•pancreatitis - midepigastric; radiates staight through to back

•renal colic (kidney stones) -LQ, colicky, radiates to testicles or labia, excruciatingly severe

•appendicitis - nausea and periumbilical pain (peaks in 4-6 h), may subside to reappear in RLQ at McBurney's •point (5 cm from the ASIS to the umbilicus)

•cholelithiasis- RUQ

•colitis - LLQ and RLQ, constant or spasmic, assoc. w/ or relieved by defecation

•diverticulitis - LLQ

•peptic ulcer disease - epigastric leads to duodenal pain (that is relieved by eating, develops with fasting)

•small intestinal gastroenteritis- diffuse pain

1. Stretching of encapsulated organs (e.g. liver, spleen, kidneys)

a. the capsules surrounding the solid organs may become tightly stretched due to swelling or inflammation of the organ itself; contant and dull or moderate in intensity

b. RUQ pain secondary to livercongestion in CHF; LUQ pain secondary to splenic congestion or enlargement

flank pain secondary to kidney swelling and inflammation (pyelonephritis)

2. irritation of the mucosal lining (esophagus, stomach, or duodenum in esophagitis, gastritis or peptic ulcer, or duodenitis)

a. burning, severe

3. smooth muscle spasm (viral gastroenteritis or IBS)

a. most common cause of abdominal pain; crampy or colicky

4. peritoneal irritation (acute appendicitis, diverticulitis, and acute cholecystitis)

a. sharp stabbing pain, tenderness with palpation

5. direct splanchnic nerve stimulation (expanding aortic aneurysm and pancreatic cancer)

a. poorly localized abdominal pain of moderate severity

acute abdomen "abby": sudden onset of severe abdominal pain

"Abby lives in the ATTIC"

(1) Abdominal distention with tympany on percussion (since blood is diffuse in peritoneum)

(2) Tenderness to palpation

(3) Rebound/Cough Tenderness

(4) Increased or decreased bowel sounds

(5) Cutaneous hypersensitivity

(6) Rigidity

abby's require immediate surgical attention:

Peritonitis

Bowel infarction

Perforated hollow organ

Ruptured aortic aneurysm

The sequence is different from the usual sequence of (IPPA - Inspection, Palpation, Percussion, and auscultation);

IAPP - Inspection, Auscultation, Percussion, and Palpation

Ausculation is performed early so that not to alter the bowel sounds by physical manipulation in percussion and palpation.

Ecchymosis in one or both flanks (Grey Turner's sign) - retroperitoneal and intraperitoneal bleeding; including ovarian cyst hemorrhage, hemorrhagic ascities secondary to metastatic cancer, bilateral salpingitis, and strangulated bowel with hemorrhage.

=> collection of blood in the subcutaneous fascial planes; it shouldn't blanch, since it's outside the vessels

Ecchymosis in periumbilical region (Cullen's sign) -

also retroperitoneal and intraperitoneal bleeding

=> blood travels to periumbilical area through the falciform ligament

A. To assess the contour of the anterior abdominal wall

-Scaphoid => malnourished

-flat => healthy

-protuberant => abdominal distention secondary to

(a) fat

(b) fluid (ascites)

(c) flatus (air)

(d) fetus (pregnancy)

(e) feces

(f) fatal groths (tumors)

B. To assess how far the umbilicus deviates from the midpoint between the symphysis pubis and xiphoid

-Normal is +/- 1cm.

-Hepatomegaly moves the umbilicus downward, such that XU  ≥ USp + 2cm

-Pelvic tumors and pregnancy moves the umbilicus upward, such that XU + 2cm  ≤ USp

C. To assess to exterior abdominal wall for...

1. scars => surgery

2. discoloration => retroperitoneal or intraperitoneal bleed

3. Striae (stretch marks) => chronic stretching due to obesity, pregnancy, ascites, expanding tumors

-Erythrocytosis and adrenal androgens give striae a purplish hue (Cushing's syndrome)

D. To assess the venous pattern (SVC, IVC, and cirrhotic obstruction)

E. To assess for visible peristalsis - peristaltic waves are visible (mechanical bowel obstruction)

F. To assess for abdominal aorta - inc. amlitude assoc. w/ wide pulse pressure, tortuosity of the aorta, or an abdominal aortic aneurysm

G. To assess for hernias

Umbilical hernia: navel protrudes during straining or relaxation (ascities, pregnancy, and severe emphysema)

Spigelian hernia: tender mass in abdominal wall 3-5cm above the inguinal ligaments

Diastasis rectus: separation of the abdominal rectus muscles results in a linear midline bulge with increased intra-abdominal pressure (pregnancy or obesity), pat. is supine lifts his or her head off the table. BENIGN

