Abdomen Chapter 221

Abdomen Overview

Chapter 22

Organs of the Abdomen

• Inferior vena cava: A large vein that carries deoxygenated blood from the lower body to the heart.

• Right kidney: One of two bean-shaped organs responsible for filtering blood and producing urine. The right kidney is positioned slightly lower due to the presence of the liver.

• Duodenum: The first section of the small intestine, where a significant amount of digestion occurs, involving enzymes from the pancreas and bile from the liver.

• Pancreas: A vital organ that has both endocrine functions (insulin production) and exocrine functions (digestive enzymes).

• Right ureter: A duct that conveys urine from the right kidney to the bladder.

• Sacral promontory: The protruding part of the sacrum, which can be a landmark in pelvic examinations.

• External iliac artery & vein: Major blood vessels that supply blood to the lower limbs.

• Uterus: A muscular organ where a fertilized egg develops into a fetus in females. It is located in the pelvic cavity.

• Bladder: A hollow organ that stores urine before it is expelled from the body.

• Aorta: The largest artery in the body, which carries oxygenated blood from the heart to the rest of the body.

• Left kidney: Contains similar functions to the right kidney, crucial for filtration and urine production.

• Small intestine: Comprising the duodenum, jejunum, and ileum; major site for digestion and nutrient absorption.

• Left ureter: Similar function to the right ureter, transporting urine from the left kidney to the bladder.

• Common iliac artery & vein: Branches from the abdominal aorta that supply blood to the pelvis and lower limbs.

• Peritoneum: A serous membrane lining the abdominal cavity and covering the abdominal organs, providing a smooth surface for organs to move upon.

• Rectum: The final section of the large intestine, leading to the anus. It stores feces until excretion.

• Ovary: Female reproductive organs that produce eggs and hormones.

• Pubic symphysis: A cartilaginous joint located between the two pubic bones, providing stability to the pelvis.

Contents of Each Abdominal Quadrant

• Right Upper Quadrant (RUQ): Includes the liver, gallbladder, duodenum, pancreas head, and parts of the right kidney.

• Right Lower Quadrant (RLQ): Contains the appendix, part of the small intestine, and the right ovary in females.

• Midline: Houses structures such as the abdominal aorta and the bladder.

• Left Upper Quadrant (LUQ): Encompasses the stomach, spleen, and parts of the left kidney and pancreas.

• Left Lower Quadrant (LLQ): Comprises the sigmoid colon and the left ovary in females.

Developmental Considerations

• Infants and Children: Organ development and functions varying across age groups, with distinct considerations for abdominal examination.

• Pregnant Female: Anatomical and physiological changes during pregnancy impact abdominal examination and organ positioning.

• Aging Adults: Changes such as reduced muscle mass and increased abdominal fat can affect organ function and examination findings.

Genetics and Environment

• Lactase: A digestive enzyme necessary for the absorption of lactose, found in milk and dairy products.

• Lactose intolerance: A common condition in which individuals lack sufficient lactase to digest lactose, leading to gastrointestinal symptoms.

• Celiac disease: An autoimmune disorder triggered by gluten that affects the absorption of nutrients in the small intestine, leading to a range of gastrointestinal and systemic symptoms.

Collecting Subjective Data

• Appetite: Changes in appetite may indicate underlying health issues.

• Dysphagia: Difficulty swallowing, which can signify esophageal disorders.

• Food intolerance: Symptoms that occur due to certain foods; distinct from allergies.

• Abdominal pain: A critical symptom requiring thorough assessment to determine origin and cause.

• Nausea/Vomiting: Important indicators of gastrointestinal health and possible obstructions or infections.

• Bowel habits: Changes in frequency or characteristics of stools can indicate gastrointestinal health.

• Past abdominal history: Previous abdominal surgeries or conditions can influence current health.

• Medications: Review of medications can highlight potential gastrointestinal side effects.

• Nutritional assessment: Analyzing dietary intake to identify deficiencies or excesses.

Collecting Objective Data

• Inspect: Visually examining the abdomen for abnormalities.

• Auscultate: Listening for bowel sounds and vascular noises.

• Percuss: Tapping to assess underlying structures and check for fluid or masses.

• Palpate: Feeling the abdomen to assess organ size, tenderness, or masses.

• Assessment order: Inspect, auscultate, percuss, then palpate to prevent altering bowel sounds. Examine tender areas last to avoid discomfort and masking of conditions.

Inspection Considerations

• Symmetry: Check for unusual bulging or deformities.

• Umbilicus: Inspect for discoloration or protrusions.

