Abdomen

CHAPTER 21

Structure and Function

Subjective Data—Health History Questions
Objective Data—The Physical Exam
Abnormal Findings
 Chapter 21

Structure and Function of ABDOMINAL CAVITY p 527 ff

 Surface landmarks
 Borders of abdominal cavity:
diaphragm to pelvic brim in
front; vertebral column and rib
cage in back
 4 Layers form anterior wall;
joined at midline by a
tendinous seam, “linea alba”
 Abdominal muscles: external
obliques, internal obliques,
transversus, and rectus
abdominus
 Inside abdominal cavity are all
the internal organs (viscera):
solid and hollow
Slide 21-2
VISCERA: Internal
organs in abdominal
cavity
SOLID viscera …
maintain a
characteristic shape;
many are palpable :
Liver, Pancreas,
Spleen, Kidneys,
Adrenal glands,
Ovaries, Uterus
HOLLOW viscera …
shape depends on
contents; usually are
not palpable: Stomach,
Gallbladder, Small
intestine, Colon,
Bladder
More internal anatomy
Spleen
 Soft mass of lymph tissue; not normally palpable
 Lies on posterolateral wall of abdominal cavity, right under the
diaphragm
Aorta
 Just left of midline in upper abdominal cavity; can palpate pulsations
in upper anterior abdominal wall
 Bifurcates into R & L iliacs at L4; R&L Iliacs become R&L Femoral in
groin
Pancreas
 Soft, lobulated gland, lies behind the stomach in LUQ

Kidneys
 Bean-shaped; lie posterior to abdominal contents
 R kidney lower than L because of liver placement
Abdominal Wall divided into 4 abdominal quadrants

Right upper quadrant (RUQ)

Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
Anatomic Location of Organs by Quadrant;
What is in each quadrant?

RUQ LUQ

RLQ LLQ
RUQ
 Liver
LUQ
• Stomach
 Gall bladder
• Spleen
 Duodenum
• L lobe of liver
 Head of Pancreas
• Body of pancreas
 R Kidney & adrenal
• L kidney & adrenal Midline
 Hepatic flexure of colon
• Splenic flexure of colon • Aorta
 Part of ascending & • Part of transverse & • Uterus
descending colon (if
transverse colon enlarged)
• Bladder
RLQ LLQ (if
• Part of descending distended)
 Cecum
 Appendix
colon
• Sigmoid colon
 R ovary & tube
• L ovary & tube
 R ureter
• L ureter
 R spermatic cord
• L spermatic cord
The AGING ADULT
 Altered appearance of abdominal wall
during/after middle age; more pronounced related
to more sedentary lifestyle
Female…fat accumulation on suprapubic area from decrease
estrogen production
Male…fat deposits is in abdominal area resulting in “spare tire”

 Changes in gastrointestinal tract; (but do not

affect function unless disease is present)
1) salivation;  sense of taste; dry mouth
2)  esophageal emptying (risk aspiration in supine);
More GI tract CHANGES in AGING ADULT
4) gastric acid secretion (causes pernicious anemia

from decreased Vit B12 absorption; iron deficiency

anemia; calcium mal- absorption)
5) Liver size (so, drug metabolism from  blood
flow..so  side effects from meds)
6) incidence of gallstones, esp females
7)  Constipation ( from  activity,  intake of water,
 fiber diet, side effects of meds, IBS (irritable
bowel syndrome), bowel obstruction,
hypothyroidism, difficulty ambulating to toilet)
A TRANSCULTURAL ISSUE:
Lactose Deficiency or Intolerance

Lactase , enzyme necessary for absorption of the

carbohydrate “lactose” (milk sugar)
Lactose Intolerant S/S: Abdominal pain, bloating,
flatulence
Incidence: 70-90% in Blacks, Native Americans,
Asians, and Mediterraneans
15% in northern and western Europeans
and Americans of those heritages
Chapter 21

Subjective Data— Health History Questions pp 532 ff

1. APPETITE -changes
Anorexia: loss of appetite for food
..?disease ?meds ?pregnancy ? Psych disorders

2. ABILITY to chew / swallow foods

Dysphagia- difficulty swallowing

3.FOOD INTOLERANCE
Lactose deficiency –bloating/excess gas after milk products
Pyrosis- burning sensation in esophagus from gastric acid reflux

