1. Gastroenterology “A Cute Abdomen” Dr Baxter Larmon Professor 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 Somatic 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 Bleeding nausea, vomiting,
tachycardia,
diaphoresis;
Bleeding
within the organ itself;

10. Referred Pain Definition Cause
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 a Physical Exam of 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
PERCENT
Peptic Ulcer 45
Gastric erosions 23
Varices 10
Mallory-Weiss Tear 7
Esophagitis 6
Duodenitis
Other 2

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 Treatment 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 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.

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 Treatment
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 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.

31. 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.

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

33. Bowel Obstruction OR 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 Treatment
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 Toxins Altered immune response;
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

51. Renal Calculi Pathophysiology
Results when “too much insoluble stuff” accumulates in the kidneys.
Stone types
Calcium salts
Struvite stones
Uric acid
Cystine

52. Renal Calculi Assessment Focused History Physical Exam
Severe pain in one flank that increases in intensity and migrates from the flank to the groin
Painful, frequent urination with visible hematuria
Prior history of calculi
Physical Exam
Difficult due to patient discomfort
Tachycardia with pale, cool, and moist skin

53. Urinary Tract Infection
Pathophysiology
Risk Factors
Increased risk in female or catheterized patients
Sexual activity
Lower and Upper UTIs
Urethritis
Cystitis
Prostatitis
Pyelonephritis
Community-acquired vs. nosocomial infections

54. Urinary Tract Infection
Assessment
Focused History
Abdominal pain
Frequent, painful urination
A “burning sensation” associated with urination
Difficulty beginning and continuing to void
Strong or foul-smelling urine
Similar past episodes

55. Thanks for listening