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Abdominal Examination
- 1. Abdominal Examination Prof. Dr. Osman Cavit Özdoğan Gastroenterology
- 2. Aproach to GIS Symptoms
- 3. Gi Symptoms Localizaiton • Upper Gi • Lower Gi • Other Cardinal Symptoms • Heartburn • Dyspesia • Dysphagia • Non-cardiac chest pain • Nausea • Diarea • Constipation • Abdominal pain • Weight loss • Gi bleeding
- 4. Upper GI • Dysphagia • İntermittant • Progressive • Malignite • Orofarengeal • Özofageal • Odynofagia • Reflax • Pill özofagitis • Reflux Sypmtoms – Heartburn – Chest pain – Regurgitation
- 5. • Hoarseness • Hiccups • Refractory cough • Bad taste • Belching • Halitosis
- 6. Regurgitation • effortless return of esophageal or gastric contents into the hypopharynx… – Esophageal regurgitation • Achalasia • Esophageal tumor – Gastric regurgitation • GERD
- 7. Abdominal Distention • increased abdominal girth… – Fat – Flatus – Fetus – Fluid
- 8. • Hematemesis –Fresh blood –Coffe ground • Melena –Appereance –Smell
- 9. Globus • “Stuck of moutfull at the farenx” • GI related causes: – GERD (oropharyngeal reflux) – Achalasia • Globus hystericus
- 10. Lower GI • Abdominal Pain • Visceral pain • Pariatel pain • Reflecting pain : Acute Cholecystitis • Localization – Epigastric – Other quadrants – Diffuse abdomen – Lower abdomen • Related to meals or defecation
- 11. Stool patern • Frequency • Volume • Shape • Goat stool • Slimming • Color – Black – Red
- 12. Constipation • an inability to have spontaneous complete and releiving bowel movements… – Slow colonic transit type • Frequency<2 per week • Consistency: Hard • Colonic dysfunction – Difficult evacuation type • Frequency>2 per week • Consistency: Soft • Anorectal dysfunction
- 13. Hematochesia • Fresh red • Purple brown • Small driblets • Diffuse
- 14. Diarrhea • a decrease in stool consistency due to increased water content… – Acute Diarrhea • Viral • Bacterial (E. coli, etc.) – Chronic Diarrhea • IBS • IBD (CD and UC) • Infectious (Amoeba, Tbc.) • Antibiotic associated • Others
- 15. Steatorrhea • presence of excess fat in feces… • Causes – Chronic pancreatitis – Celiac disease – Postgastrectomy – Cholestasis (esp. PSC) – Giardiasis – Crohn’s disease
- 16. Fecal Incontinence • involuntary defication… • Causes: – Accidental injury to the rectum/anus – Diabetes Mellitus – Rectoanal tumors – Fecal impaction
- 17. Anal Symptoms • Pruritis • Pain • Tenesmus • Hard Defecation
- 18. Hepatitis and liver failure • Jaundice • Fatique • Weight loss or gain • Loss of apetite • Cirrhosis – History of jaundice – Abdominal distention – Change in consinousness
- 19. Asterixis • Synonyms: Liver flap, Flepping tremor • Causes: – Hepatic: Liver failure→ Hepatic Encephalopathy – Renal: Renal failure → Uremic syndrome – Pulmonary: Severe respiratory insufficiency
- 20. Why Abdominal Examination? • Treatment should be urgent or elective – GI Bleeding? Perforation? Acute abdomen? – Peptic ulcer activation? Or Acute pancreatitis? • Findings in physical examination targets to the diagnosis • Differential diagnosis? • How do we decide the lab. Tests for diagnosis • Does the patient need any intervention immediately?
