GI Emergencies Flashcards
What are common manifestations of GI emergencies?
-Abdominal pain
-Anorexia
-Nausea
-Vomiting
-Diarrhea
-Constipation
What is anorexia?
-Decreased appetite
-Many factors can stimulate hunger (regulated by the hypothalamus) and many things can cause anorexia (fear, depression, disease, drugs)
What is referred pain?
Perceived pain at a site different from its point of origin but innervated by the same spinal segment
What is hematemesis?
-Blood in emesis
-Can be bright red (fresh) or dark and appear like coffee grounds (older)
What is melena?
Black, tarry stool associated with upper GI tract hemorrhage
What questions are important to ask regarding GI complaints?
-Bowel movements (regularity, quality, consistency)
-Urinary habits (frequency, pain, odorous, consistency)
-Pain (OPQRST, isolate area - pinpoint vs vague)
-Nausea, vomiting, anorexia
-Change in diet, exercise, or medication
-Chronic complaint, flareups, compare
-Females - OBS questions
What is esophageal varices?
-Common complication of portal hypertension and liver cirrhosis
-Almost always associated with alcoholism
-Thin-walled veins that have become very superficial in the submucosa of the esophagus
-They are very prone to rupture and can cause catastrophic hemorrhage and airway
compromise
What is esophagitis?
-Inflammation of the esophagus
-Caused by reflux of stomach contents, infectious process, food allergies, medications or medical procedures
-Most common cause is GERD
-Can produce difficulty swallowing and chest discomfort
What is Gastroesophageal Reflux?
-The backward movement of gastric contents into the esophagus
-Probably the most common GI disorder
-Produces heartburn and regurgitation
-Lower esophageal sphincter typically prevents reflux of gastric contents
-Many stimuli can cause relaxation of the LES including gastric distension and fatty meals
What is Gastroesophageal Reflux Disease (GERD)?
-A more serious and long lasting form of GER
-Symptoms of mucosal damage produced by chronic abnormal reflux of gastric contents into the esophagus
-Commonly occurs 30-60 minutes after eating and can be made worse by bending at the
waist and lying supine. May also be nocturnal.
-Symptoms may include: excessive gas (burping) and chest pain (often epigastric or retrosternal that radiates up the throat) that is often described as burning
What is gastritis?
-Inflammation of the gastric mucosa - acute or chronic
-Acute - acute mucosal inflammatory process often associated with emesis, pain and
occasionally hemorrhage and ulcers
-Can be caused by overuse of alcohol, NSAIDs or bacterial toxins
-Chronic - visible erosions and chronic inflammatory changes leading to the eventual
atrophy of the glandular epithelium of the stomach
-Can be caused by a bacterium (H. pylori), autoimmune disorder or reflux of duodenal
contents into the stomach
What is peptic ulcer disease?
-Group of ulcerative disorders that occur in areas of the upper GI tract that are exposed to acid-pepsin secretions
-A peptic ulcer may penetrate one or all layers of the stomach and may occasionally penetrate the outer wall of the stomach or duodenum
-Healing of the muscular layer may produce scar tissue and regeneration of the covering tissues becomes more prone to repeat ulcers
What is an ulcer?
an excavation of the surface of an organ or tissue, which results from necrosis that accompanies some inflammatory or infectious process
What are the clinical manifestations of peptic ulcer disease?
-Epigastric pain (burning, cramping) on an empty stomach - uncomplicated peptic ulcer
-Hemorrhage - disruption of healing tissue or ulceration into a vein or artery
-Significant and life threatening hemorrhage may occur and present as hematemesis or melena
-Perforations - ulceration erodes through all layers of the stomach or duodenum allowing for a leakage of gastric contents into the peritoneum causing peritonitis - sepsis may occur!
What are symptoms of an upper GI bleed?
-Hematemesis - bright red coloring indicates fresh blood vs. Dark black/brown “coffee grounds” emesis indicates blood that has coagulated and reacted with the stomach acid (not fresh)
-Melena - black tarry stool - blood becomes darker because it gets “digested” in the intestines before becoming feces
What are symptoms of a lower GI bleed?
Bright red or clotted blood in stool. Occasionally melena.
What is an intestinal/bowel obstruction?
Any blockage of the lower GI tract preventing the passage of food/stool
What are the mechanical causes of a bowel obstruction?
Impacted stool, Stricture, Intussusception, Volvulus, Inguinal Hernia
What is impacted stool?
Retention of hardened or putty like stool in the rectum and colon
What is stricture?
