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GASTROENTEROLOGY

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Title: GASTROENTEROLOGY


1
GASTROENTEROLOGY
2
OBJECTIVES
  • Upon completion, the student will be able to
  • Describe the incidence, morbidity and mortality
    of gastrointestinal emergencies.
  • Identify the risk factors most predisposing to
    gastrointestinal emergencies.
  • Discuss the anatomy and physiology of the
    gastrointestinal system.
  • Discuss the pathophysiology of abdominal
    inflammation and its relationship to acute pain.

3
OBJECTIVES
  • Define somatic, visceral, and referred pain as
    they relate to gastroenterology.
  • Differentiate between hemorrhagic and
    nonhemorrhagic abdominal pain.
  • Discuss the signs and symptoms and differentiate
    between local, general, and peritoneal
    inflammation relative to acute abdominal pain.
  • Describe the questioning technique and specific
    questions when gathering a focused history in
    patient with abdominal pain.

4
OBJECTIVES
  • Describe the technique for performing a
    comprehensive physician examination on a patient
    complaining of abdominal pain.
  • Discuss the pathophysiology, assessment findings,
    and management of the following
    gastroenterological problems
  • a) Upper gastrointestinal bleeding
  • b) Lower gastrointestinal bleeding
  • c) Acute gastroenteritis
  • d) Colitis

5
OBJECTIVES
  • e) Gastroenteritis
  • f) Diverticulitis
  • g) Appendicitis
  • h) Ulcer disease
  • i) Bowel obstruction
  • j) Crohns disease
  • k) Pancreatitis
  • l) Esophageal varices

6
OBJECTIVES
  • m) Hemorrhoids
  • n) Cholecystitis
  • o) Acute hepatitis
  • Differentiate between gastrointestinal
    emergencies based on assessment findings.
  • Given several scenarios involving patients with
    abdominal pain and symptoms, provide the
    appropriate assessment, treatment, and transport.

7
Introduction
  • Account for 500,000 emergency visits yearly
  • 300,000 are due to GI bleeds
  • Will increase because of an aging population
  • Usually result from an underlying pathologic
    process that is predictable by risk factors
  • Excessive alcohol consumption
  • Excessive smoking
  • Increased stress
  • Ingestion of caustic substances
  • Poor bowel habits

8
General Pathophysiology
  • Pain is the hallmark of the acute abdominal
    emergency.
  • Three main classifications of abdominal pain
  • Visceral
  • Somatic
  • Referred

9
Visceral Pain
  • Originates in the walls of hollow organs,
  • In the capsules of solid organs,
  • Or in the visceral peritoneum
  • Three separate mechanisms can produce this pain
  • Inflammation
  • Distention (being stretched out or inflated)
  • Ischemia (inadequate blood flow)

10
Visceral Pain
  • All transmit a pain signal from visceral afferent
    neural fibers back to the spinal column
  • Pain is usually not localized to any one specific
    area
  • Described as very vague or poorly localized, dull
    or crampy
  • Body responds through sympathetic stimulation
    causing N/V, diaphoresis and tachycardia

11
Somatic Pain
  • Sharp type of pain that travels along definite
    neural routes (determined by the dermatomes) to
    the spinal column
  • This pain is usually associated with perforations
    or ruptures of hollow organs
  • Cause can be bacterial (ruptured appendix or gall
    bladder) or chemical (perforated ulcer or
    inflamed pancreas-leakage of acidic juices)
  • Resulting peritonitis can lead to sepsis, and
    death

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13
Referred Pain
  • Originates in a region other than where it is
    felt.
  • Many neural pathways from various organs pass
    through or over regions where the organ was
    formed during embryonic development.
  • Example inflammation or injury of the diaphragm
    will have a referred pain in their necks or
    shoulders.
  • Example dissecting abdominal aortic aneurysm
    produces pain felt between the shoulder blades.

14
General Assessment
  • Similar to a trauma assessment with an expanded
    history.
  • Remember scene safety and BSI
  • Observe the scene for clues and/or potential
    evidence of your pts problem meds, alcohol,
    ashtrays, emesis buckets, etc..

