Infants

The pancreatic buds, liver, and gallbladder al begin to form during the week 4 of gestation, by which time the intestine already exists as a single tube.

By week 17 of gestation the motility of the gastrointestinal tract develops in a cephalocaudal direction, permitting amniotic fluid to be swallowed and production of meconium shortly thereafter

By 36-38 weeks, the GI tract is capable of adapting to extrauterine life. However the elasticity, musculature and control mechanisms of the GI tract continue to develope reaching adult function at 2 to 3 years of age

During gestation, the liver begins to form blood cells at about week 6, synthesize glycogen at week 9 and produce bile by week 12

The liver's role as a metabolic and glycogen storage organ accounts for the large size at birth- liver remains the heaviest organ in the body

Pancreatic islet cells are developed by 12 weeks gestation and begin producing insulin.

The spleen is active in blood formation during fetal development and the first year of life

The spleen also aids in the destruction of blood cells and functions as a lymphatic organ for immunologic response

Nephrogenesis begins during the second embryologic month

By 12 weeks, the kidney is able to produce urine, and the bladder expands as a sac.

Development of new nephrons ceases by 36 weeks of gestation.

After birth, the kidney increases in size because of enlargement of the existing nephrons and adjoining tubules.

The GFR is approximately 0.5ml/min before 34 weeks of gestation and gradually increases in a linear fashion to the adulthood rate

As the uterus enlarges, the muscles of the abdominal wall stretch and lose tone. During the 3rd trimester the rectus abdominis muscles may seperate, allowing abdominal contents to protrude at the midline

The umbilicus flattens or protrudes. The abdominal contour changes when lightening occurs (about two weeks before term in a nullipara), and the fetal presenting part descends into the true pelvis. Striae may form as the skin is stretched. A line of pigmentation at the midline (linea nigra) often develops

Abdominal muscles have less tone and are less active

After pregnancy, the muscles gradually regaine tone, although seperation of the rectus abdominis muscles may persist.

During the second trimester lower esophageal spinchter pressure decreases. Peristaltic wave velocity in the distal esophagus also decreases

Gastric emptying appears to be normal; however gastrointestinal transit time is prolonged in the second and third trimesters, leading to constipation.

Incompetence of the pyloric spinchter may result in alkaline reflux of duodenal contents into the stomach.Heartburn is a common concern

The kidneys enlarge slightly (by about 1 cm in length) during pregnancy. The renal pelvis and ureters dilate from the effect of hormones and pressure from the enlarging uterus. Dilation of the ureter is greater on the right side than on the left, probably because it is affected by displacement of the uterus to the right by an enlarged right ovarian vein. The ureters also enonlage and form single and double curves of varying sizes and angulation

Changes can lead to URINARY STASIS and pyelonephritiis in gravid women with asymptomatic bacteriuria.

Renal function is most efficient if the woman lies in the lateral recumbent position, which helps prvent compression of the vena cava and aorta. These changes can last 3-4 weeks after delivery

The bladder has increased sensitivity and compresssion during preganancy, leading to frequency and urgency of urination during the first and third trimesters.

After the fourth month, the increase in uterine size, hyperemia of all pelvic organs, and hyperplasia of muscle and connective tissue elevate the bladder trigone by the end of the pregnancy and may result in microhematuria.

During the third trimester, compression may also result from the descent of the fetus into the pelvis; this, in turn, causes a sense of urgency and or incontinence, even with a small amount of urine in the bladder

The colon is displaced laterally upward and posteriorly, peristaltic activity may decrease, and water absorption is increased, As a result bowel sounds are diminished and constipation and flatus are more common

The appendix is displaced upward and laterally, away from McBurney's point, an anatomic landmark one third of the distance from the anterior superior iliac spine and umbilicus.

