Transcript Gastrointestinal Emergencies

Gastrointestinal
Emergencies
The Abdomen
Illustration of defined abdominal muscles,
commonly referred to as “six pack abs”
The Emergency Room patient with
“six pack abs”
Abdominal organs
Focused
Assessment
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Subjective
Objective
Subjective Data
•History
Pain (PQRST)
 Vomiting
 Appetite / weight changes
 Bowel habits
 Trauma—blunt/ penetrating
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Abdominal Pain
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Visceral
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Somatic
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Referred
Abdominal Pain
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Visceral
• Caused by stretching of hollow organ
• Waxes and wanes
• “crampy” or “gas like”
• Often difficult to localize
• Autonomic responses may include:
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Diaphoresis
Nausea / vomiting
BP changes
Tachycardia
Abdominal Pain
Visceral
* Associated Conditions
• Gastroenteritis
• Early appendicitis
• Cholecystitis
• Early pancreatitis
• Crohn’s disease
• Irritable bowel syndrome
• Intestinal obstruction
Abdominal Pain
Somatic Pain
 Caused by chemical or bacterial
irritation of abdominal nerve fibers
 Sharp, intense
 Usually localized
 Associated with:
• Involuntary guarding
• Rebound tenderness
Abdominal Pain
Somatic Pain
 Associated conditions:
• Late appendicitis
• Late pancreatitis
• Peritonitis
• ANY condition with perforation of organ
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bowel, stomach, pancreas, gall bladder,
liver, spleen
Abdominal Pain
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Referred Pain
• Pain experienced distant from point of
origin
• May be sharp and localized or “aching”
in character
Abdominal Pain
Referred Pain
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Fluid under diaphragm
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• Top of shoulder
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• Through to back, lower
back, thighs
Ruptured peptic ulcer
• Back
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Pancreas
• Midline back or directly
through to back
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• Lower back
Appendicitis
• right lower quadrant,
epigastrum, periumbilical area
Biliary tract
Rectal disease
Renal colic
• Groin, external genitalia
• Around right side to
scapula
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Dissecting or ruptured
aneurysm
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Uterine disorders
• Lower back
Assessment:
Vomiting
Onset, frequency, duration
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Characteristics
• Blood
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Bright: has not mixed with stomach acids
Coffee ground emesis
• Bile
• Feces
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Intestinal obstruction
Assessment:
Bowel movements
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Frequency
Last bowel movement
Characteristics
• Changes from patient’s “normal”
• Constipation
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Slowing of gut
Medications, diet, illness, fluid intake
• Diarrhea
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Color, mucus present, blood
Watery diarrhea sometimes with obstruction
Black, tarry stools with upper GI bleeds
Subjective cont’d
•Medical history
Past diseases, surgeries
 Medications
 Allergies/immunizations
 Alcohol/drug use
 Recent foreign travel
 LMP
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Objective
Look at patient!
 How are they positioning self?
 Can they sit or lie still? Knees bent?
 Breathing
• Quiet Tachypnea
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Acute infectious process or metabolic process
• Shallow and tachypneic
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Skin
peritonitis
• Febrile, flushed
• Cool, clammy
Objective data
•Physical exam
Inspection
 Auscultation
 Percussion
 Palpation
•Light
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Objective cont’d
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Diagnostic procedures
• Lab
 CBC with diff
 Chemistries:
• Glucose, BUN, Creatinine
• Electrolytes (including Calcium, Magnesium)
 Amylase, Lipase
 Phosphate, Lactate
 Liver Functions
 Urinalysis
 Consider as appropriate
• Toxicologic screen, Helicobacter pylori
• Stool analysis
• Sickle Cell screen
• T & C, coagulation studies
• HCG
Objective
• Radiography
Abdominal Series
 CT (with contrast / without contrast)
 Ultrasound
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• Other
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EKG, CXR
Age-related considerations
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Pediatric
Immature kidney function infants
 Higher metabolic rate
 Decreased glucose stores
 Greater fluid needs
 Hypotension- late sign shock
 Diarrhea is major cause of
metabolic acidosis, dehydration
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Age-related considerations
Pediatric
 Pearls
• Avoid restraints if possible
• Use distraction for relaxation and pain
control
• Monitor early signs of shock:
tachycardia, decreased urine output,
changes in mental status
• Replacement fluids
Age-related considerations
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Geriatrics
• 75% over 65 have some degree of impaired
cognitive function
• Diminished vision, hearing, & slower
psychomotor performance
• Reduced ability to respond to extremes
Age-related considerations
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Geriatrics
• Alterations in GI function with increased
gastric secretions & decreased motility
• Monitor pain & other assessment
findings closely (elderly tend to underreport symptoms)
Gastroenteritis/
Infectious Diarrhea