15
Scene-Size Up and Initial Assessment
  • Determine if medical or traumatic cause.
  • If trauma remember C-spine.
  • ABCs as always With most medical patients, you
    can check responsiveness and airway by asking the
    patient his name and chief complaint.

16
History and Physical
  • History including SAMPLE
  • Then move on to History of Present Illness

17
History of Present IllnessOPQRST - ASPN
  • Onset when did the pain start, was it sudden or
    gradual?
  • Provocation/Palliation makes the pain worse or
    better?
  • Quality dull, sharp, constant?
  • Region/radiation pain travel?
  • Severity scale 1-10
  • Time when and how long?
  • Associated Symptoms
  • Pertinent Negatives

18
Physical Examination
  • Patients general appearance and posture/position
  • Complete set of vital signs
  • Visually inspect the abdomen before palpation
    (distention, discoloration)
  • Cullens Sign Periumbilical ecchymosis
  • Grey-Turners Sign Ecchymosis in the flank
  • Remove clothing as necessary
  • Auscultation and percussion are difficult
    techniques in a noisy environment

19
Physical Examination
  • Palpation can give you a large amount of
    information
  • Can define the area of pain and identify the
    associated organs
  • Palpate the area of discomfort last
  • Palpation should be done with gentle pressure,
    feeling for
  • Muscle tension or its absence
  • Masses, pulsation, tenderness

20
General Treatment
  • Once assessment, focused history and exam have
    been completed you now will make treatment and
    transport decisions.
  • Monitor ABCs, high-flow O2, IV access, cardiac
    monitor
  • Transport in position of comfort
  • Provide emotional reassurance
  • The use of analgesics could limit further
    evaluation
  • NOTE Persistent abdominal pain lasting longer
    than 6 hours is considered a surgical emergency

21
Specific Illnesses
  • Broken down into two broad categories
  • Upper Gastrointestinal Diseases
  • Lower Gastrointestinal Diseases
  • Upper GI consists of mouth, esophagus, stomach,
    and duodenum
  • Lower GI consists of remainder of small
    intestine and the large intestine

22
Upper GI Bleeding
  • Bleeding within the GI tract proximal to the
    ligament of Treitz
  • This ligament supports the duodenojejunal
    junction
  • Accounts for 300,000 hospitalizations yearly
  • Mortality of 10, reasons
  • Increasing age of population with associated
    medical problems
  • Over-the-counter treatments, until problem
    becomes severe

23
Upper GI Bleeding
  • Six major identifiable causes of upper GI bleed
  • Peptic ulcer disease
  • Gastritis
  • Variceal rupture
  • Mallory-Weiss syndrome (esophageal laceration,
    usually secondary to vomiting)
  • Esophagitis
  • Duodenitis

24
General Presentation
  • Complain of some type of abdominal discomfort
    ranging from a vague burning sensation to an
    upset stomach, gas pain, or tearing pain in the
    upper quadrants
  • N/V
  • If bleeding is in the upper GI, pt. may have
    Hematemesis (bloody vomitus)

25
General Presentation
  • Bleeding passes in to the lower GI tract, pt. may
    have Melena (tarry, foul smelling
    stool..partially digested blood)
  • Bleeding can be light or life-threatening
  • Part of your assessment should include the tilt
    test (orthostatic hypotension 10-mmHg change in
    BP or 20-bpm change in HR when pt. goes from
    supine to standing)

26
General Presentation
  • If available the hematocrit could be normal in
    early stages but will definitely drop in the
    latter stages
  • Other general complaints include malaise,
    syncopal near-syncopal, tachycardia, and
    indigestion.

27
General Treatment
  • Maintain airway, oxygenation and circulatory
    status
  • Lateral recumbent position or semi-Fowlers
  • High-flow O2
  • Two large bore IVs when you suspect GI bleed
  • Cardiac Monitor

28
Esophageal Varices
  • Swollen vein in the esophagus
  • If they rupture mortality is 35
  • Cause is usually a rise in portal pressure, due
    to impeded circulation through the liver.
  • This will cause a backup of blood into the left
    gastric vein and into the esophageal veins.
  • This will cause the veins to dilate outward,
    under pressure, and as the engorgement continues,
    cause them to rupture

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Esophageal Varices
  • Primary cause is the consumption of alcohol and
    the ingestion of caustic substances.
  • Alcohol consumption can result in cirrhosis of
    the liver.
  • This will result in fatty deposits and fibrosis
    in the liver obstructing portal blood flow.
  • Caustic substances can erode the esophagus from
    the inside out, causing hemorrhage of a vessel.

