Week 10: Abdomen Anatomy and GI Problems PDF

WEEK 10: ABDOMEN        Describe the anatomy of the abdomen     **Landmarks for Abdominal Exam **   Abdominal venous patterns  Abdominal Arteries: Renal, Iliac, Femoral; Aorta   Alimen...

WEEK 10: ABDOMEN        Describe the anatomy of the abdomen     **Landmarks for Abdominal Exam **   Abdominal venous patterns  Abdominal Arteries: Renal, Iliac, Femoral; Aorta   Alimentary Tract: Mouth to Anus - Esophagus - Stomach: Fundus, Body, Pylorus - Small Intestine: Duodenum - Large Intestine: Cecum, Ileocecal valve, vermiform appendix, ascending, transverse, and descending colon  - Rectum  - Anal Canal -\> Anus Liver: RUQ, 4 lobes containing lobules which each lobule is made up of liver cells radiating around a central vein. Branches of portal vein, hepatic artery, and bile duct penetrate periphery of lobules - Bile secretion, Metabolism, Glucose -\> Glycogen, & Glucogenogenesis, Bile salts, Synthesizing fats from carbs & proteins, waste products of protein breakdown via hydrolysis converted to urea  - Hepatic artery transport blood to liver - Portal vein carry blood from digestive tract and spleen to liver  Gallbladder: Concentrates and stores bile  Pancreas: Exocrine gland, acinar cells - digestive enzymes to breakdown proteins, fats, and carbs. Endocrine gland - islet cells produce insulin & glucagon Spleen: LUQ, lymph organ, filter blood & produce lymphocytes + monocytes ; storage and release of blood  Kidneys, Ureters, and Bladder Vasculature: Abdominal portion of descending aorta -\> 2 common iliac arteries (splenic and renal arteries) supply respective organs -\> branch off within the abdomen  Obtain a pertinent health history for diagnosis of common gastrointestinal problems HISTORY OF PRESENT ILLNESS (HPI) [Abdominal Pain] - Onset and duration: sudden or gradual; persistent, recurrent, intermittent - Character: dull, sharp, burning, gnawing, stabbing, cramping, aching - Location: at time of onset, change over time, radiation to another area, superficial or deep - Associated symptoms: vomiting, diarrhea, constipation, passage of flatus, belching, jaundice, change in abdominal girth, weight loss or weight gain - Relationship to: menstrual cycle, change in menses, intercourse, urination, defecation, inspiration, change in body position, food or alcohol intake, stress, time of day, trauma - Recent stool characteristics: color, consistency, odor, frequency - Urinary characteristics: frequency, color, volume congruent with fluid intake, force of stream, ease of starting stream, ability to empty bladder - Medications: high doses of aspirin, steroids, nonsteroidal antiinflammatory drugs (NSAIDs) [Indigestion (Dyspepsia)] - Character: feeling of fullness, heartburn, discomfort, excessive belching, flatulence, loss of appetite, severe pain - Location: localized or general, radiating to back, arms or shoulders - Relationship to: amount, type, and timing of food intake; menses - Onset of symptoms: time of day or night, sudden or gradual - Symptom relieved by antacids, change in diet, rest, activity - Medications: antacids (calcium carbonate, H2 blockers, proton pump inhibitors) [Nausea, Associated With Vomiting, Particular Stimuli (Odors, Activities, Time of Day, Food Intake), and Menses] - Vomiting - Character: nature (color, bright red blood or coffee grounds, bilious, undigested food particles), quantity, duration, frequency, ability to keep any liquids or food in stomach - Associated symptoms: constipation, diarrhea, fever, chills, headache, nausea, weight loss, abdominal pain or cramping, heartburn - Relationship to: previous meal, change in appetite, medications, menses [Diarrhea] - Character: watery, copious, explosive; color; presence of blood, mucus, undigested food, oil, or fat; odor; number of times per day, duration; change in pattern - Associated symptoms: fever, chills, thirst, weight loss, abdominal pain or cramping, fecal incontinence - Relationship to: amount, type and timing of food intake, stressful life events or daily stressors - Travel history and/or ill contacts - Medications: laxatives or stool softeners; antidiarrheals [Constipation] - Character: presence of bright red blood, black or tarry appearance of stool; diarrhea alternating with constipation; accompanied by abdominal pain or discomfort - Pattern: last bowel movement, pain with defecation, change in consistency or size of stool - Diet: recent change in diet, intake of high-fiber foods, change in fluid intake - Medications: laxatives, stool softeners, iron, diuretics [Fecal Incontinence] - Character: stool characteristics, timing in relation to meals, number of episodes per day; occurring with or without warning sensation - Associated with: use of laxatives, presence of underlying disease (cancer, inflammatory bowel disease, diverticulitis, colitis, proctitis, - diabetic neuropathy, spinal cord injury) - Relationship to: fluid and dietary intake, immobilization - Medications: laxatives, stool softeners, diuretics [Jaundice] - Onset and duration - Color of stools or urine - Associated with abdominal pain, chills, fever - Exposure to hepatitis, use of illicit drugs, high-risk sexual activity - Medications: high doses of acetaminophen; antipsychotics, antiepileptics, antibiotics [Dysuria] - Character: location (suprapubic, distal urethra), pain or burning, frequency or volume changes - Associated fever or other systemic signs of illness: bacterial infection, tuberculosis, fungal or viral infection, parasitic infection - Increased frequency of