An abnormal temporary or permanent narrowing of the lumen or a duct, canal or passage
What is intussusception?
Intussusception - telescoping of the bowel into the adjacent section. More common in young children
What is a volvulus?
Complete twisting of the bowel
What is an Inguinal Hernia?
intestine, peritoneum and other abdominal tissues protrude into the scrotum
What are the paralytic causes of a bowel obstruction?
-Neurogenic or muscular impairment of peristalsis
-Postoperative, inflammatory bowel diseases, back/spinal injuries
What are the clinical manifestations of a bowel obstruction?
-Abdominal distension/pain (can be severe) - stagnant contents and gases
-Strangulation of the bowel - interrupted blood flow (severely painful)
-Bowel perforation - contents cause extensive inflammation and sepsis
What is inflammatory bowel disease?
Refers to two related inflammatory intestinal disorders:
-Crohn’s Disease
-Ulcerative Colitis
Both diseases:
-Produce inflammation of the bowel
-Lack evidence of a proving causative agent
-Have a pattern of familiar occurrence
-Can be accompanied by systemic manifestations
What does Crohn’s effect?
commonly affects the distal small intestine and proximal colon
What does ulcerative colitis effect?
the colon and rectum
What is Crohn’s disease?
-A recurrent and exaggerated inflammatory response that can affect any area of the GI
tract (most commonly the distal small intestine and proximal colon)
-Most commonly presents itself in a patient’s early 20s or 30s
-A characteristic feature is isolated granulomatous lesions surrounded by normal appearing mucosal tissue - when the lesions are multiple, they are referred to as skip lesions
-The lesions affect all layers of the GI tract and, with multiple recurrences, may become scarred and ineffective
What are the clinical manifestations of Crohn’s disease?
-Involves period of exacerbations and remissions with symptoms being related to the location of the lesions
-Symptoms include: diarrhea, abdominal pain, weight loss, fluid and electrolyte imbalance, malaise, occasional fevers
-The absorption of the affected lesions becomes disrupted and nutritional deficiencies are common
-Common complications include: fistulas (alternate pathway), abscess formation, intestinal obstruction and surgical removal of bowel segments
How is Crohn’s disease treated?
-Treatment is targeted at reducing inflammation, promoting healing, maintaining adequate nutrition and treating acute complications as they arise
-Surgical resection of damaged bowel, drainage of abscesses or repairing fistulas are commo
What is ulcerative colitis?
-A nonspecific inflammatory condition of the colon
-Inflammation is limited to the mucosa and submucosa and is generally isolated to the colon and rectum
-The disease typically starts in the rectum and spreads proximally
-Unlike Crohn’s, the disease tends to be continuous instead of skipping areas
-The inflamed areas often develop pinpoint mucosal hemorrhages which fester and
develop into abscesses
-Ulcers often develop tongue-like projections similar to polyps (pseudopolyps)
-The bowel wall thickens over time due to repeated episodes of colitis and results in a
loss of flexibility and function
What are the clinical manifestations of ulcerative colitis?
-Typically presents as relapses marked by episodes of diarrhea which may persist for
days, weeks or even months
-The remission periods may last for months to years
-Due to the affected location (mucosal layers) the stool often contains mucous and blood
-Mild abdominal cramping, anorexia and weakness are also common
-Other symptoms and comorbidities vary with the severity of the disease
What is diverticulosis?
-A diverticulum is an out-pouching of a hollow structure in the body.
-Diverticulosis is the condition of having diverticula in the colon that are not inflamed
-Most commonly affects the distal descending and sigmoid colon
-Most cases of diverticulosis are asymptomatic and aproblematic however abdominal
What is diverticulitis?
-Diverticulitis is a complication of diverticulosis in which there is inflammation and/or perforation of the diverticulum
Clinical Manifestations:
-Pain and tenderness (usually LLQ)
-Nausea, vomiting, fever (+/-)
Serious Complications include:
-Perforation of diverticula with peritonitis
-Abscess, hemorrhage
-Bowel obstruction
What is gangrene?
localized death and decomposition of body tissue, resulting from obstructed circulation or bacterial infection
What is appendicitis?
-Acute inflammation of the appendix - can become swollen, gangrenous and often perforates if
not treated promptly
-Usually caused by intraluminal obstruction with feces, gallstones, tumors, parasites or lymphatic tissue
-Onset of appendicitis is usually very abrupt and must be treated quickly
-Perforation of the appendix can be a serious complication resulting in significant peritonitis
and sepsis
What are the clinical manifestations of appendicitis?