The uterus involutes rapidly

Immediately after delivery, the uterus is approximately the size of a 20-week pregnancy (palpable at the umbilicus)

By the end of the first week, it is about the size of a 12 week pregnancy, palpable at the symphysis pubis. the muscles of the pelvic floor and the pelvis supports gradually regain tone during the postpartum period and may require 6-7 weeks to recover. Streching of the abdominal wall during pregnancy may result in persistent striae and disastisis of the rectus muscles

Older Adults

Motility of the intestine is the most severly affected;

secretion and absorption are affected to a lesser degree. Altered motility may be caused by age-related changes in neurons of the central nervous system and by changes in collagen properties that increase the resistance of the intestinal wall to stretching. Reduced circulation to the intestine often folllows other system changes associated with hypoxia and hypocolemia. Thus, functional abilities of the intestine can decrease secondary to systemic changes in the older adult

Older adult- liver

 Gestational age and birth weight- preterm and less than 1500 g at higher risk for necrotizing enetercolitis

vomiting; increasing in amount or frequency, forecful or projectile, failure to gain weight, insatiable appetitie, blood in emesis (pyloric stenosis or gastroesophageal reflux)

Intermittent abdominal pain or drawing of the legs (intussusception)

Diarrhea, colic, failure to gain weight, weight loss, streatorrhea (malabsorption)

Have pt. empty bladder before the examination begins; a full bladder interferes with accurate examination of nearby organs and makes the examination uncomfortable. Place the patient in a supine position with arms at the sides. Approach the patient from the right side. The patient's abdominal musculature should be relaxed to allow access to the underlying structures.

Divide abdominal region into 9 areas- two horizontal lines and one across the lowest edge of the costal margin and the other across the edge of the iliac crest and two vertical lines running bilaterally from the midclavicular line to the middle of the poupart ligament

to determine venous return, place the index fingers of both hands side by side perpendicularly over a vein. Press and seperate the fingers, milking empty a section of vein. Release one finger and time the refill. Release the other finger and time the refill. The flow of venous blood is in the direction of the faster filling.

A glistening taut appearance indiciates ascites.

A bluish periumbilical discolaration cullen sign suggests intraabdominal bleeding

Age older than 50 yo

family history in one or more first degree relatives

personal history of colon cancer, intestinal polyps, inflammatory bowel disease

history of ovarian or endometrial cancer

African American

Jewish, eastern european descent

Low-fiber, high in red meat and processed meats, low fruit and vegetable intake

obesity

smoking

lack of physical activity

heavy alcohol use

type 2 diabetes

Abdominal distention

distended abdominal with hypoactive bowel sounds

there is no particular pain and you feel no masses-the deep tendon reflexes are diminished. you know that the patient is on diuretics for treatment of hypertension. Think of hypokalemia as a cause of a parlytic ileus (intestinal psuedo obstruction)

DIURETICS/DISTENTION/DEFICIENCY OF POTTASIUM. narcotics and hypothyroidism can do the same thing

Ask the patient to take a deep breath and hold it. the countour should remain smooth and symmetric

this maneuver lowers the diaphragm and compresses the organs of the abdominal cavitiy, which may cause previously unseen bulges or masses to appear, next ask the patient to raise his or her head from the table. This contracts the rectus abdominis muscles, which produces muscle prominence in thin and athletic individuals. Superficial abdominal wall masses may become visible. if a hernia is present, the increased abdominal pressure may cause it to protrude

Most hernias are reducible, meaning that the contents of the hernia can be pushed back into place, if not the hernia is nonreductible or incarcerated

Abdominal muscles may become apparent when the pt raises their head- diastasis recti occurs often in pregnancy and the postpartum period

Surface motion from peristalsis, seen as a rippling movement across the abdomen, may be seen in thin individuals but can also be a sign of intestinal obstruction.

Abdominal aortic pulsations seen in the upper midline are often visible in thin adults. Marked pulsations may occur as the result of increased pulse pressure or abdominal aortic aneurysm

To determine the upper border of the liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. continue downward until the percussion tone changes to one of dullness; this marks the upper border of the liver. The upper border is usually in the 5th ICS. An upper border below this may indiciate downward displacement or liver atrophy. Dullness above the 5th ICS suggests upward displacement from abdominal fluid or masses.

Measure the difference - **** usually span is 6-12cm

Liver span larger indicates liver enlargement, whereas a lesser span suggests atrophy. Age and gender influence liver size. Liver size is usually greater in men and in tall individuals.

