GI System: Anatomy, Physiology, and Nutrition

Enabling Learning Objectives

• Interpret principles of A&P and apply concepts related to the GI system
• Differentiate macronutrients from micronutrients
• List and define carbohydrates, lipids, proteins and their utilization
• Distinguish between vitamins and minerals
• List fat and water soluble vitamins, summarize their general functions
• Understand effects of vitamin deficiency
• List major minerals with general functions of each
• Name organs of the digestive system
• Explain parasympathetic and sympathetic innervation of the GI tract
• Explain drainage of pancreatic enzymes
• List anatomical structures found in each abdominal quadrant
• List the functions of each organ of the digestive system
• Identify numbering of teeth
• Describe each part of the intestines and functions
• List and find the salivary glands with associated ducts
• Identify patient positioning for abdominal exams
• List normal and abnormal findings on auscultation of the abdomen
• Define order of exam techniques of the abdominal exam
• List normal and abnormal findings of percussion of the abdomen
• Goal is to perform and interpret physical exams with under 6 mistakes

Overview of the GI System

• Nutrition
• Anatomy and Physiology
• Abdominal Exam

Nutrition

• Nutrients are chemicals an organism requires for survival

Macronutrients

• Needed in bulk
• Includes Carbohydrates, Lipids, and Proteins

Micronutrients

• Only a small amount is needed daily
• Vitamins and Minerals

Water

• The body needs a daily supply of water, though is not a nutrient

Metabolism

• The way nutrients are altered to support life
• Anabolism is building up
• Catabolism is breaking down

Essential Nutrients

• Vital nutrients that the body cannot otherwise produce

Carbohydrates

• Are key to cellular energy: C6H1206 produces CO2 + H2O + Energy
• The CNS and heart work exclusively off glucose

Simple carbohydrates

• Include Monosaccharides
  • Honey or fruits
  • Fructose, galactose, glucose, which is the most common fuel
• Includes Disaccharides
  • Milk sugars, cane sugar, beet sugar
  • Lactose, sucrose, maltose

Complex carbohydrates

• Glycogen is found in meats
• Starches and cellulose are found in plants
  • Cellulose is undigestible
  • Cellulose provides bulk, facilitating movement of food through the intestines, and is also fiber

Carbohydrate utilization

• Galactose and fructose are converted to glucose by enzymatic reactions in the liver
• Excess glucose is converted by the liver to glycogen, this is glycogenesis
  • Glycogen is stored in liver and muscles
  • Limited glycogen storage depends on the individual
  • Excess glucose surpassing glycogen capacity forms fat and stores in adipose tissue
  • Glycogen is converted back into glucose as needed, this is glycogenolysis.
• Glucose is converted into:
  • Glycogen for glycogenesis
  • Fat for lipogenesis
  • CO2 + H2O + Energy for respiration
• If glucose is not readily available the liver can convert other energy sources (proteins, fats), this is gluconeogenesis.

Lipids

• Consist of triglycerides, phospholipids, and cholesterol
• Functions
  • Energy source for cellular processes
  • Thermoregulation
  • Provides cushioning and protection of vital organs
  • Steroid formation
  • Carriers of certain proteins, fats, and Vitamins
  • Necessary in synthesis of every cell

Lipid utilization

• Contains more chemical energy than carbohydrates or protein
• Triglycerides are the most common dietary lipid
  • When used as energy, triglycerides separate into glycerol and fatty acids
  • Fatty acid breakdown produces ketones, which can cause ketoacidosis
  • Fatty acids synthesize other fat-containing substances in the liver
  • Essential fatty acids cannot be produced by the liver
• Unsaturated fats are healthier than saturated fats, and include at least one double bond

Proteins

• Polymers of amino acids
• Found in meats, dairy products, and legumes
• Functions
  • Structural material, like elastin, collagen, keratin, actin, and myosin
  • Enzymes
  • Immunity, like antibodies
  • Plasma proteins, influencing colloid osmotic pressure
  • Hormones
  • Energy