• Skin: Note any rashes, lesions, or abnormalities in texture.

• Pulsation or movement: Observe for abnormal pulsations or peristalsis.

• Hair distribution: Patterns might indicate hormonal changes or issues.

• Demeanor: Patient demeanor can reflect underlying pain or discomfort.

Auscultation of Bowel Sounds

• Listening for:

  • Hypoactive: Fewer sounds or absent sounds may indicate obstruction or ileus.

  • Hyperactive: Increased sounds may be associated with diarrhea or gastrointestinal upset.

• Auscultating for Vascular Sounds:

  • Assess aorta, renal arteries, iliac arteries, and femoral arteries for bruits.

  • Listen for peritoneal friction rub that may indicate inflammation or infection.

Percussion Techniques

• General Tympany: Perform light percussion in all quadrants to check for normal tympany; a dull sound may indicate fluid or masses.

• Costovertebral Angle Tenderness: Assess kidney regions via indirect percussion; pain may indicate infection.

Palpation Techniques

• Light Palpation: Begin with gentle pressure to assess surface abnormalities; use distraction for ticklish patients.

• Deep Palpation: Apply pressure in circular motions to assess for deeper structures; use bimanual technique for large abdomens.

Identifying Masses: Consider location, size, shape, consistency, and mobility while palpating for abnormalities.

• Liver: Normally not palpable unless there are underlying conditions.

• Spleen: Must be three times its normal size to be felt.

• Kidneys: Right kidney lower pole may be palpable in healthy individuals; otherwise non-palpable.

Special Tests (Palpation)

• Fluid Wave Test: Assesses for ascites; positive results indicate fluid accumulation.

• Palpating the Aorta: Use caution to avoid palpating if an Abdominal Aortic Aneurysm (AAA) is suspected.

Additional Special Tests

• Rebound Tenderness: Indicates potential peritoneal irritation or appendicitis.

• McBurney Point: Pain upon palpation suggests appendicitis.

• Iliopsoas Muscle Test: Pain during extension indicates appendicitis.

• Obturator Test: Pain during internal rotation may indicate a perforated appendix.

• Murphy's Sign: Inspiratory arrest upon palpation of the gallbladder suggests cholecystitis.

• Alvarado Score (MANTRELS Score): Assessing risk of appendicitis based on signs like migration of pain, anorexia, nausea/vomiting, tenderness, rebound tenderness, fever, leukocytosis, and left shift in blood profile.

Developmental Competence

• Consider variations in assessment findings across different populations, including infants, children, and aging adults, who may present differently clinically.

Abnormal Findings on Inspection

• Umbilical Hernia: May appear as a bulge at the umbilicus, potentially requiring surgical intervention.

• Epigastric Hernia: A protrusion that occurs in the upper part of the abdomen.

• Incisional Hernia: Develops post-surgery due to weak abdominal wall.

• Diastasis Recti: Separation of abdominal muscles often seen in pregnancy.

• Marked Peristalsis: Observing exaggerated intestinal movements may indicate obstruction.

Abnormal Findings: Abdominal Distention

• Obesity: Excess abdominal fat alters organ function.

• Ascites: Fluid accumulation in the peritoneal cavity, often resulting from liver disease or malignancies.

• Air or Gas: Bloating or distention can indicate gastrointestinal issues.

• Ovarian Cyst (large): May present with abdominal fullness or pain.

• Pregnancy: Distention due to fetal growth.

• Feces: High amounts can cause abnormal distension, indicating constipation or obstruction.

• Tumor: Mass presence can indicate malignancy or other serious conditions.

Common Sites of Referred Pain

• Liver: Pain may be referred to the right shoulder due to diaphragmatic irritation.

• Heart: Can refer pain to the epigastric region and left arm.

• GERD: Gastroesophageal reflux can present as abdominal pain or chest discomfort.

• Pancreatitis: Pain may radiate to the back.

• Perforated Duodenal Ulcer: Can cause upper abdominal pain radiating to the back.

• Penetrating Duodenal Ulcer: Similar to perforated ulcer presentation.

• Biliary Colic: Associated with gallstones can cause severe right upper quadrant pain.

• Appendicitis: Can present initially as diffuse pain but typically migrates to the right lower quadrant.

• Colon Pain: Various conditions can cause referred pain in the abdominal region, including peptic ulcers, renal colic, or gastrointestinal obstructions.

• Rectal Lesions: May cause referred pain to the lower abdomen or pelvic region.

Questions

• Review pertinent conditions, symptoms, special tests, and assessments related to abdominal examination, emphasizing the importance of thorough patient evaluation and clinical awareness.