Abdominal Anatomy

Surgery Abdominal Anatomy (Dr. Mata) 07 February 2008 ABDOMINAL ANATOMY Abdominal Cavity  boundaries ▫ superior: diaphragm ▫ inferior: pelvis ▫ posterior: lumbar spine ▫ anterior: muscular abdominal wall Anatomic Landmarks  quadrants ▫ RUQ, LUQ, LLQ, RLQ  anatomic ▫ epigastrium ▫ umbilical ▫ suprapubic (hypogastrium) Peritoneum  abdominal cavity lining  double-walled structure ▫ visceral ▫ parietal  separates abdominal cavity into two parts ▫ peritoneal cavity ▫ retroperitoneal space Primary GI Structures 

Mouth ▪ lips, cheeks, gums, teeth, tongue

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Pharynx ▪ portion of airway between nasal cavity and larynx

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Esophagus ▪ portion of digestive tract between pharynx and stomach

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Stomach ▪ hollow digestive organ ▪ receives food from the esophagus

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Small Intestine ▪ between stomach and cecum ▪ composed of duodenum, jejunum, ileum ▪ site of nutrient absorption into the body Large Intestine ▪ from ileocecal valve to anus ▪ composed of cecum, colon, rectum ▪ recovers water from GI tract secretions

Accessory GI Structures 

Salivary Glands ▫ produce, secrete saliva ▫ connect to mouth by ducts

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Liver ▪ large solid organ in RUQ ▪ produces, secretes bile ▪ produces essential proteins ▪ produces clotting factors ▪ detoxification ▪ stores glycogen

Leu, Brim, Virns – cyempre ang 2D

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Gall Bladder ▪ detoxifies many substances ▪ stores and concentrates bile ▪ sac located beneath the liver

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Pancreas ▪ endocrine pancreas secrete insulin into the bloodstream ▪ exocrine pancreas secrete digestive enzymes, bicarbonate

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Vermiform Appendix ▪ hollow appendage attached to LI ▪ no physiologic function

MAJOR BLOOD VESSELS  aorta  IVC SOLID ORGANS  liver, spleen, pancreas, kidney, ovaries (F) HOLLOW ORGANS  stomach, SI, LI, gall bladder, uterus, urinary bladder, uterus, fallopian tubes, bile ducts RUQ  LUQ  RLQ 

liver, gall bladder, duodenum, transverse colon (part), ascending colon (part) stomach, liver (part: left lobe), pancreas, spleen, transverse colon (part), descending colon (part) right ovary, ascending colon, right fallopian tube, vermiform appendix

LLQ

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left ovary, descending colon, left fallopian tube, sigmoid colon

DISORDERS OF THE ALIMENTARY TRACT Motor (Motility Disorders) ▪ achalasia ▪ post vagotomy atony ▪ Hirschprung’s disease Bleeding ▪ ▪ ▪ ▪ ▪ ▪

varices Mallory-Weiss disease PUD cancer Meckel’s diverticulum diverticulosis

Perforation ▪ instrumental  laparoscopic procedures ▪ ulcers ▪ obstruction and gangrene  in combination dapat perforation

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cause

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▪ diverticulitis Obstruction ▪ esophagus- cancer, reflux, esophagitis, substances (in suicidal attempt) ▪ pylorus- PUD ▪ small bowel- adhesions, hernia ▪ colon- cancer, volvulus, other

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Inflammations ▪ esophagitis ▪ gastritis ▪ regional enteritis ▪ ulcerative colitis ▪ granulomatous colitis

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Allergies  bugs, bites, stings EXAMINATION OF THE ACUTE ABDOMEN 

Observe The Patient

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Reasurre  show self-confidence Auscultate Percuss And Palpate • begin in the quadrant opposite the suspected pathology • percussion is a very sensitive peritoneal sign Look • description of abdominal habitus (scaphoid, flat, distended) • scars, wounds, erythema, anatomic confines  ano yung most likely organs involved Listen • with stethoscope  not necessary in all quadrants • qualitative  normal, borborygmus, obstructive, bruit • quantitative  absent, decreased, hyperactive

