Abdominal Anatomy History Taking, PE Dr.


4th Shifting 2-7-08 Class no.

1 Kristel, Leiza

SURGERY Abdominal Anatomy Dr. Mata date Tg 4: Jam, Madel, Pao, Joven

Una sa lahat, hindi kami ang gumawa ng trans na ito…SOBRANG THANK YOU

MOUTH/ ORAL CAVITY Lips, Cheek, Gums, Teeth, Tongue PHARYNX -Portion of airway between nasal cavity and larynx ESOPHAGUS - digestive tract between the pharynx and stomach STOMACH - hollow digestive organ - receives food from the esophagus SMALL INSTESTINE - between stomach and Cecum - Duodenum, jejunum, ileum - site of nutrient absorption into the body LARGE INTESTINE - ileocecal valve to the anus - Cecum, colon, rectum - recovers water form the gastrointestinal tract secretions ACCESSORY ORGANS SALIVARY GLAND -produces and secretes saliva - connected to mouth by ducts LIVER - larges solid organ in Right upper quadrant - produce and secrete bile - produce essential proteins - produces clotting factors - detoxification process -stores glycogen
pao anna cess sheen a xtian jam abi pau edward eagleman banana jeff car toni

Krizzie, Prei Mommy Rose, Madel, and esp. Jam dahil shinare nila sa atin
ang trans na ito na pinaghirapan at pinagtulungan nilang gawin. THANK YOU, great help talaga ito.
ABDOMINAL ANATOMY ABDOMINAL CAVITY Superior Border = Diaphragm Inferior Border = Pelvis Posterior Border = Lumbar Spine Anterior Border - Musculature of Abdominal wall ANATOMIC LANDMARKS -Divided in quadrants RUQ, LUQ, RLQ, LLQ ANATOMIC Epigastric Umbilical Suprapubic (hypogastric) PERITONEUM - Abdominal Cavity Lining - Double - Walled Structure - Visceral Peritoneum - Parietal Peritoneum - Separates Abdominal cavity into 2 parts - Peritoneal Cavity - Retroperitonel Space PRIMARY GASTRO-INTESTINAL STRUCTURES
apriL jat aLLain bambi madeL erika yna jen raLph roche tLe bam jovs aLex

GALL BLADDER - located beneath liver - stores and concentrates bile PANCREAS - endocrine pancreas secretes insulin -exocrine pancreas secretes digestive enzymes, bicarbonate into the gut VERMIFORM APPENDIX -hollow appendage -attached to large intestine - no physiologic function MAJOR BLOOD VESSELS -Aorta - Inferior Vena Cave SOLID ORGANS -Liver -Spleen -Pancreas - Kidney - Ovaries (female) HOLOW ORGANS -Stomach - Intestines - Gall bladder and Bile Ducts - Ureter - Urinary Bladder - Uterus (Female) - Fallopian Tube (Female) RIGHT UPPER QUADRANT - Liver - Gall bladder -Duodenum - Transverse Colon (part) - Ascending Colon (part) LEFT UPPER QUADRANT

-Stomach - Liver (part) - Pancreas - Spleen - Transverse colon (part) - Descending colon (part) RIGHT LOWER QUADRANT - Ascending Colon - Vermiform appendix - ovary - fallopian tube LEFT LOWER QUADRANT - Descending colon -Sigmoid -ovary (female) -fallopian tube (female) DISORDERS OF THE ALIMENTARY TRACT I. MOTOR (Motility Disorders) 1. Achalasia 2. Post Vagotomy Atony 3. Hirchsprung Disease II. BLEEDING 1. Varices (most often located in esophagus) 2. Mallory Weiss 3. Peptic Ulcer 4. Cancer 5. Merckel's Diverticulum 6. Diverticulosis (know the difference between diverticulosis and diverticulitis) * Bright red and tarry color III. PERFORATION 1. Instrumental 2. Ulcer 3. Obstruction and gangrene

