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

2. 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

4. 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.

5. 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

6. 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

7. Anatomy - 9 Quadrant System

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

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

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

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

22. 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

23. 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.

24. 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.

25. 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.

26. 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

27. Percutaneous Transhepatic Cholangiography (Continued)
Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen

28. Other Tests Computed tomography
Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope
S&P

29. 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

30. 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)

31. Endoscopic Retrograde Cholangiopancreatography (Continued)
Return of gag reflex checked
Assessment for pain
Colicky abdominal pain

32. 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

33. 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

34. 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

35. 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

36. 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

37. Other Tests Ultrasonography Endoscopic ultrasonography
Liver-spleen scan