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The Gastrointestinal and Renal Systems

Anatomy

Abdomen: is large oval cavity extended from
the diaphragm down to the brim of the pelvis.
From back it is protected by the vertebral
column and paravertebral muscles, from sides
by the lower rib cage and abdominal muscles,
and from the front by abdominal muscles.

Brim of the pelvis

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Viscera: internal organs in the abdominal cavity. spleen. ovaries…). small intestine. Can be divided into: Solid viscera: is the viscera that maintain a characteristic shape (ex. Liver. colon. kidneys. bladder). Stomach. . gallbladder. Hollow viscera: its shape depends on the contents (ex.

area around umbilicus *Suprapubic.area above the pubic bone . and left lower quadrant (LLQ). *Umbilical.For descriptive purposes. the abdomen is often divided by imaginary lines crossing at the umbilicus. right lower quadrant (RLQ). left upper quadrant (LUQ). Terms to know: *Epigastric-area between the costal margins. forming the right upper quadrant (RUQ).

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 body and tail of pancreas. rt uretra LUQ:  descending colon. cecum. uterus.  lt kidney.  descending colon.  bladder.  lt ureter.  lt ureter .  sigmoid colon.  ascending colon. rt uretra LLQ:  bladder.  duodenum. and fallopian tube” or “prostate and spermic cord”. and fallopian tube” or “prostate and spermic cord”.  transverse colon.  stomach.  overy.  small intestin.  rt kidney. „overy. RLQ:  appendix.  gallbladder.  liver. uterus.  head of the pancreas  transverse colon.  spleen. rectum.RUQ:  ascending colon.

 Gallbladder is located under the posterior surface of the liver. Note that the liver fills most of the RUQ and extend over the midclavicular line. .  Small intestine is located in all four quadrants.

Not palpable normally. .  It lies obliquely & its width extends from the 9th – 11th rib about 7cm. Spleen is located on the posterolateral wall of the abdominal cavity “under the diaphragm”.

.  Pancreas. lobulated gland located behind the stomach.soft. stretches obliquely across the LUQ. bifurcates into the Rt & Lt renal arteries then common iliac arteries opposite 4th lumbar vertebra. Aortic pulsations easily palpable in the upper anterior wall.  Rt & Lt iliac arteries become the femoral arteries in the groin area. Their pulsations are palpable as well. Aorta is located at left of midline in the upper part of abdomen.

 Kidneys are bean shaped & located posterior to the abdominal contents.  Lt kidney lies at the 11th & 12th rib. .  Rt kidney is 1-2 cm lower than the Lt kidney & may be sometimes palpable.

. *Bladder may be palpated in the lower midline (above the symphysis pubis) when it is distended.The costovertebral angle: the angle formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae (for kidney tenderness).

nausea. . vomiting  Loss of appetite. constipation  Jaundice *Gastrointestinal disorders may be divided into lower and upper problems. early satiety  Dysphagia.Subjective Data Concerning symptoms of the abdomen are:  Abdominal pain  Indigestion. odynophagia (pain with swallowing)  Change in bowel function  Diarrhea.

Categories of abdominal pain: Visceral pain:  Occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. .  Solid organs such as the liver can also become painful when their capsules are stretched. It is typically palpable near the midline at levels that vary according to the structure involved.  Visceral pain may be difficult to localize.

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 When it becomes severe. nausea. it may be associated with sweating. and restlessness. .  Visceral periumbilical pain may signify early acute appendicitis from distention of an inflamed appendix. vomiting. It gradually changes to parietal pain in the right lower quadrant from inflammation of the adjacent parietal peritoneum. pallor. Visceral pain varies in quality and may be gnawing. or aching. cramping. burning.

Parietal pain:  originates from inflammation in the parietal peritoneum. which are innervated at approximately the same spinal levels as the disordered structures. Referred pain:  Is felt in more distant sites.  May be felt superficially or deeply and is usually well localized.  It is a usually more severe than visceral pain and more precisely localized.  Develops as the initial pain becomes more intense.  Patients with this type of pain usually prefer to lie still.  It is increased by movement or coughing. .

Heartburn: is a rising retrosternal burning pain or discomfort.Dyspepsia: is defined as chronic or recurrent discomfort or pain centered in the upper abdomen. It is typically aggravated by food. Dysphagia: difficulty swallowing. upper abdominal fullness. nausea. It can include various symptoms such as bloating. Discomfort: is defined as a subjective negative feeling that is nonpainful. Odynophagia: pain with swallowing. GERD: Gastroesophageal reflux disease. . and heartburn.

