Chapter 21 – AbdomenFour layers of large, flat muscles form the ventral abdominal wall. These are joined at the midline by a tendinous seam, the Linea Alba.

Inside the abdominal cavity, all the internal organs are called the viscera.

Solid Viscera - are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus).Hollow Viscera - these depend on the contents (stomach, gal bladder, small intestine, colon, and bladder).

The twelfth rib forms an angle with the vertebral column, the costovertebral angle. The left kidney lies here at the 11th and 12th ribs. Because of the placement of the liver, the right kidney rest 1 to 2 cm lower than the left kidney and sometimes may be palpable.

The abdominal wall is divided into four quadrants:Epigastric – the area between the coastal margins.Umbilical – the area around the umbilicus.Hypogastric or Suprapubic - the area above the pubic bone.

RIGHT UPPER QUADRANT (RUQ)LiverGall BladderDuodenumHead of PancreasRight Kidney & AdrenalHepatic Flexure of ColonPart of Ascending and Transverse Colon

LEFT UPPER QUADRANT (LUQ)StomachSpleenLeft Lobe of LiverBody of PancreasLeft Kidney and AdrenalSplenic Flexure of ColonPart of Transverse and Descending Colon

RIGHT LOWER QUADRANT (RLQ)CecumAppendixRight Ovary and TubeRight UreterRight Spermatic Cord

LEFT LOWER QUADRANT (LLQ)Part of Descending ColonSigmoid ColonLeft Ovary and TubeLeft UreterLeft Spermatic Cord

MIDLINEAortaUretus (if enlarged)Bladder (if distended)

The Aging Adult Aging alters the appearance of the abdominal wall area. During after middle age, some fat accumulates in the suprapubic area in females as a result of decreased estrogen levels. Males also show some fat deposits in the abdominal area, resulting in the “big belly”.

Salivation decreases, causing a dry mouth and a decrease sense of taste. Esophageal emptying is delayed. If an aging person is fed in the supine position, this increases the risk for

aspiration. Gastric acid secretion decreases with aging. This may cause pernicious anemia (because it interferes with

vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium. The incidence of gallstones increases with age, occurring in 10% to 20% of middle aged and older adults,

being more common in females. Liver size decreases by 25% between the ages of 20 and 70 years, although most liver function remains

normal. Drug metabolism by the liver is impaired, in part because age 65 blood flow through the liver is decreased by 33%. Therefore the liver metabolism that is responsible for the enzymatic oxidation, reduction, and hydrolysis of drugs is substantially decreased with age. Prolonged liver metabolism causes increased side effects (example, older people taking benzodiazepines scored lower on functional status measures and had increased risk for hip fracture.)

Aging persons frequently report constipation; most prevalence estimates are between 12% and 19%. Because there is confusion as to what defines constipation, the Rome criteria have developed a standardized symptom criteria. These symptoms include reduced still frequency (less than three bowel movements per week), as well as other common and troubling associated symptoms (i.e. straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual maneuvers.

Common causes of constipation include decreased physical activity, inadequate intake of water, a low fiber diet, side effects of medications (opiates, tricyclic antidepressants), irritable bowel syndrome, bowel obstruction, hypothyroidism, and inadequate toilet facilities (i.e. difficulty ambulating to the toilet may cause the person to deliberately retain the stool until it becomes hard and difficult to pass.

Culture And GeneticsLactase is the digestive enzyme necessary for absorption of the carbohydrate lactose (milk sugar). In some racial groups, lactase activity is high at birth but declines to low levels by adulthood. These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed. Millions of American adults have the potential for lactose intolerance symptoms and traditional estimated rates were that 50% of whites, 50% of Mexican Americans, and 80% of African-Americans had the condition.This is clinically significant because dairy foods meet crucial nutritional requirements including calcium, magnesium, and potassium.

