abdomen jarvis

Percussion

At times you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of a distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward. You can differentiate ascites from gaseous distention by performing two percussion tests. Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Fluid Wave.First test for a fluid wave by standing on the person’s right side. Place the ulnar edge of another examiner’s hand or the patient’s own hand firmly on the abdomen in the midline (Fig. 22.24). (This stops transmission across the skin of the upcoming tap.) Place your left hand on the person’s right flank. With your right hand reach across the abdomen and give the left flank a firm strike.

22.24 Fluid wave.

If ascites is present, the blow will generate a fluid wave through the abdomen, and you will feel a distinct tap on your left hand. If the abdomen is distended from gas or adipose tissue, you will feel no change. A positive fluid wave test occurs with large amounts of ascitic fluid. Also note edema in the legs.

Shifting Dullness.The second test for ascites is percussing for shifting dullness. In a supine person ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel to the periumbilical space. You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid (Fig. 22.25). Then percuss down the side of the abdomen. If fluid is present, the note will change from tympany to dull as you reach its level. Mark this spot.

22.25

The right hand is placed on top of the left hand and it is pressed against the right side of the patient's hip region towards the groin area. Tympany and dullness are marked on the right side of the groin area. An arrow mark is used for the reference which is pointed from tympany towards the line drawn in the groin area.

Now turn the person onto the right side (roll them toward you) (Fig. 22.26). The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward. Begin percussing the upper side of the abdomen and move downward. The sound changes from tympany to a dull sound as you reach the fluid level; but this time the level of dullness is higher, upward toward the umbilicus. This shifting level of dullness indicates the presence of fluid.

22.26

The right hand is placed on top of the left hand and it is pressed against the right side of the patient's hip region towards the groin area. Tympany and shifting level of dullness are marked on the right side of the groin area. An arrow mark is used for the reference which is pointed from tympany towards the line drawn in the groin area.

This test has less diagnostic value than the fluid wave test. Shifting dullness is positive with a large volume of ascitic fluid; it will not detect less than 500 to 1100 mL of fluid.15

Both tests, fluid wave and shifting dullness, are not completely reliable. Ultrasound study is the definitive tool.

Palpation

Rebound Tenderness.Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site remote from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down slowly and deeply (Fig. 22.27A); then lift up quickly (Fig. 22.27B). This makes structures that are indented by palpation rebound suddenly. A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination because it can cause severe pain and muscle rigidity.

22.27

Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation. Peritoneal inflammation accompanies appendicitis.

Cough tenderness that is localized to a specific spot also signals peritoneal irritation.

Rebound tenderness occurring in the right lower quadrant when pressure is applied to the left lower quadrant (Blumberg sign) may indicate appendicitis. Refer the person with suspected appendicitis for computed tomography (CT) scanning.

Inspiratory Arrest (Murphy Sign).Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder (cholecystitis), pain occurs. Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain. (Note: This sign is less accurate in patients older than 60 years; evidence shows that 25% of them do not have any abdominal tenderness.15 When the test is positive, as the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway.

Other Special Tests for Appendicitis

McBurney Point Tenderness.Draw a straight line from the anterior superior spinous process of the ileum to the umbilicus. McBurney point is located 1.5 to 2 inches from the ileum along this line. (McBurney point is at the hand placement in Fig. 22.16, p. 549.) Inflammation of the appendix usually produces RLQ pain to palpation, with maximal tenderness sometimes occurring over McBurney point.15

Iliopsoas Muscle Test.Perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspected. With the person supine, lift the right leg straight up, flexing at the hip (Fig. 22.28); then push down over the lower part of the right thigh as the person tries to hold the leg up. When the test is negative, the person feels no change.

22.28 Iliopsoas muscle test.

When the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the RLQ, and the test is positive.

Obturator Test.For the obturator test, lift the person’s right leg, flexing at the hip, and 90 degrees at the knee. Hold his or her ankle, and rotate the leg internally and externally. There should be no pain. This test is less specific.15 An inflamed appendix irritates the obturator muscle, and this leg movement produces pain in a positive finding.