31
Esophageal Varices
  • Patients usually present initially with painless
    bleeding and signs of hemodynamic instability.
  • May complain of hematemesis with bright red
    blood, dysphagia, and a burning or tearing
    sensation as the varices continue to bleed.
  • Clotting time increases because the high portal
    pressure backs up blood into the spleen,
    destroying platelets.
  • Classic signs of shock are common.

32
Esophageal Varices
  • Treatment should focus on aggressive airway
    management (suction!), intravenous fluid
    resuscitation, placing pt. in the shock position,
    and rapidly transporting to the ED.
  • ED management may include the use of a
    Sengstaken-Blakemore tube to tamponade the
    bleed, endoscopic cauterization, or sclerotherapy
    (injection of a thrombus-forming drug into the
    vein itself).

33
Acute Gastroenteritis
  • Inflammation of the stomach and intestines with
    associated sudden onset of vomiting and/or
    diarrhea.
  • Affects 3-5 million people yearly (worldwide).
  • 20 of all hospitalized patients.
  • The inflammation causes hemorrhage and erosion of
    the mucosal and submucosal layers of the GI tract.

34
Acute Gastroenteritis
  • Also can damage the villi inside the intestine,
    which absorb water and nutrients.
  • The water will now move through the bowel at an
    increased rate.
  • Dehydration secondary to diarrhea is a common
    cause of death.
  • Volume replacement is the major prehospital
    intervention to minimize hypovolemia.

35
Acute Gastroenteritis
  • Alcohol and tobacco abusers are at a high risk
    for gastritis and gastroenteritis
  • Also nonsteroidal anti-inflammatory drugs such as
    aspirin can lead to acute gastritis
  • Alcohol and tobacco have the same effect on the
    mucosa as aspirin (breakdown the mucosal surfaces
    of stomach and GI tract)
  • Other causes include stress, chemotherapeutic
    agents and the ingestion of acidic or alkalotic
    agents

36
Acute Gastroenteritis
  • Infections such as salmonellosis and
    staphylococcus can lead to acute gastroenteritis.
  • Onset is rapid and severe.
  • Multiple problems arise
  • Diarrhea leading to dehydration. Especially
    effects pediatric and geriatric patients.
  • Stool may show melena or hematochezia (bright red
    blood from erosion of the lining of the lower GI
    tract)

37
Acute Gastroenteritis
  • Hematemesis
  • Fever
  • N/V
  • General malaise
  • Patient may complain of widespread and diffuse
    abdominal pain that is not specific to any one
    region.

38
Acute Gastroenteritis
  • Treatment is mainly supportive and palliative
  • Position to decrease the risk of aspiration
  • Oxygenation
  • Rehydration
  • Antiemetics prochlorperazine (compazine) or
    promethazine (phenergan)
  • Electrolyte replacement may be necessary at the
    hospital

39
Chronic Gastroenteritis
  • Inflammation of GI mucosa marked by long-term
    mucosal changes or permanent mucosal damage.
  • Primarily due to microbial infection.
  • Most prevalent pathogen in the US is Helicobacter
    pylori bacillus.
  • Others include Escherichia coli, Klebsiella
    pneumoniae, Enterobacter, Campylobacter jejuni,
    Vibrio cholerae, Shigella, and Salmonella.

40
Chronic Gastroenteritis
  • Viral pathogens include Norwalk virus and
    rotavirus.
  • Parasitic causes protozoa Giardia lamblia,
    Cryptosporidium parvum, and Cyclosporidium
    cayetenis.
  • More common in underdeveloped countries.
  • Transmitted via the fecal-oral route or through
    infected food or water.

41
Chronic Gastroenteritis
  • Commonly present with N/V, fever, diarrhea,
    abdominal pain, cramping, anorexia, lethargy and
    if severe, shock.
  • The H. pylori presents with heartburn, abdominal
    pain, and gastric ulcers.
  • Treatment BSI (protect against
    cross-contamination), monitoring ABCs and
    transport.
  • Medical treatment will require identification of
    the offending organism.

