HAN477 GI Emergencies

What is the purpose of anatomy?

Anatomy can direct you to the problem

- location of the pain often correlates to the involved organ

Associated symptoms of abdominal pain or discomfort with?:

- unstable vital signs

- gastrointestinal bleeding

- nausea and vomiting

- diarrhea

- jaundice

- vaginal bleeding

What are the anatomical landmarks indicative of?

- umbilicus

- McBurney's point

- borders/names of quadrants and regions

Adominopelvic Regions

- right upper quadrant

- right lower quadrant

- left upper quadrant

- left lower quadrant

Where is the most common location for the base of the appendix?

McBurney's Point

Questions we ask for clinical presentations?

- Where is the pain?

- What else is going on?

- Who is the pt?

- Any associated symptoms?

Scenario 1:

- Triage Compliant: 40 yr old female complains of abdominal pain

- Report: You have the chart for a female with a c/c of abdominal pain and vomiting that went to the bathroom prior to being evaluated by the RN

Across the room: awake female, found sitting in the bathroom

Cardinal presentation: abdominal pain with vomiting

Primary Survey:

- LOC: awake

- A: patent

- B: Tachypnea at 24; lungs clear to auscultation bilaterally

-C: BP 144/76. Strong regular rapid at 110bpm

Acute Cholecystitis

- Pregnant women are at risk for developing due to biliary stasis

Detailed Assessment:

- sudden onset

-cramping has become constant

- right upper quadrant that radiates to right shoulder/upper back area

S: nauseas/ vomiting

A: penicillin

M: none regular

PMH: last menstrual period 3 months ago; normal-confirms she was ay doc and is pregnant

L: Dinner abt 3 hours ago

E: sitting watching tv

R: pregnant

Acute Cholangitis and Cholecystitis

consider due to pain presentation

- upper right quadrant radiating to right shoulder

- more common in females and in pregnancy ***

Gastric ulcer

ulcer located in the stomach

-consider for initial epigastric pain

Ectopic pregnancy

A pregnancy outside of the womb, usually in a fallopian tube

Gastroenteritis

inflammation of the stomach and intestines

Food poisoning

an illness usually caused by eating food that contains harmful bacteria

Consider w/ epigastric pain with nausea and vomiting

Bowel Perforation

puncture in the wall of the GI tract, contents within the stomach or intestine may then spill into abdominal cavity with potential to cause infection known as peritonitis

Consider w/ abdominal pain w/ nausea and vomiting with peritoneal irritation

What is referred pain?

pain felt in a part of the body other than its actual source

Acute Cholecystitis Pain

Usually begins in the epigastric area and migrates to the right upper quadrant

- pain may be cramps initially and then becomes constant

- pain may radiate to right scapula/back area

- peritoneum may become irritated, causing peritoneal signs and symptoms

- positive Murphy sign is present

How to identify Murphy sign?

While palpating the right subcostal region, have the pt take a deep breath. If the patient stops inhaling or complains of pain during the breath, the test is positive

Ongoing Management of Acute Acute Cholecystitis

- Support of airway- have suction available; vomiting is common

- Oxygen

- IV fluid

- Position of comfort

- Antiemetics

- Analgesics

- Sonogram at the facility

Scenario 2: Triage: 38 year old complains of abdominal pain

Report: Abdominal pain intermittently for the past 4 days that has gotten worse progressively worse

- LOC: awake

- A: Patent

-B: shallow @ 18 bpm, lung crackles in lower left lobe on auscultation

- C: strong, regular, rapid at 108

-S: nausea

- A: codeine

-M: none regularly

- P: Gastric reflux

-L: tried to eat but couldn't

- E: sitting and watching tv; hx of partying 3 days ago during the weekd but has not been drinking

-R: alc

Pancreatitis

Diagnostics:

- ECG

- Glucose

- SpO2

-EtCO2

-Labs

-imaging

Spleen Inflammation/Infarct

- Consider due to the pain in the upper left quadrant.

- An elevated temperature is associated with inflammation.