The Alvarado Score.This scoring system combines findings to assist evaluation in patients with RLQ pain. Also called the MANTRELS score, from the mnemonic in the following list, a score of 4 or less significantly decreases the probability of appendicitis.15

Finding Points

Symptoms

M igration to right iliac fossa 1

A norexia a 1

N ausea and vomiting 1

Signs

T enderness, RLQ 2

R ebound tenderness 1

E levation of temperature (oral ≥37.3°C) 1

Laboratory Findings

L eukocytosis (white blood cell count > 10,000/μL) 2

S hift to the left (>75% neutrophils) 1

Total Possible Points 10

a For anorexia, may substitute acetone in urine.15

A key finding, present in >90% of people with acute appendicitis.17An Alvarado score of ≥7 increases the probability of appendicitis.

Developmental Competence

The Infant

Inspection.The contour of the abdomen is protuberant because of the immature abdominal musculature. The skin contains a fine, superficial venous pattern. This may be visible in lightly pigmented children up to the age of puberty.

Scaphoid shape occurs with dehydration.

Dilated veins.

Inspect the umbilical cord throughout the neonatal period. At birth it is white and contains two umbilical arteries and one vein surrounded by mucoid connective tissue, called Wharton’s jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin covers the area by 3 to 4 weeks.

The presence of only one artery signals the risk for congenital defects.

Inflammation.

Drainage after cord falls off.

The abdomen should be symmetric, although two bulges are common. You may note an umbilical hernia. It appears at 2 to 3 weeks and is especially prominent when the infant cries. The hernia reaches maximum size at 1 month (up to 2.5 cm or 1 inch) and usually disappears by 1 year. Another common variation is diastasis recti, a separation of the rectus muscles with a visible bulge along the midline (see Table 22.4). The condition is more common with Black infants, and it usually disappears by early childhood.

Refer any umbilical hernia larger than 2.5 cm (see Table 22.4). Asymptomatic hernias may be monitored safely until 4 to 5 years of age while awaiting spontaneous closure.11

Refer diastasis recti lasting more than 6 years.

The abdomen shows respiratory movement. The only other abdominal movement you should note is occasional peristalsis, which may be visible because of the thin musculature. Marked peristalsis with pyloric stenosis (see Table 22.5, p. 568).

Auscultation.Auscultation yields only bowel sounds, the metallic tinkling of peristalsis. No vascular sounds should be heard.

Bruit.

Venous hum.

Percussion.Percussion finds tympany over the stomach (the infant swallows some air with feeding) and dullness over the liver. The abdomen sounds tympanitic, although it is normal to percuss dullness over the bladder. This dullness may extend up to the umbilicus.

Palpation.Aid palpation by flexing the baby’s knees with one hand while palpating with the other (Fig. 22.29). Alternatively you may hold the upper back and flex the neck slightly with one hand. Offer a pacifier to a crying baby. The abdomen feels soft and supple.

22.29

The liver fills the RUQ. It is normal to feel the liver edge at the right costal margin or 1 to 2 cm below. Normally you may palpate the spleen tip and both kidneys and the bladder. Also easily palpated are the cecum in the RLQ and the sigmoid colon, which feels like a sausage in the left inguinal area.

Make note of the newborn’s first stool, a sticky, greenish-black meconium stool within 24 hours of birth. By the 4th day, stools of breastfed babies are golden yellow, pasty, and smell like sour milk, whereas those of formula-fed babies are brown-yellow, firmer, and more fecal smelling.

The Child

Younger than 4 years, the abdomen looks protuberant when the child is both supine and standing. After age 4 years the potbelly remains when standing because of lumbar lordosis, but the abdomen looks flat when supine. Normal movement on the abdomen includes respirations, which remain abdominal until 7 years of age.

A scaphoid abdomen is associated with dehydration or malnutrition.

Younger than 7 years, the absence of abdominal respirations occurs with inflammation of the peritoneum.

To palpate the abdomen, position the young child on the parent’s lap as you sit knee-to-knee with the parent. Flex the knees up and elevate the head slightly. The child can “pant like a dog” to further relax abdominal muscles. Hold your entire palm flat on the abdominal surface for a moment before starting palpation. This accustoms the child to being touched (Fig. 22.30). If the child is very ticklish, hold the child’s hand under your own as you palpate or apply the stethoscope and palpate around it.

