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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.

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  • 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


  • 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.

Right Upper Quadrant (RUQ)

  • diaphragm
  • liver
  • gallbladder
  • kidney
  • Hepatic flexure -large colon
  • small intestine

Left Upper Quadrant (LUQ)

  • spleen
  • kidney
  • pancreas
  • stomach
  • Splenic Flexure –large colon
  • small intestine

Right Lower Quadrant (RLQ)

  • appendix
  • large ascending colon
  • ovary
  • uterus
  • bladder
  • small intestine

Left Lower Quadrant (LLQ)

  • descending colon
  • ovary
  • uterus
  • bladder
  • small intestine

Anatomy - 4 Quadrant System


Right Hypochondriac


Left Hypochondriac

Right Lumbar


Left Lumbar

Right Iliac



Left Iliac

Anatomy - 9 Quadrant System

See graphic on next slide


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


  • 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 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

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


  • 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 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

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


  • 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 painO-P-Q-R-S-T


  • 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


  • 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
Assessment techniques
  • History
  • Demographic data
  • Family history and genetic risk
  • Personal history
  • Diet history
  • -anorexia
  • -dyspepsia
physical assessment
Physical assessment
  • Mouth and pharynx
  • Abdomen and extremities
  • -inspection
  • -auscultation
  • -percussion
  • -palpation
laboratory tests
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
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
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
  • 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
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


percutaneous transhepatic cholangiography continued
Percutaneous Transhepatic Cholangiography(Continued)
  • Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen
other tests
Other Tests
  • Computed tomography
  • Endoscopy: direct visualization of the gastrointestinal tract by means of a flexible fiberoptic endoscope
  • 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
endoscopic retrograde cholangiopancreatography
Endoscopic RetrogradeCholangiopancreatography
  • 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


endoscopic retrograde cholangiopancreatography continued
Endoscopic Retrograde Cholangiopancreatography(Continued)
  • Return of gag reflex checked
  • Assessment for pain
  • Colicky abdominal pain
small bowel capsule enteroscopy
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
  • 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
  • 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.


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
gastric analysis
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 tests1
Other Tests
  • Ultrasonography
  • Endoscopic ultrasonography
  • Liver-spleen scan