Abd Alimentary Tract

• Large intestine: Starts @ cecum-blind pouch 2-3 in.
• Ileal content empties into cecum thru illeocecal valve.
• Vermiform appendix extends from the base of cecum
• Ascending colon rises fron the cecum along R posterior abd wall > undersuface of the liver> turns toward the midline @ hepatic flexure > becomes transverse colon
• Transverse colon crosses the abd wall to the rim of pelvis> turns medially & inferiorly to form S-shape sigmoid colon
• Rectum extends from sigmoid >muscles of the pelvic floor> continues as anal canal & terminates @ anus
• Large intestines 4.5-5ft long diameter 2.5in
• Functions: absorbs h2o & transports waste. Mucous glands secret large quantities of alkaline mucus> lubricates intestinal contents & neutralize acids formed by intestinal bacteria.
• Live bacteria: decomposes undigested food residue, unabsorbed amino acids, cell debris & dead bacteria through a process of putretactions.

• Peritoneum: a serous membrane, lines the cavity & forms a protective cover for many of the abd organs. Double folds of the peritoneum around the stomach constitue the greater & lesser omentum.
• Mesentery: fan shaped fold of the peritoneum, covers most of the small intestine & anchors it to the posterior abd wall

• tube 27ft long
• Starts at mouth-anus (espohagus, stomach, small intestine, & large  intestine)
• Functions: ingest & digests food; absorbs nutrients, electrolyes & water, & excrete waste products
• Peristalsis moves food & products thru tract, under autonomic nervous system control.
• Esophagus 10cm- connects pharynx to stomach
• posterior to trachea-descends thru the mediastinal cavity & diaphragm, entering the stomach at the cardiac orifice
• Stomach lies transversely in upper abd cavity, below diaphragm
• 3 sections: fundus (lying above & to the left of cardiac orifice)
• middle 2/3 or body (pyloris)(most distal portion that narrows & terminates in the pyloric orifice)
• secrets hydrochloric acid & digestive enzymes
• pepsin acts to digest proteins
• Gasteric lipase acts on emulsified fats
• little absorbtion takes place in stomach

ABD Alimentary Tract

• Small intestines 21ft long, begins @ pylorus. Coiled
• Joins the large intestine @ ileocecal valve
• First 12in duodenum, forms C-shaped curve around the head of the pancreas
• Commonbile duct & pancreatic duct open into the duodenum @ the duodenal papilla
• 3in below pylorus of the stomach
• Next 8ft jejunum gradually becomes larger & thicker
• ileum makes up 12 ft- ileocecal valve b/t the ileu & large intestine prevents back flow of fecal material
• Small intestine completes digestion thru the action of pancreatic enzymes, bile, & several other enzymes.
• Nurtients absorbed through mucosa
• Surface area increased circular folds and villi.

• In the RUQ, below the diaphragm and above the gallbladder, right kidney and hepatic flexure of the colon.
• heaviest organ in the body 3 lbs
• 4 lobes containing lobules, functional units
• lobule: liver cells radiating around a central vein.
• Branches of portal vein, hepatic artery, and bile duct penetrate to the periphery of the lobes.
• Bile secreted by the liver cells drains from the bile duct into the hepatic duct which joins the cytic duct from the gallbladder to form the common bile duct.
• Hepatic artery supplies blood to liver from aorta
• Portal vein carries blood from digestive tract and spleen to liver
• Liver very vascular from branching
• 3 hepatic veins carry blood from liver and empties in vena cava
• Important role in metabolism of carbohydrates, fats, & proteins
• Glucose converted and stored as glycogen until, in response to varying levels of insulin and regulator hormones, it is reconverted and released again as glucose.
• Amino acids convertd to glucose (gluconeogenesis)
• Fats, arrive in the liver in the form of fatty acids, oxidized to two-carbon components in prep for entry into the tricarboxylic acid cycle.
• Cholesterol is used to form bile salts.
• Synthesis of fats from carbohydrates and proteins
• Proteins broke down through hydrolysis and waste products converted to urea for excretion
• Other functions: storage of vitamins, iron; detoxificaion of harmful substances; production of antibodies, conjugation and excretion of steriod hormones; production of prothrombin, fibrinogen, & other blood coags
• Responsible for production of the majority of proteins circulating in the plasma.
• Serves excertory organ through the synthesis of bile, the secretion of organic wastes into bile and the conversion of fat soluble wastes to water soluble material for renal excretion.

