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

why assess the abdomen in the prehospital setting?why assess the abdomen in the prehospital setting? abdominal pain accounts for up 10% of emergency visitsabdominal pain accounts for up 10% of emergency visits 15-30% of patients with an acute abdomen will require a 15-30% of patients with an acute abdomen will require a

surgical proceduresurgical procedure

IntroductionIntroduction

Gastrointestinal system involves the Gastrointestinal system involves the esophagus ,stomach, small and large intestinesesophagus ,stomach, small and large intestines

They work with the pancreas liver and gallbladder They work with the pancreas liver and gallbladder to convert nutrients from food into energy. to convert nutrients from food into energy.

Waste is then excreted.Waste is then excreted.

AnatomyAnatomy

Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ) descending colondescending colon ovaryovary uterusuterus bladderbladder small intestinesmall intestine

Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ) descending colondescending colon ovaryovary uterusuterus bladderbladder small intestinesmall intestine

Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ) appendixappendix large ascending colonlarge ascending colon ovaryovary uterus uterus bladderbladder small intestinesmall intestine

Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ) appendixappendix large ascending colonlarge ascending colon ovaryovary uterus uterus bladderbladder small intestinesmall intestine

Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ) spleenspleen kidney kidney pancreaspancreas stomachstomach Splenic Flexure –large Splenic Flexure –large

coloncolon small intestinesmall intestine

Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ) spleenspleen kidney kidney pancreaspancreas stomachstomach Splenic Flexure –large Splenic Flexure –large

coloncolon small intestinesmall intestine

Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ) diaphragmdiaphragm liverliver gallbladdergallbladder kidneykidney Hepatic flexure -large colonHepatic flexure -large colon small intestinesmall intestine

Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ) diaphragmdiaphragm liverliver gallbladdergallbladder kidneykidney Hepatic flexure -large colonHepatic flexure -large colon small intestinesmall intestine

Anatomy - 4 Quadrant SystemAnatomy - 4 Quadrant System

Left IliacLeft IliacLeft IliacLeft IliacHypogastricHypogastric

(suprapubic)(suprapubic)

HypogastricHypogastric

(suprapubic)(suprapubic)Right IliacRight IliacRight IliacRight Iliac

Left LumbarLeft LumbarLeft LumbarLeft LumbarUmbilical Umbilical Umbilical Umbilical Right LumbarRight LumbarRight LumbarRight Lumbar

Left Left Hypochondriac Hypochondriac

Left Left Hypochondriac Hypochondriac

EpigastricEpigastricEpigastricEpigastricRight Right HypochondriacHypochondriac

Right Right HypochondriacHypochondriac

Anatomy - 9 Quadrant SystemAnatomy - 9 Quadrant System

See graphic on next slide

Anatomy - 9 Quadrant SystemAnatomy - 9 Quadrant System

ONSETONSET rapid onset of severe pain is more consistent with a rapid onset of severe pain is more consistent with a

vascular catastrophe, passage of a ureteral or gallbladder vascular catastrophe, passage of a ureteral or gallbladder stone, torsion of the testes or ovaries, rupture of a hollow, stone, torsion of the testes or ovaries, rupture of a hollow, viscous, ovarian cyst, or ectopic pregnancyviscous, ovarian cyst, or ectopic pregnancy

slower onset is more typical of an inflammatory process slower onset is more typical of an inflammatory process such as appendicitis or cholecystitis such as appendicitis or cholecystitis

Assessment of Abdominal painAssessment of Abdominal painOO-P-Q-R-S-T -P-Q-R-S-T

Provokes / palliatesProvokes / palliates pain provoked/aggravated by movement, such as hitting bumps on pain provoked/aggravated by movement, such as hitting bumps on

the road or walking is typical of somatic (parietal) peritoneal pain the road or walking is typical of somatic (parietal) peritoneal pain such as that seen in pelvic inflammatory disease or appendicitissuch as that seen in pelvic inflammatory disease or appendicitis

eating often relieves ulcer related paineating often relieves ulcer related pain eating exacerbates biliary colic – especially fatty foods (usually 1-4 eating exacerbates biliary colic – especially fatty foods (usually 1-4

hours following a meal)hours following a meal) Pancreatitis is palliated (relieved) by curling up in a fetal positionPancreatitis is palliated (relieved) by curling up in a fetal position frequent movement or writhing in pain is more typical of renalfrequent movement or writhing in pain is more typical of renal colic colic

