CHAPTER 5 – GASTROINTESTINAL SYSTEM First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised October 2011. Table of Contents ASSESSMENT OF THE GASTROINTESTINAL SYSTEM ......................................5–1 EXAMINATION OF THE ABDOMEN ........................................................................5–2 COMMON PROBLEMS OF THE GASTROINTESTINAL SYSTEM .........................5–4 Anal Fissure .......................................................................................................5–4 Constipation .......................................................................................................5–5 Dehydration (Hypovolemia) ...............................................................................5–8 Diarrhea ...........................................................................................................5–11 Diverticular Disease .........................................................................................5–15 Diverticulitis ......................................................................................................5–15 Diverticulosis ....................................................................................................5–16 Dyspepsia ........................................................................................................5–17 Gallbladder Disease .........................................................................................5–18 Biliary Colic ......................................................................................................5–21 Cholecystitis or Cholangitis ..............................................................................5–21 Gastroesophageal Reflux Disease (GERD) .....................................................5–22 Hemorrhoids ....................................................................................................5–24 Hernia ..............................................................................................................5–26 Irritable Bowel Syndrome .................................................................................5–28 Peptic Ulcer Disease (PUD) .............................................................................5–30 EMERGENCIES OF THE GASTROINTESTINAL SYSTEM ..................................5–31 Abdominal Pain (Acute) ...................................................................................5–31 Appendicitis ......................................................................................................5–34 Gastrointestinal Bleeding (Upper and Lower) ..................................................5–36 Obstruction of the Small or Large Bowel .........................................................5–38 Pancreatitis (Acute) ..........................................................................................5–40 SOURCES ..............................................................................................................5–42 Clinical Practice Guidelines for Nurses in Primary Care 2011 Gastrointestinal System 5–1 ASSESSMENT OF THE GASTROINTESTINAL SYSTEM The following characteristics of each symptom Jaundice should be elicited and explored: – History of acute hepatitis (Viral – A,B,C, – Onset (sudden or gradual) Epstein-Barr, alcohol/drug induced) – Chronology – History of chronic liver diseases – Current situation (improving or deteriorating) – Scleral icterus – Location – Yellow skin tones – Radiation – Tea-coloured urine – Quality – Clay-coloured bowel movements – Timing (frequency, duration, pattern) – Itchy skin – Severity Dysphagia – Precipitating and aggravating factors – Relieving factors – Solids or liquids – Associated symptoms – Site where food gets stuck – Effects on daily activities – Food is regurgitated – Previous diagnosis of similar episodes – Food/medication intake history – Previous treatments – Sensation that food is stuck, but improves – Efficacy of previous treatments with eating CARDINAL SYMPTOMS Other Associated Symptoms In addition to the general characteristics outlined – Fever above, additional characteristics of specific symptoms – Malaise should be elicited, as follows. – Headache – Dry skin Abdominal Pain – Dehydration Ask about all of the characteristics (see “Assessment – Dry mouth of the Gastrointestinal System”). – Diet recall, appetite and foods avoided (including reasons for avoidance) Nausea and Vomiting – Meal pattern (for example, small, frequent meals) – Frequency, amount – Anorexia – Presence of bile – Recent weight loss or gain that is not deliberate – Presence of blood and its colour (for example, bright red, dark, colour of coffee grounds) MEDICAL HISTORY Gastrointestinal: Bowel Habits – Esophageal