GI Assessment And Diagnostics Flashcards
Assessment
- General Nutritional Status Interview
- Health History
- Physical Assessment
- Should begin with questions regarding client’s dietary habits
- Questions should elicit information about average daily intake of food and liquids, types and quantities consumed, where and when food is eaten, and any conditions or diseases that affect intake of absorption
Questions: - Food intake history, time, food/ drink, amount, method of preparation
. General Nutritional Status Interview
- Elicit a description of present illness and chief complaint or symptoms through COLDSPA (Characteristics, Onset, Location, Duration, Precipitating Factors, and Alleviating Factors)
- Family history, prenatal history, medications, use of tobacco and alcohol
- Complete nutritional history including 24-hour dietary intake
Health History
- Elicit description of present illness and chief complaint
o Onset, course, duration, location, and precipitating and
alleviating factors
o Cardinal signs and symptoms indicated altered hepatic,
biliary, and pancreatic function include:
▪ Jaundice, pruritus
▪ Changes in urine and stool color
▪ Vague to severe abdominal pain especially after eating
fatty foods
▪ Abdominal tenderness and distention
▪ Easy bruising and bleeding - Alcohol consumption
- Diet high in fat
- Infectious agents (transmitted through nonsterile needle
puncture, unprotected sexual activity, ingestion of potentially
contaminated food, etc.) - Recent blood transfusion
- Medications and herbal remedies
o Some sample drugs with high potential for hepatotoxicity
▪ NSAIDS (ibuprofen, acetaminophen, etc.)
▪ Antiseizure medications (phenytoin, valproic acid)
▪ TB drugs (isoniazid, pyrazinamide)
Health HIstory
On altered Hepato-Biliary and Pancreatic Disorders
- The general physical assessment is IPPA (inspection, palpation,
percussion, auscultation). - But for abdominal physical assessment, have it in this order:
Inspection, auscultation, percussion, palpation
Physical Assessment
Skin, mucosa & sclerae:
* Jaundice (yellow skin and sclera)
* Petechiae or ecchymotic area
* Spider angiomas
* Palmar erythema
Extremities:
* Muscle atrophy
* Edema
* Skin excoriation due to scratching
Abdomen:
* Contour
* Girth
* Pigmentation
* Color
* Scars
* Striae
* Visible masses
* Peristalsis
* Pulsations
Cognitive and neurologic status
Inspection
.Auscultation
- Auscultate bowel sounds before percussion and palpation (5-30
clicks/ min using diaphragm of stethoscope for 5 min) - Normal bowel sounds occur 5-30 times a min or every 5-15
seconds - Auscultate in all abdominal quadrants
- Auscultate for vascular sounds (bruits, hepatic friction rub)
Percussion
- Percuss all 4 quadrants noting tympany and dullness
Palpation
- Palpate deeply over all 4 quadrants for any masses and note
location, size and shape, pulsation - Palpate liver, spleen, kidneys, aorta for enlargement
- Always palpate tender areas last, because if you start there, you
may aggravate the pain and make the patient uncomfortable.
Diagnostic Assessment
NON-INVASIVE
1. GUAIAC TEST
2. HEPATOBILIARY SCAN/ LIVER SCAN
3. RADIONUCLIDE IMAGING/ CHOLESCINTOGRAPHY
4. BARIUM SWALLOW
5. BARIUM ENEMA
INVASIVE
1. COMPLETE BLOOD GLUCOSE (CBG) MONITORING
2. ESOPHAGOGASTRODUODENOSCOPY (EGD)
3. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
4. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
5. LIVER BIOPSY
6. LIVER FUNCTION TESTS
- Looks for hidden (occult/ old) blood in a stool sample
- Detect GI bleeding (GI cancer)
- Increase fiber diet (48-72 hours)
- No red meats, poultry, fish, turnips, horse radish, melons,
salmon, sardines
o Avoid red/ colorful food that may alter stool color for
examination) - Withhold 48 hours: iron, steroids, indomethacin, colchicine,
vitamin C
o These will cause stool discoloration and may cause false
positive results - Three stool specimens (3 successive days)
- Hydrogen peroxide will be placed.
o Positive bleeding: BLUE color
GUAIAC TEST
- Non-invasive nuclear medicine study using radioactive materials
to show size and shape of liver tissue and visualize replacement
of liver tissue with scars, cysts, and tumors - Radioactive agent is injected IV which is taken up by the liver/
hepatocytes and excreted rapidly through the biliary tract - Patient is placed on NPO and NO opioids given 4H before
procedure
HEPATOBILIARY SCAN/ LIVER SCAN
- Procedure is more or less the same with liver scan but this time,
images of the gallbladder and biliary tract are obtained after IV
administration of radioactive agent.
