1. Gastrointestinal Tract
lecture Seven

2. Anatomy of the Abdomen
Abdominal Cavity

3. Quadrants

4. Quadrants RUQ LUQ Liver Gallbladder Duodenum Head of pancreas
Right kidney and adrenal gland
Hepatic flexure of colon
Part of ascending and transverse colon
LUQ
Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal gland
Splenic flexure of colon
Part of transverse and descending colon

5. Quadrants Right lower quadrant (RLQ) Left lower quadrant (LLQ) Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
Left lower quadrant
(LLQ)
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord

6. Subjective Data Appetite Dysphagia Food intolerance Abdominal pain
Nausea and vomiting
Bowel habits
Abdominal history
Medications

7. Subjective Data Appetite Dysphagia
Any change in appetite? Is this a loss of appetite?
Any change in weight? How much weight gained or lost?
Dysphagia
Any difficulty swallowing? When did you first notice this?

8. Subjective Data Food intolerance
Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloating, or indigestion?
Do you use antacids? How often?

9. Subjective Data Abdominal pain Any abdominal pain? Please point to it.
Is pain in one spot or does it move around?
How did it start? How long have you had it?
Is it constant, or does it come and go? Does it occur before or after meals?
How would you describe the character of the pain: cramping (colic type), burning in pit of stomach, dull, stabbing, or aching?
Is pain relieved by food, or worse after eating?

10. Subjective Data Abdominal pain (cont.)
Is pain associated with stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination?

11. Subjective Data Nausea and vomiting Any nausea or vomiting?
How often? How much comes up? What is the color? Is there an odor?
Is it bloody?
Is nausea and vomiting associated with colicky pain, diarrhea, fever, or chills?
What foods did you eat in last 24 hours? Is there anyone else in family with same symptoms in last 24 hours?

12. Subjective Data Bowel habits How often do you have a bowel movement?
What is the color and consistency?
Any diarrhea or constipation? Any recent change in bowel habits?
Use laxatives? Which ones? How often do you use them?

13. Subjective Data Abdominal history
Any history of gastrointestinal problems such as ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, or hernia?
Ever had any operations in abdomen? Please describe.
Any problems after surgery?
Any abdominal x-ray studies? What were results?

14. Objective Data Inspect the abdomen Contour Symmetry
contour describes nutritional state and normally ranges from flat to rounded
Symmetry
Abdomen should be symmetric bilaterally
Note any localized bulging, visible mass, or asymmetric shape
Ask person to take a deep breath to further highlight any change
Abdomen should stay smooth and symmetric
Ask person to perform a sit-up without pushing up with his or her hands

15. Contour

16. Objective Data Inspect the abdomen (cont.) Umbilicus Skin
Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia
Skin
Surface smooth and even, with homogeneous color
One common pigment change is striae, silvery white, linear, jagged marks about 1 to 6 cm long
Occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain; recent striae are pink or blue; then they turn silvery white
Normally, no lesions are present, although you may note well-healed surgical scars

17. Objective Data Inspect the abdomen (cont.) Pulsation or movement
Normally, you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation
Respiratory movement also shows in abdomen, particularly in males
Finally, waves of peristalsis sometimes are visible in very thin persons; they ripple slowly and obliquely across abdomen

18. Objective Data Auscultate bowel sounds and vascular sounds
This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds
Use diaphragm endpiece because bowel sounds are relatively high pitched
Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds
Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here

19. Objective Data Auscultate bowel sounds and vascular sounds
Note character and frequency of bowel sounds
Bowel sounds originate from movement of air and fluid through small intestine
Depending on 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
Judge if they are normal, hypoactive, or hyperactive

20. Objective Data Auscultate bowel sounds and vascular sounds (cont.)
As you listen to abdomen, note presence of any vascular sounds or bruits
Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension
Usually, no such sound is present

21. Objective Data Percuss general tympany, liver, and splenic dullness
Percuss to assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses
General tympany
First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness
Move clockwise; tympany should predominate because air in intestines rises to surface when person is supine