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Neoplasia ▪ may occur at any level of the alimentary tract Abdominal Pain

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visceral- most common somatic referred

Visceral Pain ▪ stretching of peritoneum or organ capsules by distention or edema ▪ diffuse ▪ poorly localized ▪ may be perceived at remote locations related to organ’s sensory innervation

Pain Vs Tenderness

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Distinction is critical in diagnosis Be precise o Conceptually o Verbally o Written documentation PAIN- is a subjective symptom TENDERNESS- objective sign

Acute Abdomen STABLE OR UNSTABLE resuscitative measures  considerations ▫ precipitating factors/ alleviating factors ▫ quality- bright, sharp, dull, achy ▫ radiation- scapula, inguinal, supraclavicular ▫ severity- 1 to 10 scale ▫ timing- sudden, insidious, crampy/continuous HPI  Past Surgical History ▫ previous abdominal or pelvic operation ▫ prior work-up for abdominal pain

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PMI

▪ Insulin Dependent DM ▪ Aterosclerotic CerebroVascular Disease (ASCVD)  Common Abdominal Conditions ▪ ileus from narcotics ▪ constipation/obstipation ▪ appendicitis ▪ pancreatitis ▪ perforated PUD ▪ small bowel obstruction ▪ cholecystitis/biliary colic PMH

Medications ▫ valproic acid

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Bowel Tones Pathologic  obstruction ▫ hollow ▫ air-fluid interface ▫ like a pebble dropped into a partially filled barrel ▫ tinkles and rushes Percussion • abdomen- tympanitic gas, dull fluid (ascites or blood) • bladder, uterus- rising out of the pelvis • liver span - midclavicular line by convention • percussion is also a very sensitive sign of peritonitis Palpation  Prepare The Patient ▪ warn them ▪ make them comfortable ▪ take tension of the abdomen (pillow/bend the knees) ▪ expose the entire abdomen (xiphoid to pubis)  After Percussion ▪ softly at first ▪ deeper ▫ LUQ, RUQ, note liver edge ▫ then LLQ, RLQ ▪ watch their eyes as you touch them ▪ Note px’s attitude EXAMINATION OF ACUTE ABDOMEN II Guards  Voluntary  Involuntary Peritoneal Signs  Rebound  Percussion Tenderness  Peritoneal Tenderness Associated Findings  Eyes Dilate  Electric-Shock Like  Bright Tenderness

Surgery – Abdominal Anatomy by Dr Mata

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Surgery – Abdominal Anatomy by Dr Mata

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EXAMINATION OF THE PAINFUL ABDOMEN Advanced ▪ ▪ ▪ ▪ ▪

Palpation Tricks Sneak Up On Them Distract With Converstion Watch Their Eyes Palpate With Stethoscope Bump The Stretcher

Advanced ▪ ▪ ▪ ▪ ▪

and Adjuvant Exams Shifting Dullness Listen To Lower Lung Fields CVA Tenderness Digital Rectal Exam  mortal sin if not done! Bimanual Pelvic Exam

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EXAMINATION FOR ASCITES   

Fluid Wave Shifting Dullness Associated Findings ▫ caput medusa ▫ spider angioma

DERMATOMAL PAIN SYNDROME  due to poorly localizing visceral innervation, disease can present in vague confusing manner ▪ pneumonia ▪ hepatitis ▪ pancreatitis ▪ PUD ▪ biliary colic ▪ acute MI ▪ GERD Diagnostic Approach Essential Questions ▫ stable/unstable? ▫ do I need a surgeon now? ▫ is it obvious that they need an operation? What is your Clinical Diagnosis?

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Options ▫ upright CXR and abd KUB (kidney, ureter, bladder) ▫ CT + IV or PO contrast ▫ ultrasound ▫ nothing

Diagnostic Modalities

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CT- 15-20% false neg for acute perforation ▫ poor study of gall stones ▫ contrast obscures kidney stones

When To Call A Surgeon?

