pf abdomen
TRANSCRIPT
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PF Abdomen
Hilda Fakhrani Fardiani
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Urutan Pemeriksaan
1. Inspeksi2. Auskultasi3. Palpasi4. Perkusi
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INSPEKSI• Cara pemeriksaan : inspeksi saat pasien posisi
berdiri dan terlentang• Penilaian – Ukuran dan bentuk perut
• Pot belly, Simetris/tdk, Cekung / tdk (cekung/skafoid : hernia diafragmatika, malnutrisi, dehidrasi berat, ileus obstruksi letak tinggi)
– Dinding perut• Umbilikus, gambaran vena, diastesis rekti, omfalkel,
gastroskisis, paten urakus– Gerakan dinding perut
• Pergerakan dinding perut utk pernafasan, gerakan peristaltik usus, lokasi peristaltik
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AUSKULTASI
• Cara pemeriksaan : mendengar suara peristaltik dg stetoskop. Normal : intensitas rendah, tiap 10 – 30 dtk sekali
• Penilaian– Intensitas – Frekuensi
• Meningkat : gastroenteritis• Menurun : peritonitis, ileus paralitik
– Bruit– Venous hum : obstruksi vena porta
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Perkusi
• Cara pemeriksaan : mengetuk dinding abdomen dengan lembut dan ketukan perlahan, dilakukan dr epigastrium ke arah bawah
• Penilaian– Cairan bebas intraperitoneal (shifting dullness, fluid
wave, puddle sign)– Udara bebas intraperitoneal (pekak hati menghilang)– Batas hati– Batas massa intrabdomen
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Palpasi
• Cara pemeriksaan : – alihkan perhatian pasien
selama memeriksa, – dalam keadaan otot
perut relaksasi (lutut ditekuk, palpasi saat inspirasi)
– kedua tangan pemeriksa hangat
– Monomanual/bimanual
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Palpasi
• Penilaian – Ketegangan dinding perut– Palpasi organ dalam• Hati• Limpa• Ginjal• Kandung kencing• Massa intraabdomen
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Palpasi Hati
• Penilaian– Ukuran• Patokan :
– Garis yang menghubungkan umbilikus dg titik potong garis midklavikula kanan dan arkus kosta
– Garis yang menghubungkan umbilikus dg prosesus xifoideus
– Konsistensi– Tepi– Permukaan– Nyeri tekan
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Palpasi Limpa
• Normal : teraba 1 – 2 cm di bawah arkus kosta pd neonatus.
• Besar limpa diukur berdasarkan garis Schuffner
• Splenomegali : infeksi, talasemia, anemia sel sabit, sirosis, leukemia.
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• Palpasi ginjal– Normal : ginjal tidak teraba– Cara pemeriksaan : ballotement
• Palpasi Kandung Kencing– Hanya bisa dilakukan pada keadaan kandung
kencing
• Palpasi massa intraabdomen– Letak, ukuran, konsistensi, tepi– Contoh massa intraabdomen : tumor Wilms, kista
duktus koladokus, stenosis pilorus, invaginasi.
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Abdomen exam
• Use supine position with pillow under the head and knee flexed.
• Divide abd. to 4 Quadrant, and examine from button to top.
• Examination of the abdomen involve the inspection, auscultation, palpation and percussion.
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Abdominal Girth
Abdominal girth should be measured over the umbilicusWhenever possible.
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Inspection
• For contour, symmetry, ch.ch of umbilicus, skin pulsation and movement.
• Tense board is a serious sign of paralytic illus and intestinal obstruction.
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Auscultation
• Listen for peristalsis or bowel sounds for full minute.
• Listen for bruit of the major arteries.• Listen around the umbilicus and epigastric
region for venous hum (soft low pitched and con.).
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Bowel Sounds
• Normally occur every 10 to 30 seconds.• Listen in each quadrant long enough to hear
at least one bowel sound.• Absence of bowel sounds may indicate
peritonitis or a paralytic ileus.• Hyperactive bowel sounds may indicate
gastroenteritis or a bowel obstruction.
