Chapter 26 Gastrointestinal Disorders 1 Learning Objectives Describe the incidence, morbidity, and mortality rates of GI emergencies Identify risk factors predisposing to GI emergencies Discuss the anatomy, physiology of organs, structures related to GI diseases 2 Learning Objectives (Cont d) Discuss the pathophysiology of inflammation, relation to acute abdominal pain Define somatic pain related to gastroenterology Define visceral pain related to gastroenterology 3 1
Learning Objectives (Cont d) Define referred pain related to gastroenterology Differentiate hemorrhagic from nonhemorrhagic abdominal pain Discuss signs, symptoms of local inflammation relative to acute abdominal pain 4 Learning Objectives (Cont d) Discuss signs, symptoms of peritoneal inflammation relative to acute abdominal pain List signs, symptoms of general inflammation relative to acute abdominal pain Based on assessment findings, differentiate local, peritoneal, and general inflammation as related to acute abdominal pain 5 Learning Objectives (Cont d) Discuss the following autoimmune disorders: Systemic lupus erythematosus Insulin-dependent diabetes mellitus Rheumatoid arthritis Celiac disease Chronic active hepatitis Multiple sclerosis Define allergic reaction 6 2
Learning Objectives (Cont d) Define anaphylaxis Describe the questioning technique with a focused history in a patient with abdominal pain Describe the technique for a comprehensive physical examination on a patient with abdominal pain Define abdominal wall hernia 7 Learning Objectives (Cont d) Define incarcerated hernia Etiology, signs/symptoms, treatment of incarcerated hernia Define esophagitis Describe common causes, signs/symptoms, treatment of esophagitis 8 Learning Objectives (Cont d) Define candidiasis of the esophagus Describe the etiology, signs/symptoms, treatment of candidiasis esophagitis Describe gastroesophageal reflux Define the cause of gastroesophageal reflux 9 3
Learning Objectives (Cont d) Describe the symptoms of reflux, how they differ from other forms of esophagitis Describe the treatment for gastroesophageal reflux Define, provide examples of caustic substances 10 Learning Objectives (Cont d) Define the type of necrosis that occurs with acidic, alkali substances Describe the importance of obtaining a history in caustic ingestion Describe pertinent parts of the physical examination, treatment in caustic ingestion 11 Learning Objectives (Cont d) Define Boerhaave syndrome Describe signs/symptoms, treatment of Boerhaave syndrome Define esophageal foreign body Describe signs/symptoms, treatment of esophageal foreign body 12 4
Learning Objectives (Cont d) Define hiatal hernia Describe the signs, symptoms of hiatal hernia Define Mallory-Weiss syndrome Describe the signs/symptoms, treatment of Mallory-Weiss syndrome 13 Learning Objectives (Cont d) Define esophageal stricture and stenosis Describe the signs/symptoms, treatment of esophageal stricture, stenosis Define tracheoesophageal fistula Describe the signs/symptoms, treatment of tracheoesophageal fistula 14 Learning Objectives (Cont d) Define esophageal varices Discuss the pathophysiology of esophageal varices Describe the signs/symptoms, treatment of esophageal varices 15 5
Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with esophageal varices Define cirrhosis Describe the pathophysiology of cirrhosis 16 Learning Objectives (Cont d) Describe the signs/symptoms, treatment of cirrhosis Define hepatorenal failure Describe the signs/symptoms, treatment of hepatorenal failure Define acute hepatitis 17 Learning Objectives (Cont d) Discuss the pathophysiology of acute hepatitis Recognize the signs/symptoms related to acute hepatitis Describe the management of acute hepatitis 18 6
Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and to implement a treatment plan for a patient with acute hepatitis Define hepatic tumors Describe signs/symptoms, treatment of hepatic tumors 19 Learning Objectives (Cont d) Define cholecystitis, cholelithiasis, cholangitis, choledocholithiasis Discuss the pathophysiology of cholecystitis Recognize the signs/symptoms, treatment of cholecystitis 20 Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with cholecystitis Define pancreatitis 21 7
Learning Objectives (Cont d) Recognize signs, symptoms related to pancreatitis Describe the management of pancreatitis Discuss the pathophysiology of pancreatitis 22 Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with pancreatitis Define pancreatic tumors Define adenocarcinoma, cyst adenoma, neuroendocrine tumors 23 Learning Objectives (Cont d) Describe the signs/symptoms, treatment of pancreatic tumors Define peritonitis Describe the signs/symptoms, treatment of peritonitis Define gastritis 24 8