Pacreatitis

inflammation of the pancreas

- consider due to race, location of pain in upper left quadrant and alcohol hx

Kidney stone

tremendous pain in the lower quadrants, radiating in pulse-like waves from the rear flank, downward toward the pubic symphysis worsens as the stone is pushed along

anxiety, restlessness

nausea and or vomiting

hematuria

Ruptured aortic abdominal aneurysm (AAA)

- Pain radiating into the back makes this a consideration.

AORTA bulges and tears leading to severe internal bleeding and a high risk of death

Pancreatitis risk factors

inflammation of the pancreas

- higher frequency in African American, white and Native American males (in that order)

-Hx of alcohol abuse is the number one risk factor

Onset after binge consumption is common

Ingestion of alcohol can be recent or within several days

Biliary disease is also a common risk factor

Pain Presentation of pancreatitis

o Pain usually begins in the epigastric area or upper left

upper quadrant.

o May come on suddenly or gradually.

o Pain is described as going through the body to the

back, not around the body.

o Abdomen is usually distended with rigidity and

guarding

Pain of Pancreatitis

Pain usually begins in the

epigastric area or upper

left upper quadrant.

- Pain may come on suddenly

or gradually.

- Pain is described as going

through the body to the back,

not around the body.

- Abdomen is usually distended with

rigidity and guarding.

• Grey Turner sign and Cullen sign may be present due to hemorrhagic pancreatitis

Ongoing Management for Pancreatitis

- May be life threatening so be prepared to support the ABCs

- Support airway have suction available as vomiting may occur

- NPO sometimes

- Oxygen

- IV fluid- crystalloids or blood if hemorrhage present

- Pain medication (fentanyl or dilaudid)

Scenario 3: Triage: 60 yr old female complains of abdominal pain Report: pt has abdominal pain over past couple hrs

LOC: Awake

A: Patent

B: regular at 14 bpm, lungs clear

C: strong regular rapid 98 bpm

S: diarrhea w some bleeding present w her last stool(bright red)

A: none

M: plavix, simavastin

P: cardiac had an MI 3 yrs ago hx diverticulosis

L: ate a bit of several things yesterday

E: not been feeling well few days progressively worse

R: diverticulosis, Plavix (clopidogrel)

Sigmoid Diverticulitis

aortic anuerysm

A weakness in the wall of the aorta that makes it susceptible to rupture.

Sigmoid diverticulitis

LLQ inflammation of the diverticula

Ovarian Cyst/abcess

Right lower quadrant and fever cyst in ovaries

Pelvic Inflammatory disease

inflammation and infection of organs in the pelvic region

Endometriosis

a condition in which patches of endometrial tissue escape the uterus and become attached to other structures in the pelvic cavity

Ureteral Calculi

stones in the ureters

Urinary Tract Infection

microbial infection of any part of the urinary tract

Irritable bowel syndrome

a common condition of unknown cause with symptoms that can include intermittent cramping, abdominal pain, bloating, constipation, and/or diarrhea; intestinal disorder

Peritonitis

inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it)

Risk factors of sigmoid diverticulitis

Inflammation of the diverticula

(pouches that have developed in the

bowel)

o Risk factor

o Diverticulosis

o NSAID use

o Low fiber use

o Chronic Constipation

o Elderly

o Most commonly presents with lower

left quadrant pain

Pain of Sigmoid Diverticultis

Usually localized to the lower left quadrant

-Often severe, may be present for several

-Change in bowel habits

-Bleeding may be present

-Urinary symptoms may also be present (i.e.,

pain with urination)

• Fever is common due to inflammation.

• Peritonitis may be present.

• A mass may be palpated if an abscess develops.

• CT may be used to confirm disease and severity.

Ongoing Management of Sigmoid Diverticulitis

- IV fluid (crystalloids or blood if hemorrhage is present)

- Pain meds

- Antibiotics?

How many organ systems does the abdomen contain

Multiple

So this complicates assessment, diagnosis and ultimately treatment

What is key to sort through the disorders?

Consider life threats and to use history and assessment skills