GI/GU

Anatomical Landmarks, Quadrants, and Vasculature

  • Reference Lines and Quadrants:

    • Division uses a vertical midline (xiphoid process to pubic symphysis) and a horizontal transumbilical line.

    • Right Upper Quadrant (RUQ): Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic flexure, parts of ascending and transverse colon.

    • Left Upper Quadrant (LUQ): Stomach, spleen, left lobe of liver, body/tail of pancreas, left kidney and adrenal gland, splenic flexure, parts of transverse and descending colon.

    • Right Lower Quadrant (RLQ): Cecum, appendix, portion of ascending colon, right ovary/fallopian tube or spermatic cord, right ureter, and bladder (when distended).

    • Left Lower Quadrant (LLQ): Sigmoid colon, portion of descending colon, left ovary/fallopian tube or spermatic cord, left ureter, and bladder (when distended).

  • Cavities and Vasculature:

    • Peritoneum: Sterile, double-layered serous membrane (parietal and visceral) that lubricates and shields viscera.

    • Retroperitoneal Cavity: Houses structures posterior to the parietal peritoneum, including the kidneys (positioned at T12T12 to L3L3; right kidney is lower due to liver position). Kidneys are protected by the renal capsule, adipose capsule, and renal fascia.

    • Vasculature: Abdominal aorta extends downward and bifurcates at the lower lumbar spine into the bilateral common iliac arteries.

Subjective Assessment and Symptom Analysis

  • Urgent Signs: Severe dehydration from vomiting/diarrhea and acute, localized, or radiating abdominal pain.

  • Core Gastrointestinal Symptoms: Dyspepsia/GERD, dysphagia, nausea, vomiting, hematemesis, bowel alterations (diarrhea, constipation, melena, hematochezia), and jaundice.

  • Genitourinary Symptoms: Dysuria, urinary urgency, frequency, incontinence, flank pain, and gross hematuria.

  • Health History: Collect PMH (GI disorders, hepatitis, surgery), FH (colorectal cancer, gallbladder disease, nephropathies), and personal/social history (24-hour24\text{-hour} diet recall, alcohol/tobacco use, and Last Menstrual Period [LMP, defined as Day 11 of the cycle]).

Physical Examination: Sequence and Inspection

  • Sequence: Inspection, Auscultation, Percussion, Palpation. Auscultation precedes percussion and palpation to avoid artificially inducing peristalsis.

  • Patient Preparation: Instruct the patient to empty their bladder completely, lie supine with knees slightly flexed, and examine painful or tender areas last.

  • Inspection:

    • Abdominal Contour: Flat (normal/athletic), Scaphoid (sunken/malnourished), Rounded (mild convex), Protuberant (distended/ascites/obesity).

    • Surface Features: Midline inverted umbilicus, surgical scars, striae, caput medusae (portal hypertension), and Cullen's sign (periumbilical ecchymosis indicating retroperitoneal hemorrhage or hemorrhagic pancreatitis).

    • Abdominal Wall Defects: Hernias (protrusions through fascial defects; classified as reducible, incarcerated, or strangulated surgical emergencies) and Diastasis recti (separation of the rectus abdominis muscle bellies without a fascial tear).

Auscultation: Bowel and Vascular Sounds

  • Bowel Sounds:

    • Auscultate with the stethoscope diaphragm starting at the ileocecal valve in the RLQ, proceeding clockwise (RLQ →\rightarrow RUQ →\rightarrow LUQ →\rightarrow LLQ).

    • Normoactive: 5 to 30 sounds/min5\text{ to }30\,\text{sounds/min}.

    • Hyperactive / Borborygmus: Loud, high-pitched, rushing/growling sounds; heard proximal to bowel obstruction or with gastroenteritis.

    • Hypoactive: Diminished, infrequent sounds (<5 sounds/min5\,\text{sounds/min}); heard distal to obstruction, postoperatively, or with peritonitis.

    • Absent: Complete silence confirmed only after continuous auscultation for 5 minutes5\,\text{minutes}.

  • Vascular Sounds:

    • Bruits: Assessed with the bell over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries.

    • Friction Rubs: Assessed with the diaphragm over the liver and spleen; grating sounds synchronized with respiration reflecting peritoneal inflammation.

    • Venous Hum: Rare continuous hum over the epigastric/umbilical areas signaling portal hypertension.

Percussion and Palpation

  • Percussion:

    • Tympany: Dominant musical note over hollow, air-filled stomach and intestinal loops.

    • Dullness: Heard over solid organs (liver, spleen), fluid collections (ascites), a full bladder, or fecal masses.

    • Costovertebral Angle (CVA) Tenderness: Indirect fist percussion over the 12th12^{\text{th}} rib posteriorly; sharp pain indicates renal inflammation or pyelonephritis.

  • Palpation Techniques:

    • Light Palpation: Depress 1 cm1\,\text{cm} using finger pads in rotary motions to assess tenderness, voluntary muscle guarding, and involuntary rigidity.

    • Deep Palpation: Depress 5 to 8 cm5\text{ to }8\,\text{cm} using a bimanual technique to delineate organ edges and detect deep masses.

    • Liver: Palpated under the right costal margin during deep inspiration; hepatomegaly presents as an edge extending below the costal margin.

    • Spleen: Normally non-palpable; must enlarge to 3×3\times its normal size to be felt below the left costal margin (avoid over-palpation to prevent splenic rupture).

    • Kidneys: Evaluated via bimanual capture method; occasionally the lower pole of the right kidney is palpable in slender patients.

    • Abdominal Aorta: Normal transverse pulsation width measures approximately 2 cm2\,\text{cm}; lateral expansile pulsations exceeding 3 cm3\,\text{cm} suggest an abdominal aortic aneurysm (AAA).

Special Clinical Tests

  • Fluid Wave Test: Differentiates ascites from adipose tissue; requires three hands to block subcutaneous fat wave transmission while tapping one flank to feel an impulse on the other.

  • Murphy's Sign: Palpation under the right costal margin halts inspiration midway due to sharp pain; indicates acute cholecystitis.

  • McBurney's Point: Localized tenderness 1/31/3 the distance from the anterior superior iliac spine (ASIS) to the umbilicus; classic sign of appendicitis.

  • Blumberg Sign (Rebound Tenderness): Performed at the end of the exam by pressing deeply and releasing rapidly; pain on release indicates peritoneal irritation.

  • Rovsing's Sign: Deep palpation in the LLQ produces referred pain in the RLQ; indicative of appendicitis.

  • Iliopsoas and Obturator Tests: Pain provoked with resisted right hip flexion or internal/external rotation of the flexed hip indicates appendiceal irritation of underlying musculature.

Lifespan Considerations and Health Promotion

  • Pediatrics: Lower esophageal sphincter tone is relaxed until approximately 1 month1\,\text{month} of age. Stomach capacity expands from 10 to 20 mL10\text{ to }20\,\text{mL} at birth to 500 mL500\,\text{mL} by 2 years2\,\text{years}. Renal functional development and concentrating ability remain immature until 2 years2\,\text{years}.

  • Older Adults: Decreased abdominal muscle tone, subcutaneous fat redistribution to the abdomen/hips, reduced gastric acid and enzyme secretions, and decreased GI motility predisposing to constipation.

  • Health Promotion & Prevention: Routine colorectal cancer screening starting at age 5050, promotion of high-fiber diets, and active immunization against Hepatitis A and Hepatitis B.