42
Peptic Ulcers
  • Erosions caused by gastric acid
  • Can occur anywhere in the GI tract
  • Location is based on the area of small intestine
    involved (ex. duodenal ulcer) gastric
    ulcers-only in the stomach
  • Occurs 4 times more frequently in males
  • Duodenal ulcers occur 2-3 times more often than
    gastric ulcers

43
Peptic Ulcers
  • Gastric ulcers more common in patients over 50,
    work in jobs requiring physical activity
  • Pain usually increases after eating or with a
    full stomach and they usually have no pain at
    night
  • Duodenal ulcers are more common in patients from
    25-50 who are executives or leaders under high
    stress possible genetic predisposition
  • Commonly have pain at night or whenever their
    stomach is empty

44
Peptic Ulcers
  • Nonsteroidal anti-inflammatory medications,
    acid-stimulating products, or Helicobacter pylori
    bacteria are the most common causes
  • GI mucosal lining is irritated by hydrochloric
    acid, and pepsin. Adding any of the above agents
    increases the irritation.
  • Treatment is focused on antacid treatment and
    support of any complications (hemorrhage)

45
Peptic Ulcers
  • Blocked pancreatic duct can also contribute to
    duodenal ulcers. This duct releases an alkalotic
    solution in opposition to the high acid contained
    in chyme.
  • Another cause is Zollinger-Ellison Syndrome
    Where an acid-secreting tumor provokes the
    ulcerations condition causes stomach to secrete
    excess HCl acid and pepsin.

46
Peptic Ulcers
  • Findings on exam can vary
  • Chronic ulcers can cause a slow bleed with
    resulting anemia
  • Visual inspection of the abdomen is only helpful
    with a significant bleed
  • Palpation, the pain may be localized or diffuse
  • Patients usually have relief of pain after eating
    or coating their GI tract with a liquid such as
    milk
  • Acute, severe pain is probably due to a rupture
    of the ulcer

47
Peptic Ulcers
  • Depending on location the patient may have
    hematemesis or may have melena-colored stool
  • N/V common
  • Patient will appear ill with signs of hemodynamic
    instability
  • Treatment is based on severity
  • Position of comfort, psychological support
  • Oxygenation, IV access for fluid resuscitation
  • Pharmacological administration and rapid
    transport
  • Meds include Zantac and Pepcid (histamine
    blockers) and antacids, like Carafate

48
Lower GI Diseases
  • Lower GI tract consists of the jejunum and ileum
    of the small intestine, and the entire large
    intestine, rectum and the anus.

49
Lower GI Bleeding
  • Bleeding in the GI tract distal to the ligament
    of Treitz.
  • Most frequently occur in conjunction with chronic
    disorders and anatomic changes associated with
    advanced age.
  • Most common cause is diverticulosis.
  • Other causes colon lesions, rectal lesions, and
    inflammatory bowel disorders such as ulcerative
    colitis and Crohns disease.

50
Lower GI Bleed
  • Assessment is identical as with upper GI bleeds
  • Ask patient whether this is a new or old problem
  • Frequent complaints with lower GI bleeds include
    cramping pain that may be described as like a
    muscle cramp or like gas pain, N/V, and changes
    in stool
  • Melenic stool usually indicates a slow bleed
  • Bright red blood, bleed is very large or has
    occurred in the distal colon

51
Lower GI Bleed
  • If in the distal colon, hemorrhoids or rectal
    fissures are possible causes
  • Physical presentation is similar to peptic ulcers
  • Management is based on physiological status
  • ABCs, oxygenation
  • IV access, fluid resuscitation
  • Position of comfort, cardiac monitor
  • MAST if directed in local protocols

52
Ulcerative Colitis
  • An idiopathic inflammatory bowel disorder (IBD),
    that is, one of unknown origin.
  • Creates a continuous length of chronic ulcers in
    the mucosal layer of the colon.
  • As ulcers heal, granular tissue replaces the
    ulcerations, thickening the mucosa.
  • Typically involve the rectum or rectosigmoid
    portion of the large intestine.

