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.
abdominal inspection
look for bruising, pulsating masses, shape of abdomen, scars
abdominal auscultation
normal bowel sounds 5-35/min
listen for bruits
best indicator for peristalsis is flatus
abdominal percussion
liver, splenic borders
liver edge soft, distinct, even with right costal margin
normal sounds: tympany over hollow organs, dullness over solid organs
abdominal palpation
assess rigidity, guarding, pain, masses, hernia
tenderness - pain upon pressure
rebound tenderness - pain upon removal of pressure
palpate painful quadrant last
patient position indicating abdominal emergencies
movement less likely to indicate serious etiology
rigidly still or fetal position classic sign of peritonitis
sx with abdominal pain suggestive of surgical or emergent conditions
fever
protracted vomiting
syncope or pre-syncope
evidence of GI blood loss
define GERD
reflux of gastric contents into esophagus, causing sx
define esophagitis
inflammation of esophagus, often 2ndary to long-term GERD
causes of esophagitis
long-term GERD
infection
radiation
ingestion of caustic substances
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
complications of GERD/esophagitis
sore throat, hoarse throat
nausea, anorexia, weight loss
occasional vomiting
cholingergics for GERD/esophagitis
increases lower esophageal sphincter pressure, facilitates gastric emptying
types of cholinergics for GERD/esophagitis
bethanechol
dopamine antagonist for GERD/esophagitis
moves food through GI system more quickly
types of dopamine antagonist for GERD/esophagitis
metoclopramide
antacids for GERD/esophagitis
neutralizes acids in stomach
types of antacids for GERD/esophagitis
calcium carbonate
histamine (H2) receptor antagonists for GERD/esophagitis
blocks acid production
types of histamine (H2) receptor antagonists for GERD/esophagitis
ranitidine
proton pump inhibitors for GERD/esophagitis
inhibits acid pumps in stomach
types of proton pump inhibitors for GERD/esophagitis
lansoprazole
acid protective agents for GERD/esophagitis
provides thick protective coating over lower esophagus and stomach
types of acid protective agents for GERD/esophagitis
sucralfate
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
most common causes of non-variceal upper GI bleeding
duodenal/gastric ulcers gastric erosions Mallory-Weiss tears esophagitis frequent NSAIDs presence of varices
sx upper GI bleed
hematemesis/melena
weakness, dizziness, syncope
postural hypotension
sx hypovolemic shock
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
labs with upper GI bleeds
BUN increases, creatinine remains same d/t breakdown of blood cells
if both elevate, suspect renal disease as cause
define peptic ulcer disease
disruption of protective mucosal barriers and increased acid secretion
contributing factors to peptic ulcers
NSAID
H. pylori
types of peptic ulcers
duodenal
gastric
stress
duodenal ulcers
age 30-55
pain before eating
pain relieved with eating, antacids
heals spontaneously
gastric ulcers
age 55-70
pain after eating
weight loss
chronic
stress ulcers
usually ischemic stress d/t prolonged physical stress such as illness, trauma, neural injury
more ICU than ED
interventions for peptic ulcers
H2 blockers or PPIs
stop NSAIDs
abx for H pylor
-clarithromycin and amoxicillin
define GERD
reflux of gastric contents into esophagus, causing sx
define esophagitis
inflammation of esophagus, often 2ndary to long-term GERD
causes of esophagitis
long-term GERD
infection
radiation
ingestion of caustic substances
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
complications of GERD/esophagitis
sore throat, hoarse throat
nausea, anorexia, weight loss
occasional vomiting
cholingergics for GERD/esophagitis
increases lower esophageal sphincter pressure, facilitates gastric emptying
