ࡱ> q` 8bjbjqPqP .<::78*Dn Xvv:$eh77777,j 0(,|0  o~oP,,o<?-~=X 7777JnZEnZ  School of Nursing Christopher W. Blackwell, Ph.D., ARNP-C Assistant Professor, School of Nursing College of Health & Public Affairs University of Central Florida NGR 5003: Advanced Health Assessment & Diagnostic Reasoning Unit Six: Gastrointestinal (GI) System: Basic assessment of the gastrointestinal system Advanced assessment of the gastrointestinal system Assessment findings of abnormal presentations in the gastrointestinal system Differential diagnoses of the gastrointestinal system Advanced Clinical reasoning: A case study approach advanced assessment of gastrointestinal (gi) system LEARNING OBJECTIVEs 1. Conduct a history related to the abdomen. 2. Discuss examination techniques for the abdomen. 3. Identify normal age and condition variations of the abdomen. 4. Recognize findings that deviate from expected findings. 5. Relate symptoms or clinical findings to common pathologic conditions. Outline for Chapter 17: Abdomen Anatomy and Physiology The abdominal cavity contains several vital organs. The peritoneum forms a protective covering for many of the abdominal structures. The mesentery covers most of the small intestine and anchors it to the posterior abdominal wall. Alimentary Tract The alimentary tract extends from the mouth to the anus and acts to ingest and digest food; absorb nutrients, electrolytes, and water; and excrete waste products. The esophagus is a collapsible tube about 10 inches long, connecting the pharynx to the stomach. It passes just posterior to the trachea, descends through the mediastinal cavity, travels through the diaphragm, and enters the stomach at the cardiac orifice. The stomach lies below the diaphragm and secretes hydrochloric acid and digestive enzymes that break down fats and proteins. The small intestine begins at the pyloric orifice and consists of the duodenum, the jejunum, and the ileum. The ileocecal valve prevents backflow of feces. Digestion is accomplished in the small intestine through the action of pancreatic enzymes, bile, and small intestine enzymes. The large intestine begins at the cecum. The ascending colon extends to the liver, where it becomes the transverse colon. The transverse colon crosses the abdominal cavity toward the spleen. The descending colon extends to the rim of the pelvis and forms the sigmoid colon. The rectum extends from the sigmoid colon to the pelvic floor, where it continues as the anal canal and ends at the anus. Liver The liver lies in the right upper quadrant of the abdomen below the diaphragm. At 3 pounds, it is the heaviest organ of the body. It is composed of four lobes, each containing liver cells. Branches of the portal vein, hepatic artery, and bile duct embrace the periphery of the lobules. The liver functions in the metabolism of carbohydrates, fats, and proteins. It stores glycogen, converts amino acids to glucose, and stores vitamins and iron. The liver detoxifies harmful substances and secretes bile and steroid hormones. It produces antibodies, substances for blood coagulation, and plasma proteins. Gallbladder The gallbladder lies recessed in the inferior surface of the liver. It concentrates and stores bile and releases it into the cystic duct. Bile serves to maintain the alkaline pH of the small intestine to permit emulsification of fats. Pancreas The pancreas lies in the curve of the duodenum and extends to the spleen. The acinar cells of the pancreas produce digestive juices containing inactive enzymes for the breakdown of proteins, fats, and carbohydrates. The pancreatic duct lies next to the common bile duct. Islet cells scattered throughout the pancreas produce insulin and glucagon to regulate glucose level. Spleen The spleen lies above the left kidney and below the diaphragm. Lymphoid tissue constitutes most of the spleen and functions to filter blood and manufacture lymphocytes and monocytes. The spleen stores and releases blood. Kidneys, Ureters, and Bladder The two kidneys, the excretory organs responsible for removing water-soluble waste, are located in the retroperitoneal space of the upper abdomen, and extend from about the vertebral level of T-12 to L-3. Each kidney contains more than 1 million nephrons composed of capillaries, glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule that empties into a collecting tubule. Each kidney receives about one eighth of the cardiac output through its renal artery. Filtered material is actively reabsorbed in the proximal tubule. Urinary volume is controlled by antidiuretic hormone (ADH). Urine passes into the renal pelvis via the collecting tubules and then into the ureter. It then moves on to the urinary bladder, which holds about 400 to 500 mL of urine in the adult. The kidneys produce renin to control aldosterone secretion and erythropoietin, thus influencing the bodys red cell mass. The kidneys also synthesize prostaglandins and produce an active form of vitamin D. Musculature and Connective Tissue The rectus abdominis and oblique muscles protect the abdominal cavity. Vasculature The descending aorta travels from the diaphragm through the abdominal cavity. The aorta branches into two common iliac arteries at the umbilical level. The aorta branches into the splenic and renal arteries and the two common iliac arteries within the abdomen. Age- and Condition-Related Variations Infants. During week 4 of gestation, the pancreatic buds, liver, and gallbladder begin to form. The ability to swallow amniotic fluid begins by 17 weeks. At about 6 weeks, red blood cells form in the liver. Glycogen is synthesized by week 9, and bile is produced by week 12. By 12 weeks of gestation, pancreatic cells develop and begin producing insulin. The spleen is active in blood formation until 1 year of age, after which time it aids in the destruction of blood cells and the formation of hemoglobin. By 12 weeks, the kidneys are able to produce urine. New nephron development ceases by 36 weeks of gestation. Pregnant women. During the last trimester, the rectus abdominis muscles may separate, allowing abdominal contents to protrude at the midline. After pregnancy, the umbilicus flattens or protrudes. Striae may form, and linea nigra often appears at the midline. The gallbladder may become distended, accompanied by decreased emptying time and change in tone. The combination of gallbladder stasis and secretion of lithogenic bile increases formation of cholesterol