53
Ulcerative Colitis
  • Usually starts in the rectum and then extends
    proximally into the colon.
  • If it spreads throughout the entire colon it is
    called pancolitis if limited to the rectum it is
    called proctitis.
  • 10,000 new cases are diagnosed yearly.
  • Affects patients between the ages of 20-40.

54
Ulcerative Colitis
  • Contributing factors
  • Psychological
  • Allergic and other immunological
  • Toxic
  • Environmental
  • Infectious
  • Current research has found that the release of
    cytokines can cause an overwhelming inflammatory
    response in the submucosa.

55
Ulcerative Colitis
  • Acute ulcerative colitis is difficult to
    differentiate from other causes of lower GI
    bleeds.
  • Diagnosing may require hematocrits and hemoglobin
    results, guaiac analyses of the stool and
    endoscopic examinations.
  • Severity is based on the extent of the current
    inflammation in the colon.
  • Severe presentations usually involve the entire
    colon, instead of one segment.

56
Ulcerative Colitis
  • Presents as a recurrent disorder with occasional
    bloody diarrhea or stool containing mucus.
  • Colicky abdominal pain (cramping)
  • N/V
  • Fever
  • Weight loss
  • Cramping is usually isolated to the lower
    quadrants
  • Typically appear restless due to discomfort

57
Ulcerative Colitis
  • Typically are not hemodynamically unstable
  • More severe cases may present with bloody
    diarrhea and intense colicky abdominal pain.
  • Electrolyte derangements due to fluid loss
    through the colon
  • Ischemic damage to the colon itself
  • Eventually perforation of the bowel
  • These patients will present with SS of
    hypovolemic shock

58
Ulcerative Colitis
  • Management is based on physiological status.
  • If presenting with shock, treat as such.
  • Additional management may include antiemetics and
    antispasmodic medications.
  • Transport for diagnostic evaluation.

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Crohns Disease
  • The other idiopathic inflammatory bowel disorder
    in humans.
  • More common in the Western Hemisphere,
    20,000-30,000 new cases annually in the U.S.
  • Tends to run in families, most prevalent in white
    females, those under frequent stress, and in the
    Jewish population.
  • Can occur anywhere from the mouth to the rectum.

61
Crohns Disease
  • 35-45 of less severe cases occur in the small
    intestine.
  • 40 involve the colon.
  • Severe cases may involve any portion of the GI
    tract, causing a variety of problems ranging from
    diarrhea to intestinal and perianal abscesses and
    fistulas.
  • Complete intestinal obstruction can also occur.
  • Significant lower bleeding is rare.

62
Crohns Disease
  • It damages the innermost layer of the tissue the
    mucosa.
  • Affected section of intestinal wall eventually
    becomes rubbery and nondistendable due to
    hypertrophy and fibrosis of the muscles
    underlying the submucosa.
  • This will decrease the intestines internal
    diameter, resulting in fissures (incomplete
    tears) in the mucosa.

63
Crohns Disease
  • If a tear extends into the blood vessels in the
    submucosal layer, small bleeds result.
  • Clinical presentations vary drastically as the
    disease progresses, and prehospital diagnosis is
    virtually impossible.

64
Signs Symptoms
  • GI bleeding
  • Recent weight loss
  • Intermittent abdominal cramping/pain
  • N/V
  • Diarrhea
  • Fever

65
Crohns Disease
  • Flare-up is usually rapid, requiring a visit to
    the doctor.
  • Abdominal pain cannot be localized to any
    specific quadrant.
  • Physical exam is also nonspecific, and
    non-localized, with diffuse tenderness the most
    commonly found sign.
  • Prehospital treatment is palliative because the
    patient is generally hemodynamically stable.

66
Crohns Disease
  • Management depends on the patients physiological
    status.
  • Additional management may include antiemetics and
    antispasmodic medications.

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Diverticulitis
  • Relatively common complication of diverticulosis.
  • Diverticulosis is a condition characterized by
    the presence in the intestine of diverticula,
    small outpouchings of mucosal and submucosal
    tissue that push through the outermost layer of
    the intestine, the muscle.
  • Diverticulitis is an inflammation of diverticula
    secondary to infection.