disease (gastroesophageal reflux – Usual and changes in the frequency, colour, disease [GERD], Barrett’s esophagus, toxic injury) consistency of stool – Gastric/duodenal disease (gastric ulcers, diabetic – Changes in the diameter of stool gastroparesis, hiatus hernia, peptic ulcer disease) – Presence of blood or melena – Gallbladder disease (biliary colic, cholelithiasis, – Pain before, during or after defecation choledocholithiasis, cholecystitis) – Sense of incomplete emptying after bowel – Liver disease (hepatitis, chronic diseases, cirrhosis) movement – Pancreatic disease (pancreatitis) – Tenesmus – Small/large bowel disease (inflammatory – Use of laxatives bowel disease, ischemic colitis, diverticulosis/ – History of hemorrhoids, anal fissure diverticulitis, polyps, history of bleeding) – Belching, bloating and flatulence – Functional bowel problems (irritable bowel syndrome [IBS], constipation, previous obstruction) Clinical Practice Guidelines for Nurses in Primary Care 2011 5–2 Gastrointestinal System – Rectal/anal disease (anal fissure, proctitis) – Cardiac disease – Presence of hernia, masses – Renal disease – Blood transfusion – Abdominal neoplasm PERSONAL AND SOCIAL HISTORY (SPECIFIC TO GASTROINTESTINAL SYSTEM) – Abdominal surgery – Past and current use of medications, supplements, – Alcohol use herbs (for example, nonsteroidal anti-inflammatories, – Smoking estrogen, progesterone, calcium channel blockers, – Caffeine intake anticholinergics, antacids, antibiotics, thiazide – Use of street drugs, including injection drugs diuretics, steroids, digoxin, azathioprine) – Use of anabolic steroids Nongastrointestinal considerations (may cause – Travel to area where infectious gastrointestinal gastrointestinal illness/symptoms): conditions are endemic – Body piercing or tattoos – Cardiovascular disease (myocardial infarction, congestive heart failure, vasculitis, hypertension) – Stress at work, home or school – Renal disease (polycystic kidneys) – Dietary intake of nitrates (for example, smoked foods) – Gynecologic conditions (pregnancy, endometriosis, ovarian cysts) – Diet (including wild game) – Obesity FAMILY HISTORY (SPECIFIC TO – Intake of untreated water GASTROINTESTINAL SYSTEM) – Sanitation problems at home or in the community – Alcoholism – Sexual practices – Any history related to the gastrointestinal system (see “Medical History”) OCCUPATIONAL OR SCHOOL ENVIRONMENT – Household contact with gastroenteritis, food – Health care occupation poisoning – Institutional environment – workers or residents – Metabolic disease (for example, diabetes mellitus, (for example, nursing home) porphyria) – Environmental exposure – Chemical exposure EXAMINATION OF THE ABDOMEN – Apparent state of health ABDOMINAL INSPECTION – Appearance of comfort or distress – Abdominal contour, symmetry, scars, dilatation – Preferred position of comfort (supine, sitting of veins forward, lying on side) – Movement of abdominal wall with respiration – Colour (for example, flushed, pale, jaundiced) – Visible masses, hernias, pulsations, peristalsis – Nutritional status (obese or emaciated) – State of hydration (skin turgor) AUSCULTATION – Match between appearance and stated age Auscultation should be performed before percussion and palpation so as not to alter bowel sounds. VITAL SIGNS – Presence, character and frequency of bowel sounds – Temperature and pulse – Presence of bruits (renal, iliac or abdominal aortic) – Respiratory rate – Blood pressure 2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–3 PERCUSSION CARDIOVASCULAR AND PULMONARY EXAMINATION – Percuss from resonant to dull areas – Liver: define upper and lower borders, measure A cardiovascular and pulmonary exam should also span (normal: 6–12 cm in the mid-clavicular line) be performed. – Spleen: confirm presence of normal resonance – Heart sounds over lowest rib interspace in anterior axillary line – Lungs (crackles, bronchial breath sounds in – Bladder: identify distention and fullness lower lobes) – Identify other areas of dullness, increased – Peripheral pulses (may be altered or asymmetric resonance or tenderness with aortic aneurysm) – Assess for ballotment if suspect ascites – In shock, vital signs and capillary refill may be altered LIGHT PALPATION – Abdominal pain (may be referred from the lungs – Tenderness, muscle guarding, rigidity in pneumonia, heart in myocardial infarction) – Superficial organs or masses Considerations for the Elderly DEEP PALPATION – Classic symptom patterns for disease are not – Tender areas, rebound tenderness reliable with older adults due to decreased pain perception, comorbid conditions and reduced organ – Liver: size, tenderness, whether edge is smooth function due to the aging