Gastroenterology “A Cute Abdomen” Dr Baxter Larmon Professor UCLA School of Medicine

1. Gastroenterology“A Cute Abdomen”Dr Baxter LarmonProfessor UCLA School of Medicine

2. Incidence of GI/GU Disorders • Every year about 62 million people are diagnosed with a gastrointestinal disorder. • The incidence and prevalence of most digestive diseases increase with age, although there are exceptions.

3. Morbidity & Mortality of GI/GU Disorders • In 1992, GI disorders cost nearly $107 billion in direct health care expenditures. • Currently, GI disorders result in nearly 200 million sick days, • 50 million visits to a physician, • 16.9 million days lost from school, • 10 million hospitalizations, • And nearly 200,000 deaths per year.

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. Etiology of Pain • Inflammation • Foreign chemical • Bacterial contamination • Stimulation of nerve endings. • Irritation • Stretching, distention, bleeding

6. Visceral vs. Somatic • Visceral pain • Caused by stimulation of autonomic nerve fibers that surround a hollow viscus • Cramping or gas type • Generally diffuse drill • Somatic pain • Produced by Bacterial or chemical irritation of autonomic nerve • Guarding • Don’t want to move • Superficial

7. Solid Organs • Dull and steady in nature. • More localized. • Bleeding • Within capsule, • Rupture;

8. Hollow Organs • Colicky, crampy, dull, or gassy, • Typically intermittent. • Diffuse and poorly localized. • Path of a tube. • The place where the patient is feeling the most pain may not be the most tender on palpation.

9. Hollow Organs • Usually associated with • nausea, • vomiting, • tachycardia, • diaphoresis; • Bleeding • within the organ itself;

10. Referred Pain • Definition • Pain in area removed from tissue that caused the pain • Caused by visceral fibers that synapse in the spinal cord • Cause • same spinal segment, • skin has more receptors, • unable to distinguish,

11. Referred Pain • NOT ALL ABDOMINAL PAIN IS OF ABDOMINAL ETIOLOGY.

12. 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

13. General Assessment • Physical Exam • General assessment and vital signs • Abdominal assessment • Inspection, Auscultation, and Palpation, Percussion • Cullen’s Sign: Discoloration around the umbical area • Grey-Turner’s Sign: Discoloration in the flank area

14. Let’s Review aPhysical Examof the Abdomen

15. 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.

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

17. Upper Gastrointestinal Bleeding • Causes • Peptic Ulcer Disease • Gastritis • Esophagitis • Duodenitis

18. Upper Gastrointestinal Bleeding Etiology

19. 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.

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

21. 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

22. 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 • Systemic infections

23. 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.

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

25. 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.

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

27. 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).

28. Crohn’s Disease • Pathophysiology • Inflammatory bowel disease, ? Autoimmune etiology • Can affect the entire GI tract. • Pathologic inflammation: • Damages mucosa. • Hypertrophy and fibrosis of underlying muscle. • Fissures and fistulas.

29. 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.

30. 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.

31. 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.

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

33. Bowel Obstruction • Pathophysiology • Occlusion of the intestinal lumen that results in blockage of the normal flow of intestinal fluids • OR

34. Bowel Obstruction • Pathophysiology • Twisting of the bowel

35. Bowel Obstruction • Pathophysiology • Adhesions

36. Bowel Obstruction • Signs & Symptoms • Decreased Appetite, Fever, Malaise • Nausea and Vomiting • Diffuse Visceral Pain, Abdominal Distention • Signs & Symptoms of Shock • Treatment • Follow general treatment guidelines.

37. Accessory Organ Diseases • GI Accessory Organs • Liver • Gallbladder • Pancreas • Appendix

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

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

40. 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.Viral Hepatitis • A viral inflammatory disease: 1. Hepatitis A Virus (HAV), 2. Hepatitis B Virus (HBV), 3. Hepatitis C Virus (HCV) aka non-A, non-B hepatitis, 4. Hepatitis D Virus (HDV) only occurs in individuals with HBV, 5. Hepatitis E Virus (HEV).

41. Cirrhosis • Infection • Viral hepatitis • Toxins • ETOH • Altered immune response; • Vascular disturbance;

42. Urology & Nephrology

43. Anatomy & Physiology • Ureters • Urinary Bladder • Urethra • Testes • Epididymus and Vas Deferens • Prostate Gland • Penis

44. General Mechanisms of Nontraumatic Tissue Problems • Inflammatory or Immune-Mediated Disease • Infectious Disease • Physical Obstruction • Hemorrhage

45. General Pathophysiology, Assessment and Management • Differentiating GI and Urologic Complaints • Pathophysiologic Basis of Pain • Causes of Pain • Types of Pain • Visceral pain • Referred pain

46. Renal and Urologic Emergencies • Risk Factors • Older Patients • History of Diabetes • History of Hypertension • Multiple Risk Factors • Renal and Urologic Emergencies • Acute Renal Failure • Chronic Renal Failure • Renal Calculi • Urinary Tract Infection

47. Acute Renal Failure • Pathophysiology • Prerenal Acute Renal Failure • Dysfunction before the level of kidneys • Most common and most easily reversible • Renal Acute Renal Failure • Dysfunction within the kidneys themselves • Postrenal Acute Renal Failure • Dysfunction distal to the kidneys

48. Acute Renal Failure • Assessment • Focused History • Change in urine output • Swelling in face, hands, feet, or torso • Presence of heart palpitations or irregularity • Changes in mental function

49. Acute Renal Failure • Physical Assessment • Altered mental status • Hypertension • Tachycardia • ECG indicative of hyperkalemia • Pale, cool, moist skin

50. Acute Renal Failure • Physical Assessment • Edema of face, hands, or feet • Abdominal findings dependent on the cause of ARF