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Presentation on theme: "ABDOMEN."— Presentation transcript:


2 Anatomical landmark in clinical exploration of the abdomen

3 What is normal?

4 Bony landmarks Lower ribs Spine Iliac bone Inguinal ligament
Pubic bone Sacrum – pelvic aperture

5 Anatomic landmarks Xifoid apendix Costal margins
Spina iliaca antero-superior Simphisis pubis Umbilical scar

6 Topography of abdomen

7 Topography of abdominal wall
Vertical lines Midline between pubis and antero-superior iliac spine Horizontal lines Through both iliac spines Subcostal (lower most part of costal margin)

8 Antero-lateral wall. Essentials of anatomy. I
Skin Subcutaneous tissue Vascular and nervous structures Umbilical scar Inguinal arrea

9 Antero-lateral wall. Essentials of anatomy II
Muscles and corresponding fascia (internal and external oblique, transversalis and rectus abdomini) Linea alba Posterior aspect of the inguinal region Umbilical region Vessels and nerves

10 Fascial structures in the middline

11 Posterior wall. Essentials of anatomy
Diaphragm Diaphragmatic communications Muscles of the lumber region Muscles of the pelvic diaphragm

12 Arteries of the abdominal wall

13 Veins of the abdominal wall

14 Nerves of the abdominal wall

15 Inguinal region Skin projection of the region (triangle)
Inguinal ligament Lateral aspect of rectus abdomini Perpendicular through the middle of ilio-pubic line

16 Inguinal region

17 Inguinal region

18 Examination of the abdomen The abdominal wall
Inspection Palpation Percussion Auscultation

19 Inspection Shape Asymmetry Changes in decubitus and standing Scars
Cutaneous changes Vascular pattern

20 Palpation - superficial
The structure of the abdominal wall Sensibility Cutaneous reflexes Subcutaneous tissue Weak points and areas Muscular structures Check muscle position within the structures

21 Clinical exploration of abdominal organs

22 Anatomic landmarks

23 Sagital and transverse sections

24 Serial tomographic section

25 Clinical examination of the abdomen
Decubitus + pillow Arms close to the body Ask patient for painful areas and examine them later Warm hands Avoid sudden movements Distract his attention if anxious Follow his reactions – face changes Good light Relaxed patient Correct exposure. Whole abdomen to the level of symphisis and inguinal region Protect the genital areas

26 Methods Anamnesis Inspection Palpation Percution Auscultation
Rectal and vaginal examination

27 History taking PAIN Onset and time changes Location How significant
Radiation of pain Association with other symptoms

28 Types of abdominal pain
Hollow organs Paroxistic crampy pain Difficult to pinpoint Associated with peristaltic movement Pacient is agitated – would not find a relaxed position Perioneal inflamation Constant or steadily increasing pain Well circumscribed Patient will be reluctant to move as it increases pain

29 Radiated pain Billiary colic Duodenal ulcer Renal pain
Genital originated pain

30 Essentials of anamnesis
Nausea, vomiting, diarrhea, constipation Stool – melena, blood, Vomiting – blood, digested blood Urinary symptoms : frequency, discomfort Weight loss Sexual history Sexual activity, contraceptive pills, last cycle Any fertile women may be pregnant Pregnancy test if in doubt

31 INSPECTION Skin Venous pattern Umbilical scar Shape of abdomen
Peristaltic movement Pulsations Mobility during cough or respiration

32 AUSCULTATION Preferable before palpation – stimulates movements
Listen for sounds produced by bowels Vascular abnormal sounds (stenotic vessels)

33 PERCUSSION First orientation – “in cross” in four quadrant
Map of the abdomen Generalized/localized meteorism Dull area localized +/- movable Signs of peritoneal irritation

34 PALPATION Essential and the most important
One or two hands are used for deep palpation depending mostly on muscular tonus Systematic, avoid very painful areas at the beginning After a screening examination – characterize different organs which are accessible Sudden decompression

35 Rectal examination Sensible area
Put yourself (only in theory…) in his/her place He/she should trust you A special room – respect his/her dignity

36 Rectal examination Lateral decubitus or in all fours
Explain what you do. It is not painful nor pleasant All you need is a glove and lubricant

