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Chapter 22: Abdomen ⭐

📘Abdomen Extra Notes

Internal Anatomy

General Overview

  • Inside the abdominal cavity, all internal organs are called viscera.
  • The peritoneum lines the abdominal wall (parietal peritoneum) and covers the surface (visceral peritoneum) of most organs.
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Types of Viscera

  • Hollow Viscera – they have a hole or space inside:
    • Stomach
    • Gallbladder
    • Small intestine
    • Colon
    • Bladder
  • Solid Viscera – maintain a characteristic shape:
    • Liver
    • Pancreas
    • Spleen
    • Adrenal glands
    • Kidneys
    • Ovaries
    • Uterus

Anatomical Divisions

  • The abdomen is divided into four quadrants:
    • Right Upper Quadrant (RUQ)
    • Left Upper Quadrant (LUQ)
    • Right Lower Quadrant (RLQ)
    • Left Lower Quadrant (LLQ)
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  • Midline organs:
    • Aorta
    • Uterus (if enlarged)
    • Bladder (if distended)
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Quadrant Contents

Developmental Competence: Pregnant Woman

  • Nausea and vomiting (“morning sickness”), also known as nausea and vomiting of pregnancy. The cause is unknown; may be due to hormone changes, such as production of human chorionic gonadotropin (hCG)
  • “Acid indigestion” or heartburn (pyrosis)
    • Caused by esophageal reflux
  • Enlarged uterus leads to displacement of abdominal organs
  • During pregnancy, GI motility slows down because hormones like progesterone relax smooth muscles. This causes food to move more slowly through the intestines → delayed stomach emptying, less nutrient absorption, and constipation.
  • Constipation and increased venous pressure in lower pelvis → hemorrhoids
  • Skin changes: Linea nigra and Striae.

Developmental Competence: Aging Adult

  • Abdominal wall musculature relaxes.
  • GI system changes occur with aging but usually do not affect function unless disease is present.
  • Salivation decreases, leading to dry mouth and decreased sense of taste.
  • Esophageal emptying and gastric acid secretion are delayed.
  • Incidence of gallstones increases with age.
  • Liver size decreases, but most liver functions remain normal; however, drug metabolism is impaired.
  • Constipation is frequently reported.
  • ROME III standardizes symptom criteria for functional constipation.

Common Causes of Constipation (Older Adults)

  • Decreased physical activity
  • Inadequate intake of water
  • Low-fiber diet
  • Side effects of medications
  • Irritable bowel syndrome
  • Bowel obstruction
  • Hypothyroidism
  • Inadequate toilet facilities (difficulty ambulating to toilet may cause stool retention → stool becomes hard and difficult to pass)

Culture and Genetics

Lactose Intolerance

  • Lactase is the digestive enzyme needed for absorption of lactose (milk sugar).
  • Lactose-intolerant individuals experience abdominal pain, bloating, and flatulence after consuming milk products.
  • Ethnic variation:
    • 20–30% of whites
    • 70% of Mexican Americans
    • 80% of blacks
    • 100% of American Indians

Celiac Disease

  • Autoimmune disorder
  • Intolerant of gluten

Bowel Habits: Ask About

  • Frequency, color, consistency
  • Diarrhea or constipation
  • Any recent changes
  • Laxative use — type, amount, and frequency

Dysphagia

  • Meaning: Difficulty swallowing

Additional History for Adolescents

Ask about:

  • Dietary pattern for meals, snacks, and calorie consumption
  • Exercise pattern
  • Weight status (gain or loss)
  • Impact on activity and/or body changes
  • Influence of peers and family

Inspection of the Abdomen

Sequence and Preparation

  • Auscultate prior to palpation and percussion
    • This is done because percussion and palpation can increase peristalsis, which may lead to false interpretation of bowel sounds.
  • Use distraction to help the patient relax and facilitate muscle relaxation.

Inspection Components

  1. Contour
  2. Symmetry
  3. Umbilicus
  4. Skin

Pulsation or Movement

  • Normally, pulsations from the aorta may be seen beneath the skin in the epigastric area, particularly in thin individuals with good muscle wall relaxation.

Hair Distribution

  • Adult males: Diamond-shaped pattern
  • Adult females: Inverted triangle pattern

Demeanor

  • A comfortable person appears relaxed, with a benign facial expression and slow, even respirations while lying quietly on the examination table.

