Chapter 23 Abdominal and Gastrointestinal Disorders Image source: Microsoft clipart Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Objectives Image source: Microsoft clipart

Anatomy Review Borders of the abdominal cavity Diaphragm Pelvis Spine Abdominal wall Major blood vessels Aorta Inferior vena cava The abdominal cavity is bordered superiorly by the diaphragm, inferiorly by the pelvis, posteriorly by the spine, and anteriorly by the abdominal wall. The major blood vessels of the abdomen are the aorta and inferior vena cava.

Anatomy Review Peritoneum Retroperitoneum (retroperitoneal space) Because the abdominal cavity is lined by a smooth membrane called the peritoneum, the abdominal cavity is sometimes called the peritoneal cavity. If the peritoneum becomes inflamed, the condition is called peritonitis. The area behind the peritoneum is called the retroperitoneum or retroperitoneal space. The kidneys, ureters, and rectum are examples of structures located in the retroperitoneal space.

Abdominal Quadrants To simplify identifying the abdominal organs and the location of pain or injury, the abdominal cavity is divided into four quadrants. These quadrants are created by drawing an imaginary line that intersects with the midline through the navel (umbilicus). The right upper quadrant (RUQ) contains the liver, gallbladder, portions of the stomach, right kidney, and major blood vessels. The left upper quadrant (LUQ) contains the stomach, spleen, pancreas, and left kidney. The right lower quadrant (RLQ) contains the appendix. The left lower quadrant (LLQ), along with the other three quadrants, contains the intestines. In females, the right and left lower quadrants contain the ovaries and fallopian tubes. The uterus is in the midline above (superior to) the pelvis and just behind (posterior to) the bladder.

Solid Organs Abdomen Liver Spleen Retroperitoneal space Kidneys The abdomen contains solid and hollow organs. Solid organs of the abdomen and retroperitoneal space include the liver, spleen, and kidneys. Solid organs bleed.

Hollow Organs Abdomen Stomach Intestines Gallbladder Retroperitoneal space Urinary bladder When hollow organs are cut or burst, their contents spill into the abdominal cavity causing pain and soreness. Hollow organs include the stomach, intestines, gallbladder, and urinary bladder.

Primary Digestive System Organs Mouth Pharynx Esophagus Stomach Small intestine Large intestine Rectum Anal canal Image source: Microsoft clipart The primary organs of the digestive system are the mouth, pharynx, esophagus, stomach, small intestine, large intestine, rectum, and anal canal.

Accessory Digestive System Organs Teeth Tongue Salivary glands Liver Gallbladder Pancreas Image source: Microsoft clipart The accessory organs of digestion are the teeth and tongue, salivary glands, liver, gallbladder, and pancreas.

Process of Digestion

The Acute Abdomen Image source: Microsoft clipart

Acute Abdomen Sudden onset of abdominal pain Possible associated assessment findings and symptoms Nausea and vomiting Abdominal tenderness and/or rigidity Signs and symptoms of shock may also be present The phrase acute abdomen means a sudden onset of abdominal pain. The patient who has an acute abdomen often has associated symptoms such as nausea and vomiting, abdominal tenderness and/or rigidity. Signs and symptoms of shock may also be present.

Abdominal Pain Abdominal pain may or may not be the result of a problem involving an organ within the abdominal cavity.

Referred Pain Pain that is felt in a part of the body that is away from the tissues or organ that causes the pain. It is also possible for the pain from an injured or diseased abdominal organ to be felt in areas distant from the original source. For example, pancreatic pain may be felt in the back and pain due to gallbladder disease may be felt in the area below or between the shoulders. Pain that is felt in a part of the body that is away from the tissues or organ that causes the pain is called referred pain.

Hemorrhagic Causes of Acute Abdominal Pain

Gastritis Inflammation of the stomach lining Possible causes Increased gastric secretion associated with excessive consumption of alcohol Infection caused by bacteria such as Helicobacter pylori (H. pylori) Prolonged use of medications Severe physical stress such as burns, severe infection, surgery, or trauma Gastritis is an inflammation of the stomach lining. Possible causes include increased gastric secretion associated with excessive consumption of alcohol, infection caused by bacteria such as Helicobacter pylori (H. pylori), and prolonged use of medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and aspirin. Gastritis can develop after severe physical stress such as burns, severe infection, surgery, or trauma.

