Download 01. Assessment of the gastro

Assessment of the
gastro-intestinal
system. Instrumental
methods of
examination.
Introduction
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why assess the abdomen in the
prehospital setting?
abdominal pain accounts for up 10% of
emergency visits
15-30% of patients with an acute
abdomen will require a surgical
procedure
Anatomy
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Gastrointestinal system involves the
esophagus ,stomach, small and large
intestines
They work with the pancreas liver and
gallbladder to convert nutrients from
food into energy.
Waste is then excreted.
Anatomy - 4 Quadrant System
Right Upper Quadrant (RUQ)
 diaphragm
 liver
 gallbladder
 kidney
 Hepatic flexure -large colon
 small intestine
Left Upper Quadrant (LUQ)
 spleen
 kidney
 pancreas
 stomach
 Splenic Flexure –large
colon
 small intestine
Right Lower Quadrant (RLQ)
 appendix
 large ascending colon
 ovary
 uterus
 bladder
 small intestine
Left Lower Quadrant (LLQ)
 descending colon
 ovary
 uterus
 bladder
 small intestine
Anatomy - 9 Quadrant System
Right
Hypochondriac
Epigastric
Left
Hypochondriac
Right Lumbar
Umbilical
Left Lumbar
Right Iliac
Hypogastric
(suprapubic)
Left Iliac
See graphic on next slide
Anatomy - 9 Quadrant System
Assessment of Abdominal pain
O-P-Q-R-S-T
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
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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
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eating often relieves ulcer related pain
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eating exacerbates biliary colic – especially fatty foods
(usually 1-4 hours following a meal)
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Pancreatitis is palliated (relieved) by curling up in a fetal
position
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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
Associated signs & symptoms
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
Urgency to defecate
may suggest…
 intra-abdominal bleeding
 inflammation/irritation in the recto sigmoid
area
 ectopic pregnancy
 abdominal aortic aneurysm (AAA)
 retro peritoneal hematoma
 omental vessel hemorrhage
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
 dysurea, urgency and frequency are
suggestive of cystitis (inflammation of the
bladder), salpingitis, diverticulitis or
appendicitis
 Hematurea with pain suggests urinary tract
infection, but can also indicate renal colic,
prostatitis or cystitis
Associated signs & symptoms
Extra-abdominal symptoms
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myocardial infarction
can present with abdominal pain
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pneumonia
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pulmonary embolus
Assessment techniques
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History
Demographic data
Family history and genetic risk
Personal history
Diet history
-anorexia
-dyspepsia
Physical assessment
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Mouth and pharynx
Abdomen and extremities
-inspection
-auscultation
-percussion
-palpation
Laboratory tests
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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
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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
Percutaneous
Transhepatic
Cholangiography (Continued)
 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
Esophagogastroduodenos
copy
 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
Endoscopic Retrograde
Cholangiopancreatography
(Continued)
 Return of gag reflex checked
 Assessment for pain
 Colicky abdominal pain
Small Bowel Capsule
Enteroscopy
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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 kneechest posture.
(Continued)
Proctosigmoidoscopy
(Continued)
 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