The Gastrointestinal and Renal Systems

Anatomy

Abdomen: is large oval cavity extended from

the diaphragm down to the brim of the pelvis.
From back it is protected by the vertebral
column and paravertebral muscles, from sides
by the lower rib cage and abdominal muscles,
and from the front by abdominal muscles.

Brim of the pelvis

Viscera: internal organs in the abdominal

cavity.
Can be divided into:
Solid viscera: is the viscera that maintain a
characteristic shape (ex. Liver, spleen, kidneys,
ovaries).
Hollow viscera: its shape depends on the
contents (ex. Stomach, gallbladder, small
intestine, colon, bladder).

For descriptive purposes, the abdomen is often

divided by imaginary lines crossing at the
umbilicus, forming the right upper quadrant
(RUQ), right lower quadrant (RLQ), left upper
quadrant (LUQ), and left lower quadrant (LLQ).
Terms to know:
*Epigastric-area
between the costal
margins.
*Umbilical- area
around umbilicus
*Suprapubic- area
above the pubic bone

RUQ:
ascending colon,
duodenum,
gallbladder,
rt kidney,
liver,
head of the pancreas
transverse colon, rt uretra

LUQ:
descending colon,
lt kidney,
body and tail of pancreas,
spleen,
stomach,
transverse colon,
lt ureter.

RLQ:
appendix,
ascending colon, cecum,
rectum,
bladder,
overy, uterus, and fallopian
tube or prostate and spermic
cord, rt uretra

LLQ:
bladder,
descending colon, overy,
uterus, and fallopian tube or
prostate and spermic cord,
small intestin,
sigmoid colon,
lt ureter

 Note that the liver fills most of the RUQ and

extend over the midclavicular line.
Gallbladder is located
under the posterior
surface of the liver.
Small intestine is located
in all four quadrants.

 Spleen is located on the posterolateral wall of the

abdominal cavity under the diaphragm.
It lies obliquely & its width extends from the 9th 11th
rib about 7cm. Not palpable normally.

Aorta is located at left of

midline in the upper part of
abdomen; bifurcates into the Rt
& Lt renal arteries then common
iliac arteries opposite 4th lumbar
vertebra; Aortic pulsations
easily palpable in the upper
anterior wall.

Rt & Lt iliac arteries become the

femoral arteries in the groin area.
Their pulsations are palpable as
well.
Pancreas- soft, lobulated gland
located behind the stomach;
stretches obliquely across the
LUQ.

 Kidneys are bean shaped & located posterior to

the abdominal contents;
Lt kidney lies at the 11th & 12th rib;
Rt kidney is 1-2 cm lower than the Lt kidney &
may be sometimes palpable.

The costovertebral angle: the angle formed by the

lower border of the 12th rib
and the transverse processes of the upper lumbar
vertebrae (for kidney tenderness).

*Bladder may be palpated in the lower midline (above

the symphysis pubis) when it is distended.

Subjective Data
Concerning symptoms of the abdomen are:
Abdominal pain
Indigestion, nausea, vomiting
Loss of appetite, early satiety
Dysphagia, odynophagia (pain with swallowing)
Change in bowel function
Diarrhea, constipation
Jaundice

*Gastrointestinal disorders may be divided into lower and

upper problems.

Categories of abdominal pain:

Visceral pain:
Occurs when hollow abdominal organs such as the
intestine or biliary tree contract unusually forcefully or
are distended or stretched.
Solid organs such as the liver can also become painful
when their capsules are stretched.
Visceral pain may be difficult to localize. It is typically
palpable near the midline at levels that vary according to
the structure involved.

 Visceral pain varies in quality and may be

gnawing, burning, cramping, or aching.
When it becomes severe, it may be associated
with sweating, pallor, nausea, vomiting, and
restlessness.
Visceral periumbilical pain may signify early
acute appendicitis from distention of an inflamed
appendix. It gradually changes to parietal pain in
the right lower quadrant from inflammation of the
adjacent parietal peritoneum.

Parietal pain:
originates from inflammation in the parietal
peritoneum.
It is a usually more severe than visceral pain and
more precisely localized.
It is increased by movement or coughing.
Patients with this type of pain usually prefer to lie
still.
Referred pain:
Is felt in more distant sites, which are innervated at
approximately the same spinal levels as the disordered
structures.
Develops as the initial pain becomes more intense.
May be felt superficially or deeply and is usually well
localized.