Assessment of Abdominal painAssessment of Abdominal painO-O-PP-Q-R-S-T -Q-R-S-T

QualityQuality dull, achy or crampy is more likely to be visceraldull, achy or crampy is more likely to be visceral sharp, stabbing pain is more likely to be somatic or sharp, stabbing pain is more likely to be somatic or

peritonealperitoneal severe tearing pain is classic of dissecting severe tearing pain is classic of dissecting

aneurysmaneurysm

Assessment of Abdominal painAssessment of Abdominal painO-P-O-P-QQ-R-S-T -R-S-T

Region / radiationRegion / radiation location of pain can vary with timelocation of pain can vary with time periumbilical pain that migrates to the right lower periumbilical pain that migrates to the right lower

quadrant is classic of appendicitisquadrant is classic of appendicitis epigastric pain localizing to the right upper quadrant epigastric pain localizing to the right upper quadrant

for several hours is typical of cholecystitis for several hours is typical of cholecystitis

Assessment of Abdominal painAssessment of Abdominal painO-P-Q-O-P-Q-RR-S-T -S-T

SeveritySeverity the patient’s quantification of severity of pain is generally unreliable the patient’s quantification of severity of pain is generally unreliable

for distinguishing the benign from the life-threatening for distinguishing the benign from the life-threatening assigning a 1-10 pain scale rating does however allow for a baseline assigning a 1-10 pain scale rating does however allow for a baseline

to gauge the patient’s response to treatmentto gauge the patient’s response to treatment pain that increases in severity over time suggests a surgical pain that increases in severity over time suggests a surgical

conditioncondition Severe epigastric or mid-abdominal pain out of proportion to Severe epigastric or mid-abdominal pain out of proportion to

physical findings is classic for mesenteric ischemia or Pancreatitisphysical findings is classic for mesenteric ischemia or Pancreatitis

Assessment of Abdominal painAssessment of Abdominal painO-P-Q-R-O-P-Q-R-SS-T -T

TimingTiming crampy pain that comes in waves is generally crampy pain that comes in waves is generally

associated with obstruction of a viscousassociated with obstruction of a viscous constant pain has a worse diagnostic outcome constant pain has a worse diagnostic outcome

Assessment of Abdominal painAssessment of Abdominal painO-P-Q-R-S-O-P-Q-R-S-TT

Nausea & vomiting (N/V)Nausea & vomiting (N/V) N/V generally associated with visceral disorderN/V generally associated with visceral disorder excessive vomiting should raise suspicion of a bowel excessive vomiting should raise suspicion of a bowel

obstruction or Pancreatitisobstruction or Pancreatitis lack of vomiting is common in uterine or ovarian disorderslack of vomiting is common in uterine or ovarian disorders pain present before vomiting is more likely caused by a pain present before vomiting is more likely caused by a

disorder that will require surgerydisorder that will require surgery vomiting that precedes Abdo pain is more likely a vomiting that precedes Abdo pain is more likely a

gastroenteritis or other non-surgical conditiongastroenteritis or other non-surgical condition

Associated signs & symptomsAssociated signs & symptoms

Urgency to defecateUrgency to defecatemay suggest…may suggest… intra-abdominal bleedingintra-abdominal bleeding inflammation/irritation in the recto sigmoid areainflammation/irritation in the recto sigmoid area ectopic pregnancy ectopic pregnancy abdominal aortic aneurysm (AAA)abdominal aortic aneurysm (AAA) retro peritoneal hematomaretro peritoneal hematoma omental vessel hemorrhageomental vessel hemorrhage

Associated signs & symptomsAssociated signs & symptoms

AnorexiaAnorexia intra-abdominal inflammationintra-abdominal inflammation common in appendicitiscommon in appendicitis

