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Abdominal Anatomy, Exam Techniques, and GI Disorders — Study Notes

Abdominal Anatomy and Landmarks

  • Abdominal quadrants and regions help localize symptoms and findings.
  • Surface landmarks and regions from the transcript:
    • RUQ (Right Upper Quadrant): liver (right lobe), gallbladder, bile duct, kidney, and portions of bowel; spleen is not in RUQ.
    • LUQ (Left Upper Quadrant): stomach (cut), spleen, pancreas, left kidney, portions of colon and small intestine.
    • Epigastric region: area above the umbilicus; commonly related to stomach and pancreas symptoms.
    • Umbilical region: around the umbilicus; small intestine, and transverse colon portions.
    • Hypochondrium (right and left): areas overlying the diaphragmatic surfaces of the liver and spleen.
    • Flank (right/left) and lumbar regions: lateral aspects of the abdomen.
    • Iliac fossa: RLQ and LLQ areas where intestines and reproductive organs reside.
    • Right/Left iliac regions (inguinal areas) and supra-pubic (hypogastric) region.
    • Typical contents per quadrant (as outlined in the transcript diagram):
    • RUQ: liver, gallbladder, bile duct, right kidney, portions of colon; pancreas head may be related to RUQ imaging.
    • LUQ: spleen, stomach, pancreas, left kidney, portions of colon; transverse and descending colon.
    • RLQ: cecum, appendix, portions of small bowel, uterus (in females), ovaries.
    • LLQ: descending and sigmoid colon, portions of small bowel, uterus (in females), ovaries.
  • Umbilicus is a landmark for locating abdominal quadrants and assessing distention or organ involvement.

Peritoneum and Assessment Fundamentals

  • Peritoneum: a serous membrane lining the abdominal cavity that can become inflamed in peritonitis; the exam often targets signs of peritoneal irritation.
  • Objective data collection in abdominal exams follows the sequence IAPP:
    • Inspection: observe symmetry, contour, surface characteristics, movement, and peritoneal signs such as distention or visible peristalsis.
    • Auscultation: listen with diaphragm for bowel and vascular sounds; do not rush or count sounds—evaluate normal vs abnormal patterns by listening.
    • Percussion: identify tympany vs dullness to infer gas, fluid, or organ size; historically used for hepatomegaly and splenomegaly but imaging is more reliable.
    • Palpation: perform light then deep palpation to assess tenderness, masses, distention; end in the quadrant that is painful; use bimanual techniques if needed.
  • Important signs sometimes observed on exam:
    • Cullen’s sign and Turner’s sign as indicators of intraabdominal bleeding.
    • Faint abdominal aortic pulsation can be normal; marked pulsations may indicate aneurysm.
  • Normal bowel sounds: with a stethoscope, assess all four quadrants in a clockwise sequence starting RLQ.
  • Do not count; assess for presence, frequency, and character (normoactive, hypoactive, hyperactive, absent).

Subjective Data and History

  • Health history sections to cover during assessment:
    • Past Medical History (PMH): gastrointestinal conditions, prior surgeries, current medications.
    • Review of Systems: focused GI symptoms and systemic signs.
    • Family history relevant to GI and abdominal diseases.
    • Functional assessment: substance use, dietary habits.
    • Focused assessment framework: OPQRSTU (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing, Understanding).

Bowel Movements: History and Abnormalities

  • Key questions:
    • When was the last bowel movement?
    • How often do you have bowel movements?
    • What is the color and consistency of stool?
  • Abnormal findings to assess for:
    • Dyschezia: pain or straining with bowel movements.
    • Tenesmus: feeling of incomplete emptying after bowel movement.
    • Diarrhea: increased stool frequency/loose stools.
    • Hematochezia: bloody stool from lower GI bleed (colon or rectum).
    • Melena: black, tarry stools from upper GI bleed (stomach or small intestine).
    • Steatorrhea: fat malabsorption, pale/oily stools.
  • Documentation should note frequency, consistency, color, odor, and any associated symptoms (pain, fever, vomiting).

