Anatomy and Physiology of the Abdomen Houses multiple major organs Lined by peritoneal membrane Greater & lesser omentum Mesentery

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)

Abdominal Variations-Pregnancy Rectus abdominis Umbilicus, striae, linea nigra Striae, linea nigra Colon Peristalsis Gallbladder Renal pelvis, ureters

Abdominal Variations-Elderly Motility/Peristalsis Blood flow Pain perception Liver Lean body mass, fat

Describing the Abdomen Abdomen split into quadrants to help organize organs.

Describing the Abdomen The abdomen can also be split into 9 sections as well.

Right Upper Quadrant (RUQ) Liver & Gallbladder Head of Pancreas Duodenum Right adrenal gland Hepatic flexure of colon Portion of right kidney

Right Lower Quadrant (RLQ) Appendix Ascending colon Ovary Right ureter Bladder Uterus

Left Upper Quadrant (LUQ) Spleen Stomach Pancreas Left lobe of liver Splenic flexure of colon Portions of transverse and descending colon

Left Lower Quadrant (LLQ) Lower left kidney Sigmoid colon Ovary Left ureter Descending colon Bladder Uterus

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

Importance of History Present Illness GI versus cardiac causes Clues to Differential Abdominal “Review of Systems” Seven attributes of a symptom

Review of Systems for the Abdomen Abdominal pain Indigestion Nausea Vomiting Diarrhea Constipation Jaundice Dysuria Urinary frequency Hematuria

Past Medical History Gastrointestinal disorders • Review of Related History Past Medical History Gastrointestinal disorders Urinary Tract Infections Surgeries Medications/Immunizations Trauma/Injury Blood transfusions Hepatitis Cancer

Family History Familial Mediterranean Fever Inflammatory bowel disease • Review of Related History Family History Familial Mediterranean Fever Inflammatory bowel disease Familial cancer syndromes Congenital malformations Cystic fibrosis, Celiac’s Kidney disease Gallbladder disease

Personal and Social History • Review of Related History Personal and Social 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

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

Older Adults Urinary Tract Infections Constipation Indigestion • Review of Related History Older Adults Urinary Tract Infections Constipation Indigestion Dietary habits

Abdominal Exam Preparation Inspection Auscultation Percussion Palpation

Preparation for the Abdominal Exam Empty bladder Positioning Abdomen exposure Visualize anatomy Warm hands & stethoscope Approach from the right Remember chief complaint Watch face

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

Auscultation Bowel sounds: frequency, character Vascular sounds: bruits, venous hums

Percussion (1) Assess size & density of organs Detect presence of fluid, air, masses, tenderness Can be done independently or concurrently with palpation

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

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

Palpation (1) Evaluation of organs for: size, shape, consistency, tenderness Evaluate umbilical ring Palpate for pulsation of abdominal aorta Detection of masses

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

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

Additional Abdominal Tests • Examination and Findings Additional Abdominal Tests Rebound tenderness Iliopsoas muscle test Obturator muscle test

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

Differential by Anatomic Region-RUQ Duodenal ulcer Hepatomegaly Hepatitis Pneumonia Cholecystitis

Differential by Anatomic Region-LUQ Ruptured spleen Gastric ulcer Aortic aneurysm Perforated colon Pneumonia

Differential by Anatomic Region-Periumbilical Region Intestinal obstruction Acute pancreatitis Early appendicitis Mesenteric thrombosis Aortic aneurysm Diverticulitis

Differential by Anatomic Region-RLQ Appendicitis Ovarian cyst or mass/salpingitis Ruptured ectopic pregnancy Renal/ureteral stone Strangulated hernia Perforated cecum/regional ileitis Diverticulitis

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

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

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

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

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

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

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

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

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

Renal Calculi Pain: intense flank pain extending to groin & genital area; may be episodic Associated findings: fever, hematuria, + Kehr

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

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

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

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

References Mosby’s 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/