37 Rectal examination Inspection: Eritematous lesions
Incontinence for feaces Scars Fistula – puss Tumors Ulcerations Fissura in ano

38 Rectal examination Palpation: Bimanual examination
Sphyncter tonus Fissura in ano Prostate Tumors Rectal content Cervix and uterus Peritoneal “Coul de sac” or Douglas pouch Bimanual examination Look for faces aspect on you glove

39 Exploration of the liver

40 Inspection Volume Venous collateral circulation
Uniform distension in ascites Asymmetric distension in tumors Venous collateral circulation

41 Inspection Umbilical hernia Spider hemangioma Gynecomastia Rinofima

42 Auscultation More often unhelpful
Before ascites there is a period with paretic distension with dimished intestinal sounds Large tumors with lare tributaries – arterial murmurs Acoustic finding of liver edge

43 Percussion Evaluate the area of liver dullness
If significantly increased you need to find both edges In general the liver is underestimated

44 Percussion Meteorism before ascites Movable dullness
Iceberg sign Wave sign Prehepatic tympanism Sdr. Chilaiditi Pneumoperitoneum Situs inversus

45 Palpation Inferior limit of the liver Tumors Limits Morphologic aspect
Sensibility Tumors charcaterize

46 Palpation

47 Rectal examination Faeces with melena aspects
Fresh Old Large volume internal hemorrhoids (portal hypertension) Metastasis in the Douglas pouch

48 Clinical exploration of the spleen

49 Inspection Changes determined by anemia or hematological diseases
Abdominal deformities Peritoneal irritation in trauma with blood in peritoneum

50 Percussion. – dull area of the spleen
Percussion – dull area of the spleen - movable dullness – liquid in peritoneum

51 Palpation

52 Auscultation Murmurs projected on the area of the splenic artery in stenosis, arterio-venous fistula, aneurism

53 Rectal examination Douglas shout Hemoperitoneum due to splenic rupture
Douglas pouch is full and painful

54 Clinical exploration of the kidney

55 Inspection Situated deep in the back structures
Deformity is unusual, only in very large tumors Peripheric signs of chronic renal failure Exteriorization of retroperitoneal hematoma

56 Palpation Bimanual Forced inspiration – the kidney descends
Costo-vertebral angle Anterior Forced inspiration – the kidney descends Ectopic kidney Sensibility Ureteral points: Superior Middle Inferior

57 Percussion Auscultation Pain induced by vibration Giordano maneuver
-Murmurs generated by stenotic arteries in patients with arterial hypertension

58 Exploration of the aorta
Bimanual palpation to evaluate the lateral margins and the transverse diameter Fat tissue may produce error in measurements Auscultation for murmurs Palpate iliac arteries for puls

59 Exploration of the digestive tract – hollow organs

60 Anamnesis Might be completely non-characteristic Pain
Location and character may help in orientation for organ Topographic delimitation helps Abnormalities in bowel movements Changes in aspect of stool Other symptoms Weight loss

61 Inspection Changes in abdominal volume Peristaltic movements
In intestinal obstruction the volume increases significantly Changes in symmetry of the abdomen You may even see intestinal tumors Marked asymmetric distention of the abdomen in intestinal volvulus Peristaltic movements Spontaneous Induced: Kussmaul’s sign Significant or sugestive cutaneous signs Anemia Tumors frequently associated with digestive lesions Rendu-Osler

62 Auscultation Absence of intestinal sounds
Paralytic ileus due to diverse medical problems Accentuate peristaltic sounds Mechanic obstruction Might help to appreciate the area with the obstruction

63 Percussion Meteorism Tympanism
Aeric distension of bowell loops above obstruction In dynamic ileus the aspect of a chase table Tympanism In aeric distension of the stomach Acute gastric dilation Pyloric stenosis Combination of liquid and air in stomach produces a specific sound

64 Palpation Screening for a large palpable tumor Locate in quadrants
Suggest a possible organ as a source of the tumor Superficial and deep mobility Dimensions Shape

65 Rectal examination Lesions in the perineum Tumors of the rectum
E.g. in Crohns disease – fistula in ano Inferior rectal cancer may appear on inspection Tumors of the rectum Malignant – limits are important Benign – some are every soft – might be missed Tumors in the Douglas pouch Tumors from organs outside rectum Content – blood or mucus on the glove

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