types of cholinergics for GERD/esophagitis
bethanechol
dopamine antagonist for GERD/esophagitis
moves food through GI system more quickly
types of dopamine antagonist for GERD/esophagitis
metoclopramide
antacids for GERD/esophagitis
neutralizes acids in stomach
types of antacids for GERD/esophagitis
calcium carbonate
histamine (H2) receptor antagonists for GERD/esophagitis
blocks acid production
types of histamine (H2) receptor antagonists for GERD/esophagitis
ranitidine
proton pump inhibitors for GERD/esophagitis
inhibits acid pumps in stomach
types of proton pump inhibitors for GERD/esophagitis
lansoprazole
disposition for pediatric V/D
mild-moderate:
- dc with oral replacement therapy and when to return
- PCP in 1-2 days
severe: admission
types of acid protective agents for GERD/esophagitis
sucralfate
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
most common causes of non-variceal upper GI bleeding
duodenal/gastric ulcers gastric erosions Mallory-Weiss tears esophagitis frequent NSAIDs presence of varices
sx upper GI bleed
hematemesis/melena
weakness, dizziness, syncope
postural hypotension
sx hypovolemic shock
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
labs with upper GI bleeds
BUN increases, creatinine remains same d/t breakdown of blood cells
if both elevate, suspect renal disease as cause
define peptic ulcer disease
disruption of protective mucosal barriers and increased acid secretion
contributing factors to peptic ulcers
NSAID
H. pylori
types of peptic ulcers
duodenal
gastric
stress
duodenal ulcers
age 30-55
pain before eating
pain relieved with eating, antacids
heals spontaneously
gastric ulcers
age 55-70
pain after eating
weight loss
chronic
types of gastric tubes for esophageal varices
Sengstaken-Blakemore tube
Minnesota tube
Linton-Nicholas tube
all w/ similar functions
interventions for peptic ulcers
H2 blockers or PPIs
stop NSAIDs
abx for H pylor
-clarithromycin and amoxicillin
define lower GI bleed
blood loss originating distal to ligament of Treitz
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
assess lower GI bleed
occult blood
consider CA in patients > 50 yo
sx Mallory-Weiss tears
bleeding self limiting
red/coffee ground hematemesis
red, bloody stool (hematochezia)
infectious causes of acute gastroenteritis
rotavirus Norwalk virus S. dysenteriae salmonella e.coli campylobacter jejuni (bloody diarrhea and fever)
intervene for Mallory-Weiss tears
antiemetics
NG tube for occult blood test
endoscopy
avoid balloon tamponade except as a last resort
sx acute gastroenteritis
diarrhea, N/V diffuse/cramping lower abd pain fever dehydration splenomegaly - bacterial consider food, travel
complications of acute gastroenteritis
metabolic acidosis
potassium, glucose, calcium abnormalities
consider cardiac workup esp for women
pharm for acute gastroenteritis
antiemetics
anticholinergic
abx (bacterial)
corticosteroids (parasite)
dc for acute gastroenteritis
hydrate
clear fluids if watery stool
advance diet with loose stool
regular diet with partially formed stool
define pediatric vomiting and diarrhea
usually self-limiting viral gastroenteritis
infectious causes of pediatric V/D
fecal-oral or person-person
viral during winter
bacterial during summer
noninfectious causes of pediatric V/D
toxins GI bleed malabsorption syndromes bowel disorders cathartic abuse abx and other meds
sx pediatric V/D
sunken fontanels reduces LOC dry mucus membranes reduced skin turgor sunken, tearless eyes tachypnea oliguria tachycardia hypotension
intervene for pediatric V/D
oral, VI zofran
oral rehydration qh
IV hydration for moderate-severe
-isotonic crystalloid 20ml/kg
disposition for pediatric V/D
mild-moderate:
- dc with oral replacement therapy and when to return
- PCP in 1-2 days
severe: admission
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.