• Saclike, pear shaped organ ~4in lying recessed in the inferior surface of the liver
• concentrates and stores bile from liver
• Response to cholecystokinin, hormone produced on the duodenum, releases bile into cystic duct
• Cystic duct and hepatic duct form common bile duct
• Contraction propels bile along common bile duct into the duodenum at the duodenal papilla
• Bile: cholesterol, bile salts, & pigments, serves to maintain the alkaline pH of small intestine, permitting emulsification of fats so that absorption of lipids can be accomplished.

• Lies behind and beneath the stomach: head resting in the curve of duodenum and tip extending across the abd cavity, almost touching the spleen.
• exocrine gland, acinar cells produce digestive juices containing inactive enzymes for the breakdown of proteins, fats, & carbohydrates.
• Collecting ducts empty the juice into the pancratic duct (duct of Wirsung), runs as long as the organ
• Pancreatic duct empties into the duodenum at the duodenal papilla,
• when introduced in the duodenum, digestive enzymes are activated
• Islet cells scatterd throughout the pancreas produce the hormones insulin and glucagon.

ABD Spleen

• LUQ, lying above the L kidney, just below the diaphragm.
• White pulp (lyphoid tissue) makes up most of the organ, functions as part of the reticuloendothelial system to filter blood and manufacture lymphocytes and monocytes
• Red pulp of the spleen contains a capillary network and venous sinus system that allows storage and release of blood, permitting the spleen to accomodate up to several hundred ml at once.

• Kidneys retroperitoneal space upper abd, extends from T12-L3  R kidney lower, embedded in fat and fascia which anchor and protect
• 1 million nephrons, the structual and functional units
• nephrons: composed of tuft of capillaries in the glomerulus, proximal convoluted tubule, the loop of Henle, and distal convoluted tubule
• Receives 1/8 cardiac output thorugh the renal artery
• Glomeruli filter blood rate 125mL/min in male & 110mL/min in women
• Filtered material electrolytes, glucose, water, and small proteins are actively resorbed in the proximal tubule. Organic acids are also actively secreted by the distal tubule
• Urinary volume is carefully controlled by ADH (antidiuretic hormone) to maintain a constatant total body fluid volume.
• Urine passes into the renal pelvis via the collecting tubules and then into the ureter.
• Peristaltic waves moves urine to the urinary bladder, which has a capacity of about 400 to 500mL
• Serves as an endocrine gland responsible for the production of renin, which contorls aldosterone secretion.
• Primary source of erythropoietin production in adults, influencing the body's red cell mass
• synthesizing  several prostaglandins, produces the bioloigical active form of vitamin D

• Rectus abdominis muscles anteriorly and the internal and external oblique muscles laterallly from and protection
• Linea alba, tendinous band
• Ingunial ligament (Poupart ligament) extends from the anterior superior spine of the ilium on each side to the pubis.

ABD Vasculature

• Abdominal portion of the descending aorta travels from the diaphragm through the abd cavity just left of midline
• Aorta branches at the level of unbilicus into 2 iliac artieries
• splenic and renal arteries also branches off in the abd

• pancreatic buds, liver, and gallbladder all begin to form at week 4 of gestation
• motility develops in a cephalocaudle direction, permitting amniotic fluid to be swallowed by 17 weeks. Meconium fetal metabolizes
• 36-38 weeks of gestation, the gastrointestinal tract is capable of adapting to extrauterine life.
• gestation, liver begins to form blood cells at about week 6, synthesize glycogen by week 9 and produce bile by week 12
• livers role; a metabolic and glycogen storage organ accounts for the large size at birth
• pancreatic islet cells are developed at 12 weeks and begin producing insulin
• spleen is acive in blood formation during fetal development and the first year of life.
• After, the spleen aids in the destruction of blood cells and functions as a lymphatic organ for immunologic response
• Nephrogenesis begins during the second embryologic month
• 12 weeks the kidney is able to produce urine and the bladder expands as a sac.
• Development of new nephrons ceases by 36 weeks
• after birth kidney increases in size b/c of enlargement of the exsisting nephrons and adjoining tubules.
• glomerular filteration rate is approximately 0.5mL/min b4 34 weeks and gradually increases in a linear fashion