Learning Objectives (Cont d) Describe the signs/symptoms, treatment of gastritis Define peptic ulcer disease Discuss the pathophysiology of peptic ulcer disease Recognize the signs, symptoms related to peptic ulcer disease 25 Learning Objectives (Cont d) Describe the management of peptic ulcer disease Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with peptic ulcer disease Define upper GI bleeding 26 Learning Objectives (Cont d) Discuss the pathophysiology of upper GI bleeding Recognize signs/symptoms, treatment of upper GI bleeding Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with upper GI bleeding 27 9
Learning Objectives (Cont d) Define lower GI bleeding Discuss the pathophysiology of lower GI bleeding Describe the signs/symptoms, treatment of lower GI bleeding 28 Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with lower GI bleeding Define acute gastroenteritis Discuss the pathophysiology of acute gastroenteritis 29 Learning Objectives (Cont d) Describe the signs/symptoms, treatment of acute gastroenteritis Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with acute gastroenteritis Define bowel obstruction 30 10
Learning Objectives (Cont d) Discuss the pathophysiology of bowel obstruction Describe the signs/symptoms, treatment of bowel obstruction Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with bowel obstruction 31 Learning Objectives (Cont d) Define appendicitis Discuss the pathophysiology of appendicitis Describe the signs/symptoms, treatment of appendicitis 32 Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with appendicitis Define colitis Discuss the pathophysiology of colitis 33 11
Learning Objectives (Cont d) Describe the signs/symptoms, treatment of colitis Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with colitis Define Crohn s disease 34 Learning Objectives (Cont d) Discuss the pathophysiology of Crohn s disease Describe the signs/symptoms, treatment of Crohn s disease Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with Crohn s disease 35 Learning Objectives (Cont d) Define diverticulitis Discuss the pathophysiology of diverticulitis Describe the signs/symptoms, treatment of diverticulitis 36 12
Learning Objectives (Cont d) Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with diverticulitis Define hemorrhoids Discuss the pathophysiology of hemorrhoids 37 Learning Objectives (Cont d) Describe the signs/symptoms, treatment of hemorrhoids Integrate the pathophysiological principles and assessment findings to formulate a field impression and implement a treatment plan for a patient with hemorrhoids Integrate the pathophysiologic principles of a patient with gastrointestinal emergency 38 Learning Objectives (Cont d) Differentiate gastrointestinal emergencies on the basis of assessment findings Correlate abnormal findings in assessment with clinical significance in a patient with abdominal pain Develop a management plan based on field impression in a patient with abdominal pain 39 13
Introduction Abdominal pain is usually the first sign of gastrointestinal disorder May be the only sign Approximately 7% of patients with abdominal pain complaints have life-threatening conditions 40 Anatomy and Physiology GI tract All structures in eating and processing food Food degradation Nutrient absorption Waste elimination 41 Anatomy and Physiology (Cont d) Anatomy of GI Tract 42 14
Anatomy and Physiology (Cont d) GI tract Esophagus Starts from pharynx Distally through chest cavity Passes through diaphragm Terminates at stomach Hollow muscular organ Contracts as swallowed food moves downward from mouth to stomach Lies posterior to trachea, compressible Begin to right of aorta, passes anterior to aorta as it traverses inferiorly 43 Anatomy and Physiology (Cont d) GI tract Stomach Lies inferior to diaphragm in left upper quadrant of abdomen Partially covered by left lobe of liver Protected by ribcage Food passes from stomach, enters duodenum through pyloric sphincter 44 Anatomy and Physiology (Cont d) GI tract Duodenum First part of small intestine Nutrients absorbed as food moves through small intestine by muscular contractions peristalsis Food progresses from duodenum through jejunum and ileum 45 15
Anatomy and Physiology (Cont d) GI tract Ligament of Treitz Located at junction of duodenum and jejunum Appendix Small appendage arises from initial part of colon Can become inflamed, infected 46 Anatomy and Physiology (Cont d) GI tract Large intestine Water absorbed Bacteria break down ingested food into nutrients Ascending, transverse, descending 47 Anatomy and Physiology (Cont d) GI tract Small intestine Long structure, 6-7 m Curled back and forth within the abdominal cavity Colon Short, 1.5 m long 48 16
Anatomy and Physiology (Cont d) Small and Large Colon 49 Anatomy and Physiology (Cont d) Colon 50 Anatomy and Physiology (Cont d) Transverse Colon 51 17
