Assessment of the gastro-intestinal system. Instrumental methods of examination.

Anatomy - 4 Quadrant System

Anatomy - 9 Quadrant System

ONSET  rapid onset of severe pain is more consistent with a vascular catastrophe, passage of a ureteral or gallbladder stone, torsion of the testes or ovaries, rupture of a hollow, viscous, ovarian cyst, or ectopic pregnancy  slower onset is more typical of an inflammatory process such as appendicitis or cholecystitis Assessment of Abdominal pain O-P-Q-R-S-T

Provokes / palliates  pain provoked/aggravated by movement, such as hitting bumps on the road or walking is typical of somatic (parietal) peritoneal pain such as that seen in pelvic inflammatory disease or appendicitis  eating often relieves ulcer related pain  eating exacerbates biliary colic – especially fatty foods (usually 1-4 hours following a meal)  Pancreatitis is palliated (relieved) by curling up in a fetal position  frequent movement or writhing in pain is more typical of renal colic Assessment of Abdominal pain O-P-Q-R-S-T

Quality  dull, achy or crampy is more likely to be visceral  sharp, stabbing pain is more likely to be somatic or peritoneal  severe tearing pain is classic of dissecting aneurysm Assessment of Abdominal pain O-P-Q-R-S-T

Region / radiation  location of pain can vary with time  periumbilical pain that migrates to the right lower quadrant is classic of appendicitis  epigastric pain localizing to the right upper quadrant for several hours is typical of cholecystitis Assessment of Abdominal pain O-P-Q-R-S-T

Severity  the patient’s quantification of severity of pain is generally unreliable for distinguishing the benign from the life-threatening  assigning a 1-10 pain scale rating does however allow for a baseline to gauge the patient’s response to treatment  pain that increases in severity over time suggests a surgical condition  Severe epigastric or mid-abdominal pain out of proportion to physical findings is classic for mesenteric ischemia or Pancreatitis Assessment of Abdominal pain O-P-Q-R-S-T

Timing  crampy pain that comes in waves is generally associated with obstruction of a viscous  constant pain has a worse diagnostic outcome Assessment of Abdominal pain O-P-Q-R-S-T

Nausea & vomiting (N/V)  N/V generally associated with visceral disorder  excessive vomiting should raise suspicion of a bowel obstruction or Pancreatitis  lack of vomiting is common in uterine or ovarian disorders  pain present before vomiting is more likely caused by a disorder that will require surgery  vomiting that precedes Abdo pain is more likely a gastroenteritis or other non-surgical condition Associated signs & symptoms

Anorexia  intra-abdominal inflammation  common in appendicitis Associated signs & symptoms

Change in bowel habits  diarrhea with vomiting is almost always associated with gastroenteritis  diarrhea may occur with Pancreatitis, Diverticulitis and occasionally Appendicitis  bloody stool indicates GI bleed  constipation or difficulty passing stool or gas may be due to an ileas (impairment in paristalsis) of bowel obstruction Associated signs & symptoms

Genitourinary symptoms  dysuria, urgency and frequency are suggestive of cystitis (inflammation of the bladder), salpingitis, diverticulitis or appendicitis  Hematuria with pain suggests urinary tract infection, but can also indicate renal colic, prostatitis or cystitis Associated signs & symptoms

Extra-abdominal symptoms  myocardial infarction  pneumonia  pulmonary embolus Associated signs & symptoms can present with abdominal pain

Physical assessment  Mouth and pharynx  Abdomen and extremities  -inspection  -auscultation  -percussion  -palpation

Laboratory tests  Complete blood count  Clotting factors  Electrolytes  Assays of liver enzymes-aspartat and alanin aminotransferase  Serum amylase and lipase  Bilirubin:the primary pigment in bile

Laboratory tests ( continued )  Evaluation of oncofetal antigens CA19-9 and CEA  Urine tests-amylase, urine urobilinogen  Stool tests-fecal occult blood test,ova parasites, Clostridium difficile infection.  Radiographic examination.

Upper gastrointestinal series and small bowel series.  Before test:  -maintain NPO for 8 hr  -withhold analgesics and anticholinergics for 24 hr.  Client drinks 16 ounces of barium.  Rotate examination table.  After the test:  -give plenty of fluids  -administer mild laxative or stool softener; stools may be chalky white for 24 to 72 hr.

Barium Enema  Barium enema enchances radiographic visualization of the large intestine.  Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing is done.  After the test,expel the barium:drink plenty of fluids; stool is chalky white for 24 to 72 hr.

Percutaneous Transhepatic Cholangiography  X-ray study of the biliary duct system  Laxative before the procedure  NPO for 12 hr before test  Coagulation tests, intravenous infusion  Bedrest for several hours after procedure  Assessment of vital signs  Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen

Other Tests  Computed tomography  Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope

Esophagogastroduodenoscopy  Visual examination of the esophagus, stomach, and duodenum  NPO for 6 to 8 hr before the procedure  Conscious sedation  After the test, assessment of vital signs every 30 min  NPO until gag reflex returns  Throat discomfort possible for several days

Endoscopic Retrograde Cholangiopancreatography  Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas  NPO for 6 to 8 hr before test  Access for intravenous sedation  After the test, assessment of vital signs every 15 min  Return of gag reflex checked  Assessment for pain  Colicky abdominal pain

Small Bowel Capsule Enteroscopy  Visualization of the small intestine  Only water for 8 to 10 hr before test  NPO for first 2 hr of the testing  Application of belt with sensors

Colonoscopy  Endoscopic examination of the entire large bowel  Liquid diet for 12 to 24 hr before procedure, NPO for 6 to 8 hr before procedure  Bowel cleansing routine  Assessment of vital signs every 15 min  If polypectomy or tissue biopsy, blood possible in stool

Proctosigmoidoscopy  Endoscopic examination of the rectum and sigmoid colon  Liquid diet 24 hr before procedure  Cleansing enema, laxative  Position client on left side in the knee-chest posture.  Mild gas pain and flatulence from air instilled into the rectum during the examination  If biopsy was done, a small amount of bleeding possible

Gastric Analysis  Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome)  Basal gastric secretion and gastric acid stimulation test  NPO for 12 hr before test  Nasogastric tube insertion

Other Tests  Ultrasonography  Endoscopic ultrasonography  Liver-spleen scan