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unstable vs call –immediately ( hypotension, ↓pulse pressure, ↓RR) obvious peritonitis work up complete in stable, less obvious ▫ CBCs, coags, blood gases, lytes, amylase, bilirubins, LFTs(liver fxn tests), imaging

Chores in the Interim  ABCs ▫ does this patient need intubation? ▫ IVS- 2 large bore if unstable ◦ Resuscitation NS(normal saline) vs (lactated ringer) ▫ bolus therapy- 20cc/kg repeat if necessary ▫ foley catheter  to monitor urine output ▫ ? central line

LR

Type And Cross  if there’s blood loss

Surgery – Abdominal Anatomy by Dr Mata 

Antibiotics- gram neg and anaerobic ▫ ciprofloxacin/ flagyl ▫ piperazin, tazobactam –Pip- Tazo ▫ cefotetan ▪ pain medication?  not sure coz if there’s abdominal pain you can’t just give analgesic dapat alam mu muna yung diagnosis

Common Pitfalls ▪ acute mesenteric ischemia ▪ intestinal volvulus ▪ gallstone ileus ▪ aortic abdominal aneurysm/back pains ▪ “it’s just gastroenteritis” EVALUATION OF THE ABDOMINAL PATIENT (SUMMARY) ▪ ▪ ▪ ▪

patient condition guides the urgency clinical diagnosis is the first step imaging studies depend on clinical diagnosis patient preparation is crucial to outcome

Lab Tests ▪ WBC and differential Diagnostic Imaging  Plain Films ▪ upright CXR- free air (pneumoperitoneum) ▪ KUB ▫ calcification ▫ foreign bodies  whee. Santol seeds! ▫ reactive bowel patterns ▫ fluid/ air levels  Lateral Decubitus Film  Ultrasound ▪ rapid, safe, low cost, always available ▫ operation dependent ▪ fluid, inflammation, air in walls, masses  either cystic or solid ▪ liver, GB, CBD, spleen, pancreas, appendix, kidneys, ovaries, uterus  CT Scan ▪ better than plain films and US for evaluation of solid and hollow organs ▫ IV contrast ▫ oral contrast ▫ per rectal contrast ▪ use in appendicitis, diverticulitis, abscess, pancreatitis WHEN TO OPERATE? ▪ ▪ ▪ ▪ ▪

peritonitis (excluding primary peritonitis) abdominal pain/tenderness + sepsis make sure pancreatitis is excluded pneumoperitoneum acute interstitial ischemia

WHAT IF ITS NOT CLEAR? Challenging Patients ▪ neurologically compromised ▪ intoxicated ▪ steroids ▪ immunosuppressed If signs and symptoms are equivocal ▪ serial exams (same person) ▪ imaging ▪ serial labs ▪ keep off antibiotics ▪ tincture of time

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WHEN NOT TO OPERATE? ▪ ▪ ▪ ▪ ▪ ▪

cholangitis appendiceal abscess acute diverticulitis + abscess acute hepatitis/pancreatitis ruptured ovarian cyst long standing perforated ulcer

Non Surgical Causes o Rectus Muscel Hematoma o Acute Salphingitis o Acute Porphyria o DKA, Acute Adrenal Insufficiency o GE Reflux, Hepatitis o Pulmonary Nodule, Pulmonary Infarction o MI, Acute Pericarditis o Pyelonephritis

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Sickle Cell Crisis

Approach In Patients With Jaundice  Check For Signs Of The Underlying Disease For Examination Example cirrhosis • Spider Nevi, Liver Palm • Flapping Tremor • Splenomegaly • Finger Clubbing • Ascites • Leg Edema • TB  Investigations (Jaundice) Initial • checking urinary bilirubin and urobilinogen • checking liver function tests • ultrasound, CT, MRI • liver biopsy • laparoscopy Nausea & Vomiting Causes o Viral Infections o Medications o Motion Sickness/ Sea sickness o Migraine Headaches o Morning Sickness During Pregnancy o Food Poisoning o Allergies o Chemotherapy  in CA patients