precautions for NG tube insertion
contraindicated w/ facial/head trauma or basilar skull fx
attending should insert w/ varices
monitor for hyponatremia if irrigating
define pyloric stenosis
hyperplasia/hypertrophy of pylorus muscle at outflow tract of stomach to duodenum, preventing stomach from emptying
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
intervene for pyloric stenosis
IV fluids K+ replacement I/O gastric tube surgery
pleural effusions in pancreatitis
pancreatic inflammation and tissue damage from pancreatic enzymes trigger inflammatory cascade, causing increased capillary permeability
sx esophageal obstruction
“something stuck”
difficulty swallowing
drooling
subcutaneous emphysema of neck if esophageal perforation has occurred
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
define esophageal varices
bleeding from distended blood vessels in esophagus and stomach, usually 2ndary to liver disease
risk factors for esophageal varices
cirrhosis
portal HTN
chronic alcohol use
intervene for esophageal varices
treat hypovolemic shock
caution with gastric tube
endoscopic procedures to stop bleeding
types of gastric tubes for esophageal varices
Sengstaken-Blakemore tube
Minnesota tube
Linton-Nicholas tube
Segstaken-Blakemore tube
emergency control for bleeding esophageal varices
diagnostic aid
oral or nasal
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
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
define Mallory-Weiss syndrome
small tears in junction of esophagus and stomach
sx Mallory-Weiss tears
bleeding self limiting
red/coffee ground hematemesis
possible hematochezia
risk factors for Mallory-Weiss tears
hx retching, vomiting following by hematemesis
alcohol, aspirin use, heavy lifting, coughing, bulimia or pregnancy
intervene for Mallory-Weiss tears
antiemetics
endoscopy
avoid balloon tamponade except as a last resort
define cholecystitis
inflammation of gallbladder
sx cholecystitis
pain, cramping, bloating, guarding, rigidity
worse after deep breath and fatty foods/large meal
fever, chills, jaundice, dar urine
Murphy sign
tips for assessing jaundice
yellow discoloration of elastic tissue such as sclera or hard palate, esp in darker-skinned patients
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.
assessing cholecystitis
CBC - leukocytosis
LFTS - elevated ALT and bili
abd US
intervene for cholecystitis
antiemetics, analgesics
NPO, gastric tube
abx, cholecystectomy
dc teaching for all hepatitis
avoid alcohol, steroids
small, frequent meals
low fat, high carbs
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
sx pediatric liver disease
usually asymptomatic
symptoms: obesity RUQ, nonspecific pain hepatomegaly fatigue
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
intervene for pancreatitis
IV calcium replacement analgesia (not morphine) decrease vagal stimulation antispasmodics antacids H2 blockers calcium gluconate (hypocalcemia) corticosteroids glucagon
why not morphine for pancreatitis?
can cause spasm in sphincter of Oddi
why glucagon in pancreatitis
decrease pancreatic inflammation, amylase, pancreatic secretions
complications of pancreatitis
hypocalcemia pleural effusions ARDS retroperitoneal bleeding pancreatic infection
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
pleural effusions in pancreatitis
pancreatic inflammation and tissue damage from pancreatic enzymes trigger inflammatory cascade, causing increased capillary permeability
ARDS in pancreatitis
inflammatory cascade causes fluid to leak into pleural space, leading to pleural effusions and fluid in the alveoli (ARDS)
retroperitoneal bleeding and hypovolemia in pancreatitis
autolysis caused by pancreatic enzymes can cause bleeding from pancreas and other abd structures
sx retroperitoneal bleeding due to pancreatitis
hypotension, tachycardia decreasing hematocrit abd distention Grey-Turner sign Cullen sign
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
other causes of Grey-Turner and Cullen sign
bleeding d/t abd trauma
aortic rupture
ruptured ectopic
interventions for UC or Crohn’s disease
lifestyle changes analgesia, antipyretics IV fluids anticholinergics antidiarrheal anti inflammatories antimicrobials corticosteroids immunosuppressant
sx pancreatic infection
worsening fever
increasing abd pain
sepsis
hepatitis A
fecal-oral exposure can cause epidemic
vaccination
hepatitis B
parenteral, sexual, occupational, human bite exposure
acute or chronic
vaccination
hepatitis C
parenteral, sexual, occupational, human bite exposure
50% chronic, may be asymptomatic at first
hepatitis D
needs Hep B to duplicate and survive
hepatitis E
enteric (contaminated food, water) from fecal matter
rare in US
sx mild hepatitis
malaise fatigue anorexia N/V RUQ pain joint pain generalized edema ascites
sx severe hepatitis
jaundice clay-colored stool steatorrhea dark-colored, foamy urine generalied edema ascites
labs in hepatitis
increased ammonia, bili, LFTs, PT, PTT
decreased urea, albumin, Ca
intervene for hepatitis
lactulose
remove peritoneal fluid
replace albumin, vit K
meds for severe or chronic hepatitis
interferon
ribavirin
intervene for intestinal obstructions
NPO, NG tube barium enema (intussusception) surgery: -volvulus -pyloric stenosis -perforation
dc teaching for hepatitis B,C,D
do not donate blood or tissue
safe sex
do not share personal items
dc teaching for all hepatitis
avoid alcohol, steroids
small, frequent meals
low fat, high carbs
pediatric considerations in liver disease
obesity most common cause
nonalcoholic fatty liver disease occurs in 38% of obese children
also cholelithiasis
sx pediatric liver disease
usually asymptomatic
symptoms: obesity RUQ, nonspecific pain hepatomegaly fatigue
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
pediatric considerations for appendicitis
most common cause of abdominal pain in children
rare in children under 2 yo
early sx pancreatitis
dull, steady, periumbilical pain
anorexia, nausea
mild fever
later sx pancreatitis
12-48 hours
RLQ pain
flexing knees may help
rebound tenderness
what is rebound tenderness a sign of?