3 Kristel, Leiza

4. Diverticulitis – IV. OBSTRUCTION 1. ESOPHAGUS - cancer, reflux, esophagitis, caustic substance 2. PYLORUS - peptic ulcer 3. SMALL BOWEL - adhesion, hernias 4. COLON - cancer, volvulus, other V.INFLAMMATION 1. Esophagitis 2. gastritis 3, regional enteritis 4. ulcerative colitis 5. granulomatous colitis VI. NEOPLASM -many occur at any level of the alimentary tract ABDOMINAL PAIN -most common manifestation of the GI disease -Visceral -Somatic - referred VISCERAL - Stretching of peritoneum or organ capsules by distension or edema - diffuse - poorly localized -may be perceived at remote locations related to organ’s sensory innervations THE PAINFUL ABDOMEN Pain - subjective symptom Tenderness -objective sign Common Abdominal Conditions: – Ileus form narcotics – Constipation / Obstipation – Appendicitis – Cholecystitis/ biliary Colic – Small Bowel Obstruction – Perforatied Peptic Ulcer – distinction is critical to making the diagnosis Be precise! ○ ○ ○ • conceptually verbally with documentation

pain can occur without tenderness, tenderness always associated with pain

ACUTE ABDOMINAL PAIN Considerations – VS : stable/ unstable – PQRST ○ Precipitating or Alleviating Factors ○ Quality –bright, sharp, dull, achy ○ Radiation – scapula, inguinal, supraclavicular ○ Severity – 1 to 10 scale ○ Timing – sudden, insidious -crampy /continuous HISTORY OF PRESENT ILLNESS Past Surgical History – Previous Abdominal / Pelvic operation – prior work-up for abdominal pain Past Medical History – IDDM (Insulin-Dependent Diabetes Melllitus) – ASCVD (Atherosclerotic Cardiovascular Disease)

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PMH Medications: - Valproic acid Allergies Bugs Bites / Stings EXAMINATION OF THE ACUTE ABDOMINAL PAIN – – – – observe the patient reassure auscultate percuss and palpate ○ Begin in quadrant opposite the suspected pathology ○ Percussion is very sensitive peritoneal sign - description of abdominal habitus Scaphoid Flat Distended Scar, Wounds, Erythema Anatomic Confines

-Pathologic - obstructive -hollow - air fluid interface -like a pebble dropped into a partially filled barrel -“Tinkles and Rushes” PERCUSSION Abdomen -Tympanitic - Dull (ascites/blood)

Gas Fluid

Liver Span -midclavicular line by convention Bladder, Uterus -rising out of the pelvis *Percussion is also a very sensitive sign of peritonitis PALPATION – – – – Prepare the patient Warm them Make them comfortable Take tension off the abdominal wall Pillow / bend the knees Expose the entire abdomen (xiphoid to pubis) Note the patient’s attitude Physically and emotionally Watch their eyes as you touch them After percussion Softly at first Deeper LUQ – RUQ note the liver edge Then LLQ – RLQ

LOOK – – – – –

LISTEN – listen with stethoscope – not necessary in all quadrants – pulses: aorta, iliac artery, renal artery, femoral artery – – – – – – – – – – Quantitative Absent Decreased Hyperactive (in diarrhea and obstruction) Qualitative Normal Borborygmus Obstructive Bruits

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5 Kristel, Leiza

-Grading - voluntary - involuntary -Peritoneal Signs - rebound - percussion tenderness PAINFUL ABDOMEN Peritoneal tenderness associated finding -eyes dilate -exquisitely tender -“bright tenderness” -“electric shock-like” Advanced Palpation trick – sneak up on them – distract with conversation – watch their eyes – palpate with the stethoscope – bump the stretcher Advanced and Adjunct signs – Shifting dullness – CVA tenderness – Digital Rectal Exam – Bimanual Pelvic Exam – Listening to lower lung fields EXAM – – – – – FOR ASCITES fluid wave shifting dullness associated findings caput medusae Spider angioma


DIAGNOSTIC APPROACH – Essential Questions – Stable/ unstable? (check for vital signs) – Do I need the surgeon now? (If not sure, just refer your patient) – Is it obvious that they need an operation CLINICAL DIAGNOSIS Options: – upright CXray and Abdomen, KUB – CT –IV or PO contrast – Ultrasound – Nothing DIAGNOSTIC MODALITIES – CT: 15-20% false negative for acute perforation – CT-poor study for gallstones (compared to ultrasound – Contrast obscure kidney stones When to call a surgeon? – unstable VS – call immediately – work-up complete in stable, less obvious – CBC, coags – Blood gas – Lytes – to check for fluid imbalance – Amylase – to dx pancreatitis – Bilirubins – for biliary pathology – LFTs – Imaging Change in the Interim ABCs – does the patient need intubated o2 – IVs – large bore, 2 if unstable – Resuscitation – NS vs LR (normal saline vs.lactated ringers) – Bolus therapy – 20cc/kg repeat if necessary