Associated signs & symptomsAssociated signs & symptoms

Change in bowel habitsChange in bowel habits diarrhea with vomiting is almost always associated with diarrhea with vomiting is almost always associated with

gastroenteritisgastroenteritis diarrhea may occur with Pancreatitis, Diverticulitis and diarrhea may occur with Pancreatitis, Diverticulitis and

occasionally Appendicitisoccasionally Appendicitis bloody stool indicates GI bleedbloody stool indicates GI bleed constipation or difficulty passing stool or gas may be due to an constipation or difficulty passing stool or gas may be due to an

ileas (impairment in paristalsis) of bowel obstructionileas (impairment in paristalsis) of bowel obstruction

Associated signs & symptomsAssociated signs & symptoms

Genitourinary symptomsGenitourinary symptoms dysurea, urgency and frequency are suggestive of dysurea, urgency and frequency are suggestive of

cystitis (inflammation of the bladder), salpingitis, cystitis (inflammation of the bladder), salpingitis, diverticulitis or appendicitisdiverticulitis or appendicitis

Hematurea with pain suggests urinary tract infection, Hematurea with pain suggests urinary tract infection, but can also indicate renal colic, prostatitis or cystitisbut can also indicate renal colic, prostatitis or cystitis

Associated signs & symptomsAssociated signs & symptoms

Extra-abdominal symptomsExtra-abdominal symptoms myocardial infarctionmyocardial infarction pneumoniapneumonia pulmonary emboluspulmonary embolus

Associated signs & symptomsAssociated signs & symptoms

can present with abdominal pain

Assessment techniquesAssessment techniques

HistoryHistory Demographic dataDemographic data Family history and genetic riskFamily history and genetic risk Personal historyPersonal history Diet historyDiet history -anorexia-anorexia -dyspepsia-dyspepsia

Physical assessmentPhysical assessment

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

Laboratory testsLaboratory tests

Complete blood countComplete blood count Clotting factorsClotting factors ElectrolytesElectrolytes Assays of liver enzymes-aspartat and Assays of liver enzymes-aspartat and

alanin aminotransferasealanin aminotransferase Serum amylase and lipaseSerum amylase and lipase Bilirubin:the primary pigment in bileBilirubin:the primary pigment in bile

Laboratory tests (Laboratory tests (continuedcontinued))

Evaluation of oncofetal antigens CA19-9 Evaluation of oncofetal antigens CA19-9 and CEAand CEA

Urine tests-amylase, urine urobilinogenUrine tests-amylase, urine urobilinogen Stool tests-fecal occult blood test,ova Stool tests-fecal occult blood test,ova

parasites, parasites, Clostridium difficileClostridium difficile infection. infection. Radiographic examination.Radiographic examination.

Upper gastrointestinal Upper gastrointestinal series and small bowel series and small bowel series.series.

Before test:Before test: -maintain NPO for 8 hr-maintain NPO for 8 hr -withhold analgesics and -withhold analgesics and

anticholinergics for 24 hr.anticholinergics for 24 hr. Client drinks 16 ounces of barium.Client drinks 16 ounces of barium. Rotate examination table.Rotate examination table. After the test:After the test: -give plenty of fluids-give plenty of fluids -administer mild laxative or stool softener; -administer mild laxative or stool softener;

stools may be chalky white for 24 to 72 hr.stools may be chalky white for 24 to 72 hr.

Barium EnemaBarium Enema

Barium enema enchances radiographic Barium enema enchances radiographic visualization of the large intestine.visualization of the large intestine.

Only clear liquids are given 12 to 24 hr before Only clear liquids are given 12 to 24 hr before the test; NPO the night before; bowel cleansing the test; NPO the night before; bowel cleansing is done.is done.

After the test,expel the barium:drink plenty of After the test,expel the barium:drink plenty of fluids; stool is chalky white for 24 to 72 hr.fluids; stool is chalky white for 24 to 72 hr.

