Cathy Beland, MD 7/20/05

1. Cathy Beland, MD 7/20/05 Prehospital Gastroenterology

2. Topics • GI anatomy • Focused GI history and physical exam • Cases • GI pathology • BLS/ALS treatments/stabilization

3. We will not be covering GI trauma

4. GI Anatomy

5. Boundaries of the Abdomen • Diaphragm • Anterior abdominal wall • Pelvic skeletal structure • Vertebral column • Muscles of the abdomen and flank

6. Surface Anatomy

7. Surface Anatomy • Upper quadrants • Right and left • Upper border is xiphoid • Lower quadrants • Right and left • Lower border is symphysis pubis The point of intersection is the umbilicus.

10. Right upper quadrant: • Liver • Gallbladder • pylorus • Head of pancreas • Right kidney-upper pole • Right adrenal • Part of duodenum • Part of colon

12. Left upper quadrant: • Spleen • Tail of pancreas • Stomach • Left kidney-upper pole • Left adrenal • Part of colon

14. Right lower quadrant: • Appendix • Cecum • Right kidney-lower pole • Part of colon • Right ovary • Right fallopian tube • Right ureter • Right spermatic cord • Uterus/bladder if enlarged

16. Left lower quadrant: • Sigmoid colon • Part of colon • Left kidney-lower pole • Left ovary • Left fallopian tube • Left ureter • Left spermatic cord • Uterus/bladder if enlarged

17. GI Pathology

18. Nausea/vomiting Diarrhea Constipation Last bowel movement Melena Hematochezia Anorexia Fever Weakness/syncope Previous episodes Abdominal surgeries Historical questions

19. Asking about abdominal pain… Pprovoking factors Qquality Rradiation Sseverity Ttime of onset

20. Abdominal exam • Inspection • Auscultation • Palpation • Percussion • Perineal exam

21. Abdominal exam • Inspection: • Old scars • Distention • Skin findings • Auscultation: • Bowel sounds

22. Abdominal exam • Palpation: • Tenderness • Peritoneal findings • Rigidity/guarding • Rebound tenderness • Mass • Percussion and Perineal exam • Not usually prehospital *Remember other physical findings help with overall assessment

23. Case 1 • Dispatch information: 36 year old patient vomiting blood

24. On arrival: • You see a 36 year old male who is complaining of vomiting for past four hours. • He is currently feeling lightheaded and weak. On exam you notice he has “coffee grounds” on his shirt. • Upon questioning he mentions that he has noticed his bowel movements have become increasingly darker over past 3-4 days. • He also mentions this happened approximately six months ago but resolved on its own. • His primary care recently started him on Pepcid for persistent “heartburn” like discomfort. • He admits he is a smoker and heavy coffee drinker.

25. Physical Exam: • He looks pale and diaphoretic. • His blood pressure is 90/60 and heart rate is 115. • Abdominal exam is benign

26. hemorrhoids duodenal ulcer gastric (stomach) ulcer bleeding diverticulum ulcerative colitis Crohn's disease esophageal varices arterio-venous malformations nose bleed Mallory-Weiss tear (tear in esophagus after vomiting) esophagitis ischemic bowel colon cancer dysentery (bloody, infectious diarrhea) intestinal polyps celiac sprue radiation injury to the bowel portal hypertensive gastropathy stomach cancer intestinal vasculitis small intestinal cancer Dieulafoy's lesion Meckel's diverticulum Aorto-enteric fistula cow's milk allergy intestinal volvulus (twisted bowel) intussusception (bowel telescoped on itself) anal fissure Causes of GI Bleeding:

27. Upper GI Bleeding • Proximal to the ligament of Treitz • Peptic ulcer disease are most common causing 60% of all cases. • Duodenal ulcers, approximately 29% of the total, will rebleed in approximately 10 percent of cases, usually within 24 to 48 hours. • Gastric ulcers are 16% of cases and are more likely to rebleed.

