The Abdomen/Rectal

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The Abdomen/Rectal
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The Abdomen

• Anatomy and Physiology

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The Abdomen

• Anatomy and Physiology

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The Abdomen
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Gastrointestinal Bleeding

• Upper
• Esophagus, stomach, duodenum
• Causes
• Peptic ulcers- localized erosions of wall of
  digestive tract leading to damage of blood
  vessels and bleeding
• Gastritis- general inflammation of stomach wall
  which can result in bleeding
• Esophageal varices- swelling in veins in
  esophagus or stomach and usually associated with
  alcoholic liver cirrhosis
• Mallory-Weiss tears- a tear in the esophagus or
  stomach wall after vomiting, forceful coughing,
  laughing, lifting, childbirth, or recent binge
  drinking
• Also, ingestion of caustic poisons or stomach
  cancer

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Gastrointestinal Bleeding

• Lower
• Other segments of small intestine, large
  intestine, rectum, anus
• Causes
• Diverticulosis- Small outpouchings from colon
  wall, usually in weakened area of bowel
• Angiodysplasia- Malformation in blood vessels of
  wall of GI tract. Often associated with elderly
  chronic kidney failure
• Polyps- Noncancerous tumors of GI tract that
  occur mostly in those gt40 y/o. Small number
  become cancerous
• Hemorrhoids- Swelling of veins around rectum,
  often from straining
• Anal fissures- tears in anal wall often from
  forced straining of hard stool
• Blood in stool can results from cancer,
  inflammatory bowel disease, infectious diarrhea

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Gastrointestinal Bleeding

• Acute
• Vomiting blood (hematemesis) (franks vs. coffee
  ground)
• Bloody bowel movement (hematochezia)
• Black tarry stools (melena)
• Fatigue, weakness, shortness of breath, pale
  appearance
• Associated with blood loss
• Long-term
• Fatigue
• Anemia
• Black stools

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Peritonitis

• An inflammation of the peritoneum the serous
  membrane that lines part of the abdominal cavity
  and viscera
• Causes
• Peritoneal dialysis-An infection may occur during
  peritoneal dialysis due to unclean surroundings,
  poor hygiene or contaminated equipment.
• Ascites- Diseases that cause liver damage, such
  as cirrhosis, can result in a large amount of
  fluid buildup in your abdominal cavity, which is
  susceptible to bacterial infection.
• A ruptured appendix, stomach ulcer or perforated
  colon- Allow bacteria to get into the peritoneum
  through a hole in your gastrointestinal tract.
• Pancreatitis-Inflammation of your pancreas
  complicated by infection may lead to peritonitis
  if the bacteria spread outside the pancreas.
• Diverticulitis-Infection of small, bulging
  pouches in your digestive tract may cause
  peritonitis if one of the pouches ruptures,
  spilling intestinal waste into your abdomen.
• Trauma-Injury/trauma may cause peritonitis by
  allowing bacteria or chemicals from other parts
  of your body to enter the peritoneum.

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Peritonitis

• Common symptoms
• Acute abdominal pain
• Abdominal tenderness
• Abdominal guarding
• Rigidity
• Abdominal distention
• Fever chills
• Nausea/vomiting
• Anorexia
• Decreased bowel sounds
• Inability to pass stool or gas
• Oliguria
• Fatigue

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Health History- GI

• Pain- Abdominal or rectal
• OLDCART
• Normal bowel habits/Stool character
• Presence of any of the following
• Indigestion
• Belching (more than usual)
• Anorexia/Nausea/Vomiting
• Weight loss
• Difficulty swallowing (dysphagia)
• Flatulence (more than usual)
• Diarrhea
• Constipation

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Health History-GI

• Medications
• Aspirin, ibuprofen, steroids, antibiotics,
  laxatives, cathartics, codeine, iron preparations
• Abdominal surgery, trauma, or diagnostic tests of
  GI tract
• Personal or family history of
• Cancer, alcoholism, polyps, chronic inflammatory
  bowel disease.
• Chance that pregnant?
• Risk factors for HBV exposure
• Health care occupation, hemodialysis, IV drug
  use, household/sexual contact with HBV person,
  unprotected sexual practices

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Health History-GU

• Urinary/Renal
• Suprapubic pain
• Dysuria, urgency, or frequency
• Hesitancy, decreased stream in males
• Polyuria (gt3L in 24 hours) or nocturia
• Urinary incontinence
• Hematuria (trace or gross)
• Kidney or flank pain
• History of kidney disease

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The Abdomen Techniques of Examination

• Have Patient
• Empty bladder
• Lye in Supine position
• Arms to the side or laying across
• chest
• Bend knees
• Point to any painful area
• Examiner
• Warm hands and stethoscope
• Watch patients face for signs of pain
• Distract patient if necessary
• Begin palpation with patients hand under yours
  if patient is ticklish, then slip your hand
  underneath directly

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Inspection

• Demeanor
• Knees drawn up, motionless, restlessness
• Contour of the abdomen
• Distention causes
• Obesity, air/gas, ascites, ovarian cyst, uterine
  fibroids, pregnancy, feces, tumor
• Symmetry
• Bulges, masses, asymmetric shape
• Pulsations or movement

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Inspection

• Skin
• Scars, striae, dilated veins, rashes, lesions, or
  ostomy
• Umbilicus
• Assess for location, discoloration,inflammation,
  or hernia
• Everted- Ascites, pregnancy, mass, hernia
• Sunken- Obesity
• Bluish- Cullins sign indicator of intraabdominal
  bleeding
• Have pt raise head
• Abdominal wall mass, hernias, muscle separation

