Clinical Examination of the GI tract and abdomen

Andy Simmons 22 march 2013

Aims

• Increase knowledge of abdominal & GI A&P

• Understand basic principles of abdominal & GI examination

• Be able to perform a basic abdominal examination

• Be aware of abnormal findings and what to do when discovered

What we are covering today

• Anatomy of abdomen and GI tract• History taking• Examination• Common signs and symptoms of conditions and abnormalities• Assessing the findings• Ongoing care-options

Abdominal Examination

Abdominal Examination

GI Tract• Oral Cavity• Oesophagus• Stomach-pylorus• Small intestine-5 metres long

• Duodenum-duodenojejunal flexure• Jejunum• Ileum-ileocaecal juction

• Large intestine• Caecum• Colon-ascending/transverse/descending/sigmoid• Rectum• Anal canal

Anatomy-GI tract

PylorusDuojejunal flexure

Ileocaecal junction

GI tract

• Begins at the oral cavity • Tongue/teeth/oropharynx• Saliva

• Saliva production-produced in ancini cells/secreted by salivary glands(exocrine)• 99.5% water• Enzymes begin process of digestion-breaking down fats and starches• Lubricates food for swallowing• Protects oral mucosa

• Swallowing• V, VII, IX, X, XI, XII cranial nerves involved with swallowing• http://www.youtube.com/watch?v=uxHUUgLeNzk&list=PL0F91E3E2F280FFF9

GI tract

• Oesophagus• Transports food between mouth and stomach• Peristalsis(begins when food enters oesophagus)• Cardiac sphincter relaxes• http://www.youtube.com/watch?v=rJS-Kh5wCQU

• Stomach-continuous with oesophagus-beyond the cardiac sphincter• Divided into 3 regions fundus/body/pylorus• Differs as has 3 layers of muscle• 2 litres gastric juice secreted into stomach daily

GI tract

• Small intestine• Duodenum• Jejunum• Ileum• Ileocaecal junction

• Functions• Food breakdown into nutrients• Absorbtion of nutrients

GI tract

• Villus• Small finger like projections in

small intestine-0.5-1.6• Microvillus on surface• Increase surface area of intestine• More prevalent at start of small

intestine• Small intestine joins bowel at

ileocaecal joint

GI tract

• Large intestine• 1.5M length• Digestion completed proximal

portion• B12,thiamine,riboflavin & Vit K

produced by bacteria and stored in the liver• Main function absorbtion of water

and electrolytes • Gastrocolic reflex/mass movement

Common Conditions

• Dysphagia• Carcinoma-Barretts oesophagus• GORD• Oesophageal stricture• Coeliacs disease• Ulcers-• Oesophageal/gastric varisces• Diverticulitis• Chrohns• Gastroenteritis• Ulcerative colitis

Abdominal Cavity

Structures-Organs• Liver• Pancreas• Spleen• kidneys• GI tract

Other structures-• Gall bladder• Peritoneum• Abdominal wall• Aorta• Inferior vena cava• Nerve supply

Abdominal muscles

Peritoneum

• Thin folded sack forming peritoneal cavity• Parietal and visceral layers-

separated by serous fluid• Peritoneum-• Protects intraperitoneal organs• supports the organs • Serves as a conduit for blood,

lymph vessels and nerves

Peritoneum

• Peritonitis-• Sterile until punctured• Infection within viscera • Characterised by rebound

tenderness

Intraperitoneum

• Stomach• First 5cm of duodenum• Jejunum, ileum, Caecum, • Appendix• Transverse colon, sigmoid colon• Rectum• Upper 1/3 Liver• Spleen• Women: Uterus, Fallopian tubes,

ovaries

Retroperitoneum

• Mnemonic• S= Suprarenal glands (aka the adrenal glands)• A=Aorta/IVC• D=Duodenum (second and third segments