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Palpation
• Put patient in comfortable position.• Warm your hands.• Teach to be calm.• Start in superficial to deep.• Late any tender area.• Palpate LQ and upward, for liver and spleen.• Kidneys.
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Abdomen
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Tips – Abdomen Exam
• Relaxation and quiet– Bottle/pacifier/nursing– On parent’s lap
• Dr. sits facing the parent, knees touching
• Use the respiratory cycle – Abdomen should be soft during inspiration– If abdomen remains hard during both inspiration and
expiration, suspect peritoneal irritation
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• Ticklish?– Firm touch– Place the child’s hand under your palm leaving your
fingers free to palpate
• Tenderness and pain can be difficult to detect and localize– Distract the child with a toy– Start away from the area suspected– Observe for changes… as you move to identify the
area of greatest pain• Change in pitch of crying• Rejection of the opportunity to suck• Drawing the knees to the abdomen• Facial expression• Constriction of pupils
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InspectionMovement with respiration ShapeContourPulsations
– Pulsations: common in infants– Distended veins dDx: vascular obstruction, abdominal
distension or abdominal obstruction – Spider nevi dDx: liver disease
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Infant…• Abdomen should be rounded and dome shaped
Distended abdomen?• Feces, mass, organ enlargement
Scaphoid abdomen?• Abdominal contents are displaced
• Abdominal and chest movements should be synchronous– slight bulge of the abdomen at the beginning of
respiration
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Toddler• Abdomen protrudes slightly
“pot-bellied”
After age 5… • Abdomen may become concave when
laying supine
• Respirations continue to be abdominal until 6-7 years of age– In young children, restricted abdominal respiration
may be related to peritoneal irritation
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Umbilical stump • should be dry and odorless
Inspect all skin folds for:• Discharge• Redness• Induration• Skin warmth• Granulomatous tissue
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Granuloma
• Serous or serosanguinous discharge once the stump has separated
• No other signs of infection
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• Umbilicus is usually inverted– Often everts with increased abdominal pressure
• Note any protrusion through the umbilicus or rectus abdominus muscle– Hernia– Diastasis recti
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Umbilical Hernia
• Protrusion of omentum and intestine through the umbilical opening
• Common in infants– Reach maximum size by 1 month– Generally close spontaneously by 1-2 years
• To determine size, measure the diameter of the opening (not the protruding contents)
• Should “reduce” with light pressure
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Diastasis Recti
• Midline separation (1-4 cm) of the rectus abdominus– between the xiphoid and umbilicus
• No need to repair in most cases– herniation through the rectus abdominus does
require surgery
• Usually resolves by 6 years of age
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Peristaltic Waves• Use tangential lighting• Observe abdomen at eye level
Usually not visible– Sometimes seen in thin, malnourished babies– Suggests intestinal obstruction
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Auscultation
• Peristalsis (“metalic tinkling”)– Heard every 10-30 seconds– Bowel sounds should be present 1-2 hours after
birth
• No bruits or venous hum should be detected
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Light Palpation
• Knees flexed• Place your hand gently on the abdomen– Thumb at the right upper quadrant– Index finger at the left upper quadrant
• Press very gently at first, only gradually increasing pressure
• Identify the spleen, liver, and masses close to the surface
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Spleen• Palpable 1-2 cm below the left costal margin for the
first few weeks after birth
• A detectable spleen tip is common in well infants but increase in spleen size may indicate:– blood dyscrasias– septicemia
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Liver (lower border) • Newborn: just below the right costal margin• Infants & toddlers: 1-3cm below • Children: 1-2cm below
Hepatomegaly: lower border >3 cm below the right costal margin– Infection– Cardiac failure– Liver disease
Liver Scratch test
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Deep Palpation
• Palpate all quadrants for masses– Location– Size– Shape– Tenderness– Consistency
Transillumination can be used to distinguish cystic from solid masses…
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• Fixed masses should be investigated with special studies if…– Laterally mobile– Pulsatile
• Palpate the aorta for signs of enlargement– Located along vertebral column
If any suspicion of neoplasm exists, limit palpation of the mass– May cause injury or spread of malignancy!
