Guide — Gastrointestinal
Gastrointestinal Assessment
Systematic GI assessment follows a specific sequence: inspection → auscultation → percussion → palpation. This order prevents artificially stimulating bowel sounds before listening.
11 min read · Gastrointestinal
Educational use only. This content is intended for nursing students and exam preparation. Clinical decisions require licensed professional judgment and institutional protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Subjective Assessment
Begin with a thorough history before physical examination. Use OLDCARTS for any GI complaint:
| Component | Key Questions |
|---|---|
| Onset | When did it start? Sudden or gradual? Relation to meals? |
| Location | Where is the pain? RUQ, LUQ, RLQ, LLQ, epigastric, umbilical, suprapubic? Does it radiate? |
| Duration | Constant or intermittent? How long has it been present? |
| Character | Sharp, dull, cramping, burning, colicky, pressure? |
| Aggravating factors | Food, position, activity, bowel movements? |
| Relieving factors | Eating, fasting, antacids, defecation, position change? |
| Treatment tried | OTC antacids, laxatives, anti-diarrheals, PPIs? |
| Symptoms associated | Nausea, vomiting, diarrhea, constipation, hematochezia, melena, hematemesis, jaundice, weight loss? |
Abdominal Regions & Pain Localization
The abdomen is divided into four quadrants for systematic assessment. Pain location narrows the differential diagnosis.
| Region | Common Pain Sources |
|---|---|
| RUQ (Right Upper Quadrant) | Liver, gallbladder, bile ducts, right kidney, hepatic flexure of colon |
| LUQ (Left Upper Quadrant) | Stomach, spleen, left kidney, pancreas (tail), splenic flexure |
| RLQ (Right Lower Quadrant) | Appendix, cecum, right ovary/tube (females), right ureter |
| LLQ (Left Lower Quadrant) | Sigmoid colon, left ovary/tube (females), left ureter, descending colon |
| Epigastric | Stomach, duodenum, pancreas, aorta, cardiac referred pain |
| Periumbilical | Early appendicitis, small intestine, aorta |
| Suprapubic | Bladder, uterus, sigmoid colon, ovaries |
Inspection
Inspect the abdomen with the patient supine, arms at sides, knees slightly flexed. Observe in good lighting for contour, symmetry, skin changes, and movement.
Contour
- ✦Flat (normal)
- ✦Scaphoid (concave — malnutrition)
- ✦Rounded/protuberant (common)
- ✦Distended (ascites, obstruction, obesity, gas)
Skin Changes
- ✦Jaundice — liver disease
- ✦Caput medusae (dilated veins) — portal HTN
- ✦Striae — stretching or Cushing's
- ✦Surgical scars, ostomy stomas
Symmetry
- ✦Asymmetry may suggest mass or organomegaly
- ✦Visible peristaltic waves — consider bowel obstruction
- ✦Umbilical protrusion — hernia or ascites
Movement
- ✦Restricted abdominal movement with breathing — peritonitis
- ✦Visible epigastric pulsations — aortic aneurysm
- ✦Flank fullness bilaterally — ascites
Auscultation
Auscultation precedes percussion and palpation to avoid artificially altering bowel sounds. Listen in all four quadrants with the diaphragm of the stethoscope.
| Finding | Characteristics | Clinical Significance |
|---|---|---|
| Normal | 5–30 clicks/gurgles per minute, irregular | Normal peristalsis — present in all 4 quadrants |
| Hypoactive (<5/min) | Decreased or distant sounds | Ileus, postoperative state, peritonitis, narcotics |
| Absent | No sounds after 5 min per quadrant | Paralytic ileus, peritonitis, complete obstruction |
| Hyperactive (>30/min) | High-pitched, rushing, borborygmi | Diarrhea, early obstruction, GI bleed, gastroenteritis |
| Bruit (vascular) | Whooshing over aorta or renal arteries | Aortic aneurysm, renal artery stenosis |
| Friction rub | Leathery/grating over liver or spleen | Hepatic or splenic inflammation, tumor, infarct |
Absent bowel sounds require 5 minutes of continuous listening per quadrant before documentation. Always document the specific character, frequency, and quadrant location.