1. SVC Obstruction: Blood in upper abdomen flows downward

2. IVC Obstruction: Blood in lower abdomen flows upward

3. Intrahepatic portal vein obstruction (cirrhosis): blood radiates outwards from the umbilicus (caput medusa)

Light palpation can be used to distinguish between intra-abdominal masses and intra-mural masses

intramural: if it becomes more prominent when the head is raised

intra-abdominal: if it becomes less prominent when the head is raised

Mechanical ileus

Mechanism: anatomic obstruction that causes dilation, congestion, and edematous obstructed bowel => cessession of peristaltic activity => bowel sounds stop; visible peristalsis (initially)

Mechanical SBO: Secondary to adhesions, hernia, volvulus, gallstone ileus, intussuception; can see haustra on film; tinkles, borborygmi

Mechanical LBO: Secondary to tumor, volvulus, hernia, diverticulitis, intussusception; air more lateral

paralytic ileus (adyanamic)

Mechanism: inflammation of the bowel, ischemia of the bowel, electrolyte abnormalities; abdominal distention, and air everywhere

secondary to Post-op abdominal surgery; Peritoneal irritation (localized or diffuse); Electrolyte disturbances; Narcotic medications; Intestinal ischemia

Bruits - indicate turbulence in dilated, narrowed, or tortuous arteries

A. Innocent- happen most frequently in celiac artery, up to 20% of normal people

B. Epigastric systolic bruits - midline bet. xiphoid and umbilicus; bet. 6-16% of normal people, esp. in women of childbearing age

a. aortic aneurysms- less than 50% of those have systolic epigastric bruits

C. Renal artery bruits - band 2 in. above the umbilicus, radiating into the flank or costovertebral angle

a. renal artery stenosis <= if both systolic and diastolic  components are found

D. Common iliac artery bruits - midway between the umbilicus and the tangent to the inguinal ligament

E. Liver Tumor bruits - RUQ, systolic or continuous

a. hepatomas => 14% have systolic bruit

b. aortic compression => only over left lobe of the liver that decreases with standing, secondary to hepatomegaly

c. DO NOT CHANGE WITH POSITION

d. could be a benign vascular tumor => RUQ

Peritoneal friction rubs -> spleen or liver, when their capsules rub against the peritoneum.

A. splenic infarction - most common cause; LUQ; also splenic abscess and metastatic tumors

B. metastatic tumors of liver - RUQ; also liver absecess and hepatitis

C. hepatoma - primary liver cell tumor

Light palpation is used to...

(1) assess the abdominal wall for intramural masses

(2) evaluate areas of tenderness before deep palpation

(3) to detect cutaneous hypersensitivity

Deep palpation is the most important step:

1. Evaluate areas of pain and tenderness

2. Evaluate abdominal wall muscle tone

3. Evaluate position, size, shape, and consistency of abdominal organs

4. Detect abnormal massess or ascites within the peritoneal cavitiy

Voluntary rigidity (guarding): willful tensing of the abdominal wall musculature for any reason -- fear, anticipation, ticklishness, cold hands, or malingering;

symmetric; induced by palpating with the stethoscope or by palpatiting and applying pressure over the lower sternum during inspiration

Involuntary rigidity: secondary to peritoneal irritation, unilateral or bilateral; does not move with respiration; board-like abdomen.

Courvoisier's sign: the presence of a palpably enlarged gallbladder w/ jaundice

indicates obstructionof the biliary tract with cancer; argues strongly for extrahepatic obstruction (common bile duct) as opp. to hepatocellular disease as the cause for jaundice

Rebound tenderness (knife-like): indicates peritoneal irritation and inflmmation

Direct rebound: pain localizes beneath site of pressure => localized peritoneal inflammation

Indirect rebound: pain radiates at sites remote from the involved area => generalized peritoneal inflammation

Generally, hepatic dullness to percussion, is so inaccurate, but still widely used.

Normal patients: liver span is 9-12 cm, with men > women; normal upper liver border = 7th or 8th rib

Emphysema: upper margin of hepatic dullness is lower than the 8th rib, shifted down.

Hepatomegaly: upper liver border is higher than 6th rib, shifted up

Cirrhosis: nodularity of the lower liver edge, also can be due to cancer

Percussion

Normal Tympany - gastric air buble in LUQ

Generalized tympany - mechnica land paralytic ileus and perforated hollow organ

Dullness to percussion - normally over solid organs, fecal-filled bowel, and laterally over the flanks, and ascites

Normally, spleen not palpable

Palpable spleen is indicative of splenomegaly

The ilio-psaos sign and obsturator test are tests for retroperitoneal irritation.

(+) ilio-psaos: pelvic pain when patient extends a straight leg at the hip against resistance applied by the examiner => ureteral calculus, retroperitoneal bleed, or tuboovarian abscess

(+) obsturator test: pelvic pain when examiner rotates the leg internally and externally at the hip by grasping the ankle and knee => inflamed obturator internus and retroperitoneal irritation

Good for detection of rectal carcinoma, perirectal abscess, tubo-ovarian abscess, uterine lesions, and even appendiceal abscess

intra-abdominal cancer => hard shelf in the rectovesical pouch (Blumer's shelf)

(+) stool guaic test -> conditions assoc. w/ passage of blood through GI tract