Anatomy and Physiology (Cont d) Descending Colon, Rectum, and Anal Canal 52 Anatomy and Physiology (Cont d) GI tract Waste Remaining byproducts of food Feces 53 Anatomy and Physiology (Cont d) GI tract Liver Maintains blood glucose Detoxifies drugs, hormones, foreign substances Produces plasma proteins, aids in blood clotting Bile salts produced, help with food digestion 54 18
Anatomy and Physiology (Cont d) GI tract Gallbladder Stores bile Sphincter of Odi 55 Anatomy and Physiology (Cont d) Liver, Gallbladder, and Stomach 56 Anatomy and Physiology (Cont d) Abdominal Contents 57 19
Anatomy and Physiology (Cont d) GI tract Pancreas Located in midepigastric region Endocrine functions Exocrine functions Pancreatic duct expels substances at junction with duodenum Pancreatic failure indicators 58 Anatomy and Physiology (Cont d) GI tract Peritoneum Thin layer, covers most intraabdominal structures Parietal peritoneum Visceral peritoneum Peritoneal cavity Mesentery 59 Anatomy and Physiology (Cont d) Omentum 60 20
Anatomy and Physiology (Cont d) GI tract Visceral pain Activation of pain receptors enclosed within cavity of chest, abdomen, pelvis Visceral sensory nerve fibers travel with autonomic nerves to communicate with CNS Dully, poorly localized in midline Cramping, burning, gnawing 61 Anatomy and Physiology (Cont d) Pathways of Visceral Pain 62 Anatomy & Physiology (Cont d) Localization of Visceral Pain 63 21
Anatomy and Physiology (Cont d) GI tract Somatic pain Activation of pain in receptors in cutaneous tissues of body s surface or deep body tissues Referred pain Pain perceived as occurring in a part of the body other than the true source 64 Anatomy and Physiology (Cont d) Patterns of Referred Pain 65 Anatomy and Physiology (Cont d) GI tract Hemorrhage Trauma or rupture of solid or hollow organ Fibrous capsule or organs bleed Inflammation Infection, chemical irritation, toxins, autoimmune conditions Source and location help determine cause of disorder 66 22
Assessment Adequate history, thorough physical examination History more valuable than physical examination OPQRST Pain Constant Intermittent 67 Assessment (Cont d) Adequate history, thorough physical examination Nausea, vomiting, diarrhea, constipation, bleeding Family history Past medical problems Social history Medication use Open-ended questions 68 Assessment (Cont d) Adequate history, thorough physical examination Inspection Looking at abdomen, pelvis Distention Bruising Swelling Scars Pulsations Discoloration 69 23
Assessment (Cont d) Adequate history, thorough physical examination Auscultation All four quadrants Gurgling Bowel sounds 70 Assessment (Cont d) Adequate history, thorough physical examination Palpation Presence/absence of tenderness Guarding Abdominal rigidity Masses Organomegaly Rebound tenderness 71 Assessment (Cont d) Palpation of Abdominal Quadrants 72 24
Assessment (Cont d) Adequate history, thorough physical examination Percussion Hyperresonant/tympanic 73 Assessment (Cont d) Adequate history, thorough physical examination Disease-specific findings Murphy s sign Rebound tenderness Roving s sign Psoas sign Oburator sign Cutaneous hyperesthesia Cullen s sign Grey Turner s sign Kehr s sign 74 Management (Cont d) Primary measures Determination, treatment of immediate life threats ABCs Comfort measures Pharmacological treatment per local protocol Transport Position of comfort 75 25
Abdominal Wall Hernias Abdominal hernia Protrusion of abdominal content Defect/weakness in abdominal wall muscle Congenital Acquired, causes Age Obesity Prior abdominal surgery 76 Abdominal Wall Hernias (Cont d) Incarcerated hernia Abdominal contents will not return through defect into abdominal cavity Can lead to strangulation Pain, fever, nausea, vomiting, obstruction signs Do not attempt to reduce Supportive care IV fluids Rapid transport 77 Esophageal Disorders Esophagitis Any inflammation/infection of esophagus Causes Candidas Infection Caustic ingestions Esophageal reflux Esophageal rupture Pills 78 26
Esophagitis Higher incidents Diabetes HIV Alcoholism Cancer Pregnancy Corticosteroids 79 Esophagitis Burning in center of thorax, worse with swallowing History important With pain, use OPQRST Focused examination of neck, chest, abdomen No specific treatment 80 Esophagitis with Esophageal Ulceration 81 27
Esophageal candidiasis May grow in oropharynx, down into esophagus Burning pain in esophagus, pain on swallowing Dehydration, IV fluids Urge handwashing 82 Esophageal candidiasis Infectious esophagitis Hemorrhage Nausea, vomiting Fever, chills Necrosis of esophagus Chest pain Difficult pain/swallowing Supportive treatment 83 Severe Candida Esophagitis 84 28
Endoscopic View of Esophagus 85 Gastroesophageal reflux disease (GERD) Weakened lower esophageal sphincter Stomach contents move backward up into esophagus Burning, irritation Obesity, smoking, alcohol use weaken lower esophageal sphincter Burning pain in center of thorax 86 Caustic ingestions Intentional, accidental ingestion Toilet bowl cleaners Oven cleaners Bleach Batteries Coagulation necrosis limits penetration through tissues 87 29
