5. General Assessment
Scene Size-up & Initial
Assessment
Scene clues.
Identify and treat life-threatening conditions.
Focused History & Physical Exam
Focused History
Obtain SAMPLE History.
Obtain OPQRST History.
• Associated symptoms
• Pertinent negatives
6. General Assessment
Physical Exam
General assessment and vital signs
Abdominal assessment
• Inspection, Auscultation, and Palpation
• Cullen’s Sign
• Grey-Turner’s Sign
7. General Treatment
Maintain the airway.
Support breathing.
High-flow oxygen or assisted ventilations.
Maintain circulation.
Monitor vital signs and cardiac
rhythm.
Establish IV access.
Transport in position of comfort.
8. Specific Illnesses
The
Gastrointestinal
System
Upper
Gastrointestinal
Tract
Lower
Gastrointestinal
Tract
Liver
Gallbladder
Pancreas
Appendix
13. Acute Gastroenteritis
Cause
Damage to Mucosal GI Surfaces
Pathologic inflammation causes hemorrhage and
erosion of the mucosal and submucosal layers of
the GI tract.
Risk Factors
Alcohol and tobacco use
Chemical ingestion (NSAIDs, chemotherapeutics)
Systemic infections
14. Acute Gastroenteritis
Signs & Symptoms
Rapid Onset of Severe Vomiting and Diarrhea
Hematemesis, Hematochezia, Melena
Diffuse Abdominal Pain
Classic Signs of Shock
Treatment
Follow General Treatment Guidelines.
Fluid Volume Replacement.
Consider Administration of Antiemetics.
15. Gastroenteritis
Similar to Acute Gastroenteritis
Long-Term Mucosal Changes or Permanent
Damage.
Primarily due to microbial infection.
More frequent in developing countries.
Follow General Treatment Guidelines.
16. Peptic Ulcers
Pathophysiology
Erosions caused by
gastric acid.
Terminology based
on the portion of
tract affected.
Causes:
NSAID Use
Alcohol/Tobacco Use
H. pylori
17. Peptic Ulcers
Signs & Symptoms
Abdominal Pain
Observe for signs of hemorrhagic rupture.
Acute pain, hematemesis, melena
Treatment
Follow general treatment guidelines.
Consider administration of histamine
blockers and antacids.
18. Lower Gastrointestinal
Bleeding
Pathophysiology
Bleeding distal to the ligament of Treitz
Causes
Diverticulosis
Colon lesions
Rectal lesions
Inflammatory bowel disorder
19. Lower Gastrointestinal
Bleeding
Signs & Symptoms
Determine acute vs. chronic.
Quantity/color of blood in stool.
Abdominal pain
Signs of shock.
Treatment
Follow general treatment guidelines.
Establish IV access with large-bore catheter(s).
21. Crohn’s Disease
Pathophysiology
Causes unknown.
Can affect the entire
GI tract.
Pathologic
inflammation:
Damages mucosa.
Hypertrophy and
fibrosis of underlying
muscle.
Fissures and fistulas.
22. Crohn’s Disease
Signs and Symptoms
Difficult to differentiate.
Clinical presentations vary drastically.
GI bleeding, nausea, vomiting, diarrhea.
Abdominal pain/cramping, fever, weight loss.
Treatment
Follow general treatment guidelines.
23. Diverticulitis
Pathophysiology
Inflammation of small
outpockets in the
mucosal lining of the
intestinal tract.
Common in the elderly.
Diverticulosis.
Signs &
Symptoms
Abdominal
pain/tenderness.
Fever, nausea, vomiting.
Signs of lower GI
bleeding.
Treatment
General treatment
guidelines.
24. Hemorrhoids
Pathophysiology
Mass of swollen veins in
anus or rectum.
Idiopathic.
Signs &
Symptoms
Limited bright red
bleeding and painful
stools.
Consider lower GI
bleeding.
Treatment
General treatment
guidelines.
31. Appendicitis
Pathophysiology
Inflammation of the vermiform appendix.
Frequently affects older children and young
adults.
Lack of treatment can cause rupture and
subsequent peritonitis.
32. Appendicitis
Signs & Symptoms
Nausea, vomiting, and low-grade fever.
Pain localizes to RLQ
(McBurney’s point).
Treatment
Follow
general
treatment
guidelines.
33. Cholecystitis
Pathophysiology
Inflammation of the
Gallbladder
Cholelithiasis
Chronic
Cholecystitis
Bacterial infection
Acalculus
Cholecystitis
Burns, sepsis,
diabetes
Multiple organ failure
34. Cholecystitis
Signs & Symptoms
URQ Abdominal Pain
Murphy’s sign
Nausea, Vomiting
History of Cholecystitis
Treatment
Follow general treatment guidelines.
35. Pancreatitis
Pathophysiology
Inflammation of the Pancreas
Classified as metabolic, mechanical, vascular, or
infectious based on cause.
Common causes include alcohol abuse, gallstones,
elevated serum lipids, or drugs.
36. Pancreatitis
Signs & Symptoms
Mild Pancreatitis
Epigastric Pain, Abdominal Distention, Nausea/Vomiting
Elevated Amylase and Lipase Levels
Severe Pancreatitis
Refractory Hypotensive Shock and Blood Loss
Respiratory Failure
Treatment
Follow general treatment guidelines
37. Hepatitis
Pathophysiology
Injury to Liver Cells
Typically due to inflammation or infection.
Types of Hepatitis
Viral hepatitis (A, B, C, D, and E)
Alcoholic hepatitis
Trauma and other causes
Risk Factors
38. Hepatitis
Signs & Symptoms
URQ abdominal tenderness
Loss of appetite, weight loss, malaise
Clay-colored stool, jaundice, scleral icterus
Photophobia, nausea/vomiting
Treatment
Follow general treatment guidelines.
Use PPE and follow BSI precautions
39. Gastroenterology
General Pathophysiology,
Assessment, and Management
Specific Illnesses
Upper Gastrointestinal Diseases
Lower Gastrointestinal Diseases
Accessory Organ Diseases
Editor's Notes
Visceral – dull, poorly localized pain the originates in the walls of hollow organs such as gallbladder or appendix Somatic – sharp localized pain that originates in walls of the body such as skeletal muscle Peritonitis – inflammation of the abd cavity such as caused by ruptured appendix Referred – originates in a region other than where it is felt Dissecting Abdominal Aortic Anuerism – pain is felt between the shoulder blades Diaphram Inflamation – pain in neck or shoulders Appendicitis – periumbilical pain
Onset – was onset sudden or gradual? Sudden perferation while gradual is blockage Provocation – If pain lessens when the pt draws legs up to chest or lies on side usually indicates peritoneal inflammation of GI origin Quality – Localized tearing pain associated with organ rupture Dull steadily increasing may indicate bowel obstruction Sharp flank pain indicative of kidney stone Region/Radiation – Severity – pain worsens with worsening pathology (ischemia, inflammation, stretching) Time – Any pain lasting longer than 6 hours is considered surgical emergency Associated Symptoms – nausea, vomiting, bright red or coffee ground emesis, any changes in bowel habits, constiption, diarrhea, dark tarry stools loss of appetite or weight loss Pertinenet Negatives Pain in lower abd pelvis area may mean problems with reproductive system Inferior MI can irritate diaphragm and cause referred pain in shoulder and neck. Ask about cardiac history Chest pain may be GI referred pain – ie gastroesophageal reflux, gastric ulcers. Ask pt have they ever experienced pain like this before.
Physical Exam – posture and general appearance are key. They usually lay still often in fetal position because moving around causes more pain Distension may be an obvious sign. May be caused by build up of free air due to bowel obstruction. Abd can hold 4 o 6 L blood before any noticable change. Periumbilical ecchimosis (cullen’s sign) ecchymosis in flank (Grey-Turner’s sign Palpate – from area of no pain to area of pain. Stop palpating if you feel pulsating mass.
Note that any pain lasting longer than 6 hours is classified as a surgical emergency. Establish IV to replace fluids. NPO. Anti emetic helpful.
Upper GI include esophagus stomach duodenum to ligament of treitz. Appendix is part of the large intestine.
Upper GI bleed – peptic ulser disease, gastritis, esophageal varises, mallory-weiss tear (caused by vomiting). If ulcer erodes through the gastic mucosa can be life threatening. Blood in GI tract causes irritation and vomiting (hematemesis). Bleeding may be light or heavy and life threatening. Signs of shock, syncope, tilt test >10mmHg change. Maintain airway and prevent aspiration. Circulatory support. 20 cc/kg infusion Esophageal Varices – swollen vein of esophagus often rupture. Caused by increased portal vein pressure due to liver disease. Acute Gastroenteritis – inflammation of the stomach and intestines with asociated acute vomitingor diarrhea. Inflammation causes hemorrhage and erosion of the mucosal and submucosal layers of the GI tract which can damage villa that absorb water and nutrients.caused by alcohol abuse, asprin, stress, chemo agents, salmonella, staphylococcus. Pt may be hemodynamicaly unstable, electrolyte imbalance can cause chest pain and disrythmias. c/o widespread diffuse abd pain. Suction airway as needed and replace fluids Chronic Gastroenteritis – non acute inflammation of the gastrointenstinal mucosa due primarily to infection ie E. coli Peptic Ulcers – erosions caused by gastric acid
Lower GI Disease – rarely result in massive hemorrhage like those that occur in the upper GI Lower GI Bleed Ulcerative Colitis – inflammatory bowel disorder (IBD) of colon or large intestine Crohn’s Disease – IBD of small intestine, s/s diffuse abd cramping/pain, GI bleed, weight lose, nausea vomiting and diarrhea. Absence of Abd sounds signifies obstruction which requires surgery Diverticulitis – inflammation of diverticula (small outpouchings in the mucosal lining of the intestinal tract. Seeds popcorn and other things can get trapped and cause inflammation, bleeding and peritonitis) s/s low grade fever, lower left quad abd pain nausea and vomiting Hemorrhoids – small mass of swolen veins in the anus or rectum. (recked him, damn near killed him) rarely do they cause significant hemorrhage. May call 911 because of bleeding and pain. Alcoholics have increased risk Bowel Obstruction – blockage within the intestine either partial or complete. Can be caused by herniation, intussuseption, adhesion, volvulus twisting, prior surgery. Pt present with diffuse visceral pain, s/s shock (pale clammy skin tachycardia Alt LOC, hypotension. Can result in peritonitis if ruptured. Vomit may contain bile or smell like feces.
Appendicitis – inflammation of juncture between large and small intestine. (p. 244) affects mostly older children and young adults. The appendix can become inflammed and infected due to blockage and if not treated may rupture spilling contents into peritoneal cavity causing peritonitis. s/s pain lower right quandrant (McBurney’s point) Cholecystitis – inflammation of gallbladder. Usually caused by gallstones cholesterol or bilirubin based. Common among obese woman with more than one child. The gallbladder releases bile with removes cholesterol from body. s/s right upper abd pain. Pancreatitis – caused by alcohol abuse, gallstones, high cholesterol. Pancrease produces digestive enzymes as well as insulin and glucagon. When digestive enzymes back up into pancrease causing inflammation. s/s left upper quad abd pain may radiate to back. Nausea and vomiting. Hepatitis – injury to liver infectious A,B,C,D,E alcohol cirrosis, trauma. c/o upper right abd pain, loss of appetitie and weight loss, jaundice. Liver filters and detoxifies blood, and turns glucose into glycogen. Carefully consider pharmacological admin because liver breaks down many active drug metabolites.