Gastrointestinal Clinical Assessment and Diagnostic Procedures

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Chapter 29

Gastrointestinal Clinical Assessment and Diagnostic Procedures

Kathleen M. Stacy

Assessment of the critically ill patient with gastrointestinal (GI) dysfunction includes a review of the patient’s history, a thorough physical examination, and analysis of the patient’s laboratory data. Numerous invasive and noninvasive diagnostic procedures may also be performed to identify the disorder.

History

Taking a thorough and accurate history is extremely important to the assessment process. The patient’s history provides the foundation and direction for the rest of the assessment. The overall goal of the patient interview is to expose key clinical manifestations that will facilitate the identification of the underlying cause of the illness. This information can then assist in the development of an appropriate management plan.

The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to a few questions about the patient’s chief complaint and the precipitating events. For a patient in no obvious distress, the history should focus on current symptoms, the patient’s medical history, and the family’s history. Specific items regarding each of these areas are outlined in Box 29-1, Data Collection.3,4

Box 29-1   Data Collection

Gastrointestinal History

Patient Lifestyle

• Usual height and weight

• Dietary habits

• Nutrient intake

• Bowel elimination

• Alcohol intake (e.g., frequency, usual amounts)

• Exercise patterns

Physical Examination

The physical examination helps establish baseline data about the physical dimensions of the patient’s situation.3 The abdomen is divided into four quadrants (left upper, right upper, left lower, and right lower), with the umbilicus as the middle point, to specify the location of examination findings (Fig. 29-1 and Box 29-2). The assessment should proceed when the patient is as comfortable as possible and in the supine position; however, the position may need readjustment if it elicits pain. To prevent stimulation of GI activity, the order for the assessment should be changed to inspection, auscultation, percussion, and palpation.4

Inspection

Inspection should be performed in a warm, well-lit environment, and the patient should be in a comfortable position, with the abdomen exposed. Although assessment of the GI system classically begins with inspection of the abdomen, the patient’s oral cavity also must be inspected to determine any unusual findings. Abnormal findings of the mouth include temporomandibular joint tenderness, inflammation of gums, missing teeth, dental caries, ill-fitting dentures, and mouth odor.

Observe the skin for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and venous pattern. Pigmentation may vary considerably and still be within normal limits because of race and ethnic background, although the abdomen usually is of a lighter color than other exposed areas of the skin. Abnormal findings include jaundice, skin lesions, and a tense and glistening appearance of the skin. Old striae (stretch marks) usually are silver, whereas pinkish purple striae may indicate Cushing syndrome.4 A bluish discoloration of the umbilicus (Cullen sign) and of the flank (Grey-Turner sign) indicates retroperitoneal bleeding.1

Observe the abdomen for contour, noting whether it is flat, slightly concave, or slightly round; observe for symmetry and for movement. Marked distention is an abnormal finding. In particular, ascites may cause generalized distention and bulging flanks. Asymmetric distention may indicate organ enlargement or a mass. Peristaltic waves should not be visible except in very thin patients. In the case of intestinal obstruction, hyperactive peristaltic waves may be observed. Pulsation in the epigastric area is often a normal finding, but increased pulsation may indicate an aortic aneurysm. Symmetric movement of the abdomen with respirations is usually seen in men.4,5

Auscultation

Auscultation of the abdomen provides clinical data regarding the status of the bowel’s motility. Initially, listen with the diaphragm of the stethoscope below and to the right of the umbilicus. The examination proceeds methodically through all four quadrants, lifting and then replacing the diaphragm of the stethoscope lightly against the abdomen (see Fig. 29-1). Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Colonic sounds are low pitched and have a rumbling quality. A venous hum may be audible sometimes.6 Table 29-1 provides a list of abnormal abdominal sounds.

TABLE 29-1

ABNORMAL ABDOMINAL SOUNDS

SOUND CAUSE
Hyperactive bowel sounds (borborygmi), loud and prolonged Hunger, gastroenteritis, or early intestinal obstruction
High-pitched, tinkling sounds Intestinal air and fluid under pressure; characteristic of early intestinal obstruction
Decreased (hypoactive) bowel sounds Possible peritonitis or ileus
Infrequent and abnormally faint sounds  
Absence of bowel sounds (confirmed only after auscultation of all four quadrants and continuous auscultation for 5 minutes) Temporary loss of intestinal motility, as occurs with complete ileus
Friction rubs Pathologic conditions such as tumors or infection that cause inflammation of organ’s peritoneal covering
High-pitched sounds heard over liver and spleen (RUQ and LUQ), synchronous with respiration  
Bruits Abnormality of blood flow (requires additional evaluation to determine specific disorder)
Audible swishing sounds that may be heard over aortic, iliac, renal, and femoral arteries  
Venous hum Increased collateral circulation between portal and systemic venous systems
Low-pitched, continuous sound  

LUQ, Left upper quadrant; RUQ, right upper quadrant.

