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Gastrointestinal Emergencies Flashcards

1. Explain the concepts related to care of an emergency department patient experiencing a gastrointestinal emergency. 2. Describe the various patient presentations related to gastrointestinal emergencies. 3. List interventions necessary for a patient presenting with a gastrointestinal emergency. (180 cards)

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1
Q

abdominal inspection

A

look for bruising, pulsating masses, shape of abdomen, scars

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2
Q

abdominal auscultation

A

normal bowel sounds 5-35/min

listen for bruits

best indicator for peristalsis is flatus

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3
Q

abdominal percussion

A

liver, splenic borders

liver edge soft, distinct, even with right costal margin

normal sounds: tympany over hollow organs, dullness over solid organs

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4
Q

abdominal palpation

A

assess rigidity, guarding, pain, masses, hernia

tenderness - pain upon pressure

rebound tenderness - pain upon removal of pressure

palpate painful quadrant last

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5
Q

patient position indicating abdominal emergencies

A

movement less likely to indicate serious etiology

rigidly still or fetal position classic sign of peritonitis

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6
Q

sx with abdominal pain suggestive of surgical or emergent conditions

A

fever
protracted vomiting
syncope or pre-syncope
evidence of GI blood loss

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7
Q

define GERD

A

reflux of gastric contents into esophagus, causing sx

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8
Q

define esophagitis

A

inflammation of esophagus, often 2ndary to long-term GERD

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9
Q

causes of esophagitis

A

long-term GERD
infection
radiation
ingestion of caustic substances

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10
Q

sx GERD/esophagitis

A 
steady substernal pain
discomfort increase with swallowing
burning of esophagus
-may radiate
-onset 30-60 min after eating
-discomfort occurs with activities that increase intra-abdominal pressure
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11
Q