crystals in the development of gallstones. Gallstones are more common in the second and third trimesters. The kidneys enlarge slightly (by about 1 cm in length) during pregnancy. The bladder has increased sensitivity and compression during pregnancy, which may lead to frequency and urgency of urination during the first and third trimesters. The colon is displaced upward, and peristalsis may decrease. Blood flow to the pelvis increases. After pregnancy, muscles gradually regain tone during the postpartum period and may require 6 to 7 weeks to recover. Older adults. With age, intestinal motility decreases. Reduced circulation to the intestine often occurs. Epithelial atrophy results in decreased secretion of digestive enzymes. Mucosal cells exhibit a reduced secretory ability and higher susceptibility to ingested carcinogens. Bacterial flora may undergo qualitative and quantitative changes and become less biologically active. After 50 years of age, hepatic blood flow and liver cell numbers decrease. The liver may lose some ability to metabolize certain drugs. The functional reserve of the pancreas may decrease. Review of Related History History of Present Illness Abdominal pain. Patients should be asked about the onset and duration of the pain, the location of discomfort, and specific characteristics of the pain (e.g., burning or aching sensations). Associated symptoms and factors should also be explored (e.g., vomiting, abdominal girth, recent stool characteristics, urinary characteristics, medications, or relationship to menstrual cycle). Indigestion. When indigestion occurs, patients should be questioned about the character of discomfort (e.g., heartburn or severe pain), location of pain, and any association with food ingestion. The onset of symptoms (e.g., time of day) and treatment response (e.g., relief from antacids) should be documented. Nausea and vomiting. The character (nature, quantity, duration, and frequency) as well as relationship to factors such as eating, diarrhea, pain, or medications should be determined. Any stimuli to symptoms (e.g., odors or food intake) should be noted. Diarrhea. Examiner should record a description of characteristics (amount, consistency, color), associated symptoms (e.g., fever or thirst), relationship to food intake or stress, medications taken, and a travel history. Constipation. The character of the stool should be noted, and questions about the pattern of passing stool should be asked. Any changes in dietary habits should be noted, as well as medications taken. Fecal incontinence. The character of the stool should be noted, as well as any association with the use of any laxatives, or the presence of any underlying disease, such as diverticulitis, colitis, or irritable bowel disease. The relationship to fluid and dietary intake, medications used, and any alternative treatments should be explored. Jaundice. If jaundice is present, questions should focus on duration of color, color of stools, abdominal pain, medications taken, and factors that might be associated with jaundice, such as exposure to hepatitis. Dysuria. Questions should be asked about the character of dysuria (e.g., pain or volume changes) and exposure to contributing factors (e.g., tuberculosis or infection). Urinary frequency or incontinence. Changes in usual urination pattern or volume, dribbling, and characteristics of current problem should be noted. Examiner should also record any associated factors (e.g., coughing and nocturia) as well as medications taken. Hematuria. The character of hematuria (e.g., red or rusty color) associated symptoms (e.g., pain on voiding), and alternate possibilities (e.g., ingestion of red food dyes) should be documented. Chyluria. Questions should be asked about exposure to tuberculosis or parasitic infections, as well as medications taken. Past Medical History Relevant data include past gastrointestinal disorders (e.g., ulcers), liver problems (e.g., cirrhosis), and abdominal or urinary tract injuries. Information should be collected about urinary tract infections, major illnesses (e.g., cancer or kidney disease), blood transfusions, and medications. Family History Pertinent data include family history of periodic peritonitis, gallbladder or kidney disease, malabsorption syndrome, Hirschsprung disease, polyposis, or colon cancer. Personal and Social History Relevant data include nutritional habits, last menses, physical or emotional stress, and use of alcohol or street drugs. Exposure to infectious diseases or trauma from work or other activity should be noted. Age- and Condition-Related Variations Infants. Relevant data include birth weight, meconium stool passage, jaundice, and abdominal enlargement. The amount, frequency, and presence of blood, as well as any weight pattern associated with vomiting should be noted. If diarrhea has occurred, colic and weight patterns should be recorded. Children. If constipation occurs, data on toilet training, diet, and associated factors (such as pica or painful passage of stool) should be noted. Data relevant to abdominal pain include positioning factors, such as splinting or flexed knees. Pregnant women. Inquire about any urinary symptoms, abdominal pain, fetal movement, and contractions. Older adults. Note any urinary symptoms of nocturia or incontinence or any change in bowel patterns or dietary habits, such as a change in food tolerance or appetite. See Risk Factors: Persons at Risk for Viral Hepatitis (p. 529). Examination and Findings Summary of ExaminationAbdomen Preparation and Positioning Patient should have an empty bladder. Place patient in the supine position with arms at side and a small pillow under the head and knees. Ensure good lighting and full exposure of the patients abdomen. Make sure your hands are warm and your fingernails are trimmed. Drape towel over patients chest for warmth and privacy. Help the patient feel as comfortable and relaxed as possible. Inspection Note contour, color, symmetry, and surface motion of abdomen (males: abdominal movement; females: costal movement), venous patterns, and lesions. Have patient take a deep breath and hold. Have patient raise his or her head off the table. Auscultate Listen for bowel and vascular sounds (bruits, friction rubs, venous hums). Percussion Perform overall percussion first. Examine tender/painful areas last. Note size and density of abdominal organs. Note liver span (do direct and indirect