DIAGNOSTIC TESTS FOR GASTROINTESTINAL SYSTEM.pdf

HEALTH ASSESSMENT OF GASTRO
INTESTINAL SYSTEM AND DIAGNOSTIC
ASSESSMENT OF GI SYSTEM
MRS. JISHA SRIVASTAVA, FACULTY RAKCON

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TEXT
OBJECTIVES

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LEARN THE STRUCTURES AND FUNCTIONS OF THE GASTROINTESTINAL TRACT AND OF THE ACCESSORY
GLANDS: LIVER, GALLBLADDER, AND PANCREAS
LEARN AGE AFFECT ON THE GASTROINTESTINAL TRACT AND ACCESSORY GLANDS.
LEARN THE TECHNIQUES USED IN PHYSICAL EXAMINATION OF THE ABDOMEN CONDUCTED FOR A PATIENT
WITH POSSIBLE GASTROINTESTINAL SYSTEM, LIVER, GALLBLADDER AND PANCREATIC DISEASE.
LEARN THE DIAGNOSTIC TESTS FOR THE DISORDERS OF THE GASTROINTESTINAL SYSTEM, LIVER,
GALLBLADDER AND PANCREAS.
LEARN TO DIFFERENTIATE NORMAL AND ABNORMAL FINDINGS.
LEARN THE NURSING INTERVENTIONS FOR DIAGNOSTIC TESTS FOR THE DISORDERS OF THE
GASTROINTESTINAL SYSTEM, LIVER, GALLBLADDER AND PANCREAS.

TEXT
ANATOMY AND PHYSIOLOGY OF GI SYSTEM
1.ORAL CAVITY AND PHARYNX
2. ESOPHAGUS
3. STOMACH
4. SMALL INTESTINE
5. LARGE INTESTINE
6. LIVER
7. GALLBLADDER
8. PANCREAS

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TEXT
1. ORAL CAVITY
The boundaries of the oral cavity
are the hard and soft palates
superiorly, the cheeks laterally,
and the floor of the mouth
inferiorly.
Within the oral cavity are the teeth
and tongue and the openings of the
ducts of the (salivary glands
-parotid, submandibular, and
sublingual glands).

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TEXT
1. ORAL CAVITY
The tongue is made of skeletal
muscle innervated by the
hypoglossal nerve (twelfth cranial
nerve).
The papillae on the upper surface
of the tongue contain taste buds,
innervated by the facial and
glossopharyngeal nerves (seventh
and ninth cranial).

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TEXT
The pharynx is a muscular tube
that is a passageway for food
exiting the oral cavity and entering
the esophagus.
When a mass of food is pushed
backward by the tongue, the
constrictor muscles of the pharynx
contract as part of the swallowing
reflex.
This reflex is regulated by the
medulla and pons.
1. ORAL CAVITY

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TEXT
2.ESOPHAGUS
The esophagus is about 10
inches long and carries food
from the pharynx to the stomach.
Peristalsis of the muscle layer in
the wall of the esophagus is one
way; food reaches the stomach
even if the body is upside down.

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TEXT
2.ESOPHAGUS
The esophagus is surrounded by
the lower esophageal sphincter
(LES, or cardiac sphincter), a
circular smooth muscle.
The LES relaxes to permit food to
enter the stomach and then
contracts to prevent the back-up
of stomach contents
Incomplete closure of the LES
may allow gastric juice to splash
up into the esophagus.

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TEXT
3. STOMACH
The stomach is in the upper left
abdominal quadrant, to the left of
the liver and in front of the
spleen.
It is a J-shaped, saclike organ
that extends from the esophagus
to the duodenum of the small
intestine.
Some digestion takes place in
the stomach, and it also serves
as a reservoir for food so that
digestion may take place

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TEXT
3. STOMACH
The fundus forms the upper
curve of the stomach.
The body of the stomach is the
large, central portion, below
that is antrum.
The pylorus is adjacent to the
duodenum, and the pyloric
sphincter surrounds the
junction of the two organs.
When the stomach is empty,
the mucosa has folds called
rugae.

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TEXT
The mucosa contains gastric
pits, the glands of the stomach
that produce gastric juice.
Gastric juice is mostly water and
contains mucus, pepsinogen,
hydrochloric acid, gastric lipase,
and intrinsic factor.
3. STOMACH

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TEXT
4. SMALL INTESTINE
The small intestine is about 1
inch in diameter and
approximately 10 feet long.
The small intestine extends
from the stomach to the cecum
of the colon.
The duodenum is the first 10
inches and contains the
hepatopancreatic ampulla
(ampulla of Vater), the entrance
of the common bile duct and
the pancreatic duct.

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TEXT
5. LARGE INTESTINE
The large intestine extends from
the ileum of the small intestine to
the anus. It is about 5 feet long
and 2.5 inches in diameter.
The cecum is the first part, and at
its junction with the ileum is the
ileo cecal valve, which prevents
back-up of colon contents into the
small intestine.
Attached to the cecum is the
small, dead-end appendix.

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6. LIVER
The liver fills the right and center
of the upper abdominal cavity. It
has a larger right lobe and a
smaller left lobe.
The blood supply of the liver
differs from that of other organs.
The liver receives oxygenated
blood by way of the hepatic artery.

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TEXT
6. LIVER
The only digestive function of the
liver is the production of bile by
the hepatocytes (liver cells).
Bile flows through small bile
ducts, converges into larger
ones, and leaves the liver by way
of the common hepatic duct.

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TEXT
CARBOHYDRATE
METABOLISM.
AMINO ACID METABOLISM.
LIPID METABOLISM.
SYNTHESIS OF PLASMA
PROTEINS.
PHAGOCYTOSIS BY
KUPFFER CELLS.
FORMATION OF BILIRUBIN.
STORAGE
DETOXIFICATION.
ACTIVATION OF VITAMIN D
AND K.
6. LIVER

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TEXT
7. GALLBLADDER
The gallbladder is a muscular sac
about 3 to 4 inches long located on the
undersurface of the liver.
Bile in the common hepatic duct from
the liver flows through the cystic duct
into the gallbladder, which stores bile
until it is needed in the small intestine.
The gallbladder also concentrates bile
by absorbing water.