complications of GERD/esophagitis

A

sore throat, hoarse throat
nausea, anorexia, weight loss
occasional vomiting

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12
Q

cholingergics for GERD/esophagitis

A

increases lower esophageal sphincter pressure, facilitates gastric emptying

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13
Q

types of cholinergics for GERD/esophagitis

A

bethanechol

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14
Q

dopamine antagonist for GERD/esophagitis

A

moves food through GI system more quickly

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15
Q

types of dopamine antagonist for GERD/esophagitis

A

metoclopramide

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16
Q

antacids for GERD/esophagitis

A

neutralizes acids in stomach

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17
Q

types of antacids for GERD/esophagitis

A

calcium carbonate

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18
Q

histamine (H2) receptor antagonists for GERD/esophagitis

A

blocks acid production

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19
Q

types of histamine (H2) receptor antagonists for GERD/esophagitis

A

ranitidine

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20
Q

proton pump inhibitors for GERD/esophagitis

A

inhibits acid pumps in stomach

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21
Q

types of proton pump inhibitors for GERD/esophagitis

A

lansoprazole

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22
Q

acid protective agents for GERD/esophagitis

A

provides thick protective coating over lower esophagus and stomach

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23
Q

types of acid protective agents for GERD/esophagitis

A

sucralfate

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24
Q

dc teaching for GERD/esophagitis

A 
small, frequent meals
low fat diet
raise HOB
weight loss
avoid:
-eating <2 hrs before bed
-peppermint, spearmint
-chocolate, hot/cold food, spicy food, citrus, carbonation
-tobacco, salicylates, caffeine, alcohol
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25
most common causes of non-variceal upper GI bleeding
``` duodenal/gastric ulcers gastric erosions Mallory-Weiss tears esophagitis frequent NSAIDs presence of varices ```
26
sx upper GI bleed
hematemesis/melena weakness, dizziness, syncope postural hypotension sx hypovolemic shock
27
occult blood testing in upper GI bleeds
false positives: red meat, radishes, turnips, cabbage, cauliflower, horseradish, raw broccoli, cantaloupe false negatives: citrus, vitamin C, supplements
28
labs with upper GI bleeds
BUN increases, creatinine remains same d/t breakdown of blood cells if both elevate, suspect renal disease as cause
29
define peptic ulcer disease
disruption of protective mucosal barriers and increased acid secretion
30
contributing factors to peptic ulcers
NSAID | H. pylori
31
types of peptic ulcers
duodenal gastric stress
32
duodenal ulcers
age 30-55 pain before eating pain relieved with eating, antacids heals spontaneously
33
gastric ulcers
age 55-70 pain after eating weight loss chronic
34
stress ulcers
usually ischemic stress d/t prolonged physical stress such as illness, trauma, neural injury more ICU than ED
35
interventions for peptic ulcers
H2 blockers or PPIs stop NSAIDs abx for H pylor -clarithromycin and amoxicillin
36
define GERD
reflux of gastric contents into esophagus, causing sx
37
define esophagitis
inflammation of esophagus, often 2ndary to long-term GERD
38
causes of esophagitis
long-term GERD infection radiation ingestion of caustic substances
39
sx GERD/esophagitis
``` steady substernal pain discomfort increase with swallowing burning of esophagus -may radiate -onset 30-60 min after eating -discomfort occurs with activities that increase intra-abdominal pressure ```
40
complications of GERD/esophagitis
sore throat, hoarse throat nausea, anorexia, weight loss occasional vomiting
41
cholingergics for GERD/esophagitis
increases lower esophageal sphincter pressure, facilitates gastric emptying
42
types of cholinergics for GERD/esophagitis
bethanechol
43
dopamine antagonist for GERD/esophagitis
moves food through GI system more quickly
44
types of dopamine antagonist for GERD/esophagitis
metoclopramide
45
antacids for GERD/esophagitis
neutralizes acids in stomach
46
types of antacids for GERD/esophagitis
calcium carbonate
47
histamine (H2) receptor antagonists for GERD/esophagitis
blocks acid production
48
types of histamine (H2) receptor antagonists for GERD/esophagitis
ranitidine
49
proton pump inhibitors for GERD/esophagitis
inhibits acid pumps in stomach
50
types of proton pump inhibitors for GERD/esophagitis
lansoprazole
51
disposition for pediatric V/D
mild-moderate: - dc with oral replacement therapy and when to return - PCP in 1-2 days severe: admission
52
types of acid protective agents for GERD/esophagitis
sucralfate
53
dc teaching for GERD/esophagitis
``` small, frequent meals low fat diet raise HOB weight loss avoid: -eating <2 hrs before bed -peppermint, spearmint -chocolate, hot/cold food, spicy food, citrus, carbonation -tobacco, salicylates, caffeine, alcohol ```
54
most common causes of non-variceal upper GI bleeding