22. Objective Data
Percuss general tympany, liver, and splenic dullness (cont.)
Liver span
Percuss to map out boundaries of certain organs
Measure height of liver in right midclavicular line
Begin in area of lung resonance, and percuss down interspaces until sound changes to a dull quality.
Measure distance between two marks; normal liver span in adult ranges from 6 to 12 cm

23. Objective Data
Percuss general tympany, liver, and splenic dullness (cont.)
Splenic dullness
Often spleen obscured by stomach contents, but you may locate it by percussing for a dull note from 9th to 11th intercostal space just behind left midaxillary line
Costovertebral angle tenderness
To assess kidney, place one hand over 12th rib at costovertebral angle on back
Thump that hand with ulnar edge of your other fist

24. Objective Data (cont.)
Percuss general tympany, liver, and splenic dullness (cont.)
Special procedures
At times, you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of 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
Fluid wave test
Shifting dullness test

25. Objective Data Palpate surface and deep areas Perform palpation
Judge size, location, and consistency of certain organs and screen for an abnormal mass or tenderness
Bend person’s knees
Teach person to breathe slowly; in through nose, and out through mouth

26. Objective Data Palpate surface and deep areas (cont.)
Light and deep palpation (cont.)
Begin with light palpation
With first four fingers close together, depress skin about 1 cm
Make gentle rotary motion, sliding fingers and skin together
Then lift fingers (do not drag them) and move clockwise to next location around abdomen

27. Objective Data Palpate surface and deep areas (cont.)
Light and deep palpation (cont.)
Now perform deep palpation using same technique described earlier, but push down about 5 to 8 cm Moving clockwise, explore entire abdomen
To overcome resistance of a very large or obese abdomen, use a bimanual technique
Place your two hands on top of each other
Top hand does pushing; bottom hand relaxed and can concentrate on sense of palpation

28. Objective Data Palpate surface and deep areas (cont.)
Light and deep palpation (cont.)
With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses

29. Objective Data Palpate surface and deep areas (cont.)
Light and deep palpation (cont.)
Then note the following:
Location
Size
Shape
Consistency: soft, firm, hard
Surface: smooth, nodular
Mobility, including movement with respirations
Pulsatility
Tenderness

30. Normally Palpable Structures

31. Objective Data Palpate surface and deep areas (cont.) Liver
Place your left hand under person’s back parallel to 11th and 12th ribs and lift up to support abdominal contents
Place your right hand on RUQ, with fingers parallel to midline
Push deeply down and under right costal margin
Ask person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation
It feels like a firm regular ridge; often liver is not palpable

32. Objective Data Palpate surface and deep areas (cont.) Liver (cont.)
Hooking Technique
An alternative method of palpating liver is to stand up at person’s shoulder and swivel your body to right so that you face person’s feet
Hook your fingers over costal margin from above
Ask person to take a deep breath
Try to feel liver edge bump your fingertips

33. Objective Data Palpate surface and deep areas (cont.) Spleen
Normally spleen is not palpable and must be enlarged three times its normal size to be felt
To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs
Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just inferior to rib margin
Push your hand deeply down and under left costal margin and ask person to take deep breath
You should feel nothing firm

34. Objective Data Palpate surface and deep areas (cont.) Kidneys
Search for right kidney by placing your hands together in a “duck-bill” position at person’s right flank
Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask person to take deep breath
In most people, you will feel no change
Occasionally, you may feel lower pole of right kidney as a round, smooth mass slide between your fingers
Either condition is normal

35. Objective Data Palpate surface and deep areas (cont.) Kidneys (cont.)
Left kidney sits 1 cm higher than right kidney and is not palpable normally
Search for it by reaching your left hand across abdomen and behind left flank for support
Push your right hand deep into abdomen and ask person to breathe deeply
You should feel no change with inhalation

36. Objective Data Palpate surface and deep areas (cont.) Aorta
Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline
Normally, it is 2.5 to 4 cm wide in adult and pulsates in an anterior direction

37. Sample charting

38. Sample charting (cont.)

39. Reference Physical Examination and Health Assessment, 5th Edition
By Carolyn Jarvis, PhD, APN, CNP