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ABDOMEN. Anatomical landmark in clinical exploration of the abdomen.

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Presentation on theme: "ABDOMEN. Anatomical landmark in clinical exploration of the abdomen."— Presentation transcript:

1 ABDOMEN

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

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  Good light  Relaxed patient  Correct exposure. Whole abdomen to the level of symphisis and inguinal region  Protect the genital areas  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

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

57 Percussion  Pain induced by vibration Giordano maneuver Auscultation -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 – 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 – 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 – 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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