Download Chapter 7 Body Systems

Abdomen
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Abdominal examination is performed:
◦ As part of the comprehensive physical examination
◦ When patient has signs or symptoms of an
abdominal disease process
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It involves the core examination skills in a
particular sequence:
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Inspection
Auscultation
Percussion
Palpation
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Inspect the abdomen for the following:
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Skin characteristics
Venous return patterns
Symmetry
Surface motion
Inspect abdominal muscles as patient raises
head to detect presence of the following:
◦ Masses
◦ Hernia
◦ Separation of muscles
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Auscultate with stethoscope diaphragm for
the following:
◦ Bowel sounds
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Auscultate with bell of stethoscope for the
following:
◦ Bruits over aorta and renal and femoral arteries
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Percuss the abdomen for the following:
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Tone in all four quadrants (or nine regions)
Liver borders to estimate span
Splenic dullness in left midaxillary line
Gastric air bubble
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Lightly palpate in all quadrants or regions for
the following:
◦ Muscular resistance
◦ Tenderness
◦ Masses
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Deeply palpate for the following:
◦ Bulges and masses around the umbilicus and
umbilical ring
◦ Liver border in right costal margin
◦ Gallbladder below liver margin at lateral border of
the rectus muscle
◦ Spleen in left costal margin
◦ Right and left kidneys
◦ Aortic pulsation in midline
◦ Other masses
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With patient sitting, percuss the left and right
costovertebral angles for kidney tenderness.
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The peritoneum, a serous membrane, lines
the cavity and forms a protective cover for
many of the abdominal structures.
◦ Double folds of the peritoneum around the stomach
constitute the greater and lesser omentum