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TEXT
The pancreas is about 6 inches long,
and is located posterior to the greater
curvature of the stomach.
The digestive secretions of the
pancreas are produced by exocrine
glands called acini.
The small ducts of these glands unite
to form larger ducts and finally
converge into the pancreatic duct,
which joins the common bile duct to
enter the duodenum at the
hepatopancreatic ampulla.
7. PANCREAS

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TEXT
1. HEALTH HISTORY
GI SYMPTOMS
‣ PAIN
‣ EXPOSURE TO CHEMICALS SUCH AS PAINT,
FUMES, INDUSTRIAL DYES, ACIDS
PESTICIDES TOXIC SUBSTANCES.
STRESSORS

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TRAVEL HISTORY
‣ DEMOGRAPHIC DATA
ALCOHOL ABUSE/ TOBACCO CHEWING/
SMOKING/ USE OF OTHER RECREATIONAL
DRUGS
DISCOMFORT IN FOOD INTAKE,
PAIN IN SWALLOWING
BLOOD TRANSFUSIONS OR BLOOD
PRODUCTS DENTAL PROCEDURES, BODY
PIERCING OR TATTOOING
PRE-EXISTING DISEASE

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1. HEALTH HISTORY
‣ LIVER OR GALLBLADDER DISEASE MAY HAVE PALE OR CLAY
COLOURED STOOLS.
‣ EVIDENCE OF FOUL SMELL, FAT, PUS, BLOOD, OR MUCUS IN STOOL

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BLOODY OR TARRY STOOLS, RECTAL BLEEDING, ABDOMINAL PAIN
PATIENT’S NORMAL BOWEL PATTERN AND CHANGES IN BOWEL
PATTERNS OR HABITS.
ULCERS, CANCER, CROHN’S DISEASE, OR COLITIS; OR AN UNEXPLAINED WEIGHT
LOSS OR GAIN.
MOUTH ULCERS

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1. HEALTH HISTORY
ABDOMINAL DISTENTION IN THE PRESENCE OF NAUSEA AND VOMITING MAY INDICATE
INTESTINAL OBSTRUCTION.
‣ PATIENTS WITH LIVER, GALLBLADDER, OR PANCREATIC DISEASE MAY ALSO COMPLAIN OF
FEELING BLOATED, OF HAVING GAS OR BELCHING FREQUENTLY, OR OF RIGHT UPPER
QUADRANT (RUQ) TENDERNESS.
PREVIOUS GI SURGERIES
PREVIOUS DIAGNOSTIC TESTS

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‣ THE TOXINS PRODUCED BY C. DIFFICILE CAN CAUSE DIARRHEA, COLITITS, TOXIC MEGACOLON,
DEHYDRATION, COLONIC PERFORATION, AND SOMETIMES DEATH.

TEXT
2. MEDICATIONS
‣Non-
steroidal anti-
inflammatory
drugs (NSAIDs),
aspirin, vitamins,
laxatives,
enemas, or
antacids.
Elderly
patients may
use laxatives
regularly and
develop a
dependence
on them.
Over the
counter
preparations
and herbal or
natural
products
Medications
are being
taken with or
without a
physician’s
prescription.

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TEXT
3. NUTRITIONAL ASSESSMENT

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A DIET HISTORY SHOULD INCLUDE
USUAL FOODS AND FLUIDS,
ALLERGIES, APPETITE PATTERNS,
SWALLOWING DIFFICULTY, AND USE
OF NUTRITIONAL AND HERBAL
SUPPLEMENTS
ACID REFLUX CAN BE
ASSESSED BY ASKING
PATIENTS IF THEY
EXPERIENCE REFLUX WITH A
BILE TASTE OR AWAKEN WITH AN
UNPLEASANT TASTE IN THEIR
MOUTH.
ABNORMAL WEIGHT LOSS OR
UNEXPECTED WEIGHT GAIN
CHANGES IN FOOD
TOLERANCE, INCLUDING
THE TYPE OR AMOUNT OF
OFFENDING FOODS

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3. NUTRITIONAL ASSESSMENT

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PATIENTS
WITH
GALLBLADDER
DISEASE MAY REPORT
THAT THEY FEEL
NAUSEATED OR BLOATED
AFTER EATING FRIED
INDIGESTION,
HEARTBURN,
NAUSEA,
VOMITING,
DIARRHEA,
CONSTIPATION, FLATULENCE
INCONTINENCE, ALL OF
WHICH MAY INTERFERE WITH
PROPER NUTRITION.
PATIENTS WITH DISEASE OF
THE LIVER, PANCREAS, OR
GALLBLADDER
COMMONLY HAVE
CHANGES IN APPETITE
SUCH AS ANOREXIA OR
ALTERATIONS IN EATING
PREFERENCES.
THE ELDERLY PATIENT’S
DAILY FOOD INTAKE
SHOULD BE
EXPLORED

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4. FAMILY HISTORY
Family history of close relatives with conditions that may
influence the patient’s GI status is assessed.
Some GI problems such as colon cancer are thought to be
hereditary.
The patient’s history should note whether there is a family
history of liver, pancreas, or gallbladder diseases, such as
diabetes mellitus, alcoholism, cancer, heart disease, or
bleeding tendencies.
These diseases have a high incidence within families.

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5. CULTURAL INFLUENCES
1. ARABS
MANY ARABS EAT FOOD ONLY WITH THEIR
RIGHT HAND BECAUSE IT IS REGARDED AS
THE CLEAN HAND.
THE LEFT HAND, COMMONLY USED FOR
TOILETING, IS CONSIDERED UNCLEAN.
MUSLIM ARABS MAY REFUSE TO EAT MEAT
THAT IS NOT HALAL
2. ASIAN INDIAN
BERIBERI (THIAMINE DEFICIENCY)
IS FOUND IN PEOPLE EMIGRATING FROM
RICE-GROWING AREAS.
PELLAGRA (NIACIN DEFICIENCY), CAUSING
SKIN AND MENTAL DISORDERS AND DIARRHEA,
IS FOUND IN PEOPLE EMIGRATING FROM
MAIZE-MILLET AREAS.
THIAMINE DEFICIENCY IS COMMON
AMONG PEOPLE MOSTLY DEPENDENT
ON RICE.

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1. HEIGHT, WEIGHT, AND BODY MASS INDEX
When the GI system is
assessed, the patient’s
height and weight are
obtained for planning
care.
The patient’s ideal body
weight according to
height is obtained using
current reference charts.