sexual intercourse or high-risk sexual activity - Amount of daily fluid intake [Urinary Frequency] - Change in usual pattern and/or volume - Associated with dysuria or other urinary characteristics: urgency, hematuria, incontinence, nocturia; increased thirst, weight loss - Change in urinary stream; dribbling - Medications: diuretics [Urinary Incontinence] - Character: amount and frequency, constant or intermittent, dribbling versus frank incontinence - Associated with: urgency, previous surgery, coughing, sneezing, walking up stairs, nocturia, menopause - Medications: diuretics [Hematuria] - Character: color (bright red, rusty brown, cola-colored); present at beginning, end, or throughout voiding - Associated symptoms: flank or costovertebral pain, passage of wormlike clots, pain on voiding - Alternate possibilities: ingestion of foods containing red vegetable dyes (may cause red urinary pigment); ingestion of laxatives - containing phenolphthalein - Medications: aspirin, NSAIDs, anticoagulants, diuretics, antibiotics PAST MEDICAL HISTORY - Gastrointestinal disorder: peptic ulcer, polyps, inflammatory bowel disease, irritable bowel syndrome, intestinal obstruction, pancreatitis, hyperlipidemia - Hepatitis or cirrhosis of the liver - Abdominal or urinary tract surgery or injury - Urinary tract infection: number of episodes, treatment - Major illness: cancer, arthritis (steroids, NSAIDs or aspirin use), kidney disease, cardiac disease - Blood transfusions - Immunization status (hepatitis A and hepatitis B) - Colorectal cancer or related cancers-breast, ovarian, endometrial - Sexually transmitted infections (STIs) FAMILY HISTORY - Colorectal cancer and familial colorectal cancer syndromes-familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer (Lynch syndrome) - Gallbladder disease - Kidney disease: renal stone, polycystic disease, renal tubular acidosis, renal or bladder carcinoma - Malabsorption syndrome: cystic fibrosis, celiac disease - Hirschsprung disease (aganglionic megacolon) - · Familial Mediterranean fever (periodic peritonitis) PERSONAL & SOCIAL HISTORY - Nutrition: 24-hour dietary recall; food preferences and dislikes; ethnic foods, religious food restrictions, food intolerances, lifestyle - effects on food intake, use of probiotics or dietary supplements; voluntary and involuntary weight gain or loss - First day of last menstrual period - Alcohol intake: frequency, type, and usual amounts - Recent major stressful life events or chronic daily stressors: physical, social, and psychological changes - Exposure to infectious diseases: hepatitis, influenza; travel history; occupational or environmental exposures - Trauma: through type of work, physical activity, physical or emotional abuse, intimate partner violence, community, or neighborhood - violence - Use of illicit drugs - Tobacco use-smoking: frequency, amount, duration, pack-years INFANTS - Gestational age and birth weight (preterm and less than 1500 g at higher risk for necrotizing enterocolitis) - Passage of first meconium stool within 24 hours, constipation - Jaundice: in newborn period; exchange transfusions, prolonged use of total parenteral nutrition, phototherapy; exclusively breast-fed - infant; appearance later in first month of life - Vomiting: increasing in amount or frequency, forceful or projectile (pyloric stenosis), blood in emesis, back arching (gastroesophageal - reflux); associated with intermittent abdominal pain or drawing up of the legs (intussusception) - Diarrhea, colic, failure to gain weight, weight loss, steatorrhea (malabsorption) - Abdominal distention (with or without pain) CHILDREN - Constipation: toilet training methods; soiling; diarrhea; abdominal distention; size, shape, consistency, typical frequency, and time of - last stool; rectal bleeding; painful passage of stool - Dietary habits: lack of fiber in diet, change in appetite, daily fluid intake; pica (eating non-nutritive substances like ice or soil) - Abdominal pain: splinting of abdominal movement, resists movement, keeps knees flexed - Psychosocial stressors: home, school, neighborhood, and peers PREGNANT PATIENTS  - Urinary symptoms: frequency, urgency, nocturia (common in early and late pregnancy); burning, dysuria, odor (signs of infection) - Abdominal pain: weeks of gestation (pregnancy can alter usual location of pain) - Fetal movement - Contractions: onset, frequency, duration, intensity; accompanying symptoms; lower back pain; leakage of fluid, vaginal bleeding OLDER ADULTS - Urinary symptoms: nocturia, change in stream, dribbling, incontinence - Change in bowel patterns, constipation, diarrhea, fecal incontinence - Dietary habits: inclusion of fiber in diet, change in ability to tolerate certain foods, change in appetite, daily fluid intake Identify common abdominal symptoms and risk factors associated with gastrointestinal problems Risk Factors for Colon Cancer - Age older than 50 years - Family history of colorectal cancer or adenomatous polyps in one or more first-degree relatives (higher risk if relative was diagnosed before 45 years) - Family history of syndromic colon cancer, including hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome from a mutation in the MLH1 or MSH2 gene, familial adenomatous polyposis (FAP) from mutations in the APC gene, which includes - Turcot syndrome (associated with brain tumors), and Gardner syndrome (associated with non-cancer tumors of skin, soft tissue and bones) - Family history of Peutz-Jeghers syndrome caused by mutations in STK11 (LKB1) gene (affected individuals often have freckles around the mouth and hamartomas in digestive tract); and MYH-associated polyposis (MAP) caused by mutations in the MYH gene - Personal history of colon cancer, adenomatous polyps, inflammatory bowel disease \[IBD\] (Crohn\'s disease, ulcerative colitis \[UC\]) - African American race - Jews of Eastern European descent (Ashkenazi Jews) - Diet: low-fiber, high in red meat, processed meats, and foods fired, broiled, grilled increases risk; diet high in fruits and vegetable decreases risk - Overweight and obesity - Diet high in red meats and processed meats - Smoking cigarettes - Physical inactivity - Heavy alcohol use - Type 2 diabetes (independent of overweight/obesity) [Risk Factors for Viral Hepatitis] [Conditions Producing Acute & Chronic Abdominal Pain Charts]  [Some Causes of Pain Perceived in Anatomic Regions Charts]  [Abdominal Signs w/ Common Abdominal Conditions Chart ]  - Findings in Peritoneal Irritation - Involuntary rigidity of abdominal muscles - Tenderness and guarding - Absent bowel sounds - Positive obturator test - Positive iliopsoas test - Rebound tenderness (Blumberg sign and McBurney sign) - Abdominal pain on walking - Positive heel jar test (Markle sign) - Right lower quadrant pain intensified by left lower quadrant abdominal palpation (Rovsing sign) - Ectopic Pregnancy - Dramatic change from mild, even vague abdominal pain that's not particularly distressing to sudden onset of severe abdominal tenderness in hypogastric area\--particularly on the involved side\--is very worrisome - Rigidity and rebound may come on early or late - If a pt of childbearing age has vague abd s/s, inquire on sexual activity & menstrual hx and strongly consider performing urine pregnancy test - Don't disregard mild tenderness that might be evoked. Anticipate the emergency of a rupture  ABNORMALITIES ABDOMEN +-----------------------------------+-----------------------------------+ | **Acute Diarrhea:** 3 or more | | | watery or loose stools per day | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ | Viral gastroenteritis is most | Subjective Data | | common | | | | · Usually, abrupt onset and lasts | | cause and typically self-limited | less than 2 | | in | | | | weeks | | those without signs or symptoms | | | | · Abdominal pain | | or other organ involvement | | | |. Nausea | | · International travelers may | | | | · Vomiting | | acquire foodborne infection | | | (e.g., |. Fever | | | | | enterotoxigenic Escherichia | · Tenesmus (feeling of incomplete | | | defecation) | |. International travelers may | | | |. Vomiting within several hours | | acquire foodborne infection | of ingesting a | | (e.g., | | | | particular food suggests food | | enterotoxigenic Escherichia | poisoning | | | | | coli, Salmonella, Shigella, or | · Bloody diarrhea may occur with | | | organisms | | Entamoeba histolytica) | | | | such as Campylobacter and | |. Camping or well water exposes | Shigella | | | | | individuals to Giardia and | Objective Data | | | | | Campylobacter through untreated | · Diffuse abdominal tenderness | | water | | | | mimic | |. Cryptosporidium is a potential | | | | inflammation with right lower | | cause from contaminated water in | quadrant pain | | | | | urban areas of the United States | or guarding | | | | | · Salmonella or Campylobacter |. If severe, may have findings | | | consistent with | | jejuni from undercooked poultry | | | | moderate to severe dehydration, | | · Undercooked beef or | particularly | | unpasteurized | | | | in infants, children, and older | | milk may contain E. coli 0157:H7. | adults (e.g., | | | | |. Raw shellfish is a potential | tachycardia, hypotension, and | | | altered mental | | source of Norwalk virus | | | | status) | | · Consider food poisoning if | | | diarrhea | | | | | | develops in two or more persons | | | | | | after ingestion of the same food | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Gastroesophageal Reflux Disease | | | (GERD):** Backward flow gastric | | | contents, typically acidic, into | | | esophagus | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Caused by relaxation or | Subjective Data | | incompetence | | | | · Heartburn or acid indigestion | | of the lower esophageal sphincter | (burning chest | | | | | · Delayed gastric emptying is | pain, localized behind the | | | sternum that moves | | a predisposing factor | | | | up toward the neck and throat) | |. More common among older adults | | | |. Bitter or sour taste of acid in | | and in pregnant individuals | the back of the | | | | | | throat | | | | | |. Hoarseness | | | | | | · Infants and toddlers exhibit | | | back arching, | | | | | | fussiness with feeding, or | | | regurgitation and | | | | | | vomiting; can be severe enough to | | | cause weight | | | | | | loss and failure to thrive | | | | | | · Can precipitate an acute asthma | | | exacerbation | | | | | | or cause chronic respiratory | | | problems from | | | | | | aspiration and esophageal | | | bleeding | | | | | | Objective Data | | | | | | · Generally, no physical findings | | | | | | · With severe disease may have | | | erythema of the | | | | | | posterior pharynx and edematous | | | vocal cords | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Irritable Bowel Syndrome | | | (IBS)**: Functional chronic GI do | | | w/ s/s of pain & change in | | | stooling patterns | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Cause unknown | Subjective Data | | | | | · Most common disorder seen by | · Commonly report a cluster