69
Diverticulitis
  • It is symptomatic, patients complain of lower
    left-sided pain (located in sigmoid colon).
  • Exam and testing will show fever and an increased
    WBC count.
  • Pathogenesis of a diverticulum is twofold
  • Stool passes sluggishly through the colon, a
    condition associated with the relatively low
    fiber diets common in developed countries. Colon
    responds with muscle spasms to move the fecal
    material forward.

70
Diverticulitis
  • The outermost layer of colon tissue is made up of
    fibrous bands of muscle wrapped around one
    another. The muscles (teniae coli) become
    weakened with age, and the increased pressure of
    muscle spasms can cause the inner layers of
    tissue, the mucosa and submucosa, to herniate
    through the openings, forming diverticula.

71
Diverticulitis
  • The diverticula then trap small amounts of fecal
    material, including sunflower seeds, popcorn
    fragments, okra seeds, sesame seeds etc.. the
    trapped feces can allow bacteria to grow and
    result in an infection.

72
Diverticulitis
  • When diverticula become inflamed the result is
    diverticulitis
  • Complications include possible hemorrhage, larger
    perforations of the colon in which the fecal
    matter is spilled into the peritoneal cavity and
    cause peritonitis.
  • Most common presentation is colicky pain
    associated with low grade fever, N/V, tenderness
    upon palpation.

73
Diverticulitis
  • If they begin to bleed significantly the
    presentation is similar with any serious lower GI
    bleed (sympathetic response).
  • Bleeding diverticula can also result in bright
    red and bloody feces (hematochezia).
  • Prehospital treatment is mainly supportive, treat
    for shock as necessary.
  • Antiemetics (Phenergan or Vistaril) for comfort.
  • In hospital antibiotic therapy, endoscopy,
    radiological tests.
  • .

74
Hemorrhoids
  • Small masses of swollen veins that occur in the
    anus (external) or rectum (internal).
  • Frequently develop during the fourth decade of
    life.
  • Most are idiopathic, but can result from
    pregnancy or portal hypertension.
  • External hemorrhoids often result from lifting a
    heavy object.

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Hemorrhoids
  • Other causes include
  • Straining at defecation
  • Diet low in fiber
  • Internal hemorrhoids most often involve the
    inferior hemorrhoidal plexus and vasculature.
  • Commonly bleed during defecation and then
    thrombose into closed state again.
  • External hemorrhoids result from a thrombosis of
    a vein, often following lifting or straining.

77
Hemorrhoids
  • External hemorrhoids cause bright red blood with
    bowel movement.
  • Vessels can erode from increased venous pressure,
    causing free bleeding and high risk for
    infection.
  • Patients usually call because of bright red
    bleeding and pain on defecation.
  • Patients are typically hemodynamically stable
  • Treatment is based on patients condition

78
Bowel Obstruction
  • Blockages of the hollow space, or lumen, within
    the small and large intestines
  • Can be either partial or complete
  • Can be catastrophic if not rapidly diagnosed and
    treated

79
Bowel Obstruction
  • Many different causes. Four most frequent are
  • Hernia protrusion or organ through its
    protective sheath
  • Intussusception part of intestine slips into
    the part just distal to itself
  • Volvulus twisting of the intestine
  • Adhesions union of normally seperated tissue by
    a fibrous band of new tissue

80
Bowel Obstruction
  • Other causes include foreign bodies,
    gallstones, tumors, adhesions from previous
    abdominal surgery, and bowel infarction.
  • Most common location is the small intestine, due
    to its smaller diameter and its greater length,
    flexibility, and mobility.
  • Obstruction may be chronic, as with tumor growth
    or adhesion progression.
  • Or acute as with foreign body obstruction.

81
Bowel Obstruction
  • Chronic obstruction usually results in a
    decreased appetite, fever, malaise, N/V, weight
    loss, or if rupture occurs (peritonitis).
  • Acute-onset pain may follow ingestion of a
    foreign body. Pain may also be due to
    strangulation, possibly leading to infarction.
  • Patients frequently vomit, vomitus often
    containing a significant amount of bile.

