Tummy Troubles Evaluation of the Acute Abdominal Complaint

Lacey A. Collins, MSEd, ATC, CSCSBrian G. Collins, MSPAS, PA-C, VAEMTP

Housekeeping Notes

Learning ObjectivesAfter this session, attendees will be able to:

● Identify surface and internal anatomy of the abdomen● Obtain a pertinent medical history for abdominal

complaints● Evaluate acute abdominal complaints utilizing observation,

inspection, auscultation, percussion and palpation● Formulate a differential diagnosis for acute abdominal

complaints based on exam history and findings● Identify red flags for emergent referral associated with

acute abdominal complaints

Anatomy of the abdomen

Location descriptors:

4 Quadrants (quick and dirty)

9 Regions (more descriptive)

Surface Anatomy

Muscles

Organs

4 Quadrants

RUQ- Liver- Pancreas (head)- Gallbladder- Large intestine (hepatic flexure)- R kidney

LUQ- Liver (tail)- Pancreas (body/tail)- Stomach- Spleen- Large intestine (splenic flexure)- L kidney

RLQ- Appendix- R ovary- Psoas- Large intestine (ascending)

LLQ- L ovary- Psoas- Large intestine (descending)

From Swartz, Textbook of Physical Diagnosis, 4ed

9 RegionsR hypochondriac

- Lung (RLL)- R kidney- Liver/gallbladder

Epigastric- Stomach- Pancreas- Duodenum- Aorta (supra-renal)

L hypochondriac- Lung (LLL)- L kidney- Liver (tail)- Spleen

R lumbar- Liver- Hepatic flexure- Ascending colon

Umbilical- Small intestine- Umbilical hernia- Aorta (infra-renal)

L lumbar- Descending colon

R iliac- R ovary/fallopian tube- Appendix

Hypogastric- Bladder- Uterus- Sigmoid colon- Aorta (infra-renal)

L iliac- L ovary/fallopian tube- Descending colon

From Swartz, Textbook of Physical Diagnosis, 4ed

Surface Anatomy

Borders:- Superior → 12th ribs and costal angle- Inferior → Iliac crests, inguinal ligaments, and os pubis- Lateral??

Landmarks:- Umbilicus → T10- Iliac crests → L4-5- Linea alba → midline

Medical HistoryOPQRST

Associated symptoms

Context

PMH, FH, SH

Other factors

OPQRST

Onset

Palloration/Provocation

Quality

Radiation

Severity

Timing

Pertinent History

PMH:- Diagnoses (including any acute/new diagnoses)- Medications (rx, OTC, vitamins, supplements, BC, etc)

FH:- Diabetes, Crohn’s/UC, sickle cell, etc

SH:- Tobacco, ETOH, drug use- Sexual activity

Context

Recent travel (overseas, long car/plane trip, open air markets, etc)

Recent trauma

Sick contacts (home, dorm, etc)

Similar symptoms in the past?

Menstrual cycle

Other Factors

Conditioning

Recent schedule/activity

Clinician “gestalt”

Evaluation Techniques

● Observation● Inspection● Auscultation● Percussion● Palpation

Observation

General nutritional state

Pallor

Jaundice

Mental state

Inspection

Shape and movements

Scars

Distention (localized versus generalized)

Striae

Bruises

Pigmentation

Hernias

Swelling (6 F’s)

- Fat

- Flatus

- Fetus

- Fluid

- Feces

- Fatal growth

Guarding/splinting

Facial expressions (i.e. grimmace)

Key Findings on InspectionCullen’s Sign- Bluish periumbilical discoloration (bruising)- Pancreatitis, ruptured ectopic, ruptured spleen, ruptured common bile duct, perforated duodenal ulcer, ...

Grey Turner’s Sign

- Bruising of the flank(s) from subcutaneous blood tracking- Severe acute pancreatitis, severe abdominal trauma

Charcot’s Triad

- Fever + Jaundice + RUQ Pain- Infection of the biliary tract following biliary obstruction and stasis

Cullen’s sign

Grey Turner’s Sign (UpToDate Graphic 95719 Version 1.0)

Auscultation

ALWAYS auscultate before palpation (we don’t want to create sounds)

Diaphragm (deep pressure) → bowel sounds

Bell (gently rested) → vascular sounds

Auscultation

Listen until you hear bowel sounds OR for a full minute

Normal frequency = 5-35 per minute

Bruits (aorta, renal arteries, iliacs, femorals) → blowing sound with the bell, could be related with aortic aneurysm or renal artery stenosis

Tinkling bowel sounds → high pitched sounds that are an early sign of small bowel obstruction

Percussion

Percuss in all four quadrants

Tympany → gas/air

Dullness → fluid/feces

PalpationPalpate in systematic fashion, avoid painful areas until last if possible (to avoid a “pan-positive” exam)

Do not be afraid to palpate areas of tenderness (you must examine in order to determine the characteristics of pain)

Liver (sometimes palpable, usually far right edge on inspiration)

Spleen (palpable spleen = enlarged spleen)

Kidneys (don’t forget to check CVA tenderness)