Coagulative Necrosis 88 Caustic ingestions Alkali ingestions cause liquification necrosis Leads to full-thickness esophageal burns Orofacial burns Drooling Vomiting Pain on swallowing Hoarseness, stridor Chest pain 89 Liquification Necrosis 90 30
Caustic ingestions Record accurate history, relay to receiving hospital Identify and transport container Time, amount of ingestion Self-treatment 91 Caustic ingestions Late complications Tissue sloughing Scarring Esophageal stricture formation Gastric outlet obstruction 92 Caustic ingestions Drooling, protect airway Intubation Cricothyroidectomy for extensive upper airway edema Do not induce vomiting NG tube only under medical direction orders 93 31
Boerhaave syndrome Perforation of esophagus after forceful vomiting Mortality rate of 50% without surgery within 24 hours History of diffuse pain in chest, radiates to neck, back, abdomen Difficulty breathing or swallowing, may vomit blood Cyanotic 94 Boerhaave syndrome Late cases, esophageal content enters mediastinum Subcutaneous emphysema common if neck perforation Tachycardia, tachypnea Rigid abdomen, fever, hypotension 95 Boerhaave syndrome Treatment Early surgical intervention Rapid transport Airway, hypoxia, shock treatment while en route 96 32
Esophageal foreign bodies Some may easily pass Larger ones may obstruct airway Esophagus narrows in four places 97 Esophageal Constriction 98 Esophageal foreign bodies Signs/symptoms Acute onset of difficulty swallowing Foreign body sensation Oral secretion pooling 99 33
Esophageal foreign bodies Physical examination Airway, breathing assessment Pooling of oral secretions raises suspicion 100 Esophageal foreign bodies Airway management Rapid transport Glucagon 101 Hiatal hernia Stomach extends proximally, upward through weakness in diaphragm Symptoms similar to GERD Heartburn predominant Assess ABCs Look for esophageal rupture Abdominal pain, cardiac examination performed 102 34
Hiatal Hernias 103 Mallory-Weiss syndrome Longitudinal tears in distal esophagus, proximal stomach At stomach level, gastroesophageal junction Involve arterial bleeding into esophagus and stomach 104 Mallory-Weiss syndrome Hematemesis, ask about history of vomiting Transport, position of comfort Continued vomiting, antiemetics IV fluids 105 35
Esophageal stenosis and stricture Stenosis Abnormal narrowing 106 Esophageal stenosis and stricture Stricture Specific form of narrowing, usually from scar tissue ABCs Oral secretion management No prehospital treatment IV fluids for decreased oral intake Unable to swallow foods, liquid, oral secretions should be transported Transport in position of comfort 107 Tracheoesophageal fistula (TEF) Communication between trachea and esophagus Mostly congenital Associated with esophageal atresia, esophagus not continuous from mouth to stomach 108 36
TEF Potentially fatal respiratory complications Acquired after malignancy, infection, trauma Intubation and prolonged mechanical ventilator support 109 TEF Symptoms, infants Frothy white bubbles despite suctioning Rattling cough Choking Cyanosis Worsens during feeding 110 TEF Symptoms, adult Cough Fever Chills Respiratory distress Pulmonary infections 111 37
TEF During transport: Reduce aspiration risk Suctioning Head elevation IV hydration ET intubation 112 Esophageal Atresia and Tracheoesophageal Fistula 113 Esophageal varices Dilated vein enlarged from increased pressure Damages to valves within vein Venous pressure Retrograde blood flow Elevated pressure transmission back through GI collaterals 114 38
Esophageal varices Asymptomatic unless bleeding Cirrhosis most common cause 115 Esophageal varices History Alcoholism Anorexia Nausea, vomiting Weight loss Jaundice 116 Esophageal varices Sudden hematemesis Shock Risk of GI hemorrhage 117 39
Esophageal varices Internal bleeding Pallor Unexplained shock Cyanotic Dyspneic Tachypneic 118 Esophageal varices If ruptured, life-threatening Management ABCs Hypoxia corrected with O 2 Hemorrhagic shock with IV crystalloid Large-bore IV lines 119 Hepatic Disorders Cirrhosis Chronic liver disease complication Tissue replacement by fibrotic scar tissue Progressive liver function loss 120 40
Hepatic Disorders (Cont d) Cirrhosis Causes Alcoholic liver disease Hepatitis C 121 Hepatic Disorders (Cont d) Cirrhosis Signs/symptoms Spider angiomata Palmar erythema Dupuytren s contracture Gynecomastia Testicular atrophy Ascites 122 Hepatic Disorders (Cont d) Cirrhosis Signs/symptoms Caput medusa Fetor hepaticus Jaundice Asterixis Encephalopathy Esophageal varices 123 41
