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Chapter 32 Gastroenterology

General PathophysiologyGeneral Risk Factors for GI emergencies: Excessive ______________________________________ ConsumptionExcessive Smoking Increased ______________________________________ Ingestion of Caustic SubstancesPoor Bowel HabitsEmergenciesAcute emergencies usually arise from chronic underlying problems.

GI PainPain is the ______________________________________ of the acute abdominal

emergencyAcute abdominal pain is normally NOT treated with

______________________________________ medications in EMS as it may mask diagnostic evaluations

Types of Abdominal Pain______________________________________ Pain: dull, poorly localized

– Originates in hollow organs such as gallbladder or appendix– Normally caused by inflammation, distention, or ischemia

______________________________________ Pain: sharp and localize– Travels along a definite neural route to the spinal column– Results from bacterial and chemical irritation– Can lead to ______________________________________

Types of Abdominal Pain______________________________________ Pain: originates in an area other than where

it is felt– Abdominal aortic aneurism: felt between the shoulder blades– Diaphragm injury: felt in ______________________________________ or shoulders– Appendicitis: felt around ______________________________________

Focused History & Physical ExamScene Size-up & Primary Assessment:Scene clues. Identify and treat life-threatening conditions.Focused HistoryObtain ______________________________________ History.Obtain OPQRST History.

– Associated symptoms– ______________________________________ negatives

General AssessmentPhysical Exam:General assessment and vital signsAbdominal assessment

– Inspection, Auscultation, and Palpation– ______________________________________ Sign: discoloration around umbilicus

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(internal bleeding)– Grey-Turner’s Sign: discoloration around ______________________________________

(internal bleeding)

General TreatmentMaintain the airway.Support breathing.High-flow oxygen or assisted ventilations.

Maintain circulation.Monitor vital signs and ______________________________________ rhythm.Establish IV access.Transport in position of comfort.

Upper Gastrointestinal BleedingCauses:Peptic Ulcer DiseaseGastritis: inflammation of the ______________________________________ liningVessel RuptureMallory-Weiss ______________________________________ : lacerated esophagus

secondary to vomitingEsophagitis: inflammation of the esophagusDuodenitis: inflammation of the ______________________________________

Upper Gastrointestinal BleedingSigns & Symptoms:General abdominal discomfortHematemesis and ______________________________________ Classic signs and symptoms of shock Changes in ______________________________________ vital signsTreatmentFollow general treatment guidelines.

– Begin volume replacement using 2 large-bore IVs.Differentiate life-threatening from ______________________________________ problem.

Esophageal VaricesCause by Portal ______________________________________ :Chronic alcohol abuse and liver cirrhosis Ingestion of ______________________________________ substances

Esophageal VaricesSigns & SymptomsHematemesis, ______________________________________ (inability or difficulty to

swallow)Painless BleedingClassic Signs of ShockTreatmentFollow General Treatment Guidelines.Aggressive Airway ManagementAggressive ______________________________________ Resuscitation

Esophageal Varices

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Prehospital placement of ______________________________________ tubes and esophageal airways should be avoided in cases of suspected esophageal varices.

Acute GastroenteritisCause: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 useChemical ingestion (______________________________________ , chemotherapeutics)Systemic infections

Acute GastroenteritisSigns & Symptoms______________________________________ Onset of Severe Vomiting and DiarrheaHematemesis, Hematochezia, MelenaAbdominal PainClassic Signs of ______________________________________ TreatmentFollow General Treatment Guidelines.Fluid Volume Replacement.Consider Administration of ______________________________________ .

GastroenteritisSimilar to Acute GastroenteritisLong-Term Mucosal Changes or Permanent Damage.

– Primarily due to ______________________________________ infection.– More frequent in developing countries.

Follow General Treatment Guidelines.

GastroenteritisMost cases of gastroenteritis are ______________________________________ . Patients

with ______________________________________ gastroenteritis tend to be considered more ill than those with viral gastroenteritis.

Peptic UlcersPathophysiology:Erosions caused by gastric ______________________________________ .Terminology based on the portion of tract affected.Causes:

– NSAID Use– ______________________________________ /Tobacco Use– H. pylori

Peptic UlcersSigns & Symptoms:Abdominal PainObserve for signs of ______________________________________ rupture.

– Acute pain, hematemesis, melenaTreatment:

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Follow general treatment guidelines.Consider administration of ______________________________________ blockers and

antacids.

Lower Gastrointestinal BleedingPathophysiology:Bleeding distal to the ligament of ______________________________________ (supports

the duodenojecunal junction)Causes

– Diverticulitis– ______________________________________ lesions: (Ulcerative Colitis, Crohn’s

Disease)– Rectal lesions– Inflammatory ______________________________________ disorder

Lower Gastrointestinal BleedingGeneral Signs & SymptomsDetermine acute vs. ______________________________________ .Quantity/color of blood in ______________________________________ .______________________________________ painSigns of shock.Treatment:Follow general treatment guidelines.

– Establish IV access with large-bore catheter(s).

DiverticulitisPathophysiologyInflammation of small ______________________________________ in the mucosal

lining of the intestinal tract.Common in the ______________________________________ .

DiverticulitisSigns & Symptoms:Abdominal pain/ ______________________________________.Fever, nausea, ______________________________________ .Signs of lower GI bleeding.Treatment:General treatment guidelines.