Physical Exam: IAPP Details

  • Preparation and general survey:
    • Ensure good lighting, appropriate exposure, empty bladder, patient supine with knees slightly bent and arms at sides.
    • Observe overall appearance, skin color, and signs of bleeding (Cullens, Turner’s signs).
    • Umbilicus midline and inverted as a normal finding.
  • Inspection:
    • Assess symmetry for hernias or masses from the side and the foot of the bed.
    • Contour: flat or rounded is normal; watch for distention.
    • Movement and visible peristalsis; a noticeable aortic pulsation in the epigastrium may be normal.
    • Pain with visible waves of peristalsis suggests obstruction.
  • Bowel sounds:
    • Normal (normoactive): 5-30 ext{ sounds per minute}; high-pitched, gurgling, irregular.
    • Hypoactive: <30 ext{ sounds/min} or less frequent; often after surgery, inflammation, or with medications like opioids; ileus or obstruction can alter.
    • Absent: no sounds after a full 5 minutes.
    • Hyperactive: >30 ext{ sounds/min}; may occur with hunger, early obstruction, diarrhea, gastroenteritis, or laxatives.
  • Vascular sounds:
    • Use the bell to listen over the aorta, renal, iliac, and femoral arteries for bruits, which may indicate aneurysm or stenosis.
  • Percussion:
    • Tympany typically predominates; dullness may indicate liver, fecal matter, ovarian cysts, or adipose tissue.
    • Bladder distention may cause dullness in the suprapubic region.
  • Physical tests:
    • CVA (costovertebral angle) tenderness test (FIST PERCUSSION): place nondominant hand over the 12th rib at CVA and thump with the ulnar edge of the dominant fist; bilateral testing checks for kidney inflammation (nephrolithiasis, pyelonephritis).
  • Palpation:
    • Use 4 fingers in a rotary motion for light palpation to assess tenderness and surface characteristics.
    • Abdomen should be soft and non-tender; end palpation in the quadrant that is painful.
    • Mild tenderness over the sigmoid colon (LLQ) can be normal.
    • Deep palpation is an advanced technique to palpate organs; often requires a deep, bimanual approach (depress 5-8 cm). 5-8 ext{ cm} ext{ (}2 ext{-}3 ext{ in)}
  • Guarding:
    • Voluntary guarding is a muscle splinting response due to pain or anxiety; can be influenced by distraction or medications.
    • Inflammation, spasm, or acute abdomen can cause involuntary guarding.

Normal Findings: Abdominal Organs by Palpation

  • Liver:
    • In RUQ, may be palpable or nonpalpable; if palpable, should be smooth, firm, non-tender, and extend no more than 2 ext{ cm} outside the right costal margin.
  • Gallbladder:
    • Normally not palpable.
  • Spleen:
    • Normally not palpable; rupture risk means palpation is approached cautiously.

The Aging Adult: Abdominal Changes

  • Aging is associated with:
    • Increased abdominal fat and altered body composition.
    • Higher risk for nutritional deficits due to reduced appetite, dentition issues, and decreased gastric acid secretion.
    • Greater likelihood of constipation from multiple contributing factors.
    • Decreased abdominal musculature and possible diminished abdominal wall rigidity; peritonitis signs may be less apparent.

Disorders of the Abdomen & GI System

  • GERD (Gastroesophageal Reflux Disease)
    • Stomach contents move up into the esophagus; reflux becomes a disease when symptoms are frequent/severe or cause injury.
    • Clinical findings: regurgitation, pyrosis (heartburn), symptoms worsened when lying down; can damage esophagus, pharynx, or respiratory tract.
  • Peptic Ulcer Disease (PUD)
    • Ulcers in lower esophagus, stomach, or duodenum; duodenal ulcers are most common.
    • Causes: Helicobacter pylori infection, stress, certain medications.
    • Clinical findings: burning/gnawing epigastric pain; duodenal ulcers often relieved by food; gastric ulcers worsen with food; nausea, bloating; bleeding may present as melena or hematemesis.
  • Bowel Obstruction
    • Mechanical or paralytic ileus; usually involves the small intestine.
    • S/S: abdominal pain and distention, vomiting, constipation or lack of flatus, visible peristaltic waves, early hyperactive sounds followed by hypoactive sounds, tenderness on palpation, rebound tenderness if peritoneal irritation.
    • Management: NPO (nothing by mouth).
  • Ascites
    • Fluid accumulation in the peritoneal cavity; common causes include cirrhosis, heart failure, cancer.
    • S/S: protuberant abdomen with taut skin and bulging flanks, possible jaundice with cirrhosis, dyspnea, diminished bowel sounds over fluid, increasing abdominal girth (routine measurement of abdominal girth for early detection).
    • Exam finding: shifting dullness in large effusions.
  • Appendicitis
    • Dull abdominal pain that localizes to severe RLQ pain; McBurney’s point tenderness; Rovsing’s sign (LLQ palpation elicits RLQ pain); iliopsoas/psoas sign (leg extension against resistance); obturator sign (flex right knee, internally rotate hip); rebound tenderness; N/V/D; fever; hypoactive bowel sounds; NPO; monitor abdominal softness, pain, vital signs.
  • Cholecystitis
    • Inflammation of the gallbladder, often due to gallstones blocking the bile duct.
    • Common S/S: RUQ pain that may radiate to the shoulder, worsened after fatty meals or caffeine, positive Murphy sign (inspiratory arrest), fever, steatorrhea, N/V; jaundice can occur.
  • Diverticulitis
    • Inflammation of diverticula (often due to chronic constipation).
    • Common S/S: crampy pain often in LLQ, fever, chills, localized tenderness, possible blood-streaked stool.
  • Inflammatory Bowel Diseases
    • Ulcerative Colitis (UC): exacerbations with profuse bloody diarrhea with mucus; pain could be generalized.
    • Crohn’s disease: symptoms depend on location and involvement (fissures, fistulas, ulcers).
    • Both can present with abdominal pain, weight loss, and diarrhea.
  • Peritonitis
    • Bacterial infection leads to peritoneal inflammation.
    • Causes: peritoneal dialysis, ruptured appendix, pancreatitis, trauma, perforated bowel.
    • S/S: fever, tachycardia, bloating, pain, abdominal rigidity, rebound tenderness, hypoactive bowel sounds.
  • Abdominal Aortic Aneurysm (AAA)
    • Dilation of the abdominal aorta due to vessel wall weakness.
    • Often asymptomatic until catastrophic event; may have a bruit, abdominal or back pain, pulsatile abdominal mass, hypotension if rupture, and a sense of impending doom.
  • Diabetes Mellitus
    • Chronic hyperglycemia with signs: polydipsia, polyphagia, polyuria, weight loss, paresthesias, poor wound healing.
    • Diabetic Ketoacidosis (DKA) signs: Kussmaul respirations, fruity breath, dehydration, lethargy, N/V.
    • Hypoglycemia signs: confusion, diaphoresis, shakiness, dizziness, tachycardia.
  • Urinary Tract Infection (UTI)
    • Symptoms: dysuria, frequency, urgency, fever, suprapubic pain, malodorous urine; CVA tenderness if kidneys involved.
    • Labs: WBC count, positive urine culture.
    • Treatment: antibiotics; may involve cystoscopy if invasive.
  • Sepsis
    • A systemic response to infection; needs prompt recognition and management (not detailed in depth in the transcript but highlighted as an important consideration).