Dyspepsia: is defined as chronic or recurrent discomfort or pain

centered in the upper abdomen.
Discomfort: is defined as a subjective negative feeling that is
nonpainful. It can include various symptoms such as bloating, nausea,
upper abdominal fullness, and heartburn.
Heartburn: is a rising retrosternal burning pain or discomfort. It is
typically aggravated by food.
GERD: Gastroesophageal reflux disease.

Dysphagia: difficulty swallowing.

Odynophagia: pain with swallowing.

Hematemesis: blood with vomit.

Melena: black terry stool.
Hemtochezia: stool that is red.
Regurgitation: raising gastric content, because of
the problems with sphincter (without vomiting).
Steatorrhea: presence of excessive fat in the stool.
What are normal characteristics of the vomit?
Give example of abnormal characteristics of the
stool.
What is constipation?

Concerning symptoms of the abdomen are:

Suprapubic pain
Dysuria, urgency, or frequency
Polyuria, nocturia
Urinary incontinence
Hematouria
Kidney or flank pain
Ureteral colic

Suprapubic pain may be related to bladder dysfunctions such as

bladder infection it is dull and pressure like.

Dysuria: pain with urination, or difficult urination

Urgency: immediate desire to urinate.

Frequency: frequent going to the bathroom, the volume of the

urine may be large or small.

Polyuria: increase in urine volume (more than 3 liters pay day).

Urinary incontinence: involuntary loss of urine.

Hematuria: blood in urine, may be gross or microscopic.

Kidney pain versus ureteral colic:

kidney pain:
On the side of the body between upper
abdomen and the back.
May radiate toward umbilicus.
Visceral, dull, steady.
Ureteral colic
Originate at the costovertebral angle
Radiate around the trunk into the lower
quadrant of abdomen or to the thigh.
Is severe and colicky.

Objective Data
Tips for Enhance Examination of the Abdomen

Check that the patient has an empty bladder.

Make the patient comfortable in the supine position, check that
he is relaxed.
Ask the patient to keep the arms at the sides or folded across the
chest.
With palpation, ask the patient to point to any areas of pain so
you can examine these areas last.
Warm your hands and stethoscope.
Approach the patient calmly and avoid quick, unexpected
movements.
Begin with inspection, then auscultation, percussion, and
palpation.

Inspection
Contour: shape of the abdomen.

Symmetry: any visible masses, bulging.

Describe the location and size.
A hernia occurs when an organ pushes through an
opening in the muscle or tissue that holds it in place.

The masses may be

related to tumors or
enlargements.
Above: enlarged spleen

Scars:
describe scares if any; location, size,
symmetry (traumatic or from surgery).

Kocher: open cholecystectomy,

mcBurneys: appendectomy,
Pfannenstiel: for gynecological procedures,
small incision; laparoscopy.

Striae: stretch marks. Silver striae: old, pink-purple:

new. Most common in pregnant women and obese.

The umbilicus: midline, inverted, no signs of

inflammation or hernia.
Skin: smooth, even no scar or lesion (redness, jaundice
,striae , moles, scars)
Dilated veins: a few veins may be visible normally.
Pulsation or movements: peristalsis (slow and oblique
across abdomen), respiration, pulsation of the aorta
(epigastric area). Are more visible in thin people.

Auscultation
Describe bowel motility.
The auscultation is performed before percussion and
palpation because they can altered the frequency of
the bowel sounds.
Normal: high pitch sound, gurgling, irregular 5-30
time /min.
Must listen 5 minutes to say absent.
Check over the aorta, renal arteries, and iliac arteries.
Normal: No Bruit
Listen over liver and spleen for friction rub.

A peritoneal friction rub

produced by friction between roughened peritoneal
surfaces, for example from inflammation or tumor.
heard as a creaking or grating noise during respiration.

Percussion
To assess the amount of gas
in the abdomen, to identify
solid or fluid-filled masses,
to estimate the size of liver
or spleen.
Percuss the abdomen in 4
quadrants to assess
distribution of tympany and
dullness.
General Tympany.

Percuss the liver

- to determine the Liver span: 6-12 cm in tall male;
mean 10.5 cm in men and 7 cm in women.
Measure the height of the liver in the Rt. MCL.
Percuss from up to down until note changes from
resonance to dullness.
Mark the spot.

 Find abdominal tympany and percuss up until

note changes to dullness.
Mark the spot.
Normal : at the right costal margin.

Scratch Test:
Define the liver border in distended abdominal or
muscles tense.
Place stethoscope over the liver.
Scratch with one fingernail over the abdomen starting in
the RLQ.
Move up toward the liver.
Normal: sound becomes magnified in the border of the
liver.