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Auscultation

• Listen to bowel sounds using diaphragm of
  stethoscope (high pitch).
• Begin in right lower quadrant and move clockwise
  to all 4 quadrants.
• Temporarily turn off GI tubes connected to suction

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Auscultation

• Bowel sounds
• Normal/Active - high pitched gurgling noise.
  Approx 5-35 sounds per minute, or at least 1
  every 5-15 seconds.
• Hypoactive Often soft and widespread. Less than
  5 BS per minute.
• Post operatively following general anesthesia
• Absent No bowel sounds heard. Must listen for 5
  minutes before concluding that bowel sounds are
  absent
• Late stage bowel obstruction, paralytic ileus,
  peritonitis
• Hyperactive - Loud, gurgling, frequent sounds.
  Greater than 35 BS a minute.
• Inflammation of bowel, anxiety, diarrhea,
  bleeding, excessive ingestion of laxatives, rxn
  of intestines to certain foods
• Borborygmi Loud stomach growling, rumbling
  sound produced by movement of gas in stomach and
  intestines. Heard with or without stethoscope

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Auscultation

• Arterial sounds for bruits
• Aorta
• Renal artery
• Iliac artery
• Femoral artery
• Use Bell

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Percussion

• Performed to detect fluid, gaseous distention,
  and masses, and to assess position and size of
  liver and spleen.
• Percuss in all 4 quads for tympany and dullness
• Large dull areas may indicate mass or enlarged
  organ

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Percussion

• The Kidney
• Assessing for costovertebral angle tenderness
  (CVA)
• Normal non-tender
• Tenderness occurs in acute infection
  (pylonephritis)

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Palpation- Light

• Press fingertips gently into abdominal wall,
  approx ½ inch
• Use one hand approach
• Assess for abdominal tenderness, muscle
  guarding/rigidity, pulsations, large or
  superficial masses

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Palpation-Light

• Routinely check the bladder for distention if
• Unable to void
• Incontinent
• Indwelling catheter is not draining well
• Bladder non-palpable without
• tenderness.

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Palpation - Deep

• Use two hand approach press approx 1-3 inches.
• Assess masses, tenderness, and organ enlargement.
• Masses Note location, size, shape, consistency,
  tenderness, pulsation.
• Never over surgical incision, extremely tender
  organs, or pulsatile mass

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Palpation - Deep

• Organs liver
• Liver- Place left hand behind patient parallel to
  right 11th and 12th rib. Place right hand lateral
  to rectus muscle and well below lower border of
  liver. Press in and up.
• Ask patient to take deep breath. On inspiration
  normal liver palpable about 3cm below right
  costal margin in the midclavicular line
• Can use hooking technique
• Note tenderness (normally may be a little
  tender), should feel soft/firm, sharp, and
  regular with a smooth surface
• http//www.youtube.com/watch?vSi0PHV991t0feature
  related

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The Abdomen Abnormal liver
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Assessing for Cholecystitis

• Hold fingers under liver border
• Ask person to take deep breath
• Assess for sharp pain and abruptly stopping
  inspiration midway
• Negative Murphys sign (complete deep breath
  without pain)

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Assessing for Ascites

• A protuberant abdomen with bulging flanks
  suggests ascites
• Testing for shifting dullness
• Map borders between tympany and dullness. Ask
  patient to roll to side. Percuss and mark borders
  again. In ascites dullness shifts to more
  dependant side

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Assessing for Ascites

• Test for fluid wave
• Ask patient or assistant to press edges of both
  hands firmly down on midline of abdomen.
• While you tap one flank sharply with fingertips
  feel for fluid pulse on opposite flank with other
  hand

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Assessing for Appendicitis Peritonitis

• Rebound Tenderness- Pain upon removal of pressure
  rather than application
• Rovsings sign- Rebound tenderness on the left
  lower quadrant
• Psoas sign- Pain with flexion of the right leg at
  the hip
• Obturator sign Pain with rotation of the right
  leg internally at the hip

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Rectum/Anus

• Rectal/Anus exam includes inspection and
  palpation
• Position patient in left lateral or Sims
  position
• For prostate exam have bend over forward with
  hips flexed and upper body resting on table or
  bed.
• Drape the patient to avoid unnecessary exposure
  of genitalia

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Rectum/Anus- Inspection

• Perianal areas/Anus
• Masses/Rectal Prolapse
• Lesions
• Venereal warts, herpes, syphilitic chancre, or
  carcinoma
• Hemorrhoids
• Ulcers/Fissures/Fistulas
• Inflammation/Rashes
• Excoriation
• Use clock reference to describe lesion location

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Rectum/Anus- Palpation

• Lubricate gloved index finger prior to insertion
• As sphincter relaxes gently insert finger towards
  umbilicus
• Do not force finger
• Rotate hand clockwise
• Feel for tenderness, induration, irregularities/
  nodules

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Colorectal Cancer

• Early stages often without symptoms so screening
  is key
• Change in frequency of bowel movements
• Constipation or diarrhea
• Pencil stools/feeling cant empty bowel
  completely
• Hematochezia or melena
• Abdominal discomfort, bloating, frequent gas
  pains, or cramps
• Unintentional weight loss
• Anorexia
• Fatigue

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Anatomy of the Prostate Gland and Seminal
Vesicles
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Prostate Gland

• Prostate gland
• Size
• Shape
• Surface
• Consistency
• Sensitivity

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Sample Charting
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Sample Charting (cont.)