82
Bowel Obstruction
  • Patients present with diffuse visceral pain,
    usually poorly localized to any one specific
    location.
  • Hemodynamically unstable due to necrosis of an
    organ, SS of shock may be present.
  • Abdominal distention may be obvious (free air)
    from a rupture of the strangulated segment.
  • Palpation will reveal tenderness.
  • Treatment is based on physiological status.

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Accessory Organ Disease
  • These include
  • Liver
  • Gallbladder
  • Pancreas
  • Vermiform Appendix

88
Appendicitis
  • Inflammation of the vermiform appendix.
  • Occurs in approximately 10-20 of the population
    in the US.
  • Most common in young adults.
  • Acute appendicitis is the most common surgical
    emergency you will encounter in the field.
  • There are no particular risk factors.

89
Appendicitis
  • Appendix serves no anatomic or physiologic
    function, lymphoid tissue.
  • It can become inflamed and rupture if left
    untreated, resulting in peritonitis.
  • Pathogenesis most often due to obstruction of
    the appendiceal lumen by fecal material.
  • Results in inflamed lymphoid tissue and leads to
    bacterial or viral infection.

90
Appendicitis
  • The inflammation also causes the internal
    diameter to expand, blocking the artery, causing
    infarction and necrosis. Leading to rupture.
  • Mild or early appendicitis causes diffuse,
    colicky pain associated with N/V, and low-grade
    fever.
  • Pain is initially located in the periumbilical
    region.
  • Patient also loses their appetite.
  • Continued dilation causes pain to localize in the
    right lower quadrant.

91
Appendicitis
  • Once the appendix ruptures the pain becomes
    diffuse due to development of peritonitis.
  • Physical exam shows a patient in discomfort.
  • Abdominal exam reveals tenderness or guarding
    around the umbilicus or RLQ.
  • Common site of pain is McBurneys point.
  • 2/3 the distance from the umblicus to the
    superior illac crest.
  • Prehospital care is based on the hemodynamic
    state of the patient.

92
McBurneys Point
93
Cholecystitis
  • Inflammation of the gallbladder.
  • Cholelithiasis (formation of gall stones),
    causing 90 of cholecystitis in the US.
  • 1 million new cases annually.
  • Two types of gallstones
  • Cholesterol-based
  • Bilirubin-based

94
Cholecystitis
  • Cholesterol-based stones are far more common and
    are associated with a specific risk profile
    obese, middle-aged women with more than one
    biological child.
  • Definitive treatment of acute cholecystitis
    include antibiotic therapy, laparoscopic surgery,
    lithotripsy (ultrasound) and surgery.

95
Cholecystitis
  • Gallstones occur because of calculi build up
    lodging in the common bile duct.
  • When the movement of bile is obstructed
    gallbladder inflammation and irritation result.
  • Over time blood flow to the local epithelium will
    be reduced.
  • Other causes of cholecystitis include
  • Acalculus cholecystitis (no stones)
  • Chronic inflamation caused by bacterial
    infection

96
Cholecystitis
  • Acalculus cholecystitis usually results from
    burns, sepsis, diabetes, and multiple organ
    failure.
  • Inflamed gallbladder usually causes an acute
    attack of upper right quadrant abdominal pain,
    with referred pain in the right shoulder.
  • If gallstones are lodged in the cystic duct, the
    pain may be colicky, due to expansion and
    contraction.

97
Cholecystitis
  • The pain occurs after a meal that is high in fat
    content because of the secondary release of bile
    from the gallbladder.
  • Palpation may reveal either diffuse right-sided
    tenderness or point tenderness under the right
    costal margin, a positive Murphys sign.
  • Prehospital treatment is mainly palliative.
  • Position of comfort, maintain ABCs, establish IV
  • Pain medication meperidine (demerol)
    butorphanol (stadol).

98
Pancreatitis
  • Inflammation of the pancreas.
  • Four main categories, based on cause
  • Metabolic
  • Mechanical
  • Vascular
  • Infectious

99
Pancreatitis
  • Metabolic causes, specifically alcoholism,
    account for 80 of all cases.
  • Mechanical obstructions caused by gallstones or
    elevated serum lipids account for another 9
  • Vascular injuries caused by thromboembolisms or
    shock, along with infectious diseases, account
    for the remaining 11.
  • Mortality (30-40) is due sepsis and shock.