Auscultation of the Abdomen

Technique

  • Use the diaphragm endpiece of the stethoscope (bowel sounds are high-pitched).
  • Hold the stethoscope lightly against the skin—pressing too hard may stimulate extra bowel sounds.
  • Begin in the RLQ at the ileocecal valve area, because bowel sounds are normally always present there.

Bowel Sounds

  • Normal frequency: 5 to 30 times per minute
  • Abnormal sounds:
    • Hypoactive: Decreased sounds; may occur after abdominal surgery or with inflammation
    • Hyperactive: Loud, high-pitched sounds signaling increased motility
  • Borborygmus: The sound of hyperperistalsis (“stomach growling”)
  • A perfectly silent abdomen is uncommon—listen for 5 full minutes before deciding bowel sounds are completely absent.

Vascular Sounds

  • While auscultating, note the presence of vascular sounds or bruits.
  • A small percentage of healthy people may have a bruit.
  • Using firmer pressure, check over:
    • Aorta
    • Renal arteries
    • Iliac arteries
    • Femoral arteries
  • Especially important in people with hypertension.
  • Do not use auscultation to confirm nasogastric (NG) tube placement.
    • Evidence-Based Practice (EBP): Confirm initial placement by imaging study, and continue to assess by external tube length and pH of stomach aspirate.

Percussion of the Abdomen

General Tympany

  • Percuss in a clockwise pattern to assess general tympany, liver, and splenic dullness.

Costovertebral Angle (CVA) Tenderness

  • Located at the 12th rib.
  • A positive finding indicates inflammation of the kidney.

Palpation of the Abdomen

General Technique

  • Begin with light palpation, then proceed to deep palpation.
  • Inexperienced examiners may feel that the abdomen “all feels the same.”
  • Remember that some structures are normally palpable.
  • Mild tenderness is normal when palpating the sigmoid colon.
  • Any other tenderness should be investigated further.
  • If a mass is identified, first determine whether it is a normally palpable structure or an enlarged organ.

Normally palpable structures.

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Palpation of the Liver

Hooking Technique

  • An alternative method to palpate the liver:
    • Stand at the patient’s shoulder, facing their feet.
    • Hook your fingers under the costal margin and ask the patient to take a deep breath.
    • The liver edge may be felt as it descends during inspiration.

Liver Span — Scratch Test

  • A method to estimate liver size:
    • Place your stethoscope over the liver.
    • Gently scratch the skin moving upward from below the liver border.
    • The sound becomes louder when your finger passes over the liver’s edge.

Palpation of the Spleen

  • Normally, the spleen is not palpable.
  • It must be enlarged about three times its normal size to be felt.

Palpation of the Aorta

  • Using opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen, slightly left of midline.
  • Normally:
    • Width: 2.5 to 4 cm in adults.
    • Pulsates in an anterior direction.
  • A widened pulsation may indicate an abdominal aortic aneurysm (AAA).

Differentiating Ascites from Gaseous Distention

Fluid Wave Test

  • Used to detect free fluid (ascites) in the abdomen.
    • Ask the patient (or an assistant) to place the edge of their hand firmly along the midline of the abdomen.
    • Tap one side of the abdomen while feeling on the opposite side.
    • If fluid is present, a distinct wave of vibration will be felt across the abdomen.

Shifting Dullness Test

  • Used when ascites is moderate or large.
    • Percuss from the midline outward; note where the sound changes from tympany to dullness.
    • Have the patient turn to one side and repeat.
    • If dullness shifts, fluid is present.

Developmental Competence: The Aging Adult

  • Inspection:
    • May show increased deposits of subcutaneous fat on the abdomen and hips due to redistribution from extremities.
  • Musculature:
    • Abdominal muscles are thinner and less toned than in younger adults.
    • In the absence of obesity, peristalsis may be visible.
  • Palpation:
    • Organs (especially liver and kidneys) are easier to palpate due to a thinner, softer abdominal wall.
  • Liver position:
    • With distended lungs and a depressed diaphragm, the liver may be palpated 1–2 cm below the costal margin during inhalation.

Would you like me to turn this into a Notion study layout next (with emojis, highlights, and collapsible sections for “Tests” and “Aging Adult”)?