Errors can occur if there is lung consolidation (dullness) Gas in the colon can obscure dullness with tympany

The prevalence of palpable splenomegaly is low. begin with percussion of Traube's space, if dullness is appreciated, palpation should follow. For thin patients, palpation may be more useful than percussion. if clinical suspicion is high, and splenomegaly is not appreciated on examination, radiologic may be necessary

Palpate the liver margin at the lateral border of the rectus abdominis muscle

A healthy gallbladder will not be palpable, a palpable tender gallbladder indicates cholecystitis, whereas nontender enlargement suggests common bile duct obstruction

Ask the pt to take a deep breath during inspiration as the inflamed gallbladder comes in contact with the examining fingers, the patient will experience pain and abruptly halt inspiration (Murphy's sign)

Place your hand beneath the pt over the L costovertebral angle Press upward with that hand to lift the spleen anteriorly toward the abdominal wall. Place the palmar surface of your r hand on the patients abdomen below the L costal margin. Press your fingertips inward toward the spleen as you ask the patient to take a deep breath Try to feel the edge of the spleen, the spleen is not usually palpable in an adult; if you can feel it, it is probably enlarged. Be sure to palpate with your fingers below the costal margin so that you will not miss the lower edge of an enlarged spleen.

** Patients with splenomegaly from infectious mononucleosis have a small risk for splenic rupture

Standing on the R side, reach accross with your left hand as you did in spleen palpation and place your hand over the L flank. Place your right hand at the patient's L costal margin. Have the patient take a deep breath and then elevate the L flank with your left hand and palpate deeply with your R hand. The L kidney is ordinarily not palpable.

*Capture the kidney- move to the patient's left side and position your hands as before with your L hand on the flank and R on the costal margin, Ask the patient to take a deep breath and at inspiration try to capture and release on expiration

Mark the presence between dullness and tympany

Shifting Dullness-->After identifying the borders between the two, have the patient lie on one side and again percuss, the borders will remain relatively constant. With ascites- the border of dullness shifts to the dependent side as the fluid resettles with gravity

Fluid Wave- Need two examiners- With the patient supine- ask him or her to press the edge of the hand and forewarm firmly along the vertical midline of the abdomen. the positioning helps stop the trasmission of a wave through adipose tissue. Place your hands on each side of the abdomen and strike one side sharply with your fingertips. Feel for the impulse of a fluid wave with the fingers.

* flank dullness and fluid wave Typmpany shifts up when fluid goes down dullness

Most common indication for emergency surgery

Adults- RLQ pain, initial periumbilical pain with migration to RLQ, and the presence of pain before vomiting. The presence of rigidity, a positive psoas sign, fever, and or rebound tenderness

In children, vomiting, rebound tenderness, rectal tenderness, and fever are more helpful, whereas r lower quadrant tenderness is less helpful

ecchymosis around umbilicus- ectopic pregnancy- hemoperitoneum and pancreatitis

Duodenal ulcer

Hepatitis

Hepatomegaly

Lower lobe pneumonia

Choleycystitis

Appendicitis

Salpingtiis

Ruptured ectopic pregnancy

Ovariab abscess

Renal/uteral stone

Strangulated hernia

Meckel diverticulitis

regional ileitis

perforated cecum

Intestinal obstruction

Acute pancreatitis

Early appendicitis

Mesenteric thrombosis

aortic aneurysm

Diverticulitis

L upper quadrant

pain

Ruptured spleen

Gastric ulcer

Aortic Aneurysm

Perforated colon

Lower lobe pneumonia

Sigmoid diverticulitis

Salpingitis

Ovarian cysts

Ruptured ectopic pregnancy

Ovarian abscess

renal stone

strangulated hernia

perforated colon

regional ileitis

ulcerative colitis

sudden, dramatic change from mild, even vague abdominal pain that is not particularly distressing to sudden onset of severe abdominal tenderness in the hypogastric ara, rigidity and rebound may come on early or late,

*** if women comes in vague abdominal symptoms, be sure to inquire about her sexual activity and menstraul history conduct a pelvic examination and strongly consider performing a urine pregnancy test, try to be aware of the emergency

Used when you suspect appendicitis

Ask the patient to lie supine and then place your hand over the lower right thigh, ask the patient to raise the r leg, flexing at the hip while you push downward.

Used when you suspect a ruptured appendix or pelvic abscess due to irritation of the obturator muscle

While in the supine position- ask the patient to flex the right leg at the hip and knee to 90 degrees. Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially. Pain in the r hypogastric region is a positive sign

Used to assess and organ or a mass

Place your fingers hand and forwarm at a 90 degree angle to the abdomen. Push in toward the organ or mass with fingertips

Bimanual is pushing and recieving hand to detect fluid or moveable mass

Infants

Have the patient sit in the parents lap and examine pt. in this position for the first several years of life.