Percussion
Percussion identifies organ size, air/fluid distribution, and masses. Percuss all four quadrants, then assess specific organ borders and assess for ascites.
| Sound | Meaning | Where Expected |
|---|---|---|
| Tympany (hollow) | Air-filled bowel — normal | Most of abdomen |
| Dullness (flat) | Solid organ or fluid | Liver (RUQ), spleen (LUQ), ascites (flank) |
| Shifting dullness | Fluid shifts with position change | Ascites — dullness shifts >3 cm when patient turns |
| Fluid wave | Fluid transmission across abdomen | Significant ascites — tap one flank, feel wave opposite |
| Liver span | Normal: 6–12 cm at midclavicular line | Enlarged = hepatomegaly; decreased = atrophy or failure |
Palpation
Always begin with light palpation and progress to deep. Start away from areas of reported pain. Watch the patient's face for nonverbal pain cues.
| Finding | Description | Significance |
|---|---|---|
| Guarding | Voluntary or involuntary abdominal muscle rigidity | Involuntary guarding = peritoneal irritation (surgical emergency) |
| Rigidity (board-like) | Rock-hard abdominal wall | Perforated viscus, peritonitis — surgical emergency |
| Rebound tenderness | Pain worse on release of pressure (Blumberg's sign) | Peritoneal inflammation — appendicitis, peritonitis |
| Murphy's sign | Inspiratory arrest when pressing RUQ during inspiration | Acute cholecystitis — highly suggestive when positive |
| Rovsing's sign | RLQ pain when palpating LLQ | Appendicitis |
| Psoas sign | RLQ pain with right hip extension | Appendicitis (retrocecal appendix) |
| McBurney's point | Tenderness 1/3 from ASIS to umbilicus | Classic appendicitis location |
Red Flag GI Findings
Immediate Emergency
- ✦Rigid, board-like abdomen (perforated viscus)
- ✦Rebound tenderness + fever + tachycardia (peritonitis)
- ✦Hemodynamic instability with GI bleed
- ✦Absent bowel sounds + distension (obstruction/ileus)
Urgent Assessment
- ✦Involuntary guarding
- ✦Murphy's sign positive (cholecystitis)
- ✦Charcot's triad: RUQ pain + fever + jaundice (cholangitis)
- ✦Hematemesis or large-volume hematochezia
Concerning Symptoms
- ✦Unintentional weight loss >10%
- ✦Progressive dysphagia
- ✦Nocturnal symptoms waking from sleep
- ✦Persistent vomiting with inability to tolerate fluids
Stool Abnormalities
- ✦Melena (black, tarry) — upper GI bleed
- ✦Hematochezia (bright red blood) — lower GI bleed
- ✦Clay-colored stool — biliary obstruction
- ✦Steatorrhea (fatty, oily) — pancreatic disease/malabsorption
NCLEX Pearls
- ✦GI assessment order: Inspection → Auscultation → Percussion → Palpation. Auscultation BEFORE palpation to avoid altering bowel sounds.
- ✦Absent bowel sounds require 5 minutes of listening per quadrant — never document absent after a brief listen.
- ✦Involuntary guarding = peritoneal irritation = potential surgical emergency. Voluntary guarding is a conscious muscle contraction — different significance.
- ✦Rebound tenderness (Blumberg's sign) = pain worse on release than on application of pressure — peritoneal irritation.
- ✦Murphy's sign (cholecystitis): patient stops breathing in on inspiration when pressed under the right costal margin.
- ✦McBurney's point = 1/3 from ASIS to umbilicus = classic appendicitis tenderness location.
- ✦Charcot's triad = RUQ pain + fever + jaundice = ascending cholangitis (biliary emergency — needs urgent decompression).
- ✦Shifting dullness and fluid wave on percussion = ascites — seen with cirrhosis, heart failure, nephrotic syndrome.
- ✦Caput medusae (dilated periumbilical veins) + jaundice + ascites = portal hypertension from cirrhosis.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American College of Gastroenterology (ACG) / AGA · ASPEN (nutrition support). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →