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GI System and Abdominal Exam Physical Diagnosis Worksheet Surface Anatomy / Inspection The abdomen is a box and as such has six sides. What structure is the “top” of the box and which structures comprise the border around the top? What structures comprise the “bottom” of the box and which structures comprise the border around the bottom? The top consists of the diaphragm, central tendon, and three hiatuses. Starting at the spine, the border of the top consists of the T12 vertebral body, the bottom of the rib cage (which consists ribs posteriorly and laterally and intercostal muscle fascia and costal cartilages anteriorly), and then the sternum/xiphoid. The bottom consists of the organs of the pelvis that have peritoneal lining: the anterior pelvis (bladder, and in women uterus, a portion of vagina, and adenexal structures) , the posterior structures (the pelvic floor at the base of the rectouterine/rectovesicular pouch and the rectum), and the lateral structures (iliacus muscle, and neurovascular plexus). Starting at the spine, the lower border of the abdomen consists of the top of the sacrum, the iliac crest to the ASIS (anterior superior iliac spine), the inguinal ligament, and the pubis. This differs from the upper border of the pelvis, which consists of the top of the sacrum, the iliac crest past the ASIS to the top of the ischium, the superior pubic ramus, and the pubis. The difference is the extended “femoral space” through which most of the neurovascular structures and thigh flexors leave the abdomen and travel to the lower extremity. What are the most common surgical findings found during inspection of the abdomen? Common are surgical scars. Common scars include midline, subcostal, “appendectomy,” “hernia,” “C-section,” “Tubal Ligation,” ostomy sites, and healed port sites from laparoscopic surgery. Quotes are used as there are a variety of similar incisions used for the same surgical procedure. Commonly missed scars are very low c-section (pfannenstiel) scars (missed when the abdomen is not fully inspected), and periumbilical tubal ligation / laparscopic port site scars (hidden in the umbilicus). They are useful to catch patient who forget to tell you things during history. What are the most common findings of systemic disease found during inspection of the abdomen? Neurofibromas are common in genetic disorders. Spider angiomata are common in liver disease. Advanced liver disease often has noticable ascites and engorged collateral venous drainage; caput medusae is an unusual but unmistakable finding in portal hypertension. Cherry hemangiomata, actinic keratoses, and seborrheic keratoses are common with aging and sun exposure. Abdominal wall movement abnormalities are common in severe respiratory disease (respiratory alternans and abdominal paradox). Striae are a common finding in obesity and pregnancy. Visible peristalsis, although unusual, can sometimes be seen and is a big clue to diagnosis. Sister Joseph’s Nodule, often thought to be a periumbilical lymph node, can be either extension of tumor, non- lymphatic metastasis, or nodal metastasis protruding through the umbilical ring, presenting as a palpable umbilical mass. Who was Sister Joseph? Sister Joseph (of the St. Mary’s Hospital and therefore often referred to as Sister Mary Joseph, though silly since all of the nuns at St. Mary’s adopted Mary as their first name) in the early days of the Mayo Clinic drew Dr. William Mayo’s attention to this physical exam finding that predicted the outcome of an abdominal exploration. In decreasing order of frequency the primary sites of umbilical metastases are stomach, ovary, rectum, and pancreas. What is the significance of ecchymosis? Ecchymosis is suggestive of either active intra-abdominal or retro-peritoneal bleeding, or a bleeding diathesis. Periumbilical Ecchymosis (Cullen’s Sign) and Flank Ecchymosis (Grey Turner Sign) can occur in as many as 3% of patients with acute pancreatitis – a few days after onset. Occasionally, they also present with ectopic / ruptured ectopic pregnancy, though with a sensitivity of about 1%. Specificity is low, since it can occur in many catastrophes – such as strangulation of gut, strangulation in an umbilical hernia, hemorrahagic ascites, bilateral salphingitis, etc. Small Petechiae are signs of platelet disfunction (iatrogenic or naturally occurring). Palpable Purpura are signs of small vessel vasculitis. What are the layers of the anterior abdominal wall from skin to peritoneum at the following points: 1) midline above the umbilicus. 2) one centimeter to the side of the umbilicus. 3) twenty centimeters to the side of the umbilicus. 4) one centimeter to the side of the midline and two centimeters above the pubis. 1) Epidermis, Dermis, Subcutaneous Fat (sometimes with a noticeable presence of Scarpa’s Fascia), Linea Alba (composed of fascia from Anterior and Posterior Rectus Sheath), Tranversalis Fascia, Preperitoneal Fat, Peritoneum. 2) Epidermis, Dermis, Subcutaneous Fat (sometimes with a noticeable presence of Scarpa’s Fascia), Anterior Rectus Sheath, Rectus Abdominus, Posterior Rectus Sheath, Tranversalis Fascia, Preperitoneal Fat, Peritoneum. 