RADIONUCLIDE IMAGING/ CHOLESCINTOGRAPHY
- An examination of the upper GIT under fluoroscopy after the
client drinks a contrast medium: barium sulfate (BaSO4) - To visualize the esophagus, stomach, duodenum, and jejunum
PRE-OP
* NPO PM (post-midnight)
before the day of test
* Withhold opioids 24H
before test
POST-OP
* Laxative
* Encourage oral fluids
* Monitor for passage of
barium (chalky white
stools for 24-72 hours)
BARIUM SWALLOW
- An examination of the lower GIT
- A fluoroscopic and radiographic examination of large intestine is
performed after rectal instillation of BaSO4 - Indicated for detecting bowel obstruction and cause of diarrhea
and constipation - Contraindication
o Patients with color perforation or fistula
PRE-OP
* Low residue diet 1-2 days
* Clear liquid diet and a laxative the evening before test
* NPO PM before the day of test
* Suppository/ cleansing enema on the morning of test
POST-OP
* EOF (early oral feeding)
* Administer mild laxative as
prescribed
* Monitor passage of
barium and notify
physician if bowel does
not occur 2 days after
BARIUM ENEMA
- Convenient way of monitoring blood glucose patterns and can be useful aid in guiding treatment changes in patients with Type 1 and Type 2 diabetes, especially during periods of illness or frequent hypoglycemia
- Let patient fast prior to extraction 2-3 hours prior to getting CBG.
Collect before lunch. - rotate sites
- discard first drop of blood because it is considered as “dirty blood”
COMPLETE BLOOD GLUCOSE (CBG) MONITORING
- An upper GI fibroscopy
- Done with fiberscopes
- After sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters, and duodenum
- Tissue specimens can be obtained for direct visualization of esophagus, stomach, and duodenum
- Esophagus → stomach → duodenum
PRE-OP
* Obtain written consent
* NPO 6-8H or 12H before test
* Sedatives, narcotics, tranquilizers as prescribed
(diazepam, meperidine hydrochloride)
* Atropine sulfate (SO4) to reduce salivation and glucagon as ordered
* Remove dentures or prevent airway obstruction
* Airway patency is monitored during the test
* Apply mouthguard
POST-OP
* Patient is positioned on left side (to allow secretions to flow and avoid asphyxia)
* NPO until gag reflex returns
* Monitor for signs of perforation
* Maintain bedrest for the sedated patient until alert
and advise to avoid driving 12H if sedative was used
* Lozenges, saline, gargle, or oral analgesics can relieve
minor sore throat, after the gag reflex returns
ESOPHAGOGASTRODUODENOSCOPY (EGD)
- Endoscopic visualization of common bile, pancreatic, and
hepatic ducts with a flexible fiber-optic endoscope inserted into
the esophagus, passed through the stomach and into the
duodenum - The common bile duct and the pancreatic duct are cannulated
and contrast medium is injected into the ducts, permitting
visualization and radiographic evaluation.
PRE-OP
* Assess for allergies to iodine,
seafood, or contrast media
* Place patient on NPO 4H before
procedure
* Remove dentures and instruct to
gargle and swallow topical
anesthetic to decrease gag reflex,
as ordered
* Verify informed consent before
sedation
* Establish baseline vital signs and
IV access
* Administer antibiotic prophylaxis,
glucagon and anticholinergics as
ordered
POST-OP
* Monitor and document vital signs
* Monitor complications (esophageal bleeding, GI perforation, pancreatitis, sepsis)
* Monitor for return of gag reflex
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
- A fluoroscopic examination of the intrahepatic and extrahepatic
biliary ducts after injection of contrast medium into the biliary
tree through percutaneous needle injection - Useful for distinguishing jaundice caused by liver disease
(hepatocellular jaundice) from that caused by biliary obstruction,
for investigating the gastrointestinal symptoms of a patient
whose gallbladder has been removed, for locating stones within
the bile ducts, and for diagnosing cancer involving biliary system.