The mesentery, a fan-shaped fold of the
peritoneum, covers most of the small
intestine and anchors it to the posterior
abdominal wall.
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A 27-foot tube from mouth to anus
Parts
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Esophagus: 10 inches long
Stomach
Small intestine: 21 feet long
Large intestine (colon): 4.5 to 5 feet long
Functions
◦ Ingest and digest food
◦ Absorb nutrients, electrolytes, and water
◦ Excrete wastes
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Peristalsis moves food along tract under
autonomic nervous system control
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A 10-inch collapsible tube
Connects pharynx to stomach
Posterior to the trachea
Descends
◦ Through the mediastinal cavity
◦ Travels through the diaphragm
◦ Enters the stomach at the cardiac orifice
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Flask-shaped, lies transversely
In upper abdomen below diaphragm
Three sections
◦ Fundus
◦ Body
◦ Pylorus
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Secretes HCl and enzymes to break down fats
and proteins
Little absorption takes place in the stomach
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Connects stomach to large intestine
Three sections coiled in abdominal cavity
◦ Duodenum: 12 inches
 Openings for bile and pancreatic ducts
◦ Jejunum: 8 feet
◦ Ileum: 12 feet
 Ileocecal valve between the ileum and large intestine
prevents backflow
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Completes digestion through action of pancreatic
enzymes, bile, and other enzymes
Nutrients absorbed through the mucosa
◦ Surface area enormously increased by circular folds and
villi
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Connects small intestine to anus
Four sections
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Cecum: vermiform appendix extends from base
Ascending colon
Transverse colon
Descending colon
 Sigmoid colon
 Rectum and anal canal
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Functions
◦ Water absorption
◦ Lubrication of contents from large quantities of
alkaline mucus that neutralize acids formed by
intestinal bacteria
◦ Putrefaction: live bacteria decompose undigested
food, unabsorbed amino acids, cell debris, and
dead bacteria
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Four lobes in right upper quadrant
Major functions
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Metabolize fats and carbohydrates
Convert amino acids to glucose
Synthesize fats from carbohydrates and proteins
Store vitamins and iron
Detoxify harmful substances
Produce antibodies and blood coagulants
Synthesize bile
Convert waste from fat to water-soluble
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Pear-shaped, saclike organ about 4 inches
long recessed in liver
Function
◦ Gallbladder concentrates and stores bile
(made up of cholesterol, bile salts, and pigments).
◦ Bile is released into cystic duct (and common bile
duct) and maintains alkaline pH of small intestine to
permit emulsification of fats for absorption.
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Located behind and beneath stomach
Functions
◦ Produces digestive juices
◦ Endocrine function produces hormones to regulate
body’s level of glucose
 Insulin (the major anabolic hormone of body)
 Glucagon
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Located in left upper quadrant below kidney
Function
◦ White pulp (lymphoid tissue)
 Filters blood
 Produces lymphocytes and monocytes
◦ Red pulp
 Allows for storage and release of blood
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Kidneys, ureters, and bladder
◦ Kidneys located bilaterally in retroperitoneum and
connected to bladder via ureters
◦ Functions
 Rid body of water-soluble waste
 Produces (endocrine) renin, erythropoietin,
and biologically active vitamin D
 Synthesizes prostaglandins
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Form and protect the abdominal cavity
◦ Rectus abdominis
◦ Internal and external obliques
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Linea alba (contains umbilicus)
Inguinal ligament (Poupart ligament)
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Descending aorta
◦ Branches
 Iliac arteries (2), formed from division at about the
umbilicus
 Splenic artery
 Renal arteries
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By 36 to 38 weeks of gestation, the
gastrointestinal tract is capable of adapting
to extrauterine life.
Elasticity, musculature, and control
mechanisms continue to develop, reaching
adult levels of function at 2 to 3 years of age.
Liver is very large at birth.
◦ Metabolic and glycogen storage organ
◦ Remains the heaviest organ in the body
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Spleen is active in blood formation during
fetal development and the first year of life.
◦ Afterward, the spleen aids in the destruction of
blood cells and functions as a lymphatic organ for
immunologic response.
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Nephrogenesis begins during the second
embryologic month.
◦ By 12 weeks, the kidney is able to produce urine.
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Abdominal wall muscles stretch and lose tone.
Linea nigra in the third trimester of pregnancy
Organs are displaced and affect functions:
◦ Heartburn results from alkaline reflux from duodenal
contents into stomach.
◦ Gallstones may result from gallbladder changes that
produce cholesterol crystals.
◦ Urinary stasis and urgency may occur.
◦ Constipation or flatus is more common.
◦ Hemorrhoids may result from increased venous
pressure.
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Functional abilities of GI tract are affected.
◦ Motility slows.
◦ Secretion and absorption may slow.
◦ Changes may impair digestive ability and may result
in food intolerances in the older adult.
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The liver loses some ability to metabolize
certain drugs.
There may be an increase of biliary lipids
resulting in the formation of gallstones.
The pancreas has no significant physiologic
changes.
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Abdominal pain
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Onset and duration
Character
Associated symptoms
Relationship factors
Stool characteristics
Urine characteristics
Medications: high doses of aspirin, steroids, NSAIDs
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Indigestion
◦ Character
◦ Location
◦ Relationship to: amount, type, and timing of food
intake
◦ Onset of symptoms
◦ Symptom relieved by antacids, rest, activity
◦ Medications: antacids
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Nausea
◦ Associated with vomiting
◦ Particular stimuli (odors, activities, time of day,
food intake)
◦ Date of last menstrual period
◦ Medications: antiemetics
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Vomiting
◦ Character: nature, color, quantity, duration,
frequency
◦ Relationship to: meals, appetite, diarrhea or
constipation
◦ Medications: antiemetics
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Diarrhea
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Character
Associated symptoms
Relationship to: food intake, stressors
Travel history
Medications: laxatives, stool softeners, antidiarrheals
Constipation
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Character
Pattern
Diet
Medications: laxatives, stool softeners, iron, diuretics
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Fecal incontinence
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Character
Associated symptoms
Related factors
Medications: laxatives, stool softeners, iron,
diuretics
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Jaundice
Onset and duration
Color of stools and urine
Associated with abdominal pain, chills, fever
Exposure to hepatitis, use of club/recreational
drugs, high-risk sexual activity
◦ Medications: high doses of acetaminophen,
antiepileptics
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Dysuria
◦ Character
◦ Location
 Suprapubic
 Distal urethra
◦ Associated fever or other systemic signs of illness
◦ Increased frequency of sexual intercourse
◦ Amount of daily fluid intake
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Urinary frequency
◦ Change in pattern or volume
