1. The Abdomen:2nd Edition Presented by Guy Havice

2. Quick Review

3. The majority of a persons organs are located within the abdominal cavity.

4. To help organize organ placement, the abdomen is split into quadrants

5. Anatomy of the 4 quadrants…

6. Abdominal Exam • Percussion • Tone in all quadrants • Liver and spleen borders • Solid masses Palpation • Tenderness /muscle guarding • Size and shape of organs • Solid masses Observation • General appearance of the abdomen • Patient's movement (or lack thereof) Auscultation • Performed before percussion or palpation • Bowel sounds – Diaphragm • Vascular sounds – Bell

7. Abdominal exam will only give part of the information you need for diagnosis.

8. Abdominal Disorders Bowel • Inflammatory Bowel Disease • Irritable Bowel Syndrome • Peptic Ulcer Disease • Gastroesophageal Reflux Disease

9. Inflammatory bowel disease is comprised of two major disorders: • Ulcerative Colitis • Crohn’s Disease

10. Ulcerative Colitis

11. Ulcerative colitis – an episodic, inflammatory disease of the colon and rectum characterized by bloody diarrhea

12. Signs / Symptoms of Ulcerative Colitis • Mild – disease is confined to the rectum • occasional rectal bleeding associated with passage of mucus • mild diarrhea • Moderate – inflammation extending to the splenic flexure • frequent loose, bloody stools (up to 10 per day) • abdominal discomfort • low grade fever • Severe – extensive colon involvement • frequent loose, bloody stools (greater than 10 per day) • severe cramps • rapid weight loss • fever

13. Crohn’s Disease

14. Crohn’s disease – an inflammatory disease that most commonly occurs in the terminal ileum • However, it can affect any part of the gastrointestinal tract

15. Patients often have an alternating inflammation pattern – normal bowel separating diseased bowel • The deeper muscular layers and regional lymph nodes are usually involved • may result in perforation or obstruction

16. Signs / Symptoms of Crohn’s Disease • Clinical presentation is more variable than ulcerative colitis because of the irregular pattern of lesion, and deeper tissue involvement • diagnosis is usually established with endoscopic findings • Typical S/S include: • fatigue, weight loss, and fever • prolonged diarrhea with crampy abdominal pain, with or without gross bleeding • Physical exam may show nonspecific S/S, be sure to review the patients medical history, including family history

17. Ulcerative Colitis vs. Crohn’s Disease • Ulcerative Colitis – large intestine involvement • Crohn's Disease – small intestine involvement

18. Irritable Bowel Syndrome (IBS)

19. Irritable bowel syndrome is defined as lower abdominal pain, and altered bowel habits (constipation, diarrhea, or alternating pattern of both) in the absence of any structural or chemical factors which might explain the symptoms.

20. Signs / Symptoms of IBS • Vague S/S – lower abdominal pain, and altered bowel habits in the absence of any factors which might explain the symptoms • Criteria methods for diagnosis of IBS • Manning Criteria • Rome Criteria

21. The predictive ability of the Manning criteria is reduced in the elderly, and in men Manning Criteria

22. The Rome criteria has been criticized for overemphasis on abdominal pain Rome Criteria

23. Peptic Ulcer Disease (PUD)

24. Peptic ulcers are defects in the gastrointestinal mucosa • The ulcers most often develop in the duodenum and stomach Endoscopy showing duodenal ulcer

25. Two common forms of peptic ulcers: • Helicobacter pylori – associated • NSAID – induced

26. Signs / Symptoms of Peptic Ulcers • Epigastric burning pain • Abdominal fullness or cramping • Nocturnal pain – circadian stimulation of acid secretion • Ulcer location • Gastric ulcer – food may precipitate ulcer pain • Duodenal ulcer – pain usually occurs 1-3 hours after meals

27. Gastroesophageal Reflux Disease (GERD)

28. GERD is the result of acid movement from the stomach into the esophagus. • Often due to a prolonged acid clearance, resulting in a increased contact time with the esophageal mucosa.