Gastritis Assessment findings and symptoms Belching Nausea and vomiting Indigestion Burning sensation in the upper abdomen

Peptic Ulcer Disease A peptic ulcer is an open sore in the lining of the stomach (gastric ulcer), duodenum (duodenal ulcer), or esophagus (esophageal ulcer). Primary cause H. pylori bacteria Contributing cause Excess secretion of digestive juices, such as hydrochloric acid, by stomach cells A peptic ulcer is an open sore in the lining of the stomach (gastric ulcer), duodenum (duodenal ulcer), or esophagus (esophageal ulcer). The primary cause of peptic ulcer disease is a stomach infection caused by H. pylori bacteria. A contributing cause is excess secretion of digestive juices. Over time, the protective mucous lining of the stomach, duodenum, or esophagus is worn away by excess secretion of digestive juices, such as hydrochloric acid, by stomach cells. The lining of the stomach, duodenum or esophagus can also be disrupted by prolonged use of medications (such as NSAIDs) or alcohol. Esophageal ulcers are typically associated with the reflux of stomach acid (gastroesophageal reflux disease [GERD]).

Peptic Ulcer Disease Gastric ulcer Duodenal ulcer Esophageal ulcer The patient who has a gastric ulcer usually complains of nausea, vomiting, and a burning pressure in the left upper quadrant of the abdomen and back that occurs 1 to 2 hours after meals. If the ulcer has penetrated the wall of the stomach, his discomfort may be aggravated with food. The patient who has a duodenal ulcer typically complains of a burning, cramping, pressurelike pain across the upper abdomen that occurs 2 to 4 hours after meals, midmorning, midafternoon, and in the middle of the night. The discomfort of a duodenal ulcer is usually relieved with antacids and food. The patient may occasionally experience nausea and vomiting. The patient who has an esophageal ulcer usually complains of indigestion, nausea, and abdominal cramping. These symptoms usually appear 2 to 3 hours after eating and may worsen if the patient does not ingest food. The discomfort of an esophageal ulcer is usually relieved with antacids and food.

Upper Gastrointestinal Bleeding Bleeding may occur from any part of the GI tract. GI bleeding is a medical emergency. Upper GI bleeding is bleeding from the esophagus, stomach, or duodenum. Bleeding may occur from any part of the GI tract. GI bleeding is a medical emergency. Upper GI bleeding is bleeding from the esophagus, stomach, or duodenum. Common causes include gastritis, peptic ulcer disease, gastritis, tumors, esophagitis (inflammation of the esophagus), and esophageal varices (enlarged and twisted veins in the esophagus).

Upper Gastrointestinal Bleeding Assessment findings and symptoms Hematemesis May be bright red or resemble coffee grounds Syncope Fatigue Shortness of breath Assessment findings and symptoms include hematemesis (vomiting blood). Vomited blood may be bright red if it is recent or if bleeding is forceful. Forceful and repeated vomiting may cause hematemesis by tearing small blood vessels lining the stomach and esophagus. If blood accumulates in the stomach and is partially digested and then vomited, the vomited material may resemble coffee grounds. The patient may also present with syncope, fatigue, and shortness of breath.

Lower Gastrointestinal Bleeding Can originate in the small intestine, colon, or rectum Common causes Tumors, hemorrhoids, colitis Assessment findings and symptoms Rectal bleeding, which may include melena Increased frequency of stools Cramping pain Lower GI bleeding can originate in the small intestine, colon, or rectum. Common causes include tumors, hemorrhoids, and colitis (inflammation of the colon). Assessment findings and symptoms include rectal bleeding, increased frequency of stools, and cramping pain. The color of blood in the stool depends on the source of the bleeding and the amount of time the blood has spent in the GI tract. For example, black, tarry stool is called melena and reflects partially digested blood from the upper GI tract. Blood from the lower colon or rectum usually appears bright red. Stools streaked with blood and blood drops on toilet paper or in the toilet bowl may caused by bleeding from hemorrhoids.