◦ Associated with dysuria or other urinary
characteristics: urgency, hematuria, incontinence,
nocturia
◦ Change in urinary stream; dribbling
◦ Medications: diuretics
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Urinary incontinence
◦ Character, amount, frequency
◦ Associated with: urgency, previous surgery,
coughing, sneezing, walking up stairs, nocturia,
menopause
◦ Medications: diuretics
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Hematuria
◦ Character, color, timing
◦ Associated symptoms: flank or costovertebral pain
◦ Alternate possibilities: ingestion of foods
containing red vegetable dyes (may cause red
urinary pigment); ingestion of laxatives containing
phenolphthalein
◦ Medications: aspirin, NSAIDs, anticoagulants,
diuretics, antibiotics
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Gastrointestinal disorders
Hepatitis or cirrhosis of liver
Abdominal or urinary tract surgery or injury
Urinary tract infections (UTIs)
Major illnesses
Blood transfusions
Immunization status (hepatitis A and B)
Colorectal or related cancers
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Colorectal cancer and familial colorectal
cancer syndromes
Gallbladder disease
Kidney disease
Malabsorption syndrome
Hirschsprung disease, aganglionic megacolon
Familial Mediterranean fever (periodic
peritonitis)
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Nutrition
LMP (first day of last menstrual period)
Alcohol intake: frequency, type, and usual
amounts
Stressful life events, physical and psychologic
changes
Exposure to infectious diseases
Travel history
Trauma
Use of recreational or intravenous drugs
Tobacco use
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Gestational age and birth weight
Passage of first meconium stool within 24
hours
Jaundice
Vomiting, frequency, projectile
Diarrhea, colic, failure to gain weight, weight
loss, or steatorrhea (malabsorption
syndrome)
Apparent enlargement of abdomen (with or
without pain), constipation, or diarrhea
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Constipation
◦ Toilet training methods; diet; soiling; diarrhea;
abdominal distention; pica; size, shape,
consistency, and time of last stool; rectal bleeding;
painful passage of stool
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Abdominal pain
◦ Splinting of abdominal movement, resists
movement, keeps knees flexed
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Psychosocial stressors
◦ Home, school, and peers
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Urinary symptoms
◦ Frequency, urgency, burning, dysuria
◦ Odor (sign of infection)
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Abdominal pain
Fetal movement
Contractions
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Onset, frequency, duration, intensity
Accompanying symptoms; back pain
Leakage of fluid
Vaginal bleeding
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Urinary symptoms
◦ Nocturia, change in stream, incontinence
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Change in bowel patterns
◦ Constipation, diarrhea, fecal incontinence
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Dietary habits
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Inclusion of fiber in diet
Food intolerances
Change in appetite
Daily fluid intake
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Good light
Full exposure of abdomen
Empty bladder
Supportive pillows
Stethoscope
Centimeter ruler and measuring tape
Marking pen
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◦ Four quadrants: navel at center of horizontal and
perpendicular lines
◦ Right upper quadrant (RUQ)
◦ Left upper quadrant (LUQ)
◦ Right lower quadrant (RLQ)
◦ Left lower quadrant (LLQ)
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Nine regions
◦ Two horizontal lines
 Across the lowest edge of the costal margin
 Across the edge of the iliac crest
◦ Two vertical lines
 Running bilaterally from the midclavicular line to the
middle of the Poupart ligament, approximating the
lateral borders of the rectus abdominis muscles
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Surface characteristics
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Skin
Venous return
Lesions and scars
Tautness and striae
Contour
◦ Contour (abdominal profile from the rib margin to the
pubis, viewed on the horizontal plane)
◦ Symmetry
◦ Surface motion
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Abdominal landmarks
Abdominal venous patterns
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Movement
◦ Smooth, even movement should occur with
respiration.
◦ Limited movement may indicate peritonitis.
◦ Surface motion from peristalsis, seen as a rippling
movement across a section of the abdomen, may be
seen in thin individuals, but can be a sign of
intestinal obstruction.
◦ Marked pulsations may occur as the result of
increased pulse pressure or abdominal aortic
aneurysm.
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Bowel sounds
◦ Frequency
◦ Character
◦ Usually heard as clicks and gurgles that occur
irregularly and range from 5 to 35 per minute
◦ Generalized so most often they can be assessed
adequately by listening in one place
◦ Loud prolonged gurgles are called borborygmi
(stomach growling)
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Bowel sounds
◦ Increased bowel sounds may occur with gastroenteritis,
early intestinal obstruction, or hunger.
◦ High-pitched tinkling sounds suggest intestinal fluid and
air under pressure, as in early obstruction.
◦ Decreased bowel sounds occur with peritonitis and paralytic
ileus.
◦ Absent bowel sounds, referring to an inability to hear any
bowel sounds after 5 minutes of continuous listening, are
typically associated with abdominal pain and rigidity and
are a surgical emergency.
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Friction rubs
◦ High-pitched sounds that are heard in association
with respiration
◦ Use the diaphragm of the stethoscope
◦ Rare in the abdomen
◦ Indicate inflammation of the peritoneal surface of
the organ from tumor, infection, or infarct
◦ Liver and spleen
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Bruits
◦ Harsh or musical intermittent auscultatory sound,
which may reflect blood flow turbulence and
indicate vascular disease
◦ Heard best with the bell of the stethoscope
◦ Well localized
◦ Epigastric region and over the aortic, renal, iliac,
and femoral arteries
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Venous hum
◦ Soft, low-pitched, and continuous sound heard best
from the bell of the stethoscope
◦ Occurs with increased collateral circulation between
portal and systemic venous systems
◦ Epigastric region and around the umbilicus
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Used to assess
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Size and density of organs
Detect the presence of fluid (ascites)
Detect the presence of air (gastric distention)
Detect the presence of fluid-filled or solid masses
Percuss all quadrants or regions of the
abdomen for a sense of overall tympany and
dullness
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Liver span
◦ Usual span is approximately 6 to 12 cm (2½ to 4½
inches)
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Spleen
Gastric bubble
Kidneys
◦ Used to assess the kidneys for tenderness
◦ Usually performed while examining the back rather
than the abdomen
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Percussion of liver span
Percussion of the spleen
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Light palpation
◦ Light, systematic palpation of all four quadrants, or
nine regions
◦ Initially avoiding any areas that have already been
identified as problem spots
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Moderate palpation
◦ Moderate pressure as an intermediate step to
gradually approach deep palpation
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Deep palpation
◦ Necessary to thoroughly delineate abdominal
organs and to detect less obvious masses
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Deep manual palpation
Liver palpation
Spleen palpation
Kidney palpation
Aorta palpation
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Masses: identify and note
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Location
Size
Shape
Consistency
Tenderness
Pulsation
Mobility
Movement with respiration