Protein utilization

• During digestion, proteins are broken down into amino acids
• Before amino acids can be used as energy, they must be deaminated
  • The nitrogen portion (-NH2) is removed from the amino acid and converted into urea in the liver
    • The kidneys remove urea as urine
    • Blood Urea Nitrogen (BUN) assesses kidney function
      • Elevated BUN indicates that kidneys are not removing urea from the blood

Protein info

• Amino acids are the building blocks of protein, of which all 20 types must be available for use at the same time.
• The 8 essential amino acids must be consumed and cannot be stored
• Complete proteins provide all amino acids for anabolism
• Incomplete proteins cannot maintain growth by themselves, but may form complete proteins if combined with other incomplete proteins, like beans and rice.

Protein Balance

• Nitrogen balance indicates that the gain of proteins equals the rate of their loss
  • Has clinical relevance as a marker of adequate nutrition
• Negative nitrogen balance indicates that loss exceeds gain
  • More protein breakdown than when it’s consumed in the diet
  • May be seen in critically ill patients
• Positive nitrogen balance indicates that gain exceeds loss
  • More protein is being built into new tissue

Vitamins

• They are enzymes that speed up spontaneous reactions between nutrients, but do not provide nutrition or energy
• Vitamins are classified by solubility
  • Fat soluble vitamins (A, D, E, K)
  • Water soluble vitamins (B complexes and C)

Fat Soluble Vitamins (A, D, E, K)

• Vitamin A
  • Function: Vision and skin maintenance
  • Deficiency: Night-blindness, skin degeneration
  • Excess: Peeling skin, hair loss, birth defects
• Vitamin D
  • Function: Promotes absorption of Ca+ and phosphorus in the intestine
  • Deficiency: Rickets
    • Excess: Diarrhea, soft tissue calcification, kidney damage
• Vitamin E
  • Function: Strong antioxidant
  • Deficiency: Rare
    • Excess: Elevated blood pressure
• Vitamin K
  • Function: Synthesis of prothrombin in the liver
  • Deficiency: Easy bruising, bleeding dyscrasias (hemophilia, leukemia, etc.)
    • Excess: Jaundice, hemolytic anemia; hyperbilirubinemia (in formula-fed infants)

Water Soluble Vitamins (B complexes and C)

• Vitamin B1 (Thiamine)
  • Function: carbohydrate metabolism, cellular synthesis
  • Deficiency: weakness, wernicke's encephalopathy, beriberi
    • Common in alcoholics (drinking alcohol rather than eating food)
    • Treated with a banana bag
  • Excess: vasodilation, cardiac dysrhythmias, headache, weakness and convulsions
• Niacin (Nicotinic acid)
  • Function: essential for carbohydrate metabolism
  • Deficiency: pellagra (dermatitis, diarrhea, confusion)
    • Excess: hyperglycemia, flushing, gout
• Vitamin B6
  • Function: essential to protein synthesis, metabolism and antibody synthesis
  • Deficiency: neuropathies
    • Supplemented in patients taking INH for + PPD
    • Excess: rare - burning pains, numbness, clumsiness, diminished reflexes and paralysis
• Vitamin B12 (Cyanocobalamin)
  • Function: synthesis of myelin and RBCs
  • Deficiency: pernicious anemia (requires IF for GI absorption)
    • Excess: rare
• Folic Acid
  • Function: synthesis of DNA, promotes RBC formation
  • Deficiency: megaloblastic anemia, neural tube defects
  • Excess: unknown
• Vitamin C (ascorbic acid)
  • Function: collagen production, iron absorption
  • Deficiency: scurvy, slow wound healing, decreased infection resistance
    • Excess: can precipitate gout and nephrolithiasis attacks

Minerals

• Inorganic elements essential in human metabolism
• Divided into major vs minor groups, based on amount present

