the abdomen 1. anatomy & physiology 2. history 3. examination & findings 4. common...

The AbdomenThe AbdomenThe AbdomenThe Abdomen1. Anatomy & Physiology1. Anatomy & Physiology

2. History2. History

3. Examination & Findings3. Examination & Findings

4. Common Abnormalities4. Common Abnormalities

The AbdomenThe AbdomenThe AbdomenThe Abdomen

Anatomy and Physiology

Anatomy and PhysiologyAnatomy and PhysiologyAnatomy and PhysiologyAnatomy and Physiology

The Gastrointestinal tractThe Gastrointestinal tract

MouthMouth Esophagus Esophagus Stomach Stomach SmallSmall IntestinesIntestines: Duodenum : Duodenum Jejunum Jejunum Ileum Ileum

Large IntestinesLarge Intestines: Cecum : Cecum Colon Colon

Sigmoid Colon Sigmoid Colon Rectum Rectum Anus Anus

Function & ControlFunction & ControlFunction & ControlFunction & Control

Ingest and Digest FoodIngest and Digest Food Absorb Nutrients, Electrolytes and Absorb Nutrients, Electrolytes and

WaterWater Excrete Waste productsExcrete Waste products

Controlled by Autonomic Nervous Controlled by Autonomic Nervous SystemSystem

The LiverThe LiverThe LiverThe Liver

Location: right upper quadrantLocation: right upper quadrant Weight: 3 lbsWeight: 3 lbs Composition: four lobes containing lobules, the Composition: four lobes containing lobules, the

functional units of the liverfunctional units of the liver Blood supply: hepatic artery brings blood from the Blood supply: hepatic artery brings blood from the

aorta directly to the liver.aorta directly to the liver. The portal vein brings blood from the digestive tract The portal vein brings blood from the digestive tract

and the spleen to the liverand the spleen to the liver Three hepatic veins empty blood from the liver into Three hepatic veins empty blood from the liver into

the inferior vena cavathe inferior vena cava

Liver FunctionLiver FunctionLiver FunctionLiver Function

Metabolism of carbohydrates, fats and proteinMetabolism of carbohydrates, fats and protein Glucose is converted and stored as GlycogenGlucose is converted and stored as Glycogen Amino acids are broken down and their waste Amino acids are broken down and their waste

products converted to urea for excretionproducts converted to urea for excretion Amino acids can be converted to glucose: Amino acids can be converted to glucose:

gluconeogenesisgluconeogenesis Fats arriving as fatty acids are oxidized into Fats arriving as fatty acids are oxidized into

carbon componentscarbon components

Liver FunctionLiver FunctionLiver FunctionLiver Function

Cholesterol is used to form bile saltsCholesterol is used to form bile salts Storage of vitamins and ironStorage of vitamins and iron Detoxification, production of antibodies, Detoxification, production of antibodies,

conjugation & excretion of steroid hormonesconjugation & excretion of steroid hormones Production of prothrombin, fibrinogen and Production of prothrombin, fibrinogen and

other substances for coagulationother substances for coagulation The liver is responsible for the majority of the The liver is responsible for the majority of the

proteins circulating in the plasmaproteins circulating in the plasma

The GallbladderThe GallbladderThe GallbladderThe Gallbladder

Location: under the inferior surface of the liver Location: under the inferior surface of the liver in the right upper quadrantin the right upper quadrant

FunctionFunction: concentration and storage of bile : concentration and storage of bile from the liverfrom the liver

Cholecystokinin: a hormone produced by the Cholecystokinin: a hormone produced by the duodenum: causes bile to be released in the duodenum: causes bile to be released in the common bile duct and into the duodenumcommon bile duct and into the duodenum

Bile maintains the alkaline pH of the small Bile maintains the alkaline pH of the small intestines so fats can be emulsified in order to intestines so fats can be emulsified in order to be absorbedbe absorbed

The PancreasThe PancreasThe PancreasThe Pancreas

Location: behind and beneath the stomach, Location: behind and beneath the stomach, epigastric region and left upper quadrantepigastric region and left upper quadrant

Exocrine functionExocrine function: production of digestive : production of digestive juices containing inactive enzymes for the juices containing inactive enzymes for the breakdown of proteins, fats and carbohydratesbreakdown of proteins, fats and carbohydrates

The pancreatic duct empties into the The pancreatic duct empties into the duodenum, alongside the common bile ductduodenum, alongside the common bile duct

The digestive enzymes become activated in The digestive enzymes become activated in the duodenumthe duodenum

The PancreasThe PancreasThe PancreasThe Pancreas

Endocrine functionEndocrine function: the production of the : the production of the hormones insulin and glucagonhormones insulin and glucagon

Produced by the islet cells Produced by the islet cells Secreted directly into the blood, to regulate Secreted directly into the blood, to regulate

the body’s level of glucose.the body’s level of glucose.

