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Lines dividing the abdomen: L1 = Transpyloric // L5 = Transtubercular

and Two mid-clavicular lines

• Visceral pain (midline, deep, poorly localized) is conducted via symp. splanchnic nerves.
• Somatic pain (lateralised, localized) arises from the parietal peritoneum and abdominal
wall and is conducted via intercostal nerves.

Inflamation and malignancies onset is usually gradual

Rt upper quadrant to the back (tip of scapula) = biliary colic

 • Altered bowel habits = IBS, Colorectal cancer, Diverticular disease
• Breathlessness & Palpitations = non-alimentary cause
• Tachycardia & Hypotension = sepsis or bleeding

There is a silent interval of 1-2hrs after perforation

It can cause esophageal spasm and central chest pain, which may be confused with cardiac pain.

Longstanding dysphagia without weight loss but with heartburn = benign peptic stricture.

• Both are associated with pallor, sweating and hyperventilation.

• Nausea, vomiting + abdominal pain = upper GI disorders.
• Dyspepsia causes nausea without vomiting.
• Peptic ulcers cause painless vomiting unless complicated by pyloric stenosis, which causes projectile vomiting of large volumes of gastric content that is
• Obstruction distal to the pylorus = bile-stained vomit.
• Severe vomiting without significant pain = gastric outlet or proximal small bowel obstruction.
• Faeculent vomiting of small bowel contents = distal small bowel or colonic obstruction.
• Vomitus in peritonitis = small in volume but persistent.
• The more distal the level of intestinal obstruction, the more marked the accompanying abdominal distension and colic.
• Vomiting is common in gastroenteritis, cholecystitis, pancreatitis and hepatitis, typically preceded by nausea but in raised intracranial pressure may occu
• Severe pain may precipitate vomiting, as in renal or biliary colic or myocardial infarction.
• Anorexia nervosa and bulimia = self-induced vomiting.
• In bulimia, weight is maintained or increased. In anorexia nervosa profound weight loss is common.

• Belching may indicate anxiety but sometimes accompanies GERD.

• Excessive flatus occurs particularly in lactase deficiency and intestinal malabsorption.
• Loud borborygmi, particularly if associated with colicky discomfort, suggest small bowel obstruction or dysmotility.
 - Obstructive jaundice + abdominal pain = gallstones.
- Obstructive jaundice + abdominal pain + fever/rigors (Charcot’s triad) = ascending cholangitis.
- Painless obstructive jaundice = malignant biliary obstruction (cholangiocarcinoma or cancer of the head of the pancreas).

• Gilbert’s syndrome is an AD condition; haemochromatosis and Wilson’s disease are AR disorders.

• IBD = Crohn’s disease or UC.
• Colorectal cancer in a first-degree relative increases the risk of colorectal cancer and polyps.
• Peptic ulcer disease is familial, but this may be due to H. pylori.
• Autoimmune diseases (thyroid disease) are common in relatives of those with primary biliary cirrhosis and autoimmune hepatitis.
• A family history of diabetes = NAFLD.

• Smoking: increases the risk of esophageal cancer, colorectal cancer, Crohn’s disease and peptic ulcer, while pts with UC are less likely to smoke.
• Stress: irritable bowel syndrome and dyspepsia.
• Travel: relevant in liver disease and diarrhea.
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Impaired in hepatic encephalopathy

- Stria indicate weight gain, pregnancy or, rarely, Cushing's syndrome.

- Loose skin folds indicate rapid weight loss

Jaundice & Pallor

- Iron deficiency = angular cheilitis and atrophic glossitis

- Folate and B12 deficiency = beefy, raw tongue.
- Celiac and IBD = aphthous ulcers
- Odors such as that from alcoholic patients and fetor hepaticus

Troisier's sign = enlargement of the left supraclavicular LN in

gastric and pancreatic cancer.

Widespread LAP + Hepatosplenomegaly = Lymphoma.

Breast (atrophy/gynaecomastia), hair distribution, scratch marks, and spider naevi

Altered mental state, jaundice and ascites

Fetor hepaticus = Portosystemic shunting +/- encephalopathy

Bilateral parotid swelling = chronic alcohol abuse and bulimia.

Skin creases & Muscle wasting

Gyaencomastia, loss of body hair and testicular atrophy

= Due to reduced estrogen breakdown in Liver failure

Finger clubbing & Tar staining = liver cirrhosis,

IBD and malabsorbtion (Celiac).

Koilonychia & Leuconychia = Hypoalbuminemia

Palmar erythema and spider naevi

Dupuytren's contracture = Alcohol-related CLD

 Dupuytren's contracture = Alcohol-related CLD

Asterixis = Hepatic encephalopathy

- Shape: Flat, scaphoid, rounded or protuburebt

- Umbilicus: Flat or everted (ascites), sunken (obese), or inverted (normal).
- Thoracic respiration in case of peritonitis.

1- Seborrheic warts: age-related

2- Hemangiomas (Campbell de morgan/cherry angiomas): age-related

1- Diffuse due to ascites or intestinal obstruction

2- Localized due to a mass or an enlarged organ

1- Portal HTN (caput medusae)

2- Vena cava obstruction (mainly inferior)

1- Incisional hernia
2- Infraumbilical incision or puncture scars (previous laparoscopy)
3- Surgical stomas (ileostomy/colostomy)

Obvious when a patient coughs or raises his head

Anxiety, protection

Parietal peritoneum inflammation

Generalized peritonitis

- Tenderness in several areas

- Board-like rigidity; it no longer moves with respiration

‘Rebound tenderness’

Murphy's sign

- Pulsatile mass palpable in the upper abdomen = normal aortic pulsation in a thin person, a gastric
or pancreatic tumor, or an aortic aneurysm.
- Hard subcutaneous nodule at the umbilicus = metastatic cancer (‘Sister Mary Joseph’s nodule’).
 - Hepatic enlargement due to metastatic tumor is hard and irregular.
- In RHF the congested liver is usually soft and tender; a pulsatile liver indicates TR.

- The normal liver is dull over the right anterior chest between the 5th rib and the costal margin.
- The liver is enlarged in early cirrhosis but shrunken in advanced cirrhosis.
- Resonance below the 5th intercostal space suggests hyperinflated lungs or the interposition of
the transverse colon between the liver and the diaphragm (Chilaiditi’s sign).

- A bruit over the liver = acute alcoholic hepatitis, hepatocellular cancer and AV
malformation // or a transmitted heart murmur.

Rarely palpable and results from either obstruction of the cystic duct (mucocoele,
empyema of the gallbladder), or a patent cystic duct (pancreatic cancer).

For mild-moderate ascites

For massive ascites

- Absence of bowel sounds = paralytic ileus or peritonitis.

- Increased sounds = intestinal obstruction.

Atheromatous or aneurysmal aorta, or superior mesenteric artery stenosis.

Over the liver (perihepatitis) or spleen (perisplenitis).

An audible splash (>4hrs after eating) = delayed gastric emptying (pyloric stenosis).