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1. HEIGHT, WEIGHT, AND BODY MASS INDEX
BMI Categories:
Underweight <18.5
Normal weight 18.5–24.9
Overweight 25–29.9
Obesity is BMI of 30 or greater
Excess waist circumferences (for women, more than 35 inches;
for men, more than 40 inches) place people at greater risk for
diabetes and cardiovascular disease.

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ASSESSMENT OF ORAL CAVITY
‣ ≈
Gastrointestinal assessment begins with the oral cavity.
The lips are examined for lesions, abnormal colour, and
symmetry.
With a penlight and tongue blade, the oral cavity is inspected for
inflammation, tenderness, ulcers, swelling, bleeding, and
discolouration.
Any odour of the patient’s breath is noted. A foul odour may
indicate infection or poor oral care.
The tongue should be pink with a rough texture and assessed for
signs of dehydration such as dryness, cracks, or furrows.
The patient’s gums should be pink without swelling, redness, or
irregularities.

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TEXT
The teeth or dentures are examined for loose, broken, or absent
teeth and the fit of the dentures or dental work.
Ill-fitting dentures can affect the patient’s nutritional intake and
obstruct the airway.
Loose teeth can become dislodged and aspirated into the airway.
Broken teeth can be a source of pain and contribute to poor
nutritional intake.
The ability of the patient to perform oral care is noted and included
in the plan of care if there are deficits.
ulcers, sores, or tender areas in the mouth that won’t heal after a
week or two

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TEXT
Bleeding or swollen gums after brushing or flossing
Chronic bad breath
Sudden sensitivity to hot and cold temperatures or beverages
Pain or tooth ache, loose teeth
Receding gums
Pain with chewing or biting
Swelling of the face and cheek
Clicking of the jaw

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1. ABDOMEN INSPECTION.
To inspect the abdomen, patients
are placed in a supine position with
their arms at their sides.
The contour may be rounded, flat,
concave, or distended, depending
on the patient’s body type.
Irregularities in contour may be due
to distention, tumors, hernia, or
previous surgeries
Abdominal pulsatile masses are
noted, they may be visible in thin
persons or they may indicate an
abdominal aortic aneurysm.

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TEXT
The bluish
discoloration of the
umbilicus (Cullen's
sign) or flanks (Grey
Turner's sign).

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TEXT
Inspect the patient’s skin
for bruising, caput medusa
(bluish purple swollen vein
pattern extending out from
the navel), and spider
angiomas (thin reddish
purple vein lines close to
the skin surface).
The skin should be
inspected for striae, or
"stretch marks," and
surgical scars.

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TEXT
Note any petechiae, visible movement or peristalsis, or jaundice (also
called icterus, a yellowing of the skin and the sclerae of the eyes).
Jaundice is a cardinal symptom of liver or gallbladder disease and red
blood cell disorders.
Urine becomes dark, and if bile flow to the bowel is obstructed, stools
will be a light clay color.

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TEXT
2. AUSCULTATION.
When auscultating the patient’s
abdomen, the upper right
quadrant is auscultated first.
Then a clockwise direction is
followed to listen to the other
quadrants.
The stethoscope is pressed
lightly on the abdomen to listen
for bowel sounds, which are
soft clicks and gurgles that
may be heard every 5 to 15
seconds, occurring irregularly
5 to 30 times per minute.

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2. AUSCULTATION.
Bowel sounds are produced
when peristalsis moves air
and fluid through the GI tract
and are categorised as
normal, hyperactive,
hypoactive, or absent.
Bowel sounds are considered
absent if no sounds are
auscultated after listening to
all four quadrants for 2 to 5
minutes in each quadrant.
Abdominal surgery.

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TEXT
2. AUSCULTATION.
Hyperactive bowel sounds are usually rapid, high pitched, and loud
and may occur with hunger or gastroenteritis.
Hypoactive bowel sounds are bowel sounds that are infrequent and
can occur in patients with a paralytic ileus or following surgery.
With a bowel obstruction, a high-pitched tinkling sound that is
proximal to the obstruction.
Auscultation for abdominal bruits is the next phase of abdominal
examination. Bruits are "swishing" sounds heard over major
arteries during systole . The area over the aorta, both renal arteries.
and the iliac arteries should be examined carefully for bruits.

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TEXT
3. PERCUSSION.
Percussion produces a sound that identifies the density of the
organs beneath and is performed by the physician or advanced
nurse practitioner.
Percussion is used to detect fluid, air, and masses in the
abdomen and to identify size and location of abdominal organs
(especially the liver and spleen).
Tympanic high-pitched sounds indicate the location of air, and
dull thuds indicate fluid or solid organs.
Palpation and percussion are used to evaluate ascites. A
rounded, symmetrical contour of the abdomen with bulging
flanks is often the first clue.

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TEXT
3. PERCUSSION.
Palpation of the abdomen in the patient with ascites will often
demonstrate a doughy, almost fluctuant sensation. In advanced
cases the abdominal wall will be tense due to distention from the
contained fluid.
Gas-filled intestines will float to the top of the fluid-filled abdomen.
Thus, in the supine patient with ascites there should be
periumbilical tympany with dullness in the flanks.
A change in the level of dullness is termed shifting dullness and
usually indicates more than 500 ml of ascitic fluid.
Another physical sign of ascites is demonstration of a transmitted
fluid wave. The patient or an assistant presses a hand firmly
against the abdominal wall in the right and tapped from left if a
thrill present, it shows fluid.

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TEXT
3. PERCUSSION.

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The examiner places the flat of the left hand on the right flank and then
taps the left flank with his right hand. In the presence of ascites, a sharp
tap will generate a pressure wave that will be transmitted to the left hand.
Unfortunately, fat will also transmit a fluid wave, and there are frequent
false-positives with this test.
In addition to detection of ascites, percussion can be used to help define the
nature of an abdominal mass. Tympany of an abdominal mass implies that
it is gas filled (i.e., intestine). Percussion is also used to define liver size.
Abdominal girth is measured by placing a tape measure around the
patient’s abdomen at the iliac crest.
Abnormal or absent bowel sounds are important findings and should be
documented and reported to the physician.