6 DERMATOMAL PAIN SYNDROME - due to poorly localized visceral innervation disease can present in vague, confusing manner – – – – – – Pneumonia Acute MI GERD Biliary Colic PUD Pancreatits

6 Kristel, Leiza

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Foley catheter (for checking the hourly urine output of the pt.) Central line

Lateral Decubitus Film Ultrasound – rapid, safe, low cost – operator dependent – fluid, inflammation, air in walls, masses – Liver , GB, CBD, Spleen, Pancreas, appendix, kidney, ovaries, uterus CT Scans – better than plain films and ultrasound for evaluation of solid and hollow organs – IV contrast, oral, per rectal High use in appendicitis, diverticulitis, abscess, pancreatitis When to operate – peritonitis – abdominal pain/tenderness + sepsis – acute intestinal ischemia – pneumoperitoneum – make sure pancreatitis is excluded What if it’s not clear? -Challenging Patients neurologically compromised Intoxicated Steroids Immunosuppressed - if signs and symptoms are equivocal – serial exams (same person) – imaging – serial labs (check for WBC increase) – keep off antibiotics (initially as much as possible) – ‘Tincture of time’ When – – – – – – not to operate cholangitis appedicial abscess acute diverticulitis acute pancreatitis ruptured ovarian ? long-standing ovarian ulcers

Type and Gross Antibodies – Gram (-) and Anaerobe – Cipro / Flagyl – Pip-Tazo – Cefotetan – Pain Medication Common Pitfalls Acute Mesenteric Ischemia Intestinal Volvulus Gallstone “ileus” AAA and Back Pain ‘its just gastroenteritis’ – antacids (given by general practitioners) EVALUATION OF ABDOMINAL PAIN Summary: – patient’s condition guides the urgency – clinical diagnosis is the 1st step – imaging studies depend on clinical diagnosis – patient preparation is crucial to outcome Lab Tests: WBC and differential, basic chemistry panel (K, bicarbs), amylase, liver function tests, urinalysis) DIAGNOSTIC IMAGING - upright CXR -free air - KUB (Kidney/ Ureter / Bladder) - calcification - air/fluid - reactive bowel pattern - foreign bodies

7 Kristel, Leiza

– Non Surgical Causes – MI, acute pericarditis – PN, Pulmonary infection – GE reflux, hepatitis – DKA, Ac Adrenal insufficiency – Acute Porphyria – Rectus Muscle Hematoma – Pylonephritis, Acute salpingitis – Sickle cell crisis Check for underlying signs For example in cirrhosis – spider nevi – liver nevi In gynecomastia – testicular atrophy – flapping tremors – splenomegaly – finger clubbing – ascites – leg edema Investigate for Jaundice – check urinary bilirubin and urobilinogen – Liver function test – Ultrasound, CT, MRI, others – Liver biopsy – Laparoscopy MANIFESTATION Vomiting – viral infection – medications – sea sickness / motion sickness – chemotherapy in cancer patients – alcoholism – morning sickness in pregnancy – food poisoning – food allergy – migraine headache – brain tumors Constipation

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decrease in frequency of bowel movement compared to a child’s usual pattern ( more than 3 bowel movements per week) passage of hard, often has large caliber, dry bowel movement bowel movements that are difficult or painful to push out

Obstipation – more serious type of constipation Causes – diet – lack of exercise – busy children – emotional – physical problems that can cause constipation includes the ff: – endocrine problem (hypothyroidism) – problem of nervous system (cerebral palsy) – certain medication ( iron preparation and narcotics such as Codeine) – abnormalities of the intestinal tract, rectum or anus SIGNS AND SYMPTOMS – crampy abdominal pain that comes and goes (intermittent) – nausea – vomiting – inability to have a bowel movement or pass gas – swelling of abdomen (distention) – abdominal tenderness – abdominal distention Cause of Small intestinal Obstruction – intestinal adhesion – most common – hernias – tumors – telescoping of a portion of the intestine into a greater portion (intussusception) – twisting of the intestine (volvulus) – Narrowing of outlet (strictures)

8 Kristel, Leiza

Mechanical Obstruction of Colon – cancer – diverticulitis – twisting of colon (volvulus) – Less common causes – Intussuception (telescoping of a portion of the colon to another portion) – Impacted feces – Narrowing of colon (strictures) – Foreign bodies (swallowed objects that block the colon)

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