ABD Pregnant Women

• Abd wall stretch and loses tone
• rectus abdominis muscles may separate, allowing abdominal wall contents to protrude at the midline
• abd contour changes when lightening occurs (about 2 weeks before term in a nullipara) and fetal presenting part descends into the true pelvis
• linea nigra
• Abd muscles have less tone and are less active
• after pregnancy muscles gradually regains tone, separation of the rectus abdominis muscles may persist.
• second trimester lower esophageal sphincter pressure decreases
• peristaltic wave velocity in the distal esophagus decreases
• gastrointestinal transit time is prolonged in the second and third trimesters, leading to constipation.
• Incompetence of the pyloric spincter may result in alkaline reflux of duodenal contents in to the stomach
• heartburn is a common concern
• gallbladder may become distended, accompanied by decreased emptying time and change in tone
• gallbladder stasis and secretions of lithogenic bile increases formation of cholesterol crystals and th devel.of gallstones, common in the second and third trimesters
• kidneys enlarge slightly
• renal pelvis and ureters dilate from the effects of hormones and pressure from the enlarging uterus
• dilation of ureters is greater on the right side than on the left side b/c affected by displacement of the urterus to the right by an enlarged right ovarian vein
• ureters also elongate and form single and double curves of varying sizes and angulation
• Changes can lead to urinary stasis and pylelonephritis with asymptomatic bacteriuria
• Renal function is most efficient if the woman lies in the lateral recumbent position, helps prevent compression of the vena cava and aorta.
• Bladder increased sensitivity and compression leads to frequency and urgency of urination during the first and third trimester
• 4th month hypereremia of all pelvic organs and hyperplasia of the muscle and connective tissue elevate the bladder trigone and cause thickening of the posterior margin
• marked deepening and widening of the trigone by the end of the pregnancy and may result in microhematuria
• 3rd trimester compression may also result from the descent of the fetus into the pelvis; in turn causes a sense of urgency and/or incontinence even with a small amount of urine in the bladder
• colon is displaced laterally upward and posteriorly peristaltic activity may decrease and water absorption is increased
• bowelsounds are diminished and constipation and flatus are more common
• 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 to the umbilicus
• postpartum, the uterus involutes rapidly

• Motility of the intestine is the most severely affected secretion and absorbtion are affected to a lesser degree
• caused by, are 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 follows other system changes associated with hypoxia and hypovolemia
• functional abilities of the intestine can decrease secondary to systemic changes in the older adult
• epithelial atrophy, the secretion of both digestive enzymes and protective mucus decrease in the intestinal tract.
• Bacterial flora of the intestine can undergo both qualitative and quantitative changes and become less biologically active
• changes impair digestive ability and thereby cause food intolerances in the older adult
• Liver size decreases after 50 years of age which parallels the decrease in the lean body mass.
• Hepatic blood flow decreases as a result of a decline in cardiac output associated with aging
• liver loses ability to metabolize certain drugs
• type 2 diabetes puts liver at risk for development of nonalcoholic steatoheoatitis
• pancreas is unaffected by aging although the main pancreatic duct and branches widen.
• increase in fibrous tissue and fatty deposition with acinar cell atrophy
• the large reserve of the organ results in no significant physiologic changes
• Increase of biliary lipids, specifically the phospholipids and cholesterol resulting in the formation of gallstones

Inspection

Surface Characteristics

• Observe the skin color and surface characteristics
• skin will have the same expected variations in color and surface charac. as the rest of the body but paler, fine venous networks
• Above the umbilicus, venous return should be toward the head, below the umbilicus, it should be toward the feet
• Determine the direction of venous return: place the index fingers of both hands side by side perpendicularly over a vein.  Press and separate 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.  Flow patterns are altered in some disease states.
• Unexpected findings inculde generalized color changes such as jaundice of cyanosis. Glistening taut appearance suggests ascites.
• inspect for bruises adn localized discoloration. Redness inflammation
• bluish periumbilical discoloration (Cullen sign) suggests intraabdominal bleeding.
• Inspect for lesions and particularly nodules.  Lesions are of particular importance b/c gastrointestinal diseases often produce secondary skin changes.  pearl-like, enlarge and sometimes painful umbilical nodule, known Sister Mary Joseph's nodule, may be the first sign of an intraabdominal malignancy.
• Skin and gastrointestinal lesions may rise from the same cause ot may occur w/o relationship to one another