TEXT
4. PALPATION.
Light palpation of the
abdomen concludes the
physical assessment.
If the patient is having
pain that area should be
palpated last.
Using the same
quadrant approach as
previously mentioned,
lightly depress the
abdomen not more than
0.5 to 1.0 inch during the
palpation .
Note any muscle
tension, rigidity,
masses, or expressions
of pain.
Deep
palpation of the
abdomen is
done only by
physicians and
highly skilled
nurses such as
nurse
practitioners.
Daily
measurements
should be
obtained and
recorded to
monitor
changes when
abdominal girth
is abnormal.
Abdominal girth is
increased in patients
with distention or
conditions such as
ascites (accumulation
of fluid in the
peritoneal cavity).
The liver is not
normally palpable, but
if enlarged, it may be
felt below the right
lower rib cage.
Rebound tenderness is
determined by
pressing down on the
abdomen a few inches
and quickly releasing
the pressure.

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TEXT
4. PALPATION.
If the patient feels a sharp pain
during this procedure,
appendicitis may be indicated.
Rigidity is thus a clear-cut sign of
peritoneal inflammationRebound
tenderness is the elicitation of
tenderness by rapidly removing
the examining hand.
Spasm or rigidity is the
involuntary tightening of the
abdominal musculature that
occurs in response to underlying
inflammation.

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TEXT
4. PALPATION.
All that needs to be done is smoothly but quickly to lift the palpating
hand off the abdomen and observe for pain, facial grimace, or spasm
of the abdominal wall.
palpation of the left lower quadrant may produce tenderness and
rebound tenderness in the right lower quadrant in appendicitis
(Rovsing's sign). This is called referred tenderness and referred
rebound.
When abdominal masses are palpated, the first consideration is
whether the mass is intra-abdominal or within the abdominal wall.
This can be determined by having the patient raise his or her head or
feet from the examining table.
This will tense the abdominal muscles, thus shielding an intra-
abdominal mass while making an abdominal wall mass more
prominent. If the mass is intra-abdominal, important points are its
size, location, tenderness, and mobility.

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TEXT
4. RECTAL INSPECTION AND PALPATION
The anal canal is approximately 2.5 to 4 cm (1 to 1.6 inches) in
length and opens into the perineum.
Concentric rings of muscle, the internal and external sphincters,
normally keep the anal canal securely closed.
Gloves, water- soluble lubrication, a penlight, and drapes are
necessary tools for the evaluation.
Positions for the rectal examination include knee-chest, left
lateral with hips and knees flexed, or standing with hips flexed
and upper body supported by the examination table.
External examination includes inspection for lumps, rashes,
inflammation, excoriation, tears, scars, pilonidal dimpling, and
tufts of hair at the pilonidal area.
The discovery of tenderness, inflammation, or both should alert
the examiner to the possibility of a pilonidal cyst, perianal
abscess, or anorectal fistula or fissure.

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TEXT
4. RECTAL INSPECTION AND PALPATION
The patient’s buttocks are carefully spread and visually inspected
until the patient has relaxed the external sphincter control.
The patient is asked to bear down, thus allowing the ready
appearance of fistulas, fissures, rectal prolapse, polyps, and
internal hemorrhoids.
Internal examination is performed with a lubricated index finger
inserted into the anal canal while the patient bears down.
The tone of the sphincter is noted, as are any nodules or
irregularities of the anal ring.
Because this is an uncomfortable part of the examination for most
patients, the patient is encouraged to focus on deep breathing and
visualization of a pleasant setting during the brief examination.

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GERONTOLOGIC CONSIDERATIONS

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DIAGNOSTIC STUDIES

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LABORATORY TESTS
IMAGING TESTS
ENDOSCOPIC PROCEDURES
OTHERS PROCEDURES

COMMON LABORATORY TESTS

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2.6-21.2IU/H

TEXT
A. LACTOSE INTOLERANCE BREATH TEST
The patients are given to drink a
lactose heavy beverage
Analyze patient’s breath at regular
intervals to measure the amount
of hydrgen.
If the lactose is not digested by the
body, it will be fermented by
bacteria, leading to a production of
various gases, including
hydrogen.
High levels of hydrogen in the
breath indicate that the body
cannot properly digest lactose

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TEXT
B. HELICOBACTER PYLORI (H. PYLORI) BREATH TEST
The patient will be instructed not
to eat or drink one hour before
the test.
The patient will be connected to a
nasal breath cannula attached to
a Breath Analyser.
After measuring a baseline
sample, The patient will be given
a 5 ounce solution to drink.
If H. pylori is present, CO2 will be
released into the bloodstream
and carried to the lungs where it
will be released and electronically
analyzed if H. pylori is present.
Testing time is about 10 minutes.

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C. FRUCTOSE INTOLERANCE BREATH TEST
This test determines whether The patient
have difficulty absorbing fructose, a sugar
found in onions, artichokes, pears and
wheat. It is also used as a sweetener in
some drinks.
If The patient have symptoms such as
bloating, gas, cramping and diarrhea, it may
be due to fructose malabsorption.This test is
similar to the test for lactose.
Analyze the breath for hydrogen gas after
drinking a cup of fructose dissolved in water.
We obtain more breath results for the next
three hours.
If there is a high presence of hydrogen, that
indicates your body has difficulty absorbing
the fructose.

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TEXT
D. BACTERIAL OVERGROWTH SYNDROME (SIBO)
Bacteria growing uncontrolled in the
small intestine can cause small
intestine bacterial overgrowth (SIBO).
The patient may experience
excessive bloating, gas, cramping
and diarrhea.
The patient drink a sugar solution.
Breathe into a breath analyser.
If bacteria are fermenting in the
patient small intestine, they will
come out in the patient breath.
The doctor can confirm a diagnosis
of SIBO

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TEXT
A. FLAT PLATE OF THE ABDOMEN
A flat plate of the abdomen is an
x-ray examination giving an
anterior-to-posterior view .
Can detect tumors, obstructions,
and strictures.
For an x-ray examination, the
patient should be dressed in a
hospital gown without any metal
such as zippers, belts, or
jewelry.
Pregnant patients or those
thought to be pregnant should
avoid x-ray examinations.