A thick umbilical cord suggests a well-nourished fetus; a thin cord suggests otherwise

The umbilical stump area should be dry and odorless. Inspect it for discharge, redness, induration, and skin warmth. Once the stump has seperated, typically by 2 weeks of age, serous or serosanguienous discharge may indicate a granuloma when not other signs.

If infant is vomiting frequently- observe for peristaltic waves- malnourished infants, usually suggests intestinal obstruction such as pyloric stenosis

Hepatomegaly is present when the liver is more than 3 cm below the R costal margin before 2 yo females have a larger liver than males

10 years old 5-6 cm

Nausea and vomiting are common in the first trimester

Constipation is a common occurence and hemorrhoids often develop

Bowel sounds will be diminished as a result of decreased peristaltic activity

Assessment of the abdomen is uterine size , fetal growth, position of the fetus, monitoring of fetal well-being and presence of uterine contractions

Abdominal wall becomes thinner and less firm as a result of the loss of connective tissue and muscle mass

A pulsating abdominal aortic aneurysm may be more readily palpable than in younger patients. Deposition of fat over the abdominal area is common. Abdominal contour is often rounded as loss of muscle tone.

COPD will cause the liver to be displaced downward not relating to enlarged liver

Decrease in liver size after 50 yo may find a smaller span

Decreased intestinal motility are common - constipation and gas are common

Obstruction may be a problem with older adults, occuring as a result of hypokalemia, myocardial infarction or infections

GI cancer- dysphagia, nausea, vomiting, anorexia, and hematemesis

Frequent liquid stools lasting less than 4 weeks duration

-Foodborne infection, viral

Abrupt onset and lasts less than 2 weeks, abdominal pain, nausea, vomiting, fever, tenesmus, bloody diarrhea

Objective- Diffuse abdominal tenderness, examination may minic peritoneal inflammation with R Lower quadrant pain or guarding

May have symptoms consistent with dehydration- tachy, hypotension, altered mental status

Gastroesophageal Reflux Disease

Backward flow of gastric contents, which are typically acidic into esophagus

older adults-pregnancy

Heartburn or acid indigestion, bitter or sour taste, hoarseness, regurgitation/vomiting

usually unremarkable- sometimes erythema of the poserior pharynx and edematous vocal cords

disorder of the intestinal motility

more often in women- usually early adult life

abdominal pain, bloating, constipation, and diarrhea

alternating diarrhea and constipation

mucus may be present- emotional stress

at least 3 days per month during 3 months with two or more of following:

relieved by defecation, onset associated with change in stool frequency, onset with change in stool form

altered stool passage (straining/urgency) muccorhea

Cook all ground beef and poultry

do not drink unpasteurized milk or juice

refrigerate ground beef

wash hands and food utensils with hot soapy water after handling meat

avoid cooked food that has been at room temperature

avoiding eating foods or drinking beverages purchased from street vendors

avoid eating raw or undercooked meat

avoid eating raw vegetables unless the traveler peels them

avoid ice

avoid dishess containing raw or undercooked eggs

hot tea and coffee generally safe to drink due to being boiled

Hiatal Hernia with Esophagitis

Part of the stomach passes through the esophageal hiatus in the diaphragm into the chest cavity

associated with obesity, pregnancy, ascites, and use of tight fitting belt and clothes, muscle weakness

epigastric pain and heartburn that worsens with lying down and is relieved by sitting up or antacids

water brash- mouth fills with fluid from esophagus, dysphagia, sudden onset of vomiting, pain, and complete dysphagia

erythema of the posterior pharynx and edematous vocal chords

Hpylori

localized epigastric pain that occurs when the stomach is empty and is relieved by food or antacids

upper gi bleeding, symptoms include hematemesis and melena (dark feces)

anterior wall feces may produce tenderness on palpation

ulceration, fibrosis, and malabsorption, terminal ileum and colon are common

chronic diarrhea with compromised nutritional status

arthritis, iritis, and erythema, flares & remissions

RLQ tenderness, abdominal mass secondary to inflamed bowel, perianal skin tags, fistulae, abscesses, cobblestone appearance of the mucosa, fistula and abscess formation extending to the skin