Hepatic Disorders (Cont d) Cirrhosis Effects on body Immune system Coagulation cascade Kidneys CNS Sexual organs Bone formation 124 Hepatic Disorders (Cont d) Cirrhosis Physical examination Head-to-toe Abdomen Skin and sclera, signs of icterus 125 Hepatic Disorders (Cont d) Hepatorenal failure Onset of kidney dysfunction in patients with liver disease No identifiable reason for renal pathology Decreased renal blood flow Decreased urine output Increased leg swelling 126 42
Hepatic Disorders (Cont d) Hepatorenal failure Dyspnea GI bleeding history ABCs Mental status for encephalopathy Ascites present No prehospital treatment 127 Hepatic Disorders (Cont d) Ascites 128 Hepatic Disorders (Cont d) Acute hepatitis Any inflammation of liver Hepatitis A Recovery, lifelong immunity Vaccine available 129 43
Hepatic Disorders (Cont d) Acute hepatitis Hepatitis B Cause acute and chronic hepatitis Transmitted by infected body fluid contact Tattoos Sexual contact Infected needles Infected mother can pass it to unborn child 130 Hepatic Disorders (Cont d) Acute hepatitis Hepatitis B Complications Chronic hepatitis Cirrhosis Liver failure Hepatocellular carcinoma Vaccine, all healthcare workers should be inoculated 131 Hepatic Disorders (Cont d) Acute hepatitis Hepatitis C Transmitted through infected blood/body fluids Leads to chronic hepatitis and cirrhosis No vaccine available Asymptomatic up to 20 years Apply standard precautions in every patient Treat life-threatening problems 132 44
Hepatic Disorders (Cont d) Acute hepatitis Alcoholic hepatitis Increased alcohol consumption Acute liver inflammation Leads to jaundice, liver failure Mortality high 133 Hepatic Disorders (Cont d) Acute hepatitis Drugs, toxins can cause hepatitis Halothane INH phenytoin Zidovudine NSAIDs Acetaminophen 134 Hepatic Disorders (Cont d) Hepatic tumors Prone to develop cancerous tumors after hepatitis B infection Liver common site for primary and metastatic cancers 135 45
Hepatic Disorders (Cont d) Hepatic tumors Signs/symptoms Mimic hepatitis Pain Abdominal distention Cirrhosis/liver failure signs/symptoms Cancer signs Treat life-threatening conditions Supportive care 136 Biliary Disorders Cholecystitis, cholelithiasis, and choledocholithiasis Cholelithiasis Bile solidifies as gallstones 80% formed from cholesterol 137 Biliary Disorders (Cont d) Gallstones 138 46
Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Acalculous cholecystitis Obstruction of cystic duct from gallbladder sludge or inflammation Gallbladder or binary colic Persists, gallbladder becomes inflamed, distended Gallbladder wall edema, ischemia, necrosis Left untreated, bacterial infection 139 Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Cholangitis Infection spreads to remainder of biliary tree Life-threatening Rare 140 Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Choledocholithiasis Stones stuck or formed in common bile duct Risks Associated with racial, ethnic factors Five Fs 141 47
Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Asymptomatic Location of pain Biliary colic 142 Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Symptoms Nausea, vomiting, fever Indigestion, belching, bloating, fatty food intolerance 143 Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Physical examination Right upper quadrant, epigastric tenderness Guarding Positive Murphy s sign Febrile Hypotensive ortachycardic 144 48
Biliary Disorders (Cont d) Cholecystitis, cholelithiasis, and choledocholithiasis Treatment IV fluids Pain medications Antiemetics 145 Pancreatic Disorders Pancreatitis Inflammation of pancreatic gland Decrease in peristalsis Pancreatic enzymes that aid in food digestion autodigest pancreatic tissue, leads to inflammation Bowel wall edema 146 Pancreatic Disorders (Cont d) Acute Pancreatitis 147 49
Pancreatic Disorders (Cont d) Pancreatitis Causes Alcohol consumption Gallbladder disease Gallstones 148 Pancreatic Disorders (Cont d) Pancreatitis Findings Constant, severe midepigastric pain, radiates directly to back Pain may travel to right or left upper abdominal quadrant OPQRST Check for history of trauma, medication ingestion, illness 149 Pancreatic Disorders (Cont d) Pancreatitis Findings Symptoms Fever, nausea, vomiting Appear systemically ill Restless Tachycardia Tachypnea Febrile Hypotensive Jaundice Epigastrum or right upper quadrant tender Breath sounds diminished or absent Distention, guarding, rigidity of abdomen 150 50
Pancreatic Disorders (Cont d) Pancreatitis Treatment Symptomatic Address life-threatening conditions Hypotensive, dehydrated, shock, provide IV crystalloids Nasogastric tube Analgesics 151 Pancreatic Disorders (Cont d) Pancreatic tumors Divided according to cell type 95% pancreatic cancers, adenocarcinomas derived from exocrine cells Cyst adenomas Neuroendocrine tumors/islet cell tumors 152 Pancreatic Disorders (Cont d) Pancreatic tumors Symptoms Dull pain in upper abdomen, radiates to back Painless jaundice develops as tumor obstructs the bile duct Weak, dizzy, hypoglycemic 153 51
