i bc27f85be50b71b1 (158 page)

Churchill LivingstOne, 1991; 1 13; and CC Goodman. The Gastrointestinal System. In

CC Goodman, WG Boisonnault (eds), Pathology: Implications for the Physical Therapist. Philadelphia: Saunders, J 998;456-460.

appearance, and presence of abdominal scars indicative of previous abdominal procedures or trauma. The presence of incisions, tubes, and drains should also be noted during inspection, because

these may require particular handling or placement during mobility exercises. I

Righi upper

lefl�r

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s_

GaI_

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Colon (hegebc llexure and lransverse) Pancntes

KlOOey and adrenal gland

Kd1ey and adrenal gland

DuOCl8nt.m with head of pancreas

Colon (spleric t\eJcUfe and IransvetSeJ

Smallnlestlne

SmaI in186lnt (jejl.R.lm)

Right lower

t..fllower

Smallnleslne

Figure 8-2. The four abdominal quadrants. shOlv'''g the vIscera found III

each. (With permission from N Pa/astanga, D Field, R Soames. Anatomy and

Human Movement: Structure and Function {2nd ed}. Oxford, UK: B"tter�

worth-Heinemann, 1989;783.)

GASTROINTESTINAL SYSTEM

507

Clinical Tip

Changes in abdominal girth, especially enlargement,

should be documented by the physical therapist. In addition, the nurses and physicians should be notified. Abdominal enlargement may hinder the patient's respiratory and mobility status.

Auscultation

The abdomen is auscultated for the presence or absence of bowel

sounds and bruits (murmurs) to help evaluate gastric motility and

vascular flow, respectively. Bowel sounds can be altered postoperatively, as well as in cases of diarrhea, intestinal obstruction, paralytic ileus, and peritonitis. The presence of bruits may be indicative of

renal artery stenosis. I

Percussion

Mediate percussion is used to evaluate liver and spleen size and borders, as well as ro identify ascitic fluid, solid- or fluid-filled masses, and air in the stomach and boweL' The technique for mediate percussion is described in the physical examination section of Chapter 2.

Palpation

Light palpation and deep palpation are used to identify abdominal

tenderness, muscular resistance, and superficial organs and masses.

The presence of rebound tenderness (i.e., abdominal pain worsened

by a quick release of palpatory pressure) is an indication of peritoneal

irritation from possible abdominal hemorrhage and requires immediate medical attention. Muscle guarding during palpation may also indicate a protective mechanism for underlying visceral pathology.'

Diagnostic Stlldies

Discussion of the diagnostic evaluation for the GI system will be

divided into ( I ) the examination of the GI tract and (2) the examination of the hepatic, biliary, pancreatic, and splenic systems. Examination of the GI tract includes the esophagus, sromach, and the intestines (small and large). Table 8-5 summarizes the laboratory tests

Table 8-5. Laboratory Tests for the Gastroimestinal System-

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Test

Descripcion

>

Ca,rcinoembryonic amigen (CEA)

Purpose: tumor marker used to monitor recurrence of colorec

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Reference value:

tal cancer.

\:

Adul, nonsmoker <2.5 nglml

Venous blood is drawn periodically to morutor for increases

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Adul, smoker: up to 5 nglml

above the reference range, indicating recurrence of colorecral

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cancer and presence of metastases.

Z

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o-Xylose absorption test (xylose tolerance test, xylose

Purpose: investigate the cause of steatorrhea, to diagnose mal1)

absorption test)

absorption syndrome, and to evaluate digestive ability of

\l

Reference value:

duodenum and jejunum.

23

"

Urine

A 25-g dose of D-Xylose (carbohydrate) mixed in 250 ml of

�

Adul, (25-g dose) >4.5 gl5 hrs

water is ingested by the patient. Blood samples are drawn

;;;

Whole blood

periodically in the next 2 hrs. All urine samples for the next 5

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Adul, (25-g dose) >25 gl2 hrs

rus are also measured.

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Decreased levels of D-Xylose recovered in the blood or urine

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during those time periods could indicate malabsorption.

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Gastric stimulation test (tube gastric analysis, pemagastrin

Purpose: to evaluate the ability of the stomach to produce acid

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stimulation test, gastric acid srimulacion test)

secretions in a resting state and after maximal stimulation.

Reference value: gastric pH 1.5-3.5

Stomach acids are aspirated by a nasogasrric rube during rest

Basal acid output:

ing states (basal output) and after injection of pentagastrin to

Male, 0-10.5 mEqlhr; female, 0-5.6 mEq/hr

stimulate gastric acid stimulation (peak output).

Peak acid Output:

Increased values can occur with duodenal ulcers and Zollinger

Male, 12-60 mEq/hr; female, 8-40 mEqlhr

Ellison syndrome.

Decreased values can occur with gastric ulcers or cancer:

Gastrin

Purpose: used to confirm the diagnosis of Zollinger-Ellison syn

Reference value: 25-90 pg/ml

drome.

Elevated levels of gastrin in venous blood occurs with

Zollinger-Ellison syndrome.

Helicobacter pylori tests

Purpose: to confirm the diagnosis of H. pylori infection, which

is the cause of most peptic ulcers and is a proven carcinogen

for gastric carcinoma.

Serologic test

Purpose: identifies the presence of immunoglobulin G antibody

Reference value: immunoglobulin G negative

[0 H. pylori in the blood.

Urea breath test

Purpose: identifies the presence of H. pylori in the stomach.

Reference value: negative

Tissue biopsy

Purpose: to visualize the H. pylori bacteria.

Reference value: negative for H. pylori

A tissue biopsy is obtained during an endoscopy procedure and

microscopically examined.

5-Hydroxyindoleacetic acid (5-HlAA)

Purpose: used to diagnose carcinoid tumor and provide ongo

Reference value: 1-9 mg/24 hrs

ing evaluation oJ tumor stabiliry.

5-HlAA is a urinary metabolite of serotonin and is produced by

most carcinoid tumors.

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Lactose tolerance test (oral lactose tolerance test)

Purpose: to identify lactose intolerance-lactase deficiency as a

Reference value:

cause of abdominal cramps and diarrhea, as well as to help

Blood glucose >30 mg/dl

I

identify the cause of malabsorption syndrome.

Urine lactose 12-40 mg/dl in 24 hrs

An oral dose of lactose is provided to a fasting patient, and

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serial blood and urine samples are measured.

Minimal rise in blood glucose or urine lactose levels indicates

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lactose intolerance-lactase deficiency.

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Table 8-5. Continued

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Test

Description

"

g

Occult blood (fecal occult blood test, FOBT, FOB)

Purpose: used as a screening tool for early diagnosis of bowel

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Reference value: negative

cancer.

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Three stool specimens are collected and examined for the pres

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ence of occult (nonvisible) blood in the feces, which can be

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indicative of adenocarcinoma and premalignanr polyps in the