sign of peritoneal irritation aka peritonitis
pregnancy considerations in appendicitis
pain may be in RUQ instead of RLQ due to uterus pushing appendix upward
labs in appendicitis
CBC - leukocytosis
intervene for appendicitis
NPO, serial abd exams
surgery
define ulcerative colitis
chronic inflammatory disease affecting only large intestine, usually sigmoid and rectal areas
affects mucosal and submucosal layers
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
complications of UC or Crohn’s disease
fistulas (Crohn's) intestinal obstructions malnutrition bowel perf toxic megacolon
toxic megacolon
severe dilation of bowel associated with colitis
interventions for UC or Crohn’s disease
lifestyle changes analgesia, antipyretics IV fluids anticholinergics antidiarrheal anti inflammatories antimicrobials corticosteroids immunosuppressant
causes of intestinal obstructions
physical
nervous system disorders
inflammatory conditions
physical intestinal obstructions
fecal impaction
hernia
intussusception
volvulus
nervous system intestinal obstructions
paralytic ileus
inflammatory intestinal obstructions
abscess
inflammatory bowel disease
onset of intestinal obstructions
small: rapid
large: gradual
vomiting in intestinal obstructions
small: frequent, copious (bile and feces)
large: rate
pain in intestinal obstructions
small: colicky, cramp-like, intermittent, wave-like pain
large: low grade, cramping
bowel movements in intestinal obstructions
small: BMs early, constipation late
large: absolute constipation
abd distention in intestinal obstructions
small: minimally increased
large: greatly increased
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)
complications of intestinal obstructions
dehydration
electrolyte imbalances
bowel ischemia
ruptured bowel
intervene for intestinal obstructions
NPO, NG tube barium enema (intussusception) surgery: -volvulus -pyloric stenosis -perforation
define intussusception
telescoping of one segment of bowel into another
who does intussusception affect?
commonly children 3 mo to 5 years
usually 6 mo
males > females
causes of intussusception
after viral infection
polyps
hyperactive peristalsis
abnormal bowel lining
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
assessing intussusception
barium or air enema can be diagnostic
define volvulus
strangulation of superior mesenteric artery and bowel infarction d/t abnormal bowel rotation with mesenteric attachment
volvulus overview
usually first month of life
congenital
intermittent volvulus can occur (also in adults)
sx volvulus
bilious vomiting abd pain and distention bloody stools hematemesis visible peristaltic waves peritoneal signs if perforation
define diverticula
outpouching of colon
define diverticulitis
inflammation of diverticula of colon - usually sigmoid
define diverticulosis
presence of noninflamed diverticula
sx diverticulitis
generalized, abrupt onset of aching, cramping pain local to LLQ
anorexia, N/V
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
define peritonitis
inflammation of peritoneum
primary peritonitis
blood-borne organisms enter peritoneal cavity
secondary peritonitis
abd organs perforate and release contents into peritoneal cavity (more common than primary)
causes of peritonitis
ruptured appendix
pancreatitis
penetrating trauma
peritoneal dialysis
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