Pancreatic Disorders (Cont d) Pancreatic tumors Treatment Supportive care Life-threatening emergencies treated Treat pain, nausea, vomiting Transport 154 Pancreatic Disorders (Cont d) Peritonitis Peritoneal membrane inflammation Causes Infection Trauma Bowel rupture 155 Pancreatic Disorders (Cont d) Peritonitis Signs/symptoms Abdominal pain Fever Nausea, vomiting Anorexia in appendicitis Rebound tenderness Septic with fever Hypothermia Chills Hypotension Bowel sounds decreased, absent 156 52
Pancreatic Disorders (Cont d) Peritonitis Spontaneous bacterial peritonitis (SBP) Occurs in liver cirrhosis Asymptomatic Portal hypertension with cirrhosis causes bowel wall and mucosa swelling 157 Pancreatic Disorders (Cont d) Peritonitis Spontaneous bacterial peritonitis (SBP) Symptoms Worsening hepatic or renal function Underlying liver disease Septic shock IV fluids for tachycardia or shock Pain, nausea medications 158 Stomach Disorders Gastritis Gastric mucosa inflammation Chronic gastritis Caused by Helicobacter pylori 159 53
Stomach Disorders (Cont d) Gastritis Acute gastritis Result of local injury to gastric mucosa Viral infection, substance ingestion that irritates gastric mucosa Alcohol, prescription and OTC medications common causes 160 Stomach Disorders (Cont d) Acute Gastritis 161 Stomach Disorders (Cont d) Gastritis Acute gastritis Signs/symptoms Dyspepsia Bloating Indigestion Heartburn Belching Nausea, vomiting 162 54
Stomach Disorders (Cont d) Gastritis Acute gastritis Hemorrhagic gastritis development Hematemesis Melena Hemorrhagic shock 163 Stomach Disorders (Cont d) Gastritis Acute gastritis Thorough history Current pain Medical history Medications Social history 164 Stomach Disorders (Cont d) Gastritis Acute gastritis Treatment Treat life-threatening conditions Hemorrhagic shock, do not delay treatment Rapid transport Position of comfort Manage pain, nausea Continual reassessment ABCs 165 55
Stomach Disorders (Cont d) Peptic ulcer disease Stomach and small intestine gastric mucosa defects Bleed, causing pain, morbidity, death Formed when production of hydrochloric acid and pepsin by gastric mucosa increased 166 Stomach Disorders (Cont d) Chronic Peptic Ulcer 167 Stomach Disorders (Cont d) Peptic ulcer disease Causes Aspirin NSAIDs Smoking Heavy, prolonged alcohol consumption H. pylori Imbalance between stomach acid production Inability of gastric mucosa to prevent acid damage Zollinger-Ellison syndrome 168 56
Stomach Disorders (Cont d) Peptic ulcer disease Occurs in stomach or first part of duodenum Findings Burning, gnawing pain in epigastric region Vague or cramping pain 169 Stomach Disorders (Cont d) Peptic ulcer disease Complications Perforation Inflammation and swelling to create acute obstruction Hemorrhage Bleeding Pallor Tachycardia Hypotension Frank hemorrhagic shock 170 Stomach Disorders (Cont d) Peptic ulcer disease History Focus on symptoms Pain type Relation of pain to food Previous diagnosis 171 57
Stomach Disorders (Cont d) Peptic ulcer disease Physical examination Primary survey Treat frank hematemesis, melena, shock with fluid resuscitation Rapid transport If stable, complete abdominal examination 172 Stomach Disorders (Cont d) Peptic ulcer disease Treatment None available Antacids, H2 blockers for pain 173 Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Upper GI bleed Above ligament of Treitz Causes Caustic ingestions Mallory-Weiss tears Esophageal varices Gastritis and peptic ulcers Male predominance 174 58
Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Upper GI bleed Abdominal pain Hematemesis Coffee ground emesis Melena 175 Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Lower GI bleed Below ligament of Treitz Causes Distal to ligament of Treitz Diverticular disease Tumors Polyps Hemorrhoids Autoimmune disease Anal fissures Female predominance 176 Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Lower GI bleed Hematochezia Implies larger, more rapid blood loss Rule out other sources of hemorrhage Hemorrhoids 177 59
Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Lower GI bleed Good medical history History of bleeding Social history Fatigue, shortness of breath, vomiting, black tarry stool 178 Stomach Disorders (Cont d) Upper and lower gastrointestinal bleeding Lower GI bleed Treatment Mild Massive 179 Bowel Disorders Gastroenteritis Inflammation of stomach lining and intestines Causes disruption in normal functioning of the mucosal lining 180 60
Gastroenteritis Symptoms Cramping Abdominal pain Nausea, vomiting Fever Anorexia Malaise Headache Watery diarrhea 181 Gastroenteritis Causes Virus Typically passed from person to person, eating contaminated food Norwalk virus Norovirus Adenovirus Astrovirus Rotavirus 182 Gastroenteritis Transmission causes Fecal-oral route from poorly cooked meat, poorly refrigerated food, contaminated food Parasites Wheat intolerance Lactose intolerance Allergies Autoimmune conditions Medications Radiation therapy Chemical toxins 183 61