Obesity is the accumulation of excess body fat. Obesity is caused by a complex interaction of genetic predisposition, dietary intake, physical inactivity, and what is now called “obesogenic environment” (one that encourages large populations of high-fat, energy dense foods).Among the children, Mexican-American boys had a greater prevalence of overweight than had white or black boys. Mexican-American and black girls were significantly more likely to be overweight than white girls. No differences were found in overweight rates in men of various racial groups. But in adult woman, Mexican Americans and African Americans were significantly more likely to be obese than were whites.Obesity in adults results in comorbidities of type II diabetes and cardiovascular disease. Obese children have an increased risk for asthma, diabetes, liver disease, cardiovascular disease, sleep apnea, and joint problems, and they risk becoming obese adults.

Anorexia is a loss of appetite from gastrointestinal disease, as a side effect of some medications with pregnancy or with psychological disorders.

Dysphasia occurs with disorders of the throat or esophagus.

Food intolerance (e.g. lactase deficiency resulting in bloating or excessive gas after taking milk products).

Pyrosis (heartburn), a burning sensation in the esophagus and stomach, from reflux of gastric acid.

Abdominal pain may be visceral from an internal organ (dull, general, poorly localized); parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement); or referred from a disorder in another site. Acute pain requiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or a perforated organ.

Nausea/vomiting is common with G.I. disease, many medications, and with early pregnancy.

Hematemisis (coffee grind material, bleeding) occurs with stomach or duodenal ulcers and esophageal varices.Assess usual bowel habits. Black stools may be tarry due to occult blood (melena) from G.I. bleeding or non-tarry from iron medications. Gray stools occur with hepatitis.

How do you acquire your groceries and prepare your meals - assess risk for nutritional deficit: limited access the grocery store, income, or cooking facilities; physical disability (impaired vision, decreased mobility, decreased strength, and neurologic deficit). Food pattern may differ during the month if monthly income (e.g. Social , Security check) runs out.

SkinOne common pigment change is striae (leneae albicantes) - silvery white, linear, jagged marks about 1 to 6 cm long. They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, as in pregnancy or a lot of weight gain. Recent striae are pink or blue then they turn silvery white.

Pulsation or movementMarked pulsation of aorta occurs with widened pulse pressure (e.g. hypertension, aortic insufficiency, thyrotoxicosis) and with aortic aneurysm.

Abdominal Assessment - Inspect, Auscultate, Percuss, Palpate.Usual Assessment - Inspect, Palpate, Percuss, Auscultate.

Auscultate Bowel Sounds & Vascular SoundsDepart from the usual examination sequence and auscultate the abdomen next. This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. Use the diaphragm endpiece because bowel sounds are relatively high pitched. Hold the stethoscope lightly against the skin; pushing too hard may stimulate more bowel sounds. Begin in the RLQ at the ileocecal valve area because bowel sounds are normally always present here.

Bowel SoundsNote the character and frequency of bowel sounds. Bowel sounds originate from the movement of air and fluid through the small intestine. Depending on the time elapsed since eating, a wide range of normal sounds can occur. Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute. Do not bother to count them. Judge if they are normal, hypoactive, or hyperactive.One type of hyperactive bowel sounds is fairly common. This is the hyper peristalsis when you feel your “stomach growling” termed borborygmus. A perfectly “silent abdomen” is uncommon; you must listen for five minutes by your watch before deciding bowel sounds are completely absent.1. Hyperactive sounds are loud, high pitched, rushing, tinkling sounds that signal increased motility2. Hypoactive or Absence Sounds follow abdominal surgery or with inflammation of the peritoneum.

Vascular SoundsAs you listen to the abdomen, note the presence of any vascular sounds or bruits. Using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. Usually, no such sound is present. However, a small number of healthy persons (usually younger than 40 years) may have a normal bruit originating from the celiac artery. This is systolic, medium to low in pitch, and heard between the xiphoid process and umbilicus.

General TympanyFirst, percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness. Move clockwise. Tympany should predominate because air in the intestines rises to the surface when the person is supine - Dullness occurs over a distended bladder, adipose tissue, fluid, or a mess. Hyperresonance is present with gaseous distention.