percussion); determine splenic borders and contour; note gastric bubble. Note poles of kidneys (perform fist percussion on back). Assess for ascites. Percuss for shifting dullness, fluid wave. Palpation Do overall light palpation, then deep palpation. Assess for muscle guarding, masses, fluid, areas of tenderness, and size and shape of organs. Palpate epigastric area for aortic pulsation. Palpate umbilical area. Feel for gallbladder. Palpate for liver, spleen, kidneys. Summary of Abdomen Findings Life Cycle VariationsNormal FindingsTypical VariationsFindings Associated with DisordersAdultsContralateral areas should be symmetric with deep breath. Contour should be smooth and symmetric. Bowel sounds range from 5 to 55 per minute. Dullness is heard over organs. Liver dullness is heard at costal margin or just below it. Splenic dullness is heard from the sixth to the tenth rib. Umbilicus is free from bulges, nodules, granulation.Scaphoid or concave contour is seen in thin adults. Rounded or convex abdomen is the result of subcutaneous fat or poor muscle tone. Umbilicus may be inverted or may protrude slightly. Pulsations may be visible in thin persons. Aortic pulse may be felt in thin persons. Liver span is greater in males and tall persons. Full stomach and intestinal feces mimic dullness of splenic enlargement. Muscles, arteries, and feces mimic abdominal masses.Jaundice, cyanosis, and ascites are signs of physiologic problems. Cullen sign suggests intraabdominal bleeding. Purplish striae result from Cushings disease. Pearl-like umbilical node suggests intraabdominal lymphoma. Scarring is associated with internal adhesions. Distention is caused by obesity, enlarged organs, fluid, or gas. Venous hum is caused by increased portal and systemic circulation. Friction rubs are rare; they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarction. A liver border more than 2 to 3 cm below costal margin indicates organ displacement. Rigidity occurs over peritoneal irritation. Murphy sign occurs with inflamed gallbladder. Rebound tenderness over the McBurney point suggests appendicitis. Infants and childrenNewborn cords should contain two arteries and one vein. Infants should have synchronous abdominal and chest movements with breathing. Superficial veins may be seen in thin infants. Pulsations in the epigastric area are common. Liver is palpated 1 to 3 cm below right costal margin. Umbilicus is usually inverted. Bladder is palpated in suprapubic area in infants and toddlers. Abdomen is rounded or convex and protrudes in young children. Infant of a diabetic mother may have an enlarged liver.Infant abnormalities include intussusception, umbilical hernia, pyloric stenosis, meconium ileus, biliary atresia, Meckel diverticulum, gastroesophageal reflux, and necrotizing enterocolitis. Abnormalities of children include neuroblastoma, Wilms tumor, and Hirschsprung disease. Bowel sounds in the chest suggest a diaphragmatic hernia. Adolescents Tanning lines and fine venous networks are often visible. Flat contour is common in athletic persons.Pregnant womenDiminished abdominal reflex occurs during pregnancy. Nausea and vomiting may occur in the first trimester. During the last trimester, the rectus abdominis muscle may separate and the umbilicus flattens or protrudes. The colon is displaced upward and peristaltic activity may decrease.Abdominal striae result from weight gain or pregnancy. Linea nigra often appears at midline. Hemorrhoids are common. Older adultsWith age, intestinal motility decreases. Decreased circulation to the intestines may occur. After 50 years of age, hepatic blood flow and liver cell numbers decrease. Certain drugs may not be metabolized by the liver.In older adults, abdominal wall becomes thinner and less firm. Fat over abdominal area and loss of muscle tone is common. Midclavicular liver span may be somewhat less. Intestinal motility decreases. Pain perception may not be as strong.The chance of diverticulitis and colon cancer increases with age.  See Box 17-1: Landmarks for Abdominal Examination (p. 534); Table 17-1: Percussion Notes of the Abdomen (p. 538); and Box 17-2: Examining the Abdomen in a Ticklish Patient (p. 541). See Box 17-7: Palpating an Infants Abdomen (p. 559) and the Mnemonics box for intussusception for infants (p. 560). See Box 17-3: An Enlarged Spleen or an Enlarged Left Kidney? (p. 547); the Mnemonics box for features of peritonitis (p. 551); Box 17-6: Findings in Peritoneal Irritation (p. 553); Table 17-5: Symptoms or Signs Elicited in Other Systems That May Relate to the Abdominal Examination (p. 554); and Table 17-6: Abdominal Signs Associated with Common Abnormalities (p. 557). See Table 17-2: Common Conditions Producing Acute Abdominal Pain (p. 552); Table 17-3: Common Conditions Producing Chronic Abdominal Pain (p. 553); Table 17-4: Quality and Onset of Abdominal Pain (p. 553); Box 17-4: Clues in Diagnosing Abdominal Pain (p. 551); and Box 17-5: Some Causes of Pain Perceived in Anatomic Regions (p. 551). See the Mnemonics boxes for causes of constipation (p. 565) and reversible causes of urinary incontinence: DRIP (p. 578). See cultural differences discussed in the Physical Variations box (p. 574). Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc Course Lecture Content: Gastrointestinal (GI) System: Advanced assessment of the gastrointestinal system Assessment findings of abnormal presentations in the gastrointestinal system Differential diagnoses of the gastrointestinal system Christopher W. Blackwell, Ph.D., ARNP-C Assistant Professor, School of Nursing College of Health & Public Affairs University of Central Florida NGR 5003: Advanced Health Assessment & Diagnostic Reasoning Advanced Assessment of the GI System Anatomy and Physiology: Peritoneum covers GI tract; folds of perigastric peritoneum form >/< omentum; mesentery covers small intestine Alimentary Tract: 27 long tube running from mouth-to-anus Esophagus, stomach, small intestine, large intestine Esophagus meets stomach through cardiac sphincter Stomach consists of fundus, body, and pylorus (meets small intestine through pyloric sphincter) Mechanical degradation of foods main function of stomach (water/Rx also absorbedsome protein fat breakdownpH 2) Common bile/pancreatic ducts open into duodenum at the papilla; ileocecal valve prevents backflow from large to small intestines; small intestines completes digestion through pancreatic enzymes, bile, other