The SpleenThe SpleenThe SpleenThe Spleen

Location: left upper quadrant, above the left Location: left upper quadrant, above the left kidney, below the diaphragmkidney, below the diaphragm

Composition: lymphoid tissueComposition: lymphoid tissue FunctionFunction: filter blood as part of the : filter blood as part of the

reticuloendothelial system (RES): defense reticuloendothelial system (RES): defense against infection and disposal of products of against infection and disposal of products of the breakdown of cells the breakdown of cells

Manufactures lymphocytes and monocytesManufactures lymphocytes and monocytes Storage area for bloodStorage area for blood

Kidneys Posterior ViewKidneys Posterior ViewKidneys Posterior ViewKidneys Posterior View

The Kidneys, Ureters, and The Kidneys, Ureters, and BladderBladder


FunctionFunction: reabsorption of electrolytes, small : reabsorption of electrolytes, small proteins and water, The kidneys control the proteins and water, The kidneys control the water and electrolyte balances of the bodywater and electrolyte balances of the body

Elimination of waste products in urineElimination of waste products in urine Endocrine GlandEndocrine Gland: produces renin, important in : produces renin, important in

the control of aldosterone secretionthe control of aldosterone secretion Erythropoietin production:regulates the red Erythropoietin production:regulates the red

blood cell productionblood cell production Production of the active form of vitamin DProduction of the active form of vitamin D



Urine passes into the renal pelvis via the Urine passes into the renal pelvis via the collecting tubules and then into the uretercollecting tubules and then into the ureter

Peristaltic waves move the urine into a Peristaltic waves move the urine into a reservoir: the bladderreservoir: the bladder

The Bladder has a capacity of 400-500 mlThe Bladder has a capacity of 400-500 ml Urine then is eliminated from the body via the Urine then is eliminated from the body via the

urethra urethra


History

Present ProblemPresent ProblemPresent ProblemPresent Problem

Abdominal Pain:Abdominal Pain:

Onset and DurationOnset and Duration

CharacterCharacter

LocationLocation Associated symptoms: nausea,vomiting, diarrhea, Associated symptoms: nausea,vomiting, diarrhea,

constipation, flatus, belching, jaundiceconstipation, flatus, belching, jaundice Relationship: body position, inspiration, food intake, Relationship: body position, inspiration, food intake,

menstrual cycle, urination, defecation, time of daymenstrual cycle, urination, defecation, time of day

Referred PainReferred PainReferred PainReferred Pain


Indigestion: GERDIndigestion: GERD Character: fullness, heartburn, discomfort, belching, Character: fullness, heartburn, discomfort, belching,

loss of appetiteloss of appetite Association: with food intake, time, amount, type of Association: with food intake, time, amount, type of

food intakefood intake Onset of symptoms: sudden, gradual, day or nightOnset of symptoms: sudden, gradual, day or night Symptom relieve: rest, antacidsSymptom relieve: rest, antacids Medication: OTC and prescribedMedication: OTC and prescribed Nausea: stimuli, with or without vomitingNausea: stimuli, with or without vomiting

GI TractGI Tract

Types of Antacids to Look UP

Types of Antacids to Look UP

OTC (Old Remedy- Tablespoon of Baking Soda)– Alka-Seltzer– Tums– Milk of Magnesia– Pepto-Bismol– Gaviscon– Maalox– Mylanta– Rolaids

H2 Histamine AntagonistsH2 Histamine Antagonists

Axid AR ( Acid Reducer ) Pepcid AC ( Acid Controller ) Tagamet HB ( Heartburn ) Zantac 75

Proton Pump InhibitorsProton Pump Inhibitors

Prevacid 24 HR Prilosec OTC Zegerid OTC Aciphex

Odd Man OutOdd Man Out

Carafate ( Multi-Uses)–Indigestion–Ulcers (peptic and duodenal)–Esophageal Varices