inflammatory disorder of the colon and rectum that produces mucosal friability and areas of ulceration

predisposes an individual to developing colon cancer

bloody, frequent, watery diarrhea, 20 to 30 diarrhea stools per day, weight loss, fatigue, general debilitation, mild to severe depending on degree , may remain in remission for years

sclerosing cholangitis (inflammation and scarring of bile ducts) fatigue, jaundice

generally do not have fistulae or perianal disease, radiographs typically show loss of normal mucosal pattern, sclerosing cholangitis may occur with elevated transaminase levels

*endoscopic---mucosal edema with ulcerations and bleeding

Arises from epithelial cells of the mucous membrane

usually lower half of stomach- mucosa/submucosa/muscle/metastisis

vague and nonspecific symptoms, loss of appetite, feeling of fullness, weight loss, dysphagia, persisitent epigastric pain

midepigastric tenderness, hepatomegaly, enlarged supraclavicular nodes, and ascites, epigastric mass may be palpable in the late stages

saclike mucosal outpouchings through colonic muscle, sigmoid most common, defects in collagen and aging

diverticula become inflamed may experience LLQ pain, anorexia, nausea, vomiting, and altered bowel habits (usually constipation), pain usually localizes to site of inflammation

may have abdominal distention and be tympanic to percussion with decreased bowel sounds and localized tenderness, lower GI bleeding may occur

rectum, sigmoid, proximal and descending colon

abdominal pain, blood in the stool, recent change in character of stool, occult blood in the stool

if disease progressed, abdominal mass in R or L LQ or show signs of anemia from blood loss (pallor tachycardia)

Rectal cancer may be palpable with digital rectal exam

at risk if

50 yo

Annual Fecal occult blood test

Tests that detect polyps and cancer

Sigmoidoscopy every 5 years

colonoscopy every 10 years

contrast barium enema every 5 years

Positive FOBT have colonoscopy recommended

diffuse or patchy hepatocellular necrosis

viral infection, alcohol, drugs, or toxins

jaundice, anorexia, abdominal pain, clay-colored stools, tea colored urine, and fatigue

liver function tests are abnormal, jaundice, hepatomegaly

cirrhosis

diffuse heaptic process characterized by fibrosis and alteration of normal liver architecture into strutcturally abnormal nodules

hep c and alcoholic liver disease

jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, fatigue, abdominal vasculature, cutaneous spider angiomas, hematemesis, and abdominal fullness, enlarged liver with a firm non tender border on palpation; as scarring progresses, liver size reduced and cannot be palpated

Hepatic encephalopathy* muscle wasting and nutritional deficiencies, liver function tests and coagulopathy

usually in cirrhosis

jaundice, anorexia, fatigue, abdominal fullness, clay-colored stools, and tea colored urine

hepatomegaly with a hard irregular liver border, liver nodules may be present and palpable, liver may be tender or nontender

stone formation in the gallbladder with certain substances reach a high concentration in bile and produce crystals

Cholesterol usually* and calcium bilirubinate

chronic disease can result in fibrosis and gallbladder dysfunction and predispose to gallbladder CA

indigestion, colic, and mild transient jaundice

acute cholecystitis* s/s

inflammatory process of the gallbladder most commonly due to obstruction of the cystic duct from cholelithiasis, acute or chronic

RUQ pain with radiation around the midtorso to the R scapular region; pain is abrupt and severe and lasts for 2 to 4 years

may have fever, jaundice, and anorexia, fat intolerance, flatulence, nausea, anorexia, abd pain