enzymes; nutrients absorbed through intestinal crypts Large intestine begins at cecum (vermiform appendix) folds at hepatic and splenix flexures; joins sigmoid, rectum, and anusmajor site for water absorption; live bacteria digests remaining food particlesassist in eliminating dead ones Advanced Assessment of the GI System Liver: Lies in RUQ; inferior surface embrased stomach, gallbladder, and hepatic flexure of colon 4 lobesfunctional units; VERY vascular organ Converts glucose into stored glycogen; converts amino acids to glucose; makes cholesterol to form bile salts; proteins/wastes broken down to urea for excretion; forms clotting factors, stores/metabolizes vitamins, produces antibodies, converts organic wastes into bile/urea for excretion Gallbladder: 4 longpear shaped inferior to liver surface Secretes bile into duodenum through common bile duct (best visualized through HIDA scan), composed of cholesterol, bile salts, and pigments, which emulsifies fat and maintains intestinal pH Pancreas: Stretches behind stomach to spleen; acinar glands produce digestive juicesbreakdown fats, proteins, carbs, secreted into dudenum via pancreatic duct; islet cells secrete insulin (beta) and glucagon (alpha) Spleen: LUQlying above L kidney; filters dead blood cells and manufactures lymph/monoocytesmajor storage site for blood Kidney, Urters, and Bladder: Located retroperitoneally at T12-L3; R lower than L; each contains > 1 mil nephrons, functional units, composed of glomerulus, prox. convoluted tubule, loop of Henle, and distal convoluted tubule; renal artery receives 1/8 total CO, filtering 110-125ml/min; most lytes/glucose/proteins absorbed through prox tubule; urinary volume controlled by ADHbladder w/ max capacity of 400-500 ml in adult; secretes renin (controls aldosterone) and erythropoietin, which stimulates marrow to manufacture RBCs Advanced Assessment of the GI System Musculature and Connective Tissue: Rectus abdominus; internal/external obliques; linea alba; inguinal ligament Vascultare: Descending aorta ( common iliac arteries (2) ( splenic/renal arteries Infants: GI fully functional at 36-38 weeks gestation; continues to grow until 2-3 years Liver begins growth and function at weeks 6-12; growth during infancy not rapid but remains heaviest organ Pancreatic cells w/ insulin production form by week 12 Kidney fully formed by 36 weeks gestation; grows rapidly in 1st year due to expanding nephrons Pregnant Women: ABD wall stretches and loses tone; 3rd trimester may se separation of rectus abdominus w/ organ protrusion ABD contour changes 2 weeks prior to delivery; striae common; after delivery, muscles slowly regain tone (rectus abdominus may remain splitdiastasis recti) Incompetence in gastric sphincters (resulting from hormonal dec in pressures) results in frequent dyspepsia Gallbladder stretching and dec emptying time promotes formation of cholelithiasis, esp in 2nd/3rd trimesters Kidney and reproductive organ enlargement promotes urinary stasis and pyelonephritis; lateral recumbent position inc urine production Advanced Assessment of the GI System Fetal positioning, increased sensitivity and compression can lead to increase in incontinence, frequency and urgency; trigone enlargment and thickening can cause microhematuriaassess from UTI/pyelonephritis through UA & C/Slook specifically at number of WBCs (> 2+) and colonization; > 100K indicates acute infection Displacement of colon lateral and upward posteriorly decreases peristalsis and inc water absorption, resulting in ! bowel sounds; constipation/ flatus common Blood flow and venous pressure ! to pelvis, resulting in hemorrhoids Pelvic muscle regain tone approx 6-7 weeks postpartum Older Adults: Mobitlity of the intestines significantly !; this is caused by death of CNS stimulation and changes in collagen, which ! resistance to stretching; Epithelial atrophy results in a ! in secretion of digestive enzymes and protective mucosa, making mucosal cells more susceptible to carcinogenic changes and impairing digestion and making some foods intolerance Overall ! in CO leads to ! in blood flow through liver, decreasing ability to metabolize certain Rx and promoting DM2; pancreatic function unchanged Overall ! in biliary lipids, including cholesterol; ! opportunity for cholelithiasis Advanced Assessment of the GI System Hx of Present Illness: ABD Pain: onset and duration (when began, sudden vs. gradual, persistent, recurrent, intermittent); character (dull, sharp, gnawing, stabbing, cramping, aching, colicky); location (of onset, change in location over time, radiation, superficial vs. deep); associated symptoms (N/V/D, constipation, flatus, belching, jaundice, change in ABD girth); relationships (to menses/abnormal menses, urination, defecation, inspiration, change in body position, food or ETOH intake, stress, time of day, trauma); recent stool characteristics (color, consistency, odor, frequency); urinary characteristics (frequency, color, volume, congruent w/ fluid intake, ease of stream, ability to empty bladder); Rx (non/script, high-dose ASA/NSAID, steroids, APAP, steroids); use of complimentary Tx Indigestion: character (feeling of fullness, dyspepsia, discomfort, excessive belching, flatulence, anorexia, pain); location (localized, general, radiation to arms/shoulders); assoc w/ (food intake/timing of food/amount/type, date of LMP); onset of symptoms (time of day, night, sudden vs. gradual); symptoms relieved (by rest, antacids, activity); Rx (non/script, antacids); use of complimentary Tx Nausea (N): assoc w/ (vomiting, particular stimuliodors, activities, time of day, food intake, date of LMP); Rx (non/script, antiemetics); complimentary Tx Advanced Assessment of the GI System Vomiting (V): character (naturecolor, fresh blood vs. coffee grounds, undigested food particles, qty., duration, frequency, ability to keep food/liquid in stomach); relationship to (previous meal, change in appetite, D/C, fever, sweats, chills, wt. loss, ABD pain, Rx, HA, N, date of LMP); Rx (non/script, antiemetics); complimentary Tx Diarrhea (D): character (watery, copious, explosive, presence of blood, mucus, undigested foods, oil, fats, odor, number of x/day, duration, changes in patterns); associated symptoms (chills, fever, sweats, thirst, wt. loss, ABD pain/cramping, incontinence); relationship to (timing and nature of food intake, stress); travel Hx, Rx (non/script, lax/stool softeners, antidiarrheals); complimentary