From Doughty DB, Jackson DB. Gastrointestinal Disorders. St. Louis: Mosby; 1993.

Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush). Absent bowel sounds may result from inflammation, ileus, electrolyte disturbances, and ischemia. Bowels sounds may be increased with diarrhea and early intestinal obstruction.6

The abdomen should be auscultated for the presence of bruits, using the bell of the stethoscope (Fig. 29-2). Bruits are created by turbulent flow over a partially obstructed artery and are always considered an abnormal finding. The aorta, the right and left renal arteries, and the iliac arteries should be auscultated.5,6

Percussion

Percussion is used to elicit information about deep organs such as the liver, spleen, and pancreas (Fig. 29-3). Because the abdomen is a sensitive area, muscle tension may interfere with this part of the assessment. Percussion often helps relax tense muscles, and it is performed before palpation. Percussion in the absence of disease helps delineate the position and size of the liver and spleen, and it assists in the detection of fluid, gaseous distention, and masses in the abdomen.5

Percussion should proceed systematically and lightly in all four quadrants. Normal findings include tympany over the empty stomach, tympany or hyper-resonance over the intestine, and dullness over the liver and spleen. Abnormal areas of dullness may indicate an underlying mass. Solid masses, enlarged organs, and a distended bladder also produce areas of dullness. Dullness over both flanks may indicate ascites and necessitates further assessment.6

Palpation

Palpation is the assessment technique most useful in detecting abdominal pathologic conditions. Light and deep palpation of each organ and quadrant should be completed. Light palpation, which has a palpation depth of approximately 1 cm, assesses to the depth of the skin and fascia (Fig. 29-4A). Deep palpation assesses the rectus abdominis muscle and is performed bimanually to a depth of 4 to 5 cm (see Fig. 29-4B). Deep palpation is most helpful in detecting abdominal masses. Areas in which the patient complains of tenderness should be palpated last.6

Normal findings include no areas of tenderness or pain, no masses, and no hardened areas. Persistent involuntary guarding may indicate peritoneal inflammation, particularly if it continues even after relaxation techniques are used. Rebound tenderness, in which pain increases with quick release of a palpated area, indicates an inflamed peritoneum.4

Assessment Findings for Common Disorders

Table 29-2 presents a variety of common GI disorders and their associated assessment findings.

TABLE 29-2

ASSESSMENT FINDINGS OF COMMON GASTROINTESTINAL DISORDERS

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CONDITION HISTORY SYMPTOMS SIGNS
Right Lower Quadrant (RLQ) of the Abdomen
Appendicitis Children (except infants) and young adults Anorexia Signs may be absent early
    Nausea Vomiting
    Early vague epigastric, periumbilical, or generalized pain after 12-24 hours; RLQ at McBurney point Localized RLQ guarding and tenderness after 12-24 hours
    Rovsing sign: pain in RLQ with application of pressure, iliopsoas sign
      Obturator sign
      White blood cell count of 10,000/mm3 or shift to left
      Low-grade fever
      Cutaneous hyperesthesia in RLQ
      Signs highly variable
Perforated duodenal ulcer Prior history Abrupt onset pain in epigastric area or RLQ Tenderness in epigastric area or RLQ
Signs of peritoneal irritation
      Heme-positive stool
      Increased white blood cell count
Cecal volvulus Seen most often in older adults Abrupt severe abdominal pain Distention
      Localized tenderness
      Tympany
Strangulated hernia Any age Severe localized pain If bowel obstructed, distention
  Women: femoral If bowel obstructed, generalized pain  
  Men: inguinal    
Right Upper Quadrant (RUQ) of the Abdomen
Liver hepatitis Any age, often young blood product user Fatigue Hepatic tenderness
Malaise Hepatomegaly
  Drug addict Anorexia