VomitingVomiting Character: nature, quantity, duration, Character: nature, quantity, duration,

frequency, ability to keep liquids downfrequency, ability to keep liquids down Relationship: meals,change in appetite, fever, Relationship: meals,change in appetite, fever,

weight loss weight loss


DiarrheaDiarrhea Character: copious, watery, explosive, color, Character: copious, watery, explosive, color,

presence of blood, number of times a daypresence of blood, number of times a day Associated symptoms: chills, fever, thirst, weight Associated symptoms: chills, fever, thirst, weight

loss, pain and or cramping, incontinenceloss, pain and or cramping, incontinence Relationship: timing, nature of food intake, stressRelationship: timing, nature of food intake, stress Travel HistoryTravel History Medication: OTC or prescribed, laxatives, stool Medication: OTC or prescribed, laxatives, stool

softeners, antidiarrhealssofteners, antidiarrheals


ConstipationConstipation Character: presence of blood: black, bright, Character: presence of blood: black, bright,

tarry. Alternating with diarrhea, with or without tarry. Alternating with diarrhea, with or without abdominal discomfortabdominal discomfort

Pattern: last BM, pain with passage of BM, Pattern: last BM, pain with passage of BM, changes in patternchanges in pattern

Diet: recent changes in dietDiet: recent changes in diet Medication: OTC and prescribed, laxatives, Medication: OTC and prescribed, laxatives,

stool softeners, diuretics, ironstool softeners, diuretics, iron


JaundiceJaundice Onset and DurationOnset and Duration Color of stool and urineColor of stool and urine Associated with abdominal pain, fever, chillsAssociated with abdominal pain, fever, chills Exposure to HepatitisExposure to Hepatitis Medications: high doses of acetaminophenMedications: high doses of acetaminophen

Past Medical ProblemPast Medical ProblemPast Medical ProblemPast Medical Problem

Gastrointestinal Disorders: Peptic Ulcer Gastrointestinal Disorders: Peptic Ulcer Disease, GERD, inflammatory Bowel Disease, Disease, GERD, inflammatory Bowel Disease, intestinal Obstruction, Pancreatitisintestinal Obstruction, Pancreatitis

Hepatitis or Cirrhosis of the LiverHepatitis or Cirrhosis of the Liver Surgery: abdominal or urinary tract Surgery: abdominal or urinary tract Major Illness: Cancer, arthritis( steroids/aspirin Major Illness: Cancer, arthritis( steroids/aspirin

use), Kidney Disease, Cardiac Diseaseuse), Kidney Disease, Cardiac Disease Blood TransfusionsBlood Transfusions Hepatitis VaccineHepatitis Vaccine

Family HistoryFamily HistoryFamily HistoryFamily History

Gallbladder DiseaseGallbladder Disease Kidney Disease: kidney stones, Kidney Disease: kidney stones,

polycystic diseasepolycystic disease Malabsorption syndrome: cystic fibrosis, Malabsorption syndrome: cystic fibrosis,

celiac diseaseceliac disease

Personal and Social Personal and Social HistoryHistory

Personal and Social Personal and Social HistoryHistory

Nutrition: preferences and dislikes, ethnic Nutrition: preferences and dislikes, ethnic foods, religious food restrictions, food foods, religious food restrictions, food intolerance's, weight gain or lossintolerance's, weight gain or loss

Alcohol Intake and use of illegal drugsAlcohol Intake and use of illegal drugs Recent physical or psychological changesRecent physical or psychological changes Exposure to infectious disease: flu, travel Exposure to infectious disease: flu, travel

historyhistory TraumaTrauma


Examination and Findings

Epigastric RegionEpigastric RegionEpigastric RegionEpigastric Region

1.Pyloric end of 1.Pyloric end of the stomachthe stomach

DuodenumDuodenum

PancreasPancreas

Portion of the liverPortion of the liver

Umbilical RegionUmbilical RegionUmbilical RegionUmbilical Region

2.Omentum2.Omentum

MesenteryMesentery

Transverse ColonTransverse Colon

Lower part of the Lower part of the DuodenumDuodenum

Jejenum and Jejenum and IleumIleum

Hypogastric RegionHypogastric RegionHypogastric RegionHypogastric Region

3.Ileum3.Ileum

BladderBladder

Uterus in Uterus in pregnancypregnancy

Right Hypochondriac Right Hypochondriac RegionRegion

Right Hypochondriac Right Hypochondriac RegionRegion

4.Right lobe of the liver4.Right lobe of the liver

GallbladderGallbladder

Portion of the DuodenumPortion of the Duodenum

Hepatic Flexure of the Hepatic Flexure of the ColonColon

Portion of the right KidneyPortion of the right Kidney

Suprarenal GlandSuprarenal Gland

Left Hypochondric RegionLeft Hypochondric RegionLeft Hypochondric RegionLeft Hypochondric Region

