02 gastroenterology


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02 gastroenterology

  1. 1. Gastroenterology Dutchess Community College EMS
  2. 2. 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. Dutchess Community College EMS
  3. 3. Abdominal Pain Types      Visceral Somatic Referred Hemorrhagic Non-hemorrhagic Causes    Inflammation Distention Ischemia Dutchess Community College EMS
  4. 4. General Assessment Scene Size-up & Initial Assessment Scene clues.  Identify and treat life-threatening conditions.  Dutchess Community College EMS
  5. 5. General Assessment Focused History & Physical Exam Obtain SAMPLE History.  Obtain OPQRST History.  Associated symptoms  Pertinent positives and negatives  Previous history of same event  Nausea/ vomiting  Change in bowel habits/ stool    Constipation, Diarrhea Weight loss Dutchess Community College EMS
  6. 6. General Assessment  Physical Exam General assessment and vital signs  Appearance  Posture  Level of consciousness  Apparent state of health  Skin color  Vital signs  Inspect, Auscultate, Percuss, Palpate, abdomen  Female abdominal exam  Male abdominal exam  Dutchess Community College EMS
  7. 7. General Treatment Airway and ventilatory support  Maintain an open airway  High flow oxygen Circulatory support  Electrocardiogram  Monitor blood pressure Dutchess Community College EMS
  8. 8. General Treatment Pharmacological interventions Consider initiating intravenous line  Avoid intervention which mask signs and symptoms  Non-pharmacological interventions Nothing by mouth  Monitor LOC  Monitor vital signs  Position of comfort  Dutchess Community College EMS
  9. 9. General Treatment Transport consideration Persistent pain for greater than six hours requires transport  Gentle but rapid transport  Psychological support All actions reflect a calm, caring, competent attitude  Keep patient and significant others informed of your actions  Dutchess Community College EMS
  10. 10. The Gastrointestinal System Upper Gastrointestinal Tract Lower Gastrointestinal Tract Liver Gallbladder Pancreas Appendix Dutchess Community College EMS
  11. 11. Upper GI Tract Dutchess Community College EMS
  12. 12. Upper Gastrointestinal Bleeding Signs & Symptoms     General abdominal discomfort Hematemesis and melena Classic signs and symptoms of shock Changes in orthostatic vital signs Treatment  Follow general treatment guidelines.   Begin volume replacement using 2 large-bore IVs. Differentiate life-threatening from chronic problem. Dutchess Community College EMS
  13. 13. Esophageal Anatomy Dutchess Community College EMS
  14. 14. Upper Gastrointestinal Bleeding Causes Peptic Ulcer Disease  Gastritis  Rupture of Varicies  Mallory-Weiss Tear  Esophagitis  Duodenitis  Dutchess Community College EMS
  15. 15. Peptic Ulcers Pathophysiology    Ulcerative disorder Acid-pepsin formation Loss of protective effects      Gastric mucosa Bicarbonate ions Prostoglandins Terminology based on the portion of tract affected. Causes: NSAID Use Alcohol/Tobacco Use H. pylori Dutchess Community College EMS
  16. 16. Benign Ulcer Dutchess Community College EMS
  17. 17. Stomach Ulcer with Bleeding Dutchess Community College EMS
  18. 18. Use of ASA / NSAIDS, smoking These NSAIDs can penetrate the lining of the stomach and release substances that damage cells. NSAIDs and smoking also block natural chemicals called prostaglandins that can help repair those cells. Using NSAIDS regularly for a long time, such as for arthritis pain, especially adds to this problem. Dutchess Community College EMS
  19. 19. NSAID Erosion Dutchess Community College EMS
  20. 20. Helicobacter pylori A bacterium called Helicobacter pylori causes most ulcers - about 80-85% of duodenal ulcers and 60-80% of gastric ulcers. The bacteria can spread into the mucus lining that usually protects the stomach and small intestine from digestive acids, damaging it in the process. Dutchess Community College EMS
  21. 21. Helicobacter Pylori Initiating Inflammation Dutchess Community College EMS
  22. 22. Peptic Ulcers Symptoms Gnawing or burning pain  In the abdomen between sternum and navel  Can be a dull ache or strong hunger pains  The elderly may not feel symptoms at all  Dutchess Community College EMS
  23. 23. Pain from Ulcers Gastric ulcers  strike at any time of the day, but it's usually worst after eating a meal, up to three hours later. Duodenal ulcers  typically shows up when the stomach is empty at night or between meals. It may last for a number of weeks and then temporarily go away. Food or antacids can often relieve this kind of pain. Dutchess Community College EMS
