, thus the percussion tone
over the distended area is dullness,
with tympany at the periphery. The
umbilicus may be everted.

ASCITIC FLUID

Fluid in the abdomen causes generalized
protuberance, bulging flanks, and an everted umbilicus. Percussion
reveals dullness over fluid (bottom of
abdomen and flanks) and tympany
over intestines (top of abdomen).

UMBILICAL HERNIA

results from the bowel protruding through a weakness in the umbilical ring. This condition occurs more frequently in infants, but also occurs in adults.

DIASTASIS RECTI

occurs when the bowel protrudes through
a separation between the two rectus abdominis muscles.
It appears as a midline ridge. The bulge may appear only
when the client raises the head or coughs. The condition is
of little significance.

EPIGASTRIC HERNIA

occurs when the bowel protrudes through a weakness in the linea alba. The small bulge
appears midline between the xiphoid process and the
umbilicus. It may be discovered only on palpation.

INCISIONAL HERNIA

occurs when the bowel protrudes through a defect or weakness resulting from a surgical
incision. It appears as a bulge near a surgical scar on the abdomen.

ENLARGED LIVER

is defined as a span greater than 12 cm
at the mid-clavicular line (MCL) and greater than 8 cm at the midsternal line
(MSL). An enlarged nontender liver
suggests cirrhosis. An enlarged tender
liver suggests congestive heart failure,
acute hepatitis, or abscess.

LIVER LOWER THAN
NORMAL

A liver in a lower position than normal with a normal span may be caused by emphysema because the diaphragm is low.

ENLARGED KIDNEY

may be due to a
cyst, tumor, or hydronephrosis. It may
be differentiated from an enlarged spleen by its smooth rather than sharp
edge, the absence of a notch, and tympany
on percussion.

ENLARGED NODULAR LIVER

An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis.

ENLARGED SPLEEN

(splenomegaly) is
defined by an area of dullness exceeding
7 cm. When enlarged, the spleen
progresses downward and in toward the
midline.

ENLARGED GALLBLADDER

An extremely tender, enlarged …
suggests acute cholecystitis.
A positive finding is Murphy's sign
(sharp pain that causes the client to
hold the breath).

LIVER HIGHER THAN NORMAL

A liver that is in a higher position than normal span may be caused by
an abdominal mass, ascites, or a paralyzed
diaphragm.

AORTIC ANEURYSM

A prominent, laterally pulsating mass
above the umbilicus strongly suggests
an aortic aneurysm. It is accompanied
by a bruit and a wide, bounding pulse.

Psoas Sign

• Pain in RLQ when leg is hyperextended

• Irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix)

Obturator sign

• Pain in the RLQ when hip and knee are flexed and leg is rotated internally and externally

• Irritation of the obturator muscle due to appendicitis or a perforated appendix

Murphy sign

• Pain elicited when pressure is applied under the liver border at the right costal margin and client inhales deeply

• Inflammation of the gallbladder

Rovsing Sign

• Pain in the RLQ during pressure in the LLQ

• Acute Appendicitis

Blumberg sign

• Abdominal pain or tenderness experienced when examiner tests for rebound tenderness by palpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest (McBurney point)

• Peritoneal irritation

Indigestion (pyrosis), often described as heartburn, may be an indication of acute or chronic gastric disorders including hyperacidity, gastroesophageal reflux disease (GERD), peptic ulcer disease, and stomach cancer.