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Lamke's study guide for the assessment of the abdomen, Fall 2013

Define: Solid viscera

Abdominal organs that maintain a characteristic shape: liver, spleen, kidneys etc.

Abdominal organs: Liver
(All organs Jarvis p528-29)

Fills most of the RUQ and extends to the MCL (mid clavicular line). Mostly behind rib cage.

Abdominal organs: Pancreas

Soft lobulated gland which lies behind the stomach and stretches obliquely across the abdominal wall in the LUQ

Abdominal organs: Spleen

Soft mass of lymphatic tissue on posteriolateral wall of abdominal cavity , immediately under diaphragm
-lies behind and parallel to the 10th rib
-width approx. 7 cm, extends from 9th-11th ribs
- not normally palpable unless enlarged

Abdominal organs: Kidneys & adrenal glands

In retroperitoneal space, posterior to abdominal contents and wel protected by posterior ribs/muscles
- left kidney lies between 11-12th ribs
-right kidney lies 1-2 cm below left due to the liver

Abdominal organs: Ovaries & uterus
(Slide 7)

Found midline on pelvic bimanual exam

Abdominal organs: Prostate

Inferior to bladder and can only be palpated during a rectal exam

Define: Hollow viscera

Shape of organs depends on contents, usually not palpable (except colon when distended w/excrement) yum.... (or bladder distended with urine)

Abdominal organs: Stomach

Lies just below diaphragm, between liver and spleen

Abdominal organs: Gallbladder

Rests under posterior surface of liver, just lateral to right MCL

Abdominal organs: Small intestine

Located in all four quadrants
-Begins at stomach's pyloric valve and goes until it meets w/ colon at ileocecal valve

Abdominal organs: Colon

Ascending, transverse, and descending
-Goes through all 4 quadrants
-Descending is normally where fully formed poops can be palpated

Abdominal organs: Bladder

Lowest organ in anterior abdomen at midline.
-Can only be inspected/palpated when distended

Abdominal vessels: Aorta

Located just to the left of the midline in upper abdomen
-Descends behind peritoneum
-2 cm below umbilicus (aka belly button) the aorta bifurcated into the Rt and Lt common iliac arteries (just opposite the 4th lumbar vertebrae.
-Can palpate aortic pulsations in upper, anterior abdominal wall

What are the (3) regions of the abdomen?
(Jarvis p.530)

1. Epigastric - area between costal margins (above stomach)
2. Umbilical - area around belly button
3. Hypogastric/Suprapubic - area above pubic bone
(Divide abdomen into 3 layers, top, mid, bottom)

Which organs are located in the RUQ?

1. Liver
2. Gallbladder
3. Duodenum
4. Head of pancreas
5. Rt kidney/adrenal gland
6. Hepatic flexure of colon
7. Parts of ascending & transverse colon

Which organs are located in the LUQ?

1. Stomach
2. Spleen
3. Lt lobe liver
4. Body pancreas
5. Lt kidney/adrenal gland
6. Splenic fixture of colon
7. Part of transverse and descending colon

Which organs are located in the LLQ?

1. Descending colon
2. Sigmoid colon
3. Lt ovary/fallopian tube
4. Lt ureter
5. Lt spermatic cord

Which organs are located in the RLQ?

1. Cecum
2. Appendix
3. Rt ovary/fallopian tube
4. Rt ureter
5. Rt spermatic cord

Which organs lie in the midline?

1. Aorta
2. Uterus (if enlarged)
3. Bladder (if distended)

What are the sections of the small intestine?

1. Duodenum (first)
2. Jejunum (approx 8 ft long)
3. Illeum (approx 12 ft long)
(Dow Jones Index)

List the 3 functions of the small intestine

1.) Mechanical Digestion
2.) Chemical Digestion
3.) Absorption

List what happens during mechanical and chemical digestion, as well as absorption, in the small intestine

1.) Mechanical Digestion - Segmentation and peristalsis move chyme (partially digested food/drink & gastric acid) down the intestines, while bile helps to break up the fat
2.) Chemical Digestion - Enzymes from the s. intestine and pancreas break down all 4 groups of molecules (polysaccharides, protein, fats, nucleic acid) into their component molecules
3.) Absorption - Primary location for absorption of GI nutrients

What is the function of the large intestine?