22.30

The liver remains easily palpable 1 to 2 cm below the right costal margin. The edge is well-defined and moves easily. On the left the spleen also is easily palpable with a well-defined movable edge. Usually you can feel 1 to 2 cm of the right kidney and the tip of the left kidney.

In assessing abdominal tenderness, remember that the young child often answers this question “yes” no matter how the abdomen actually feels. Use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, moving away from you, and guarding.

School-age children have a slim abdominal shape as they lose the potbelly. This slimming trend normally continues into adolescence, although adolescents may not show slimming given the concerning incidence of childhood obesity.2 Variation in body image means that some adolescents are comfortable with exposure to the abdomen and others may be embarrassed. Be sensitive to this and use adequate draping or keep them in personal clothing (Fig. 22.31). The physical findings are the same as those listed for the adult.

22.31 Aim to keep adolescent in own clothing.

The Aging Adult

On inspection you may note increased deposits of subcutaneous fat on the abdomen and hips because it is redistributed away from the extremities. The abdominal musculature is thinner and has less tone than that of the younger adult; thus in the absence of obesity, you may note peristalsis.

Because of the thinner, softer abdominal wall, the organs may be easier to palpate (in the absence of obesity). The liver is easier to palpate. Normally you will feel the liver edge at or just below the costal margin. With distended lungs and a depressed diaphragm, the liver is palpated lower, descending 1 to 2 cm below the costal margin with inhalation. The kidneys are easier to palpate.

Abdominal rigidity with acute abdominal conditions is less common in aging.

With an acute abdomen the aging person often complains of less pain than a younger person would.

a Early research suggests this change in the order of examination sequence may not be necessary. That is, abdominal palpation did not change the number of bowel sounds in a small number of healthy people and in GI outpatients. Further research is necessary.26

Health Promotion and Patient Teaching

Hepatitis B and Hepatitis C

Let’s talk about your potential risks for viral hepatitis, which is a liver infection. There are 3 major types of hepatitis: A, B, and C. Hepatitis B and C are spread through blood and body fluids, for example, by sharing contaminated needles or by sexual contact. Both hepatitis B and C can cause a brief period of illness and then either be cleared from the body entirely or go on to cause a long-term, or chronic, infection. Chronic infection is especially common with hepatitis C. Chronic hepatitis can eventually cause the liver to fail by causing liver scarring (fibrosis and cirrhosis). Chronic hepatitis also increases your risk for liver cancer.23–25

The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis B and C through blood testing, including screening high-risk adolescents and adults for hepatitis B and all individuals ages 18 to 79 for hepatitis C.24,25 In general, hepatitis B virus (HBV) is most often transmitted perinatally and in childhood (especially in regions of high prevalence), whereas hepatitis C virus (HCV) transmission occurs with current or past injection drug use.23 Risk for HBV is also high among people born in the United States but not vaccinated in infancy with parents who were born in high-risk countries, people with HIV-positive status, users of injection drugs, men who have sex with men, and people with sexual partners with HBV or who have household contacts with HBV.24 High-risk individuals should be screened once and at periodic intervals if the risk persists (e.g., if the person continues to use injection drugs).24,25

Health promotion and disease prevention teaching are essential components of the disease screening process. Please be aware of the sensitive nature of risk assessment; use open-ended and direct questioning to explore patients’ risks for viral hepatitis and to assess if screening is warranted. Primary prevention involves risk-factor modification, which includes providing resources to make the necessary lifestyle changes to reduce risk of exposure. For example, be prepared to provide referrals to drug treatment programs, information about condom use, and recommendations for vaccines. Currently, there is no vaccine for HCV, although efforts to develop one continue.19 There is, however, a safe, effective vaccine against HBV. All infants should receive the hepatitis B vaccine, as well as people in high-risk groups and all health care workers. For a complete list of who should be vaccinated against HBV, along with recommended vaccines and vaccination schedule, visit https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#vaccFAQ. For both HBV- and HCV-infected people, secondary prevention includes antiviral treatment regimens to prevent the long-term complications that can cause significant liver disease and death. HCV especially has a high cure rate (greater than 95%), whereas HBV is much more difficult to cure. The frequently asymptomatic nature of early HCV infection, the burden of chronic liver disease from undetected infection, and the likelihood of treatment success are factors supporting universal screening of adults for HCV.20

Documentation and Critical Thinking

Sample Charting

Subjective

States appetite is good with no recent change, no dysphagia, no food intolerance, no pain, no nausea/vomiting. Has one formed BM/day. Takes OTC multivitamins, no other prescribed or over-the-counter medication. No history of abdominal disease, injury, or surgery. Diet recall of past 24 hours listed at end of history.

