Professional Documents
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Abdomen NSC
Abdomen NSC
Acute Abdomen
Anatomy review
Non-hemorrhagic abdominal pain
Gastrointestinal hemorrhage
Assessment
Management
Abdominal Anatomy
Review
Abdominal Cavity
Esophagus
» Portion of digestive
tract between
pharynx and stomach
Stomach
» Hollow digestive
organ
» Receives food from
esophagus
Primary GI Structures
Small intestine
» Between stomach and cecum
» Composed of duodenum,
jejunum and ileum
» Site of nutrient absorption
into body
Large intestine
» From ileocecal valve to anus
» Composed of cecum, colon,
rectum
» Recovers water from GI tract
secretions
Accessory GI Structures
Salivary glands
» Produce, secrete saliva
» Connect to mouth by ducts
Accessory GI Structures
Liver
» Large solid organ in right upper quadrant
» Produces, secretes bile
» Produces essential proteins
» Produces clotting factors
» Detoxifies many substances
» Stores glycogen
Gallbladder
» Sac located beneath liver
» Stores and concentrates bile
Accessory GI Structures
Pancreas
» Endocrine pancreas secretes insulin into
bloodstream
» Exocrine pancreas secretes digestive
enzymes, bicarbonate into gut
Vermiform appendix
» Hollow appendage
» Attached to large intestine
» No physiologic function
Major Blood Vessels
Aorta
Inferior vena cava
Solid Organs
Liver
Spleen
Pancreas
Kidneys
Ovaries (female)
Hollow Organs
Stomach
Intestines
Gallbladder and bile ducts
Ureters
Urinary bladder
Uterus and Fallopian tubes (female)
Right Upper Quadrant
Liver
Gallbladder
Duodenum
Transversecolon (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 (female)
Fallopian tube (female)
Left Lower Quadrant
Descending colon
Sigmoid colon
Ovary (female)
Fallopian tube (female)
Acute Abdomen
Abdominal Pain
Visceral
Somatic
Referred
Abdominal Pain
Visceral pain
» Stretching of peritoneum or organ
capsules by distension or edema
» Diffuse
» Poorly localized
» May be perceived at remote locations
related to organ’s sensory innervation
Abdominal Pain
Somatic pain
» Inflammation of parietal peritoneum or
diaphragm
» Sharp
» Well-localized
Abdominal Pain
Referred pain
» Perceived at distance from diseased organ
» Pneumonia
» Acute MI
» Male GU problems
Non-hemorrhagic
Abdominal Pain
Esophagitis
Craters in mucosa of
stomach, duodenum
Males 4x > Females
Duodenal ulcers 2 to 3x
> Gastric ulcers
Causes:
» Infectious disease:
Helicobacter pylori (80%)
» NSAIDS
» Pancreatic duct blockage
» Zollinger-Ellison Syndrome
Peptic Ulcer Disease
Gall bladder
inflammation, usually
2o to gallstones (90% of
cases)
Risk factors
» Five Fs: Fat, Fertile,
Febrile, Fortyish,
Females
» Heredity, diet, BCP
use
Cholecystitis
Acalculus cholecystitis
» Burns
» Sepsis
» Diabetes
» Multiple organ systems failure
Chronic cholecystitis (bacterial
infection)
Cholecystitis
Signs and Symptoms
» Sudden pain, often severe, cramping
» RUQ, radiating to right shoulder
» Point tenderness under right costal
margin (Murphy’s sign)
» Nausea, vomiting
» Often associated with fatty food intake
» History of similar episodes in past
» May be relieved by nitroglycerin
Appendicitis
Inflammation of
vermiform appendix
Usually secondary to
obstruction by fecalith
May occur in older
persons secondary to
atherosclerosis of
appendiceal artery and
ischemic necrosis
Appendicitis
Signs and Symptoms
» Classic: Periumbilical pain RLQ pain/cramping
» Nausea, vomiting, anorexia
» Low-grade fever
» Pain intensifies, localizes resulting in guarding
» Patient on right side with right knee, hip flexed
Appendicitis
Signs and Symptoms
» McBurney’s Sign: Pain on palpation of RLQ