- 21. Be carefull!! • Introduce yourself before examination • Outpatient clinic should not be crowded – Only one person with the patient, close relative • Be calm and cool – Do not shout, be angry or talk with sarcastic words • Always have the records on the files • Always give detailed information for the diagnosis & the treatment
- 22. General Physical Examination • Always before the abdominal examination • Upper part of the patient’s body should be naked • Outpatient room should be warm • Be at the right side of the patient • All your belongings should be ready – White coat – Light source – ruler – Pencil, notebook etc. • Enogh day light • Hands should be warm and clean
- 23. Periferic Findings at the general physical examination • Generally • Cachexia • Orianted or not, dehidrated? Etc. • Head and Neck • Pale conjuctiva • Jaundice or icterus • xantelazma • Kayser-Fleisher ring • Temporal muscle wasting • Rhinophyma • Periferic extremities • Clubbing • White nail • Palmar erythema • Dupuytren Contractures • Tenar ve hypotenal muscle atrophia • Spider nevus, • pyoderma gangrenozum
- 26. Glossitis • inflammation of the tongue… • GI related causes – Pernisious anemia – Pemphigus vulgaris – Iron deficiency anemia
- 27. Angular Stomatitis • an inflammatory lesion at the labial commissure… • GI related causes: – Celiac disease – Crohn’s disease – Plummer-Vinson syndrome Fe, B vit. deficiency
- 28. Aphtous ulcers
- 32. Abdominal Examination • Inspection • Oscultation • Percussion • Palpation
- 33. – Midclavicular line – Anterir, posterior and midaxillary lines – Midline – Horisontal line • Points – Murphy – Mc-Burney
- 34. – Left and right hypochondrium – Left and right paraumblical (lumbar) regions – Left and right iliac regions – Epigastrium, umblical and hypogastric regions
- 35. Findings of inspection – Abdominal respiration • Increases at lower lung function • Decreases at large ascitis – Peritonitis • Shape – Protuberant – Flat – Saggy – Obese
- 36. • You should define the lesion and its location when you find a lesion. – Diastasis recti – Hernias • İncisisonal • Umblical • ınguinal • Others – Scars
- 37. Collateral veins ve Caput medusa
- 38. – moles – Stria – Dilated veins – Dilated intestinal loops – Cullen’s sign • Acute pankreatitis • Abdominal trauma • Ektopic pregnancy – Grey Turner sign • Acute pankreatitis – 24-48 hr – High mortalitiy
- 39. – Sister Mary Joseph nodule: • Skin metastasis of gastric ca – Pultations • Aortic anuerysm – Eccyhmosis – Cafe au lait sign
- 42. Abdominal auscultation Bowel sounds at 4 quadrants Listen for 2 miutes Hyperactive bowel sounds •Postprandial physiologic •Laksatif consumption •Diare •Early mechanical obstruction •Hypoactive/Paralitik ileus •Adinamic ileus •Peritonitis
- 43. Venous hums Both sistolic and diastolic sounds Portal hipertansion Collatersal circulation Hepatoma Arterial Bruits: •Abdominal aorta : Aneurysm, plaque •Renal arteria: Stenosis
- 44. Friction Rubs On the liver side – After liver biopsy – Acute Budd-Chiari syndrome – Perihepatitis with gynecologic infections – Hepatoma localised at he capsule of the liver On the Spleen Side – Spleen infarction – Subcapsuller hematoma after trauma
- 45. Percussion rgans – Liver • Midclavicular line and 2. intercostal • Through the midclavicular line • Total vertical diamter of hte liver, right lobe 12 cm, left lobe 8 cm
- 46. Spleeen • Splenic percussion sign – Right anterior axillay line and 12th intercostal space – Dullness at deep inspiration
- 47. Spleen Total vertical diameter • Percussion – Midaxllay line and 2.th intercostal – Located at 9-12th . costal spaces – Diameter: 6-8 cm
- 48. Traube Triangle Falsely Dullness: Cardiyomegaly, pleural effusion , Lung Ca pericardia effusion
- 49. Ascites
- 52. Paracentesis
- 53. Other methods of Ascites examination • Sensasyon de Flue (fluid thrill) • Ballotman
- 54. Palpation • Superficial Palpation: – How is the situation at the abdomen? – Are there any sensitive sides – Any mass – Ant dull – Localizations
- 55. Deep palpation: – Sensitive sides • Patient has defence ? • Muscular defense • Abdominal guarding – automically • Rebound • Rigidity – Mass lesions • Steely, smooth, subcutan, deep, with pain, or painless
- 56. Liver Palpation • Diameter – Midclavicular 6-12 cm right lobe – 4-8 cm left lobe – Use midsternal line for left lobe • Steely, fibrotic, smooth • Any pain • Nodüler, irregüler
- 58. Large Hepatomegaly • Amiloidosis • Malign infiltration • Polycystic liver • Congestive Heart Failure – Hepatojuguler reflax • Faty liver
- 59. Spleen Palpation
- 60. Large Splenomegaly • KML infiltration • Non-Hogkin lymphoma • Kala azar Disease (Leismaniasis) • Agnogenic Myeloid Metaplasia
- 61. • Murphy’s sign: Tenderness over the gall bladder • Palpable gall bladde: Courvoisier gallbladder Pankreas Ca at the head of it
- 62. Kidney Palpation
- 63. Conclusion • Repeat again and again • Spend more time at internal medicine ward • Performphysical examinaitonto your parents • My kid is a doctor, oh ı am so happy • Of course ask any time you want • Look at B.Bates
- 64. Unutmamak lazım ki doktorun çok hastası olabilir, ancak size gelen hastanın tek doktoru var o da sizsiniz.