  24. 24. Acute Gastroenteritis Causative organisms Rotavirus, Norwalk virus, and many others Parasites    Protozoa giardia lamblia Crypto sporidium parvum Cyclosporidium cayetensis Contracted via fecal-oral transmission, contaminated food and water Cyclosporidium reported to be contracted by swimming in contaminated waters Dutchess Community College EMS
  25. 25. Acute Gastroenteritis Causative organisms Bacteria       Escherichia coli Klebsiella pneumonia Enterobacter Campylobacter jejuni Vibrio cholera Shigella   Not part of normal intestinal flora Salmonella  Not part of normal intestinal flora Dutchess Community College EMS
  26. 26. Acute Gastroenteritis Modes of transmission Fecal-oral Ingestion of infected food or non-potable water Susceptibility and resistance Travelers into endemic areas are more susceptible Populations in disaster areas, where water supplies are contaminated, are susceptible Native populations in endemic areas are generally resistant Dutchess Community College EMS
  27. 27. Acute Gastroenteritis Signs & Symptoms Rapid Onset of Severe Vomiting and Diarrhea  Hematemesis, Hematochezia, Melena  Diffuse Abdominal Pain  Classic Signs of Shock  Dutchess Community College EMS
  28. 28. Gastroenteritis Similar to Acute Gastroenteritis  Long-Term Mucosal Changes or Permanent Damage. Primarily due to microbial infection.  More frequent in developing countries.  Dutchess Community College EMS
  29. 29. Gastroenteritis Patient management and protective measures EMS personnel - do not work when ill if your job involves patient contact Environmental health and development/ availability of clean water reservoirs, food preparation and sanitation Disaster workers and travelers to endemic areas must be vigilant in knowing the sources of their water supplies or drink hot beverages that have been brisk-boiled or disinfected Dutchess Community College EMS
  30. 30. Gastroenteritis Patient management and protective measures Health care workers treating gastroenteritis patients must be careful to avoid habits that facilitate fecaloral/ mucous membrane transmission, observe BSI and effective hand washing Selected organisms may be sensitive to antibiotics Epidemic treatment is normally symptomatic Dutchess Community College EMS
  31. 31. Erosive Gastritis LESIONS Dutchess Community College EMS
  32. 32. Esophageal Varices Cause  Increased Portal Hypertension Chronic alcohol abuse and liver cirrhosis  Ingestion of caustic substances  Result  Esophagitis with erosion Dutchess Community College EMS
  33. 33. Esophageal Varices Signs & Symptoms     Hematemesis, Dysphagia Painless Bleeding Hemodynamic Instability Classic Signs of Shock Treatment  Follow General Treatment Guidelines.   Aggressive Airway Management Aggressive Fluid Resuscitation Dutchess Community College EMS
  34. 34. Varicies Dutchess Community College EMS
  35. 35. Inverted esophagus on post showing varicies Dutchess Community College EMS
  36. 36. Esophagitis Dutchess Community College EMS
  37. 37. Erosive Esophagitis Dutchess Community College EMS
  38. 38. Mallory-Weiss Tear A tear in the lower end of the esophagus Caused by severe vomiting. Common in alcoholics. May also be caused by increased pressure in the abdomen from coughing, hiatal hernia, or childbirth. Dutchess Community College EMS
  39. 39. Mallory Weiss Tear Dutchess Community College EMS
  40. 40. Lower GI Tract Dutchess Community College EMS
  41. 41. Lower Gastrointestinal Bleeding Pathophysiology Bleeding distal to the ligament of Treitz  Causes  Diverticulosis  Colon lesions  Rectal lesions  Inflammatory bowel disorder  Dutchess Community College EMS
  42. 42. 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). Dutchess Community College EMS
  43. 43. Lesions Dutchess Community College EMS
  44. 44. Ulcerative Colitis Pathophysiology  Causes Unknown Signs & Symptoms    Abdominal Cramping Nausea, Vomiting, Diarrhea Fever or Weight Loss Treatment  Follow general treatment guidelines. Dutchess Community College EMS
  45. 45. Ulcerative Colitis Dutchess Community College EMS
  46. 46. Irritable Bowel Syndrome (IBS)* Pathophysiology  Patients often show: Hypersensitivity of bowel pain receptors  Hyperresponsiveness of the smooth muscle  Psychiatric disorder connection 
  47. 47. Irritable Bowel Syndrome (IBS)* Pathophysiology (cont’d)  Hyperresponsiveness can cause spasm.  Can cause constipation and bloating or diarrhea Typically begins during childhood  Can be triggered by various stimuli 
  48. 48. Irritable Bowel Syndrome (IBS)* Assessment  You will typically be called when the patient is having a flare-up of symptoms. Management Mainly supportive  Assessment should include the patient’s mood. 
