Transcript Integrated Abdominal Examination Review and Post-Op OMT

Rebecca L. Alsip, D.O.
Charlotte A. Ebner, D.O.
VCOM Carolinas
September 18, 2012

Demonstrate in the correct order an abdominal
exam on a patient which includes the following:
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Observation/Inspection
Auscultation
Percussion
Palpation
Describe the autonomic innervation to the lower
GI tract.
 Integrate a complete osteopathic approach for a
patient with post-op atelectasis and ileus which
includes both abdominal and structural exam and
findings.
 Demonstrate on your partner the OMM
techniques taught for post-op atelectasis and
ileus.

 Inspection
 Auscultation
 Percussion
 Palpation
 Special
Tests
 Inspection
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Symmetry
Contours
Jaundice
Cyanosis
Erythema
Bruising
Striae
Ascites
Scars
Masses/Hernias
Movement
 Auscultation
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Normal
Decreased
(peritonitis)
Increased
(gastroenteritis)
High-pitched, tinkling
(early obstruction)
Decreased/absence


No sounds in 5 minutes
Bruits
 Percussion

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Percuss all four
quadrants
Assess for increased
gas or ascites
Assess for size of
organs


Liver – midclavicular
line in RUQ
Spleen – midaxillary
line in LUQ
 Palpation
Detect organ size,
muscle spasms,
masses, fluid and
tenderness
 Start light in all 4
quadrants, then
advance to
moderate and deep
palpation
 Rebound
 Guarding


Special Tests

McBurney’s Point


Murphy’s Sign



RUQ (pain on palpation
during inspiration)
Rovsing’s Sign


RLQ (1/3 distance from
ASIS, 2/3 distance from
umbilicus)
LLQ (pain in RLQ on
palpation of LLQ)
Iliopsoas Test
Somatic Dysfunctions


Chapman Points
Abdominal collateral
ganglia
 Stomach
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Acidity – EG junction – left 5th intercostal space
Peristalsis – left 6th intercostal space
 Pylorus
– anywhere along center portion of
sternum
 Liver – right 5th and 6th intercostal spaces
 Gallbladder – right 6th intercostal space
 Pancreas – right 7th intercostal space
 Small Intestine – right 8th-10th intercostal
spaces
 Appendix – distal tip of right 12th rib
 Colon – along iliotibial bands

Sympathetics

Greater Splanchnic Nerve T5-9 – Celiac Ganglion


Lesser Splanchnic Nerve T10-11 – Superior Mesenteric
Ganglion


Distal Duodenum, Jejunum, Ileum, Ascending Colon,
Proximal 2/3 of Transverse Colon
Least Splanchnic Nerve T12-L2 – Inferior Mesenteric
Ganglion


Distal Esophagus, Stomach, Liver, Gallbladder, Proximal
Duodenum and portions of Pancreas
Distal 1/3 of Transverse Colon, Descending Colon,
Sigmoid Colon, Rectum
Parasympathetics
Vagus Nerve: Esophagus, Stomach, Small Intestine,
Ascending Colon, Transverse Colon
 Sacral nerves S2-4: Descending Colon, Pelvic organs

 Chief
Complaint
 History of Present Illness

Onset, Provocation/Palliation, Quality,
Radiation, Severity, Timing
 PMH/PSH
 Medications/Allergies
 Family
History
 Social History
 REVIEW OF SYSTEMS
Vital signs
 Cardiovascular
 Pulmonary
 ABDOMINAL EXAM
 Rectal exam if indicated