Reabsorption of water, formation of feces, and any other nutrients that need to be absorbed

What are the developmental differences in the abdomen of older adults?

1.) Redistribution of fat towards middles (women near suprapubic due to estrogen, men in stomach). Abdominal musculature relaxes
2.) Changes in GI system (don't change fxn much as long as no dz present). Decrease in salivation = dry mouth & decrease taste. Esophageal emptying delayed = increase risk aspiration. Reduced gastric acid secretion may cause calcium malabsoprtion, iron defiiciency anemia, or pernicious anema. Increase in gall stones. Decrease liver size by 1/4 and hepatic blood flow by 33%. Delayed metabolism of drugs, increase in constipation...

What are the causes of constipation?

Decreased physical activity, inadequate water intake, low-fiber diet, side effects of meds, IBS, bowel obstruction, hypothyroidism, inadequate facilities.

Causes of Splenomagly
*Not on test but useful to know

Congestion/ Cellular infiltration
Haematological (eg haemolytic anaemia, Sickle cell)
Infection/ Infarction (eg malaria, GF, CMV)
Neoplasia (eg CML, lymphoma, other myeloproliferative)

Spleen: Weight, dimensions, surface anatomy
*Not all on test, but should know spleen size and location for HTT and poss. 314 as well

Spleen dimensions are 1 inch x 3 inches x 5 inches.
Weight is 7 ounces.
It underlies ribs 9 through 11.

Name some questions to ask older adults to gain subjective data related to the abdomen (GI issues, eating habits, bowel movements). i.e. constipation

1.) "What did you eat yesterday from the time you woke up to when you went to bed?" (24 hour diet recall)
2.) "How often do you have a BM?"
3.) If they have constipation, ask "Is it difficult to go, do you not go often, or does it seem almost completely absent?"
4.) "Are your stools hard and lumpy or dry?"
5.) "Do you take anything to help you go" and if so "What do you take and how often?"
6.) "How much fiber is in your diet? How much liquids are in your diet?"
7.) "How do you acquire groceries and prepare your food?"
8.) "Do you have difficulty swallowing?"

What objective data can you obtain while performing an abdominal assessment on an older adult?
(Hint: Think HTT)

1.) Increased deposits of sub q fat around abdomen/hips
2.) Thinner abdominal mm. more relaxed
i. Decreased overall fat, easily palpable organs
ii. Liver/kidneys easier to palpate
3.) Feel for hardened or compacted stool in colon

Identify the important topics to review while obtaining subjective data
(r/t abdominal assessment)

1.) Appetite - unintentional weight change (esp. >5lbs/1 month), anorexia, change in satiety
2.) Dysphagia - odynophagia (feeling of lump in throat, trouble swallowing) or from disorders of throat/esophagus
3.) Food intolerance - pyrosis (gastric acid reflux, burning sensation in esophagus/stomach), chronic indigestions, eructation, flatus
4.) Abdominal pain - visceral (from internal organ), parietal (inflammation of overlying peritoneum), referred
5.) Nausea/vomiting - Frequency? Medicine related? Fever or chills present? Time of last meal? Hematemesis present?
6.) Bowel habits - (note usual vs. change) frequency, color, consistency, odor of stools, diarrhea
7.) Past abdominal hx - diverticulosis, cancer, IBD, colitis, Crohn's, abdominal surgeries, adhesions, dec. absorption of nutrients, family hx, child hood obesity
8.) Medication side-effects - Peptic ulcer dz, laxative overuse/abuse, blood thinners
9.) Nutritional assessment - 24-hr recall, diet hx, nicotine, adolescent eating habits

Define: Odynophagia

Feeling of lump in throat or painful swallowing
-Causes difficulty in swallowing foods and can pose a health risk (esp in older adults)
-Weight loss r/t decrease eating r/t pain or risk choking r/t inadequate swallowing.

Define: Pyrosis

burning sensation in esophagus and stomach, from reflux of gastric acid (subjective symptom of food intolerance)

Define: Eructation

Belching, burping

Know the 3 types of abdominal pain and their symptoms

Abdominal pain:
-Visceral (from internal organ, poorly localized)
-Parietal (inflammation of overlying peritoneum, sharp, precisely localized, aggravated by movement)
-Referred (from a disorder, felt at other site) *brain doesnt acknowledge "feeling" of certain organs (i.e. liver) and doesn't know where to feel the pain

Define: Hematemesis

Blood in vomit, occurs from stomach or duodenal ulcers and esophageal varieties

Define: Diarrhea
Under what circumstances should you have a pt describe their diarrhea to you?