  49. 49. Crohn’s Disease Pathophysiology  Inflammatory disorder  Small bowel, Large bowel Increased suppressor T-cell activity  Damages Intestinal submucosa  Lesions  Fissures and Fistulas   Can affect the entire GI tract.  Hypertrophy and fibrosis of underlying muscle. Dutchess Community College EMS
  50. 50. Dutchess Community College EMS
  51. 51. Crohn’s Disease Signs and Symptoms  Difficult to differentiate.  Clinical presentations vary drastically. GI bleeding, nausea, vomiting, diarrhea.  Abdominal pain/cramping, fever, weight loss.  Dutchess Community College EMS
  52. 52. Crohn’s Disease Dutchess Community College EMS
  53. 53. Diverticulitis* Pathophysiology Diverticulum: weak area in the colon that begins to have pockets (diverticula)  Diverticulosis: condition of having diverticula  Diverticulitis: Inflammation of diverticuli 
  54. 54. Diverticulitis* Pathophysiology A diet low in fiber creates more solid stool.  If feces gets trapped in diverticula, inflammation and infection occur and may cause:  Scarring  Adhesions  Fistula 
  55. 55. Diverticulitis* Assessment  Signs and symptoms include: Abdominal pain, usually localized on the left lower abdomen  Classic infection signs  Constipation or diarrhea 
  56. 56. Diverticulitis* Management Ensure severe infection is not present.  Patients may need fluids and/or dopamine.  In-hospital treatment includes:  Antibiotics  Liquid diet  Surgery 
  57. 57. Bowel Obstruction Pathophysiology Mechanical  Non-mechanical  Lesions  Obturation of the lumen  Small/ large bowel  Adhesions  Hernias  Dutchess Community College EMS
  58. 58. Bowel Obstruction Intussusception Dutchess Community College EMS
  59. 59. Bowel Obstruction Volvulus Dutchess Community College EMS
  60. 60. Bowel Obstruction Adhesions Dutchess Community College EMS
  61. 61. Bowel Obstruction Pathophysiology  Other Causes  Foreign bodies, gallstones, tumors, bowel infarction Signs & Symptoms     Decreased Appetite, Fever, Malaise Nausea and Vomiting Diffuse Visceral Pain, Abdominal Distention Signs & Symptoms of Shock Treatment  Follow general treatment guidelines. Dutchess Community College EMS
  62. 62. Accessory Organ Diseases GI Accessory Organs Liver  Gallbladder  Pancreas  Vermiform Appendix  Dutchess Community College EMS
  63. 63. Appendicitis Pathophysiology Inflammation of the vermiform appendix.  Obstruction of appendiceal lumen  Ulceration of appendiceal mucosa  Viral  Bacterial  Frequently affects older children and young adults.  Lack of treatment can cause rupture and subsequent peritonitis.  Dutchess Community College EMS
  64. 64. Appendicitis Signs & Symptoms   Nausea, vomiting, and low-grade fever. Pain localizes to RLQ (McBurney’s point). Treatment  Follow general treatment guidelines. Dutchess Community College EMS
  65. 65. Cholecystitis Pathophysiology Gall Stones in Cystic Duct  Inflammation of the Gallbladder  Cholelithiasis  Chronic Cholecystitis    Bacterial infection Acalculus Cholecystitis Burns, sepsis, diabetes  Multiple organ failure  Dutchess Community College EMS
  66. 66. Dutchess Community College EMS
  67. 67. Cholecystitis Signs & Symptoms  URQ Abdominal Pain  Murphy’s sign Nausea, Vomiting  History of Cholecystitis  Treatment  Follow general treatment guidelines. Dutchess Community College EMS
  68. 68. 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.  Injury or disruption of pancreatic ducts or acini  Leaked enzymes Dutchess Community College EMS
  69. 69. 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  Dutchess Community College EMS
  70. 70. 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 Dutchess Community College EMS
  71. 71. Hepatitis Signs & Symptoms       Acute/ chronic onset URQ abdominal tenderness Loss of appetite, nausea/vomiting, weight loss, malaise Fatigue, Headache, Photophobia Clay-colored stool, jaundice, scleral icterus Pharyngitis, Cough Treatment  Follow general treatment guidelines.  Use PPE and follow BSI precautions Dutchess Community College EMS
  72. 72. Hemorrhoids Pathophysiology    Mass of swollen veins in anus or rectum. Increased portal vein pressure Mucosal surface    Thrombosis Infection Erosion Signs & Symptoms   Limited bright red bleeding and painful stools. Consider lower GI bleeding. Treatment  General treatment guidelines. Dutchess Community College EMS
  73. 73. Dutchess Community College EMS
  74. 74. Rectal Abscess* Pathophysiology  Caused when the ducts carrying mucus to the rectal area become blocked  Allows bacteria to grow and spread to the anus
  75. 75. Rectal Abscess* Assessment  Symptoms may include: Rectal pain that increases with defecation  Rectal drainage  Constipation  Management  Focus on keeping the patient comfortable.