Acute** RUQ pain epigastrium pain involuntary guarding or rebound tenderness may be present

chronic a palpable gallbladder is typically not appreciated due to gallbladder fibrosis

not related to alcohol intake- steatosis to cirrhosis and hepatocellular carcinoma

result from accumulation of triglycerides in the liver, DM, fat buildup

RUQ pain, fatigue, malaise, jaundice

abnormal liver function tests; elevated AST/ALT, BMI elevated, hepatomegaly, jaundice, ascites, liver biopsy

process in which release of pancreatic enzymes results in glandular autodigestion

chronic alcohol abuse

mild to severe sudden onset of persistent epigastric pain that may radiate to the back; pain is constant and dull, nausea, vomiting, abdominal distention, fever, anorexia

diffuse abdominal tenderness to palpation; guarding and abdominal distention, decreased bowel sounds as a result of an ileus, necrotizing pancreatitis- Cullen and Grey Turner signs may be appreciated on exam

fever/tachy, dyspnea- diaphragm irritation, amylase, lipase are elevated

irreversible morphologic changes resulting in atrophy, fibrosis, and pancreatic calcifications

subjective- constant unremitting abdominal pain, weight loss, and streatorrhea

objective- pseudocyst formation, malnutrition with decreased subcutaneous fat and temporal wasting, pancreatic enzyme levels (amylase and lipase are elevated) , glucose intolerance

mva

subjective-  pain in the L upper quadrant with radiation to L shoulder (positive Kehr sign)

hypovolemia

LUQ pain with palpation; signs of peritoneal irritation (guarding, rebound tenderness)

-paracentesis or CT

inflammation of capillary loops of renal glomeruli

infection -strep

subjective- nausea, malaise, flank pain, ha, tea colored urine or gross hematuria

affected children develop peripheral and periorbital edema

Objective-edema, htn, oliguria, microscopic hematuria

dilation of the renal pelvis and calyces due to an obstruction of urine flow in urethral meatus to kidneys

intermittent severe pain (renal colic) with nausea and vomiting, abdominal pain, flank pain hematuria and fever

Objective- palpable kidneys, CVA tenderness, distended bladder, hydronephrosis

Pyelonephritis

infection of kidney and renal pelvis

Gram -

Subjective- fever, dysuria, flank pain, rigors, polyuria, urinary frequency, urgency, hematuria

Objective- ill appearing with significant pain or discomfort, cva tenderness, urinalysis may show pyuria and bacteriuria

CT, MRI, ultrasound

stones in pelvis of kidney

subjective- fever, dysuria, hematuria, flank pain, renal colic is marked by severe cramping flank pain with nausea and vomiting; flank to groin then to scrotal and labial area

objective-

emergency or urgent care facility with severe cramping pain, cva tenderness/abdominal tenderness with palpation, urinalysis may show microscopic hematuria and alevated urinary calcium to creatinine ratio

huors to days, resulting in acute episode

rise in serum creatinine concentration of 0.5 to 1.0

decreased GFR

Sub- urine output may be normal but decreased or absent (anuria) symptoms of dehydration and decreased kidney perfusion in ARF, intravascular volume depletion (SHOB, peripheral edema, chf)

Postrenal ARF, urinary tract obstruction, anuria

Intrinsic ARF-tea or cola-colored urine in glomerulonephritis or malar rash with systemic lupus erythematosus

Objective- fluid overload (increased jugular distension, peripheral edema, or deficit, hypotension, orthostatic pulse and blood pressure changes, dry mucous membranes, postrenal ARF with complete obstruction- abdominal distension, bladder and suprapubic tenderness to palpation

prolapse or telescoping, of one segment of intestine into other

infants 3-12 mo

Subjective- acute intermittent abdominal pain, abdominal distension, vomiting, (children crying and severe abdominal pain, awaking from sleep, intermittent bouts of lethargy)

child is often inconsolable, sometimes with legs and knees flexed with pain, stool appears normal in early as ischemia progresses, subsequent stools may be mixed with blood mucus with a red currant jelly appearance

Objective- Sausage shaped mass ay be palpated in the R or LUQ , RLQ feels empty (positive dance sign) , bowel perf (abd distension and guarding)

constrast enema

Pyloric Stenosis

hypertrophy of the circular muscle of the pylorus leading to obstruction of the pyloric sphincter

sub-regurgitation progressing to projectile vomiting, feeding eagerly even after vomiting and failure to gain weight

Objective-epigastric distension from obstructed stomach, visible wave of peristalsis L to R

small, rounded olive-shaped mass sometimes palpable in the RUQ, particularly after infant vomits

Ultrasound

Distal intestinal obstruction from impacted meconium

may be first manifestation of cystic fibrosis

subjective- most newborns present with failure to pass meconium in the first 24 hours after birth

sympstoms related to distal intestinal obstruction (vomiting & abdominal distension)