of | | | symptoms, | | gastroenterologists; estimated | | | 10%-15% | consisting of abdominal pain, | | | bloating, | | of U.S. adults affected, 5%-7% | | | diagnosed | constipation; or abdominal pain, | | | urgency, | |. Occurs more often in women | | | | and diarrhea; or mixed | |. Usually begins in late | constipation and | | adolescence or | | | | diarrhea | | early adult life and rarely | | | appears for | Objective Data | | | | | the first time after 45 years of | · Generally, unremarkable | | age | examination | | | | | | · Diagnosis is typically made | | | after | | | | | | excluding other potential causes. | | | | | | · Rome IV diagnostic criteria | | | abdominal pain on average at | | | least 1 | | | | | | day a week in the past 3 months | | | associated | | | | | | with two or more of the | | | following: | | | | | | · Related to defecation | | | | | | · Associated with a change in a | | | frequency | | | | | | of stool | | | | | | · Associated with a change in | | | form | | | | | | (consistency) of stool | | | | | |. Symptoms must have started at | | | least 6 | | | | | | months ago | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Hiatal Hernia:** Part of | | | stomach passes through esophageal | | | hiatus in the diaphragm into the | | | chest cavity  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. About 95% are classified as | Subjective Data | | sliding | | | |. Most are asymptomatic and | | hernias where the | discovered | | gastroesophageal | | | | incidentally | | junction is displaced above the | | | |. May have symptoms of | | diaphragm; 5% of hernias are | gastroesophageal | | | | | paraesophageal, typically | reflux like epigastric pain | | occurring | and/or heartburn | | | | | after surgical management of | that worsens with lying down and | | reflux | is relieved | | | | |. Very common; occurs most often | by sitting up or antacids, water | | | brash | | in women and older adults | | | | (mouth fills with fluid from the | | · Associated with obesity, | esophagus), | | pregnancy, | | | | or dysphagia | | heavy lifting, hard coughing, and | | | | · Symptoms of incarcerated hernia | | straining with bowel movements | include | | | | | | sudden onset of vomiting, pain, | | | and | | | | | | complete dysphagia | | | | | | Objective Data | | | | | | · Generally, no physical findings | | | | | | · With severe disease, may have | | | erythema of | | | | | | the posterior pharynx and | | | edematous vocal | | | | | | cords | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Duodenal Ulcer (Duodenal Peptic | | | Ulcer Disease (PUD))**: Chronic | | | circumscribed break in the | | | duodenal mucosa that scars with | | | healing  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Typically develops from | Subjective Data | | | | | infection with Helicobacter |. Localized epigastric pain that | | pylori | occurs when the | | | | | resulting in increased gastrin | stomach is empty and is relieved | | | by food or | | production and acid secretion | | | | antacids | |. May be caused by Zollinger- | | | | · With upper gastrointestinal | | Ellison syndrome, a rare disorder | bleeding, symptoms | | | | | where one or more tumors | include hematemesis and melena; | | | significant | | (gastrinomas) secrete gastrin | | | | blood loss may result in | |. Occurs approximately twice | dizziness and syncope | | | | | as often in men as in women | Objective Data | | | | |. Long-term use of aspirin or |. Anterior wall ulcers may | | | produce tenderness on | | NSAIDs can increase risk | | | | palpation of the abdomen. | | | | | |. Ulcers occur on both the | | | anterior and posterior | | | | | | walls of the duodenal bulb; | | | anterior ulcers are more | | | | | | likely to perforate, whereas | | | posterior ulcers are | | | | | | more likely to bleed. | | | | | | · Perforation of the duodenum | | | presents with | | | | | | signs of an acute abdomen | | | (abdominal distention, | | | | | | rebound, and guarding). | | | | | | · With significant bleeding, may | | | show hypotension | | | | | | and tachycardia | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Crohn's Disease:** chronic | | | inflammatory d/o that can affect | | | any part of the GI tract that | | | produces ulceration, fibrosis, | | | and malabsorption; terminal ileum | | | and colon are the most common | | | sites | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Cause is unknown but is thought | Subjective Data | | to | | | |. Chronic diarrhea with | | be immune-related and occurs from | compromised | | an | | | | nutritional status | | imbalance between proinflammatory | | | |. Other systemic manifestations | | and anti-inflammatory mediators | may | | in | | | | include arthritis, iritis, and | | genetically susceptible | erythema | | individuals | | | | nodosum. | | · Smokers more likely to develop | | | Crohn\'s |. Disease course | | | | | and disease course more | unpredictable flares and | | complicated | remissions | | | | | than nonsmokers | Objective Data | | | | | | · May have right lower quadrant | | | tenderness | | | | | |. Abdominal mass may be palpated | | | | | | secondary to thickened or | | | inflamed bowel | | | | | | · Perianal skin tags, fistulae, | | | and abscesses may be seen | | | | | | · Extraintestinal examination | | | findings | | | | | | include erythema nodosum and | | | pyoderma gangrenosum, as well as | | | arthritis involving the large | | | joints | | | | | | Colonoscopy | | | | | | characteristic cobblestone | | | appearance of