``` duodenal/gastric ulcers gastric erosions Mallory-Weiss tears esophagitis frequent NSAIDs presence of varices ```
55
sx upper GI bleed
hematemesis/melena weakness, dizziness, syncope postural hypotension sx hypovolemic shock
56
occult blood testing in upper GI bleeds
false positives: red meat, radishes, turnips, cabbage, cauliflower, horseradish, raw broccoli, cantaloupe false negatives: citrus, vitamin C, supplements
57
labs with upper GI bleeds
BUN increases, creatinine remains same d/t breakdown of blood cells if both elevate, suspect renal disease as cause
58
define peptic ulcer disease
disruption of protective mucosal barriers and increased acid secretion
59
contributing factors to peptic ulcers
NSAID | H. pylori
60
types of peptic ulcers
duodenal gastric stress
61
duodenal ulcers
age 30-55 pain before eating pain relieved with eating, antacids heals spontaneously
62
gastric ulcers
age 55-70 pain after eating weight loss chronic
63
types of gastric tubes for esophageal varices
Sengstaken-Blakemore tube Minnesota tube Linton-Nicholas tube all w/ similar functions
64
interventions for peptic ulcers
H2 blockers or PPIs stop NSAIDs abx for H pylor -clarithromycin and amoxicillin
65
define lower GI bleed
blood loss originating distal to ligament of Treitz
66
Linton-Nicholas tube
control of bleeding esophageal varices triple-lumen to suction esophageal fluids above balloon and gastric fluids below balloon to determine origin of bleeding large 700-800 ml latex balloon provides rapid hemorrhage control
67
assess lower GI bleed
occult blood consider CA in patients > 50 yo
68
sx Mallory-Weiss tears
bleeding self limiting red/coffee ground hematemesis red, bloody stool (hematochezia)
69
infectious causes of acute gastroenteritis
``` rotavirus Norwalk virus S. dysenteriae salmonella e.coli campylobacter jejuni (bloody diarrhea and fever) ```
70
intervene for Mallory-Weiss tears
antiemetics NG tube for occult blood test endoscopy avoid balloon tamponade except as a last resort
71
sx acute gastroenteritis
``` diarrhea, N/V diffuse/cramping lower abd pain fever dehydration splenomegaly - bacterial consider food, travel ```
72
complications of acute gastroenteritis
metabolic acidosis potassium, glucose, calcium abnormalities consider cardiac workup esp for women
73
pharm for acute gastroenteritis
antiemetics anticholinergic abx (bacterial) corticosteroids (parasite)
74
dc for acute gastroenteritis
hydrate clear fluids if watery stool advance diet with loose stool regular diet with partially formed stool
75
define pediatric vomiting and diarrhea
usually self-limiting viral gastroenteritis
76
infectious causes of pediatric V/D
fecal-oral or person-person viral during winter bacterial during summer
77
noninfectious causes of pediatric V/D
``` toxins GI bleed malabsorption syndromes bowel disorders cathartic abuse abx and other meds ```
78
sx pediatric V/D
``` sunken fontanels reduces LOC dry mucus membranes reduced skin turgor sunken, tearless eyes tachypnea oliguria tachycardia hypotension ```
79
intervene for pediatric V/D
oral, VI zofran oral rehydration qh IV hydration for moderate-severe -isotonic crystalloid 20ml/kg
80
disposition for pediatric V/D
mild-moderate: - dc with oral replacement therapy and when to return - PCP in 1-2 days severe: admission
81
inserting NG tube
high Fowler for alert L side, head down for obtunded pts measure length smallest possible tube flex head forward small sips of water only small sprays of benzocaine etc.
82
precautions for NG tube insertion
contraindicated w/ facial/head trauma or basilar skull fx attending should insert w/ varices monitor for hyponatremia if irrigating
83
define pyloric stenosis
hyperplasia/hypertrophy of pylorus muscle at outflow tract of stomach to duodenum, preventing stomach from emptying
84
sx pyloric stenosis
``` usually 2-5 weeks old projectile vomiting after eating hungry after eating/vomiting poor weight gain few stools peristaltic waves palpable RUQ mass dehydration ```
85
intervene for pyloric stenosis
``` IV fluids K+ replacement I/O gastric tube surgery ```
86
pleural effusions in pancreatitis
pancreatic inflammation and tissue damage from pancreatic enzymes trigger inflammatory cascade, causing increased capillary permeability
87
sx esophageal obstruction
"something stuck" difficulty swallowing drooling subcutaneous emphysema of neck if esophageal perforation has occurred
88
intervene for esophageal obstruction
c/f airway obstruction upright position esophagoscopy IV glucagon to relax smooth muscle if object can pass safety through GI system
89
define esophageal varices
bleeding from distended blood vessels in esophagus and stomach, usually 2ndary to liver disease
90
risk factors for esophageal varices
cirrhosis portal HTN chronic alcohol use
91
intervene for esophageal varices
treat hypovolemic shock caution with gastric tube endoscopic procedures to stop bleeding
92
types of gastric tubes for esophageal varices
Sengstaken-Blakemore tube Minnesota tube Linton-Nicholas tube
93
Segstaken-Blakemore tube
emergency control for bleeding esophageal varices diagnostic aid oral or nasal
94
Minnesota tube