5.Stomach5.Stomach

SpleenSpleen

Tail of the PancreasTail of the Pancreas

Splenic Flexure of theSplenic Flexure of the

ColonColon

Upper pole of the leftUpper pole of the left

KidneyKidney

Suprarenal GlandSuprarenal Gland

Right Lumbar RegionRight Lumbar RegionRight Lumbar RegionRight Lumbar Region

6.Ascending Colon6.Ascending Colon

Lower half of theLower half of the

right Kidneyright Kidney

Portion of thePortion of the

Duodenum andDuodenum and

JejunumJejunum

Left Lumbar RegionLeft Lumbar RegionLeft Lumbar RegionLeft Lumbar Region

7.Descending Colon7.Descending Colon

Lower half of the left Lower half of the left KidneyKidney

Portion of thePortion of the

Duodenum andDuodenum and

JejunumJejunum

Right Inguinal RegionRight Inguinal RegionRight Inguinal RegionRight Inguinal Region

8.Cecum8.Cecum

AppendixAppendix

Lower end of IleumLower end of Ileum

Right UreterRight Ureter

Right Spermatic Right Spermatic CordCord

Right OvaryRight Ovary

Left Inguinal RegionLeft Inguinal RegionLeft Inguinal RegionLeft Inguinal Region

9.Sigmoid Colon9.Sigmoid Colon

Left UreterLeft Ureter

Left Spermatic Left Spermatic CordCord

Left OvaryLeft Ovary

InspectionInspectionInspectionInspection

Inspect the abdomen for contour, symmetry Inspect the abdomen for contour, symmetry and surface motionand surface motion

Note location and contour of umbilicusNote location and contour of umbilicus Distention: above umbilicus: gastric dilation, Distention: above umbilicus: gastric dilation,

carcinoma, pancreatic cystcarcinoma, pancreatic cyst

Below umbilicus: ovarian tumor, pregnancy, Below umbilicus: ovarian tumor, pregnancy, uterine fibroids, distended bladderuterine fibroids, distended bladder

Ask patient to take a deep breath on hold itAsk patient to take a deep breath on hold it

The Fs of Abdominal DistentionThe Fs of Abdominal Distention

FatFatal GrowthFecesFibroidFlatusFluid

AuscultationAuscultationAuscultationAuscultation

Listen for bowelsounds: note frequency and Listen for bowelsounds: note frequency and charactercharacter

Borborygmi: stomach growlingBorborygmi: stomach growling High-pitched tinkling sounds: suggestive of High-pitched tinkling sounds: suggestive of

intestinal fluid and air under pressure, in early intestinal fluid and air under pressure, in early obstructionobstruction

Decreased Bowelsounds: paralytic ileus and with Decreased Bowelsounds: paralytic ileus and with peritonitisperitonitis

Vascular Sounds: listen with the bell for bruits in Vascular Sounds: listen with the bell for bruits in the aortic, renal ,iliac and femoral arteriesthe aortic, renal ,iliac and femoral arteries

AuscultationAuscultationAuscultationAuscultation

Auscultation Vascular Auscultation Vascular SoundsSounds

Auscultation Vascular Auscultation Vascular SoundsSounds

PercusionPercusionPercusionPercusion

Assessment of size and density of abdominal Assessment of size and density of abdominal organsorgans

Listen for tympany ( predominant, produced Listen for tympany ( predominant, produced by air in stomach and intestines) and by air in stomach and intestines) and dullness ( over solid organs and masses)dullness ( over solid organs and masses)

Start with an area of tympany and proceed to Start with an area of tympany and proceed to an area of dullnessan area of dullness

PercussionPercussionPercussionPercussion

PalpationPalpationPalpationPalpation

To assess the organs and detect masses, fluid, and To assess the organs and detect masses, fluid, and areas of tendernessareas of tenderness

Stand at the right side of the patient in a suspine Stand at the right side of the patient in a suspine position, with knees bend for relaxationposition, with knees bend for relaxation

Make sure your hands are warmMake sure your hands are warm Start with a light systematic palpation of all four Start with a light systematic palpation of all four

quadrantsquadrants Put hand flat on the abdomen and depress the palmar Put hand flat on the abdomen and depress the palmar

surface of your fingers one cm, use a dipping motionsurface of your fingers one cm, use a dipping motion Start away from the pain areaStart away from the pain area

Deep PalpationDeep PalpationDeep PalpationDeep Palpation

Use the bimanual methodUse the bimanual method

One hand for push (Top Hand) , the other hand for feeling One hand for push (Top Hand) , the other hand for feeling (Bottom Hand)(Bottom Hand)

Palpation of the Umbilical RingPalpation of the Umbilical RingPalpation of the Umbilical RingPalpation of the Umbilical Ring

Palpate around the umbilicusPalpate around the umbilicus There should be no bulges, nodules or There should be no bulges, nodules or

granulationgranulation The umbilical ring should be round and The umbilical ring should be round and

regularregular A soft center or irregularities are suggestive A soft center or irregularities are suggestive

for the potential of an umbilical herniafor the potential of an umbilical hernia The umbilicus should not protrudeThe umbilicus should not protrude