Major Minerals

• Calcium
  • Found in body cells, fluids, bones, and teeth
  • Necessary for nerves, muscle contraction and blood coagulation
    • Hypocalcemia is associated with tetany and osteoporosis
    • Hypercalcemia is rare, but can develop from overconsumption of supplements or various diseases causing calcium phosphate deposits, nephrolithiasis, constipation and fatigue

More Major Minerals

• Phosphorus
  • Found in phospholipid membrane of every cell.
  • Component in nearly every metabolic reaction, regulating pH and as ATP - Found in bones including the teeth
• Potassium
  • Major intracellular ion, part of intracellular osmotic pressure and pH
  • Vital role in membrane potential and nerve cell condition
    • Hypokalemia / hyperkalemia cases life threatening arrhythmias
• Sodium
  • Major extracellular ion
  • Regulates water movement between cells
  • Necessary for nerve impulse conduction and muscle fiber contraction
    • Hyponatremia can be caused by diarrhea, vomiting, kidney disorders, sweating and use of diuretics, resulting in cramps, nausea and convulsions.
    • Hypernatremia could be caused by excess intake and would shrink cells
• Chloride
  • Highly concentrated in CSF and gastric juice - Works with sodium to regulate pH and maintain electrolyte balance - Can be depleted with vomiting, diarrhea, kidney disorders, sweating or diuretic use
    • Can lead to cramps or vomiting
• Magnesium
  • Essential for providing energy for cellular processes
  • Stored in bones - Deficiency: EKG changes → arrythmias, neuromuscular hyperexcitability, tremors, seizures, agitation → psychosis - Excess: Weakness → paralysis, confusion → coma, decreased deep tendon reflexes, respiratory depression, arrythmias, constipation, nausea

Trace Elements

• Include
  • Iron
  • Copper
  • Iodine
  • Zinc
  • Fluorine

Terms regarding nutrition

• Calories = amount of potential energy food contains

Starvation

• Absence of food intake
• Healthy humans can live from 50-70 days without food
• Marasmus – skeleton-like appearance due to starvation

Malnutrition

• Poor nutrition from lack of essential nutrients
• Kwashiorkor – protein deficient
  • Loss of plasma proteins = ascites
  • Skin develops lesions, immune system depleted

Eating Disorders

• Anorexia Nervosa = intentional starvation/restriction of relative intake due to a psychological disorder
• Bulimia = recurrent episodes of binge eating with compensatory behavior Purging (self induced vomiting, or laxative or diuretic use), fasting, or driven exercise Due to a psychological disorder

Anatomy & Physiology

• Digestion is the mechanical and chemical breakdown of food for absorption of cells

Alimentary Canal

• Tube from the mouth to anus consisting of
  • Mouth
  • Esophagus
  • Stomach
  • Small Intestine
  • Large intestine
  • Anal canal

Accessory Organs

• Salivary glands
• Liver
• Gallbladder
• Pancreas

Wall structure of the alimentary canal

Includes:

• Mucosa: the innermost layer, secretes enzymes and mucus
• Submucosa: contains blood and lymph vessels to carry away absorbed material
• Muscular layer: layers of smooth muscle for peristalsis
• Serosa (visceral peritoneum): secretes serous fluid to allow organs to slide around

Innervation of the gastrointestinal tract

• Stems from the autonomic nervous system
• Parasympathetic activity
  • Promotes peristalsis increasing activity, like rest and digest
• Sympathetic activity Stops certain digestive functions, like fight or flight

Mouth

• Mechanical digestion begins via mastication
• Lips have sensory receptors that judge characteristics of food
• Cheeks hold food in mouth and have muscles of mastication
• Tongue attached to the floor of the mouth by lingual frenulum
  • Is composed of muscles that mix food with saliva; moves food toward the pharynx during swallowing
• Palate is hard and soft, holding food in the mouth and directing it toward the pharynx