Abdominal
structures
commonly felt as
masses
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Umbilical ring
◦ Palpate the umbilical ring and around the
umbilicus.
◦ Area should be free of bulges, nodules, and
granulation.
◦ Umbilical ring should be round and free of
irregularities.
 Potential for herniation
◦ Umbilicus may be either slightly inverted or everted,
but it should not protrude.
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Liver
Gallbladder
Spleen
Left and right kidneys
Aorta
Urinary bladder
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Ascites assessment
◦ Pathologic increase in fluid in the peritoneal cavity
◦ Percuss for:
 Dullness and resonance
 Shifting dullness
 Fluid wave
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Pain assesment
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Abdominal pain a common complaint
How bad is the pain?
Has there been recent trauma?
Pain so severe that the patient is unwilling to move
Accompanied by nausea and vomiting
Marked by areas of localized tenderness
Facial expression during palpation
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Appendicitis
Cholecystitis
Pancreatitis
Perforated ulcer
Diverticulitis
Intestinal obstruction
Volvulus
Peritonitis
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Leaking aneurysm
Biliary stones
Salpingitis
Pelvic inflammatory disease
Ruptured ovarian cyst
Renal calculi
Splenic rupture
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Aaron
Ballance
Blumberg Cullen
Dance
Grey Turner
Kehr
Markle
McBurney
Romberg-Howship
Rovsing
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Rebound tenderness
◦ Should be performed at the end of the examination
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Obturator muscle test
◦ Performed when you suspect a ruptured appendix
or a pelvic abscess
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Iliopsoas muscle test
◦ Performed when you suspect appendicitis
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Ballottement
◦ Palpation technique used to assess an organ or
mass
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Inspection
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Shape, contour, and movement
Pulsations and peristalsis
Umbilical cord
Muscle protrusion
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Auscultation
◦ Bowel sounds in chest as well as abdomen
 Suggests diaphragmatic hernia
◦ Bruits or hums should not be heard
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Percuss
◦ More tympany expected
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Palpate
◦ Detectable spleen tip common
◦ Pain difficult to assess
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The techniques of abdominal examination of
the adolescent are the same as those used for
adults.
Do not overlook the possibility of pregnancy
as a cause of abdominal pain or lower
abdominal mass, even in young adolescent
females.
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Bowel sounds will be diminished as a result of
decreased peristaltic activity.
Striae and a midline band of pigmentation
(linea nigra) may be present.
Common gastrointestinal complaints:
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Nausea
Vomiting
Constipation
Hemorrhoids
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Assessment of the abdomen of pregnant
women includes:
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Uterine size estimation for gestational age
Fetal growth
Position of the fetus
Monitoring of fetal well-being
Presence of uterine contractions
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Techniques of examination are the same as
those used for younger adults.
Abdominal wall of the older adult becomes
thinner and less firm.
Abdominal contour is often rounded as a
result of loss of muscle tone.
Use judgment in determining whether a
patient is able to assume a particular
position.
Decreased intestinal motility is associated
with aging.
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Decreased intestinal motility associated with
aging:
◦ Constipation
◦ Bloating
◦ Fecal Impaction
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Obstruction
Gastrointestinal cancers
Pain perception may be altered as part of the
aging process
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Acute diarrhea
◦ Frequent liquid or loose stools lasting less than 4
weeks’ duration
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Gastroesophageal reflux disease
◦ Backward flow of gastric contents, which are
typically acidic, into the esophagus
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Irritable bowel syndrome
◦ Disorder of intestinal motility
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Hiatal hernia with esophagitis
◦ Part of the stomach passes through the esophageal
hiatus in the diaphragm into the chest cavity
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Duodenal ulcer
◦ Chronic circumscribed break in the duodenal
mucosa that scars with healing
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Crohn disease
◦ Chronic inflammatory disorder that can affect any
part of the gastrointestinal tract, producing
ulceration, fibrosis, and malabsorption
◦ Terminal ileum and colon are most common sites
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Ulcerative colitis
◦ Chronic inflammatory disorder of the colon and
rectum that produces mucosal friability and areas
of ulceration

Stomach cancer
◦ Most commonly found in lower half of the stomach

Colon cancer
◦ May involve the rectum, sigmoid, proximal and
descending colon
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Hepatitis
◦ Inflammatory process characterized by diffuse or
patchy hepatocellular necrosis

Cirrhosis
◦ Diffuse hepatic process characterized by fibrosis
and alteration of normal liver architecture into
structurally abnormal nodules
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
Primary hepatocellular cancer
◦ Frequently arises in the setting of cirrhosis,
approximately 20 to 30 years after liver injury or
disease onset
◦ About 25% have no prior risk factors for cirrhosis

Cholelithiasis
◦ Stone formation in the gallbladder occurs when
certain substances reach a high concentration in
bile and produce crystals.
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
Cholecystitis
◦ Inflammatory process of the gallbladder most
commonly due to obstruction of the cystic duct
from cholelithiasis; may be either acute or chronic

Nonalcoholic fatty liver disease (NAFLD)
◦ Spectrum of hepatic disorders not associated with
excessive alcohol intake ranging from steatosis to
cirrhosis and hepatocellular cancer
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Acute pancreatitis
◦ Acute inflammatory process in which release of
pancreatic enzymes results in glandular
autodigestion

Chronic pancreatitis
◦ Chronic inflammatory process of the pancreas,
characterized by irreversible morphologic changes
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Spleen laceration/rupture
◦ Most commonly injured organ in abdominal trauma
because of its anatomic location
◦ Mechanism of injury can be either blunt or
penetrating but is more often blunt (e.g., from
motor vehicle accidents)
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Acute glomerulonephritis
◦ Inflammation of the capillary loops of the renal
glomeruli

Hydronephrosis
◦ Dilation of the renal pelvis and calyces due to an
obstruction of urine flow anywhere from the
urethral meatus to the kidneys

Pyelonephritis
◦ Infection of the kidney and renal pelvis
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Renal abscess
◦ Localized infection within the medulla or cortex of
the kidney

Renal calculi
◦ Stones formed in the pelvis of the kidney from a
physiochemical process associated with obstruction
and infections in the urinary tract

Acute renal failure
◦ Sudden impairment of renal function over hours to
days resulting in an acute uremic episode
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Intussusception
◦ Prolapse, or telescoping, of one segment of
intestine into another causes intestinal obstruction

Pyloric stenosis
◦ Hypertrophy of the circular muscle of the pylorus
leads to obstruction of the pyloric sphincter

Meconium ileus
◦ Distal intestinal obstruction caused by thick
inspissated impacted meconium in the lower
intestine
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Necrotizing enterocolitis
◦ Inflammatory disease of the gastrointestinal mucosa
associated with prematurity and immaturity of the
gastrointestinal tract

Biliary atresia
◦ Congenital obstruction or absence of some or all of the
bile duct system resulting in bile flow obstruction
◦ Most have complete absence of the entire extrahepatic
biliary tree

Meckel diverticulum
◦ Outpouching of the ileum that varies in size from a small
appendiceal process to a segment of bowel several
inches long, often in the proximity of the ileocecal valve
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Neuroblastoma
◦ Common solid malignancy of embryonal origin in
the peripheral sympathetic nervous system

Wilms tumor (nephroblastoma)
◦ Most common intraabdominal tumor of childhood;
usually appears at 2 to 3 years of age
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
Hirschsprung disease (congenital aganglionic
megacolon)
◦ Primary absence of parasympathetic ganglion cells
in a segment of the colon that interrupts intestinal
motility

Hemolytic uremic syndrome (HUS)
◦ Triad of microangiopathic hemolytic anemia,
thrombocytopenia, and uremia
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
Fecal incontinence
◦ Inability to control bowel movements leading to
leakage of stool
◦ Associated with three major causes:
 Fecal impaction
 Underlying disease
 Neurogenic disorders
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