6.1 GI Assessment & Common Disorders

Abdominal Assessment: Sequence Matters

The abdomen is the one body system where the exam order changes: inspection, auscultation, percussion, palpation. Percussing or palpating before auscultating can stimulate or suppress bowel activity and distort what you hear. Have the patient supine with an empty bladder, knees slightly flexed to relax the abdominal wall, and use a systematic four-quadrant approach, always starting in the right lower quadrant.

• Inspection: contour (flat, rounded, protuberant, scaphoid), symmetry, distension, visible peristalsis or pulsation, scars, striae, masses, and hernias. A visible peristaltic wave can signal obstruction; a prominent midline pulsation raises concern for an aortic aneurysm — do not palpate deeply in that case.
• Auscultation: use the warmed diaphragm of the stethoscope and listen in all four quadrants, beginning in the right lower quadrant near the ileocecal valve where sounds are normally most active.
• Percussion: expect tympany over air-filled bowel and dullness over solid organs, masses, stool, or ascitic fluid. The normal liver span is 6 to 12 cm at the right midclavicular line.
• Palpation: light palpation (about 1 cm) before deep palpation (4 to 5 cm), and palpate known painful areas last so guarding does not mask the rest of the exam.

Bowel Sounds

Normal bowel sounds occur at a rate of 5 to 30 clicks or gurgles per minute. Hyperactive sounds (more than 30 per minute, loud and rushing) suggest early mechanical obstruction, gastroenteritis, or diarrhea. Hypoactive sounds (fewer than 5 per minute) suggest paralytic ileus, peritonitis, or late obstruction. Before documenting absent bowel sounds, auscultate for a full 5 minutes — this is a classic exam point. High-pitched tinkling or musical sounds are characteristic of early mechanical small bowel obstruction as fluid and air are forced through a narrowed lumen.

Peritoneal Signs and Special Maneuvers

Guarding is abdominal wall muscle contraction over an inflamed area; it may be voluntary (patient tenses in anticipation) or involuntary (true rigidity suggesting peritonitis). Rebound tenderness (Blumberg sign) is pain that is worse on quick release of deep palpation than on the press itself; a rigid, board-like abdomen indicates peritonitis — keep the patient NPO and anticipate surgical evaluation. Current practice favors gentle techniques over aggressive rebound testing because it causes significant pain.

Cullen and Grey Turner signs take hours to days to appear and signal significant retroperitoneal bleeding — pair them with vital signs, hemoglobin trends, and anticipation of worsening hypovolemia.

Gastrointestinal Bleeding

GI bleeding is divided at the ligament of Treitz. Upper GI bleeding (above it) is most commonly caused by peptic ulcer disease, esophageal varices, erosive gastritis, and Mallory-Weiss tears. Lower GI bleeding is most commonly caused by diverticulosis (the leading cause of significant lower GI hemorrhage in adults), angiodysplasia, hemorrhoids, inflammatory bowel disease, and colorectal cancer.

• Hematemesis: vomiting blood. Bright red blood indicates active, brisk bleeding; coffee-ground emesis means the blood has been partially digested by gastric acid.
• Melena: black, tarry, sticky, foul-smelling stool from digested blood; as little as 50 to 100 mL of upper GI blood loss can produce it.
• Hematochezia: bright red blood per rectum, usually from a lower GI source — but a very brisk upper GI bleed with rapid transit can also present this way, and these patients are often hemodynamically unstable.

Nursing priorities follow the ABCs and circulation: establish two large-bore IV lines (18 gauge or larger), keep the patient NPO, draw a type and crossmatch, and trend CBC and coagulation studies. Remember that the hemoglobin and hematocrit lag behind acute blood loss — early values may look deceptively normal until fluid shifts and volume resuscitation dilute the sample. Expect IV proton pump inhibitor therapy for ulcer-related bleeding, octreotide for suspected variceal bleeding, and endoscopy, ideally within 24 hours. Monitor for orthostatic changes, rising heart rate, and falling urine output as early shock indicators.