28. Upper GI Bleeding • Erosive gastritis, esophagitis, and duodenitis are responsible for approximately 15% of all cases • Caused by alcohol, salicylates, NSAIDS • Esophageal and gastric varices result from portal hypertension • Mallory-Weiss syndrome • Other etiologies include stress ulcer, AVM, malignancy, aortoenteric fistula

29. Lower GI Bleeding • Hemorrhoids most common cause • Nonhemorroidal causes include diverticulosis and angiodysplasia • Other etiologies include carcinoma, inflammatory bowel disease, polyps, infectious gastroenteritis, and Meckel’s diverticulum

30. Upper: Hematemesis “Coffee grounds” Melanotic diarrhea Epigastric or left upper quadrant pain Can be painless Lower: Hematochezia Frequent stools Crampy or diffuse abdominal pain Can be painless GI Bleed Presentations

31. Starting with upper gastrointestinal bleeding…

32. Gastritis and Peptic ulcer disease • Majority due to Helicobacter pylori and NSAID use • One in ten Americans over 17 will develop PUD at some point • Most common symptom of PUD is burning epigastric pain • Acute gastritis may present with nausea and vomiting, although most common presentation GI bleeding

33. Duodenal Ulcer

34. Bleeding Varices • Sixty percent of patients with portal hypertension due to chronic liver disease will develop varices • Twenty-five to 30% will bleed

35. Other Esophageal Disorders • Mallory-Weiss tear • Arterial bleeding from longitudinal mucosal lacerations of the esophagus usually following forceful vomiting • Boerhaave’s syndrome • Postemetic perforation of esophagus • High mortality rate

36. Moving onto lower gastrointestinal bleeding.…

37. Hemorrhoids • Associated with: • Constipation • Straining • Pregnancy • Obesity • Chronic liver disease • Portal hypertension

38. Internal: Located above the dentate line and drain into the portal venous system Only visible through anoscope unless prolapsed Painless bright-red rectal bleeding with defecation External: Below the dentate line and drain through the pudendal and iliac venous systems Can be visualized on external exam Can thrombose and cause severe pain Hemorrhoids

39. Colon Cancer • May have history of resent weight loss • Also may have noticed change in bowel movements

40. Bleeding Diverticulosis • Bleeding from diverticula (outpouchings of large intestine) • Usually painless bleeding from rectum • Can have lower abdominal pain

41. Meckel’s Diverticulum

42. Intussusception • One portion of the intestines telescopes into another • GI bleeding and edema give rise to “currant-jelly” stools • Greatest incidence 3 months to 6 years • Males > females • Sudden epigastric pain with pain-free intervals • Sausage-shaped mass right side of abdomen – 2/3 patients

43. Aortoenteric Fistula • History of aortic graft should raise possibility • Potential to bleed out quickly

44. Compensated: Decompensated: Hypovolemia

46. BLS: High flow oxygen (cannula if vomiting) Trendelenberg position if indicated Orthostatic vital signs Left lateral position if vomiting Assist with ALS procedures Transport ALS: Monitor Compensated shock Large bore IV 1 L Normal Saline bolus wide open Decompensated shock (SBP < 90) 2nd line and 2nd bolus Blood samples if possible Consider Phenergan 12.5mg slow IV push Medical control Upper GI Bleed:Prehospital Management

47. BLS: High flow oxygen Trendelenberg position if indicated Orthostatic vital signs Assist with ALS procedures Transport ALS: Monitor Compensated shock Establish large bore venous access with 1 L Normal Saline bolus wide open Decompensated shock If SBP < 90 then 2nd line and 2nd bolus Obtain blood samples prior to infusion if possible Lower GI Bleed:Prehospital Management

48. Case 2 • Dispatch information: 46 year with abdominal pain

49. On arrival: • You are at the scene of a 46 year old female who has had four hours of abdominal pain complaining of fevers and chills. • She states the pain started around her belly button now is in her right lower quadrant. • She has had no previous abdominal surgeries.

50. Physical exam: • She looks uncomfortable, curled in fetal position • Her blood pressure is 150/100 and heart rate is 100 with a respiratory rate of 25. • She has tenderness in her right lower quadrant.