Chapter 9

Abdominal symptoms are common. Mastery of the abdominal examination is essential since judgments based primarily on history and physical examination are the basis for differential diagnosis and selection of laboratory and imaging studies to confirm a diagnosis. An accurate and thorough history is essential to delineate the specific characteristics and sequence of the patient's symptoms. Frequent repetition of the abdominal exam and correlation with the patient's symptoms are essential. Correct assessment of abdominal findings requires familiarity with anatomic pathology and pathophysiology. Surgeons must excel in abdominal examination because their findings influence the decision to operate.

In the supine position, the abdominal cavity is a shallow oval basin with a rigid W-shaped bottom of vertebral column and back muscles. Heavy flank muscles constitute the long sides and the diaphragm and pelvic floor muscles close either end. The brim is formed by the lower rib margins at one end, and the pubes and ilia at the other. The cover is formed by the flat muscles and fascia of the anterior abdominal wall, reinforced by two parallel bands of rectus muscles attached to the ends of the basin.

The abdominal viscera are solid or hollow. The solid viscera are the liver, spleen, kidneys, adrenals, pancreas, ovaries, and uterus. Most of these organs retain their characteristic shapes and positions as they enlarge. Many are clustered under the protecting eaves of the lower ribs. The hollow viscera are the stomach, small intestines, colon, gallbladder, bile ducts, fallopian tubes, ureters, and urinary bladder. They are normally not palpable, unless distended by gas, fluid or solid masses.

Two systems have been used to describe abdominal topography (Fig. 9–1). Most physicians prefer the simpler division into quadrants by an axial and a transverse line through the umbilicus; we use that plan here.

Fig. 9–1.

Topographic Divisions of the Abdomen.On the left are the regions of the abdomen as defined in the Basle Nomina Anatomica terminology. Most of the nine regions are small, so that enlarged viscera and other structures occupy more than one. On the right is a simpler plan with four regions; it is preferred by most clinicians and is employed in this book. Many occasions arise when the quadrant scheme needs supplementing by reference to the epigastrium, the flanks, or the suprapubic region.

Alimentary System

The alimentary system is responsible for converting ingested foodstuffs into biologically available nutrients and fuels, and for eliminating solid wastes while maintaining a barrier to an enormous variety of microorganisms, parasites, and toxic molecules. This is a complex process involving ingestion, mastication, bulk transport, storage, mechanical disruption, mixing, and digestion of ingested food and absorption of nutrients coordinated with production, storage, transport, and carefully timed release of digestive enzymes and bile acids. The alimentary system starts at the mouth and ends at the ...

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