 Percuss the spleen: Percuss from 9th. To 11th. ICS behind

the Midaxillary Line.
Normal: dullness not wider than 7cm.
Techniques to detect splenomegally:
1) Percuss the left lower anterior chest wall.

2) Check for a splenic percussion sign.

Percuss the lowest ICS in the Lt anterior Axillary Line.
Ask the pt to breath deeply.
Normal: tympany remains through full inspiration.

 Percuss the kidney:

Place one of your hands in the costovertebral
angle and strike it with the ulnar surface of your
fist. Look of tenderness.

Palpation
To detect the size, location & consistency of
organs.
To identify masses, abdominal tenderness,
and muscular resistance.
Begin with light palpation (1 cm depth) in
rotatery motion, check in all abdomen.
Perform deep palpation (5-8 cm), for
abdominal masses.

If you identify a mass note the following:

Location
size
Shape
Consistency (soft ,firm, hard)
Surface (smooth, nodular).
Mobility ( movement during respiration).
Pulsatility
Tenderness

 Assess for peritoneal inflammation:

Especially when there is muscular spasm.
Ask patient to cough and ask if there was a pain
and where.
Palpate gently the tender area.

Palpate the liver:

Lt. hand under the pts back parallel 11th.-12th. Ribs

Left up to support the abdomen
Place Rt. Hand on the RUQ.
Push deep down and under the edge of the right costal
margin in the midclavicular line
Ask pt to take deep breath
Normal: if palpable at all, soft, sharp, & regular liver
edge with a smooth surface. The normal liver may be
slightly tender. (firm: Jarvis)
If cannot fill it try hooking technique.

Hooking technique:
Stand at the pts shoulders
Swivel your body to the Rt.
Hook your fingers over the costal margin from
above

Palpate the spleen:

Reach your lt. hand over the abdomen and behind
the lt. 11th.-12th.ribs
Left for support
Place Rt. Hand obliquely on the LUQ with fingers
pointing toward lt axilla. To the rib margin.
Push deep down under the costal margin
Ask the pt to breath deeply
Normal: not palpable

Palpate the Rt kidney:

Place the 2 hands together in a duck-bill position at
the pts Rt. Flank
Press firmly while asking pt to breath deeply

Normal: not palpable or feeing of the lower pole of the

Rt kidney as:

Round smooth mass

Palpate the Lt kidney:

Reach your lt. hand across the abdomen and
behind the lt. flank
Push your Rt. hand deep while asking pt to
breath deeply
Normal: not palpable.

Palpate the aorta:

Palpate the aortic pulsation slightly left to midline
in the upper abdomen using your thumb and
fingers.
Normal: 1-4 cm wide and pulsates in an
anterior direction
Differ by the thickness of abdominal wall and
anteroposterior diameter of the abdomen.

Palpate the bladder:

When palpating the bladder it should be distended.
Located above symphysis pubis.
The dome of it feels smooth and round.
Use percussion to check the dullness and
determine how high it rises.

Special procedures:
1) ascites:
fluid wave
For differentiate ascites from gaseous.
Standing on right side .
Place the person's hand on his abdomen in the
midline (to stop transition of wave through fat).
Place your left hand on the person's right flank.
With your right hand give the left flank firm
strike if ascites is present the blow will generate
a fluid wave through the abdomen and you will
feel a distinct tap on your left hand.

Shifting Dullness/ ascites.

In supine person ,ascitic fluid setting by gravity
into the flank displacing the air filled bowel
upward.

2) Appendicitis:
A)Rebound tenderness: press down your fingers
firmly and slowly and then withdraw them
quickly. (in the RLQ)
Positive test if there is pain with finger withdraw.
The pain is caused by rapid movement of inflamed
peritoneum.
B) Rovsing sign: an indication of acute appendicitis
in which pressure on the LLQ of the abdomen
causes pain in the RLQ.

C) Psoas sign (Iliopsoas muscle pain): put your

hand above the patients Rt knee and ask the pt to
raise that thigh against your hand. Or , passively
extending the thigh of a patient lying on his side
with knees extended.

D) Obturator test: Flex the patients right thigh at the

hip, with the knee bent, and rotate the leg internally at
the hip. This maneuver stretches the internal obturator
muscle.

3) Acute cholecystitis:
check for Murphy sign: a test for gallbladder disease in
which the patient is asked to inhale while the examiner's
fingers are hooked under the liver border at the bottom of
the rib cage.
The inspiration causes the gallbladder to descend onto the
fingers, producing pain if the gallbladder is inflamed.
Deep inspiration can be very much limited.
Note that a positive Murphy sign may
also indicate the inflammation in liver.