Mouth Anatomy Facts

• Uvula and soft palate prevent food from entering nasopharynx
• Palatine tonsils protect against infection
• Teeth begin mechanical breakdown by increasing surface area
• Adult mouth contains 32 permanent teeth
  • (8) Incisors
  • (4) Cuspids
  • (8) Bicuspids
  • (12) Molars
  • Numbered 1-16: from the right upper corner to the left upper corner
  • Numbered 17-32: from the left lower corner to the right lower corner
• Jaw has two main portions
  • Crown – above the gum and covered with enamel
  • Root – below gum line and cementum with periodontal ligament anchors

Tooth Structure

• Three layers
  • Enamel: outer layer that covers the crown
  • Dentin: hard layer that is the bulk of the tooth, surrounding the root cavity
  • Root canal: contains blood vessels, nerves, and connective tissue that enter tooth

Salivary Glands

• Three pairs
  • Largest glands are parotid
    • located between the cheek and masseter muscle
    • Stensen's duct is just opposite the second upper molar
  • Submandibular glands: located on the floor of the mouth. Wharton's ducts open inferior to the tongue
  • Sublingual glands: smallest and located on the floor of the mouth. Secretions enter through many separate ducts

Salivary Glands Function

• Functions of saliva:
  • Moistens and binds food particles
  • Begins chemical breakdown from saliva
  • Dissolves food to be tasted/ helps cleanse mouth/ teeth
• Parasympathetic neurological innervation
  • Large volume of watery saliva
  • Activated reflexively during pleasant thoughts about food
• Sympathetic nervous system
  • Inhibits parasympathetic, creating less saliva and more difficulty swallowing
  • Activated if food looks, smells, or tastes unpleasant

Pharynx

• Three divisions
  • Nasopharynx: from the nose to the mouth + connects eustachian (auditory) tubes with middle ear
  • Oropharynx: back of the mouth to the epiglottis. Passageway for air and food into trachea/esophagus
  • Laryngopharynx: from the epiglottis to the cricoid cartilage

Esophagus

• Approximately 25 cm long
• Propels food via peristalsis
• Lower esophageal sphincter (LES) allows food into the stomach
  • Relaxation of the LES results in reflux, especially from tomatoes, peppermint, tobacco, caffeine, chocolate and spicy foods

Stomach Anatomy

• Four divisions
  • Cardia
  • Fundus
    • Swallowed air (gastric bubble on CXR)
  • Body
  • Pylorus - Terminal portion - Contains pyloric sphincter, a muscular valve
• Gastric juice contains:
  • Hydrochloric Acid = converts pepsinogen into pepsin and sterilizes solution
  • Pepsin = enzyme that denatures that proteins
    • Positive feedback on pepsinogen
  • Mucus = protective layer on the stomach walls
  • Intrinsic factor = required for vitamin B12 absorption

Phases of Gastric Secretion

• (gastrin release causes the release of HCl acid):
  • Cephalic phase: Sight/thought of food
  • Gastric phase: food entering/ distension of stomach
  • Intestinal phase: food entering small intestine
• Chyme is a mixture of food and acid; it exits the stomach via the pyloric sphincter to control gastric emptying
• Common diseases include gastritis, caused by inflammation of stomach lining due to irritants like viruses or toxins, and Peptic Ulcer Disease (PUD).

Pancreas

• Located under the stomach with head in the C-shaped region of duodenum
• It has an endocrine function, secreting of hormones
• Exocrine functions:
  • Bicarbonate ions: neutralizes acidic chyme from the stomach
  • Pancreatic amylase: splits glycogen
  • Pancreatic lipase: breaks down triglycerides
  • Proteolytic enzymes: enzymes that split specific amino acid combinations
  • Pancreatic nucleases: enzymes that break down nucleic acid
• Pancreatic enzymes drain down the pancreatic duct, then release into the duodenum via the hepatopancreatic ampulla
  • Commonly called the ampulla of Vater
  • Is surrounded by the Sphincter of Oddi
• If pancreatic juices are blocked the digestive enzymes will erode the pancreas, causing pancreatitis
  • Causes include stones and alcoholism