Eructation- belching

Slide 21-4
Health History Questions, continued

4. ABDOMINAL PAIN
Visceral from internal organ (dull, general, poorly
localized)
Parietal from inflammation of overlying peritoneum
(sharp, precisely localized, aggravated by movement)
Referred from a disorder at another site
Pain is referred to a site where the organ was located
in fetal development ... and the nerves persist in referring
sensations from the former locations

See common sites of referred pain p 559 

5. NAUSEA/VOMITING
Hematemesis- blood in emesis from esophageal varices or
stomach/duodenum ulcers
6. BOWEL HABITS
Melena- black tarry stools from occult blood; Red
blood in stools from GI bleeding; Gray stools occur
with hepatitis
7. PAST ABDOMINAL HISTORY Past Hx of ulcer,
GB, hepatitis/jaundice, appendicitis, colitis, hernia or other
gastrointestinal problems. Abdominal surgery.
8. MEDICATIONS Peptic Ulcer disease occurs
with frequent use of nonsteroidial antiinflamatiory drugs
(NSAIDs), alcohol, smoking, H.Pylori infection
9. NUTRITIONAL ASSESSMENT
Obtain past 24 hrs intake starting with breakfast
More Terms to Know:
borborygmi audible hyperactive intestinal peristalsis

epistaxis bleeding from nose

evisceration protrusion of internal organs from incision

gastroenteritis inflammation of stomach and intestines

hemoptysis coughing up blood-tinged sputum

hematachezia visible blood/bleeding in bowel movement

hepatomegaly enlarged liver

icteric jaundiced

melena black, tarry feces from occult blood

peritonitis inflammation of the peritoneum

pruritis the symptom of itching

purulent containing pus

Chapter 21

The Physical Exam

Preparation
Lighting and draping
Measures to enhance abdominal wall relaxation:
empty bladder, warm room,
supine w/ arms at side,
warm stethoscope, short nails,
distraction through breathing
exercises and low soothing voice
Equipment needed
Stethoscope, Small centimeter ruler, Skin-
marking pen, Alcohol swab

Slide 21-5
Chapter 21

Start the Physical Exam with INSPECTION (p536)

INSPECT the Abdomen: stand at person’s

RIGHT side and look down at abdomen; then stoop down to
gaze across abdomen

1. CONTOUR: flat; rounded; scaphoid; protuberant

2. SYMMETRY: Hernia=
protrusion of abdominal viscera through
abdominal opening in muscle wall
3. UMBILICUS: normal is midline, inverted, no
discoloration
4. SKIN: Normal is smooth, even, homogenous color

Slide 21-6
 Generalized abdominal distention: gas retention or obesity
 Lower abdominal distention: baldder distention, pregnancy,
ovarian mass
 General distention and an everted umbilicus: ascites and
tumors
 A scaphoid (sunken) abdomen: malnutrition or muscle
replaces fat
 Striae(whitish-silver stretch marks): obesity, pregnancy
 Spider angiomas: liver disease
 Dilated veins: cirrhosis of liver, ascites, portal hypertension,
venocaval obstruction
 Pulsation: increased with aortic aneurysm
 Well-healed surgical scars: clue to underlying adhesions or
excess fibrous tissues
Chapter 21

Physical Exam : Step Two

# 2. AUSCULTATE p 539
This is done out of usual sequence because percussion and
palpation can increase peristalsis and might give a false
interpretation of bowel sounds.
BOWEL sounds: Do no count. Judge if normal, hyperactive or
hypo active
NORMAL: gurgling or
clicking sounds occur every 5-15 second
HYPERACTIVE: loud, high
pitched, rushing, tinkling sounds that signal increased
motility);
Borborgymus: hyper peristalsis (“stomach growling”)
HYPOACTIVE absence of sound; (after abdominal surgery or
with inflammation of peritoneum)
Slide 21-7
Order of Ausculation, Palpation, Percussion

1.RLQ ->
2.RUQ ->
3.LUQ ->
4.LLQ

Listen for 1 minutes and if no bowel sounds are heard,

listen for up to 5 minutes (per quadrant)
HYPOACTIVE HYPERACTIVE
 AUSCULTATE for vascular sounds
Check over:
AORTA (above umbilicus,
slightly left of center) “Bruit” =
pulsatile
RENAL ARTERIES blowing
(below aorta and sound;
R & L of & above umbilicus) (stenosis
or artery
ILIAC ARTERIES occlusion)
(below umbilicus
and R & L of umbilicus)

