The Abdomen – Chapter 9
Anatomy Notes
Divisions:
4 Quadrants (RU, LU, RL, LL) or
9 Divisions
--sigmoid colon: often palpable as a narrow firm tube in LL quadrant
--cecum/ascending colon: softer palpable tube in RL quadrant
--lower margin of liver in RU quadrant (superficial to kidney)
--under ribcage/diaphragm: most of liver, stomach, normal spleen
--spleen lies against diaphragm at level of ribs 9-11 (posterior to midaxillary line)
Diagnostic Notes
Pain (Onset, Location, Duration, Character, Aggravating/Relieving, Referred, Timing
Visceral (due to forceful contraction or stretch/distension of internal organs)
--difficult to localize b/c no direct pain receptors (usually)
Qualities: gnawing, burning, cramping, aching
Typicals:
RUQ: biliary tree and liver
Epigastric: stomach, duodenum, pancreas
Periumbilical: small intestine, appendix, prox. Colon
Suprapubic/Sacral: rectum
Hypogastric: colon
Parietal (inflammatory process of parietal peritoneum)
Quality: severe; aggravated by movement
Referred (felt at distant sites w/approximate innervation)
Typicals:
Duodenal/Pancreatic pain  back
Biliary tree  R shoulder or R posterior chest
Pleurisy/Acute MI  upper abdomen
Examination
Inspection
Skin (scars, striae, dilated veins, rashes/lesions)
Umbilicus
Contour of Abdomen (flat, rounded, protuberant, scaphoid;
regional/local bulges; visible masses)
Movement (peristalsis, pulsations)
Auscultation Bowel sounds in all 4 quadrants
Bruits (Aorta, Renal aa., Iliac aa., Femoral aa.)
Percussion
Size/Location estimates (liver, spleen)
Liver: 6-12 cm (midclavicular); 4-8 cm (midsternal)
Spleen
Traube’s space – area b/t lung resonance and costal
margin in which the spleen is found
Splenic Percussion Sign – percuss lowest interspace
in L axillary line; positive sign is a change from
tympanic to dull upon deep insipration
Gastric/Intestinal fullness
Palpation
Light and Deep
Liver: tenderness on edge during inspiration
Spleen: tenderness; only moderately palpable @ inspir.
Abdominal Aorta: midline, <3 cm diam.
Inflammatory Assess (cough-induced pain, rebound tenderness)
Special Techniques
Ascites Assessment (suggested by protuberant abdomen w/bulging flanks
Palpation: medial tympany w/lateral dullness (margins move when pt
changes positions)
Fluid wave
Appendicitis
Hx: pain begins near umbilicus and shits to RLQ (increased by coughing)
--localized tenderness in RLQ (or R flank)
--suggested when rebound tenderness is present
--may present w/cutaneous hyperesthesia (tested by doing skin folds over
the abdomen)
Rovsing’s Sign – press deeply in LLQ and withdraw quickly (positive is
referred pain on pressure or release in RLQ)
Psoas sign – while holding down @ knee, ask pt to raise leg (positive is
pain)
Obturator sign – flex @ hip w/leg bent and internally rotate (positive is R
hypogastric pain)
Cholecystitis
--pain and tenderness in RUQ
Murphy’s Sign – hook under costal margin where rectus crosses (positive
is increased localized pain/tenderness upon deep inspiration)
Abnormality Notes
--Heartburn suggests gastric reflux into esophagus (precipitated by heavy meals, lying down,
alcohol, acidic foods, aspirin)
--possible DDx for regurgitation: esophageal narrowing (stricture/cancer), incompetent LES
--hematemesis indicatory of duodenal or peptic ulcer, esophageal or gastric varices, gastritis
--RUQ visceral pain indicatory of liver distension (2° to alcoholic hepatitis)
--periumbilical visceral pain indicatory of acute appendicitis (transitioning to RLQ parietal pain)
--protuberant/tympatic abdomen suggestions intestinal obstruction