Key Signs, Tests, and Clinical Concepts to Remember

  • Rebound tenderness: pain upon release of deep palpation indicating peritoneal irritation.
  • Murphy sign: inspiratory arrest on deep palpation of the RUQ during deep breath test; positive in cholecystitis.
  • Rovsing’s sign: LLQ palpation increases pain in the RLQ, suggesting appendicitis.
  • Iliopsoas sign (psoas sign): pain with resisted hip extension indicating retrocecal appendicitis or psoas irritation.
  • Obturator sign: pain with internal rotation of flexed right hip indicating pelvic involvement or appendiceal irritation.
  • CVA tenderness: tenderness at costovertebral angle indicating kidney inflammation or pyelonephritis; assessed with fist percussion over the CVA.
  • Shifting dullness: an exam finding in ascites where dullness shifts with patient position, indicating free intraperitoneal fluid.
  • Routine abdominal girth measurement: recommended for early detection of ascites.

Formulas and Numerical References (LaTeX format)

  • Normal bowel sounds cadence: 5-30\,\text{sounds per minute}
  • Hypoactive bowel sounds: <5\,\text{sounds per minute}
  • Hyperactive bowel sounds: >30\,\text{sounds per minute}
  • Palpation depth during deep palpation: 5-8\,\text{cm} (equivalent to 2''-3'')
  • Deep palpation depth note: 5-8\text{ cm} \ (2''-3'')
  • Abdominal girth assessment is highlighted as the best method for early detection of ascites, though a numeric threshold is not provided in the transcript.

Connections to Foundational Principles and Real-World Relevance

  • Anatomy and regional localization underpin symptom assessment and differential diagnoses for GI conditions.
  • The peritoneum’s role in signaling inflammation (peritonitis) guides immediate management and monitoring priorities.
  • The sequence IAPP mirrors clinical practice to minimize patient discomfort while maximizing diagnostic yield.
  • Understanding common GI disorders and their hallmark signs aids rapid triage, especially in acute settings (e.g., appendicitis, cholecystitis, bowel obstruction, AAA).
  • Recognizing age-related changes helps avoid underdiagnosis or misinterpretation of signs in older adults (e.g., muted peritoneal signs, constipation risk).

Practical and Ethical Implications

  • Accurate assessment and documentation of abdominal findings are essential for timely, evidence-based decisions and patient safety.
  • When signs suggest acute abdomen or peritonitis, prompt escalation and imaging are often warranted.
  • Patients with suspected GI bleeding or ascites require careful monitoring, IV access, and appropriate risk communication.
  • Respect for patient comfort and dignity during examination, especially with exposure and prolonged palpation, is essential.

Quick Reference: Key Definitions and Concepts

  • Dyschezia: painful or difficult bowel movements.
  • Tenesmus: sensation of incomplete rectal emptying after defecation.
  • Melena: black, tarry stools indicating upper GI bleed.
  • Hematochezia: bright red or maroon stool from lower GI bleed.
  • Steatorrhea: pale, oily stools indicative of fat malabsorption.
  • Murphy sign: inspiratory arrest during RUQ palpation; positive indicates cholecystitis.
  • Rovsing’s sign: RLQ pain with LLQ palpation; suggests appendicitis.
  • Psoas sign: pain with hip extension indicating retrocecal appendix.
  • Obturator sign: acute pain with internal rotation of flexed hip indicating pelvic irritation.
  • Rebound tenderness: pain upon rapid release, indicating peritoneal inflammation.

Sepsis: Clinical Awareness

  • Sepsis is a potential complication of abdominal infections and requires prompt recognition and treatment; look for fever, tachycardia, tachypnea, and altered mental status.

Note on Sources and Practice

  • The content reflects a nursing/medical exam review with emphasis on anatomy, physical examination technique, and common GI disorders.
  • For clinical practice, integrate these findings with current guidelines and institutional protocols for diagnosis and management.