Remember: Diaphragm for normal (high pitched)

sounds and Bell for abnormal (low pitched)
STEP THREE: PERCUSS the 4 Quadrants
WHY? How? …
To assess relative Percuss
density of lightly in all 4
abd contents; quadrants:
to locate organs;
RLQ >
RUQ >
to screen LUQ >
for abnormal fluid LLQ
or masses
TYMPANY is heard over stomach and gas-filled bowels

DULLNESS is heard over fluid, tumors, fecal mass;

Also dull over liver, spleen, enlarged kidney, full stomach
 Abdominal distention:
Feces

Abdominal
distention: Abdominal
Air or Gas distention:
Ascites
Chapter 21

STEP 4: PALPATE the 4 Quadrants

WHY? to judge size, location & consistency
to screen for abnormal masses or tenderness
BEFORE PALPATING Most people are
naturally inclined to protect the abdomen… …. so use
measures to enhance muscle relaxation (p. 545 )
 Bend the person’s knees to relax the abdomen
 Keep your palpating hands low and parallel to abdomen
 Teach person to breath (in through nose and out through mouth)
 Keep you voice low, soothing. Conversation may relax the person
 For a very ticklish person:
1. place your hand over person’s and curl your fingers over person’s
2. perform palpation right after auscultation. Keep stethoscope in
place and curl your fingers around it, palpating as you pretend to
auscultate Slide 21-8
LIGHT PALPATION: use four
fingers, depress 1/2 inch; move
clockwise to form an overall DEEP PALPATION: use four fingers,
impression Abnormal= muscle depress 2-3 inches; move clockwise
guarding; rigidity; tenderness Normal: mild tenderness over sigmoid
colon but no other areas tender
Voluntary
guarding
if cold,
tense,
ticklish

BIMANUAL PALPATION: use two hand with obese/large abdomen

 NORMALLY PALPABLE STRUCTURES: P 577

1) Xiphoid process
2) normal liver edge
3) R-kidney lower pole
4) pulsatile aorta
5) rectus muscles,
lateral borders
6) sacral promontory
7) cecum
8) ascending colon
9) sigmoid colon
10) uterus
11) full bladder
 PALPATE for specific organs: LIVER
Normal to
feel liver
bump your
fingertips as
diaphragm
pushes down
during
inspiration
Place Right hand in RUQ , fingers parallel to midline. Push down
and under right costal margin.
Place Right hand to
Ask patient intake
RUQ , fingers
deep breath parallel to midline.
Push down and under right costal margin.
Ask patient to take
deep breath
PALPATE for specific organs: SPLEEN
Normally, the spleen is not palpable and must be enlarged
3 times its normal size to be felt

Reach left hand over the abdomen and behind the left side at the 11th th

and 12thth ribs. Lift up for support. Place right hand obliquely on the LUQ

with fingers pointing toward the left axilla and just inferior to the rib
margin. Push your hand deeply down and under the costal margin and
ask the person to take a deep breath. You should feel nothing firm.
FYI: PALPATE for specific organs: KIDNEYS

Palpate by
placing hands
in duck-bill
position at
person’s
RIGHT flank
Press hands
together and
have person
take deep Normal : occasionally feel lower pole of
breath RIGHT kidney; LEFT KIDNEY is higher
than RIGHT so not palpable
 FYI: PALPATE for specific organs:
PULSATILE AORTA
HOW?
WHY?
To detect if lateral Use thumb
pulsation and pointer
and therefore finger
a possible (pincer-type)
Abdominal aortic to palpate
Aneurysm (AAA) aortic
pulsation

Normal: Aorta is 2.5 -4 cm wide and

pulsates in an anterior direction
FYI: Special Procedures for advance practice p 581
Abnormal finding
Test for when fingers are
lifted/withdrawn:
Rebound Tenderness If Peritoneal
inflammation :
pain, generalized
HOW? If Acute
Hold hand cholecystitis:
RUQ Pain
perpendicular to
If Acute
abdomen pancreatitis:
Upper Middle
Push down slowly and Quadrant pain
deeply; If Acute
then lift up quickly appendicitis:
RLQ pain
Normal: no pain on release of pressure If Acute
diverticulitis:
LLQ pain
The correct sequence of
examining the ABDOMEN

1. INSPECTION,
2. AUSCULTATION,
3. PERCUSSION,
4. PALPATION.
 This is done because percussion and palpation
can increase peristalsis and might give a false
interpretation of bowel sounds.