Gastroenterology

1. Gastroenterology

2. Sections General Pathophysiology, Assessment, and Treatment Specific Illnesses

3. Common Complaints Nausea, vomiting Acute abdominal pain UGI bleed Hemataemesis, melena Diarrhea Liver disease secondary to ETOH abuse

4. 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.

5. PAIN Hallmark of acute abdominal emergency

6. Abdominal Pain Types Visceral Somatic Referred Causes Inflammation Distention Ischemia

7. Visceral Dull, poorly localized Originates walls of hollow/ capsule of solid Because the nerves enter the spinal column at various levels , visceral pain is not localized. Gallbladder and appendix Somatic Sharp, localized, travels along a definite neural routes to the spinal column peritonitis Referred Originates in a region other than where it is Many neural pathways from various organs pass over or through regions formed during the embryonic development. Thus causing refered pain to a different area of the body. Injury or inflammation of the diaphragm often feel pain in the neck or shoulders AAA –referred pain between the shoulder blades.

8. General Assessment Scene Size-up & Initial Assessment Scene clues. MOI Identify and treat life-threatening conditions. Focused History & Physical Exam Focused History Obtain SAMPLE History. Obtain OPQRST History. AS PN Associated symptoms +N/+V, hematemesis, coffee ground emesis Pertinent negatives: BM, Urination frequency, AMI- Can irritate diaphragm causing referred pain to the neck and shoulder

9. General Assessment Physical Exam General assessment and vital signs Abdominal assessment Inspection, Auscultation, and Palpation Cullen’s Sign Periumbilical ecchymosis Grey-Turner’s Sign Flank ecchymosis

10. PE Position: Severe abdominal pathology Lie very still & sometimes in the fetal position Inspect Abd distension Free air Hemorrhage – 4-6 L’s of fluid before any noticeable changes Auscultate Each quadrant – 2 minutes in each Quadrant Prior to palpation

11. PE Palpate SNTTP – Soft Non-Tender To Palp Painful quadrant last Ridged- Fluid/mass present Trauma related – high suspicion of bleeding Guarding- Protecting painful area Pulsating- Stop palpating. Suspect AAA

12. 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.

13. Specific Illnesses The Gastrointestinal System Upper Gastrointestinal Tract- Proximal the Ligament of Treitz Lower Gastrointestinal Tract Liver Gallbladder Pancreas Appendix

14. Mouth, Pharynx, Esophagus Swallowing (deglutination): Cephalic phase Food traveling through esophagus to stomach Gastric phase Food enters stomach Stomach wall distends Releases gastrin Stimulates stomach motor function

15. Stomach Functions Hold food Mixing Parcelling chyme into small intestine

16. Small Intestine Almost all digestion Duodenum, jejunum, ileum

17. Duodenum 10”, C shaped curve Pylorus Extends from stomach to small intestine Bile and pancreatic enzymes enter Neutralize acidic chyme Aid digestion

18. Jejunum and Ileum Jejunum Duodenum to ileum Longest portion Ileum Narrowest portion

19. Large Intestine Ascending colon Absorption takes place Descending colon Transverse colon

20. Liver Carbohydrate metabolism Filter & detoxify blood Remove ammonia Produce plasma proteins, nonessential amiono acids, vitamin A Stores iron, vitamin K, D, B 12 Converts glucose to glycogen Stores fat & converts excess sugars to fat for storage

21. Gallbladder Store and concentrate bile

22. Pancreas Exocrine Digestive enzymes Endocrine Hormones Alpha Glucagon Stimulate glucose formation Beta Insulin Promote carbohydrate metabolism

23. History of the illness When and how Associated S/S Pain: OPQRST-AS PN Past Hx Anyone else with same S/S CO poisoning, food poisoning

24. Causes N/V Pain, emotion, migraine Drugs, uremia, DKA Vertigo, pressure, stroke Inflammation, stasis, bleeding Inflammation, congestion, biliary tract Inflammation, obstruction, infection Cerebral cortex ICP Brainstem Stomach Liver Bowel

25. GI S/S Diarrhea Abdominal pain Obstruction Distention Liver disease ETOH abuse

26. Causes of GI S/S  Drug Related Any new medications/ dosages Digoxin toxicity Opiate side effect Increased ICP Associated Hx: HA Meningitis Subarachnoid hemorrhage ALOC Encephalitis Cerebral mass Trauma

27. Metabolic Causes Renal failure NA++/K+ levels DKA

28. Acute Medical Conditions Migraine vs CVA vs Meningitis AMI vs Angina +N/+V + diaphoretic Sepsis Elderly immunosuppressed

29. GI Bleed How do you recognize the symptoms of GI bleeding? Because GI bleeding is internal, it is possible for a person to have GI bleeding without having pain, without knowing you are bleeding Symptoms of GI bleeding vary upper part of the digestive tract (the esophagus, stomach or the beginning of the small intestine) the lower part (small intestine, colon or rectum).