Gastroenteritis Chronic causes Infection Medication use Inflammatory conditions Toxins 184 Gastroenteritis History Onset Symptoms Pain Symptom duration Chemical exposure Possible food poisoning Camping, hiking Foreign travel Swimming in potentially infected water Previous medical conditions 185 Gastroenteritis Physical examination Detailed abdominal examination Increased bowel sounds on auscultation Mild tenderness on palpation, all four quadrants Skin for tenting, dehydration sign Muscle spasm 186 62
Gastroenteritis Treatment IV access, fluids Nausea, abdominal cramping medications Supportive 187 Obstruction Small or large bowel lumen blocked Large bowel obstructions Caused by malignant disease Bowel contents cannot flow forward Disrupts normal function of digestive system Ileus 188 Obstruction Results from complete mechanical obstruction of the intestine Adhesions Hernia Polyps Tumors Foreign body Impacted stool Intussusceptions Volvulus 189 63
Volvulus 190 Obstruction Signs/symptoms Nausea, vomiting Abdominal pain Lack of bowel movements Diarrhea Inability to pass bowel gas Abdominal distention Pain, crampy, colicky 191 Obstruction History Past medical history Previous bowel obstructions Abdominal surgery Cancer Radiation therapy Chemotherapy Hernia Abdominal illness Nausea, vomiting, bowel habits 192 64
Obstruction Physical examination Primary survey Thorough abdominal examination 193 Obstruction Treatment Position of comfort IV access, fluids Dehydration, fluids Avoid food/water by mouth NG tube removes normal fluids produced by stomach Medication for pain, nausea Transport 194 Appendicitis Inflammation of small tubular structure arising off colon near cecum Fecalith, obstruction Becomes highly distended, inflamed, gangrenous If it ruptures, bowel contents spill into abdomen causing peritonitis 195 65
Inflamed Appendix 196 Appendix Positions 197 Appendicitis Symptoms Fever, nausea Abdominal pain Poorly localized dull pain in periumbilical area Pain in right lower quadrant, right lower back 198 66
Appendicitis History Surgical history Appetite Pain location Onset Fever 199 Appendicitis Physical examination Abdominal examination Possible pain with movement of pelvis/hips Rovsing s sign Appendix location varies Retrocecal McBurney s point 200 Appendicitis Treatment IV access, fluids Avoid food/beverages Pain, nausea medications Transport in position of comfort 201 67
Ulcerative colitis Inflamed large bowel Ulcers form on mucosal surface of intestine Affects colon, mostly rectum Immune system overreacts to viral/bacterial insult 202 Acute Ulcerative Colitis 203 Ulcerative colitis Symptoms Diarrhea Abdominal cramping Bloody/purulent stools Fatigue Weakness Weight loss Appetite loss 204 68
Ulcerative colitis History Recurrent fatigue, diarrhea, abdominal discomfort Physical examination Thorough abdominal examination Appendicitis Obstruction Gastroenteritis 205 Ulcerative colitis Treatment Supportive IV fluids Pain, nausea, vomiting medications Transport in position of comfort 206 Crohn s disease Inflammatory bowel condition Affects small, large intestine Genetic tendencies 207 69
Crohn s disease Findings Significant swelling Ulcerations go through all layers of bowel Scar tissue Obstruction 208 Crohn s disease Signs and symptoms Nausea, vomiting Severe diarrhea Abdominal pain, cramping Weight loss Appetite loss Skin conditions Arthritis Gallbladder disease Inflammatory eye conditions Ulcerations of nose, mouth Kidney stones 209 Crohn s disease History Abdominal cramping RUQ pain Kidney stones Arthritis Bladder, vaginal problems Fistula with pus, stool leaking from ulcer in skin 210 70
Crohn s disease Physical examination Head-to-toe Thorough abdominal examination Peritonitis from ruptured bowel Abdominal distention Rebound tenderness Fever Severe sepsis 211 Crohn s disease Treatment Rapid assessment Treat life-threatening conditions Management of ABCs IV access, fluids Medication for pain Rapid transport 212 Diverticulosis and diverticulitis Small sacs, outpouches form along bowel wall Fiber-deficient diets 213 71
Diverticulosis and diverticulitis Diverticulosis Multiple diverticula Develop from bowel wall stretching Asymptomatic Irregular bowel movements Painless bloody stools 214 Diverticulosis and diverticulitis Diverticulitis Diverticula become inflamed, infection Digested food trapped in pouches, causes infection Fever Shaking chills Nausea, vomiting Abdominal pain Diarrhea 215 Diverticular Disease 216 72
Diverticulosis and diverticulitis History Nausea, vomiting Fever Chills Pain Compare to previous abdominal complaints 217 Diverticulosis and diverticulitis Physical examination Comprehensive Abdomen, pelvis 218 Diverticulosis and diverticulitis Treatment Supportive IV access, fluids Pain, nausea medication 219 73