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Inflammation of the
lining of the stomach &
intestines
• Viral protozoan, bacterial,
parasites
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Caution in elderly &
young
Gastroenteritis cont’d
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Lab indictors of dehydration
• Elevated BUN
• Elevated BUN/Creatinine ratio (elevated
BUN in presence of normal creatinine
• Elevated hematocrit
• Elevated potassium
• Elevated chlorides
• Elevated Serum Osmolality
• Sodium may be elevated or decreased,
depending on cause of dehydration
Gastroenteritis cont’d
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Interventions
• IV access for fluid replacement
• NPO to clear liquids
• Medications:
Analgesics, anti-emetics
 Antacids
 Histamine receptor antagonists (Axid, Pepcid,
Zantac)
or proton pump inhibitors (Prilosec, Protonix, Nexium,
Prevacid)
 Anticholinergics for diarrhea
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Ulcers
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Results from sloughing of the mucous
membrane of the esophagus, stomach or
duodenum
Etiology poorly understood
Duodenal ulcers most frequent ages 20-60
yrs
Gastric ulcers more common ages 55-70 yrs
90-95% associated with H. pylori gastritis
Ulcers cont’d
• Pain
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squeezing, burning, dull, gnawing,
colicky, feeling of fullness
• Region/radiation: midback,
epigastric
• Onset 1-3 hours before meals
• Worsen during day and worst at
night, exacerbated spring & fall
Ulcers
Physical Exam
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Acute mid-epigastric pain on palpation
N/V
Hematemesis
Decreased or absent bowel sounds
Ulcers cont’d
Interventions
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IV access
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Fluids
Blood replacement if hemorrhage
NPO, possible gastric tube
Medications
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Analgesics
Antiemetics
Antacids
H2 antagonists or Proton pump inhibitors
Antibiotics for H. pylori
GERD
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Backflow of gastric contents into the esophagus
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Can occur with/without hiatal hernia
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Severity of symptoms/pain varies
GERD
• Increased pain with activities which
increase the intra-abdominal pressure
• Pain- burning sensation that moves up
and down the esophagus, may radiate
to back, neck, jaw, chest
• Onset 30-60 minutes after meals
GERD cont’d
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Intervention
• Antacids
• H2-receptor antagonists or proton pump
inhibitors
• Cholinergic medications
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Education
• Small meals, avoid caffeine, alcohol, high fat
and spicy foods
• Elevate head of bed
• Lose weight
• Quit smoking
Bowel obstruction
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Pain: colicky, crampy, intermittent, wavelike
• Localized
• Moderate intensity
• Gradual onset in large bowel and rapid onset in
small bowel
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Hyperactive bowel sounds
• High pitched peristaltic signs proximal to obstruction
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Absent bowel sounds—late sign
Bowel Obstruction
Fecessmall bowel: passed for a short time
large bowel: absolute constipation
Diffuse abdominal tenderness and rigidity
Elevated temperature, pulse and blood
pressure
Vomiting: usually bowel content
may give temporary relief
Bowel Obstruction
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Interventions
• ABC’s, including IV access
• NPO
• Gastric tube to suction
• Antiemetics
• Antibiotics
• Pain medication
• Admission / surgical intervention
Appendicitis
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Pain localized to RLQ between umbilicus
& right iliac crest (McBurney’s point)
Nausea & vomiting
Low-grade fever
Rovsing’s sign (pain on rt side increased
when palpates left side)
Rebound tenderness over McBurney’s
point (check for this LAST)
Appendicitis
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Diagnostics
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Exam
CBC with diff, urinalysis, HCG
Abd CT
Surgical consult
Treatment
• ABC’s
• NPO
• Antiemetics, antibiotics, analgesics,
antipyretics if temp
• Surgical removal
Pancreatitis
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Acute or chronic
• Alcohol abuse, gallstone blocking pancreatic
duct, infection, medications (sulfonamides,
thiazide diuretics, glucocorticoids)
• Difficulty digesting proteins, carbs, and fats
• Respiratory involvement due to
hypoventilation, autolysis from p. enzymes
Pancreatitis
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Pain- severe, epigastric, back, &
chest
Pain is more severe after meals
and not relieved with antacids
Elevated temperature
Pancreatitis
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Abdominal distention
Hypotension, tachycardia
Pain with palpation and supine
position
Fatty, bulky stools
Vomiting bile tinged
Pancreatitis diagnostics
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Amylase and lipase elevated
Bilirubin, ALT, AST, alkaline phos
may be elevated.
Hypocalcemia because calcium binds
with free fatty acids
May see elevated glucose
CT
Pancreatitis
Interventions
 ABC’s
• if hemorrhagic may require blood
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NPO
Analgesics
• Avoid morphine if possible
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Antibiotics
Antiemetics
Cholecystitis
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Inflammation of the gallbladder
usually caused by gallstones.
Other causes include typhoid fever, a
tumor obstructing the biliary tract,
systemic staph or strep infection.