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TEXT
B. UPPER GASTROINTESTINAL SERIES (BARRIUM)
It is an x-ray examination of the
esophagus, stomach, duodenum,
and jejunum using an oral liquid
radiopaque contrast medium
(barium) and a fluoroscope to
outline the contours of the organs.
The patient drinks the thick, chalky
barium while standing in front of a
fluoroscopic tube.
X-ray films are taken in various
positions and at specific intervals
to visualize the outline of the
organs and to note the passage of
Detect strictures,
ulcers, tumors,
polyps, hiatal hernias,
and motility problems.
Cancer
Esophageal varices
Dysphagia ,Achalasia

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TEXT
B. UPPER GASTROINTESTINAL SERIES
B. UPPER GASTROINTESTINAL SERIES (BARRIUM)

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NURSING INTERVENTIONS
NPO from midnight
Avoid smoking, chewing gum and using
mints because they can stimulate gastric
motility
Morning dose Oral medications should
be withheld
Follow up care after the procedure to
ensure that the patient has eliminated
most of the ingested barium
Provide adequate fluids to facilitate
evacuation of stool and barium
A laxative is usually ordered after the
procedure to expel the barium and
prevent constipation or a barium
impaction.

TEXT
C.LOWER GASTROINTESTINAL SERIES (BARIUM)
Tumors
Diverticula
Stenosis
Obstructions
Inflammation
Ulcerative colitis
Polyps can be detected.

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TEXT
C.LOWER GASTROINTESTINAL SERIES (BARIUM
The lower GI series (barium enema)
is performed to visualize the position,
movements, and filling of the colon.
The patient is placed on a low-
residue or clear liquid diet for 2 days
before the test to empty the bowel.
Laxatives, bowel-cleansing solutions
(such as GoLYTELY), and enemas may
be administered the evening before
the test. GoLYTELY is chilled and
drunk full strength with no ice, 8 oz
every 10 minutes for a total of 4 L.
Inform the patient that a watery
diarrhea will begin in about 1 hour
and continue up to 5 hours as the
bowel is cleared. This is necessary
for adequate visualization during the

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TEXT
C.LOWER GASTROINTESTINAL SERIES (BARIUM)
If the patient has active inflammatory
disease of the colon or suspected perforation
or obstruction, a barium enema is
contraindicated. Active GI bleeding may also
prohibit the use of laxatives and enemas.
During the procedure, barium is instilled
rectally and x- ray films are taken with or
without fluoroscopy.
The patient may experience some abdominal
cramping and an urge to have a bowel
movement during the procedure. The patient
is told to take slow, deep breaths and to
tighten the anal sphincter.
The rate of flow of the barium is slowed until
the cramping diminishes. The procedure
takes about 15 minutes, and the patient is
allowed to use the bathroom immediately

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TEXT
C.LOWER GASTROINTESTINAL SERIES (BARIUM
Nursing interventions
Preparation of patient includes emptying and cleansing the lower
bowel
Low residue diet 1 to 2 days before the test, a clear liquid diet and a
laxative in the evening before, NPO after midnight and cleansing
enemas until returns are clear the following morning
The nurse ensures that barium enemas are scheduled before any
upper GI studies
Barium enemas are contraindicated if the patient has active
inflammatory disease of the colon, or patients with signs of perforation
or obstruction

70

TEXT
D. COMPUTED TOMOGRAPHY
Computed tomography (CT) uses a
beam of radiation to allow three-
dimensional visualization of
abdominal structures.
Diluted oral barium or other contrast
media may be used to distinguish
normal bowel from abnormal
masses.
The patient may have a clear liquid
diet the morning of the test.
If a contrast medium is to be used,
any allergies to iodine or contrast
media are noted, a consent form is
signed, and the patient is NPO for 2 to
4 hours before the procedure.

71

TEXT
D. COMPUTED TOMOGRAPHY
A CT scan is performed with or without
oral or IV contrast, but the enhancement of
the study is greater with the use of a
contrast agent
Any allergies to contrast agent, iodine or
shell fish, the patients current serum
creatinin level and pregnancy status in
females must be determined before
administration of an contrast agent
Kidney protective measures include the
administration of IV sodium bicarbonate 1
hour before and 6 hours after iv contrast
and oral acetylcysteine (mucomist) before
or after the study
Hydrate the patient after the procedure to
prevent renal failure

72

TEXT
E. NUCLEAR SCANNING
Nuclear scanning involves injecting
a patient with a small amount of
radioactive isotope.
The scan may be called a
cholescintigraphic, DISIDA, HIDA, or
IDA scan, depending on the
radioactive isotope and exact
procedure that is used.
Prior to the procedure, the patient
fasts and does not chew gum for at
least 2 to 6 hours.
After the injection, the isotope is
secreted into the bile and goes
anywhere the bile goes.
Visualization of these areas occurs
about 60 minutes after the IV
injection.

73

TEXT
F. ANGIOGRAPHY
Angiography may be ordered for patients with symptoms of arterial
occlusive disease of the hepatic, biliary, and pancreatic arterial vessels.
It is used to evaluate suspected neoplasms in these organs.
Medications that might cause bleeding, such as aspirin, NSAIDs, or
anticoagulants, are stopped about 1 week prior to the procedure.
A contrast medium is injected and identifies abnormalities of vascular
structure and function, masses, and show bleeding sites.
Prior to the procedure, the patient usually is NPO for 2 to 8 hours.
The injection of contrast medium is done about 1 hour before the
examination. Radiographs are taken about every 20 minutes for 1 hour
or until the structures are readily viewed.
The radiopaque material is iodine based, so ask the patient about any
allergies to iodine. Following the procedure, observe for bleeding at the
puncture site.

74

TEXT
Ask if allergies to contrast media or iodine. NPO for 2–8 hours
prior to test.
Stop medications that interfere with clotting about 1 week
prior to exam.
Assess for bleeding and hematoma formation after the exam.
F. ANGIOGRAPHY

75

TEXT
G. LIVER SCAN
A liver scan involves injecting a slightly radioactive medium that is
taken up by the liver.
An instrument is passed over the liver that records the amount of
material taken up by the liver and forms a composite “picture” of the
liver.
The physician may be able to determine tumors, masses, and
abnormal size and patterns of blood vessel. The procedure takes a
short time.

76

TEXT
H. ULTRASONOGRAPHY
The use of high-frequency sound
waves through the abdomen
allows the physician to view soft-
tissue structures.
The sound waves reflect varying
images based on the density of
the soft tissues in the abdomen.
The patient is asked not to take
anything by mouth after midnight
on the day of the examination.

77

TEXT
H. ULTRASONOGRAPHY
A clear gel is applied to the
abdomen and to the transducer
on the sonograph.
The gel improves the conduction
of sound waves and thus
improves the images obtained.
The transducer is placed on the
skin and moved over the
abdomen while the technician
views the sonograph screen and
takes periodic pictures.
The procedure takes about half
an hour and requires no follow-
up care.