3) Epidermis, Dermis, Subcutaneous Fat (sometimes with a noticeable presence of Scarpa’s Fascia), External Oblique and it’s fascia, Internal Oblique and its fascia, Transversus Abdominus and its fascia, Tranversalis Fascia, Preperitoneal Fat, Peritoneum. 4) Epidermis, Dermis, Subcutaneous Fat (sometimes with a noticeable presence of Scarpa’s Fascia), Anterior Rectus Sheath, Rectus Abdominus, Tranversalis Fascia, Preperitoneal Fat, Peritoneum. Auscultation How long should one listen to the abdomen for bowel sounds? The typical high-pitched, loud, bowel sounds of near obstruction in small and large bowel have been shown to be specific but not sensitive for the diagnosis. The lack of sensitivity is related to peristalsis – we only hear the finding during active peristalsis and mass movements. Since peristaltic waves occur about once every five minutes in small bowel and once every ten to fifteen minutes in colon, maximal sensitivity occurs if you auscultate until either you have a positive result or fifteen minutes (or so). This is generally not practical (low yield per time). Thus, auscultation is performed looking for presence / absence of bowel sounds – not specifically looking for increased sounds. Thus, auscultation for 30 seconds to 1 minute is generally adequate. Furthermore, auscultation should be performed before palpation or percussion because both techniques will have an effect on auscultatory findings. Of note, decreased bowel sounds are not pathognomic for any particular disease (unlike Austin Flint murmur) nor indicative of severity of disease (unlike abdominal paradox in respiratory failure). Thus, sensitivity and specificity are not usefully measured. This is an argument against auscultation for bowel sounds only. Even if auscultation for bowel sounds is of low utility, there is high sensitivity and specificity of abdominal vascular auscultation and many non-auscultatory uses of the stethoscope in circumventing voluntary guarding. Note that there is no prospective evaluation of the “stethoscope sign” in tenderness evaluation but there is a case-report of a false-positive stethoscope sign in a patient with appendicitis. (New England Journal, 1976, Oldstone MB “Stethoscope Treachery”) Where does one listen to the abdomen for vascular sounds? What is the significance of a murmur? What is the significance of a rub? To listen to the abdominal aorta and celiac/superior mesenteric axis– midline/just left of midline just above umbilicus. Kidneys – midrectus line just subcostal. A good vascular exam will often include abdominal and femoral artery auscultation (efficient if done sequentially) A continuous murmur is often related to portal hypertension and porto-systemic flow. Systolic murmurs can be encountered in 1-2% of patients – usually in the epigastrium and related to normal celiac axis flow (common in pregnancy and thin women; rare in men). RUQ murmurs can be related to hepatocellular carcinoma arterial flow or Tricuspid regurgitation, LUQ murmurs can be related to vascular anomalies near the spleen. Renal artery bruits are usually closer to midline. Rubs are consistant with splenic and hepatic infarcts. Percussion and Palpation What is the difference between pain and tenderness? What causes pain? What causes tenderness? Pain is a historical item – the patient is experiencing discomfort. There are three levels of “pain” – nociception, spinal cord transmission, and central perception (aka suffering). Tenderness is a physical exam finding – when a maneuver is performed (like palpation) a reflex occurs (muscle splinting, wide eyes, moaning, teeth gritting). Splanchnic pain is generally midline, and generally caused by obstruction (partial or complete) in a tube. Somatic pain is generally focal, and caused by inflammation of the peritoneum, fascial container of an organ (such as glisson’s capsule), or abdominal wall components. True abdominal tenderness is almost always caused by focal inflammation of the peritoneum (although if a fascial container is under tension – like glisson’s during acute hepatitis – this can cause tenderness as well). Pain without (or with little) Tenderness and Tenderness without (or with little) Pain give clues to diagnosis. Where is the peritoneum and how do we evaluate the peritoneum for tenderness? The abdomen is a box with six sides as above. There is an additional layer of peritoneal reflection under the liver on top of the gallbladder. To test for tenderness all seven of these areas must be examined. Diaphragm tenderness can be evaluated using deep breathing (the equivalent of palpation) and coughing (the equivalent of palpation). Anterior and Lateral wall tenderness is done with standard percussion and palpation. Posterior wall is difficult. CVA percussion can elicit both kidney tenderness and posterior peritoneal inflammation. More useful is leg manipulation which will affect the psoas muscle and move the medial posterior peritoneum. Unfortunately, thigh and spine musculoskeletal disease can disguise peritoneal processes. Pelvic tenderness is dependent on location. Anterior