30. Assessment: Symptoms of Upper GI Bleeding: vomiting bright red blood vomiting dark clots, or coffee ground-like material passing black, tar like stool. Symptoms of Lower GI Bleeding: passing pure blood or blood mixed in stool bright red or maroon colored blood in the stool

31. Assessment and RX: ABC’s PE …following TX for any immediate life threats SAMPLE HX OPQRST. Remember, the HX of the present illness as well as the past HX will be especially helpful in piecing together a clear picture of the underlying gastrointestinal pathophysiology.

32. Assessment and RX: Physical Exam…look for appearance and posture. Usually PT’s. w/ Abd. Pathology will lie as still as possible, often in fetal position. VS. Take a complete set as a baseline.

33. What are the different types of GI bleeding? GI bleeding may come from various parts of the GI tract, and may be caused by various things.

34. Assessment and RX: Inspection – BEFORE palpation or auscultation. Visualize entire abdomen Look for distention. Important to remember that if distention is present and pt. is hemodynamically unstable due to hemorrhage, pt. has lost significant amount of blood volume. Abdomen can hold from 4-6 liters of fluid BEFORE significant changes in girth appear!

35. Assessment and RX: Look for Cullen’s sign and Grey-Turners sign. Both indicate fluid loss. Auscultation usually provides little helpful information. If done, must be before palpation. Palpation. Most useful method of abdomen exam. Palpate gently w/ palpation of tender, painful area LAST.

36. Assessment and RX: RX: O2 IV CM, treat for S/S shock, provide emotional reassurance, calm patient. TX: POC. Reassess Remember….ANY Persistent Abdominal pain lasting LONGER THAN 6-HOURS is classified as a surgical emergency and requires transport !

37. GI Bleeds

38. Bleeding within GI tract proximal to ligament of Treitz Duodenum & jejunum meet Esophagus, stomach, duodenum 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. Upper Gastrointestinal Bleeding

39. Causes 75% of UG bleeds are caused by erosions or irritation of the gastric lining of the stomach Peptic Ulcer Disease- 50% Gastritis- 25% Variceal Rupture Mallory-Weiss Tear Laceration secondary to vomiting Esophagitis Duodenitis Upper Gastrointestinal Bleeding

40. Peptic Ulcers Erosions caused by gastric acid Gastric ulcers occur in the stomach Duodenal ulcers Duodenal ulcers are 2-3 times more frequent Causes: Stress – Family Hx NSAID Use Alcohol/Tobacco Use Zollinger-Ellison Syndrome H. pylori (helicobacter pylori bacteria

41. General pathophysiology: In cases of Peptic ulcers, which occur 4:1 in males opposed to females, pain and bleeding is usually slow to moderate unless actual ulcer ruptures. In which case pain and bleeding will escalate to severe.

42. Peptic Ulcers Signs & Symptoms +N/ +V Abdominal Pain Minimal to severe Observe for signs of hemorrhagic rupture. Acute pain, hematemesis, melena Treatment Follow general treatment guidelines. Consider administration of histamine blockers and antacids.

43. 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

44. 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.

45. Gastroenteritis Major cause infectious agent viral, bacterial, parasitic day care, crowded, unsanitary, winter due to viral, summer due to bacterial diarrhea, vomiting, abd pain, fever, dehydration

46. Causes Rotovirus 48 hrs; +N/V, prolonged diarrhea Adenovirus 3-10 days; low grade fever, watery diarrhea E Coli 12-72 hrs; perfuse watery diarrhea Salmonella 6-72 hs; HA, abd pain, +N/ V, diarrhea Shigella 1-7 days; fever, blood, green diarrhea; abd pain, nuchal rigidity

47. 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.

48. Gastroesophageal Reflux Disease (GERD) Reflux of chyme from stomach into esophagus Causes inflammatory response!! Hyperemia Increased capillary permeability Edema Tissue fragility Erosion

49. Clinical Heartburn Regurgitation within 1 hour of eating Increased with lying down

50. Esophagitis Inflammation of esophageal mucosa Ingestion strong alkalis or acids Alkali Liquefying necrosis Chronic reflux Inflammation Ulcer formation Bleeding Scarring

51. Barrett’s esophagus Progressive replacement of distal eroded squamous mucosa with metaplastic columnar epithelium as a result of chronic exposure of the esophagus to stomach acid Metaplasia = remember adaptation? Prone CA Hiatal Hernia Herniation of a portion of the stomach into the chest through esophageal hiatus of the diaphragm May incarcerate, strangulate to the point of causing a severe GI bleed

52. Esophageal Varices Cause Portal Hypertension Chronic alcohol abuse and liver cirrhosis Ingestion of caustic substances

53. Toxins are carried from the stomach & small intestine for detoxification in the liver Portal V. damage due to cirrohsis/hepatitis causes venous obstruction Pressure builds up Blood finds alternate route Rerouted resulting in esophageal varices

54. 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

55. Pathophysiology Bleeding distal to the ligament of Treitz Causes Diverticulosis Colon lesions Rectal lesions Inflammatory bowel disorder Lower Gastrointestinal Bleeding

56. Signs & Symptoms Determine acute vs. chronic. Quantity/color of blood in stool. Abdominal pain Signs of shock. Rate and amount of bleeding Treatment Follow general treatment guidelines. Establish IV access with large-bore catheter(s). Lower Gastrointestinal Bleeding

57. Occurs Distal of the Ligament of Treitz. For melena to be recognizable, approx. 150cc. Of blood must drain into the lower GI tract and remain there for at least 5-8 hours. Indicative of a slow GI bleed. Bright red blood represents a hemorrhage, as blood has not had time to sit in the intestines to turn dark.

58. Pt’s. will generally present with complaints of cramping or gas pain, N/V, or changes in stool habits. Because of lesser amounts of blood loss than Upper GI, PT’s. will usually present more hemodynamically stable, including W/P/D skin.

59. Most frequently occur in conjunction with chronic disorders and anatomic changes associated with advanced age. Most prevalent with elderly. Lower GI Bleeding is usually chronic and rarely results in exsanguinating hemorrhage.

60. Other causes are colon polyps or lesions, cancer, hemorrhoids, anal fissures/fistulas, and inflammatory bowel disorders (i.e. ulcerative colitis and Crohn’s disease.) These chronic disorders as well as diverticulitis rarely result in massive hemorrhage such as seen in the stomach or the esophagus.

61. Acute Pertonitis Localized pain on coughing Boardlike abd rigidity Decreased/ absent BS Does not want to move +V S/S sepsis Perforated peptic ulcer Acute appendicitis

62. Ulcerative Colitis Pathophysiology Causes Unknown Signs & Symptoms Abdominal Cramping Nausea, Vomiting, Diarrhea Fever or Weight Loss Treatment Follow general treatment guidelines.

63. Idiopathic inflammatory bowel disorder Continuous length of chronic ulcers Granular tissue replaces ulcerations Remember chronic inflammation!!

64. Ulcerative Colitis 20- 40 yrs Western hemisphere Recurrent disorder with occasional bloody dirrhea or stool containing mucus Colicky abd pain, +N, +V Fever, wt loss

65. Crohn’s Disease Pathophysiology Causes unknown. Can affect the entire GI tract. Pathologic inflammation: Damages mucosa. Granulomas Tissue rubbery and nondistendable Hypertrophy and fibrosis of underlying muscle. Fissures and fistulas. Obstruction

66. Crohn’s Disease Idiopathic inflammatory bowel disorder Signs and Symptoms Difficult to differentiate. Clinical presentations vary drastically. GI bleeding, nausea, vomiting, diarrhea. Abdominal pain/cramping, fever, weight loss. Western hemisphere, familial, white females Treatment Follow general treatment guidelines.

67. 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.

68. 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.