Objective

Inspection: Abdomen flat, symmetric, with no apparent masses. Skin smooth with no striae, scars, or lesions.

Auscultation: Bowel sounds present, no bruits.

Percussion: Tympany predominates in all 4 quadrants.

Palpation: Abdomen soft, no organomegaly, no masses, no tenderness.

Assessment

Healthy abdomen; bowel sounds present

Clinical Case Study 1

O.W. is a 33-year-old male who underwent gastric bypass surgery 1 week PTA. Preoperative BMI 62.8 (height 180 cm; weight 204 kg). Medical history of type 2 diabetes mellitus, morbid obesity, hypertension, obstructive sleep apnea, and venous stasis ulcers on bilateral lower extremities.

Subjective

1 week PTA—Laparoscopic Roux-en-Y gastric bypass surgery performed without complication.

5 days PTA—Patient discharged home in stable condition on a pureed diet. No postoperative complications.

1 day PTA—O.W. noticed increased nausea and nonspecific shoulder pain.

Present—“I feel terrible.” Reports fever with chills, nausea, constant pain in back and shoulders, abdominal pain, and palpitations. O.W. denies changes in diet or deviation from prescribed diet.

Objective

Vital signs: Temp 102°F (39°C). Pulse 130 bpm. Resp 20/min. BP 90/56 mm Hg, right arm, supine.

Inspection: Lying on side with knees tucked. Abdomen uniformly round. Grimacing with movement. Incisions approximated with no redness or drainage.

Auscultation: Hypoactive bowel sounds. No vascular sounds.

Percussion: Tympany predominates. Scattered dullness caused by adipose tissue. Percussion elicits tenderness.

Palpation: Extreme tenderness. Rebound tenderness present RLQ and LLQ. Unable to palpate organs because of tenderness and obesity.

Assessment

Acute abdomen

Possible anastomotic leaking at gastric bypass site

Acute abdominal pain due to peritoneal inflammation

Potential for intra-abdominal infection

Clinical Case Study 2

E.J. is a 63-year-old retired homemaker with a history of lung cancer with metastasis to the liver.

Subjective

Feeling “puffy and bloated” for the past week. States unable to get comfortable. Also short of breath “all the time now.” Difficulty sleeping. “I feel like crying all the time now.”

Objective

Inspection: Weight increase of 8 lb in 1 week. Abdomen is distended with everted umbilicus and bulging flanks. Girth at umbilicus is 85 cm. Prominent dilated venous pattern present over abdomen.

Auscultation: Bowel sounds present. No vascular sounds.

Percussion: When supine, tympany present at dome of abdomen, dullness over flanks. Shifting dullness present. Positive fluid wave present.

Palpation: Abdominal wall firm, able to feel liver with deep palpation at 6 cm below right costal margin. Liver feels firm, nodular, nontender. 4+ pitting edema in both ankles.

Assessment

Ascites

Grieving

Shortness of breath due to increased intra-abdominal pressure

Pain due to distended abdomen

Potential for skin breakdown due to ascites, edema, and faulty metabolism

Insomnia

Clinical Case Study 3

D.G. is a 17-year-old male high school student who enters the emergency department with abdominal pain for 2 days.

Subjective

2 days PTA, D.G. noted abdominal pain in umbilical region. Now pain is sharp and severe, and he points to location in RLQ. No BM for 2 days. No appetite. Nausea and vomiting off and on 1 day; no blood in vomitus.

Objective

Inspection: Temp 100.4°F (38°C). Pulse 116 bpm. Resp 18/min. BP 112/70 mm Hg.

Lying on side with knees drawn up under chin. Resists any movement. Face tight and occasionally grimacing. Cries out with any sudden movement.

Auscultation: No bowel sounds present. No vascular sounds.

Percussion: Tympany. Percussion over RLQ leads to tenderness.

Palpation: Abdominal wall is rigid and boardlike. Extreme tenderness to palpation in RLQ. Rebound tenderness is present in RLQ. Positive iliopsoas muscle test. Alvarado score 7 with no laboratory results available yet.

