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.
Sections General Pathophysiology, Assessment, and Treatment Specific Illnesses
General Pathophysiology General Risk Factors Excessive Alcohol Consumption Excessive Smoking Increased Stress Ingestion of Caustic Substances Poor Bowel Habits Emergencies Acute emergencies usually arise from chronic underlying problems.
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
General Assessment Physical Exam General assessment and vital signs Abdominal assessment • Inspection, Auscultation, and Palpation • Cullen’s Sign • Grey-Turner’s Sign
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.
Specific Illnesses The Gastrointestinal System Upper Gastrointestinal Tract Lower Gastrointestinal Tract Liver Gallbladder Pancreas Appendix
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
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.
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.
Peptic Ulcers Pathophysiology Erosions caused by gastric acid. Terminology based on the portion of tract affected. Causes: NSAID Use Alcohol/Tobacco Use H. pylori
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.
Lower Gastrointestinal Bleeding Pathophysiology Bleeding distal to the ligament of Treitz Causes Diverticulosis Colon lesions Rectal lesions Inflammatory bowel disorder
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).
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.
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.
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.
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.
Bowel Obstruction Pathophysiology Blockage of the hollow space of the small or large intestines Hernias
Accessory Organ Diseases GI Accessory Organs Liver Gallbladder Pancreas Vermiform Appendix
Appendicitis Pathophysiology Inflammation of the vermiform appendix. Frequently affects older children and young adults. Lack of treatment can cause rupture and subsequent peritonitis.
Appendicitis Signs & Symptoms Nausea, vomiting, and low-grade fever. Pain localizes to RLQ (McBurney’s point). Treatment Follow general treatment guidelines.
Cholecystitis Pathophysiology Inflammation of the Gallbladder Cholelithiasis Chronic Cholecystitis Bacterial infection Acalculus Cholecystitis Burns, sepsis, diabetes Multiple organ failure
Cholecystitis Signs & Symptoms URQ Abdominal Pain Murphy’s sign Nausea, Vomiting History of Cholecystitis Treatment Follow general treatment guidelines.
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.
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
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
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
Gastroenterology General Pathophysiology, Assessment, and Management Specific Illnesses Upper Gastrointestinal Diseases Lower Gastrointestinal Diseases Accessory Organ Diseases