Nonhemorrhagic Causes of Acute Abdominal Pain

Appendicitis Inflammation of the appendix Assessment findings and symptoms Sudden onset of abdominal pain that shifts to the RLQ Nausea Vomiting Fever Loss of appetite Appendicitis is a condition in which the appendix becomes inflamed and generally requires surgical removal. It is most common in adolescents and young adults, but can occur at any age. Assessment findings and symptoms include the sudden onset of abdominal pain that typically starts around the umbilicus and then shifts to the right lower quadrant of the abdomen. Most patients also experience nausea, vomiting, fever, and a loss of appetite.

Intestinal Obstruction Blockage of the large or small intestine Assessment findings and symptoms Cramping abdominal pain Nausea Vomiting or diarrhea Gradual loss of appetite Abdominal distention and tenderness Decreased or no passage of stool Inability to pass gas Fever and chills Intestinal obstruction is a blockage of the large or small intestine that prevents food and fluid from passing through. An intestinal obstruction may be partial (allowing some intestinal contents to pass) or complete (nothing can pass through the intestine). A complete obstruction is a medical emergency that requires immediate surgery to relieve the blockage. Intestinal obstruction has many causes including foreign objects (such as pins, bones, and small toys), narrowing of the intestinal opening caused by swelling and inflammation from abdominal trauma, radiation therapy, or an infection; but it is most often the result of adhesions (bands of scar tissue in the intestine that develop in some people after surgery), hernias, or tumors. Assessment findings and symptoms of intestinal obstruction include intermittent, cramping abdominal pain; nausea, vomiting or diarrhea, gradual loss of appetite, abdominal distention and tenderness, decreased or no passage of stool, inability to pass gas, fever, and chills.

Pancreatitis Inflammation of the pancreas Assessment findings and symptoms Abdominal pain that typically radiates to the back Severe, deep, piercing, and steady pain Nausea, vomiting Abdominal tenderness Fever Hypotension, tachycardia Inflammation of the pancreas is usually caused by gallstones and excessive alcohol use. Trauma, viral infections, and some drugs are among other possible causes of pancreatitis. In some cases the cause is never found. Pancreatitis can be acute or chronic. Acute pancreatitis begins suddenly and lasts for a few days. Chronic pancreatitis develops gradually and continues for many years. Assessment findings and symptoms of pancreatitis include abdominal pain that typically radiates to the back and is described as severe, deep, piercing, and steady. The pain often begins when lying down and the patient may assume many different positions in an attempt to relieve his pain. Pancreatic pain is aggravated by eating and is not relieved by vomiting. Nausea, vomiting, abdominal tenderness, fever, hypotension, and tachycardia may be present.

Cholecystitis Inflammation of the gallbladder Assessment findings and symptoms Pain in the upper middle or right upper quadrant of the abdomen Pain described as severe, steady, and worsens with movement Nausea, vomiting Constipation or diarrhea Excessive belching Inflammation of the gallbladder is called cholecystitis. It is usually caused by gall stones that lodge in the duct that drains the gallbladder or in the nearby bile duct. Gallstones may or may not produce symptoms. The presence and severity of symptoms depends on whether the stones are stationary or mobile and whether they cause an obstruction. Assessment findings and symptoms of cholecystitis include pain in the upper middle or right upper quadrant of the abdomen that occurs 3 to 6 hours after meals and is unrelieved by antacids. The pain is described as severe, steady, and worsens with movement. The pain generally lasts from 1 to 4 hours and may radiate to the shoulder blades. The patient may also experience nausea, vomiting, constipation or diarrhea, and excessive belching.

