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Gastroenterology“A Cute Abdomen”
Dr Baxter LarmonProfessor
UCLA School of Medicine
Incidence of GI/GU Disorders
Every year about 62 million people are Every year about 62 million people are diagnosed with a gastrointestinal diagnosed with a gastrointestinal disorder.disorder.
The incidence and prevalence of most The incidence and prevalence of most digestive diseases increase with age, digestive diseases increase with age, although there are exceptions.although there are exceptions.
Morbidity & Mortality of GI/GU Morbidity & Mortality of GI/GU DisordersDisorders
In 1992, GI disorders cost nearly $107 billion In 1992, GI disorders cost nearly $107 billion in direct health care expenditures.in direct health care expenditures.
Currently, GI disorders result in nearly 200 Currently, GI disorders result in nearly 200 million sick days,million sick days,
50 million visits to a physician,50 million visits to a physician, 16.9 million days lost from school,16.9 million days lost from school, 10 million hospitalizations,10 million hospitalizations, And nearly 200,000 deaths per year.And nearly 200,000 deaths per year.
General Pathophysiology
General Risk FactorsExcessive Alcohol ConsumptionExcessive SmokingIncreased StressIngestion of Caustic SubstancesPoor Bowel Habits
EmergenciesAcute emergencies usually arise from
chronic underlying problems.
Etiology of Pain
InflammationForeign chemicalBacterial contaminationStimulation of nerve endings.Irritation
Stretching, distention, bleeding
Visceral vs. SomaticVisceral pain
Caused by stimulation of autonomic nerve fibers that surround a hollow viscus
Cramping or gas typeGenerally diffuse drill
Somatic painProduced by Bacterial or chemical irritation
of autonomic nerveGuardingDon’t want to moveSuperficial
Solid Organs
Dull and steady in nature.More localized.Bleeding
Within capsule,Rupture;
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.
Hollow OrgansUsually associated with
nausea, vomiting, tachycardia,diaphoresis;
Bleedingwithin the organ itself;
Referred PainDefinition
Pain in area removed from tissue that caused the pain
Caused by visceral fibers that synapse in the spinal cord
Causesame spinal segment,skin has more receptors,unable to distinguish,
Referred Pain
NOT ALL ABDOMINAL PAIN IS OF ABDOMINAL ETIOLOGY.
General Assessment
Scene Size-up & Initial AssessmentScene clues.Identify and treat life-threatening
conditions.Focused History & Physical Exam
Focused HistoryObtain SAMPLE History.Obtain OPQRST History.
Associated symptomsPertinent negatives
General AssessmentPhysical Exam
General assessment and vital signs
Abdominal assessmentInspection, Auscultation, and
Palpation, PercussionCullen’s Sign: Discoloration
around the umbical areaGrey-Turner’s Sign:
Discoloration in the flank area
Let’s Review aPhysical Exam
of the Abdomen
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
CausesPeptic Ulcer DiseaseGastritisEsophagitisDuodenitis
Upper Gastrointestinal Bleeding
Upper Gastrointestinal Upper Gastrointestinal Bleeding EtiologyBleeding Etiology
ETIOLOGYETIOLOGY PERCENTPERCENT
Peptic Ulcer Peptic Ulcer 4545
Gastric erosionsGastric erosions 2323
VaricesVarices 1010
Mallory-Weiss TearMallory-Weiss Tear 7 7
EsophagitisEsophagitis 66
DuodenitisDuodenitis 66
OtherOther 22
Signs & SymptomsGeneral abdominal discomfortHematemesis and melenaClassic signs and symptoms of shock Changes in orthostatic vital signs
TreatmentFollow general treatment guidelines.
Begin volume replacement using 2 large-bore IVs.
Differentiate life-threatening from chronic problem.
Upper Gastrointestinal Bleeding
Esophageal Varices
CausePortal
HypertensionChronic alcohol
abuse and liver cirrhosis
Ingestion of caustic substances
Esophageal Varices
Signs & SymptomsHematemesis, DysphagiaPainless BleedingHemodynamic InstabilityClassic Signs of Shock
TreatmentFollow General Treatment Guidelines.
Aggressive Airway ManagementAggressive Fluid Resuscitation
Acute Gastroenteritis
CauseDamage to Mucosal GI Surfaces
Pathologic inflammation causes hemorrhage and erosion of the mucosal and submucosal layers of the GI tract.
Risk FactorsAlcohol and tobacco useChemical ingestionSystemic infections
Acute Gastroenteritis
Signs & SymptomsRapid Onset of Severe Vomiting and
DiarrheaHematemesis, Hematochezia, MelenaDiffuse Abdominal PainClassic Signs of Shock
TreatmentFollow General Treatment Guidelines.Fluid Volume Replacement.Consider Administration of Antiemetics.
