Gastrointestinal emergencies Flashcards by Gull Peretz

Name indicators of a GI complaint

*Pain
*Vomiting
*Fever
*Diarrhoea
*Constipation
*Haematemesis (blood in vomit)
*Melaena (dark black stools)
*Weight loss/change

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Name risk factors for GI Complaint and differentiators

*Alcohol
*Smoking
*Medications (NSAIDS, Aspirin, Anticoagulants, Corticosteroids)
*Sexual hx and LMP
*Self-neglect
*GI Hx
*GU (genito-urinary) Hx
*Gynae Hx
*Appendectomy
*Overseas travel

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Name non-GI conditions that could present as GI Sx

UTI
Nephritis, kidney stones, kidney injury
Ectopic pregnancy
Polycystic ovaries
ACS
Low PE
Hormonal imbalance
Diabetes
Thyroid issues
MS
Parkinson’s
Anxiety
Stress
FND

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Name chronic GI conditions

IBS
inflammatory bowel syndromes (ulcerative colitis and Crohn’s disease)
gastric and duodenal ulcers
intra-abdominal malignancy

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Name some acute GI conditions

appendicitis
cholecystitis
Intestinal obstruction
gastritis
perforated peptic ulcer
gastroenteritis
pancreatitis
diverticular disease
leaking or ruptured abdominal aortic aneurysms
gynaecological disorders
Ischaemic bowel
Peritonitis
Haemorrhage

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Name and point to the 9 regions of the abdomen

(from top left to bottom right)
- Left hypochondriac
- Epigastric
- Right hypochondriac
- Left lumbar
- Umbilical
- Right lumbar
- Left iliac region
- Hypogastric (suprapubic)
- Right iliac region

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In what order do you do a physical assessment for GI sx?

Inspect
Auscultate
Percuss
Palpate

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What should you look out for when inspecting the abdominal region?

Scars
Distension
Symmetrical
Pulsating masses
Hernias
Stomas
Striae
Bruising

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What should you listen out for when auscultating the abdomen?

Absent bowel sounds
Hypoactive bowel sounds
Hyperactive bowel sounds
Bruits (vascular murmur)

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Which arteries do you listen for when auscultating the abdomen?

Aorta
Renal arteries
Iliac arteries
Femoral arteries

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What do you look / listen out for when percussing the abdomen?

Hyper/ hypo-resonance
Organ enlargement (Liver/Spleen)
Air
Mass
Fluid

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What do you look out for when palpating the abdomen?

Light and deep palpation
Ascertain pain/tenderness (superficial, deep or rebound)
Guarding (reflex contraction of abdominal muscles)
Rigidity (hard and inflexible)
Masses (don’t palpate further if pulsatile!)
Enlarged organs

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What condition could be related to the right upper quadrant of the abdomen?

Acute cholecystitis
Duodenal ulcer
Hepatitis
Congestive hepatomegaly
Appendicitis
Pneumonia

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What condition could be related to the epigastric region of the abdomen?

Pancreatitis
MI
Peptic ulcer
Acute cholecystitis
Perforated oesophagus

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What condition could be related to the left upper quadrant of the abdomen?

Ruptured spleen
Gastric ulcer
Aortic aneurysm (AAA)
Perforated colon
Pyelonephritis
Pneumonia

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What condition could be related to the right lower quadrant of the abdomen?

Appendicitis
Salpingitis
Tubo-ovarian abscess
Ruptured ectopic
Pregnancy
Renal / ureteric stone
strangulated hernia
Mesenteric adenitis
Meckel’s diverticulitis
Crohn’s disease
Perforated caecum
Psoas abscess

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What condition could be related to the umbilical region of the abdomen?

Intestinal obstruction
Acute pancreatitis
early appendicitis
Mesenteric thrombosis
Aortic aneurism
Diverticulitis

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What condition could be related to the left lower quadrant of the abdomen?

Sigmoid diverticulitis
Salpingitis
Tubo-ovarian abscess
Ruptured ectopic
Pregnancy
Strangulated hernia
Perforated colon
Crohn’s disease
Ulcerative colitis
Renal / ureteric stone

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What is appendicitis?

Inflammation of the appendix

How does appendicitis develop?

Infection/obstruction blocks the appendix
Mucus outflow blocked
Appendix distends
Pressure builds until rupture
Infection into the abdominal cavity

Name signs and symptoms of appendicitis

Umbilical pain shifting to RLQ, but can be in the flank
Low grade fever
Nausea and vomiting
Diarrhoea / constipation
Rovsing and Psoas sign

Name the risk factors of appendicitis

Not clearly understood
More prevalent in men
More prevalent between puberty and age 25
Still have an appendix
Very young and elderly are more likely to suffer misdiagnosis and perforation (difficulty in communication)

What is the pre-hospital treatment for appendicitis?