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Nephroblastoma (Wilms Tumor)
• MC intraabdominal tumor of childhood (2-3 years of age)
• Malignant
– Firm, non-tender mass deep within the flank– Only slightly moveable– Not usually crossing the midline; sometimes bilateral– Possibly:• Low-grade fever• Hypertension
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Neuroblastoma • Frequently appears as a mass in the adrenal medulla • Malignancy in early childhood– Firm, fixed, non-tender, irregular and nodular abdominal
mass– Malaise– Loss of appetite– Weight loss– Protrusion of eye(s)– Other symptoms may occur with:• compression of the mass or • metastasis to adjacent organs
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Percussion
• May be more tympanic (vs. adults)– Swallow air when feeding & crying
Tympany with distended abdomen?• Gas
Dullness with distended abdomen?• Fluid, solid mass
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Examine the Bladder
• Palpate and percuss over the suprapubic area• Determine size• Distention?
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Rebound Tenderness
• Observe child’s facial expression and pupils• Be cautious…
Once a child has experienced palpation that is too intense, a subsequent examiner has little chance for easy access to the abdomen
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Common Conditions
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What if you find… ?
• Sausage-shaped mass in the left lower quadrant…Feces in the sigmoid colon…Constipation
• Midline, suprapubic mass …Feces in the rectosigmoid colon…Hirschsprung disease
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Hirschsprung Disease aka Congenital Aganglionic Megacolon
• Absence of parasympathetic ganglion cells in a segment of the colon… no peristalsis
Newborn: – May fail to pass meconium in the first 24-48 hrs
Older infants and young children:– Intestinal obstruction or severe constipation– Failure to thrive– Abdominal distention– Episodes of vomiting and diarrhea
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What if you find… ?
• Sausage-shaped mass in the left or right upper quadrant…Intussusception
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Intussusception
• Prolapse of one segment of intestine into another resulting in intestinal obstruction
• MC 3-12 months old; cause is unknown
– Acute intermittent abdominal pain– Abdominal distention– Vomiting– Stools mixed with blood and mucus
• Red current jelly appearance– Sausage-shaped mass in R or L upper quadrant– R lower quadrant feels empty (Dance sign)
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Intussusception – “ABCDEF”
A bdominal or anal “sausage”B lood from the rectum C olic: babies draw up their legsD istention, dehydration, and shockE mesisF ace pale
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What if you find… ?
• Olive-shaped mass in the right upper quadrant (deep palpation) immediately after the infant vomits…Pyloric stenosis
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Pyloric Stenosis • Hypertrophy of the circular muscle of the
pylorus or obstruction of the pyloric sphincter
– Regurgitation ~> projectile vomiting– Feeding eagerly (even after vomiting)– Failure to gain weight– Signs of dehydration– Small, rounded mass palpable in the R upper quadrant• especially after the child vomits
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Gastroesophageal Reflux (GER)
• Relaxation or incompetence of the lower esophagus persisting beyond the newborn period
– Regurgitation and vomiting– Weight loss and failure to thrive– Respiratory problems • aspiration
– Bleeding from esophagitis
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Biliary Atresia
• Congenital obstruction or absence of some or all of the bile duct system
– Jaundice• Becomes apparent at 2-3 weeks
– Hepatomegaly– Abdominal distention– Poor weight gain– Pruritis– Stools become lighter in color– Urine darkens
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Meconium Ileus
• Thickening and hardening of meconium in the lower intestine ~> intestinal obstruction
– Failure to pass meconium • 1st 24 hrs after birth
– Abdominal distention
*Must consider cystic fibrosis
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Meckel Diverticulum
• Outpouching of the ileum – MC congenital anomaly of the GI
tract– Varies in size & presentation
– May be asymptomatic– Intestinal obstruction? Diverticulitis?• Bright or dark red rectal bleeding• Little abdominal pain
– Symptoms like those of acute appendicitis
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Omphalocele
• Intestine present in the umbilical cord or protruding from the umbilical area– Visible through a thick transparent membrane
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Necrotizing Enterocolitis
• Inflammatory disease of the gastrointestinal mucosa– Associated with prematurity • Immaturity of the GI tract
– Abdominal distention– Occult blood in stool– Respiratory distress– Often fatal: perforation and septicemia