What is constipation? . What are normal characteristics of the vomit? Give example of abnormal characteristics of the stool. Melena: black terry stool. Regurgitation: raising gastric content. because of the problems with sphincter (without vomiting). Steatorrhea: presence of excessive fat in the stool.Hematemesis: blood with vomit. Hemtochezia: stool that is red.

nocturia  Urinary incontinence  Hematouria  Kidney or flank pain  Ureteral colic .Concerning symptoms of the abdomen are:  Suprapubic pain  Dysuria. or frequency  Polyuria. urgency.

. may be gross or microscopic.  Polyuria: increase in urine volume (more than 3 liters pay day).  Frequency: frequent going to the bathroom.  Dysuria: pain with urination.  Hematuria: blood in urine. Suprapubic pain may be related to bladder dysfunctions such as bladder infection it is dull and pressure like. the volume of the urine may be large or small. or difficult urination  Urgency: immediate desire to urinate.  Urinary incontinence: involuntary loss of urine.

steady.  Visceral.  May radiate toward umbilicus. .Kidney pain versus ureteral colic: kidney pain:  On the side of the body between upper abdomen and the back.  Is severe and colicky. Ureteral colic  Originate at the costovertebral angle  Radiate around the trunk into the lower quadrant of abdomen or to the thigh. dull.

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ask the patient to point to any areas of pain so you can examine these areas last. Begin with inspection. unexpected movements. . then auscultation. percussion. Ask the patient to keep the arms at the sides or folded across the chest. Make the patient comfortable in the supine position. Approach the patient calmly and avoid quick. and palpation. With palpation. Warm your hands and stethoscope. check that he is relaxed.Objective Data Tips for Enhance Examination of the Abdomen        Check that the patient has an empty bladder.

Inspection Contour: shape of the abdomen. .

bulging. •A hernia occurs when an organ pushes through an opening in the muscle or tissue that holds it in place.Symmetry: any visible masses. . Describe the location and size.

The masses may be related to tumors or enlargements. Above: enlarged spleen .

small incision. Kocher: open cholecystectomy. .Scars:  describe scares if any. mcBurneys: appendectomy. laparoscopy. size. Pfannenstiel: for gynecological procedures. location. symmetry (traumatic or from surgery).

Most common in pregnant women and obese. . pink-purple: new.Striae: stretch marks. Silver striae: old.

inverted. pulsation of the aorta (epigastric area). Skin: smooth. Are more visible in thin people.The umbilicus: midline. no signs of inflammation or hernia. . respiration. even no scar or lesion (redness.striae . scars) Dilated veins: a few veins may be visible normally. Pulsation or movements: peristalsis (slow and oblique across abdomen). moles. jaundice .

irregular 5-30 time /min.  The auscultation is performed before percussion and palpation because they can altered the frequency of the bowel sounds.Auscultation  Describe bowel motility.  Normal: high pitch sound. gurgling.  Check over the aorta. .  Normal: No Bruit  Listen over liver and spleen for friction rub. and iliac arteries. renal arteries.  Must listen 5 minutes to say absent.

A peritoneal friction rub  produced by friction between roughened peritoneal surfaces.  heard as a creaking or grating noise during respiration. . for example from inflammation or tumor.

 General Tympany. to identify solid or fluid-filled masses.Percussion  To assess the amount of gas in the abdomen. to estimate the size of liver or spleen.  Percuss the abdomen in 4 quadrants to assess distribution of tympany and dullness. .

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MCL.to determine the Liver span: 6-12 cm in tall male.Percuss the liver .5 cm in men and 7 cm in women.  Percuss from up to down until note changes from resonance to dullness. .  Mark the spot. mean 10.  Measure the height of the liver in the Rt.

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 Normal : at the right costal margin.  Mark the spot. . Find abdominal tympany and percuss up until note changes to dullness.

 Move up toward the liver.Scratch Test:  Define the liver border in distended abdominal or muscles tense.  Place stethoscope over the liver.  Scratch with one fingernail over the abdomen starting in the RLQ.  Normal: sound becomes magnified in the border of the liver. .

. Percuss the spleen: Percuss from 9th. To 11th. ICS behind the Midaxillary Line.  Normal: dullness not wider than 7cm.  Techniques to detect splenomegally: 1) Percuss the left lower anterior chest wall.