Liver SpanNormal liver span in the adult ranges from 6 to 12 cm–an enlarged liver span indicates big liver (Hepatomegaly)

Splenic DullnessOften the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the9th to 11th intercostal space just behind the left midaxillary line. The area of splenic dullness normally is not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble - a dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection.

Costovertebral Angle TendernessTo assess the kidney, place one hand over the 12th rib at the costovertebral angle on the back. Thump that hand with the ulnar edge of your other fist – sharp pain occurs with inflammation of the kidney or paranephric area.

Special Procedures 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 – Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. You can differentiate ascites from gaseous distention by performing two percussion tests.

1. Fluid Wave – First, test for a fluid wave by standing on the person’s right side. Place the ulnar edge of another examiners hand or the patient’s own hand firmly on the abdomen in the midline (this will stop 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 – 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.

2. Shifting Dullness – In a supine person, ascetic fluid settles by gravity into the flanks, displacing the air filled bowel upward. You will hear a tympanitic note as you percuss over the top of the abdomen because gas filled intestines float over the fluid. 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. Now turn the person onto the right side. The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward. Begin percussing the upper side of the 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 with the umbilicus. This shifting level of dullness indicates the presence of fluid - Shifting Dullness is positive with a large volume of ascitic fluid: it will not detect less than 500 mL of fluid.

Palpate Surface And Deep AreasPerform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness.

Light And Deep PalpationBegin with light palpation. With the first four fingers close together, depress the skin about 1 cm.Voluntary guarding occurs when the person is cold, tense or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary- involuntary rigidity is a constant, board like hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit up.

Now perform deep palpation using the same technique described above but this time down push down about 5 to 8 cm and move clockwise to explore the area.

Normal FindingsMild tenderness normally is present when palpating the sigmoid colon. Any other tenderness should be investigated. If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:

1. Location2. Size3. Shape4. Consistency (Soft, Firm, Hard)5. Service (Snow, Nodular)6. Mobility (Including Movement With Respirations)7. Pulsatility8. Tenderness

LiverAsk the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver. Bump your fingertips as the diaphragm pushes it down during inhalation. It feels like a firm, regular ridge. Often, the liver is not palpable and you feel nothing firm.

SpleenNormally, spleen is not palpable and must be enlarged three times its normal size to be felt - the spleen enlarges with mononucleosis, trauma, leukemias, and lymphomas. If you feel an enlarged spleen (spleenomegaly), refer the person but do not continue to palpate it. An enlarged spleen is friable and can the rupture easily with overpalpation.

KidneysSearch for the right kidney by placing your hands together in a “duck-bill” position at the person’s right flank. Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath. In most cases you will feel no change. The left kidney sits 1 cm higher than the right kidney and is not palpable normally.

AortaUsing your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of the midline. Normally, it is 2.5 to 4cm wide in the adult and pulsates in an anterior direction.

Tenderness occurs with local inflammation, with inflammation of the peritoneum, or underlying organ, and with an enlarged organ whose capsule is stretched.

Special Procedures for Advanced PracticeRebound Tenderness (Blumberg Sign) - assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area. Hold your hand 90°, or perpendicular, to the abdomen. Push down slowly and deeply then lift up quickly. 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 - pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation. Peritoneal inflammation accompanies appendicitis

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.) - 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.

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, 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 - when the iliopsoas muscle is inflamed (which occurs within an inflamed or perforated appendix), pain is felt in the right lower quadrant.

Common Sites Of Preferred Abdominal PainEsophagus – Gastroesophageal reflux disease (GERD) is a complex of symptoms of esophagitis, including burning pain in midepigastrium or behind lower sternum that radiates upward, or “heartburn.” Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over.

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

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, 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 – typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney point). Pain is aggravated by movement, coughing the, deep breathing; associated with anorexia, then nausea and vomiting, fever.