-Initially vague epigastric or periumbilical pain (referred) that progresses to severe over 2-12 hours - pain is often colicky (intermittent/waves)
-Once pain and inflammation has worsened, the pain usually involves the LRQ
-Nausea, pallor, diaphoresis, and fever (+/-)
-Rebound tenderness is a common telltale sign
-Pain when pressure is removed rather than applied
What is gastroenteritis?
-Inflammation of the stomach and intestinal lining, commonly referred to as the “stomach flu”
-May be viral, bacterial or parasitic - most common cause is norovirus
-Symptoms include: Fever, Abdominal cramping, Nausea, Vomiting, Diarrhea
-Treatment is targeted at fluid and nutrient replenishment and waiting for the pathogen to run its course
What is cholelithiasis/gallstones?
-Precipitation of substances contained in bile (mainly cholesterol and bilirubin)
-Contributing factors include: Increased cholesterol, stasis of bile, women on oral contraceptives
-Stones get lodged in the common bile duct and produce indigestion, biliary colic (URQ or
epigastric pain) and jaundice due to the buildup of bilirubin - may have referred pain to the upper right back/shoulder
-Symptoms usually follow a large, fatty meal
-Nausea and vomiting also typically associated
What is cholecystitis?
- Diffuse inflammation of the gallbladder usually secondary to obstruction of the flow of bile
-Most commonly caused by gallstones but can also be due to sepsis, trauma or infection of the gallbladder
-Can be acute or chronic (recurring episodes of gallstones and cholecystitis) leading to varying
degrees of chronic inflammation and decreased function
What are the clinical manifestations of cholecystitis?
-URQ/Epigastric pain
-Fever
-Anorexia
-Jaundice
-Nausea
-Vomiting
What is acute pancreatitis?
-A reversible inflammatory process of the pancreatic acini caused by premature activation
of pancreatic enzymes
-Pancreatic enzymes are released in their inactive forms and become activated once they reach the duodenum
-Inflammation and autodigestion can spread beyond the pancreas resulting in a systemic
inflammatory response syndrome (SIRS) and subsequent sepsis
-Commonly caused by gallstones and alcohol
What are the clinical manifestations of acute pancreatitis?
-Epigastric or periumbilical pain that may radiate to the back, chest or flank
-Fever (+/-), tachycardia, abdominal tenderness/distension, hypotension/respiratory
distress (severe cases)
-Fluid shifting into the retroperitoneal cavity
-May result in hyperglycemia (more common in chronic pancreatitis)
What is chronic pancreatitis?
-Characterized by progressive destruction of the exocrine pancreas.
-May progress to complete destruction of the exocrine cells
-Similar factors that cause acute pancreatitis by the main difference is chronic pancreatitis creates irreversible damage
-The main cause of chronic pancreatitis involves alcoholism
What are the clinical manifestations of chronic pancreatitis?
-Persistent and recurrent episodes
of epigastric/LUQ pain precipitated by alcohol abuse and overeating
-May eventually cause diabetes
What is cirrhosis?
-End-stage chronic liver disease in which much of the functional liver tissue has been replaced with fibrous tissue
-Most commonly associated with alcoholism
-The fibrous tissue can disrupt blood flow and biliary ducts
-The disruption of blood flow often leads to portal hypertension and all of its complications
-The obstruction of biliary ducts leads to bile stasis, destruction of hepatocytes and eventually liver failure
What are the clinical manifestations of cirrhosis?
-Manifestations are variable depending on the severity and spread of the fibrous tissue -symptoms don’t usually arise until the disease is advanced
-Hepatomegaly - abnormal enlargement of the liver (may be asymptomatic or produce
abdominal pain - URQ/epigastric)
-Weight loss, weakness, anorexia, jaundice
-Diarrhea or constipation (abnormal bowel activity)
-Late complications - splenomegaly, ascites, portosystemic shunts, bleeding (decreased
clotting factors), thrombocytopenia, gynecomastia (testosterone atrophy), spider angiomas, palmar erythema, encephalopathy
What is portal venous blood flow?