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Use of stool guaiac card
Differential Diagnosis
(minimum of 3)
 Plan
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Diet/lifestyle modifications?
Imaging? Labs?
Medications?
REASSURANCE!
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Always introduce yourself to the patient
Wash your hands
Drape the patient appropriately
Always listen to the heart and lungs
Fully expose the abdomen
Arms at side with legs flat, if possible
Examine painful area last
Always give your patient an explanation in non-medical
terms, a plan and follow up instructions
PRACTICE TIME!
Atelectasis
 Ileus
 Wound infection
 Pneumonia
 Renal Failure
 Peritonitis
 Empyema
 ARDS
 Peritonitis
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Incomplete expansion of the lungs due to alveolar
collapse
Most frequent pulmonary complication after surgery
Natural response of patient after surgery is abdominal
wall splinting and shallow breathing
This prevents full diaphragmatic excursion, so alveoli at
the lung bases are not expanded, decreasing oxygen
exchange in these areas
 Clinical
presentation
Low O2 saturation
 Increased respiratory rate
 Respiratory distress
 Increased respiratory secretions
 Decreased mental status
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
Acidotic
 Treatments
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Incentive Spirometer
Oxygen for hypoxemia
CPAP for increased
respiratory effort
Mucolytics/suctioning
for respiratory
secretions
Bronchodilators for
bronchospasm
OMT!
 Treatment
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Regions
OA: Muscle energy, suboccipital inhibition
C3-5: Counterstrain, Soft tissue
Diaphragm: Myofascial release
Ribs: Rib raising
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Pt supine, D.O. sitting at head
Form a “V” with thumb and index finger on the
transverse processes of the atlas, other hand grasping
the head and engage the restrictive barrier (all 3)
Instruct pt to straighten head, while D.O. provides
counterforce, hold 3-5 seconds
Have pt relax 2-3 seconds, re-engage the new
restrictive barrier, and repeat 3-4 times, each time
re-engaging the new restrictive barrier
Objective: decrease
suboccipital muscle
tone
 D.O. at head of table;
patient supine
 Pads of fingers just
beneath superior
nuchal line in the
suboccipital tissues
 Lift head slightly so its
entire weight is
supported on fingers
 Can apply a slight
traction
 Hold until a softening
of tissues is noted

 Functional
inhibition of propulsive bowel
motility
 Thought to be due to 3 pathways
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Due to visceral sensory afferents in the
splanchnic and pelvic nerves that increase
inhibitory sympathetic activity in the GI tract
Post-operatively due to an inflammatory
response from intestinal manipulation during
surgery that results in muscle dysfunction
Inhibitory neurotransmitters such as nitric oxide
and substance P slow gut motility
 Clinical
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presentation
Abdominal distention
Diffuse abdominal pain
Nausea and/or vomiting
Inability to pass flatus or stool
Inability to tolerate PO diet
 MUST
rule out mechanical small bowel
obstruction, as this may require surgical
intervention

Imaging, such as KUBs or abdominal CT scans,
will help differentiate between the two
 Treatments
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Keep patient NPO (“nil per os” – nothing by
mouth)
Start IV fluids
NG tube placement if persistent vomiting or
abdominal distention to decompress the stomach
Limit opioid pain medications due to constipation
OMT!
 Treatment
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Regions
OA: Vagus nerve
S2-4: Pelvic splanchnic nerves
T10-11: Superior mesenteric ganglion
T12-L2: Inferior mesenteric ganglion
Abdominal mesenteries
Colonic milking
Sacral Rocking
Thoracolumbar Supine Soft Tissue
Remove somatic dysfunction
 Stimulate or relax tissues
 Reduce tissue edema or congestion
 Remove or modify pain
 Permit compensation

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Allow treatments in other parts of the body unit to be
more effective
Improve immune function
 Improve respiration by improving soft tissue
diaphragm function

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Positive to negative pressure gradients=better transfer of
gases
 OA
 OA
 C3-5
 Sacral
 Doming
the
Diaphragm
 Rib raising
rocking
 Thoracolumbar
soft tissue
 Collateral ganglion
release
 Mesenteric release
 Colonic milking

References
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Cashen, Constance; Ross, Sydney. “Chapter 27, General
Surgery”. Foundations for Osteopathic Medicine, 2nd
Edition. Ward, DO, Robert C., Exec. Editor, Lippincott
Williams and Wilkins (2003), p. 399-407
CCOM Faculty. Osteopathic Manipulative Medicine.
OMM/CCOM Procedure Manual. 2006.
Dorland’s Pocket Medical Dictionary, 26th Edition.
W.B.Saunders Company (2001), p. 91, 424.
Johnson, MD, Michael, Conde, MD, Michelle. “Overview
of the management of postoperative pulmonary
complications.” UpToDate, www.uptodate.com, July
2012.
Kidz Medical Services. http://www.kidzmedical.com/k-id-z/a.html#atelectasis
Litkouhi, MD, Babak. “Postoperative ileus.” UpToDate,
www.uptodate.com, August 2012.