pelvis requires pelvic exam in females and a good rectal in males. Posterior pelvis is done by rectal. Lateral pelvis is by leg manipulation (obturator and iliopsoas) and is subject to similar constraints as with posterior peritoneum. Infrahepatic / GB peritoneum is hidden by both liver and costal margin. Deep inspiration brings it into palpation range, and is best performed with your hand already in place (thus the breathing makes the GB palpate your hand). Properly done, this is called a murphy’s sign. What is a Murphy’s Sign? Who was Murphy? Involuntary cessation of respiratory effort during deep repeated inspiration in the presence of active right upper quadrant palapation. John B Murphy (1857 – 1916) was probably the best American Surgeon / Teacher in his era (he predated other great American surgeons by a few decades). He was also from Chicago. Interestingly, he described multiple maneuvers for evaluating the acute abdomen, of which four kept his name briefly, and one still does. The other three are the deep-grip palpation of the gallbladder, hammer-stroke percussion of the gallbladder (most useful in obese patients), and palpating/percussing the costovertebral angles for tenderness. What are the gradations of tenderness? Tenderness can be focal or generalized. Tenderness can be mild to severe. Generally, the most mild tenderness is only to aggressive movement of the peritoneum or fascia – that is, with percussion. As tenderness worsens, there begins to be the same changes with les and less excursion of peritoneum (palpation). As it worsens further, small movements (of the bed, breathing, extremities, etc) also cause the same findings. Interestingly, at this worst point of tenderness, the body will involuntarily contract the abdominal musculature (splinting) – occasionally leading to focal positioning abnormalities (leaning to the right) and loss of abdominal wall reflexes. In a non-tender (or minimally tender) abdomen, what else is palpation good for? From the outside in, palpation can be used to identify skin and subcutaneous lesions (such as epidermal inclusion cyst, lipoma), abdominal wall defects (hernias), and a variety of normal and abnormal organs. Although in a overweight adult, rarely can any organs be palpated, in children and thin adults, one can often feel normal sized livers, spleens, kidneys, full bladders, and abdominal aortas. Pathologic findings include livers, distended gallbladders (Courvoisier’s sign), spleens, and abdominal aortas. One can palpate transplanted kidneys as well (a normal abnormal finding). In a non-tender (or minimally tender) abdomen, what else is percussion good for? Although the exact sound received during percussion varies based on a number of patient and examiner factors, a change in sound is significant for a change in tissue density. Thus, percussion is good for borders of solid organs, particularly near the diaphragms. The most accurately located organ is the spleen, followed by the liver. Percussion (and auscultatory percussion) can identify full urinary bladders. What is rebound tenderness? Should I test for it? No. Rebound tenderness is “tenderness elicited indirectly by the sudden realease of hand pressure.” In a sense, it is similar to cough tenderness or the leg-manipulating signs – a muscle is moved suddenly to “percuss” the peritoneum. During rebound, suddenly releasing hand pressure allows the abdominal wall to “snap” back into position, percussing the peritoneum. This tenderness is associated with a higher sensation of pain, and is not quite as reproducible as percussion itself. Thus, it is cruel and unusual punishment to attempt to elicit rebound tenderness. Sometimes rebound tenderness is accidentally elicited, such as a patient not complaining of pain who is palpated deeply. Then, it is OK to report the finding. Liver and Gallbladder What is the best way to palpate the lower edge of the liver? Patient supine, with flexed knees and hips (to relax the abdominal wall musculature). Examiner’s hand should have fingers pointing toward pt’s head, and should place them about 2-3 cm below costal margin at the lateral border of the rectus muscle. Patient should inspire with examiner’s palpation effort. What are the palpable characteristics of the liver? Tenderness, Nodules, Consistency + Contour, Size, Pulsations, Thrills. Intraobserver reliability varies widely, with tenderness always the most reliable. What are the causes of tender liver? Tenderness is a property of capsular distension – not parenchymal disease. Thus, tender livers are either acutely congested (due to inflammation such as hepatitis) or chronically congested (cardiopulmonary disease). How do we separate a tender liver from focal peritonitis? Carnett’s sign. First, the examiner finds the point of maximal tenderness. Then, the patient is instructed to contract the abdominal muscles by lifting the head up off the table during palpation. This contraction is an “induced guarding” – thus, if the patient describes an increase in pain or the examiner senses an increase in tenderness, the test is recorded as positive, and suggests abdominal wall tenderness / peritonitis. If the patient feels slightly better, the test is negative, and suggests intra-abdominal organ tenderness. Ascites What is ascites? Ascites is free fluid in the abdominal cavity. A small amount of fluid is normally present (to lubricate the guts) – produced and absorbed all the time. Ascites occurs when the absorption is unable to keep up with production – either because production is excessive (hypo-osmolar fluid overload of nephrotic syndrome, kidney failure, liver synthetic dysfunction, heart failure, pulmonary hypertension, OR portal hypertension from liver cirrhosis (usually coupled with synthetic dysfunction) or because absorption is poor (chronic peritoneal infection (like peritoneal dialysis or repeated SBP) or carcinomatosis) Is physical exam useful in identifying ascites? Like most of physical exam, its accuracy increases with severity of disease. Different maneuvers are described (inspection, bulging flanks, flank dullness, shifting dullness, fluid wave) and they all improve in accuracy as ascites volume increases. The highest sensitivity test is shifting-dullness (sensitivity > 80% in two studies) but it has low specificity. Thus, for ruling out ascites, negative shifting dullness is probably most useful. The most specific test is fluid-wave maneuver (specificity 80-90%) but it’s not very sensitive (50% or so). Thus, while a positive fluid-wave is useful for clarifying that a finding is truly ascites, it can’t be used for ruling out ascites. The key message here is: combine tests. Doing a complete physical exam and looking at the general appearance (wasting away, blue bloater, etc), sclera (icterus), skin (jaundice, sequelae of EtOH / liver disease), liver palpation, etc, helps to produce a unified picture of the patient’s disease. When combined with history, it codifies into clarity. Thus, while a focused physical fails to be sensitive or specific, a sequential physical will succeed in finding the patient at risk for and having ascites. Spleen What is the best method of evaluating the spleen? Percussion of the abdomen. There are three described methods (percussing along the posterior axillary line, percussing at the intersection of the anterior axillary line and ninth rib, and full percussion of Traube’s space: a triangle made of the sixth rib, costal margin, and midaxillary line). [These are called Nixon’s technique, Castell’s technique, and Percussion of Traube’s Space]. Despite the many names, the ultrasound evaluations demonstrate that: the more posterior you are the more specific you are for splenomegaly, the more anterior you are the more sensitive you are for splenomegaly. What is the goal in palpating the spleen? How does one palpate the spleen? The main goal is to see whether or not you can actually palpate it. This is because under most circumstances, the spleen is not palpable. There are many described methods, but they fall into two categories: bimanual palpation and hooking from above. The bimanual methods use one hand anteriorly and one hand posteriolaterally. In some cases, the combination of palpation under the rib cage contemporaneously with deep inspiration will reveal the spleen tip. In other cases, the posteriolateral hand can “lift” the spleen anteriorly into the opposite hand (called ballottement). Hooking from above gets further under the rib cage but is more uncomfortable (and without validation yet) Retroperitoneum (Kidney/Pancreas/Vasculature) How does one evaluate the retroperitoneum? In most cases, history (not physical exam) is most useful. On the physical exam of the adult, there are mostly indirect signs of retroperitoneal disease. Inspection identifies ecchymosis and scar. Percussion will identify tenderness (CVA tenderness of kidney / ureter inflammation, epigastric tenderness of pancreatitis). Palpation will sometimes identify an aorta (occasionally a normal on a thin person, more often borderline or enlarged on a regular size person) The kidneys are generally very difficult to palpate and the pancreas will never be palpated. The most useful direct signs are auscultatory evaluation of the vasculature (though rare, highly specific) Urinary Bladder How can you find the bladder? One can really only find relatively full bladders on relatively thin patients. Auscultatory percussion (similar to the scratch test) – performed by auscultation just above the symphysis pubis while scratching just above the stethoscope, can predict “full bladder.” (defined as > 250cc urine on catheterization). The actually measured predictive values are: if you cannot hear any scratches greater than 6.5 cm away from the pubis, there is a 0% likelihood of full bladder. If you hear scratches from 6.5-7.5 cm – 43% likelihood, and >7.5 cm – 91% likelihood. How can you tell if the bladder is full? Most of the physical exam correlation was done on urology patients following cystoscopy (i.e. with a known filling of the bladder). By and large, if a patient felt the need to urinate on suprapubic palpation, they had more than 100 cc, and if they didn’t feel the urge, they had less than 200 cc.
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