Liver

• The largest intestinal organ
• Divided into four lobes:
  • Right lobe
  • Left lobe
  • Quadrate Lobe, near gallbladder
  • Caudate Lobe, near the vena cava
• Portal circulation brings newly absorbed nutrients from the small intestine into the liver

Liver Function

• Multiple metabolic activities
  • Carbohydrate metabolism maintains glucose level
    • Converts excess glucose to glycogen for later use, glycogenisis - Breaks down glycogen to form glucose (glycogenolysis)
    • Converts non-carbohydrates to glucose (gluconeogenesis)
  • Lipid metabolism
    • Oxidizes fatty acids - Synthesizes lipoproteins, phospholipids, and cholesterol. - Converts portions of carbohydrates/proteins into fat molecules
  • Protein metabolism
    • Deaminates amino acids - Forms urea - Synthesizes plasma proteins (clotting factors) and converts amino acids
  • Responsible for manufacturing
    • production of bile salts for the emulsification of fats Storage
    • glycogen
      • vitamins A, D, B12
      • iron
  • Blood reservoir
  • Destruction
    • Toxins such as alcohol and drugs
      • Damaged RBCs
• Inflammation of the liver is called Hepatitis
  • Several causes such as mostly viruses
  • May present as jaundice, which causes yellowing skin when deposition of excess bilirubin occurs

Gallbladder

• Location: inferior/posterior side of Liver functions include store and releases bile
  • Hepatic lobules produce bile
  • Right and left hepatic ducts drain into the common hepatic duct (CHD)
  • The cystic duct from the gallbladder meets the CHD forming the common bile duct
  • The Common Bile duct meets the pancreatic duct @ Ampulla of Vater.
• Bile backs up the ducts and excess is stored in the gallbladder.
• Biles salts functions reduce the surface tension/and create breakdown to globules and emulsification of droplets. Enhances absorption of fatty acids/cholesterol/ allows for absorption of Vitamins (A,D,E,K)
• Common disease processes include
  • Cholecystitis-Inflammation of the gallbladder
  • Cholelithiasis-Stone formation in the Gallbladder

Small Intestine

• Three parts
  • Duodenum- recieves chyme from stomach
  • Jejunum
  • Ileum- connects to the large intestine via the ileocecal valve
• Intestinal villi: throughout small intestine to increase surface area
  • Functions
    • increasing absorption of digestive products and assist in secretion of mucus for protection
    • transport of enzymes which breakdown and assists with nutrient absorption of nutrients.
• Relevant Enzymes
  • Sucrase breaks down saccharides to monosaccharides
  • Lipase breaks down fats into fatty acids/glycerol
• Damage to villi will result with malabsorption syndromes and Diarrhea

Small Intestine Function

• Receives secretion from liver and pancreas
• Completion of digestion of nutrients to chyme Absorbs digestive products, water, and electrolytes. Very little absorbable material at the distal end.
• Nutrients absorbed through active and facilitated diffusion and osmosis into villi and blood stream
• Transports remaining material through peristaltic movement into large intestine

Large Intestine

• Major anatomical landmarks of the colon

  • Cecum- beginning contains vermiform appendix Vermiform is comprised of lymphatic tissue causing appendicitis that needs to be diagnosed immediately.
  • Ascending colon: Cecum up to hepatic flexure
  • Transvers colon: Hepatic flexure to the splenic flexure
  • Descending colon: Splenic flexure to sigmoid colon

• Contains Sigmoid colon: S-shaped curve Rectum Anus

• Large Intestine Functions

  • Reabsorbs 90% intestinal water
  • Reabsorbs digestive secretions
  • Produces mucus and forms/stores feces
  • Synthesizes certain vitamins such as vitamin K

• Common Diseases that need to watched are:

  • Appendicitis = inflammation the vermiform
  • Diverticulitis= inflammation of small pouches lining the colon
  • Diarrhea=Frequent/ rapid passage of loose feces
  • Constipation=Infrequent passage of hard feces
  • Inflammatory Conditions = Crohn's or Ulcer colitis
  • Hemorrhoids enlarged inflammation branches of the rectal vein

