Anatomy and Physiology of the Abdomen

1
Anatomy and Physiology of the Abdomen

• Houses multiple major organs
• Lined by peritoneal membrane
• Greater lesser omentum
• Mesentery

2
Musculature and Connective Tissues

• Linea alba
• Rectus abdominis muscle
• Linea alba (midline from xiphoid process to
  symphysis)
• Inguinal ligaments (bilaterally from iliac to
  symphysis pubis)

3
Abdominal Variations-Pregnancy

• Rectus abdominis
• Umbilicus, striae, linea nigra
• Striae, linea nigra
• Colon
• Peristalsis
• Gallbladder
• Renal pelvis, ureters

4
Abdominal Variations-Elderly

• Motility/Peristalsis
• Blood flow
• Pain perception
• Liver
• Lean body mass, fat

5
Describing the Abdomen

• Abdomen split into quadrants to help organize
  organs.

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Describing the Abdomen

• The abdomen can also be split into 9 sections as
  well.

7
Right Upper Quadrant (RUQ)

• Liver Gallbladder
• Head of Pancreas
• Duodenum
• Right adrenal gland
• Hepatic flexure of colon
• Portion of right kidney

8
Right Lower Quadrant (RLQ)

• Appendix
• Ascending colon
• Ovary
• Right ureter
• Bladder
• Uterus

9
Left Upper Quadrant (LUQ)

• Spleen
• Stomach
• Pancreas
• Left lobe of liver
• Splenic flexure of colon
• Portions of transverse and descending colon

10
Left Lower Quadrant (LLQ)

• Lower left kidney
• Sigmoid colon
• Ovary
• Left ureter
• Descending colon
• Bladder
• Uterus

11
Assessing the Abdomen

• Chief complaint
• History of present illness
• Past medical history
• Family history
• Personal/Social history
• Physical Exam
• Differential
• Labs

12
Importance of History Present Illness

• GI versus cardiac causes
• Clues to Differential
• Abdominal Review of Systems
• Seven attributes of a symptom

13
Review of Systems for the Abdomen

• Constipation
• Jaundice
• Dysuria
• Urinary frequency
• Hematuria

• Abdominal pain
• Indigestion
• Nausea
• Vomiting
• Diarrhea

14
Past Medical History
Review of Related History

• Gastrointestinal disorders
• Urinary Tract Infections
• Surgeries
• Medications/Immunizations
• Trauma/Injury
• Blood transfusions
• Hepatitis
• Cancer

15
Family History
Review of Related History

• Familial Mediterranean Fever
• Inflammatory bowel disease
• Familial cancer syndromes
• Congenital malformations
• Cystic fibrosis, Celiacs
• Kidney disease
• Gallbladder disease

16
Personal and Social History
Review of Related History

• Nutrition
• LMP (first day of last menstrual period)
• Stressful life events
• Travel /Exposure to infectious diseases
• Sexual history
• Use of alcohol and/or illicit drugs
• Tobacco use

17
Pregnant Women
Review of Related History

• Urinary symptoms
• Frequency, urgency, burning, suprapubic pain
• Back pain
• Abdominal pain
• Contractions
• Onset, frequency, duration, intensity
• Leakage of fluid, blood

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Older Adults
Review of Related History

• Urinary Tract Infections
• Constipation
• Indigestion
• Dietary habits

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Abdominal Exam

• Preparation
• Inspection
• Auscultation
• Percussion
• Palpation

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Preparation for the Abdominal Exam

• Empty bladder
• Positioning
• Abdomen exposure
• Visualize anatomy
• Warm hands stethoscope
• Approach from the right
• Remember chief complaint
• Watch face

21
Inspection (1)

• Skin characteristics color, striae, rashes,
  lesions, scars, dilated veins
• Umbilicus location, displacement, inflammation
• Contour rounded, flat, scaphoid
• Symmetry symmetric, bulges, distension
• Surface Motion pulsations, peristalsis

22
Auscultation

• Bowel sounds frequency, character
• Vascular sounds bruits, venous hums

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Percussion (1)

• Assess size density of organs
• Detect presence of fluid, air, masses, tenderness
• Can be done independently or concurrently with
  palpation

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Percussion (2)

• All quadrants tympany vs dullness
• Liver span at right MCL and at the MSL if
  enlarged
• Spleen percussion sign lowest left ICS before
  after deep breath
• Gastric bubble left lower anterior rib cage,
  left epigastric area
• Kidneys costovertebral angle

25
Percussion (3)

• If suspect ascites as result of percussion of
  abdominal wall may perform two additional tests
  Shifting Dullness Test and the Fluid Wave Test

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Palpation (1)

• Evaluation of organs for size, shape,
  consistency, tenderness
• Evaluate umbilical ring
• Palpate for pulsation of abdominal aorta
• Detection of masses

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Palpation (2)

• Light Palpation all 4 quadrants identify
  muscular resistance, tenderness, masses
• Deep palpation all 4 quadrants delineate
  organs and detect deeper masses
• Mass location, size, shape, consistency,
  tenderness, pulsation, mobility, movement with
  respiration, superficial or intra-abdominal

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Palpation (3)

• Liver palpate lower border of right costal
  margin
• Aorta for pulsation
• Bladder distension
• Gallbladder, Spleen, Kidney not often done unless
  physician suspects abnormality

29
Additional Abdominal Tests
Examination and Findings

• Rebound tenderness
• Iliopsoas muscle test
• Obturator muscle test

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Abdominal Signs/Associated Conditions