PRE-OP
* Assess allergies to iodine
and seafood
* Place patient on NPO 4H
prior to procedure
* Verify informed consent
before sedation
* Establish baseline vital
signs and ensure
coagulation parameters
and platelet count is
within normal limits
* Establish IV access and
administer prophylactic
antibiotics as ordered
POST-OP
* Monitor and document
vital signs
* Assess puncture site for
bleeding, hematoma, or
bile leakage
* Monitor for signs of
peritonitis and sepsis
* Report present of pain
immediately
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
- Sampling liver tissue by needle aspiration for histologic analysis
- Can establish a diagnosis of specific liver disease
- Physician inserts biopsy needle by way of transthoracic
(intercostal) or transabdominal (subcostal) route
PRE-OP
* Establish baseline hemoglobin level, hematocrit and PLT count
* Make sure PT is within normal limits
* Verify informed consent
* Establish baseline vital signs
* Positioning for liver biopsy: supine/ left lateral with right of upper abdomen exposed and with patient’s right arm extended over left shoulder behind head
* Tell patient that cooperation during the procedure is important
* He/ she is instructed to exhale and hold breath at the end of expiration for at least 10 seconds as the biopsy needle is introduced
POST-OP
* Positioning immediately after biopsy: right lateral/ side lying with small pillow or folded towel placed under costal margin of puncture site (patient is instructed to
remain immobile and maintain position for at least 3h)
* Monitor vital signs and biopsy site for hemorrhage and drainage
* Instruct patient to avoid coughing or straining
* Instruct patient to avoid heavy lifting and strenuous activity for 1 week
LIVER BIOPSY
LIVER FUNCTION TESTS
- Serum Enzymes
- Serum Proteins
- Pigment Studies
- Serum Ammonia
- Blood Coagulation Studies
Serum Enzymes
- Alkaline Phosphatase (ALP)
-13-19 units/ L
-In absence of bone disease,
it is a sensitive measure of
biliary tract obstruction - Lactate Dehydrogenase (LDH)
-100-120 units
-May be increased in liver
damage - Aminotransferase/ Transaminases
-Enzyme which are increased in liver cell damage as damaged
liver cells primarily release these liver enzymes
a. Alanine aminotransferase (ALT)
-5-35 units
* Previously called serum glutamic
pyruvic transaminase (SGPT)
* Levels are increased primarily in liver disorder
b. Aspartate Amine Transferase (AST)
-10-40 units
* Previously called serum glutamicoxaloacetic transaminase (SGOT)
* Not a sensitive index of liver function since levels are also high in damage to heart, skeletal muscle and kidney
c. Gamma Glutamyl Transferase (GGT)
-10-48 IU/L
* Also called G-glutamyl transpeptidase
* Levels are high in alcohol-induced liver damage
* Also a sensitive indicator of biliary cholestasis
Alkaline Phosphatase
(ALP)
13-19 units/ L
Lactate Dehydrogenase
(LDH)
100-120 units
Alanine aminotransferase
(ALT)
5-35 units
Aspartate Amine Transferase (AST)
10-40 units
Gamma Glutamyl Transferase (GGT)
10-48 IU/L
Serum Proteins
- Albumin
- Globulin
- Albumin/Globulin (A/G) - low in chronic liver disease
Albumin
4.0-5.0 g/dL
Globulin
1.7-3.3 g/dL
Albumin/Globulin (A/G)
Normally 2:1
Measures ability of liver to synthesize proteins
SERUM PROTEINS
- Measures ability of the liver to conjugate and excrete
bilirubin - Abnormal in liver and biliary tract disease associated with
jaundice clinically
PIGMENT STUDIES
PIGMENT STUDIES
- Total Bilirubin
- Direct (Conjugated)
Bilirubin - Indirect (Unconjugated)
Bilirubin - Urine Bilirubin
Total Bilirubin
Used as screening test
for liver or biliary
dysfunction
< 1.5 ml/dL
Direct (Conjugated)
Bilirubin
Increased in bile
obstruction
0.03 mg/dL
Indirect (Unconjugated)
Bilirubin
Increased in hepatocellular failure and hemolytic jaundice
0.1-1.1 mg/dL
High if direct bilirubin is
also high
Urine Bilirubin
Serum ammonia
- Increased in liver failure
- Indicated decreased ability of liver to convert ammonia to
urea
35-65 mcg/dL
BLOOD COAGULATION STUDIES
* Prolonged in liver failure (PT, APTT)
- Prothrombin time
- International Normalized Ratio
(INR) - Partial Thromboplastin Time (PTT)
Prothrombin time
10-40 seconds or 90% of
control
International Normalized Ratio
(INR)
0.9-1.3
Partial Thromboplastin Time (PTT)
25-40 seconds