100
Pancreatitis
  • Acute pancreatitis caused by gallstones that
    obstruct the pancreatic duct.
  • Results in backups of digestive enzymes, causing
    inflammation of the pancreas and edema, reduction
    of blood flow, ischemia and acinar destruction.
  • Acinar tissue destruction causes a second form of
    pancreatitis, chronic pancreatitis.

101
Pancreatitis
  • Acinar tissue destruction commonly occurs due to
    chronic alcohol intake, drug toxicity, ischemia,
    or infectious diseases.
  • Pain can be localized to the left upper quadrant
    or may radiate to the back or the epigastric
    region.
  • Most patients experience nausea followed by
    uncontrolled vomiting and retching that can
    further aggravate the hemorrhage.

102
Pancreatitis
  • Patient will appear acutely ill with diaphoresis,
    tachycardia, and possible hypotension.
  • Prehospital treatment is supportive and aimed at
    maintaining the ABCs.
  • Establish IVs.
  • Definitive treatment involves gastric intubation
    and suctioning for emesis control, diagnostic
    peritoneal lavage, antibiotic therapy, fluid
    resuscitation, and surgery to remove the blockage.

103
Hepatitis
  • Involves any injury to hepatocytes associated
    with an inflammation or infection.
  • Five viruses A, B, C, D, and E
  • Alcoholic hepatitis, arises from alcoholic
    cirrhosis, rather than an infectious agent.
  • Factors that increase the risk of contracting
    hepatitis include unsanitary living conditions,
    poor personal hygiene that invites oral-fecal
    transmission, exposure to blood borne pathogens,
    and chronic alcohol intake.

104
Hepatitis
  • Any of the viral pathogens, alcoholic exposure,
    or trauma can injure the hepatocytes, causing
    inflammation and, possibly, chronic liver
    disease.
  • Whatever the cause, results are similar
    enlargement and hypertrophy, fatty changes, loss
    of architecture, and appearance of lesions and
    spontaneous hemorrhages.
  • Symptoms range from mild to liver failure and
    death.

105
Hepatitis
  • Hepatitis A is probably the best known.
  • Commonly referred to as infectious hepatitis.
  • Spreads by oral-fecal route.
  • Disease is self-limiting.
  • Lasting between 2-8 weeks.
  • Low mortality rate.

106
Hepatitis
  • Hepatitis B, known as serum hepatitis.
  • Blood borne pathogen that can stay active in
    bodily fluids outside the body for days.
  • 310 million carriers worldwide, HBV is an
    epidemic.
  • Effects may be minimal, but can range to severe
    liver ischemia and necrosis.

107
Hepatitis
  • Hepatitis C caused by the pathogen most commonly
    responsible for spreading hepatitis through blood
    transfusions.
  • Marked by chronic and often debilitating damage
    to the liver.

108
Hepatitis
  • Hepatitis D, less common disorder because its
    pathogen is dormant until activated by HBV.
  • Hepatitis E is a waterborne infection that has
    caused epidemics in Africa, Mexico, and other
    third-world nations.
  • Mortality rate for pregnant women is high.

109
Hepatitis
  • Commonly present with symptoms relative to the
    severity of their disease.
  • Complain of URQ abdominal tenderness, not
    relieved by antacids, food, or positioning.
  • May lose their appetite and become anorexic,
    usually losing weight.
  • Decrease in bile production changes their stool
    to a clay color, and increased bilirubin
    retention causes jaundice, yellow coloring of the
    skin, and scleral icterus, yellowing of the white
    of the eyes.

110
Hepatitis
  • Other signs and symptoms include severe N/V,
    general malaise, photophobia, pharyngitis, and
    coughing.
  • Exam will reveal a sick patient, possibly with a
    jaundiced appearance.
  • Pain may present in URQ or the right shoulder.
  • Fever may be secondary to infection or to tissue
    necrosis.

111
Hepatitis
  • Treatment is palliative
  • Secure ABCs
  • Establish IV
  • Antiemetic administration
  • Definitive treatment involves antiviral and
    anti-inflammatory medications and symptomatic
    treatment
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