Any stool that conforms to container/cup.
1. More than 3-4 BM/day
2. Liquid/ conforming
3. Presence of blood or mucus
4. Caused by meds, infectious agents, disease process, diet
**GERD can lead to cancer

What causes peptic ulcer disease?

NSAID's r/t alcohol, GI bleed, smoking, Helicobacter pylori infection

Define: Diverticulosis

Pouches (diverticula) form along the walls of the colon - normally symptomless (80%)- blood in stools possible - when infected/irritated can cause pain/discomfort - avoid constipation

Define: GERD

Gastroesophageal reflux disease (GERD) is a chronic digestive disease that occurs when stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms.
GERD signs and symptoms include:
-A burning sensation in your chest (heartburn), sometimes spreading to the throat, and sour taste in mouth
-Chest pain
-Difficulty swallowing (dysphagia)
-Dry cough
-Hoarseness or sore throat
-Regurgitation of food or sour liquid (acid reflux)
-Sensation of a lump in the throat

What changes in stools should you ask about and why?

-Melena (occult blood) black tarry stools = Upper GI bleeding
-Gray stools=Hepatitis
-Black stools=(Fe, bismuth, peptobismal)
-Hematochezia (maroon stools, GI bleeding)
-BRBPR=bright red blood per rectum, lower gi, hemorrhoid, colitis
-Clay Colored stools = loss of bile
-Decrease in caliber of stool (pencil thin=obstruction, decrease in fiber, cancer)
-Diarrhea=any stool that conforms to a container, describe

Define: Hematochezia

Passage of fresh blood through the anus, usually in or with stools - Lower GI bleed - Diverticulosis or Hemorrhoids

Know sequence of examining technique
(Also need for HTT)

1st - Inspection - Contour (normal, scaphoid, rounded, protuberant), Symmetry (bulging, masses, asymmetric), Umbilicus (midline, inverted, discoloration, bulges, inflammation, hernia), Skin (texture, color, veins, scars, lesions), Striae/tightness, Easy bruising, petechaie
2nd - Auscultation - so not to cause abnormal or hyperactive bowel sounds by palpation first. Begin in RLQ by ileocecal valve, use diaphragm of stethoscope, borborygmus, tinkling (may be sign early obstruction), absent or hypoactive (listen full 5 min. post operative), listen for bruits @ aortic, femoral, iliac, renal arteries.
3rd - Percussion - General tymp = hollow organ/air, bowels (gas) stomach (air), dullness = distended bladder, stool in colon, fluid, mass, ascites, hyperresonance = gaseous distension, Special - differentiate ascites from gaseous dist. - fluid wave, shifting dullness
4th - Palpation - light then med. palpation, judge size, location, consistency of certain organs/mass tenderness

Know abnormal finding in abdominal assessment and what they mean:
1. Contour - Scaphoid, Protuberant
2. Umbilicus - Enlarged/everted umbilicus, Bluish periumbilical color
3. Symmetry - Bulges/masses
4. Skin - Jaundice, Redness, Striae, Cutaneous angiomas
5. Vessels - Prominent/dilated veins, Marked pulsation of aorta
6. Visible peristalsis
7. Uneven hair distribution

1. Scaphoid - extremely concave, caved in abdomen
-Protuberant - extremely distended
2. Enlarged/everted umbilicus - hernia/cancer
-Bluish periumbilical color - intra-abdominal bleeding, Cullen sign
3. Bulges/masses - hernia, enlarged liver/spleen
4. Jaundice - yellow, liver damage
-Redness - inflammation/infection
-Striae - occur w/ascites, look purple w/Cushing Syndrome
-Cutaneous angiomas - occur w/portal HTN or liver dz
5. Prominent/dilated veins - portal HTN, cirrhosis, ascites, or vena caval obstruction
-Marked pulsation of aorta - widened pulse pressure (HTN, aneurism, aortic insufficiency)
6. Visible peristalsis - w/distended abdomen = intestinal obstruction
7. Uneven hair distribution - endocrine abnormalities

Define: Ascites

Accumulation of fluid in abdomen - may be caused by portal hypertension, liver disease, cirrhosis, low levels protein albumin

Define: Cushing Syndrome

Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time. The most common cause of Cushing syndrome, sometimes called hypercortisolism, is the use of oral corticosteroid medication. The condition can also occur when your body makes too much cortisol.
S&S - a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, diabetes.