  76. 76. Acute Infectious Conditions* GI infection occurs when contaminated food is ingested or when the GI tract ruptures.  People that have a difficulty combating infection: Immunocompromised  Very old  Very young 
  77. 77. Acute Infectious Conditions* Damage may allow contents to be released into surrounding tissues. The body will begin to defend itself.  If the infection continues, it may leave the GI system and enter the bloodstream.   This is known as sepsis.
  78. 78. Hernia* Pathophysiology Organ/structure protrusion into adjacent cavity  To check for an inguinal hernia:  Place fingers on lower abdomen.  Instruct patient to cough.  Weakness in abdominal wall will present as bulging. 
  79. 79. Hernia* Pathophysiology (cont’d)  Caused by any condition that causes intraabdominal pressure: Obesity  Standing for long periods  Straining during bowel movements  Chronic obstructive pulmonary disease 
  80. 80. Hernia* Assessment  Four types Reducible  Incarcerated  Strangulated  Incisional 
  81. 81. Hernia* Management Focus on supportive measures.  Pain management  Assess for sepsis 
  82. 82. Rectal Foreign Body Obstruction* Pathophysiology  Originates from upper GI tract or anal insertion Assessment Presents with sudden rectal pain with defecation  Determine if the rectum has been perforated. 
  83. 83. Rectal Foreign Body Obstruction* Management Do NOT attempt to remove object.  Prehospital management should be limited to patient comfort.  Treat with analgesia if indicated.  Closely monitor vital signs. 
  84. 84. Mesenteric Ischemia* Pathophysiology Interruption of the blood supply to the mesentery  Can be caused by:  Arterial embolism  Thrombosis  Profound vasospasm 
  85. 85. Mesenteric Ischemia* Assessment Gradual or sudden onset  Symptoms include:  Severe pain with ill-defined location  Nausea, vomiting, and diarrhea  Possible blood in stool 
  86. 86. Mesenteric Ischemia* Management Patients require rapid transportation.  Monitor closely.  Check vitals for signs of sepsis.  Fluid resuscitation in cases of shock  Give analgesics as needed. 
  87. 87. Gastrointestinal Conditions in Pediatric Patients* GI complaints are common in children.  Prolonged vomiting, diarrhea, or bleeding can lead to severe changes in sodium and potassium levels.
  88. 88. Gastrointestinal Conditions in Pediatric Patients* Congenital GI anomalies Gastrochisis: portions of the GI system lie outside the abdominal wall © M. Ansary/Custom Medical Stock Photo 
  89. 89. Gastrointestinal Conditions in Pediatric Patients* Congenital GI anomalies (cont’d)  Intestinal malrotation: intestines rotated incorrectly during development
  90. 90. Gastrointestinal Conditions in Pediatric Patients* Congenital GI anomalies (cont’d)  Pyloric stenosis: hypertrophy of the pyloric sphincter of the stomach GI bleeding can occur in children.
  91. 91. Gastrointestinal Conditions in Pediatric Patients* Careful assessment is critical. Check skin turgor, pulse rate, and peripheral pulse status.  Severe fluid loss may cause diminished LOC.    Standard fluid resuscitation: 20 mL/kg isotonic fluid Get a detailed medical history from the parent.
  92. 92. Gastrointestinal Conditions in Pediatric Patients* Patients may have a gastrostomy tube. If dislodged, place a sterile dressing over it.  If clogged, talk about ways to clear the tube.  If the blockage cannot be easily managed, turn off the feeding, clamp the tube, and transport. 
  93. 93. Gastrointestinal Conditions in Older Adults* GI diseases more prevalent in older adults Abdominal pain can also be a symptom of a cardiac condition. Obtain a thorough history and physical exam.  Consider a 12-lead ECG.  Monitor vital signs. 
  94. 94. Prevention Strategies* Many behaviors can prevent or limit severity of GI diseases.
  95. 95. Prevention Strategies*
  96. 96. Gastroenterology Review General Pathophysiology, Assessment, and Management Specific Illnesses Upper Gastrointestinal Diseases  Lower Gastrointestinal Diseases  Accessory Organ Diseases  Dutchess Community College EMS
  97. 97. QUESTIONS ? Dutchess Community College EMS