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

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

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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.

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Anatomy - 4 Quadrant System
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Anatomy - 9 Quadrant System
See graphic on next slide
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Anatomy - 9 Quadrant System
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Assessment of Abdominal painO-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

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Assessment of Abdominal painO-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

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Assessment of Abdominal painO-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

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Assessment of Abdominal painO-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

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Assessment of Abdominal painO-P-Q-R-S-T

• Severity
• the patients 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 patients
  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

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Assessment of Abdominal painO-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

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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

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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

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Associated signs symptoms

• Anorexia
• intra-abdominal inflammation
• common in appendicitis

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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

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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

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Associated signs symptoms

• Extra-abdominal symptoms
• myocardial infarction
• pneumonia
• pulmonary embolus

can present with abdominal pain
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Assessment techniques

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

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Physical assessment

• Mouth and pharynx
• Abdomen and extremities
• -inspection
• -auscultation
• -percussion
• -palpation

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Laboratory tests

• Complete blood count
• Clotting factors
• Electrolytes
• Assays of liver enzymes-aspartat and alanin
  aminotransferase
• Serum amylase and lipase
• Bilirubinthe primary pigment in bile

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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.

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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.

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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 bariumdrink plenty of
  fluids stool is chalky white for 24 to 72 hr.

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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)

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Percutaneous Transhepatic Cholangiography
(Continued)

• Client positioned on right side with a firm
  pillow or sandbag placed against the lower ribs
  and abdomen

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Other Tests

• Computed tomography
• Endoscopy direct visualization of the
  gastrointestinal tract by means of a flexible
  fiberoptic endoscope

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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

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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)

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Endoscopic Retrograde Cholangiopancreatography
(Continued)

• Return of gag reflex checked
• Assessment for pain
• Colicky abdominal pain

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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

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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

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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)

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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

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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

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Other Tests

• Ultrasonography
• Endoscopic ultrasonography
• Liver-spleen scan