Chapter 32 Gastroenterology

Topics General Pathophysiology, Assessment, and Treatment Specific Illnesses

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.

Abdominal Pain Types Causes Visceral Somatic Referred Inflammation Distention Ischemia

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

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

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

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.

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

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

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.

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

Esophageal Varices Signs & Symptoms Treatment Hematemesis, Dysphagia Painless Bleeding Hemodynamic Instability Classic Signs of Shock Treatment Follow General Treatment Guidelines. Aggressive Airway Management Aggressive Fluid Resuscitation

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

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

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.

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.

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

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

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

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

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).

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

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.

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

Diverticulitis Pathophysiology Signs & Symptoms Treatment 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.

Hemorrhoids Pathophysiology Signs & Symptoms Treatment 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.

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

Bowel Obstruction Pathophysiology Intussusception

Bowel Obstruction Pathophysiology Volvulus

Bowel Obstruction Pathophysiology Adhesions

Bowel Obstruction Pathophysiology Signs & Symptoms Treatment 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.

Accessory Organ Diseases GI Accessory Organs Liver Gallbladder Pancreas Vermiform Appendix

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

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

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

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

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.

Pancreatitis Signs & Symptoms Treatment 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

Hepatitis Pathophysiology Injury to Liver Cells Types of Hepatitis 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

Hepatitis Signs & Symptoms Treatment 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

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