Tx Constipation (C): character (presence of bright blood/tarry stool, D alternating w/ C, accompanied by ABD pain/discomfort); diet (recent changes in diet, inclusion of high-fiber foods); Rx (non/script, lax/stool softeners, diuretics, Fe, anticholinergics); complimentary Tx Advanced Assessment of the GI System Fecal Incontinence: character (stool characteristics, timing in relation to meals, # episodes/day, occurs w/ or w/o warning); associated w/ (use of lax, presence of underlying DzCA, IBD, diverticulitis, colitis, proctitis, diabetic neuropathy); relationship to dietary intake/immobilization; Rx (non/script, lax/stool softeners, Fe, diuretics); complimentary Tx Jaundice: onset and duration; color of stools and urine; assoc w/ ABD pain, chills, fever; exposure to hepatitis; Rx (non/script, high doses of APAP); illicit Rx use, complimentary tx Dysuria: character (locationsuprapubic, distal urethra pain or burning, freq/vol changes); exposure to (TB, fungalviral/bac/parasitic infections); ! freq of intercourse; amt. of daily fluid intake; complimentary Tx Urinary Frequency: change in usual pattern/vol; assoc w/ (dysuria, urgency, hematuria, incontinence, nocturia); change in stream/dribbling; Rx (non/script, diuretics); complimentary Tx Urinary Incontinence: character (amt/freq; constant/intermittent, dribbling vs. frank); assoc w/ (urgency, previous surgery, coughing, sneezing, walking-up stairs, nocturia, menopause); Rx (non/script, diuretics); complimentary tx Hematuria: character (colorbright red, rusty brown, cola-colored present at beginning or end or entire void); assoc symptoms (flank/CVT; passage of wormlike clots, pain w/ voiding); alternate possibilities (ingestion of foods containing red veg dyesred urinary pigment, lax containing phenolphthalein); Rx (non/script, ASA, NSAIDs, anticoagulants, diuretics, ATBx); complimentary Tx Advanced Assessment of the GI System Past Medical Hx: GI Dz: PUD, polyps, IBD, intestinal obstruction, pancreatitis/Hx of hyperlipidemia Hepatitis/cirrhosis ABD/urinary tract surgery or injury (type, outcome) Major Illnesses: CA, arthritis (clue in to steroids/ASA use), renal Dz, cardiac Dz Blood/product transfusion Hepatitis immunizations CA: colorectal, breast, ovarian, endometrial Family Hx: Familiar Mediterranean fever (periodic peritonitis) Cholelithiasis Malabsorption syndromes: CF, celiac Dz Hirschsprung Dz, aganglionic megacolon Familal colorectal CA: familial adenomatous poyposis, hereditary non-polyposis colorectal CA Colorectal CA Personal/ Social Hx: Nutrition: 24-hr recall intake, food preferences, ehtnic foods, food intolerances, lifestyle effects on food intake, wt. loss/gain 1st day of LMP ETOH intake; illicit drug use; tobacco use (pack years) Recent stressful life events; physical psychological changes Exposure to infectious Dz: through travel, hepatitis, flu Trauma: type of work, physical activity, abuse Advanced Assessment of the GI System Infants: Birth wt. (< 1500 g ! risk for necrotizing enterocolitis) Passage of 1st meconium within 24 h Jaundice in newborn period, exchange transfusions, phototherapy, breast-fed infant, appearance later in 1st month of life Vomiting: ! in amt/freq; forceful/projectile; failure to gain wt; insatiable appetite, bloody emesis (pyloric stenosis vs. GERD) D, colic, failure to gain wt., wt. loss, steatorrhea (malabsorption) Apparent enlargement of ABD (w/ or w/o pain), C/D Children: C: toilet training methods, soiling, D, ABD distension, pica, size, shape, consistency, time of last stool, rectal bleeding, pain w/ passage of stool ABD Pain: splinting ABD movt, resists movt, flexes knees Pregnant Women: Urinary Symptoms: frequency, urgency, nocturia (common in early and late preg), burning, dysuria, odor (other s/s of infec) ABD Pain: weeks gestation (preg. can alter location of pain); fetal movt Contractions: onset, frequency, duration, intensity, accompanying symptoms, lower back pain, leakage of fluid, vag bleeding Older Adults: Urinary symptoms: nocturia, change in stream, dribbling, frank incontinence Change in bowel patterns, C, D, incontinence Dietary Habits: inclusion of fiber in diet, change in ability to tolerate certain foods, change in appetite, daily fluid intake Advanced Assessment of the GI System Examination and Findings: Preparation: Ensure pt. bladder is empty Ensure privacy and warmth Use qdts in place of regions Inspection: Begin inspection, seated, on R side Note slight difference in skin color and characteristics (tan lines, slight pallor, venous flow pattern towards headcompress and release, observing refill) Unexpected findings include jaundice, cyanosis, glistening taught appearance (ascites) Cullen sign (bluish discoloration to umbilicus) indicated intraabdominal hemorrhage; erythema (inflammation); assess striate closely (w/ wt. gain, pregnancy Hx) as striae can indicate tumor from ABD distension; striae from Cushing Dz remain purple Assess lesions: pearl-like enlarged ABD could be intraabdominal lymphoma; note that scarring could indicate possible internal adhesions Flat contour common in well-toned athletes; rounded common in children but in adults, excessive fat/ lack of exercise; scaphoid common in very thin adults; umbilicus should be midline w/o upward, downward, lateral displacementassess for bulges and distension (hernia); Assess contour by having pt. take in a deep breath and hold it, next lift chin to chestassess for bulging, masses Assess movtmales should have ABD movt w/ resp, limited movt. w/ resp could indicate severe pain; visualization of peristalsis NEVER normal Advanced Assessment of the GI System ABD Contours Differential Dx of the GI System: Hernia Distension from umbilicus to symphisis could be ovarian tumor, pregnancy, uterine fibroids, or distended bladder Distension of upper half of ABD could be carcinoma, pancreatic cyst, or gastric dilation Asymmetric distension seen in hernia, tumor, cyst, bowel obstruction, or organomegaly Bulging at scar sites typically indicates incisional hernia Protrusion at navel is an umbilical herniacould result from pregnancy, long-standing COPD, or ascites If non-reducible to manual manipulation, hernia is incarcerated, if pain elicited, could be strangulated, requiring immediate surgical intervention Diastasis recti normal finding in obese/pregnant Advanced Assessment of the GI System Auscultation: Always precedes percussion and palpation Bowel sounds 5-35 per minute all 4 qdts; increased