Inspection

Contour

• Look for contour, symmetry, and surface motion 
• Described as flat, rounded, scaphoid
• note location and contour the umbilicus, inverted or protrude slightly
• inspect for symmetry from seated position at the pt's side.
• Contralateral areas of the abd. look for distention and bulges
• symmetric distention caused by obesity, enlarged organs, and fluid or gas. Distention from the umbilicus to the symphysis can be caused by ovarian tumor, pregnancy, uterine fibroids or a distended bladder
• Distention of the upper half above umbilicus can be due to tumor, pancreatic cyst or gasteric dilation.
• Asymmetric distention or protrusion may indicated hernia, tumor, cysts, bowel obstruction, muscle or soft tissue hematoma, or enlargement of abd organs.
• incisional hernia is caused by a defect in the abd musculature that develops after a surgical incision, resulting in a protrusion in the area of the surgical scar. protrusion of the navel indicates an umbilical hernia.

Inspection

Movement

• Smooth, even movement should occur with respiration. males more abd movement with respiration. females more costal
• limited movement assoc. respiration may indicate peritonitis in the ill-appearing adult male
• Surfce motion from peristalsis, seen as a rippling movement across the abd, may be seen in thin individual but can also be a sign of intestinal obstruction.
• Abd aortic pulsations seen in the upper midline are often visible in thin adults.  Marked pulsation may occur as the result of increased pulse pressure or abd aortic aneurysm

Auscultation

Bowel sounds

• Listen for bowel sounds and note frequency and character. They are usually heard as clicks and gurgles that occur irregularly and range from 5-35 per min.
• Bowel sounds are generalized so most often they can be assessed adequately by listening in one place.  Loud prolonged gurgles are called borborygmi. Increased bowel sounds may occur with gasteritis, early intestinal obstruction or hunger.
• Decreased bowel sounds occur with peritonitis and paralytic ileus.
• Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 min of continuous listening, is typically associated with abd pain and rigidity and is a surgical emergency.

Auscultation

Additional Sounds and Bruits

• listen with diaphragm for friction rubs over the liver and spleen
• Friction rubs are high pitched and are heard in assoc. with respiration.  They indicate inflammation of they peritoneal surface of the organ from tumor, infection or infarct.
• Bruit or harsh to musical intermittent auscultatory sound, which may reflect blood flow turbulence and indicate vascular disease.
• Bell side, epigastric region and around the umbilicus for venous hum, which is soft, low pitches and continuous.  Venous hum occurs with increased collateral circulation b/t the portal and systemic venous system.

Percussion

• assess the size and density of the organs in the abd and to detect the presence of fluid, air, and fluid-filled or solid masses.

Liver Span

• Begin liver percussion at the right midclavicular line over an area of tympany.  Always begin with an area of typany and proceed to an area of dullness b/c that sound change is easiest to detect.
• percuss upward along the midclavicular line to determind the lower border of the liver.
• dullness is usually heard at the costal margin or slightly below it lower boarder
• Begin percussion on the right midclavicular line at an area of lung resonance around 3rd intcostal space. Continue downward until the percussion tone changes to one of dullness; this marks the upper border. Upper border is around the 5th intercostal space.
• An upper border below this may indicate downward displacement or liver atrophy. Dullness exetending above the 5th intercostal space suggests upward displacement from abd fluid or masses.
• Span should be 6-12cm
• Liver enlargement is suspected, additional percussion maneuvers can provide further information. Percuss upward and then downward over the right midaxillary line.
• Liver dullness is usually detected around the 7th intercostal space. You can also percuss along the midsternal line to estimate the midsternal liver span

Percussion

Spleen

• percuss the spleen just posterior to the midaxillery line on the left side
• percuss in several directions beginning at areas of lung resonance. you may hear a small area of splenic dullness from 6th rib to the 9th rib. Traube's space is a semilunar region defined by the 6th rib superiorly, the midaxillary line laterally, and the left costal margin inferiorly.  This is typically tympanitic b/c it overlies the fundus of the stomach.