Peptic Ulcers
PathophysiologyErosions caused
by gastric acid.Terminology based
on the portion of tract affected.
Causes:Alcohol/Tobacco UseH. pylori
Peptic Ulcers
Signs & SymptomsAbdominal PainObserve for signs of hemorrhagic
rupture.Acute pain, hematemesis, melena
TreatmentFollow general treatment guidelines.Consider administration of histamine
blockers and antacids.
PathophysiologyBleeding distal to the ligament of
TreitzCauses
DiverticulosisColon lesionsRectal lesionsInflammatory bowel disorder
Lower Gastrointestinal Bleeding
Signs & SymptomsDetermine acute vs. chronic.Quantity/color of blood in stool.Abdominal painSigns of shock.
TreatmentFollow general treatment guidelines.
Establish IV access with large-bore catheter(s).
Lower Gastrointestinal Bleeding
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.
Crohn’s Disease
Signs and SymptomsDifficult to differentiate.
Clinical presentations vary drastically.
GI bleeding, nausea, vomiting, diarrhea.Abdominal pain/cramping, fever, weight
loss.Treatment
Follow general treatment guidelines.
Diverticulitis Pathophysiology
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
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
PathophysiologyBlockage of the hollow
space of the small or large intestines
Hernias
Bowel Obstruction
PathophysiologyOcclusion of the intestinal lumen
that results in blockage of the normal flow of intestinal fluids
OR
PathophysiologyOcclusion of the intestinal lumen
that results in blockage of the normal flow of intestinal fluids
OR
Bowel Obstruction
Pathophysiology Twisting of the bowel
Pathophysiology Twisting of the bowel
PathophysiologyAdhesions
Bowel ObstructionBowel Obstruction
Bowel Obstruction
Signs & SymptomsDecreased Appetite, Fever, MalaiseNausea and VomitingDiffuse Visceral Pain, Abdominal
DistentionSigns & Symptoms of Shock
TreatmentFollow general treatment guidelines.
Accessory Organ Diseases
GI Accessory OrgansLiverGallbladderPancreasAppendix
Appendicitis
PathophysiologyInflammation of the vermiform
appendix.Frequently affects older children
and young adults.Lack of treatment can cause
rupture and subsequent peritonitis.
Cholecystitis
Pathophysiology Inflammation of the
GallbladderCholelithiasisChronic
Cholecystitis Bacterial infection
Acalculus Cholecystitis
Burns, sepsis, diabetes
Multiple organ failure
Pathophysiology Inflammation of the
GallbladderCholelithiasisChronic
Cholecystitis Bacterial infection
Acalculus Cholecystitis
Burns, sepsis, diabetes
Multiple organ failure
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).
Cirrhosis
InfectionViral hepatitis
ToxinsETOH
Altered immune response;Vascular disturbance;
Urology &
Nephrology
Anatomy & Physiology
Ureters Urinary Bladder Urethra Testes Epididymus and
Vas Deferens Prostate Gland Penis
Inflammatory or Immune-Mediated Disease
Infectious DiseasePhysical ObstructionHemorrhage
General Mechanisms of Nontraumatic Tissue Problems
Differentiating GI and Urologic Complaints
Pathophysiologic Basis of PainCauses of PainTypes of Pain
Visceral painReferred pain
General Pathophysiology, Assessment and Management
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
Renal and Urologic Emergencies
Acute Renal Failure
PathophysiologyPrerenal Acute Renal Failure
Dysfunction before the level of kidneysMost common and most easily reversible
Renal Acute Renal FailureDysfunction within the kidneys
themselvesPostrenal Acute Renal Failure
Dysfunction distal to the kidneys
Acute Renal Failure
AssessmentFocused History
Change in urine outputSwelling in face, hands, feet, or
torsoPresence of heart palpitations or
irregularityChanges in mental function
Acute Renal FailurePhysical Assessment
Altered mental status Hypertension Tachycardia ECG indicative of hyperkalemia Pale, cool, moist skin
Acute Renal Failure
Physical Assessment
Edema of face, hands, or feet
Abdominal findings dependent on the cause of ARF
Renal Calculi
PathophysiologyResults when “too
much insoluble stuff” accumulates in the kidneys.
Stone typesCalcium saltsStruvite stonesUric acidCystine
Renal Calculi
AssessmentFocused History
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 calculiPhysical Exam
Difficult due to patient discomfortTachycardia with pale, cool, and moist skin
Urinary Tract Infection
PathophysiologyRisk Factors
Increased risk in female or catheterized patients
Sexual activity
Lower and Upper UTIsUrethritisCystitisProstatitisPyelonephritisCommunity-acquired vs. nosocomial infections
Urinary Tract Infection
AssessmentFocused History
Abdominal painFrequent, painful urinationA “burning sensation” associated with
urinationDifficulty beginning and continuing to
voidStrong or foul-smelling urineSimilar past episodes
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