Gastroenteritis Inflammation of the intestinal lining Most often caused by a virus Assessment findings and symptoms Diarrhea Abdominal pain and tenderness Vomiting Headache Fever Chills Gastroenteritis, also called the “stomach flu,” is an inflammation of the lining of the intestinal tract, most often caused by a virus. Assessment findings and symptoms include diarrhea, abdominal pain and tenderness, vomiting, headache, fever, and chills.

Hepatitis Inflammation of the liver, most commonly caused by a viral infection Assessment findings and symptoms Dull right upper quadrant pain and tenderness unrelated to food consumption Nausea and vomiting Loss of appetite Extreme fatigue Dark urine, clay colored stools Jaundice Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. Hepatitis A and hepatitis E are spread primarily through food or water contaminated by feces from an infected person. Hepatitis B is spread through contact with infected blood, through sex with an infected person, and from mother to child during childbirth. Hepatitis C is spread primarily through contact with infected blood, and less commonly through sexual contact and childbirth. Hepatitis D is spread through contact with infected blood. Vaccines offer protection from hepatitis A and hepatitis B. Alcohol or substance abuse can also lead to hepatitis. Although some people who have hepatitis have no symptoms, others may have dull right upper quadrant pain and tenderness that is unrelated to food consumption, nausea and vomiting, loss of appetite, extreme fatigue, dark urine, clay colored stools, and jaundice.

Patient Assessment

Patient Assessment Scene size-up Primary survey Establish patient priorities Determine the need for additional resources Make a transport decision Patient assessment begins with a scene size-up and putting on appropriate personal protective equipment (PPE). Form a general impression and perform a primary survey. Assess the patient’s mental status, airway, breathing, and circulation. If the patient is responsive, allow the patient to assume a position of comfort. Note the rate and rhythm of respirations and any signs of increased work of breathing (respiratory effort). Listen for air movement and note if respirations are quiet, absent, or noisy. Give 100% oxygen, preferably by nonrebreather mask. Assess the patient’s heart rate, pulse regularity, and strength. Assess perfusion. Note the color, temperature, and moisture of the patient’s skin. If appropriate, evaluate for possible major bleeding. Provide calm reassurance to help reduce the patient’s anxiety. If you have not already done so, establish patient priorities, determine the need for additional resources, and make a transport decision.

Patient History Signs/symptoms Allergies Medications Past medical history Last oral intake Events prior Onset Provocation/ Palliation / Position Quality Region/Radiation Severity Time

Physical Examination Observe the patient’s position Listen to breath sounds Assess vital signs and oxygen saturation Assess the abdomen for DCAP-BTLS Begin the physical exam by observing the patient’s position. Patients with peritonitis or appendicitis usually prefer to lie absolutely still because any motion causes further peritoneal irritation and pain. Patients with a bowel obstruction are often restless and often move in an attempt to find a position of comfort. Patients may also present with their knees in a flexed position (fetal position) to decrease tension on the abdominal muscles. Listen to breath sounds and assess the patient’s pulse, respirations, blood pressure, and oxygen saturation. Assess the abdomen for DCAP-BTLS. When assessing the abdomen, look to see if abdominal distention is present (the abdomen appears larger than normal). Abdominal distention can be caused by blood, fluid, or air. Palpate the abdomen, placing one hand on top of the other. If the patient is responsive, ask him to point to the area that hurts (point tenderness). Use the pads of the fingers of the lower hand and gently feel the upper and lower areas of the abdomen for tenderness. Assess the area that hurts last. Watch the patient’s face while you palpate the abdomen. A grimace may indicate tenderness over a particular abdominal area. Determine if the abdomen feels soft or hard (rigid). Note the presence of any scars, masses, or pulsations.

Emergency Care Prehospital care is supportive Allow the patient to assume a position of comfort Provide calm reassurance Administer oxygen Reassess as often as indicated Prehospital care for a patient experiencing abdominal discomfort is supportive. Allow the patient to assume a position of comfort and provide calm reassurance. Administer oxygen. If the patient’s breathing is inadequate, give positive-pressure ventilation with 100% oxygen. Assess the adequacy of the ventilations delivered. Reassess as often as indicated until patient care is turned over to ALS personnel or medical personnel at the receiving facility.

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