Assessment

Acute abdomen, possible appendicitis

Acute abdominal pain in RLQ

Nausea and vomiting

Clinical Case Study 4

G.C. is a 5-week-old male who was brought to the clinic today by his parents for vomiting.

Subjective

Since birth G.C. has been a “great eater who nursed all the time without problems.”

10 days PTA—G.C. continues to want to nurse all the time but now “projectile vomits” soon after he feeds and “never appears comfortable.”

4 days PTA—Vomiting continued post-feeds; last reported stool at that time; 7 wet diapers/day.

1 day PTA—Vomiting continued; “only had 3 wet diapers today.”

Birth weight—9 lb 9 oz (4.3 kg)

Objective

Vital signs: Temp 98.6°F (37°C) (axillary). Pulse 128 bpm. Resp 42/min. Weight 11 lb 3 oz (5.1 kg). BP 76/40 mm Hg (sleeping).

General appearance: Infant resting comfortably in mom’s arms.

HEENT: Anterior and posterior fontanels slightly sunken; eyes clear and moist; TM pearly gray bilat; nares patent bilat; oral mucosa slightly moist

Cardiovascular: Sinus arrhythmia; no abnormal heart sounds.

Respiratory: Breath sounds clear and equal bilat; unlabored.

Abdomen: Visible gastric peristalsis and olive-shaped mass palpated in the epigastrium just right of umbilicus.

Assessment

Pyloric stenosis

Potential for protein calorie malnutrition due to vomiting secondary to pyloric sphincter obstruction

Acute abdominal pain due to abdominal fullness

Dehydration due to vomiting

Abnormal Findings

TABLE 22.1

Abdominal Distention

A cut-out graphical representation of a woman lying in a supine position is shown. Umbilicus diminish and the skin gets deepened. Tympany of the abdominal mass is noted with bulges across the corners. Dullness of skin is scattered across the tummy.

Obesity

Air or Gas

Inspection. Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it).

Auscultation. Normal bowel sounds.

Percussion. Tympany. Scattered dullness over adipose tissue.

Palpation. Normal. May be hard to feel through thick abdominal wall.

Inspection. Single round curve.

Auscultation. Depends on cause of gas (e.g., decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction.

Percussion. Tympany over large area.

Palpation. May have muscle spasm of abdominal wall.

A cut-out graphical representation of a woman lying in a supine position is shown. Tympany of the abdominal mass is noted along with bulges in the flanks. A vertical dullness is visible across side edges.

Ascites

Ovarian Cyst (Large)

Inspection. Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin due to recent weight gain; increase in abdominal girth.

Auscultation. Normal bowel sounds over intestines. Diminished over ascitic fluid.

Percussion. Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness.

Palpation. Taut skin and increased intra-abdominal pressure limit palpation.

Inspection. Curve in lower half of abdomen, toward midline. Everted umbilicus.

Auscultation. Normal bowel sounds over upper abdomen where intestines pushed superiorly.

Percussion. Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness.

Palpation. Transmits aortic pulsation, whereas ascites does not.

A cut-out graphical representation of a woman lying in a supine position is shown. The breasts appear little enlarged, tight, and hard. The umbilicus protrude outwards from the skin. Fetal heart sounds are noted on the central lower abdomen.

Pregnancya

Feces

Inspection. Single curve. Umbilicus protruding. Breasts engorged.

Auscultation. Fetal heart tones. Bowel sounds diminished.

Percussion. Tympany over intestines. Dull over enlarging uterus.

Palpation. Uterine fundus. Fetal parts. Fetal movements.

Inspection. Localized distention.

Auscultation. Normal bowel sounds.

Percussion. Tympany predominates. Scattered dullness over fecal mass.

Palpation. Plastic-like or ropelike mass with feces in intestines.

Tumor

Inspection. Localized distention.

Auscultation. Normal bowel sounds.

Percussion. Dull over mass if reaches up to skin surface.

Palpation. Define borders. Distinguish from enlarged organ or normally palpable structure.

a Obviously a normal finding, pregnancy is included for comparison of conditions causing abdominal distention.