Cholecystitis
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Pain
• RUQ referred to right scapula &
shoulder
Symptoms aggravated by deep
breathing & worse after meals
 Indigestion, nausea, anorexia, &
vomiting
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Cholecystitis
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Low-grade fever, elevated pulse
Belching & flatulence
Possible jaundice
Murphy’s sign
• Inability to take deep breath while
palpating liver area
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RUQ tenderness
Cholecystitis
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Diagnostics
• Elevated WBC
• Serum / urine bilirubin may be elevated
• Elevated ALT (liver enzyme alanine
aminotransferase)
• Amylase and lipase normal
• May visualize stones on US / CT
Cholecystitis
Interventions
 IV access for fluids, medications
 NPO
 Anti-emetics
 Analgesics
 Antibiotics
 Possible surgery
Esophageal Varices
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Dilated vessels found in the submucosa of the lower esophagus
Occurs most often as a result of
obstructed portal circulation
associated with liver cirrhosis
Esophageal Varices
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Physical exam:
• Signs of end-stage cirrhosis
• Hematemesis
• Ascites
• Melena
• Pallor
• Diaphoresis
• restlessness
Esophageal Varices
Diagnostics
 CBC with diff
• H&H may be normal or decreased
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T&C
Liver function test frequently elevated
Serum ammonia level
Coagulation profile
Stool for blood
Upper GI, CXR
Esophageal varices
Interventions
 ABC’s
 2 large bore IV’s
 Fluid resuscitation / blood
 NPO / gastric tube
 Tamponade
• Intubate prior to tamponade
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Medications
• Vasopressors (vasopressin)
• Vitamin K / Aquamephytoin
• Analgesics
Endoscopy / surgical repair
GI Bleed
Upper
 Proximal to ligament of Treitz (duodenal)
Signs & Symptoms
 Possible hx alcohol abuse
 Epigastric tenderness
 Hematemesis, melena
 Possible shock
 May be associated with jaundice,
hepatomegaly in pts with liver failure
GI Bleed
Lower
 Bleeding usually more modest,
though can be life threatening
 Signs & Symptoms
• Bright red rectal blood
• Abdominal pain
• Abdominal distension / bloating
• Anorexia, nausea, vomiting
• Constipation, diarrhea or both
GI bleed
Diagnostics
 CBC, T&C
 CT
Upper
 Gastric tube with analysis of aspirate
or lavage to check for active bleeding
GI Bleed
Interventions
 ABC’s
 Upper GI
• Large bore gastric tube
• Saline lavage
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Surgical consult
Surgery if uncontrolled or signs
shock
Abdominal Trauma
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ABC’s
• Cardiac monitoring, pulse oximetry
• 2 large bore IV’s
• Crystalloids, blood
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Gastric tube
Foley
Trauma labs
• T&C, CBC, Chemistries, coags, UA, HCG
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Preserve / document any forensic
evidence
Trauma Assessment tools
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Computed Tomography Scan
• CT
Selected Abdominal Trauma
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Liver injuries
•Pain RUQ or epigastric region
•Hypotension, rapid, thready
pulse
•Diaphoresis
•Suspect if lower right rib fx
present
Liver Injuries
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Diagnostics
• Trauma labs
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CBC with diff, serial H & H, T&C, coags,
urine, HCG, chemistries with liver enzymes
• CXR, Abdominal flat plate (portable)
• ABD CT
Liver injuries
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Interventions
• ABC’s
• Gastric tube to suction
• Antibiotics, pain medication, tetanus
• Surgical consult
• Surgery if large laceration
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Grades 4-5
• Admission / transfer
Selected Trauma Emergencies
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Splenic Injury
• The abdominal organ most
frequently injured by blunt trauma
• Suspect if left rib fx are evident or
left pneumothorax is present
Selected Trauma Emergencies
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Splenic injuries
• LUQ pain
• Kehr’s sign- pain
referred to left
shoulder
• Hypotension,
rapid, thready
pulse, diaphoresis
Splenic Injuries
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Diagnostics
• Ultrasound, CT
• Monitor H & H
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Treatment
• Surgery avoided when possible
• Immune function
• Admit for observation
Selected Trauma Emergencies
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Stomach injuries
Rarely injured in blunt traum
 Usually associated with penetrating
injuries
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• Signs & Symptoms
Pain epigastric or LUQ
 Hematemesis
 Rebound tenderness
 Hypotension
 Abdominal guarding
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Stomach trauma
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Diagnostics
• NG tube
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Check aspirate for blood
• CT abdomen
• Plain abd film may show free air
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Treatment
• ABC’s
• Surgical repair
Selected Emergencies
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Pancreatic injuries
• Pain epigastric area or back
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May be asymptomatic unless peritoneal irritation present
May occur hours after injury
Abdominal distention / rigidity especially epigastric area
Nausea / vomiting
Hypotension, tachycardia
Absent bowel sounds; ileus
Post-traumatic pancreatitis major concern
Pancreatic Injury
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Diagnostics
• CBC with diff
• Serum chemistries, inc glucose
• Amylase and lipase
•T & C
• Urine / HCG
• Abd x-ray
• Abd CT
Pancreatic Injury
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ABC’s
Gastric tube to suction
Antibiotics, analgesics, tetanus
Surgical intervention
Admission / transfer
Questions??????
Thank you!