BS + w/ bowel obstruction, hunger, gastroenteritishigh-pitched tinkling = early sign of impending obstruction; absent after 5 min x 4 qdts = 20 min Auscultated friction rubs in hepatic/splenic areas associated w/ resp indicate inflammation of peritoneum due to tumor, infection, or infarct; venous hum (heard around umbilicus) indicates increased collateral circulation between portal and systemic venous systems (hepatitis/cirrhosis/hepatic failure) Assess for bruits with bell in aortic, renal, iliac, and femoral areasnever normal Advanced Assessment of the GI System Percussion: Tympany in all regions except liver, spleen, precordium Measure liver span: 1) percuss starting at MCL (resonance), when dullness heard, mark top of liver; 2) percuss slightly below and to L of umblicus (tympany) to dullness, mark bottom of liver, > .75-1 below costal margin = organomegaly; total span > 2.5-4.5 = hepatomaegaly ( > in adults, males, tall stature)precise size obtained via MRI/US/CT (w/ contrast gives more detailNOT used in renal Dz) Spleen usually between 6th-10 ribs; percuss in several directions from resonance to dullness; enlargement suggested w/ large areas of dullnesspercuss at lowest ICS after pt. takes deep breath, should remain tympany, if dull, splenomegaly Assess kidneys posteriorly w/ light indirect/direct blows Advanced Assessment of the GI System Palpation: Evaluate organs for size, shape, mobility, consistency, and tension; Light palpation = depress finger pads < 1 cm; assess for guarding (pain) light palpation good for testing resistance and tenderness; rigidity indicates overlying peritoneal irritation; hypersensitivity (drag pin lightly over areas) noted in zones: Advanced Assessment of the GI System Moderate and deep palpation reveals more detail; pain normal with deep palpation over cecum, sigmoid, aorta, and xiphoid process ID any masses and note location, size, shape, consistency, tenderness, pulsation, mobility, and movt w/ resp If mass felt, have pt. lift head; if mass disappears, it is in the ABD cavity, if remains, in ABD wall Palpate umbilical ring for bulges, nodules, and granulation Hook the liverstand to R of pt., curl fingertips under costal margin, have pt. take deep breath, feel liver border brush fingertips Palpate below liver margin for gallbladder; tender enlargement indicates cholecystitis, nontender enlargement w/ common bile duct obstruction; have pt. take deep breath, if inflammed gallbladder taps fingertips, + Murphy Sign Spleen not normally palpable, if so, enlargement present, be gentle to avoid rupture Use duckbill technique to palpate kidneys US used to visualize kidneys, renal tumors, etc. MRI/CT also helpful Prominent lateral pulsation of aorta suggests aneurysmnormally ant direction Full bladder percussed dull Absence of ABD reflexes w/ obesity or pyramidal tract lesion; stroke upper ABD w/ hammeraway from umbilicus in upper/lower ABD Advanced Assessment of the GI System Additional Procedures For shifting dullness, have pt. lie on one side and percussassess tympany to dullness, w/o ascites, borders consistent when pt. switches sides, in ascites, dullness shifts to dependent side Fluid wave not conclusive---have assistant put hand in middle of ABD, place your hand to the L/R of the assistants hand, feel for fluid in your stationary hand Pain Rebound Tenderness: Quickly (but lightly) strike ABD with fingertips, if pain elicited when removing fingers, + Blumberg Sign; if elicited over McBurneys Point, + McBurneys Sign Ilipsoas Muscle Test: Assesses for appendicitishave pt. lie on R side, hyperextend leg (move backward)pain suggests irritation Obtruator Muscle Test: Assesses for ruptured appendix/ pelvic abscess; pain in hypogastric region when examiner rotates R leg laterally and medially when pt. raises knee to hip ( hold above knee, rotate at ankle) Ballottement: Push fingertips in at 90-degree angle, if mass moveable, it will float up and touch fingertips Differential Dx of the GI System: Signs Differential Dx of the GI System: Acute Pain Differential Dx of the GI System: Acute Pain Differential Dx of the GI System: Chronic Pain Advanced Assessment of the GI System Infants and Children: Examine ABD at the start of exam; conduct on parents lap; ABD in an infant should be round and dome shaped Note localized fullness ABD protrusion results form mass, feces, or organomegaly; scaphoid indicates ABD contents displaced into thorax Distended veins may indicate obstruction; spider nevi could be hepatic Dz; umbilicus = AVA Inspect umbilical stump for erythema,warmth, DC, odor, s/s of infection; umbilical hernia common in infantsspontaneous heals by 1-2 yrs For persistent V, view ABD w/ tangential lighting; peristalsis could indicate obstruction BS + 1-2 hours s/p delivery Differentiate renal bruits for stenosis (high frequency, soft pitch) vs AV fistula (continous) As w/ adults, dullness heard w/ masses/solids Spleen usually palpable 1-2 cm below L costal margin-- ! spleen size w/ dyscrasias/septicemia Liver edge usually palpable 1-3 cm below R costal margin on inspiration; hepatomegaly seen when edge > 3 cm below R costal margin; assess for infection, cardiac failure, or hepatic Dz Use transillumination to differentiate between cystic and solid masses; if malignancy is suspected, minimize palpation due to seeding Sausage-shaped mass in LLQ/sigmoid = feces; midline suprapubic mass = Hirchsprung Dz; sausage-shaped mass in R/LUQ = intussusception; almond-shaped mass in RUQ palpated immediately after V = pyloric stenosis Advanced Assessment of the GI System R/O distended ABD for urethral obstruction vs CNS deficit If ABD remains rigid after both inspiration and exhalation, suspect peritoneal irritation Protruding ABD common until age 5, then concave; resp are ABD until age 6-7 (> this could be pulm problems); diastisis recti hernia resolves by 6 Distract ticklish child w/ toy or cup his/her hand Observe for changes in facial expression, pupillary constriction if pain elicited Pregnancy: BS typically !; striae and linea nigra normal; N/V common in 1st trimester; C common in later preg Gestational Age: Naegele s Rule: Add 7 days to LMP and subtract 3 months Normal preg duration is 40 weeks Record fundal ht: w/ empty bladder, start at symphisis pubs ( superior fundus; most accurate between 20-30 weeks (height in cms = weeks gestation); compare measurements to charts; before this, divide cms by 3.5 for months gestation (McDonalds