29. Signs / Symptoms of GERD • Typical • heartburn • belching • regurgitation • Atypical • asthma • chronic cough • chest pain

30. Abdominal Disorders Liver • Hepatitis • Cirrhosis

31. Hepatitis

32. Hepatitis is inflammation of the liver, usually from a viral infection, but sometimes from toxic agents

33. Signs / Symptoms • Jaundice – yellow discoloration of the skin • Icterus – yellow discoloration of the sclera • Fatigue • Upper abdominal pain • Loss of appetite • Nausea • Fever

34. Three main types of viral hepatitis: • Hepatitis A, B and C Transmission • Hepatitis A – transmitted through human feces ingestion • Hepatitis B & C – transmitted through body fluids of an infected person (sex, needle sharing, childbirth)

35. CDC Fact Sheet – Hepatitis A • No chronic infection • About 15% of people infected will have prolonged symptoms over a 6-9 month period • One-third of Americans have evidence of a past infection

36. Average yearly reported cases of hepatitis Aper 100,000 population, 1987-1997 White <5 Yellow 5-10 Orange 10-20 Red >20

37. CDC Fact Sheet – Hepatitis B • Highest rate of disease occurs in 20-49-year-olds • Estimated 30% of infected persons have no signs or symptoms • Estimated 1.25 million chronically infected Americans • Death from chronic liver disease occurs in 15-25%

38. CDC Fact Sheet – Hepatitis C • Estimated 80% of infected persons have no signs or symptoms • Estimated 3.9 million (1.8%) Americans have been infected with HCV • Death from chronic liver disease occurs in 1-5% • Leading indication for liver transplant www.cnn.com 3/21/02

39. Cirrhosis

40. Cirrhosis is the term used to collectively describe the signs and symptoms resulting from diminishing functional hepatocytes and accumulation of fibrous tissue within the liver • Cirrhotic liver: • Portal Hypertension • Esophageal Varices • Ascites

41. Portal Hypertension • It becomes difficult for blood to flow through a cirrhotic liver . As a result, esophagus veins not accustomed to carrying large volumes of blood become engorged

42. Esophageal Varices • The risk of bleeding from esophageal varices is ~30% in the first year after identification • Patients who have bled once have a 70% chance of rebleeding, and approximately one third of further bleeding episodes are fatal Signs / Symtpoms • Vomiting blood • Black tarry stools • Light-headedness

43. Ascites • Ascites is accumulation of fluid in the peritoneal cavity • ~50% of patients will develop ascites within 10 years of the diagnosis of cirrhosis • The fluid retention is due to several vascular and biochemical abnormalities relating to a cirrhotic liver

44. Ask the patient to place their hand over the center of the abdomen. They should press firmly so that the subcutaneous tissue and fat do not jiggle. • Place your hands on opposite sides of the umbillicus. Next, firmly tap on the abdomen with your right hand while your left remains against the abdominal wall. • If there is a lot of ascites present, you may be able to feel a fluid wave Assessing for a fluid wave

45. Abdominal Disorders Spleen • Mononucleosis

46. Mononucleosis

47. Mononucleosis is characterized by severe fatigue, headache, low grade fever. • The infection may continue and development into tonsillitis and/or pharyngitis, cervical lymph node enlargement and tenderness, and moderate to high fever

48. Its due to the Epstein-Barr virus (EBV) – a widely disseminated herpesvirus • EBV is associated with a number of infections, complications, and a variety of malignancies • The majority of primary EBV infections go unnoticed • Approximately 90 to 95 percent of adults are EBV-seropositive

49. The spleen blood vessels are lined with macrophages which filter the blood (old RBCs and platelets). • In mononucleosis, the macrophages in the spleen become overactive and trap a higher number of cells. In the process, the spleen becomes enlarged.

50. Splenic rupture is rare but a potentially life-threatening complication • estimated 1-2 cases per thousand • almost all cases have been in males