Chapter 32 Gastroenterology

1. Chapter 32Gastroenterology

2. Topics • General Pathophysiology, Assessment, and Treatment • Specific Illnesses

3. 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.

4. Abdominal Pain • Types • Visceral • Somatic • Referred • Causes • Inflammation • Distention • Ischemia

5. General Pathophysiology • Pain from hollow organs tends to be vague and nondescript, whereas pain from solid organs tends to be localized.

6. General Assessment • Scene Size-up & Initial Assessment • Scene clues. • Identify and treat life-threatening conditions. • Focused History & Physical Exam • Focused History • Obtain SAMPLE History. • Obtain OPQRST History. • Associated symptoms • Pertinent negatives

7. General Assessment • Physical Exam • General assessment and vital signs • Abdominal assessment • Inspection, Auscultation, and Palpation • Cullen’s Sign • Grey-Turner’s Sign

8. 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.

9. Specific Illnesses • The Gastrointestinal System • Upper Gastrointestinal Tract • Lower Gastrointestinal Tract • Liver • Gallbladder • Pancreas • Appendix

10. Upper Gastrointestinal Bleeding • Causes • Peptic Ulcer Disease • Gastritis • Varix Rupture • Mallory-Weiss Tear • Esophagitis • Duodenitis

11. 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.

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

13. 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

14. Esophageal Varices • Prehospital placement of nasogastric tubes should be avoided in cases of suspected esophageal varices.

15. 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

16. 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.

17. 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.

18. Gastroenteritis • Most cases of gastroenteritis are viral. Patients with bacterial gastroenteritis tend to be considered more ill than those with viral gastroenteritis.

19. Peptic Ulcers • Pathophysiology • Erosions caused by gastric acid. • Terminology based on the portion of tract affected. • Causes: • NSAID Use • Alcohol/Tobacco Use • H. pylori

20. Peptic Ulcers • Signs & Symptoms • Abdominal Pain • Observe for signs of hemorrhagic rupture. • Acute pain, hematemesis, melena • Treatment • Follow general treatment guidelines. • Consider administration of histamine blockers and antacids.

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

22. 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).

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

24. Crohn’s Disease • Pathophysiology • Causes unknown. • Can affect the entire GI tract. • Pathologic inflammation: • Damages mucosa. • Hypertrophy and fibrosis of underlying muscle. • Fissures and fistulas.

25. Crohn’s Disease • Signs and Symptoms • Difficult to differentiate. • Clinical presentations vary drastically. • GI bleeding, nausea, vomiting, diarrhea. • Abdominal pain/cramping, fever, weight loss. • Treatment • Follow general treatment guidelines.

26. 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.

27. 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.

28. Bowel Obstruction • Pathophysiology • Blockage of the hollow space of the small or large intestines • Hernias

29. Bowel Obstruction • Pathophysiology • Intussusception

30. Bowel Obstruction • Pathophysiology • Volvulus

31. Bowel Obstruction • Pathophysiology • Adhesions

32. 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.

33. Accessory Organ Diseases • GI Accessory Organs • Liver • Gallbladder • Pancreas • Vermiform Appendix

34. Appendicitis • Pathophysiology • Inflammation of the vermiform appendix. • Frequently affects older children and young adults. • Lack of treatment can cause rupture and subsequent peritonitis.

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

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

37. Cholecystitis • Signs & Symptoms • URQ Abdominal Pain • Murphy’s sign • Nausea, Vomiting • History of Cholecystitis • Treatment • Follow general treatment guidelines.

38. 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.

39. 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

40. 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

41. 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

42. Summary • General Pathophysiology, Assessment, and Management • Specific Illnesses • Upper Gastrointestinal Diseases • Lower Gastrointestinal Diseases • Accessory Organ Diseases