Alexander ch24 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 24
Abdominal Pain and
Gastrointestinal
Disorders

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Compare and contrast the general characteristics
of hollow and solid abdominal organs.
3. List the general mechanisms and types of
abdominal pain.
4. Describe the pathophysiology, risk factors, assessment,
and management of patients with emergencies related
to hepatic diseases, including viral hepatitis, cirrhosis,
and hepatic encephalopathy.
Objectives (1 of 2)

5. Explain the pathophysiology, assessment, and
management of abdominal and gastrointestinal disorders.
6. Develop an effective line of questioning for patients
presenting with abdominal pain and gastrointestinal
complaints.
7. Communicate effectively, orally and in writing, the
assessment findings, history, and treatment of patients
with gastrointestinal complaints and abdominal pain.
Objectives (2 of 2)

• Gastrointestinal disorders often present with
abdominal pain.
– Not all abdominal pain is caused by gastrointestinal
disorders.
• Can be caused by
– Renal or urinary tract problem
– Vascular disorder
– Gynecologic disorders
– Pneumonia or myocardial infarction
– As well as gastrointestinal disorders
Introduction

Think About It
• What are the patient’s presenting problems and
risk factors that Elle and Becky will use to develop
initial hypotheses on the nature of the illness?
• What might be Elle and Becky’s initial hypotheses
about the patient’s presenting problem? What
systems and processes might be involved?
• To test Elle and Becky’s hypotheses, what aspects
of the history are relevant in determining the
underlying problem?

Figure 24-1
(A) The boundaries of the abdominopelvic cavity.

Figure 24-1 (continued)
(B) Contents of the abdominopelvic cavity by quadrant.

Anatomy and Physiology Review
• For physical examination, abdomen divided into
four quadrants by two imaginary lines that
intersect at umbilicus.
• Abdominal organs
– Hollow
– Solid
– Peritoneal
– Retroperitoneal

Figure 24-3
The gastrointestinal system.

Anatomy and Physiology Review (1 of 3)
• Large blood vessels
– Abdominal aorta, vena cava, renal arteries and veins,
and veins of the hepatic portal
• Gastrointestinal (GI) system
– Long tube from mouth to anus, accessory organs

Figure 24-4
The colon, or large intestine. The ileum of the small intestine empties into the large
intestine at the cecum through the ileocecal valve. The appendix projects inferiorly from
the cecum.

• Stomach contents (chyme) enters small intestine
(duodenum).
• Nutrients absorbed as intestinal contents move
through duodenum.
• Intestinal contents enter large intestine (colon).
• Water absorbed from large intestine, producing
more solid fecal mass, which is stored in rectum.

• Salivary glands
– Secrete saliva into oral cavity to moisten food
• Liver
– Processes nutrients and medications, detoxifies
substances from blood
• Gallbladder
– Excess bile stored
• Pancreas
– Both endocrine functions and exocrine functions

Assessment and Management (1 of 5)
• Abdominal cavity houses organs and structures
of many body systems.
• Gastrointestinal problems:
– Nausea, vomiting, diarrhea, constipation, back pain,
bloating, anorexia, jaundice, rectal pain, hematemesis,
melena, hematochezia

Table 24-1
Possible Sources of Abdominal Pain by Region
Abdominal Region Organs Sources of Referred Pain
Right upper quadrant Liver, gallbladder Pneumonia or pleuritis (right pleural cavity)
Epigastric region Stomach, pancreas AMI, appendicitis
Left upper quadrant Spleen, part of pancreas Pneumonia or pleuritis (left pleural cavity)
Umbilical and hypogastric Small intestine, large intestine, aorta,
urinary bladder, in females: uterus
Bowel obstruction, appendicitis
Right lower quadrant Appendix, ascending colon, in females:
right ovary and fallopian tube
Left lower quadrant Descending colon (diverticula usually are
located in the descending colon)

• Scene size-up
– Determine chief complaint
– Initial impression
– Degree of distress
 Level of responsiveness
 Facial expression
 Skin color
 Position

• Primary assessment
– Airway and breathing
 Position patient, prepare to suction oxygenation
and ventilation as needed.
– Circulation
 Check for hypovolemia.
 Prepare for shock:
– Dehydration, sepsis, or blood loss