Percussion

Gastric bubble & Kidneys

• Left lower anterior rib cage and left epigastric region
• typany producced by the gastric bubble is lower in pitch than the typany of the intestine.
• Kidneys:Sitting position: place the palm of your hand over the R costovertebral angle and strike your with the ulnar surface of the fist of your other hand. No tenderness, blow should be a thud

Palpation: organs of the abd cavity adn to detect muscle spasm, masses, fluid and areas of tenderness

Light palation

• Light, systemic palpation of all  4 quadrants or 9 regions, initially avoiding any areas that have been identified as problem spots
• press no more than 1cm in light and even pressing circular motion.
• Abd should feel smooth, with a consistent softeness
• Guarding, tensing of the abd musculature to protect inflammed visera, should alert you to move cautiously through the remainder of the examination
• used to identifying muscular resistance and areas of tenderness.
• large mass or distended structure may be appreciated by a sense of resistance
• If resistence is present, determine whether it is voluntary or involuntary by: Place pillow behind knees adn ask the pt to breathe slowly through the mouth as you feel for relaxtion fo the rectus abdominis muscles on expiration.  If the tenseness remains, it is probably an involuntary response to localized to generalized rigidity.  Rigidity is a boardlike hardness of the abd wall overlying areas of peritoneal irritation.

Palpation

Moderate palpation

• exert moderate pressure as an intermediate step to gradually approach deep palpation
• tenderness on elicited on light palpation may become evident with deeper pressure. 
• Additional maneuver of moderate palpation is performed with the side of your hand: useful in assesing organs that move with respiration, specifically the liver and spleen. Palpate during the entire respiratory cycle. As pt inspires, the organ is displaced downward, and you may be able to feel it as it bumps against your hand.

Palpation

Masses

• Identify any masses and note the following charac.: location, size shape, consistency, tenderness, pulsation, mobility and movement with respiration. 
• To determine whether the mass is superficial or intrabdominal have the pt lift his or her head from the examining table thus contracting the abd muscles.  Masses in the abd wall will continue to be palpable, but those located in the abd cavity wil be more difficult to feel b/c they are abscured by abd musculature.

Palpation

Umbilical Ring & Palpation of Specific Organs & Structures

• Umbilical ring and around the umbilicus should be free of bulges, nodules, and granulation
• ring should be round and free of irregularities. Note whether it is incomplete or soft in the center which suggests the potential for herniation.
• liver: place hand under 11th & 12th ribs, pressing upward to elevate the lover toward the abd wall.  Place R hand on the abd, fingers pointing toward the head and extended so the tips rest in the R midclavicular line below the level of liver dullness.Have pt breathe deeply, and try to feel the liver edge as the diaphragm pushes it down to meet your finger tips. Liver not palpable normally
• Patho conditions: liver can be palpated
• Nonpalpable: Spleen, gallbladder, L kidney, sometimes palpable R kidney
• Aorta: Palpate deeply slightly to the left of the midline and feel for the aortic pulsation. If the pulsation is prominent try to determine the direction of pulsation.  A prominent lateral pulsation suggests an aortic aneurysm.
• Urinary bladder:not palpable in healthy person unless distended smooth, round tense mass.

Abd 

Pain Assessment

• Common sypmtom but often difficult to evaluate. 
• keep eyes on pt's facial response is as important in your evaluaion as the pt's verbal response to questions about the quality and degree of pain.
• Tools: MANTRELS (Alvarado Score) Migration of pain, Anorexia, N/V, Tenderness in RLQ, Rebound pain, Elevation in temp, Leukocytosis, Shift to the left)
• Pediatric Appendicitis Score
• Ohmann Score