Rule) < = intrauterine retardation; > 2cm needs further evaluation Count fetal heart tones and assess PMI; place women in L lateral position, measure time length for 10 fetal kicks to occur (normal 10 x/ 1-12h) Assess fetal position using Leopold Maneuvers Advanced Assessment of the GI System Leopold Maneuvers Advanced Assessment of the GI System Place hand on ABD during contraction, assess contractions as: Mild: slightly tense fundus, easy to indent w/ fingers Moderate: firm fundus, difficult to indent w/ fingers Strong: rigid, hard, boardlike fundus, does not indent w/ fingers Older Adults: Older ABD wall thinner and less firm ABD contour often round due to loss of muscle tone Palpable aortic aneurysm more obvious Liver span tends to ! > age 50 Constipation more likely; ! tympany due to c/o gad and bloatedness; fecal impaction possible Vomiting, distension, D/C, can signal obstruction, which is more common r/t hypokalemia, MI, infections Gastrointestinal CA also !, symptoms are site-dependent but include dysphagia, N/V/A, hemaemesis, changes in stool frequency or characteristics (size, consistency, color) Advanced Assessment of the GI System Basic Laboratory Analysis: BMP: Glucose, Ca+, Na+, K+, CO2, Cl-, BUN, creatinine CMP: All BMP plus: Albumin, proteins; LFTs: ALP, ALT, AST, bilirubin LFT: ALP, AST, bilirubin Pancreatic Enzymes: Amylase, Lipase (more specific to pancreatic function) Pregnancy Tests/ HcG quant UA: Assess for blood, WBC, > 100K colonies bacteria; leukocyte esterase, ketones; routine dipstick not highly accurate but good for screening Hemocult/ Gastrocult studies: Occult blood Stool for O/P, WBCs, C&S Hepatitis Panel: Assess for prior immunization record Abnormal GI Presentations Acute Diarrhea (D): Acute onset w/o other symptoms results from infection w/ typical virus; cryptosporidium common with contaminated water and immunosuppression; if accompanied by ABD pain, N/V, feverassess for other etilology (stool studies, BMP/CMP; imaging studies including endoscopy; routine ABD X-Ray) GERD: Acid reflux back into the esophagus; burning moves up through chest (BMP/CMP, imaging studies, barium swallow analysis, gastroscopy) IBS: ABD pain, bloating, constipation, diarrhea; mucus present in stoolalternating D w/ C (BMP/CMP, endoscopy; routine ABD X-Ray) Hiatal Hernia w/ Esophagitis: Diaphragm pushes esophagus back into stomach; caused by preg, obesity, ascites, tight-fitting clothes; epigastric pain w/ pyrosis, worse w/ lying down; V, complete dysphagia, pain w/ incarceration (BMP/CMP; gastroscopy, imaging studies; routine ABD X-Ray) PUD: Circumscribed hole in duodenal mucosa c/o localized epigastric pain, pyrosis, hematemesis, melena, dizziness; typically infected w/ H. pylori; GI bleed often associated w/ perforationassess for s/s of acute ABD (CT Scan, MRI, gastroscopy/endoscopy; BMP/CMP, CBC w/o differential; Gastric C/S for H. pylori) Chron Dz: Inflamation along GI tract which produces ulcerations, fibrosis, malabsorption; cobbletone appearance to intestine (endoscopy); diarrhea common; arthritis, iritis, and erythema nodosum common systemic effects Abnormal GI Presentations Manifestations of Chrons Dz Erythema nodosum Perianal Tags Differential Dx: Chron vs UC Abnormal GI Presentations UC: frequent, watery/bloody diarrhea 20-30 stools/day; predisposes pt. to CA Stomach CA: Usually in the lower end of the stomach; METS very common; symptoms include anorexia, feeling of fullness, wt. loss, dysphagia, persistent epigastric pain; palpable mass in later stages; death usually within 6 weeks of Dx (CEA, Gastroscopy) Diverticulosis: inflammation of existing diverticulaLLQ pain, A/N/V, constipationpain localized at site of tenderness (BMP/CMP; endoscopy, CT, MRI) Colon CA: Usually in the rectum, sigmoid, and lower descending colon; occult blood in stool (hemocultneed imaging studies including endoscopy) Hepatitis: A, B, C, D, and E infections, ETOH, or Rx; jaundice, hepatomegaly, anorexia, ABD Pain, clay-colored stool, tea-colored urine (CT Scan, MRI, CMP/LFT, Ammonia Levels) Cirrhosis: Hepatomegaly with a large, firm, nontender boarder on palpationas scarring progreses, mass become less palpable; symptoms include ascites, jaundice, prominent ABD vasculature, spider angiomas, dark urine, light stools, splenomegaly (US of ascitic fluid/ CT/ MRI/ CMP/LFT/Ammonia Levels) Liver CA: hepatomegaly w/ irregular border on palpation; nodules may be palpable; symptoms include ascites, jaundice, anorexia, fatigue, dark urine, and light-colored stool (US/CT/MRI, CMP/LFT; Ammonia Levels, malignant hepatocytes on Bx) Abnormal GI Presentations Choleleithiasis: Stone formation in gallbladder; if symptomatic, include indigestion, colic, mild transient jaundice (US/MRI/CT Scan w/ Contrast provides great visualization; as does HIDA scan if suspecting common bile duct obstruction; CMP/LFT) Gallbladder CA: ABD pain, jaundice, wt. loss; possible palpable mass in RUQ (CT, HIDA, CMP/LFT) Cholycystitis: Typically assoc w/ formation of lith; 10% not from stones; pain in RUQ w. radiation to midtorso to R scapular area; chronic seen w/ fat intolerance, flatulence, N/A, nonspecific pain and tenderness in R hypochondriac region (CT, HIDA, CMP/LFT) Chronic Pancreatitis: constatnt, intermittent, urelenting ABD pain, epigastric tenderness, wt. loss, steatorrhea, glucose intolerance (CT/MRI/US; Amylase/Lipase, CMP) Pancreatic CA: Malignant degeneration w/ ABD pain radiating from epigastrium to upper qdts or back, wt. loss, A, jaundice (CT/MRI/US; Amylase/Lipase, CMP) Abnormal GI Presentations Splenic LAC: Blunt or penetrating trauma; pain in LUQ w/ radiation to L shoulder (+ Kehr sign), Hypovolemia, and peritoneal irritation (CT Scan, MRI, CBC) Glomerulonephritis: N, malagias, arthralgias; hematuria and possible pulmonary infiltrates (Renal US, BUN, Creatinine, BMP/CMP) Hydronephrosis: obstruction in ureter backflows urine to kidneys; typically secondary to infection w/ hematuria, pyuria, and fever (U/A w/ C&S, Renal US, cystoscopy, BUN, creatinine, BMP/CMP) Pyelonephritis: Infection of kidney characterized by flank pain, bacteriuria, pyuria, nocturia, and frequency; CVA tenderness (U/A w/ C&S, Renal US, BUN, creatintine, BMP/CMP) Renal Abscess: Localized infection within the renal cortex; chills, fever, and aching flanks; CVA tenderness Renal Calculi: stone formation in kidney pelvis; composed of calcium salts, struvite, or uric acid; fever, hematuria, flank pain to groin to