• Secondary assessment
– Complete vital signs.
– Past medical history
– Perform physical exam.
 Color of skin (jaundice or pallor)
 Examine abdomen

Table 24-2 (1 of 2)
Presentations of Problems Associated with Specific Organs
Organ or
Problem
Common Findings
Liver General: steady, dull pain in right upper quadrant, bleeding tendency, jaundice
Hepatitis: flulike symptoms; enlarged, tender liver
Cirrhosis: ascites; dyspnea from liver enlargement and ascites
Gallbladder Gallstone obstructing common bile duct: crampy, colicky pain, often 30–60 minutes after eating,
especially a high-fat meal; right upper quadrant pain that may radiate to the right shoulder,
scapula, or back; nausea and vomiting
Cholecystitis: may also have fever, jaundice
Stomach Gastritis or peptic ulcer disease: steady, burning epigastric pain, possible nausea and vomiting;
hematemesis possible
Perforated ulcer: signs of peritoneal irritation
Acute pancreatitis Sudden onset of constant, severe pain in the epigastric region that may feel as though it is
“boring through” to the back; nausea and vomiting, which may be severe
Spleen Enlarged or irritated: pain in left upper quadrant, pain may be referred to left shoulder and neck
Ruptured spleen: sudden, intense pain subsides and then intensifies and may be accompanied
by syncope and orthostatic hypotension
Large and small
intestines
Gastroenteritis, inflammatory bowel disease, ileitis, colitis: crampy, colicky pain; possible
vomiting, diarrhea, and dehydration
Food poisoning: ingestion of contaminated food two to eight hours before onset of symptoms;
vomiting and diarrhea, dehydration, and electrolyte disturbances are possible
Bowel obstruction: begins with intermittent colicky pain that increases in intensity and becomes
constant; pain is poorly localized; shallow respirations due to peritonitis; sepsis may occur
Diverticulitis: signs of peritonitis, fever, diarrhea, lower gastrointestinal bleeding

Table 24-2 (2 of 2)
Presentations of Problems Associated with Specific Organs
Organ or Problem Common Findings
Aorta Intense, tearing pain in lower back or abdomen that may radiate down one or both legs,
possible vascular and neurologic signs and symptoms in one or both lower extremities,
syncope, hypotension, shock, feeling of “impending doom,” possible pulsating mass in
midline of lower abdomen
Kidneys and ureters Nephritis: dull, constant flank pain, possible difficulty in urination and hematuria
Kidney stone: sharp, colicky pain that may intensify until the stone is passed, pain may
radiate to groin, possible hematuria; patient may be restless, prefer to stand, and be unable
to find a comfortable position
Appendix May begin with poorly localized periumbilical pain, usually localizes to right lower quadrant,
may fever. Rupture signified by sudden relief of pain followed by signs of peritonitis
Ovaries and fallopian
tubes
Ovarian cyst: dull, constant pain localized to one side in the lower quadrant
Ruptured ovarian cyst: pain may subside briefly followed by signs of peritonitis and pain may
radiate to neck or shoulder on affected side
Ectopic pregnancy: crampy, colicky pain that intensifies with rupture, followed by signs of
peritonitis, referred pain, orthostatic vital signs, and shock

• Clinical-reasoning process
– Care primarily supportive
• Treatment
– Anticipate vomiting
– IV fluid
– Position of comfort
• Reassessment
– Critical
– Noncritical

General Abdominal Complaints—
Abdominal Pain
• General causes
– Inflammation or infection
– Stretching of tissues
– Ischemia
• Visceral
• Somatic
• Referred and radiating

Think About It
• How might this information help the Advanced
EMTs refine their hypotheses?
• Describe the relevant initial physical examination
and interventions needed based on the
information so far.

Figure 24-8
A hiatal hernia with gastroesophageal reflux.

Disorders of the Esophagus
• Esophageal varices
– Mallory-Weiss tear
• Esophagitis
– GERD
• Hiatal hernia

Disorders of the Stomach
and Intestines
• Upper gastrointestinal bleeding
– Esophagus to the ligament of Treitz
– Gastritis, peptic ulcer, inflammation, or ulcers in
duodenum

and Intestines (1 of 7)
• Upper gastrointestinal bleeding (continued)
– Signs and symptoms include:
 Burning in the upper quadrants
 Acute, severe pain
 Vomiting blood
 Coffee ground emesis
 Melena
– Oxygen; assist ventilations if needed
– IV and administer fluids per protocol.