TABLE 22.2

Clinical Portrait of Intestinal Obstruction

A clinical portrait of a woman and a corresponding radiograph for intestinal obstruction. Accumulation of excess fluid is visible within the intestine. A corresponding radiograph shows scattered collection of fluid spread across the intestine of the woman.

Abnormal Findings for Advanced Practice

TABLE 22.3

Common Sites of Referred Abdominal Pain

A cut-diagram at the left for the front view of a woman for the common sites of abdominal pain. They include: heart, liver, G E R D, peptic ulcer, renal colic, small intestine pain, appendicitis, ureteral colic, biliary colic, cholecystitis, pancreatitis, duodenal ulcer, appendicitis, and colon pain. A cut-out diagram at the right for the rear view of a woman for the common sites of abdominal pain. They include: perforated duodenal ulcer, penetrating duodenal ulcer, cholecystitis, pancreatitis, renal colic, rectal lesions.

When a person gives a history of abdominal pain, the pain’s location may not necessarily be directly over the involved organ because the human brain has no felt image for internal organs. Rather, pain is referred to a site where the organ was located in fetal development. Although the organ migrates during fetal development, its nerves persist in referring sensations from the former location. The following are examples, not a complete list.

Liver. Hepatitis may have mild-to-moderate dull pain in right upper quadrant (RUQ) or epigastrium, along with anorexia, nausea, malaise, low-grade fever.Esophagus. Gastroesophageal reflux disease (GERD) involves chronic reflux resulting in esophagitis and damage to the esophagus. “Heartburn” or pyrosis is a burning pain in midepigastrium or behind lower sternum that radiates upward.21 Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over.

Gallbladder. Cholecystitis is biliary colic, sudden pain in RUQ that may radiate to right or left scapula and that builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine. Associated with nausea and vomiting and with positive Murphy sign (sudden stop in inspiration with RUQ palpation).8

Pancreas. Pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting. Pain possibly worse with eating, drinking, or supine position.16

Duodenum. Duodenal ulcer typically has dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep.

Stomach. Gastric ulcer pain is dull, aching, gnawing epigastric pain usually brought on by food, and it radiates to back or substernal area. Pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders.Appendix. Appendicitis typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney point).17 Pain is aggravated by movement, coughing, deep breathing; associated with anorexia, then nausea and vomiting, fever.

Kidney. Kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain.

Small intestine. Gastroenteritis has diffuse, generalized abdominal pain with nausea, diarrhea.

Colon. Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen and bloating. Irritable bowel syndrome (IBS) has sharp or burning cramping pain over a wide area; does not radiate. Brought on by meals; relieved by bowel movement.

Image © Pat Thomas, 2006.

TABLE 22.4

Abnormalities on Inspection

Umbilical Hernia

This is a soft, skin-covered mass, the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining; but the bowel rarely incarcerates or strangulates. More common in premature infants. Most resolve spontaneously by 1 year; parents should avoid affixing a belt or coin at the hernia because this will not help closure and may cause contact dermatitis. In an adult it occurs with pregnancy, chronic ascites, or chronic increased intrathoracic pressure (e.g., asthma, chronic bronchitis).

Epigastric Hernia

Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.

Incisional Hernia

A bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver.

Diastasis Recti

A midline longitudinal ridge that is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally (here) and as a result of pregnancy or marked obesity in which prolonged distention or a decrease in muscle tone has occurred. Usually it is not clinically significant.

See Illustration Credits for source information.

TABLE 22.5

Abnormal Bowel Sounds

A clinical portrait of an infant and a nurse to check for the abnormal bowel sounds. The legs of the infant are in a butterfly position. The nurse keeps their right hand across the lower abdomen in a horizontal position. Their left hand holds the stethoscope as placed just above the umbilicus.

Succussion Splash

Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatal hernia.

Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis, an obstruction of the pyloric valve of the stomach. Pyloric stenosis is a congenital defect and appears in the 2nd or 3rd week. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. Then one can palpate an olive-size mass in the RUQ midway between the right costal margin and umbilicus. Refer promptly because of risk for weight loss.

A cut-out diagram of the abdomen of a patient to calculate hypoactive bowel sounds. The stethoscope is placed on the center of the abdomen. The wave sound remains steady at the corners and very slow at the center.

Hypoactive Bowel Sounds

Hyperactive Bowel Sounds

Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia. Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.