.  Normal: tympany remains through full inspiration.2) Check for a splenic percussion sign.  Ask the pt to breath deeply.  Percuss the lowest ICS in the Lt anterior Axillary Line.

. Percuss the kidney:  Place one of your hands in the costovertebral angle and strike it with the ulnar surface of your fist. Look of tenderness.

 Perform deep palpation (5-8 cm). location & consistency of organs. check in all abdomen. for abdominal masses. abdominal tenderness.  Begin with light palpation (1 cm depth) in rotatery motion.  To identify masses.Palpation  To detect the size. and muscular resistance. .

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firm. Mobility ( movement during respiration). Pulsatility Tenderness . nodular). hard) Surface (smooth.If you identify a mass note the following: Location size Shape Consistency (soft .

 Assess for peritoneal inflammation:  Especially when there is muscular spasm. .  Palpate gently the tender area.  Ask patient to cough and ask if there was a pain and where.

Ribs Left up to support the abdomen Place Rt. The normal liver may be slightly tender. (firm: Jarvis)  If cannot fill it try hooking technique.-12th. soft. hand under the pt‟s back parallel 11th. Hand on the RUQ. Push deep down and under the edge of the right costal margin in the midclavicular line  Ask pt to take deep breath  Normal: if palpable at all. sharp. & regular liver edge with a smooth surface.Palpate the liver:     Lt. .

•Hooking technique:
Stand at the pt‟s shoulders
•Swivel your body to the Rt.
•Hook your fingers over the costal margin from
above

Palpate the spleen:
 Reach your lt. hand over the abdomen and behind
the lt. 11th.-12th.ribs
 Left for support
 Place Rt. Hand obliquely on the LUQ with fingers
pointing toward lt axilla. To the rib margin.
 Push deep down under the costal margin
 Ask the pt to breath deeply
 Normal: not palpable

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Palpate the Rt kidney:  Place the 2 hands together in a duck-bill position at the pt‟s Rt. Flank  Press firmly while asking pt to breath deeply  Normal: not palpable or feeing of the lower pole of the Rt kidney as:  Round smooth mass .

flank  Push your Rt. hand deep while asking pt to breath deeply  Normal: not palpable. hand across the abdomen and behind the lt. .Palpate the Lt kidney:  Reach your lt.

Palpate the aorta:  Palpate the aortic pulsation slightly left to midline in the upper abdomen using your thumb and fingers. .  Normal: 1-4 cm wide and pulsates in an anterior direction  Differ by the thickness of abdominal wall and anteroposterior diameter of the abdomen.

 Use percussion to check the dullness and determine how high it rises.  The dome of it feels smooth and round.Palpate the bladder:  When palpating the bladder it should be distended.  Located above symphysis pubis. .

• With your right hand give the left flank firm strike if ascites is present the blow will generate a fluid wave through the abdomen and you will feel a distinct tap on your left hand. .Special procedures: 1) ascites: fluid wave  For differentiate ascites from gaseous. • Place the person's hand on his abdomen in the midline (to stop transition of wave through fat). • Place your left hand on the person's right flank. • Standing on right side .

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ascitic fluid setting by gravity into the flank displacing the air – filled bowel upward.Shifting Dullness/ ascites. .  In supine person .

B) Rovsing sign: an indication of acute appendicitis in which pressure on the LLQ of the abdomen causes pain in the RLQ. • The pain is caused by rapid movement of inflamed peritoneum.2) Appendicitis: A)Rebound tenderness: press down your fingers firmly and slowly and then withdraw them quickly. . (in the RLQ) • Positive test if there is pain with finger withdraw.

C) Psoas sign (Iliopsoas muscle pain): put your hand above the patient‟s Rt knee and ask the pt to raise that thigh against your hand. Or . . passively extending the thigh of a patient lying on his side with knees extended.

and rotate the leg internally at the hip. . with the knee bent.D) Obturator test: Flex the patient‟s right thigh at the hip. This maneuver stretches the internal obturator muscle.

Note that a positive Murphy sign may also indicate the inflammation in liver. Deep inspiration can be very much limited.  The inspiration causes the gallbladder to descend onto the fingers. .3) Acute cholecystitis:  check for Murphy sign: a test for gallbladder disease in which the patient is asked to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage. producing pain if the gallbladder is inflamed.