Venous blood from the abdominal organs travels through the liver, via the portal vein, before entering the vena cava
What is portal hypertension?
increased resistance to blood flow in the portal venous system and sustained portal vein pressure
What is pre-hepatic portal hypertension?
obstruction of the portal vein before it enters the liver (thrombosis, tumours, trauma)
What is post-hepatic portal hypertension?
any obstruction to blood flow through the hepatic veins beyond the liver (thrombosis, right sided heart failure)
What is intra-hepatic portal hypertension?
obstruction of blood flow within the liver (fibrous tissue distorts the liver architecture and increases resistance to flow)
What are the complications of portal hypertension?
ascites, splenomegaly, hepatic encephalopathy, and portosystemic shunt
What is ascites?
excessive fluid build up in the peritoneal cavity due to liver damage and/or portal hypertension
What is splenomegaly?
-progressive enlargement of the spleen caused by the shunting (backflow) of blood into the splenic vein
-This leads to decreased levels of all formed elements and diminished lymphatic immunity
What are portosystemic shunts?
-collateral channels open up between the portal vein and systemic circulation
-involved in hemorrhoids, esophageal varices, caput medusae (dilated veins around the umbilicus)
What is liver failure?
-Occurs when 80-90% of hepatic functional capacity is lost
-Typically by the time this occurs, the patient has developed a plethora of other associated
comorbidities (sepsis, electrolyte imbalances, GI bleeds/obstructions, heart disease/failure
What are the clinical manifestations of liver failure?
-Anemia
-Thrombocytopenia (low platelet count)
-Coagulation defects (decreased clotting factors)
-Leukopenia
-Menstrual irregularities
-Loss of libido
-Atrophy of the testes
-Gynecomastia
-Spider angiomas
-Palmar erythema (red palms)
-Hepatorenal syndrome (renal failure caused by liver failure)
-Hepatic Encephalopathy - various nervous system complications caused by liver failure -
decreased LOA, convulsions, coma, various personality changes, axterixis - “flapping”
tremor in the hands
What are spider angiomas?
tiny red superficial blood vessels - related to hormone metabolism
What is liver cancer?
-The two main types: liver tumours and cancer of the bile ducts
-Symptoms may be insidious at onset (malaise, indigestion, loose stools, abdominal discomfort) and eventually progress to any number of liver and gallbladder related symptoms
-Primary liver cancer is when the cancer originates in the liver, when it has spread from another source it is referred to as secondary liver cancer
or liver metastasis
What is an aneurysm?
an abnormal localized dilation of a blood vessel
What is an abdominal aortic aneurysm (AAA)?
commonly found below the level of the renal artery. A pulsating mass may be palpated
in some circumstances, but they usually aren’t detected until rupture
What is a ruptured AAA?
- a significant life threat with a high mortality rate
-characterized by excruciating abdominal pain (may be described as tearing), restlessness, pallor, diaphoresis, tachycardia, and hypotension
What is hepatitis?
-Inflammation of the liver primarily caused by a viral infection
-May also be caused by an autoimmune mechanism, reaction to drugs/toxins, secondary to
another disorder
What are the known hepatotropic viruses (causing viral hepatitis)?
-Hepatitis A
-Hepatitis B
-Hepatitis B-D
-Hepatitis C
-Hepatitis E
-All of these viruses cause viral hepatitis, but they differ in their mode of transmission, incubation period, liver damage, and ability to evolve
What are the two mechanisms of liver injury?
direct cellular injury and induction of immune
response against viral antigens
What are the clinical manifestations of hepatitis?
Early:
-General malaise
-Myalgia (muscle aches)
-Arthralgia (joint pain)
-Fatigue
-Anorexia
-Nausea
-Vomiting
-Diarrhea
-Fever
7-14 days:
-URQ tenderness
-Mild weight loss
-Spider angiomas
-Jaundice
What is Hep A?
-Usually benign and self-limiting but rarely can be fatal
-Transmitted by the fecal-oral route but can also be contaminated in food
-Immunization exists
What is Hep B?
-Can produce any severity level of the disease
-Transmitted in bodily fluids including blood
-Common amongst IV drug users and during unprotected sex
-Immunization exists
What is Hep C?
-Often results in chronic hepatitis and eventual liver failure
-Blood borne transmission and unprotected sex
-No immunization exists
What is Hep D?
-Can cause acute or chronic hepatitis
-Transmitted in bodily fluid
-No vaccine, however, HepB vaccine strongly protects against D
What is Hep E?
-Typically benign and self-limiting, similar to HepA
-Fecal-oral transmission. No vaccine
What is chronic hepatitis?
-Defined as a chronic inflammatory reaction of the liver of more than 3- 6 months
-Principal cause of chronic liver disease, cirrhosis and hepatocellular cancer
-Caused by B, C and D with C being the most common cause
