Clinical examination of the gi tract and abdomen [recovered] [recovered]
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Transcript of Clinical examination of the gi tract and abdomen [recovered] [recovered]
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