Key Findings on Palpation

Blumberg’s Sign (aka Rebound Tenderness) - can indicate localized peritoneal irritation (i.e., appendicitis, pancreatitis, etc)

Appendiceal irritation - Psoas, Obturator, and Rovsing signs

Murphy’s Sign - cholecystitis

Markle Sign - abrupt abdominal pain and tenderness upon landing on heels from a tiptoe position - warrants urgent surgical consult (appy, SBO, perforation)

RED FLAGS

Sudden onset

Unexplained bleeding (hematemesis, hematuria, melena/hematochezia, non-menstrual bleeding)

Unexplained weight loss

Shortness of breath

Dysphagia

Pre-syncope

Fever

New onset dyspepsia

Persistent unexplained vomiting

Amenorrhea

Testicular pain

Questions?

Cases

Case 1: 18yo female runner

What were the key pieces?

● RLQ pain● Sudden onset● Amenorrhea● Sexually active

● Birth control +antibiotics

● Cullen’s sign positive● Muscle guarding RLQ

What is your differential?

● Ectopic pregnancy● Appendicitis

● Ovarian cyst

● Other?

What did you do?

A. Immediate referralB. Hold until she sees MD

C. Let her play

Case 2: 16yo male baseball player

What red flags did you identify?

● RLQ pain● Fever● Sudden onset● Rebound tenderness/guarding

● Positive Markle/Heel sign

● Pain relieved with rest in flexed

position

● Positive psoas sign & Rosving

What is your differential?

● Diverticulitis● IBD

● Appendicitis

● Testicular torsion

● Other?

What did you do?

A. Immediate ReferralB. Hold until he sees MD

C. Let him play

Case 3: 18yo male football player

What red flags did you identify?

● Positive family history● Increased life stress

● Unexplained weight loss● Lethargy

● Fruity breath

● Thirst

● Nausea/vomiting

What is your differential?

● T1DM● DKA

● Overtraining/burnout

● Dehydration

What did you do?

A. Immediate ReferralB. Hold until he sees MD

C. Let him play

Case 4: 19yo female softball player

What red flags did you identify?

● RUQ pain● Hx of GERD

● Family hx

● Positive Murphy’s sign

What is your differential?

● Cholecystitis● Gallstone pancreatitis

● GERD

● Peptic Ulcer Disease

● Hepatitis

What did you do?

A. Immediate ReferralB. Hold until she sees MD

C. Let her play

Case 5: 22yo male basketball player

What red flags did you identify?

● Sudden onset● Severity of nausea/vomiting

● Abdominal cramping

● Sick contacts

● Low grade fever

What is your differential?

● Traveler’s diarrhea● Viral illness

● Food poisoning

● Diverticulitis

What did you do?

A. Immediate ReferralB. Hold until he sees MD

C. Let him play

Case 6: 20yo female lax player

What red flags did you identify?

● Nausea● Dysuria

● Hematuria● Urgency

● PMH

What is your differential?

● Yeast infection● UTI

● Pyelonephritis

● Kidney stone

● STD

What did you do?

A. Immediate ReferralB. Hold until she sees MD

C. Let her play

ReferencesMartin RF, Kang SK. Acute appendicitis in adults: Diagnostic evaluation. In: UpToDate, Weiser M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Martin RF. Acute appendicitis in adults: Clinical manifestations and differential diagnosis. In: UpToDate, Weiser M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Levitsky LL, Misra M. Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Haymond MW. Clinical features and diagnosis of diabetic ketoacidosis in children and adolescents. In: UpToDate, Wolfsdorf JI (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Bordeianou L, Yeh DD. Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults. Soybel DI, Hockberger RS (Eds), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

The Abdomen, Perineum, Anus, and Rectosigmoid. In: LeBlond RF, Brown DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.suproxy.su.edu/content.aspx?bookid=1192&sectionid=68668433. Accessed January 01, 2018.

The Abdomen, Perineum, Anus, and Rectosigmoid. In: LeBlond RF, Brown DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.suproxy.su.edu/content.aspx?bookid=1192&sectionid=68668433. Accessed January 01, 2018.

ReferencesTulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. In: UpToDate, Barbieri, RL, Sharp HT, Levine D (Eds), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Vakil, NB. Peptic ulcer disease: Clinical manifestations and diagnosis. In: UpToDate, Feldman M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Pemberton JH. Clinical manifestations and diagnosis of acute diverticulitis in adults. In: UpToDate, Lamont JT (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Wanke CA. Traveler’s diarrhea: Clinical manifestations, diagnosis, and treatment. In: UpToDate, Calderwood SB (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Sharp HT. Evaluation and management of ruptured ovarian cyst. In: UpToDate, Levine D (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Corbett SW, Stack LB, Knoop KJ. CHEST AND ABDOMEN. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 4e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.suproxy.su.edu/content.aspx?bookid=1763&sectionid=125434019. Accessed January 01, 2018.

Bass G, Gilani SNS, Walsh TN. Validating the 5Fs mnemonic for cholelithiasis: time to include family historyPostgraduate Medical Journal 2013;89:638-641

THANK YOU!