78

TEXT
I.PERCUTANEOUS LIVER BIOPSY
If less invasive tests do not aid in diagnosis of liver
disease, a liver biopsy may be done.
This may be done to identify cancer, cirrhosis, hepatitis,
or other causes of liver disease.
The physician generally inserts a needle through the
skin and into the liver to withdraw a small sample for
examination.
This procedure places the patient at risk for bleeding
because the liver is highly vascular and because many
patients with liver disease have reduced clotting ability.
Before the biopsy, ensure that the patient understands
the procedure and that a consent has been signed if
required by institution policy.
You should also ensure that laboratory tests, such as a
complete blood cell count and coagulation studies, have
been completed and reviewed as ordered.
The patient may be ordered nothing by mouth for 6 to 8
hours before the procedure. Baseline vital signs are
taken, and a sedative is given if ordered.

79

TEXT
During the procedure the nurse assists the physician to position the
patient on his or her back or left side and assists the patient to hold very
still while the needle is being introduced.
The physician may also ask the patient to exhale and hold his or her
breath during the needle insertion.
After the biopsy, the patient should remain on bedrest for 24 hours.
The patient lies on the right side for the first 2 hours with a small pillow
or rolled towel under the biopsy site to provide pressure and prevent
bleeding.
Vital signs and the site are monitored for signs of bleeding.
The patient is advised to avoid coughing or straining.

80

TEXT
Signed consent.
Ensure laboratory tests such as CBC, coagulation studies have
been ordered and reviewed.
NPO for 6–8 hours prior to procedure.
Rest several hours after procedure; restricted activity 1 day.
Monitor biopsy site pressure dressing for bleeding. Monitor vital
signs after procedure.
Coughing and straining avoided after the procedure.
Medicate for pain.

81

ENDOSCOPIES

83
Endoscopy uses a tube and a fiberoptic system (endoscope) for
observing the inside of a hollow organ or cavity.
In addition to viewing the structures, the physician can also remove
polyps, take biopsy specimens, or coagulate bleeding sites that are
identified.
A consent form must be signed for any endoscopic procedure.

TEXT
Inflammation
Cancer
Bleeding
Ulcers
Injury
Infection
A. ESOPHAGOGASTRODUODENOSCOPY PROCEDURE

84

TEXT
A. ESOPHAGO GASTRODUODENOSCOPY
Visualizes the esophagus ,the stomach
and the duodenum.
The procedure is explained to the
patient.
Patients may be asked to sign an
operative consent form, and a
preoperative checklist may be
necessary, depending on institution
policy.
To prevent aspiration of stomach
contents into the lungs if vomiting
occurs, the patient is NPO for 8 to 12
hours before the procedure.
Sedatives such as diazepam (Valium) or
midazolam (Versed) may be given
before the procedure to help relax the
patient.

85

TEXT
COMPLICATIONS
Midesophageal perforation
can cause referred
substernal or epigastric pain.
Blood loss secondary to
perforation can lead to
hematoma formation, which
in turn can result in cyanosis
and referred back pain.
Distal esophageal perforation
may result in shoulder pain,
dyspnea, or symptoms
similar to those of a
perforated ulcer.
The patient may have a sore
throat for a few days.

86

TEXT
NPO for 8 hours prior to the
examination
The patient is given a local
anaesthetic gargle or spray.
sedation to be given like inj
midazolam.
Atropine may be administered to
reduce secretions.
The patient is positioned in the left
lateral position
After gastroscopy, assessment
includes level of consciousness, vital
signs, oxygen saturation, pain level,
and monitoring for signs of
perforation (pain, bleeding, rapidly
elevated temperature)

87

https://youtu.be/fV3M0jSegOQ

88

TEXT
Biliary Obstruction – suspected or known
Pancreatic Obstruction – suspected or
known Evaluation of signs/symptoms
suggesting pancreatic malignancy
Evaluation of idiopathic pancreatitis
Evaluation of sphincter of oddi by
manometry
Stent placement
High risk pts with large unremovable
common duct stones
C. ENDOSCOPIC RETROGRADE CHOLANGIO PANCREATOGRAPHY

89

TEXT
Visualize the liver, gallbladder, and pancreas.
The procedure allows both direct viewing and
use of contrast medium. An endoscope is
passed through the esophagus to the
duodenum, where dye is injected that outlines
the pancreatic and bile ducts.
The patient is prepared for an ERCP in the same
manner as for an EGD, with nothing by mouth
after 8 p.m. the night before the examination.
The patient is asked about allergies to iodine.
Ensure that any ordered laboratory studies, such
as a prothrombin time, have been done before
the procedure and that the patient has removed
dentures.
The nurse is alert to patient complaints such as
increased right upper quadrant pain, fever, or
chills, which may indicate infection.
C. ENDOSCOPIC RETROGRADE CHOLANCHOLANGIO PANCREATOGRAPHY

90

TEXT
NPO after 8 PM the night before
exam.
Check prothrombin time prior to
procedure.
Monitor for pain, fever, chills
which could indictate infection.
Monitor for onset of pancreatitis.
C. ENDOSCOPIC RETROGRADE CHOLANCHOLANGIO PANCREATOGRAPHY

91

TEXT
Ulcerations
punctures
lacerations
tumors
hemorrhoids
polyps
fissures
fistulas
abscesses can be
detected.
D. PROCTOSIGMOIDOSCOPY

92

ANOSCOPY

93
An anoscopy is a procedure that uses a small tube
called an anoscope to view the lining of your anus
and rectum.
A related procedure called high resolution anoscopy
uses a special magnifying device called a colposcope
along with an anoscope to view these areas.
fetal position on a table,
insert the anoscope, which is lubricated with K-Y
Jelly and visualise
Indications
• cancer
• tears in the tissue called anal fissures
• hemorrhoids (swollen veins around the anus and/or
rectum)
• rectal polyps

TEXT
examination of the distal sigmoid colon, the
rectum, and the anal canal using a rigid or
flexible endoscope
Malignancies at an early stage can be
detected, so an annual examination for
patients 40 years old and older is
recommended.
Proctosigmoidoscopy requires the lower
bowel to be cleaned out.
The patient usually receives a clear liquid diet
24 hours before the test and a laxative the
night before the test.
The morning of the procedure a warm tap-
water enema or sodium biphosphate (Fleet)
enema is given.
Bowel preparation may not be ordered for
patients with bleeding or severe diarrhea.

