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Gastro Exam

Abdominal Skin Changes

November 26th, 2019


Examination of the skin of the abdomen can reveal significant clues regarding the presence of portal hypertension, previous abdominal distension and previous abdominal procedures.

Abdominal Scars

Scars on the abdomen can suggest past surgery, trauma, burns and healed skin conditions.
  • Abdominal Scars
  • Common Abdominal Surgical Scars

  • A
    Midline laparotomy: xiphoid process to above or below the umbilicus
    Most abdominal procedures
  • B
    Paramedian: either side of the midline
    Lateral structures - kidney, adrenals, spleen
  • C
    Subcostal: diagonally and parallel to the costal margin on either side.
    Gallbladder, biliary tract, spleen
  • D
    Chevron: bilateral subcostal incision meeting in the midline
    Gastrectomy, B/L adrenalectomy, liver surgery
  • E
    Loin: transverse, from lateral mid-abdomen to flank
  • F
    McBurney's: oblique incision made two thirds of the way from the umbilicus to the right anterior superior iliac spine.
  • G
    Lanz: transverse incision across McBurney's point
    Appendicectomy (better scar healing)
  • H
    Pfannenstiel: long, convex incision along the suprapubic crease
    Lower GIT, urinary tract, reproductive organs incl. caesarean
  • Laparoscopy: 3-4 small incisions on the abdomen; one at the umbilicus.
    Laparoscopic procedures

Striae Distensae

Striae are colloquially known as stretch marks, and suggest either previous distension of the abdomen or weakness of the abdominal skin.
  • Look For

  • Band-like skin defects over langer's lines on the abdomen, breasts, buttocks, hips and/or thighs.
  • Interpretation

  • Erythematous - acute
  • Purple - resolving
  • Skin-coloured - healed
  • Causes of Striae Distensae

  • Distension - ascites, rapid weight gain
  • Striae gravidarum - current / past pregnancy
  • Topical or systemic steroids
  • Cushing syndrome
  • Connective tissue disorders - Marfan, Ehlers-Danlos
  • Drugs - chemotherapy, tuberculosis medications, antiretrovirals, contraceptives

Cullen's Sign

The presence of Cullen's sign and Grey-Turner's sign are suggestive of retroperitoneal haemorrhage.
Cullen's sign occurs due to tracking of blood along the gastrohepatic and falciform ligaments into the umbilical area.
  • Look For

  • Bluish discolouration / bruising around the umbilicus.
  • Causes of Cullen's Sign

  • Pancreatic - acute pancreatitis, trauma
  • Gynaecologic - ruptured ectopic pregnancy, ovarian enlargement
  • Gastrointestinal - perforated duodenal ulcer
  • Hepatobiliary - hepatocellular carcinoma, lymphoma, amoebic abscess
  • Splenic - rupture
  • Vascular - ruptured AAA / internal iliac aneurysm
  • Iatrogenic
Cullen's sign was first identified by Cullen in 1918 in a patient with ruptured ectopic pregnancy. Over time it has been associated with acute haemorrhagic pancreatitis and then many other conditions, though the common thread is the presence of retroperitoneal haemorrhage.

Caput Medusae

Caput medusae is a classical sign of portal hypertension, causing distension of the superficial veins surrounding the umbilicus.
  • Look For

  • Varicose veins arising from the umbilicus.
  • Causes of Portal Hypertension

  • Cirrhosis
  • Right heart failure (cardiac ascites)
  • Massive liver metastases
  • Fulminant liver failure
  • Portal venous thrombosis
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