Figure 24-10
Normal and inflamed appendix.

• Gastroenteritis
– Inflammation of stomach and intestines due to
presence of pathogen (viral, bacterial, parasitic)
• Appendicitis
– Inflammation of appendix
• Diverticulitis
– Infection of diverticulum; signs and symptoms similar
to appendicitis

Figure 24-12
Volvulus of the small intestine.

• Lower gastrointestinal bleeding
– Beyond the ligament of Treitz
• Bowel obstruction
– Due to fecal impaction, tumor, or bands of adhesions
in abdomen from surgery, volvulus (twisting of intestine
at cecum or sigmoid colon).

• Bowel infarction
– Portion of bowel is ischemic and cannot function
• Hernia
– Abnormal opening through which tissue protrudes

• Inflammatory bowel disease (IBD): disorders
include ulcerative colitis, Crohn’s disease
– Ulcerative colitis limited to colon
– Crohn’s disease can affect any part of gastrointestinal
tract.

• Constipation
– Infrequent bowel movements with small, hard feces
due to excessive water absorption from colon
• Hemorrhoids
– Congestion of hemorrhoidal cushions of anal canal

• Treatment of swallowed foreign bodies depends
on nature of object and location in digestive tract.
– Most objects passed through stomach will continue
through digestive tract without problem.
– Sharp objects may require surgical removal.

Figure 24-14
Accessory organs of digestion. Note the relationship between the liver, gallbladder,
and pancreas provided through the cystic and hepatic ducts, common bile duct, and
pancreatic duct.

Pancreatitis
• Inflammation of pancreas
• Acute pancreatitis
– Digestive enzymes come in contact with pancreatic
cells, resulting in autodigestion of the pancreatic tissue
• Grey-Turner’s sign
• Cullen’s sign

Think About It
• How might the additional information affect
Elle and Becky’s hypotheses?
• Given the patient’s age, risk factors, history,
and examination findings, what might be
Elle and Becky’s differential diagnoses?
• How serious is Mrs. Stoker’s condition?
• How should Elle and Becky respond to
Mrs. Stoker’s inquiry about what they think
the problem is?

Liver Disease (1 of 2)
• Hepatitis
– Both infectious and noninfectious causes
– Most are viral
– Noninfectious causes: medications and toxins
– Chronic hepatitis can lead to liver cancer, cirrhosis,
portal hypertension.

Liver Disease (2 of 2)
• Cirrhosis
– Progressive disease caused by chronic
inflammation of liver
– Normal liver tissue replaced by scar tissue
– Causes: chronic alcohol abuse, fatty liver, chronic
hepatitis

Cholecystitis
• Inflammation of gallbladder
– Occurs from presence of gallstones
• Symptoms
– Nausea, vomiting; severe cases, distended
gallbladder becomes ischemic and peritonitis
can occur

Other Causes of Abdominal Pain (1 of 2)
• Pneumonia
– Referred pain to upper quadrant
• Myocardial infarction
– Pain in epigastric region
• Spleen
– Highly vascular; may rupture if enlarged; shock
from internal hemorrhage

Other Causes of Abdominal Pain (2 of 2)
• Kidney infection and kidney stones
– May present with flank pain
• Abdominal aortic aneurysm
– Weakened area of aorta prone to rupture
• Aortic dissection
– Intimal lining of aorta allows blood to enter and
separate the layers of the aorta

Chapter Summary (1 of 2)
• Know anatomy, physiology, pathophysiology
related to gastrointestinal system and abdomen.
• Patients may experience abdominal pain that
arises from a variety of causes.
• Life-threatening nature requires transportation
of patients with abdominal pain for evaluation by
physician.

Chapter Summary (2 of 2)
• During transport
– Make patient as comfortable as possible.
– Administer oxygen if respirations shallow or patient has
signs of shock.
– Consider need for fluid replacement.
– Consult with medical direction about use of analgesia
in patients with abdominal pain.

Alexander ch24 lecture

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