94

TEXT
Specimens are labeled and
sent to the pathology
laboratory immediately for
examination.
After the procedure, the
patient is allowed to rest for a
few minutes in the supine
position to avoid orthostatic
hypotension when standing.
Pain and flatus may occur
from instilled air.
The patient is observed for
signs of perforation such as
bleeding, pain, and fever.

95

TEXT
These examinations require
only limited bowel preparation,
including a warm tap water
enema or Fleet’s enema until
returns are clear.
Dietary restrictions are not
necessary, and sedations not
usually not required.
During the procedure the nurse

96

TEXT
E. COLONOSCOPY INDICATIONS
Colonoscopy provides visualization of the lining
of the large intestine to identify abnormalities
through a flexible endoscope, which is inserted
rectally.
A biopsy specimen may be obtained or polyps
be removed during the colonoscopy.
The patient receives a liquid diet 24 hours
before the test and is NPO after midnight
before the procedure.
A bowel preparation solution such as
GoLYTELY is given the night before the
procedure. Drinking this solution can be
unpleasant for the patient.

97

TEXT
E. COLONOSCOPY.
The patient is encouraged to relax and take slow
deep breaths through the nose and out the mouth.
Vital signs are monitored throughout the procedure
to watch for a vasovagal response, which can lead to
hypotension and bradycardia.
After the procedure, the patient is monitored until
stable.
Complications such as hemorrhage or severe pain
are reported.
When giving the patient discharge instructions,
explain that flatus and cramping will occur for
several hours after the test, that blood may be
present in the stool if a biopsy specimen was taken,
and to report problems to the physician.

98

TEXT
E. COLONOSCOPY.
Adequate colon cleansing provides optimal
visualization and decreases the time needed
for procedure. The physician may prescribe a
laxative two nights prior the examination and
enema until the return is clear the morning of
the test.
The patient maintains a clear liquid diet
starting at noon the day before the procedure.
A sodium phosphate tablet can be used for
colon cleansing prior to colonoscopy.
Informed consent is obtained by the
practitioner before the patient is sedated.
Before the examination, an opoid analgesic
agent or sedative (eg.,midazolam) is
administered to provide moderate sedation
and relieve anxiety during the procedure.

99

TEXT
F.ENDOSCOPIC ULTRASONOGRAPHY
Endoscopic ultrasonography is
performed through the endoscope
using sound waves.
Tumors can be detected in various GI
structures and organs.
Preprocedure and postprocedure care
are similar to those for endoscopic
care.
During the test the patient must lie
still while a transducer with gel is
moved back and forth over the
abdomen to produce images.

100

TEXT
F.ENDOSCOPIC ULTRASONOGRAPHY
The patient is instructed to fast for 8 to 12
hours before ultrasound testing to decrease
the amount of gas in the bowel.
If gallbladder studies are being performed,
the patient should eat fat free meal evening
before the test.
If barium studies are to be performed, they
should be scheduled after USG.
Otherwise barium could interfere with the
transmission of sound waves. Patient who
receive moderate sedations are observed
for about 1 hour to assess for level of
consciousness, orientation and ability to
ambulate.

101

TEXT
G. SMALL BOWEL STUDIES
There are several methods available
for visualization of the small
intestine, including capsule
endoscopy and double balloon
endoscopy
Capsule endoscopy allows the non
invasive visualization of the entire
small intestine, particularly useful in
the evaluation of obscure GI bleeding.
The technique consists of the patient
swallowing a capsule embedded with
a wireless miniature camera, a light
source, and an image transmission
system. Images are transmitted from
the end of the capsule to a recording
device worn on a belt

102

TEXT
G. SMALL BOWEL STUDIES
The capsule is the size of a large vitamin
pill (26mm long, 11mm wide, 3.7g in
weight). It is propelled through the
intestine by peristalsis. This diagnostic
procedure is limited by its inability to allow
for obtaining tissue samples for histology
and for endoscopic therapy.
Double balloon enteroscopy, also known as
push and pull enteroscopy, has made it
possible to visualize the mucosa of the
entire small bowel as well as carry out
diagnostic and therapeutic internventions
The endoscope is advanced using a push
and pull technique that involves alternately
inflating and deflating the balloons, causes
telescoping of the small intestine on to the
overtube

103

TEXT
H.ENDOSCOPY THROUGH AN OSTOMY
Endoscopy through an ostomy stoma is useful for visualizing a
segment of the small or large intestine and may be indicated to
evaluate the anastamosis for recurrent disease, or to visualize and
treat bleeding in a segment of the bowel.

104

TEXT
A. GASTRIC ANALYSIS
To determine the cause of recurrent
peptic ulcer disease:
To determine the cause of raised
fasting serum gastrin level:
To support the diagnosis of
pernicious anemia (PA)
To distinguish
between benign and malignant ulcer
To measure the amount of acid
secreted in a patient
with symptoms of peptic ulcer
dyspepsia but normal X-ray findings
To decide the type of surgery to be
performed in a patient with peptic
ulcer

106

TEXT
A. GASTRIC ANALYSIS
The patient is NPO after midnight the night before the test.
For the procedure, a nasogastric (NG) tube is inserted and the contents
of the stomach are suctioned out through the tube using a syringe.
The NG tube is connected to wall suction, and stomach contents are
collected every 15 minutes for 1 hour.
The specimens are labeled according to the time they were collected
and the order in which they were obtained.
The gastric acid is tested for pH using indicator paper or a pH meter.
The amount of gastric acid is also measured. Too much hydrochloric
acid may indicate a peptic ulcer; too little could be a sign of cancer or
pernicious anemia.
The gastric acid stimulation test measures the amount of gastric acid
for 1 hour after subcutaneous injection of a histamine drug.

107

TEXT
B. GASTRIC MANOMETRY.