four-lumen, double-balloon to tx bleeding esophageal varices or simple esophageal hemorrhaging 3rd and 4th lumens facilitate suctioning above esophageal balloon and in stomach
95
Linton-Nicholas tube
control of bleeding esophageal varices triple-lumen to suction esophageal fluids above balloon and gastric fluids below balloon to determine origin of bleeding large 700-800 ml latex balloon provides rapid hemorrhage control
96
define Mallory-Weiss syndrome
small tears in junction of esophagus and stomach
97
sx Mallory-Weiss tears
bleeding self limiting red/coffee ground hematemesis possible hematochezia
98
risk factors for Mallory-Weiss tears
hx retching, vomiting following by hematemesis alcohol, aspirin use, heavy lifting, coughing, bulimia or pregnancy
99
intervene for Mallory-Weiss tears
antiemetics endoscopy avoid balloon tamponade except as a last resort
100
define cholecystitis
inflammation of gallbladder
101
sx cholecystitis
pain, cramping, bloating, guarding, rigidity worse after deep breath and fatty foods/large meal fever, chills, jaundice, dar urine Murphy sign
102
tips for assessing jaundice
yellow discoloration of elastic tissue such as sclera or hard palate, esp in darker-skinned patients
103
Murphy sign
associated with cholecystitis assessed via palpation of right subcostal area while pt inspires deeply. Positive response occurs when pt experiences pain w/ palpation while inspiring and may experience inspiratory arrest.
104
assessing cholecystitis
CBC - leukocytosis LFTS - elevated ALT and bili abd US
105
intervene for cholecystitis
antiemetics, analgesics NPO, gastric tube abx, cholecystectomy
106
dc teaching for all hepatitis
avoid alcohol, steroids small, frequent meals low fat, high carbs
107
sx pancreatitis
sudden onset epigastric pain radiating to back (dull and steady) abd tenderness, guarding, N/V, anorexia, fever, tachycardia worse w/ eating, alcohol, walking, supine better with leaning forward or fetal position
108
sx pediatric liver disease
usually asymptomatic ``` symptoms: obesity RUQ, nonspecific pain hepatomegaly fatigue ```
109
amylase and lipase in pancreatitis
amylase rises quickly but normalizes 24-72 hours lipase rises more slowly but is detectable for up to 2 weeks
110
intervene for pancreatitis
``` IV calcium replacement analgesia (not morphine) decrease vagal stimulation antispasmodics antacids H2 blockers calcium gluconate (hypocalcemia) corticosteroids glucagon ```
111
why not morphine for pancreatitis?
can cause spasm in sphincter of Oddi
112
why glucagon in pancreatitis
decrease pancreatic inflammation, amylase, pancreatic secretions
113
complications of pancreatitis
``` hypocalcemia pleural effusions ARDS retroperitoneal bleeding pancreatic infection ```
114
hypocalcemia in pancreatitis
free fatty acids formed by release of lipase into soft tissue space bind w/ calcium and cause decrease in ionized calcium tetany, serum Ca < 8
115
pleural effusions in pancreatitis
pancreatic inflammation and tissue damage from pancreatic enzymes trigger inflammatory cascade, causing increased capillary permeability
116
ARDS in pancreatitis
inflammatory cascade causes fluid to leak into pleural space, leading to pleural effusions and fluid in the alveoli (ARDS)
117
retroperitoneal bleeding and hypovolemia in pancreatitis
autolysis caused by pancreatic enzymes can cause bleeding from pancreas and other abd structures
118
sx retroperitoneal bleeding due to pancreatitis
``` hypotension, tachycardia decreasing hematocrit abd distention Grey-Turner sign Cullen sign ```
119
Grey-Turner and Cullen sign in pancreatitis
Grey-Turner: ecchymosis to flanks Cullen: ecchymosis to umbilical area 24-48 hours to develop each indicates pancreatitis, both indicates peritoneal necrosis
120
other causes of Grey-Turner and Cullen sign
bleeding d/t abd trauma aortic rupture ruptured ectopic
121
interventions for UC or Crohn's disease
``` lifestyle changes analgesia, antipyretics IV fluids anticholinergics antidiarrheal anti inflammatories antimicrobials corticosteroids immunosuppressant ```
122
sx pancreatic infection
worsening fever increasing abd pain sepsis
123
hepatitis A
fecal-oral exposure can cause epidemic vaccination
124
hepatitis B
parenteral, sexual, occupational, human bite exposure acute or chronic vaccination
125
hepatitis C
parenteral, sexual, occupational, human bite exposure 50% chronic, may be asymptomatic at first
126
hepatitis D
needs Hep B to duplicate and survive
127
hepatitis E
enteric (contaminated food, water) from fecal matter rare in US
128
sx mild hepatitis
``` malaise fatigue anorexia N/V RUQ pain joint pain generalized edema ascites ```
129
sx severe hepatitis
``` jaundice clay-colored stool steatorrhea dark-colored, foamy urine generalied edema ascites ```
130
labs in hepatitis
increased ammonia, bili, LFTs, PT, PTT decreased urea, albumin, Ca
131
intervene for hepatitis
lactulose remove peritoneal fluid replace albumin, vit K
132
meds for severe or chronic hepatitis
interferon | ribavirin
133
intervene for intestinal obstructions
``` NPO, NG tube barium enema (intussusception) surgery: -volvulus -pyloric stenosis -perforation ```
134
dc teaching for hepatitis B,C,D
do not donate blood or tissue safe sex do not share personal items
135
dc teaching for all hepatitis