genitals; (U/A w/ C&S and urinary strainer, Renal US, BUN, creatintine, BMP/CMP) ARF: Sudden, severe impairment of renal function; prerenal, renal, postrenal causes; urine output normal, dec. or absent (Renal US, BUN, creatintine, creatinine clearance study, BMP/CMP) CRF: gradual in onset; typically uremia results; oliguria, anuria, signs of fluid overload (Renal US, BUN, creatintine, creatinine clearance study, BMP/CMP) Renal Artery Emboli: small emboli occlude renal artery, resulting in ARF/CRF; silent or full-blown flank pain and tenderness, hematuria, HTN, fever, and decreased renal function (Renal US, BUN, creatintine, creatinine clearance study, BMP/CMP) Diagnostic Testing: UA (Healthwise, 2006) Urinary Analysis: Color. Many factors affect urine color, including fluid balance, diet, medications, and disease. The intensity of the color generally indicates the concentration of the urine; pale or colorless urine indicates that it is dilute, and deep yellow urine indicates that it is concentrated. Vitamin B supplements can turn urine bright yellow. Reddish brown urine may be caused by certain medications; by blackberries, beets, or rhubarb in the diet; or by the presence of blood in the urine. Clarity. Urine is normally clear. This test determines the cloudiness of urine, also called opacity or turbidity. Bacteria, blood, sperm, crystals, or mucus can make urine appear cloudy. Odor. Urine usually does not smell very strong, but has a slightly "nutty" (aromatic) odor. Some diseases can cause a change in the normal odor of urine. For example, an infection with E. coli bacteria can cause a foul odor, while diabetes or starvation can cause a sweet, fruity odor. Specific gravity. This measures the amount of substances dissolved in the urine. It also indicates how well the kidneys are able to adjust the amount of water in urine. The higher the specific gravity, the more solid material is dissolved in the urine. When you drink a lot of liquid, your kidneys should produce greater-than-normal amounts of dilute urine (low specific gravity). When you drink very little liquid, your kidneys should make only small amounts of concentrated urine (high specific gravity). pH. The pH is a measure of how acidic or alkaline (basic) the urine is. A urine pH of 4 is strongly acidic, 7 is neutral (neither acidic nor alkaline), and 9 is strongly alkaline. Sometimes the pH of urine may be adjusted by certain types of treatment. For example, efforts may be made to keep urine either acidic or alkaline to prevent formation of certain types of kidney stones. Protein. Protein is normally not detected in the urine. Sometimes a small amount of protein is released into the urine when a person stands up (this condition is called postural proteinuria). Fever, strenuous exercise, normal pregnancy, and some diseases, especially kidney disease, may also cause protein in the urine. Diagnostic Testing: UA (Healthwise, 2006) Glucose. Glucose is the type of sugar usually found in blood. Normally there is very little or no glucose in urine. However, when the blood sugar level is very high, as in uncontrolled diabetes, it spills over into the urine. Glucose can also be present in urine when the kidneys are damaged or diseased. Nitrites. Bacteria that cause a urinary tract infection (UTI) produce an enzyme that converts urinary nitrates to nitrites. The presence of nitrites in urine indicates a UTI. Leukocyte esterase (WBC esterase). Leukocyte esterase detects leukocytes (white blood cells [WBCs]) in the urine. The presence of WBCs in the urine may indicate a urinary tract infection. Ketones. When fat is broken down for energy, the body produces by-products called ketones (or ketone bodies) and releases them into the urine. Large amounts of ketones in the urine may signal a dangerous condition known as diabetic ketoacidosis. A diet low in sugars and starches (carbohydrates), starvation, or prolonged vomiting may also cause ketones in the urine. Microscopic analysis. In this test, urine is spun in a centrifuge so the solid materials (sediment) settle out. The sediment is spread on a slide and examined under a microscope. Types of materials that may be found include: Red or white blood cells. Normally blood cells are not found in urine. Inflammation, disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine. Strenuous exercise (such as running a marathon) can also cause blood in urine. White blood cells are often a sign of infection, cancer, or kidney disease. Casts. 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Abnormal GI Presentations Infants: Intussusception: One segment of intestine falls into another, causing obstruction; common in infants between 3-12 months; severe ABD pain, distension, V, passage of 1st of normal brown stool, then blood and mucus; sausage-shaped mass palpated in R/LUQ, LLQ empty (+ Dance sign) (CT Scan, MRI, endoscopy) Pyloric stenosis: hypertrophy if circular muscle of pylorus leads to obstruction of sphincter; regurgitation w/ possible projectile vomiting, feeding eagerly (even after vomiting); failure to gain wt., signs of dehydration; palpable mass in RUQ > s/p vomit) Meconium Ileus: lower intestinal obstruction caused by thickened and hardened meconiumunable to pass stool in 1st 24 hours of life; 1st manifestation of CF Biliary Atresia: Congenital absence or obstruction of biliary system; symptoms mimic intestinal obstruction or diverticulitis; dark red bleeding w/ little ABD pain Necrotizing Enterocolitis: seen w/ prematurity and immaturity of the GU tract; ABD distention, blood in stool, resp. distress, often fatal accompanied w/ perforation/septicemia Abnormal GI Presentations Children: Neuroblastoma: Discussed w/ neuro; mass in adrenal medulla; firm, fixed, non-tender nodular ABD mass; symptoms include malaise, A, wt. loss, protrusion of eyes Wilms Tumor: Nephroblastoma firm, nontender mass deep within flank; slightly movable; sometimes bilat; painless enlargement of ABD w/ low-grade fever, HTN Hirschsprung Dz: Absence of parasympathetic cells in colon, causes accumulation of feces and obstruction; failure to thrive, C, ABD distension, V/D Hemolytic Uremic Syndrome: D and URI most common precipitating factors; ! urinary output, fever, irritability w/ Hx of bloody D usually caused by E. coli Abnormal GI Presentations Pregnant Women: Hydramnios: ! amt of amniotic fluid; > than 95th percentile; 2-15L! 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