GERD and Peptic Ulcer Disease

Gastroesophageal reflux disease (GERD) results from an incompetent lower esophageal sphincter, producing heartburn, regurgitation, and sometimes chronic cough or hoarseness. Teaching points: avoid triggers (fatty and fried foods, caffeine, chocolate, peppermint, alcohol), stop smoking, lose weight, eat small meals, and remain upright for at least 2 to 3 hours after eating. Proton pump inhibitors such as omeprazole 20 to 40 mg daily are taken 30 to 60 minutes before the first meal for maximal effect. Alarm features — dysphagia, unintentional weight loss, bleeding, or anemia — warrant endoscopy to rule out Barrett esophagus and malignancy.

Peptic ulcer disease (PUD) is caused most often by Helicobacter pylori infection and by chronic NSAID use, which strips away the mucosal prostaglandin barrier. The pain pattern is a classic differentiator:

• Gastric ulcer: pain worsens with eating (food aggravates), so patients lose weight.
• Duodenal ulcer: pain occurs 2 to 3 hours after meals and at night and is relieved by food or antacids.

H. pylori is diagnosed by urea breath test, stool antigen, or endoscopic biopsy and treated with triple therapy (a PPI plus clarithromycin and amoxicillin for 10 to 14 days) or bismuth quadruple therapy where clarithromycin resistance is common. PUD complications to recognize: hemorrhage, perforation (sudden severe pain, rigid board-like abdomen, free air under the diaphragm — surgical emergency), and gastric outlet obstruction (succussion splash, vomiting of undigested food).

Appendicitis, Cholecystitis, and Pancreatitis

Appendicitis classically begins with vague periumbilical pain that migrates to the right lower quadrant (McBurney point), with anorexia, nausea, and low-grade fever. A critical pearl: sudden relief of pain may mean perforation, followed by escalating peritonitis. Keep the patient NPO, never give laxatives or enemas, and avoid heat to the abdomen — all can promote rupture.

Cholecystitis presents with right upper quadrant pain after a fatty meal that may radiate to the right shoulder or scapula, a positive Murphy sign, nausea, and fever. Traditional risk factors are the four Fs: female, forty, fertile, and fat. Management includes NPO status, IV fluids, analgesia, and usually laparoscopic cholecystectomy.

Acute pancreatitis causes severe, boring epigastric pain radiating to the back, worse when supine and eased by leaning forward or sitting up. The two most common causes are gallstones and alcohol. Serum amylase rises within hours but normalizes in 3 to 5 days; lipase is more specific and stays elevated longer, making it the preferred test. Watch for hypocalcemia (a poor prognostic sign), hyperglycemia, and Cullen or Grey Turner signs of hemorrhagic disease. Treatment centers on aggressive IV fluid resuscitation, pain control, and early enteral nutrition when tolerated.

Bowel Obstruction, Ileus, and Hernias

Small bowel obstruction is most often caused by postoperative adhesions, hernias, or tumors. Expect colicky periumbilical pain, profuse vomiting (which may relieve distension), high-pitched tinkling bowel sounds early that later disappear, and obstipation late. Large bowel obstruction produces marked distension, constipation, and less vomiting. Paralytic ileus is a functional (non-mechanical) stoppage common after abdominal surgery, with opioids, and with electrolyte disturbances such as hypokalemia; bowel sounds are diminished or absent throughout.

Management of obstruction and ileus: NPO, nasogastric tube decompression, IV fluids, and correction of electrolytes (especially potassium). Signs of strangulation — constant rather than colicky pain, fever, tachycardia, leukocytosis, peritoneal signs — demand immediate surgical notification.

For hernias, know the three categories: reducible (contents return to the abdomen with pressure or lying down), incarcerated (trapped and irreducible), and strangulated (blood supply cut off — severe pain, fever, tachycardia, skin changes — a surgical emergency). After hernia repair, teach patients to splint the incision when coughing, avoid heavy lifting (typically nothing over about 10 pounds for 4 to 6 weeks), and use scrotal support after inguinal repairs.