avoid alcohol, steroids small, frequent meals low fat, high carbs
136
pediatric considerations in liver disease
obesity most common cause nonalcoholic fatty liver disease occurs in 38% of obese children also cholelithiasis
137
sx pediatric liver disease
usually asymptomatic ``` symptoms: obesity RUQ, nonspecific pain hepatomegaly fatigue ```
138
define appendicitis
obstruction of appendiceal lumen, decreasing blood flow, causing necrosis and perforation, and can lead to peritonitis most common in males 10-30 yo. Extreme ages may have atypical presentations
139
pediatric considerations for appendicitis
most common cause of abdominal pain in children rare in children under 2 yo
140
early sx pancreatitis
dull, steady, periumbilical pain anorexia, nausea mild fever
141
later sx pancreatitis
12-48 hours RLQ pain flexing knees may help rebound tenderness
142
what is rebound tenderness a sign of?
sign of peritoneal irritation aka peritonitis
143
pregnancy considerations in appendicitis
pain may be in RUQ instead of RLQ due to uterus pushing appendix upward
144
labs in appendicitis
CBC - leukocytosis
145
intervene for appendicitis
NPO, serial abd exams | surgery
146
define ulcerative colitis
chronic inflammatory disease affecting only large intestine, usually sigmoid and rectal areas affects mucosal and submucosal layers
147
define Crohn's disease
chronic inflammatory disease affecting any part of GI tract (mouth to anus) most common site of inflammation is transition between small and large intestine
148
complications of UC or Crohn's disease
``` fistulas (Crohn's) intestinal obstructions malnutrition bowel perf toxic megacolon ```
149
toxic megacolon
severe dilation of bowel associated with colitis
150
interventions for UC or Crohn's disease
``` lifestyle changes analgesia, antipyretics IV fluids anticholinergics antidiarrheal anti inflammatories antimicrobials corticosteroids immunosuppressant ```
151
causes of intestinal obstructions
physical nervous system disorders inflammatory conditions
152
physical intestinal obstructions
fecal impaction hernia intussusception volvulus
153
nervous system intestinal obstructions
paralytic ileus
154
inflammatory intestinal obstructions
abscess | inflammatory bowel disease
155
onset of intestinal obstructions
small: rapid large: gradual
156
vomiting in intestinal obstructions
small: frequent, copious (bile and feces) large: rate
157
pain in intestinal obstructions
small: colicky, cramp-like, intermittent, wave-like pain large: low grade, cramping
158
bowel movements in intestinal obstructions
small: BMs early, constipation late large: absolute constipation
159
abd distention in intestinal obstructions
small: minimally increased large: greatly increased
160
general sx intestinal obstructions (small and large)
fever, tachycardia HTN early, hypotension late increased WBC borborygmi (stomach rumble) high pitched peristaltic rush proximal to obstruction leading to absent bowel sounds (late)
161
complications of intestinal obstructions
dehydration electrolyte imbalances bowel ischemia ruptured bowel
162
intervene for intestinal obstructions
``` NPO, NG tube barium enema (intussusception) surgery: -volvulus -pyloric stenosis -perforation ```
163
define intussusception
telescoping of one segment of bowel into another
164
who does intussusception affect?
commonly children 3 mo to 5 years usually 6 mo males > females
165
causes of intussusception
after viral infection polyps hyperactive peristalsis abnormal bowel lining
166
sx intussusception
sudden, acute crampy episodic pain with flexed knees pain free between episodes bilious vomiting, abd distention, sausage-shaped palpable mass in RUQ currant jelly stools w/ bloody mucus is a late sign
167
assessing intussusception
barium or air enema can be diagnostic
168
define volvulus
strangulation of superior mesenteric artery and bowel infarction d/t abnormal bowel rotation with mesenteric attachment
169
volvulus overview
usually first month of life congenital intermittent volvulus can occur (also in adults)
170
sx volvulus
``` bilious vomiting abd pain and distention bloody stools hematemesis visible peristaltic waves peritoneal signs if perforation ```
171
define diverticula
outpouching of colon
172
define diverticulitis
inflammation of diverticula of colon - usually sigmoid
173
define diverticulosis
presence of noninflamed diverticula
174
sx diverticulitis
generalized, abrupt onset of aching, cramping pain local to LLQ anorexia, N/V
175
dc teaching for diverticulitis
``` avoid straining during BMs 40 oz water qd low fat/fiber diet when acute high fiber when not acute stool softeners avoid alcohol, nuts, popcorn ```
176
define peritonitis
inflammation of peritoneum
177
primary peritonitis
blood-borne organisms enter peritoneal cavity
178
secondary peritonitis
abd organs perforate and release contents into peritoneal cavity (more common than primary)
179
causes of peritonitis
ruptured appendix pancreatitis penetrating trauma peritoneal dialysis
180
sx peritonitis
diffuse pain worse with moving, coughing, better when flexing knees ttp, rebound tenderness, guarding, rigid abdomen fever, sepsis diminished, absent bowel sounds dehydration resp difficulties

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