Editor's Notes
- Regurgitation should be distinguished from vomiting, the term applied to the ejection of gastroduodenal content preceded by nausea and accompanied by the abdominal muscular activity. Esophageal regurgitation is rarely acidic, on the other hand gastric regurgitation is frequently acidic.
- Abdominal distention refers to increased abdominal girth—the result of increased intra-abdominal pressure forcing the abdominal wall outward. Distention may be mild or severe, depending on the amount of pressure. It may be localized or diffuse and may occur gradually or suddenly. Acute abdominal distention may signal life-threatening peritonitis or acute bowel obstruction. Abdominal distention may result from fat, flatus, a fetus (pregnancy or intra-abdominal mass [ectopic pregnancy]), or fluid. Fluid and gas are normally present in the GI tract but not in the peritoneal cavity. However, if fluid and gas can&apos;t pass freely through the GI tract, abdominal distention occurs. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid, or air from perforation of an abdominal organ. Abdominal distention doesn&apos;t always signal pathology. For example, in anxious patients or those with digestive distress, localized distention in the left upper quadrant can result from aerophagia —the unconscious swallowing of air. Generalized distention can result from ingestion of fruits or vegetables with large quantities of unabsorbable carbohydrates, such as legumes, or from abnormal food fermentation by microbes. Don&apos;t forget to rule out pregnancy in all females with abdominal distention.
- The globus sensation, a sense that something is lodged continuously in the throat, must be differentiated from dysphagia or odynophagia before embarking on an unnecessary investigation . The globus sensation typically is sensed midline at the laryngeal level, but can lateralize in as many as 20% of patients. The sensation classically is reported as a “lump in the throat,” but feeling that a foreign body, sharp object, or food particle is lodged also is a compatible description. Most notably, globus sensation does not interfere with swallowing; although one in five patients with globus sensation notes something abnormal during food swallows, the original symptom abates during the process. Globus may accompany a variety of disorders that cause dysphagia, such as GERD and distal esophageal motility disorders. Furthermore, up to 45% of the general population may have intermittent symptoms resembling globus. This symptom most often reflects a functional gastrointestinal disorder. In some instances globus is associated with substantial anxiety; that anxiety is sometimes thought to be etiological (globus hystericus).
- Patients consider themselves to be constipated when they pass stools more infrequently, require more effort for passage (“straining”), or experience more pain or discomfort during passage than they think appropriate. Difficult evacuation of feces, especially when the consistency of stools is softer than normal, is more likely to be caused by disorders of the pelvic floor or anorectum than by slow colonic transit.
- A decrease in stool consistency or fluidity and stools that cause urgency or abdominal discomfort are more likely to be termed diarrhea by patients than increases in frequency alone.
- A bilateral, coarse movement, asterixis is characterized by sudden relaxation of muscle groups holding a sustained posture. This elicited sign is most commonly observed in the wrists and fingers, but may also appear during any sustained voluntary action. Typically, it signals hepatic, renal, or pulmonary disease.
- Angular cheilitis (also called cheilosis or angular stomatitis) is an inflammatory lesion at the labial commissure, or corner of the mouth, and often occurs bilaterally. The condition manifests as deep cracks or splits. In severe cases, the splits can bleed when the mouth is opened and shallow ulcers or a crust may form.
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