Ulcerative ColitisPathophysiologyCauses ______________________________________ Creates ulcers along colon

Signs & SymptomsAbdominal CrampingNausea, Vomiting, Diarrhea______________________________________ or Weight Loss

TreatmentFollow general treatment guidelines.

Crohn’s Disease

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Pathophysiology:Inflammatory bowel disorder associated with the small

______________________________________ Causes unknown.Tends to run in ______________________________________ Most prevalent in white females, those under stress, and in the

______________________________________ population Can affect the entire GI tract.

Crohn’s DiseasePathologic inflammation:

– Damages ______________________________________ .– Hypertrophy and fibrosis of underlying muscle.– ______________________________________ : grooves or tears– ______________________________________ : abnormal connections or passageways

Crohn’s Disease

Crohn’s DiseaseSigns and SymptomsDifficult to differentiate.

– Clinical presentations ______________________________________ drastically.GI bleeding, ______________________________________ , vomiting, diarrhea.Abdominal pain/cramping, fever, ______________________________________ loss.Treatment is to follow general treatment guidelines.

Keys to GI HemorrhageRegardless of the cause, GI hemorrhage can be an

______________________________________ , life-threatening condition and difficult to control

The key to management is to recognize the ______________________________________ indicators early and treat the condition before it worsens

Though diagnosis of exact cause is difficult, if not impossible, in the pre-hospital setting, aggressive examination and ______________________________________ can make a major difference in the outcome of the patient

HemorrhoidsPathophysiology:Mass of swollen ______________________________________ in anus or rectum.Idiopathic.Signs & Symptoms:______________________________________ bright red bleeding and painful stools.Consider ______________________________________ GI bleeding.

TreatmentGeneral treatment guidelines.

Hemorrhoids

Bowel ObstructionPathophysiology:Blockage of the ______________________________________ space of the small or large

intestines

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HerniasForeign bodies, ______________________________________ , tumors, bowel infarction

Bowel ObstructionSigns & Symptoms:Decreased Appetite, Fever, MalaiseNausea and VomitingVomitus often contains bile and/or looks and smells like

______________________________________ Diffuse Visceral Pain, ______________________________________ DistentionSigns & Symptoms of ______________________________________ TreatmentFollow general treatment guidelines.

Accessory Organ DiseasesGI Accessory Organs______________________________________GallbladderPancreasVermiform ______________________________________

AppendicitisPathophysiology:Inflammation of the vermiform appendix.Frequently affects ______________________________________ children and young

adults.Lack of treatment can cause rupture and subsequent

______________________________________ .

AppendicitisSigns & Symptoms:Nausea, vomiting, and ______________________________________ -grade fever.Pain localizes to RLQ (______________________________________ point).TreatmentFollow general treatment guidelines.

Appendicitis

CholecystitisPathophysiology:Inflammation of the ______________________________________ Cholelithiasis (gall stones)Chronic Cholecystitis

– ______________________________________ infectionAcalculus Cholecystitis

– Burns, ______________________________________ , diabetes– Multiple organ failure

Cholecystitis

CholecystitisSigns & Symptoms:

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URQ Abdominal Pain– ______________________________________ sign (pain caused when an inflamed

gallbladder is palpated by pressing under the right costal margin)– Often refers to right shoulder

Nausea, VomitingHistory of ______________________________________ Treatment:Follow general treatment guidelines.

PancreatitisPathophysiology:Inflammation of the ______________________________________ Classified as metabolic, mechanical, ______________________________________ , or

infectious based on cause.Common causes include alcohol abuse, ______________________________________ ,

elevated serum lipids, or drugs.

PancreatitisSigns & Symptoms______________________________________ Pancreatitis

– Epigastric Pain, Abdominal Distention, Nausea/Vomiting______________________________________ Pancreatitis

– Refractory Hypotensive Shock and Blood Loss– Respiratory Failure

Treatment: Follow general treatment guidelines

HepatitisPathophysiology:Injury to ______________________________________ Cells

– Typically due to inflammation or infection.Types of Hepatitis

– Viral hepatitis (A, B, C, D, and E)– ______________________________________ hepatitis– Trauma and other causes

HepatitisHepatitis A (HAV): ______________________________________ hepatitis

– Spread by oral, fecal routeHepatitis B (HBV): Serum hepatitis

– Bloodborne pathogenHepatitis C (HCV):

– Blood to ______________________________________

HepatitisHepatitis D (HDV): less common

– Pathogen is ______________________________________ until activated by HBVHepatitis E (HEV): ______________________________________ infection

– Caused epidemics in Africa, Mexico and other 3rd world countries

HepatitisSigns & Symptoms:

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S/S relative to severity of diseaseURQ abdominal tenderness Loss of ______________________________________ , weight loss, malaiseClay-colored stool, ______________________________________ , scleral icterus

(yellowish color in whites of the eyes)Nausea/vomitingTreatmentFollow general treatment guidelines.

– Use ______________________________________ and follow BSI precautions

Important PointsGI pain may be of ______________________________________ origin. Always apply the

heart monitor and do a 12-lead!N/V can lead to profound ______________________________________ (hypovolemic

shock). Do tilt test and give fluids if positive!______________________________________ the abdomenDon’t blow GI problems off

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