Pain relief:
* Paracetamol (PO/IV)
* Morphine (PO/IV/IM)
* Entonox (INH) – Contraindicated with obstruction
* Distraction
Anti-emetic :
* Metoclopromide (IV/IM) – Contra-indicated with GI obstruction
* Ondansetron (IV/IM)
Pathway:
* Transfer to hospital
* CABCDE, ATMIST

How is suspected appendicitis treated in hospital?

Further Tests:
* Blood test for signs of infection
* Pregnancy test (Ectopic pregnancy)
* Urine test (UTI)
* Ultrasound (Distension of the appendix)
* CT
* Laparoscopy Treatment:
* Appendectomy

What is acute cholecystitis?

Inflammation of the gall bladder. Usually precipitated by a gallstone blocking the cystic duct and the bladder distending (similar to appendicitis)

How does acute cholecystitis develop?

- Gallstone (hardened collections of bile) forms - Lodges in duct and blocks flow of bile - Gallbladder inflames and distends - Oedema of gallbladder or cystic duct - Oedema further obstructs bile and irritates gallbladder - Cells of gallbladder becoming ischaemic and then infarct as the distended organ presses on vessels and impedes blood flow - Gallbladder can then adhere to surrounding structures

Name signs and symptoms of acute cholecystitis

* RUQ Pain * Worse after eating meals that are rich in fat (may wake the pt) * Nausea and vomiting * Low grade fever * Murphy’s Sign (when a patient stops breathing due to pain when examiner palpates inflamed gallbladder)

Name risk factors for Acute cholecystitis

* Middle age * Obesity * High cholesterol * High levels of oestrogen (contraceptives, HRT, pregnancy) * Diabetes * Liver disease * Pancreatitis

What is the pre-hospital treatment for acute cholecystitis?

Pain relief: * Paracetamol (PO/IV) * Morphine (PO/IV/IM) * Entonox (INH) – Contraindicated with obstruction * Distraction Anti-emetic : * Metoclopromide (IV/IM) – Contra-indicated with GI obstruction * Ondansetron (IV/IM) Pathway: * Transfer to hospital * CABCDE, ATMIST

How is suspected acute cholecystitis treated in hospital?

Further Tests: * Blood test (Signs of inflammation) * Ultrasound (gallstones) Treatment: * Cholecystectomy (Removal of gallbladder) * Catheter into bile duct * Removal of stones * Dissolution of stones (chemical/ultrasonic)

What is a bowel obstruction?

Blockage in the small or large intestine

What can cause a bowel obstruction?

* Adhesions or scar tissue * Foreign bodies * Impacted stool * Herniation * Intussusception (telescoping of one segment of bowel into another) * Tumours

Name signs and symptoms of bowel obstruction

* Distension * faecal vomit * absent/tinkling bowel sounds * absence of flatus or faeces

What is the pre-hospital treatment for a bowel obstruction?

Pain relief: * Paracetamol (PO/IV) * Morphine (PO/IV/IM) * Distraction Anti-emetic : * Ondansetron (IV/IM) Pathway: * Transfer to hospital * CABCDE, ATMIST

What are some common causes of an acute upper GI bleed?

* Peptic ulcers (Ulcer in the stomach) * Oesophageal varices (see next slide) * Gastritis (Inflammation of the stomach) * Oesophagitis (Inflammation of the oesophagus) * Mallory–Weiss tears (Tear of lower oesophagus – from coughing or vomiting) * Caustic poison * Tumour

What is portal hypertension?

Elevated BP in the portal vein, usually a result of cirrhosis (scarring of the liver), caused by blockage in blood flow to the liver

What are Oesophageal Varices?

Oesophageal varices are dilated collateral blood vessels that develop as a complication of portal hypertension

Name risk factors for acute upper GI haemorrhage

* Over 65 * Aspirin * NSAIDs * Corticosteroids * Anticoagulants * Alcohol * Smoking

Define Haematemesis

Blood in the vomit (‘Coffee ground’ or fresh appearance)

Define Melaena

Digested blood in the stool. Black tarry presentation with a very offensive smell.

Name common causes of acute lower GI tract haemorrhage

* Diverticular disease * Inflammatory bowel disease (IBS) - rare * Haemorrhoids * Tumour

Name risk factors for an acute lower GI haemorrhage

* Male * Aspirin or NSAID use * Older age

What does PR stand for in the context of lower GI haemorrhages?

Per Rectum

What should you be suspicious of when faced with a patient with indigestion type pain or upper abdo pain?

Cardiac involvement, especially in older patients with cardiac hx

What should you be suspicious of when faced with a biological female with lower abdominal pain, especially if one sided?

Ectopic pregnancy