• Blumberg (rebound tenderness)
• Cullen ecchymosis around umbilicus
• Grey Turner ecchymosis of flanks
• Kehr abdominal pain radiating to left shoulder
• Markel (heel jar test) up on toes, fall back on
  heels
• McBurney rebound tenderness,pain over appendix
• Murphy abrupt cessation of respiration when
  gallbladder palpated

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Differential by Anatomic Region-RUQ

• Duodenal ulcer
• Hepatomegaly
• Hepatitis
• Pneumonia
• Cholecystitis

32
Differential by Anatomic Region-LUQ

• Ruptured spleen
• Gastric ulcer
• Aortic aneurysm
• Perforated colon
• Pneumonia

33
Differential by Anatomic Region-Periumbilical
Region

• Intestinal obstruction
• Acute pancreatitis
• Early appendicitis
• Mesenteric thrombosis
• Aortic aneurysm
• Diverticulitis

34
Differential by Anatomic Region-RLQ

• Appendicitis
• Ovarian cyst or mass/salpingitis
• Ruptured ectopic pregnancy
• Renal/ureteral stone
• Strangulated hernia
• Perforated cecum/regional ileitis
• Diverticulitis

35
Differential by Anatomic Region-LLQ

• Ovarian cyst or mass/salpingitis
• Ruptured ectopic pregnancy
• Diverticulitis
• Renal/ureteral stone
• Strangulated hernia
• Ulcerative colitis
• Perforated colon/regional ileitis

36
Acute Appendicitis

• Pain characteristic periumbilical or
  epigastric later localized to RLQ, McBurney
• Associated findings anorexia, nausea, possible
  vomiting, low grade fever, guarding, rebound
  tenderness, iliopsas, obturator, McBurney,
  Markle
• Peritonitis possible if rupture occurs
  guarding, shallow respirations, hypotension or
  shock, reduced or absent bowel sounds can be
  life-threatening

37
Acute Cholecystitis

• Pain severe pain in RUQ, epigastric or
  umbilical pain lasting 2-4 hours after meals
  and especially after fatty meal may be referred
  to right subscapular area
• Associated findings RUQ tenderness rigidity,
  Murphy sign, palpable gallbladder, anorexia,
  vomiting, flatulence, fever possible jaundice

38
Acute Pancreatitis

• Pain dramatic, sudden, excruciating LUQ,
  epigastric, or umbilical pain may be present in
  one or both flanks with possible ecchymosis pain
  may be referred to left shoulder
• Associated findings epigastric tenderness,
  vomiting, fever, shock Grey Turner and Cullen
  signs which occur 2-3 days after onset

39
Ectopic Pregnancy

• Pain history of vague abdominal pain followed
  by sudden severe abdominal tenderness in LQ,
  especially on involved side
• Associated findings hypogastric tenderness,
  symptoms of pregnancy, spotting, missed period,
  mass on bimanual pelvic exam if ruptured shock,
  rigid abdominal wall, distension, Kehr,
  Cullen
• Mittleschmertz pain associated w/ovulation

40
Acute Hepatitis

• Pain general abdominal discomfort malaise
• Associated findings jaundice, clay-colored
  stools and dark urine which may preceed jaundice
  by 1 to 5 days, enlarged liver
• Patients with cirrhosis will also have ascites,
  prominent abdominal vasculature, cutaneous spider
  angiomas, generalized itching

41
Perforated Gastric or Duodenal Ulcer

• Pain abrupt RUQ may be referred to shoulders
• Associated findings abdominal free air and
  distension with increased resonance over liver
  tenderness in epigastrum or RUQ rigid abdominal
  wall, rebound tenderness hematemesis, melena,
  hypotension, increased pulse rate acute
  abdomen is a life-threatening event

42
Abdominal Aortic Aneurysm

• Pain painless but pain may indicate imminent
  rupture steady throbbing midline pain over
  aneurysm which may radiate to back, flank
• Associated findings nausea, vomiting, prominent
  aortic pulsation, bruit and or mass
• Life-threatening even if occurs in hospital
  setting

43
Pyelonephritis

• Pain flank pain, back pain
• Associated findings malaise, dysuria, nocturia,
  urinary frequency, possible fever,
  costovertebral angle tenderness

44
Renal Calculi

• Pain intense flank pain extending to groin
  genital area may be episodic
• Associated findings fever, hematuria, Kehr

45
Irritable Bowel Syndrome

• Pain crampy, variable hypogastric pain
  associated with abdominal bloating, distension
  bowel sounds
• Associated symptoms flatus, constipation or
  diarrhea may see mucous in stool relief with
  passage of flatus or bowel movement

46
Diverticulitis

• Pain epigastric, radiating down left side of
  abdomen especially after eating may be referred
  to back
• Associated findings tenderness on palpation,
  borborygmus, flatulence, diarrhea, possibly
  dysuria

47
Acute Diarrhea

• Pain abrupt onset of crampy pain
• Associated findings increased bowel sounds,
  diarrhea, nausea, vomiting, fever, and tenesmus
  consider food poisoning if develops in 2 or more
  following ingestion of same food

48
Hernia

• Pain localized pain that increases with lifting
  or exertion
• Associated findings hernia on physical exam,
  history of abdominal trauma, surgery

49
References

• Mosbys Guide to Physical Examination, 6th
  Edition. Chapter 17 pp 521-578.
• Bates Guide to Physical Examination and History
  Taking. Chapter 9 pp 317-366.
• University of California, San Diego A Practical
  Guide to Clinical Medicine Accessed online
  02/09/07 at medicine.ucsd.edu/clinicalmedicine/