GI emergencies

Question 1

objectives

Answer 1

• understand the anatomy of the abdomen
• identify common and emergent causes of abdominal pain
• develop an approach to abdominal pain

Question 2

lower right quad pain

Answer 2

-appendix pain

Question 3

introduction

Answer 3

-complicated anatomy
-diverse
-presentations
-what do we care about?
-abdomen contains multiple organ systems
-complicates assessment, diagnosis, and ultimately treatment
-consider life threats and to use history and assessment skills to sort through the disorders.
Introduction
-The abdomen contains multiple organ systems:
-Vascular
-Digestive
-Renal
-Reproductive
-This complicates assessment, diagnosis and ultimately treatment

Question 4

associated symptoms

Answer 4

• because the abdomen is so complex and often presents in conjunction with other cardinal presentations, it is often useful to direct the assessment using the following:
• abdominal pain or discomfort with:
• unstable vital signs
• gastrointestinal bleeding
• nausea and vomiting
• diarrhea
• jaundice
• vaginal bleeding

Question 5

anatomy

Answer 5

• Anatomy can direct you to the problem.
• Location of the pain often correlates to the involved organ.
• Know your surface anatomy landmarks:
• What are these landmarks indicative of?
  
  • ASIS (dont need to know)
  • umbilicus * -> appendix
  • costal margin
  • McBurney’s point
  • borders/names of quadrants and regions

Question 6

abdominopelvic regions

Answer 6

• right upper quad
• left upper quad
• right lower quad
• left lower quad

Question 7

McBurneys point

Answer 7

• most common location for the base of the appendix

- look at picture on slides

Question 8

clinical questions

Answer 8

• where is the pain
• what else is going on
• who is the patient
• any associated symptoms

Question 9

referred pain

Answer 9

• abdominal pain -> referred pain

- spleen pain -> spleen is in left upper quad BUT the pain is in left shoulder

Question 10

spleen

Answer 10

• well protected
• uncommon to have splenic injury unless traumatic
• spleen in in upper left quadrant but referred pain in the left shoulder

Question 11

scenario 1

Answer 11

• 40 year old female with abdominal pain
• vomiting
• going to bathroom
• sick but no life threat
• tachypnea at 24
• 144/76
• 110 pulse
• sudden onset
• pain started in epigastric area, now in right upper quadrant that radiates to the right shoulder
• nothing makes it worse or better
• constant
• pregnant
• 99 temp

Question 12

right upper quadrant

Answer 12

• gal bladder

- liver

Question 13

acute cholecystitis

Answer 13

• biliary stasis bile levels arnt being secreted properly
• leads to wall thickening
• common in pregnant females
• pregnant women are at risk for developing due to biliary stasis
• older patients are also at greater risk
• stones
• pain begins in the epigastric area and migrates to the right upper quad
• pain may be crampy initially and then becomes constant
• pain may radiate to right scapula
• peritoneum may become irritates causing peritoneal signs and symptoms
• positive murphy sign is present*

Question 14

murphy sign

Answer 14

• while palpating the right subcostal region, have the patient take a deep breath
• if the patient stops inhaling or complains of pain during the breath, the test is positive
• detects acute cholecystitis

Question 15

acute cholecystitis management

Answer 15

• support airway- have suction available, vomiting is common
• oxygen
• IV fluid
• position of comfort
• antiemetics
• analgesics
• sonogram at the facility

Question 16

scenario 2

Answer 16

• 38 year old man
• abdominal pain intermittently for past 4 day getting progressively worse
• 18 bpm
• lung crackles in lower left lobe on auscultation
• 108 pulse
• sudden onset
• aches
• left upper quad pain radiates into back
• cant eat
• partying, alcoholism
• 100.3 temp
• 144/92
• rales
• > pancreatitis

Question 17

pancreatitis

Answer 17

• pain usually begins in the epigastric area or upper left upper quad
• 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

Question 18

pancreatitis risk factors

Answer 18

• there is a higher frequency in african american, white, and native american males, in that order
• history of alcoholism is the number one risk
• onset after binge consumption is common
• ingestion of alcohol can be recent or within several days
• 40% of people with gallstones can have pancreatitis
• 30% of alcoholics can have pancreatitis

Question 19

grey turner sign and Cullen sign may be present due to hemorrhagic pancreatitis

Answer 19

• pain usually begins in the epigastric area or upper left quad
• 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

Question 20

ongoing management of pancreatitis

Answer 20

• pancreatitis may be life threatening, so be prepared to support 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)

Question 21

scenario 3

Answer 21

• 60 year old female
• abdominal pain for past couple hours
• lower left quad
• moderate distress
• 14 bpm
• 98 pulse
• onset gradual
• no radiation
• diarrhea with some bright red bleeding
• 100.4
• 98
• 132/82
• respiration 14
• 97%
• > sigmoid diverticulitis

Question 22

sigmoid diverticulitis

Answer 22

• inflammation of the diverticula (pouches that have developed in the bowel)
• usually localized to the lower left quad
• often severe, may be present for several
• change in bowel habits
• bleeding may be present
• urinary symptoms (may also be present ex. 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

Question 23

sigmoid diverticulitis risk factors

Answer 23

• -diverticulosis
• NSAID use
• lower fiber use
• chronic constipation
• elderly
• most commonly presents with lower left quad pain

Question 24

summary

Answer 24

• The abdomen contains multiple organ systems.
• This complicates assessment, diagnosis, and ultimately treatment.
• The key is to consider life threats and to use history and assessment skills to sort through the disorders.

Question 25

ongoing management of sigmoid diverticulitis

Answer 25

- IV fluid- crystalloids or blood is hemorrhage is present - pain medication - antibiotics? - Support airway – have suction available as vomiting may occur - Oxygen - Diverticulitis is often managed with antibiotics on an outpatient status if not severe or the patient does not have comorbid conditions