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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 Subjective Objective Subjective Data •History Pain (PQRST) Vomiting Appetite / weight changes Bowel habits Trauma—blunt/ penetrating Abdominal Pain Visceral Somatic Referred Abdominal Pain Visceral • Caused by stretching of hollow organ • Waxes and wanes • “crampy” or “gas like” • Often difficult to localize • Autonomic responses may include: 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 bowel, stomach, pancreas, gall bladder, liver, spleen Abdominal Pain Referred Pain • Pain experienced distant from point of origin • May be sharp and localized or “aching” in character Abdominal Pain Referred Pain Fluid under diaphragm • Top of shoulder • Through to back, lower back, thighs Ruptured peptic ulcer • Back Pancreas • Midline back or directly through to back • Lower back Appendicitis • right lower quadrant, epigastrum, periumbilical area Biliary tract Rectal disease Renal colic • Groin, external genitalia • Around right side to scapula Dissecting or ruptured aneurysm Uterine disorders • Lower back Assessment: Vomiting Onset, frequency, duration Characteristics • Blood Bright: has not mixed with stomach acids Coffee ground emesis • Bile • Feces Intestinal obstruction Assessment: Bowel movements Frequency Last bowel movement Characteristics • Changes from patient’s “normal” • Constipation Slowing of gut Medications, diet, illness, fluid intake • Diarrhea 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 Objective Look at patient! How are they positioning self? Can they sit or lie still? Knees bent? Breathing • Quiet Tachypnea Acute infectious process or metabolic process • Shallow and tachypneic Skin peritonitis • Febrile, flushed • Cool, clammy Objective data •Physical exam Inspection Auscultation Percussion Palpation •Light Objective cont’d 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 • Other EKG, CXR Age-related considerations 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 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 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 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 Inflammation of the lining of the stomach & intestines • Viral protozoan, bacterial, parasites Caution in elderly & young Gastroenteritis cont’d 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 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 Ulcers 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 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 Acute mid-epigastric pain on palpation N/V Hematemesis Decreased or absent bowel sounds Ulcers cont’d Interventions • • IV access • • • • Fluids Blood replacement if hemorrhage NPO, possible gastric tube Medications • • • • • Analgesics Antiemetics Antacids H2 antagonists or Proton pump inhibitors Antibiotics for H. pylori GERD Backflow of gastric contents into the esophagus Can occur with/without hiatal hernia 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 Intervention • Antacids • H2-receptor antagonists or proton pump inhibitors • Cholinergic medications Education • Small meals, avoid caffeine, alcohol, high fat and spicy foods • Elevate head of bed • Lose weight • Quit smoking Bowel obstruction Pain: colicky, crampy, intermittent, wavelike • Localized • Moderate intensity • Gradual onset in large bowel and rapid onset in small bowel Hyperactive bowel sounds • High pitched peristaltic signs proximal to obstruction 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 Interventions • ABC’s, including IV access • NPO • Gastric tube to suction • Antiemetics • Antibiotics • Pain medication • Admission / surgical intervention Appendicitis 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 Diagnostics • • • • Exam CBC with diff, urinalysis, HCG Abd CT Surgical consult Treatment • ABC’s • NPO • Antiemetics, antibiotics, analgesics, antipyretics if temp • Surgical removal Pancreatitis 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 Pain- severe, epigastric, back, & chest Pain is more severe after meals and not relieved with antacids Elevated temperature Pancreatitis Abdominal distention Hypotension, tachycardia Pain with palpation and supine position Fatty, bulky stools Vomiting bile tinged Pancreatitis diagnostics 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 NPO Analgesics • Avoid morphine if possible Antibiotics Antiemetics Cholecystitis 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 Pain • RUQ referred to right scapula & shoulder Symptoms aggravated by deep breathing & worse after meals Indigestion, nausea, anorexia, & vomiting Cholecystitis Low-grade fever, elevated pulse Belching & flatulence Possible jaundice Murphy’s sign • Inability to take deep breath while palpating liver area RUQ tenderness Cholecystitis 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 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 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 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 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 Surgical consult Surgery if uncontrolled or signs shock Abdominal Trauma ABC’s • Cardiac monitoring, pulse oximetry • 2 large bore IV’s • Crystalloids, blood Gastric tube Foley Trauma labs • T&C, CBC, Chemistries, coags, UA, HCG Preserve / document any forensic evidence Trauma Assessment tools Computed Tomography Scan • CT Selected Abdominal Trauma Liver injuries •Pain RUQ or epigastric region •Hypotension, rapid, thready pulse •Diaphoresis •Suspect if lower right rib fx present Liver Injuries Diagnostics • Trauma labs CBC with diff, serial H & H, T&C, coags, urine, HCG, chemistries with liver enzymes • CXR, Abdominal flat plate (portable) • ABD CT Liver injuries Interventions • ABC’s • Gastric tube to suction • Antibiotics, pain medication, tetanus • Surgical consult • Surgery if large laceration Grades 4-5 • Admission / transfer Selected Trauma Emergencies 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 Splenic injuries • LUQ pain • Kehr’s sign- pain referred to left shoulder • Hypotension, rapid, thready pulse, diaphoresis Splenic Injuries Diagnostics • Ultrasound, CT • Monitor H & H Treatment • Surgery avoided when possible • Immune function • Admit for observation Selected Trauma Emergencies Stomach injuries Rarely injured in blunt traum Usually associated with penetrating injuries • Signs & Symptoms Pain epigastric or LUQ Hematemesis Rebound tenderness Hypotension Abdominal guarding Stomach trauma Diagnostics • NG tube Check aspirate for blood • CT abdomen • Plain abd film may show free air Treatment • ABC’s • Surgical repair Selected Emergencies Pancreatic injuries • Pain epigastric area or back • • • • • 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 Diagnostics • CBC with diff • Serum chemistries, inc glucose • Amylase and lipase •T & C • Urine / HCG • Abd x-ray • Abd CT Pancreatic Injury ABC’s Gastric tube to suction Antibiotics, analgesics, tetanus Surgical intervention Admission / transfer Questions?????? Thank you!