the mucosa and | | | pathology show | | | | | | Fistula and abscess formation, | | | sometimes | | | | | | extending to the skin, is common, | | | as well as perianal skin tags | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Ulcerative Colitis:** Chronic | | | inflammatory d/o of the colon and | | | rectum that produces mucosal | | | friability and areas of | | | ulceration | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Cause is unknown, but | Subjective Data | | immunologic, | | | | · Bloody, frequent, watery | | environmental, and genetic | diarrhea, with as | | factors | | | | many as 20-30 diarrheal stools | | have been implicated. | per day | | | | | · Active chronic ulcerative |. May exhibit weight loss, | | colitis | fatigue, and | | | | | predisposes an individual to | general debilitation | | | | | developing colon cancer. | · May range from mild to severe, | | | depending | |. Men and women equally affected | | | | on the degree of colon | |. Typically develops between 15 | involvement | | and | | | |. May remain in remission for | | 30 years of age or after age 60 | years after an | | | | |. Occurs more often in those with | acute phase of the illness | | a | | | | · Sclerosing cholangitis | | family history of inflammatory | (inflammation, | | bowel | | | | scarring and destruction of bile | | disease and those of Jewish | ducts) may | | descent | | | | present with fatigue and jaundice | | | | | | Objective Data | | | | | | · Generally, do not have fistulae | | | or perianal | | | | | | disease | | | | | |. Contrast radiographs typically | | | show loss of | | | | | | the normal mucosal pattern | | | | | | · Sclerosing cholangitis may | | | occur with a | | | | | | cholestatic pattern of elevated | | | transaminase | | | | | | levels | | | | | | · Endoscopic findings show | | | mucosal edema | | | | | | with ulcerations and bleeding | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Gastric Cancer:** Malignancy | | | that arises from epithelial cells | | | of mucous membrane | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. One of the most common | Subjective Data | | | | | malignancies worldwide | · May have vague and nonspecific | | | | |. Twice as common in males than | symptoms, including loss of | | females | appetite, | | | | |. Helicobacter pylori infection | feeling of fullness, weight loss, | | | dysphagia, | | is a major risk factor | | | | and persistent epigastric pain | |. Other modifiable risk factors | | | | Objective Data | | include smoking, alcohol | | | | · May have midepigastric | | consumption and poor diet | tenderness, | | | | |. Up to 10% of cases are familial | hepatomegaly, enlarged | | | supraclavicular | |. Most commonly found in lower | | | | nodes, and ascites | | half of the stomach | | | |. An epigastric mass may be | |. In early stages, the growth is | palpable in the | | confined | | | | late stages of disease | | to the mucosa and submucosa; as | | | disease | | | | | | progresses, the muscular layer of | | | the | | | | | | stomach becomes involved; | | | metastases, | | | | | | local and distant, are common | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Diverticular Disease**: small | | | bulges or saclike outpouchings | | | (diverticula) through colonic | | | muscle in the intestine  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. May involve any part of the | Subjective Data | | | | | gastrointestinal tract; the | · Most patients are asymptomatic | | | | | sigmoid is the most commonly | · With diverticulitis (when | | | diverticula become | | affected location | | | | inflamed), may experience left | | · Cause unknown but may be | lower quadrant | | | | | caused by colonic dysmotility, | pain, anorexia, nausea, vomiting, | | | and altered bowel | | defective muscular structure, and | | | | habits (usually constipation) | | defects in collagen and aging | | | | · Pain usually localizes to the | |  | site of inflammation | | | | | | Objective Data | | | | | | · May have abdominal distention | | | with tympany | | | | | | to percussion with decreased | | | bowel sounds and | | | | | | localized tenderness | | | | | |. Lower gastrointestinal bleeding | | | may occur | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Colon Cancer (Colorectal | | | Cancer)** | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. About 100,000 new cases of | Subjective Data | | | | | colon cancer and 40,000 new cases | · Symptoms depend on cancer | | | location, size, and | | of rectal cancer are diagnosed | | | | presence of metastases | | each year in the United States | | | |. May describe abdominal pain, | |. Lifetime risk for men and women | blood in the stool, or a | | | | | is about 4% (see Risk Factors | recent change in the frequency or | | | character of stools | | box earlier in the chapter) | | | |. Earliest sign may be occult | | | blood in the stool, which | | | | | | can be detected by guaiac-based | | | fecal occult blood | | | | | | testing (gFOBT) | | | | | | Objective Data | | | | | | · Few early examination findings | | | | | | · If disease has progressed, may | | | have palpable | | | | | | abdominal mass in right or left | | | lower quadrants or | | | | | | show signs of anemia from occult | | | blood loss (e.g., | | | | | | pallor and tachycardia) | | | | | | · Rectal cancer may be palpable | | | by digital rectal | | | | | | examination (see Chapter 21) | | | | | |. Evidence-Based Practice in | | | Physical Examination | | | | | | box highlights recent colon | | | cancer screening test | | | | | | recommendations | +-----------------------------------+-----------------------------------+ HEPATOBILIARY SYSTEM +-----------------------------------+-----------------------------------+ | **Hepatitis:** Inflammatory | | | process characterized by diffuse | | | or patchy hepatocellular | | | necrosis  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Most commonly caused by viral | Subjective Data | | | | | infection, alcohol, drugs, or |. Some are asymptomatic; others | | toxins | report | | | | |. Acute viral hepatitis is caused | jaundice, anorexia, abdominal | | by | pain, clay- | | | | | at least five distinct agents; | colored stools, tea-colored | | see Risk | urine, and fatigue | | | | | Factors box regarding hepatitis | Objective Data | | | | | A, B, and C earlier in chapter | · Liver function tests are | | | abnormal | |. Hepatitis D occurs only in | | | those |. Examination findings may | | | include | | infected with hepatitis B, either | | | as a | jaundice and hepatomegaly | | | | | coinfection in acute hepatitis B | · With severe or progressive | | or as a | disease, | | | | | superinfection in chronic | may develop cirrhosis with its | | hepatitis B | associated | | | | |. Hepatitis E is a self-limited | examination findings | | type that | | | | | | may occur after a natural | | | disaster because | | | | | | of fecal-contaminated water or | | | food | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Cirrhosis**: Late stage of | | | liver disease w/ fibrosis | | | (scarring), alteration of normal | | | hepatic architecture and loss of | | | fxn | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ | · Progression of liver disease to | Subjective Data | | cirrhosis | | | |. May be asymptomatic; others | | can happen over weeks to years | report | | | | |. Signs and symptoms occur as a | jaundice, anorexia, abdominal | | | pain, clay- | | result of decreased liver | | | synthetic | colored stools, tea-colored | | | urine, and fatigue | | function, decreased | | | detoxification | · May describe prominent | | | abdominal | | capabilities, or portal | | | hypertension | vasculature, cutaneous spider | | | angiomas, | |. Most common causes in the | | | | hematemesis, and abdominal | | United States are hepatitis C | fullness | | | | | and alcoholic liver disease | Objective Data | | | | |. Less common causes include |. On examination, the liver is | | | initially | | autoimmune hepatitis, primary | | | | enlarged with a firm, nontender | | biliary cirrhosis, Wilson | border on | | disease, | | | | palpation; as scarring | | hemochromatosis, a,-antitrypsin | progresses, liver size is | | | | | deficiency, and sarcoidosis | reduced and generally cannot be | | | palpated | | | | | | · Neurologic examination | | | abnormalities may be seen (e.g., | | | hepatic encephalopathy) | | | | | | With | | | | | | hypertension and ascites may | | | occur  | | | | | |. Muscle wasting and nutritional | | | deficiencies | | | | | | may be evident in late-stage | | | disease | | | | | |. May have abnormal laboratory | | | values (e.g., | | | | | | liver function tests and | | | coagulopathy) | | | | | | disease, portal | | | | | | progressive | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Primary Hepatocellular | | | Carcinoma** | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Most common type of liver | Subjective Data | | | | | cancer in the United States | · Symptoms may include jaundice, | | | anorexia, | | · Risk factors include hepatitis | | | C | fatigue, abdominal fullness, | | | clay-colored stools, | | infection, hepatitis B infection, | | | | and tea-colored urine | | excessive alcohol intake, | | | obesity, | Objective Data | | | | | diabetes, nonalcoholic fatty | · On examination, hepatomegaly | | | with a hard, | | liver disease, and smoking | | | | irregular liver border may be | |. Median survival time | palpated | | | | | from diagnosis is months | · Liver nodules may be present | | | and palpable, and | | (Petrick et al., 2016) | | | | the liver may be tender or | | · Can metastasize to the | nontender | | | | | lungs, portal vein, periportal | · Examination findings related to | | | cirrhosis may be | | nodes, bone, and brain | | | | seen | | · Widespread vaccination for | | | | | | hepatitis A and B, routine | | | screening | | | | | | for hepatitis B and C and | | | treatment of | | | | | | hepatitis C may reduce the | | | incidence | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Cholelithiasis:** Stone | | | formation in the gallbladder | | | occurs when certain substances | | | reach a high concentration in | | | bile & produce crystals | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Crystals mix with mucus and | Subjective Data | | form | | | | · Many patients are asymptomatic | | gallbladder sludge; over time, | | | the | · Symptoms may include | | | indigestion, colic, | | crystals enlarge, mix, and form | | | stones | and mild transient jaundice | | | | |. Main substances involved in | Objective Data | | | | | gallstone formation are |. Condition commonly produces | | cholesterol | episodes of | | | | | (\>80%) and calcium bilirubinate | acute cholecystitis | | | | | · Chronic disease can result in | | | fibrosis | | | | | | and gallbladder dysfunction and | | | | | | predispose to gallbladder cancer | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Cholecystitis**: Inflammatory | | | process of the gallbladder most | | | commonly due to obstruction of | | | the cystic