69. Bowel Obstruction Pathophysiology Blockage of the hollow space of the small or large intestines Hernias Protrusion of an organ through its protective covering

70. Bowel Obstruction Pathophysiology Intussusception Part of intestine slips into itself “Telescoping”

71. Bowel Obstruction Pathophysiology Volvulus Twisting on itself

72. Pathophysiology Adhesions scarring

73. Bowel Obstruction Pathophysiology Other Causes Foreign bodies, gallstones, tumors, bowel infarction Signs & Symptoms Decreased Appetite, Fever, Malaise Nausea and Vomiting Bile present Diffuse Visceral Pain, Abdominal Distention Signs & Symptoms of Shock Treatment Follow general treatment guidelines.

74. Appendicitis Pathophysiology Inflammation of the vermiform appendix. Frequently affects older children and young adults. Lack of treatment can cause rupture and subsequent peritonitis. Obstruction Inflammation Thrombosis Ischemia Necrosis Rupture

75. Appendicitis Most common cause of acute abdomen in children uncommon < 2 yrs pain originates periumbilical and moves to RLQ prefer supine with bent legs + iliopsoas test RLQ pain with passive extension of hip McBurney’s point area of localized pain & rebound tenderness between umbilicus & R iliac creat

76. Associated Symptoms Anorexia +N/ V fever malaise diarrhea or constipation increased pain with movement

77. Appendicitis Signs & Symptoms Nausea, vomiting, and low-grade fever. Pain localizes to RLQ(McBurney’s point). Initially periumbilical Rebound tenderness Treatment Follow general treatment guidelines.

78. Assessment and RX: BSI Scene Safety Scene Survey (Note evidence of PT’s. problem) Examination of stool for bloody diarrhea or mucus. General Impression MOI

79. Cholecystitis Pathophysiology Inflammation of the Gallbladder Cholelithiasis Chronic Cholecystitis Bacterial infection Acalculus Cholecystitis Burns, sepsis, diabetes Multiple organ failure

80. Cholecystitis Signs & Symptoms URQ Abdominal Pain Murphy’s sign Pain with palpation under right costal margin Nausea, Vomiting History of Cholecystitis Fair, fat, female, forty Treatment Follow general treatment guidelines.

81. 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.

82. 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

83. Acute Liver Failure Viral hepatitis- acute ETOH & Portal HTN- chronic S/S ALOC, jaundice, hemataemesis, pretibial bruising, ascitis Portal HTN Poor liver function Postsystemic shunting Toxic substances in bloodstream ammonia

84. Toxic Encephalopathy ALOC Cerebral edema 0.5 mg/kg Mannitol Decrease protein intake Decrease production ammonia

85. 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

86. Hepatitis Inflammation caused by viruses HAV, HBV, HCV, HDV, HEV HAV most common +N/ V, diarrhea, RUQ pain, malaise, fever jaundiced, dark yellow/ orange urine, paste colored stool, pupura

87. 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

88. Abdominal Pain Midline localized Severe with radiation to back Acute pancreatitis Deep peptic ulcer AAA RUQ/RLQ Pain Liver, gallbladder, appendix Kidney- flank pain radiating to front/groin Perforation/Blockage Severe, acute, generalized Colic- waxes & wanes Acute gastrenteritis Obstruction Strangulated hernia

89. Assessment and RX: ABC’s PE …following TX for any immediate life threats SAMPLE HX OPQRST. Remember, the HX of the present illness as well as the past HX will be especially helpful in piecing together a clear picture of the underlying gastrointestinal pathophysiology. Be sure to ask whether this is a new onset (chronic vs. acute).

90. Assessment and RX: Physical Exam…look for appearance and posture. Usually PT’s. w/LGI. Pathology will be restless due to abdominal discomfort. VS. Take a complete set as a baseline. Orthostatic VS. if possible. Inspection – BEFORE palpation or auscultation. Visualize entire abdomen. Look for distention. Important to remember that if distention is present and pt. is hemodynamically unstable due to hemorrhage, pt. has lost significant amount of blood volume. Abdomen can hold from 4-6 liters of fluid BEFORE significant changes in girth appear!

91. Assessment and RX: Look for Cullen’s sign and Grey-Turners sign. Both indicate fluid loss. Auscultation usually provides little helpful information. If done, must be before palpation.

92. Assessment and RX: Palpation. Most useful method of abdomen exam. Palpate gently w/ palpation of tender, painful area LAST. RX: O2 IV CM, treat for S/S shock, provide emotional reassurance, calm patient. (Fluid Resuscitation based on hemodynamics of PT.) TX: POC. Reassess