Abdominal Exam Areas and Considerations

• Four quadrants of the abdomen, consider the anatomical position
  • Right upper quadrant
    • Liver and gallbladder
    • Pylorus and 1st part of the duodenum
    • head of the pancreas
    • right adrenal gland/ superior aspect of right kidney
    • parts of the transverse and descending colon
  • Right lower quadrant
    • Lower pole of right Kidney
    • Cecum and Appendix
    • Part of the Ascending colon
  • Left upper quadrant - Left lobe / spleen/ stomach/ body of the pancreas - Left Adrenal gland / upper aspect of the left kidney - Splenic flexure transverse/descending
  • Left Lower quadrant
    • Lower pole of left kidney
    • Sigmoid colon part of the descending colon
  • Left Ureter if bladder is distended, left ovary; uterus if enlarged

Abdominal Exam Nine Regions

• Includes
  • Epigastric region
    • Pyloric area of the stomach
    • Duodenum
    • Pancreas
    • Part of the Liver
  • A suprapubic consists of the ilium/ bladder and uterus

Exam preparation and equipment

Exam Preparation

• Position patient right side for procedure
• Keep short fingernails
• Keep warm hands
• Clean equipment such as stethoscope need to be warm in hands not with breath Equipment and Supplies
  • Ruler in cm with marking pen
  • Good lighting
  • Appropriate draping needs to be available for procedure Patient Position and Consideration
  • Expose from Xiphoid to line of pubic synthesis.
  • Ensure Abdominal muscles are relaxed
  • Ensure Knees are bent (pillow to support), with arms at the sides

Abdominal Exam: Inspection Checklist

• Scars: describe location, shape, size, and color
• Stretch marks (striae): describe location, size, and color, if related to liver disease, aging, pregnancy
• Venous pattern: caused by dilation, aging, liver disease, or pregnancy
• Spider nevi: mole, rash, nodules around umbilicus.
• Location Umbilicus: check for contour, any inflammation or hernia present

Abdominal wall and symmetry

• Is abdomen Common and flat in normal, to thin patients with good muscles?
• Is abdomen Sunken in and is it normal/ vs disease state?
• Is abdomen rounded: usually refers to obesity vs. disease
• Is abdomen Distended or protrusive: Is it rounded/firm, or associated with disease (fluid)
• Is abdomen mass bulges or asymmetry

Peristaltic Activity

• Surface movement which requires tangential lighting. Peristalsis may be seen with a thin individual or hyperactivity related to disease.
• Aortic pulsations should be midline slightly the to left midline
• Suspicion to Aneurysm may lead to increases in lateral pulsations. May to be visible if obese/ or ascites is present

Auscultation and steps to achieve proper results

• Complete this task first after inspection! Do NOT palpate until AUs completed
• Palpation, alters Bowel sounds Listen to ALL 4 quadrants for Bowel Sounds
• Use Diaphragm Side, LIGHTLY Touching
• Know that Bowel Sounds are to be referred as "Active"/ or "Normoactive" NOT "Normal"

Describing Bowel Sounds

• Hypoactive or slow/ sluggish/scant; possible acute Abdomen
• Active Bowel sounds normal with a range (5-34 min)
• Hyeractive Rushes/Borborygmi/Gurgles
• Must reach over 34 to sounds/m
• Related to hunger/ diarrhea vs Early Intestinal obstruction
• Borygmi = "growling stomach", or prolonged hyperperistalsis.
• Absent Bowel sounds, no sounds in areas for > 2 mins that could need acute surgical abdomen, or periontes.

