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

Introduction 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 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 Left Lower Quadrant (LLQ) descending colon ovary uterus bladder small intestine Right Lower Quadrant (RLQ) appendix large ascending colon Left Upper Quadrant (LUQ) spleen kidney pancreas stomach Splenic Flexure –large colon Right Upper Quadrant (RUQ) diaphragm liver gallbladder Hepatic flexure -large colon

Anatomy - 9 Quadrant System Left Iliac Hypogastric (suprapubic) Right Iliac Left Lumbar Umbilical Right Lumbar Left Hypochondriac Epigastric Right Hypochondriac 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 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

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 myocardial infarction pneumonia pulmonary embolus can present with abdominal pain

Assessment techniques History Demographic data Family history and genetic risk Personal history Diet history -anorexia -dyspepsia

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 (Continued) S&P

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 S&P

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 S&P

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 (Continued)

Endoscopic Retrograde Cholangiopancreatography (Continued) 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 S&P

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. (Continued) S&P

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 S&P

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