Objective-abdominal distension, volvulus, signs of shock, tachy, hypotension

Hypersmolar enemas

Biliary Atresia- obstruction or absense of some or all of the bile duct system

bile flow obstruction

subjective-neonatal cholestasis -jaundice, light clay colored stools, dark urine

objective- most infants are full term and develop jaundice in the first 2 months of life; hepatomegaly may be firm to palpation

splenomegaly may occur and indicates progressive disease with portal htn, heart mumurs-heart disease

ultrasound

Meckel Diverticulum

outpouching of the ileum that varies in size from a small appendiceal process to a segment of bowel several inches long- often in the proximity of the ileocecal valve

subjective-bright or dark red rectal bleeding with little if any abdominal pain, present with abdominal pain that can be severe in character; others may present with signs of intetinal obstruction or diverticulitis, similar to acute appendicitis with bilous emesis

Objective- painless rectal bleeding is the most common presenting finding on examination , intestinal obstruction (abdominal tenderness, involuntary guarding, rebound tenderness)

severe-perforation can occur with peritoneal signs and hypovolemic shock (tachy/hypotension)

Necrotizing Enerocolitis

inflammatory disease of the gi mucosa associated with prematurity and gut immaturity

Subjective- symptoms may be subtle, including inability to tolerate feelings (oral or nasograstric); may also present suddenly and progress quickly

Abdominal distension, vomiting, and bloody stools

Objective- may display temperature instability and subtle signs of distress, lethargy, abdominal distension, apnea, and respiratory distress, plain abdominal radiograph may show pneumatosis intestinalis (air in bowel wall)

solid malignancy of embryonal origin in the peripheral sympathetic system

subjective- asymptomatic abdominal mass in a young child, malaise, loss of appetite, weight loss, and protrusion of one or both eyes

obejctive- firm, fixed, nontender, irregular, and nodular abdominal mass that crosses the midline, metastases to the periorbital region result in proptosis and infraorbital ecchymoses, horner syndrome, ataxia, and opsomyoclonus (dancing eyes and feet)

most common intra-abdominal tumor of childhood; usually appears at 2 to 3 yo

subjective- painless enlargement of the abdomen or an abdominal mass, abdominal pain, vomiting, and hematuria

objective- firm non tender mass deep within flank, only slightly moveable and usually crossing midline

primary absence of parasympathetic ganglion cells in a segment of the colon, which interrupts intestinal motility

subjective-symptoms typically begin at birth with failure to pass meconium in the first 24 to 48 hours, failure to thrive, constipation, abdominal distension, bilious vomiting, and diarrhea

objective- severe constipation include abdominal distension and stool palpated in the left lower abdomen

traid of microangiopathic hemolytic anemia,thrombocytopenia, and uremia

subjective-preceding upper respiratory infection or gastroenteritis with fever, abdominal pain, and vomiting; diarrhea often becomes bloody

acute abdomen with occasional perforation, sudden onset of pallor, weakness, lethargy and decreased urine output

objective- dehydration, edema, petechiae, and hepatosplenomegaly, peritoneal signs (abdominal distension, involuntary guarding, rebound tenderness)

inability to control BM, leakage of stool; fecal impaction, underlying disease, neurological disorder

subjective- most have "overflow incontinence" soft stool that oozes around impaction, unable to recognize rectal fullness with contractions, stools usually formed and occur in a set pattern-after meals

objective-DRE

Stress Incont- small-volume incontinence with coughing, sneezing, laughing, running; history of pelvic surgery *pelvic floor relaxation; cystocele, rectocele; lax urethral sphincter, post void residual of less than 100ml

Urge incont-uncontrolled urge to void-large volume incontinence; history of CNS disorders *unexpected findings only as related to CNS disorder, postvoid residual less than 100ml

Overflow Incont- small volume incontinence, dribbling, hesitancy-in men, symptoms of enlarged prostate, nocturia, dribbling, hesitance, decreased force and caliber of stream *distended bladder, prostate hypertrophy, stool in rectum, fecal impaction, postvoid residual greater than 100ml

neurogenic bladder- history of bowel problems, spinal cord injury, ms

Functional incont- change in mental status; impaired mobility; new environment *impaired mental status-mobility

Medications-hypnotics, diuretics,antichollinergic,alpha-adrenergic,ccb *impaired mental status