Vascular Sounds: Listening for Bruits with the Bell

• Listen
• *Abdominal Aorta: midline right between xiphoid and umbilicus
• *Renal artery: 1-1 1/2" inches lateral on upper quadrants
• *Iliac Artery- Midpoint the umbilicus to the anterior superior /iliac/spine aka ASIS
• Femoral artery and mid with groin Crease

Abdominal Exam: Percussion

• Helps to discern, Solid vs Fluid versus Air-Filled areas Percuss ALL 4 quadrants, after auscultating. Start percussing. Tympany: should be prominent when scattered across different areas when caused by fluid/ vs feces

Large areas DULLNESS indicates organ enlarged versus abnormal masss

Estimating Size of the Liver by Percussion

• In the right MCL start level the umbilicus @RLQ where tympany is present.
• Percuss upwards to area you hear dullness, placing marking or this is your lower border.
• Repeat, then start MCL starting lower end or chest where area of resonance with lower ⅓ of the sternum where using with caution - Must ensure female patients should not have interference and own movement of their tissue.

Palpate and Proceed on Downward for Area/ Dullness with Marking being Placed

After measurements are obtained, measure the difference with markings.

• 6/12 cm with right MCL which is on average. Range is noted 4-8cm along the midsternal line
• Increases with either gases, or changes with pulmonary assessments.

Abdominal Exam: Palpation

• Assesses organs,
• Muscle spasms, masses, tenderness and fluid with: -Arms by Pt side; -knees flex for relaxing abdominal muscles
• Begin light palpations/ evaluate for any sign pain (last), use the dipping method for evaluation. Avoid quick jabs!!

Palpating Four Quadrants

• Light (one hand) and deep (two hands) palpation
• Identify any masses/ then note with *Location/Size/Shape, consistency

Assess Liver Tenderness

• Deep Palpations are performed best, when Left hand (posterior rib cage [pushing upwards]) Right hand (lateral to rectus muscle with -finger tips positioned below the liver border Remember- Patient's Breathing A: perform Inspiration (Hand in Position to move) B: perform Expiration (Dipping downward and slide up hand & below anterior rub cage) C : perform Inspiration feel the Liver come downward/ fingers as it moves Evaluate: enlargement, nodularity, or tenderness Test-
• Murphy's Sign
• Assess RUQ pain and tenderness (use)
• If Positive with a 3x likeliness the sign test has acute cholecysttis. Steps:
• Hook or deeply palpate RUQ, while locating patients location of pain of costal margin Have Pt. perform a deep breath during the procedure. Which will cause the liver and gallbladder to move down towards exam/hand. Watch Pts. Breathing will taking note of their current degree vs with tenderness. Positive Test with Sharp Increase with tenderness with Inspiratory or the lack cessation vs can to full breathing (positive Murphy signs) and be considered with acute cholecystitis, in the cases with sign/symptoms

Palpate Spleen- Deep

• Patient lies left on side- (over and supports/ pushing upwards). With hand position into an oblique form with fingertips below rib and cage Perform same breathing process to perform liver palpations

Abdominal Exam: Palpate for Aorta

• To get feel for Pulsation and theWidth, look for Area or the Xiphoid process and umbilicus- slightly to the left at midline.
• Gauge sizes by placing both or lateral (then side and the placement fingers. Normal: is NOT greater than 3.0 cm with anterior pulsations
• IF there PROMIMENT lateral pulses suspect area with Aorta ANEURYSM and the Patient be complaining area/ Back pain

Assess for Palpation Rebound

• Palpate, check with RLQ where patient rebound with tenderness! How:
• Press into abdomen, but is firm will performing a moderate position and pressure (be deep during process)
• Ensure Release with Quick hand movement, or away!
• Patient has a noted increase with pain as released
• Concluding the evaluation with results can indicates with Rebound tenderness

Special Abdominal Test

• Test for peritoneal irritation
• The Obturartor
• RLW pain the side with the patient's internal rotation The Psoas
• RLQ pain with Flexion that is opposed well side the hip flexion as well.

Explore the anatomy, physiology, and nutrition related to the gastrointestinal (GI) system. Learn about macronutrients, micronutrients, vitamins, and minerals, and their roles in the body. Understand digestion, organs, and clinical exam techniques.