Percutaneous Transhepatic Percutaneous Transhepatic CholangiographyCholangiography

X-ray study of the biliary duct systemX-ray study of the biliary duct system Laxative before the procedureLaxative before the procedure NPO for 12 hr before testNPO for 12 hr before test Coagulation tests, intravenous infusionCoagulation tests, intravenous infusion Bedrest for several hours after Bedrest for several hours after

procedureprocedure Assessment of vital signsAssessment of vital signs

Percutaneous Transhepatic Percutaneous Transhepatic CholangiographyCholangiography (Continued)(Continued)

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

Other Tests Other Tests

Computed tomographyComputed tomography Endoscopy: direct visualization of the Endoscopy: direct visualization of the

gastrointestinal tract by means of a gastrointestinal tract by means of a flexible fiberoptic endoscopeflexible fiberoptic endoscope

EsophagogastroduodenoscoEsophagogastroduodenoscopypy Visual examination of the esophagus, Visual examination of the esophagus,

stomach, and duodenumstomach, and duodenum NPO for 6 to 8 hr before the procedureNPO for 6 to 8 hr before the procedure Conscious sedationConscious sedation After the test, assessment of vital After the test, assessment of vital

signs every 30 minsigns every 30 min NPO until gag reflex returnsNPO until gag reflex returns Throat discomfort possible for several Throat discomfort possible for several

daysdays

Endoscopic RetrogradeEndoscopic Retrograde CholangiopancreatographyCholangiopancreatography

Visual and radiographic examination Visual and radiographic examination of the liver, gallbladder, bile ducts, of the liver, gallbladder, bile ducts, and pancreasand pancreas

NPO for 6 to 8 hr before testNPO for 6 to 8 hr before test Access for intravenous sedationAccess for intravenous sedation After the test, assessment of vital After the test, assessment of vital

signs every 15 minsigns every 15 min

Endoscopic Retrograde Endoscopic Retrograde CholangiopancreatographyCholangiopancreatography

(Continued)(Continued) Return of gag reflex checkedReturn of gag reflex checked Assessment for painAssessment for pain Colicky abdominal painColicky abdominal pain

Small Bowel Capsule Small Bowel Capsule EnteroscopyEnteroscopy

Visualization of the small intestineVisualization of the small intestine Only water for 8 to 10 hr before testOnly water for 8 to 10 hr before test NPO for first 2 hr of the testingNPO for first 2 hr of the testing Application of belt with sensorsApplication of belt with sensors

Colonoscopy Colonoscopy Endoscopic examination Endoscopic examination of the entire large bowelof the entire large bowel Liquid diet for 12 to 24 hr before Liquid diet for 12 to 24 hr before

procedure, NPO for 6 to 8 hr before procedure, NPO for 6 to 8 hr before procedureprocedure

Bowel cleansing routineBowel cleansing routine Assessment of vital signs every 15 minAssessment of vital signs every 15 min If polypectomy or tissue biopsy, blood If polypectomy or tissue biopsy, blood

possible in stoolpossible in stool

Proctosigmoidoscopy Proctosigmoidoscopy Endoscopic examination of the rectum Endoscopic examination of the rectum

and sigmoid colonand sigmoid colon Liquid diet 24 hr before procedureLiquid diet 24 hr before procedure Cleansing enema, laxativeCleansing enema, laxative Position client on left side in the knee-Position client on left side in the knee-

chest posture.chest posture.

(Continued)(Continued)

ProctosigmoidoscopyProctosigmoidoscopy

(Continued)(Continued)

Mild gas pain and flatulence from air Mild gas pain and flatulence from air instilled into the rectum during the instilled into the rectum during the examinationexamination

If biopsy was done, a small amount of If biopsy was done, a small amount of bleeding possiblebleeding possible

Gastric AnalysisGastric Analysis

Measurement of the hydrochloric acid Measurement of the hydrochloric acid and pepsin content for evaluation of and pepsin content for evaluation of aggressive gastric and duodenal aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome)disorders (Zollinger-Ellison syndrome)

Basal gastric secretion and gastric Basal gastric secretion and gastric acid stimulation testacid stimulation test

NPO for 12 hr before testNPO for 12 hr before test Nasogastric tube insertionNasogastric tube insertion

Other TestsOther Tests UltrasonographyUltrasonography Endoscopic ultrasonographyEndoscopic ultrasonography Liver-spleen scanLiver-spleen scan