duct from | | | cholelithiasis, which may be | | | acute or chronic | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. With cystic duct obstruction, | Subjective Data | | the | | | | · Primary symptom is right upper | | gallbladder becomes distended and | | | | quadrant (RUQ) pain with | | blood flow is compromised, | radiation | | leading | | | | around the mid-torso to the right | | to ischemia and inflammation | | | | scapular region; pain is abrupt | |. Acute cholecystitis has | and severe | | associated stone | | | | and lasts for 2-4 hours | | formation (cholelithiasis) in 90% | | | of cases, | May have associated symptoms | | | | | causing obstruction and | including fever, jaundice, and | | inflammation | anorexia | | | | |. Acute cholecystitis without | · With chronic cholecystitis may | | stones | exhibit | | | | | (acalculous) results from any | fat intolerance, flatulence, | | condition that | nausea, | | | | | affects the regular emptying and | anorexia, and nonspecific | | filling of | abdominal | | | | | the gallbladder, such as | pain | | immobilization | | | | Objective Data | | with major surgery, trauma, | | | sepsis, or |. In | | | | | long-term total parenteral | examination | | nutrition | | | | tenderness in the RUQ or | | · Chronic cholecystitis refers to | epigastrium | | repeated | | | |. Involuntary guarding or rebound | | attacks of acute cholecystitis in | | | a | tenderness may be present | | | | | gallbladder that is scarred and |. Some may have a full palpable | | contracted | | | | gallbladder in the RUQ | | | | | |. Some may have subtle | | | examination | | | | | | findings, including diffuse | | | abdominal | | | | | | pain; others may have an | | | unremarkable | | | | | | examination | | | | | | · In chronic cholecystitis, the | | | gallbladder | | | | | | is typically not palpated due to | | | | | | gallbladder fibrosis | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Nonalcoholic Fatty Liver | | | Disease:** Spectrum of hepatic | | | disease dt fat stored in liver in | | | absence of excessive alcohol | | | intake  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Classified as nonalcoholic | Subjective Data | | fatty | | | | · Most patients are asymptomatic | | liver (NAFL) and nonalcoholic | | | | · Some describe right upper | | steatohepatitis (NASH) | quadrant pain, | | | | | · Genetic and environmental | fatigue, malaise, and jaundice | | | | | factors are likely to contribute | Objective Data | | | | | to disease development | · Usually identified after | | | discovering abnormal | | · Inflammation, oxidative stress | | | and | liver function tests; most have | | | elevated | | insulin resistance are thought to | | | | transaminases with aspartate | | contribute to NAFLD development | aminotransferase | | | | | · Associated with the obesity, | (AST) and alanine | | | aminotransferase (ALT) being | | dyslipidemia, hyperglycemia, | | | | two to three times the upper | | hypertension and smoking | limits of normal | | | | | (Katsiki et al., 2016) |. Other than an elevated body | | | mass index (BMI) | | · With rise in obesity, currently | | | the | (overweight or obese by | | | criteria), usually no | | most common cause of chronic | | | liver | other clinical signs | | | | | disease worldwide; in the United | · About half of patients have | | | hepatomegaly | | States, affects up to 25% of | | | adults |. In more severe disease, | | | patients may have | |. Occurs fairly equally in males | | | | jaundice and ascites. | | and females, but ethnic | | | differences | · Magnetic resonance spectroscopy | | | (MRS) and | | include a higher prevalence | | | | liver biopsy are most sensitive | | in Hispanic individuals | diagnostic | | | | | | techniques | +-----------------------------------+-----------------------------------+ PANCREAS +-----------------------------------+-----------------------------------+ | **Acute Pancreatitis:** acute | | | inflammatory process where | | | release of pancreatic enzymes | | | results in pancreatic glandular | | | autodigestion  | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ | · Although unclear what | Subjective Data | | pathophysiologic | | | | · Symptoms range from mild to | | mechanism initiates acute | severe | | pancreatitis, there | | | | sudden onset of persistent | | are a number of known causes, | epigastric | | including biliary | | | | pain that may radiate to the | | disease (cholelithiasis) and | back; pain | | chronic alcohol use, | | | | is typically described as | | accounting for approximately 80% | constant and | | of cases | | | | dull | | **Cullen's Sign** | | | | · Often associated with nausea, | |  | | | | vomiting, abdominal distention, | | Grey Turner's Sign | fever, | | | | | | and anorexia | | | | | | Objective Data | | | | | | · Most patients have diffuse | | | abdominal | | | | | | tenderness to palpation; | | | involuntary | | | | | | guarding and abdominal distention | | | | | | can occur | | | | | |. Decreased bowel sounds may be | | | | | | appreciated as a result of an | | | ileus | | | | | | · In severe necrotizing | | | pancreatitis, | | | | | | Cullen and Grey Turner signs may | | | be appreciated on examination | | | | | |. Some may present with fever and | | | | | | tachycardia | | | | | | · Others may have dyspnea due to | | | | | | diaphragm irritation | | | | | | · Pancreatic enzymes (amylase and | | | | | | lipase) are elevated | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Chronic Pancreatitis**: Chronic | | | inflammatory process of pancreas | | | w/ irreversible morphologic | | | changes resulting in atrophy, | | | fibrosis, & pancreatic | | | calcifications | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Most common cause is chronic | Subjective Data | | alcohol | | | |. Symptoms may include constant, | | use; other causes include | | | congenital | unremitting abdominal pain; | | | weight | | structural abnormalities of the | | | | loss; and steatorrhea | | pancreas, hereditary | | | pancreatitis, cystic | Objective Data | | | | | fibrosis, medication-induced | · Examination findings are | | disease, | similar to | | | | | and autoimmune pancreatitis | those in acute pancreatitis; | | | however, | | | | | | with chronic disease, there is a | | | greater | | | | | | likelihood of pseudocyst | | | formation | | | | | | · With advanced disease, some | | | | | | may exhibit signs of malnutrition | | | | | | with decreased subcutaneous fat | | | and | | | | | | temporal wasting | | | | | | · Pancreatic enzyme levels | | | (amylase | | | | | | and lipase) are elevated, and | | | glucose | | | | | | intolerance may be seen | +-----------------------------------+-----------------------------------+ SPLEEN +-----------------------------------+-----------------------------------+ | **Spleen Laceration / Rupture ** | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Most commonly injured organ | Subjective Data | | | | | in abdominal trauma because | · Symptoms include pain in the | | | left upper quadrant | | of its anatomic location | | | | with radiation to the left | | · Mechanism of injury can be | shoulder (positive Kehr sign) | | | | | either blunt or penetrating | · Depending on degree of blood | | | loss, may have symptoms of | | but is more often blunt (e.g., | hypovolemia (e.g., | | | lightheadedness, | | from motor vehicle crashes) | | | | tachycardia, syncope) | | | | | | Objective Data | | | | | | · Examination is remarkable for | | | left upper quadrant | | | | | | pain with palpation; signs of | | | peritoneal irritation may | | | | | | be seen (involuntary guarding or | | | rebound tenderness) | | | | | | · Diagnosis is made by | | | paracentesis or computed | | | | | | tomography | | | | | |. Depending on the degree of | | | blood loss, patients may | | | | | | present with hypotension and a | | | decreasing hematocrit | +-----------------------------------+-----------------------------------+ KIDNEY +-----------------------------------+-----------------------------------+ | **Acute Glomerulonephritis:** | | | Inflammation of the capillary | | | loops of the renal glomeruli | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Accounts for about 20% of | Subjective Data | | | | | chronic kidney disease |. Symptoms are usually | | | nonspecific and | | · Results from immune complex | | | | include nausea and malaise; flank | | deposition or formation | pain | | | | |. Many causes; most common | may be reported as well as | | include | headache | | | | | infection (poststreptococcal) and | secondary to hypertension | | | | | immune-mediated (IgA nephropathy) | · Some patients report | | | tea-colored urine | | | | | | or gross hematuria | | | | | | · May be asymptomatic and | | | identified | | | | | | with an elevated blood pressure | | | reading | | | | | | Objective Data | | | | | | May examination and normal blood | | | pressure | | | | | | · Examination findings may | | | include | | | | | | edema, hypertension, and oliguria | | | | | |. About 85% of affected children | | | develop | | | | | | peripheral and periorbital edema | | | have | | | | | | An unremarkable | | | | | | · Microscopic hematuria occurs in | | | all | | | | | | affected patients (red blood cell | | | casts are seen on urine | | | microscopy) | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Hydronephrosis:** Dilation of | | | the renal pelvis and calyces due | | | to an obstruction of urine flow | | | anywhere from the urethral meatus | | | to the kidneys | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ |. Increasing ureteral | Subjective Data | | | | | pressure from urine results | · With an acute obstruction, may | | | have intermittent, | | in changes in glomerular | | | | severe pain (renal colic) with | | filtration, tubular function, | nausea and vomiting | | | | | and renal blood flow | · With secondary infection, may | | | report abdominal pain, | | | | | | flank pain, hematuria, and fever | | | | | | Objective Data | | | | | | · Most will have an unremarkable | | | physical examination | | | | | | · In severe cases, the kidneys | | | may be palpable during the | | | | | | abdominal examination; | | | costovertebral angle tenderness | | | | | | may be present | | | | | |. With lower urinary tract | | | obstruction, a distended | | | | | | bladder may be palpable (e.g., | | | posterior urethral valves in | | | | | | a newborn). | | | | | | · Most are asymptomatic; | | | hydronephrosis is found during | | | | | | radiologic screening (e.g., fetal | | | ultrasound) or diagnostic | | | | | | imaging | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Pyelonephritis**: Infection of | | | kidney & renal pelvis | | +===================================+===================================+ | Patho | Patient Data | +-----------------------------------+-----------------------------------+ | · Gram-negative bacilli | Subjective Data | | (Escherichia coli | | | | · Typically present with fever, | | and Klebsiella) and Enterococcus | dysuria, and | | fecalis | | |