ABD

Infants & Children

• Start at beginning of examiniation
• shape, contour, and movement with respiration
• should be round and dome-shaped b/c the abd musculature has not fully developed
• note any localized fullness
• abd & chest movements should be sychronous
• note any pulsations over abd
• pulsations in epigastric is normal (infants adn newborns)
• Superficial veins are usually visible in thin infant, distended veins across the abd are an unexpected finding suggestive of vascular obstruction to abd distention or abstruction
• Spider nevi may indicate liver disease.
• umbilical cord count #of vessels, 2 arteries and one vein
• single umbilical artery should alert you to the possibility of congenital anomalies.
• intestinal structure present in umbilical cord or protruding into the umbilical area and visible through a thick transparent membrane suggests an omphalocele
• Stump should be dry and odorless, inspect for discharge, redness, induration and skin warmth
• once separated 2 weeks, serous to serosanguineous discharge may indicate a granuloma when no other signs of infection are present
• Note any protrusion through the umbilicus or rectus abdominis muscles when infant strains.
• Diastasis rectus abdominis, separation 1-4cm wide in the midline, usually b/t the xiphoid and the umbilicus.
• Vomiting frequently, use tangential lighting and observe the abd at eye level for peristalic waves

• 6mnths 2.4-2.8                       
• 12mnths 2.8-3.1
• 24 months 3.5-3.6
• 3 yrs 4.0
• 4 yrs 4.3-4.4
• 5 yrs 4.5-4.8
• 6 yrs 4.8-5.1
• 8 yrs 5.1-5.6
• 10 yrs 5.5-6.1

• Appendicitis   RLQ
• Peritonitis   Pain with deep palpation
• Cholecystitis  RUQ
• Pancreatitis  LUQ, epig or umbilical
• Salpingitis  Lower quad worse on left
• Pelvic inflammatory disease  Lower quadrant ^ w/activity
• Diverticulitis Epigastric radiating down L side p eating
• Perforated gastric or dudenal ulcer RUQ
• Intestinal obstruction reffered to epigastric/umbilicus
• Volvulus referred to hypogas & umbilicus
• Leaking abd aneurysm throbbing midline/penetrate to back
• Biliary Stones, colic severe RUQ/epigastrium
• Renal Calculi   flank>groin & genitals
• Ectopic pregnancy  Lower quad referred to shoulder
• Ruptured Ovarian cyst  Lower quad steady ^ c cough
• Splenic rupture  Intense LUQ radiating to L shoulder, may worsen with foot of bed elevated

• Irritabel bowel syndrome   Hypog; crampy assoc c bowel function
• Lactose intolerance  Crampy pain p drining milk or eating milk products
• Diverticular Disease Localized pain
• Constipation Colicky or dull and steady pain
• Uterine Fibroids  pain r/t menses, intercourse
• Hernia Localized pain that ^ c exertion or lifting
• Esophageal/gastroesophageal reflux disease Burning or gnawing pain in midepigastrium, worsens c recumbency & certain foods
• Peptic Ulcer Burning or gnawing pain
•  Gastritis Constant buring pain in epigastrium

• Aaron: pain or distress occurs in area of pt's heart or stomach on palpation of McBurney's point (appendicites)
• Ballance: Fixed dullness to percussion in left flank and dullness in right flank that dissappears on change of position (Peritoneal irritation)
• Blumberg: Rebound tenderness (peritoneal irritation; appendicities)
• Cullen: Eccymosis around unbilicus (hemoperitoneum; pancreatitis; ectopic pregnancy)
• Dance: Absence of bowel sounds in RLQ (Intussusception)
• Grey Turner: Eccymosis of flanks (hemoperitoneum; pancreatitis)
• Kehr: Abd pain radiating to left shoulder (spleen rupture; renal calculi; ectopic pregnancy)
• Markle(heel jar): pt stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body. Action will cause abdinal pain if + (peritoneal irritation; appendicitis)
• McBurney: Rebound tenderness and sharp pain when McBurney's point is palpated (appendicitis)
• Murphy: abrupt cessation of inspiration on palpation of gallbladder (cholecyctitis)
• Romberg-Howship: Pain down the medial aspect of the thigh to the knees (strangualtion obturator hernia)
• Rovsing: RLQ pain intesified by LLQ abd palpation

• palltion technique used to assess an organ or a mass
• one hand, place your extended fingers, hand and forearm at a 90* angle to the abd. push in toward the organ or mass with the fingerstips
• If the mass is freely movable it will float upward and touch the fingertips as fluid and other structures are displaced by the maneuver

Older adults

• abd wall thinner and less firm result from loss of connective tissue and muscle mass
• organs more palpable
• deposition of fat over abd is common