Palpable Structures Palpable Structures Palpable Structures Palpable Structures

Palpation of the LiverPalpation of the LiverPalpation of the LiverPalpation of the Liver

Place your left hand under the 11th, 12th ribs, Place your left hand under the 11th, 12th ribs, fingers pointing toward the head of the patient fingers pointing toward the head of the patient

Press upward to elevate the liver toward the Press upward to elevate the liver toward the abdominal wallabdominal wall

Have patient breath regular a few times then Have patient breath regular a few times then task to take a deep breathtask to take a deep breath

Try to feel the edge of the liver against your Try to feel the edge of the liver against your fingertips as the diaphragm pushes the liver fingertips as the diaphragm pushes the liver downdown

Liver PalpationLiver PalpationLiver PalpationLiver Palpation

Palpation of the SpleenPalpation of the SpleenPalpation of the SpleenPalpation of the Spleen

Standing on the right side, reach across and place Standing on the right side, reach across and place your left hand beneath the left costovertebral angleyour left hand beneath the left costovertebral angle

Lift the spleen towards the abdominal wallLift the spleen towards the abdominal wall Place your right hand with extended fingers on the Place your right hand with extended fingers on the

patients abdomen below the left costal marginpatients abdomen below the left costal margin Press your fingertips inwardPress your fingertips inward Ask the patient to take a deep breathAsk the patient to take a deep breath Try to feel the edge of the spleen as it moves downTry to feel the edge of the spleen as it moves down

Palpation SpleenPalpation SpleenPalpation SpleenPalpation Spleen

Enlarged LiverEnlarged LiverEnlarged LiverEnlarged Liver

Common AbnormalitiesCommon AbnormalitiesCommon AbnormalitiesCommon Abnormalities

Appendicitis:Appendicitis:

Epigastric or umbilical pain, Epigastric or umbilical pain, later becomes RLQ painlater becomes RLQ pain

McBurney: rebound McBurney: rebound tenderness and sharp tenderness and sharp pain when McBurney point pain when McBurney point is palpated is palpated

Associated findings: low Associated findings: low grade fever, N / V grade fever, N / V

Cholecystitis:Cholecystitis:

Severe, unrelenting Severe, unrelenting RUQ pain or RUQ pain or epigastric pain, may epigastric pain, may refer to right refer to right subscapular areasubscapular area

Murphy sign: abrupt Murphy sign: abrupt stopping of stopping of inspiration upon inspiration upon palpation of the palpation of the gallbladdergallbladder


Pancreatitis:Pancreatitis:

Sudden, excruciating Sudden, excruciating LUQ,epigastric pain, LUQ,epigastric pain, may be umbilical. Pain may be umbilical. Pain can refer to left shouldercan refer to left shoulder

Grey Turner: Grey Turner: ecchymosis over flanksecchymosis over flanks

Cullen sign; ecchymosis Cullen sign; ecchymosis around the umbilicusaround the umbilicus

Associated findings: Associated findings: vomiting, fever, shockvomiting, fever, shock

Perforated Ulcer:Perforated Ulcer:

abrupt pain in RUQ, abrupt pain in RUQ, may refer to both may refer to both shouldersshoulders

Associated findings: Associated findings: free air and distension free air and distension with increased with increased resonance over the resonance over the liver. Tenderness in liver. Tenderness in epigastrium, rigid epigastrium, rigid abdomenabdomen


Diverticulitis:Diverticulitis:

epigastric pain, radiating epigastric pain, radiating down the left side of the down the left side of the abdomen, may refer to the abdomen, may refer to the backback

Associated Findings: Associated Findings: flatulence, borborygmi, flatulence, borborygmi, diarrhea, dysuria, diarrhea, dysuria, tenderness on palpationtenderness on palpation

Intestinal Obstruction:Intestinal Obstruction:

abrupt, severe, abrupt, severe, spasmodic pain, may spasmodic pain, may refer to epigastrium, refer to epigastrium, umbilicusumbilicus

Associated Findings: Associated Findings: distention, vomiting, distention, vomiting, localized tenderness, localized tenderness, visible peristalsis, visible peristalsis, absent bowelsounds or absent bowelsounds or hyperactive hyperactive bowelsoundsbowelsounds

the abdomen 1. anatomy & physiology 2. history 3. examination & findings 4. common...

Documents

water n

carbohydrates n

glucagon n

coagulation n

liver n location

function control n

liver n cholecystokinin

duodenum n bile