108
This test measures electrical and
muscular activity in the stomach. The
healthcare provider passes a thin tube
down the patient's throat into the
stomach.
This tube contains a wire that takes
measurements of the electrical and
muscular activity of the stomach as it
digests foods and liquids.
This helps show how the stomach is
working, and if there is any delay in
digestion.
Evaluation of noncardiac chest pain or
esophageal symptoms not diagnosed by
endoscopy

TEXT
C. ESOPHAGEAL MANOMETRY.
This test helps determine the
strength of the muscles in the
esophagus. It is useful in
evaluating gastroesophageal
reflux and swallowing
abnormalities.
A small tube is guided into the
nostril, then passed into the
throat, and finally into the
esophagus. The pressure the
esophageal muscles produce
at rest is then measured.
‣ Diffuse esophageal spasm. This rare swallowing
problem is characterized by multiple, forceful, poorly
coordinated muscle contractions of your esophagus.
‣ Achalasia. This uncommon condition occurs when
your lower esophageal sphincter muscle doesn't
relax properly to let food enter your stomach.
‣ Scleroderma. In many people with this rare
progressive disease, the muscles in the lower
esophagus stop moving, leading to severe
gastroesophageal re
fl
ux

109

TEXT
D. ANORECTAL MANOMETRY.
This test helps determine
the strength of the muscles
in the rectum and anus.
Anorectal manometry is
helpful in evaluating
anorectal malformations
and Hirschsprung disease,
among other problems.
A small tube is placed into
the rectum to measure the
pressures exerted by the
sphincter muscles that ring
the canal.
Anal incontinence
Distal constipation
Preoperative evaluation
before sphincteroplasty
or surgical rectocele
repair

110

TEXT
E. LAPAROSCOPY
Mass or tumor
Fluid in the abdominal cavity
Liver disease
Degree to which a
particular cancer has
progressed
This test uses a long, thin tube
with a tiny camera and a light
on the end (laparoscope). It is
put into a small cut (incision) in
the belly (abdomen). It can
check the contents of the
abdomen and remove tissue
samples.

111

TEXT
F.HEPATOBILIARY SCINTIGRAPHY
Gallbladder inflammation (cholecystitis)
Bile duct obstruction
Congenital abnormalities in the bile
ducts, such as biliary atresia
Postoperative complications, such as
bile leaks and fistulas
Assessment of liver transplantThis is a
nuclear medicine imaging test. It is used
to view the liver, bile ducts, gallbladder,
and upper part of the small intestine.
This may also be called a HIDA or PIPIDA
scan. This depends on which nuclear
isotope is used.

112

TEXT
G. MAGNETIC RESONANCE
This is a type of MRI. It uses
radio waves and magnets to
take pictures of the bile
ducts and organs.

113

TEXT
H. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
A needle is put through
the skin and into the liver.
A contrast dye is injected
through the needle. This
lets the bile duct be seen
on an X-ray.

114

TEXT
I. POSITRON EMISSION TOMOGRAPHY (PET SCAN)
PET scans produce images of then
body by detecting the radiation
emitted from radioactive substances.
The radioactive substances are
injected in to the body IV and are
usually tagged with a radioactive
atom such as carbon11, flurine18,
oxygen 13.
The atoms decay quickly, do not harm
the body, have lower radiation levels
than a typical x ray or CT scan, and
are eliminated through urine or
faeces.

115

TEXT
J. DNA TESTING
Preclinical diagnosis, and
prenatal diagnosis to risk
for certain GI disorders (e.g.,
gastric cancer, lactose
deficiency, inflammatory
bowel disease, colon cancer.
DNA testing allows
clinicians to prevent (or
minimize) disease by
intervening before its onset
and to improve therapy.
Counselling to learn about
the disease and options for
preventing and treating the
disease, receive support in
coping with the situation.

116

TEXT
SUMMARY AND CONCLUSION

117
In order to reach a diagnosis for digestive disorders, a thorough and accurate
medical history will be taken by your physician, noting the symptoms you
have experienced and any other pertinent information. A physical
examination is also done to help assess the problem more completely.There
is virtually no risk with the upper and lower GI tests, unless they are
repeated several times within a few months' time, when radiation then
becomes a risk. Although radiation exposure is minimal, it is greater than for
standard still X-rays. Fluoroscopic gastrointestinal examinations are
performed by registered and licensed technologists and board-certified
radiologists who carefully limit the X-ray to the specific area to be diagnosed
so that surrounding parts of the body are not exposed. A lead apron may be
worn during the procedure to protect the parts of the body that are not being
studied.

TEXT
RESEARCH

118
How can gastro-intestinal tuberculosis diagnosis be improved? A prospective cohort study
Abstract
Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We
aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could
distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests.
Methods
We conducted a prospective cohort study of hospitalized patients in Kota Kinabalu, Malaysia, with suspected
gastrointestinal TB. We recorded clinical and laboratory characteristics and outcomes. Tissue samples were submitted
for histology, microscopy, culture and GeneXpert MTB/RIF®. Patients were followed for up to 2 years.
Conclusions
The prospective design provides important insights for clinicians managing gastrointestinal TB. We recommend wider
implementation of high-performing diagnostic tests such as GeneXpert® on extra-pulmonary samples. Gastrointestinal
TB remains diagnostically challenging. An algorithm developed to classify patients presenting with suspected
gastrointestinal TB cases was specific but insensitive. Testing of such algorithms in larger populations of patients with
suspected gastrointestinal TB will reveal whether a composite clinical score could help categorize patients while awaiting,
or in the absence of, further diagnostic information. Wider implementation of existing high-performing diagnostic tests
such as GeneXpert® on extra-pulmonary samples, and ongoing investment in new diagnostics development, is needed.
We recommend increased access to and uptake of GeneXpert® on gastrointestinal samples in suspected TB cases.

TEXT
BIBLIOGRAPHY

119
Brunner & suddarth’s, Medical-Surgical nursing,(2015) 10th edition, Page 978-990
Joyce.M.Black, Medical-Surgical nursing,(2020) 6th edition 560-590
Williams.S. Linda,Understanding Medical Surgical Nursing, 3rd edition(2007), page 678-690
Taylor Carol, Fundamentals of nursing(2010), 5th edition
Chintamani, Lewis Medical-surgical nursing,( 2011), 2nd edition,CBS Publications
Priscilla Lemonne, Medical Surgical Nursing, 2nd edition
http://www.jpma.org.pk/full_article_text.php?article_id=6346
https://www.insideradiology.com.au/image-guided-liver-biopsy/
https://badgut.org/information-centre/diagnostic-tests-and-procedures/
https://www.mometrix.com/academy/diagnostic-procedures-of-the-gastrointestinal-system/
https://badgut.org/information-centre/diagnostic-tests-and-procedures/
https://www.urmc.rochester.edu/encyclopedia/content.aspx?
ContentTypeID=85&ContentID=P00364

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