[some also include the fourth segment] )• P=Pancreas (tail is intraperitoneal)• U=Ureters• C=Colon (only the ascending and descending

colons, as transverse and sigmoid retain mesocolon

• K=Kidneys• E=Esophagus• R=Rectum

• SAD PUCKER is 112 212111

Omentum

• Greater-large fold of visceral peritoneum• Functions-

• Fat deposition• Immune contribution-milky spots of

macrophage collections• Infection and wound isolation• Greater omentum can often be found

wrapped around areas of infection and trauma

• Lesser-• Forms ligaments which support

hepatic vessels

Liver

• 4 main lobes-Left/Right/caudate/quadrate• Largest internal organ• Anatomically-R upper quadrant

beneath diaphragm• Covered by peritoneum

Liver

Liver

Liver

• Paracetamol• Alcohol• Opiates• Barbituates• Drugs-GTN

• Filters blood from GI tract • Detoxifies as blood passes through• Kupfercells• Blood vessels

• Negatve feedback• Glycogen storage• Glycogen-glucose-Glycogenolysis• Glucose –glycogen-glycogenesis

• 500-1000mls bile secreted daily

• Fat metabolism• Deamination of amino acids• Transamination• Synthesis of plasma proteins• Vitamin A,D,E,K iron and copper Storage also B12

Liver

• Conditions• Hepatitis• Cirrhosis• Hepato-megally• Carcinoma• Fatty liver• Clotting factor failure

• Signs• Spider naevi • Jaundice• Enlarged liver• Liver flap• Haemorrhage• Deranged GCS• Coma

Biliary tract & gall bladder

• Hepatocytes synthesise constituents• Blood in sinusoids• Bile salts/pigments/cholesterol

• Gall bladder-• Stores and concentrates bile• Releases stored bile

• Bile-aids digestion of lipids

Biliary tract

• Conditions• Cholecystitis• Gall stones• Cholangitis• Biliary cirrhosis

• Signs• Jaundice• Shoulder tip pain• Abdominal pain

Pancreas

• Endocrine and exocrine• Situated epigastric and Left

hypochondriac regions • Head lies in curve of duodenum

Pancreas

• Exocrine functions-• Lobules(ancini) • Pancreatic juice (enzymes)• Digests carbs/proteins/fats

• Endocrine functions-• Production of hormones in Islets of Langerhans• α-cells-Glucagon• β-cells-Insulin• Delta cells-Somastatin• Gamma cells-Pancreatic polypeptide

Pancreas

• Conditions• Exocrine-

• EPI-CF• Endocrine

• Diabetes mellitis T1 & T2• Pancreatitis • Carcinoma

• Signs• Pancreatitis

• Raised amylase• Diabetes

• Raised blood sugar• Wt loss• Neuropathy• Nephropathy• Retinopathy• Slow healing process

Spleen

• Non vital organ• Situated-Left upper quadrant• Acts as a blood filter• Recycles red blood cells• Holds store of red blood• Part of lymphatic system

Spleen

• Splenomegally- Ca• Asplenia• Ruptured spleen-blunt trauma

Kidneys

• 2 kidneys• Retroperitoneal • Paravertebral gutter• L situated T12-L3 • R slightly lower (liver) • Blood supply renal arteries

Kidneys

• Functions-•Whole body homeostasis•Acid base regulation-• HCO3

•BP regulation-• Renin angiotensin pathway

• Filters toxins•Urine production

Kidneys-

Kidneys-renin-angiotensin system

Kidneys

• Conditions• Renal cell Ca• Renal Failure

• CKD• AKI-

• Pre• Renal• Post

• Hydronephprosis• Renal calculi

• Signs• Oliguria & anuria• Deranged renal function• Deranged electrolytes

• ECG changes• Severe lower back pain

Blood Vessels

• Abdominal aorta• Continuous with thoracic aorta• T12 and L1 to L4• Ends at 2 common iliac arteries

• Conditions• AAA

• Inferior vena cava• Formed by union of 2 common

iliac veins• Drains blood from lower limbs

and abdomen• Travels alongside aorta

• Conditions• Obstructed IVC

Blood vessels

Other structures

• Gynae structures• Male structures• Lymphatic system• Adrenal glands• Bladder, ureters etc• Unborn foetus

Abdominal HistoryKey points

• HPC• Curr• FHx• SHx