» Aaron’s Sign: Epigastric pain on palpation
of RLQ
» Rovsing’s Sign: Pain in LLQ on palpation of
RLQ
» Psoas Sign: Pain when patient:
– Extends right leg while lying on left side
– Flexes legs while supine
Appendicitis
Signs and Symptoms
» Unusual appendix position may lead to atypical
presentations
– Back pain
– LLQ pain
– “Cystitis”
» Rupture: Temporary pain relief followed by
peritonitis
Bowel Obstruction
Blockage of intestine
Common Causes
» Adhesions (usually 2o to surgery)
» Hernias
» Neoplasms
» Volvulus
» Intussuception
» Impaction
Bowel Obstruction
Pathophysiology
» Fluid, gas, air collect near obstruction site
» Bowel distends, impeding blood flow/ halting
absorption
» Water, electrolytes collect in bowel lumen
leading to hypovolemia
» Bacteria form gas above obstruction further
worsening distension
» Distension extends proximally
» Necrosis, perforation may occur
Bowel Obstruction
Signs and Symptoms
» Severe, intermittent, “crampy” pain
» High-pitched, “tinkling” bowel sounds
» Abdominal distension
» History of decreased frequency of bowel
movements, semi-liquid stool, pencil-thin
stools
» Nausea, vomiting
» ? Feces in vomitus
Hernia
Pathophysiology
» Mucosa of GI tract becomes inflamed
» Granulomas form, invade submucosa
» Muscular layer of bowel become fibrotic,
hypertrophied
» Increased risk develops for
– Obstruction
– Perforation
– Hemorrhage
Ulcerative Colitis
Diverticula
» Pouches in colon
wall
» Typically in older
persons
» Usually
asymptomatic
» Related to diets with
inadequate fiber
Diverticulitis
Diverticula trap feces, become inflamed
Occasionally result in bright red rectal
bleeding
Rupture may cause peritonitis, sepsis
Diverticulitis
Signs and Symptoms
» Usually left-sided pain
» May localize to LLQ (“left-sided
appendicitis”)
» Alternating constipation, diarrhea
» Bright red blood in stool
Hemorrhoids
Dilated veins in
esophageal wall
Occur 2o to hepatic
cirrhosis, common
in EtOH abusers
Obstruction of
hepatic portal blood
flow results in
dilation, thinning of
esophageal veins
Esophageal Varices
Portal hypertension
» Hepatic scarring
slows blood flow
» Blood backs up in
portal circulation
» Pressure rises
» Vessels in portal
circulation become
distended
Esophageal Varices
Longitudinal tears at
gastroesophageal
junction
Occur as result of
prolonged, forceful
vomiting, retching
Common in alcoholics
May be complicated by
presence of esophageal
varices
Peptic Ulcer Disease
» Trauma
» Marfan’s syndrome
Aortic Aneurysm
Usually just
above aortic
bifurcation
May extend to
one or both iliac
arteries
Aortic Aneurysm
Signs and Symptoms
» Unilateral lower quadrant pain; low back
or leg pain
» May be described as tearing or ripping
» Pulsatile palpable mass usually above
umbilicus
» Diminished pulses in lower extremities
» Unexplained syncope, often after BM
» Evidence of hypovolemic shock
Ectopic Pregnancy
Urine
» Change in urinary habits?
– Frequency
– Urgency
» Color?
» Odor?
History
Bowel movements
» Change in bowel habits? Color? Odor?
– Bright red blood
– Melena = black, tarry, foul-smelling stool
– Dark stool
Suspect bleeding
Other causes possible (iron or bismuth
containing materials)
History
Bowel sounds
» Auscultate BEFORE palpating
» One minute in each abdominal quadrant
» Absent sounds = possible peritonitis,
shock
» High-pitched, tinkling sounds = possible
bowel obstruction
Physical Exam
Palpation
» Palpate each quadrant
» Palpate area of pain LAST
» Do NOT check rebound tenderness in
prehospital setting
» ALL abdominal tenderness significant until
proven otherwise
Management