Hemorrhoids Swollen venous tissue originating from anal area Internal or external Increased pressure or straining during defecation 220 Hemorrhoids Signs/symptoms Itching, pain, burning Rectal bleeding Bleeding that drips into toilet after defecation 221 Hemorrhoids History Bowel habits Presence of hemorrhoids Bleeding that stains toilet tissue Large bloody stools treated as GI bleed 222 74
Hemorrhoids Physical examination Thorough examination of the abdomen Treatment Supportive 223 Gastrointestinal Illness Accurate history important Can be life-threatening Thorough history and physical examination Open-ended questions OPQRST for pain Nausea, vomiting, diarrhea, stool consistency/color 224 Gastrointestinal Illness (Cont d) Treatment Immediately address life-threatening conditions Shock, large blood loss, assess quickly and transport IV fluids en route 225 75
Chapter Summary Abdominal pain is one of the most common reasons why patients seek emergency care Etiology of abdominal pain varies with patient s age, risk factors GI system includes all organs responsible for ingestion and digestion of food 226 Chapter Summary (Cont d) Pain well localized, somatic pain Pain poorly localized, visceral pain Pain felt at distant location, referred pain Assess pain with OPQRST 227 Chapter Summary (Cont d) Assessment, ask open-ended questions Management of GI symptoms should include primary survey, secondary survey, pain and nausea management, fluid replacement Local protocols should be followed for appropriate treatment and management 228 76
Chapter Summary (Cont d) Hernias that become strangulated/incarcerated can pose a serious medical condition Esophagitis, inflammation of the esophagus, has many causes GERD, common disorder, leads to esophagitis 229 Chapter Summary (Cont d) Caustic ingestions can cause trauma to the esophagus Historical facts, time of ingestion, chemical ingestion, and amount ingested are important Airway control important in caustic ingestions 230 Chapter Summary (Cont d) Esophageal obstruction can occur with caustic ingestions Most foreign objects will pass through the GI tract if enters the stomach Vomiting may lead to longitudinal tears in the esophagus called Mallory-Weiss tears Hematemesis may occur 231 77
Chapter Summary (Cont d) Esophageal stenosis can occur from esophagitis Tracheoesophageal fistula and esophageal atresia are congenital conditions Tracheoesophageal fistula can lead to aspiration of food and liquids into the lungs 232 Chapter Summary (Cont d) Esophageal varices can be caused by portal hypertension Hematemesis may occur with varices, may be serious Cirrhosis can lead to liver failure Cirrhosis is caused by damage to liver cells 233 Chapter Summary (Cont d) Cirrhosis can lead to ascites, fluid in the abdominal cavity Ascites can become infected, lead to sepsis (SBP) Cirrhosis can cause encephalopathy, altered consciousness/coma 234 78
Chapter Summary (Cont d) Renal failure may follow liver failure Hepatitis, an inflammatory condition of the liver Hepatitis may be self-limiting, progress to liver failure Hepatitis A transmitted by fecal-oral route 235 Chapter Summary (Cont d) Hepatitis B transmitted by sexual contact, body fluid, tattoos, blood transfusions Hepatitis C transmitted by infected blood, body fluids Cholelithiasis, the presence of stones in the gallbladder 236 Chapter Summary (Cont d) Cholelithiasis occurs in 10-20% of the population in developed countries Pancreatitis, inflammation of the pancreas Pancreatitis can present with severe abdominal pain, nausea, vomiting 237 79
Chapter Summary (Cont d) Peritonitis, inflamed lining of the abdominal cavity Rebound tenderness may be present with peritonitis Gastritis, inflammation of the gastric mucosa 238 Chapter Summary (Cont d) Gastritis can present with significant abdominal pain Peptic ulcers can cause significant GI bleeding GI bleeding has many causes; begin treatment with primary survey 239 Chapter Summary (Cont d) Appendicitis begins with periumbilical pain Appendicitis can lead to sepsis if the luminal cavity ruptures Ulcerative colitis typically affects the rectum; an inflammatory condition that involves the mucosal lining of the GI tract 240 80
Chapter Summary (Cont d) Crohn s disease can affect the small and large intestines; it can cause erosion through all layers of the bowel, leading to fistula formation Patients with Crohn s disease may have arthritis, skin conditions, inflammatory conditions of the eye, bowel symptoms 241 Chapter Summary (Cont d) Diverticular disease caused by stretching of the bowel during straining, low-fiber diets, disease of colonic diverticula, inflammation of 1+ of outpouchings Hemorrhoids, distended veins either internal or external to the anal opening 242 Questions? 243 81