Define: Cutaneous angiomas

Spider nevi, a benign vascular lesion, red mole, often w/"spider like legs" or small skinny red lines winding out from middle dot. Occur w/portal hypertension/liver disease

Define: Borborygmus

Hyperactive bowel sounds - hungry

What organs are usually palpable in the abdomen?

Muscles, liver, abdominal aorta, small/large intestines, kidneys, bladder w/fluid, pregnant uterus, femoral artery, feces in LLQ colon, enlarged spleen

Common abnormal findings in abdominal assessment/palpation

Enlarged liver/spleen, aortic aneurysm, masses, fluid in peritoneum, excess air, adhesions (internal scars), hernias

Define: Adhesion

Internal scar, on under-side of skin, can be palpated

Know the location of vascular sounds - where to listen w/diaphragm (press more firmly than over bowels)

Aorta - Lt of midline
Renal - costal margin - just down and over from aorta
Iliac - 2 cm below umbilicus and to the side
Femoral - over the groin
*Renal not normally audible

Identify the percussion sounds found in abdomen

Tympany - hollow organ/air - air in intestines rise to surface when person lying down
Dullness - solid organ or liquid - distended bladder, adipose tissue, fluid, or mass
Hyperresonance - gaseous distension

Light versus deep palpations

Light - form overall impression of skin surface, superficial musculature, circular motions, pt legs bent, areas of pain last
Deep - Feel for organs, mobility, enlargement, consistency, masses, deeper, exploratory, direct or circular movements
Rebound tenderness - pain when let of pressure, peritoneal inflammation

Know information on percussing liver span/size

Begin in lung of Rt MCL purcuss down until resonance turns into dullness (5th intercostal space)
Then find tympany below and percuss up to dullness (Rt intercostal margin)
Measure distance btwn two (normally 6-12 in
Height liver goes w/height person, men large than women

Know referred pain sites for gallbladder, pancreatitis, kidney, & kidney stones

Gallbladder - cholecystitis (inflammation r/t biliary colic) is biliary colic (gallstone transiently obstructs the cystic duct and the gallbladder contracts.) Sudden pain in RUQ, radiates to scapula, builds over 2-4 hour period
Pancreatitis - acute, boring, midepigastric pain radiates to back/left scapula or flank, nausea and vomiting
Kidney - kidney stones prompt sudden onset of severe colicky flank or lower abdominal pain

Nociceptive vs. Neuropathic abdominal pain

Nociceptive - outside effect on nervous system, dull, cramping, crushing, throbbing (gallstone, hernia)
Neuropathic - abnormal processing of pain, can be acute or chronic, shooting, stabbing, burning, tingling (phantom limb syndrome)
Both - described as sharp, intense

Know difference between visceral, somatic, referred, cutaneous pain

Visceral - organs
Somatic - mm, tendons, bone, vessels
Cutaneous - skin, shingles
Referred - radiating from any source: neuropathic: hollow organ i.e. ureter due to kidney stone refers to inguinal area: solid organ i.e. prostate due to prostatitis refers to lower back perineum

What are the activities for promoting a health lifestyle? (Health promotion activities)

Colonoscopy - 5/10 yrs
Prostate exam - every yr in male over 50
Pelvic exam - female
Don't do drugs, have safe sex, use meds wisely, get vaccinated, be aware of environment....etc

Ethnic differences:
Lactose Intolerance
Gluten Intolerance

Lactose Intolerance - Increase w/age, Hispanic, African Americans
Gallstones - Native Americans, Hispanic esp. women/ African Americans have lower rates than rest
Gluten Intolerance - Becoming more of a problem

Know GI disorders that alter nutrition

Vomiting/electrolytes, anorexia/lack nutrients, dysphagia, dumping syndrome, GERD/hypoglycemia/nausea/diarrhea, lactose intolerance/gas/diarrhea, ileostomy/fluid loss, pancreatitis/loss fluids/electrolytes/carbs/fats, liver dz/malnutrition

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