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Alcoholism Brain Tumors

Constipation  a decrease in frequency of bowel movements compared to a child’s usual pattern ( some physicians define constipation as fewer than 3 bowel movements per week)  the passage of hard, oftentimes large caliber, dry bowel movements  bowel movements that are difficult or painful to push out  Obstipation- severe constipation Causes of Constipation o diet o lack of exercise o busy children o emotional o physical problems that can cause constipation (abnormalities of intestinal tract, rectum, anus, problems of the nervous system  like cerebral palsy)

Surgery – Abdominal Anatomy by Dr Mata o

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endocrine problems (hyperthyroidism) medications (iron preparation, narcotics codeine)

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SIGNS AND SYMPTOMS OF INTESTINAL OBSTRUCTION such

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crampy abdominal pain that comes and goes (intermittent) nausea vomiting inability to have bowel movement/pass gas swelling of abdomen (distention) abdominal tenderness

Mechanical Obstruction of the SI Common causes include the ff: o Intestinal Adhesions o Hernias o Tumors o Telescoping Of A Portion Of The Intestines ( intussusception) o Volvulus (Twisting Of Intestine) o Narrowing Of The Outlet From Stomach (Stricture) Colon Most Common Causes Of Colonic Obstruction o Cancer o Diverticulitis o Volvulus Less Common o Impacted Feces o Intussusception o Stricture o Foreign Bodies/swallowed object that block the colon WAITING FOR A BUS... You know, love is just like someone waiting for a bus. When the bus comes, you look at it and you say to yourself "eeee...so full.... cannot sit down. Ill wait for the next one". So you let the bus go and waited for the second bus. Then the second bus came, you looked at it you say,"eeee...this bus is so old...so shabby!" So you let the bus go and again, decided to wait for the next bus. After a while another bus came, it's not crowded, not old but you said, "eeee... not air-conditioned ...better wait for the next one. So again you let the bus go and decided to wait for the next bus. Then the sky started to get dark as it is getting late. You panicked and jumped immediately inside the next bus. It is not until much later that you found out that you had boarded the wrong bus! So you wasted your time and money waiting for what you want! Even if an air-conditioned bus comes, you can't ensure that their-conditioned bus won't break down or whether or not the airconditioner will be too cold for you. So people... wanting to get what you want is not wrong. But it wouldn't hurt to give other person a chance, right? If you find that the "bus" doesn't suit you just press the red button and get off the bus! (as simple as that!) Hey who said life is fair??? The best thing to do is be observant and open while you scrutinize the bus. If it doesn't suit you, get off. But you must always have an extra something, which you could use for the next bus that comes. But wait... I'm sure you have this experience before...You saw a bus coming (the bus you want, of course) you flagged it but the driver acted as if he did not see you and zoomed pass you! It just wasnt meant for you! The bottom line is, being loved is like waiting for a bus you want. Getting on the bus and appreciating the bus by giving it a chance depends totally on you. If you haven't made any choice, WALK! Walking is like being out of love. The good side of it is you can still choose any bus you want... the rest who couldnt afford another ride would just have to be content with the bus they rode on, ugly or not. One more thing.... sometimes its better to choose a bus you are already familiar with rather than gamble with a bus that is unfamiliar to you. But then again, life wouldn't be complete without the risks involved. BUT THERE'S ONE BUS THAT I FORGOT TO TELL YOU ABOUT - THE BUS THAT YOU DON'T HAVE TO WAIT FOR... IT WILL JUST STOP ON ITS OWN AND WILL ASK YOU TO COME INSIDE AND TAKE A FREE RIDE FOR THE REST OF YOUR LIFE… You Never Lose By Loving You Always Lose By Holding Back Yay! mush mush. valentines na kasi.. tsk tsk. ;) Special thanks sa 2D for the notes.. complete na to’.. wl some notes yung nkaitalicized 9as if it helps..).. haha.

Surgery – Abdominal Anatomy by Dr Mata --brim

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