Module 24- GI Assessment and Treatment Flashcards
Symptoms of GI Tract Diseases
- Pain
- Vomiting and/ or diarrhea
- Bleeding
- Alterations in bowel habits
- Alterations of liver or pancreatic function
What patient history should you obtain when your pt obtains abdominal pain?
- Nature
- Time course
- Location
- Aggravating and relieving factors
- Referred pain- due to autonomic nervous system pain nerves arising from a large area
- Appendicitis
- Peritonitis
Fluid losses- dehydration
- Vomiting, diarrhea, poor oral intake, or malabsorption
- Tachycardia
- Hypotension heralds severe dehydration
- Can be mild or life threatening
GI Bleeding
- GI tract has generous blood supply to ensure nutrient absorption but make it vulnerable to severe hemorrhage
- Hypovolemia
- Since blood loss from GI tract can not be controlled by pressure dressing, GI bleeding can be fatal
Location can be determined by presentation
- Vomiting of blood or a material that resembles coffee ground
- Upper GI
Melena
- Upper GI
Peptic ulcers, diverticular disease, cancer
- Present with bleeding from the rectum
Crohn’s disease or ulcerative colitis
- May develop bleeding ulcers of the intestines
- Usually have additional systems
- Pain, fever
Trauma
- Not common mechanisms for GI bleeding
What are the alterations in bowel habits?
- Contaminated food
- Constipation
- Bowel obstruction
Contaminated food
- Food contains bacteria, viruses, and fungi
- Most destroyed through cooking or pasteurization of food
- Organisms that remain are usually killed by stomach acid and digestive juices
- Bypass the immune system which can lead to gastrointestinal infection
- One sixth of the Canadian population each year are infected
- Deaths are rare
Constipation
- Common complaint
- Associated with severe pain and discomfort
- Can occur from medications
- Decreased activity
- Acute or chronic
- Able to still pass gas
- No vomiting
Bowel Obstruction
- Failure to peristalsis
- Due to diseases, systemic illness, medications or blockage
- Common reason is when intestines become twisted or entrapped
- Twisting can occur in patients who have scar tissue from previous surgery or hernias
- Can occur from structures that narrow the pathway
- Present with crampy, poorly localized abdominal pain
- Absence of stool and gas
- Sometimes vomiting
Altered Organ Function
- May be difficult to distinguish the organ without specific testing or imaging unless specific signs are present
Liver failure
- Once at advanced stage pt’s develop yellow skin and sclerae from jaundice
- Altered mental status from buildup of bilirubin, ammonia, and other toxins
Cirrhosis- chronic liver failure
- Distended abdomen
- Blood backs up in the GI organs and fluid accumulates in the abdomen
Esophageal Varices
- Pressure increases within the blood vessels of the distal esophagus portal hypertension
What are causes of esophageal varices?
- Liver damage
- Cirrhosis
- Alcohol (industrialized countries)
- Viral hepatitis (developing countries)
- Upper GI bleeding
- Chronic alcohol consumption damages and scars the interior of liver leading to slower blood flow and higher venous pressure
Mallory-Weiss Syndrome
- May lead to severe hemorrhage
- Affect men and women equally
- More prevalent in older adults and older children
What are causes of mallory-weiss syndrome?
- Esophageal lining tears during severe vomiting
- Boerhaave syndrome- rupture of esophagus
- Pneumothorax- spillage of gastric contents
- Sepsis
Hemorrhoids
- Swelling and inflammation of blood vessels surrounding the rectum
- Common problem
- Increased pressure on the rectum
- Irritation of the rectum
What are possible causes of hemorrhoids?
- Pregnancy
- Straining at stool
- Chronic constipation
- Anal intercourse
- Diarrhea
Peptic Ulcer Disease
- High levels of acidity
- In the stomach and duodenum
- Protective layer is eroded, allowing the acid to eat into the organ
What are some causes of peptic ulcer disease?
-In the past, thought to be the types of food that people were eating
- Variety of etiologies
- Majority are a result of infection of the stomach
- H-pylori bacteria
- Chronic use of NSAIDS- inhibits enzyme that protects the stomach lining and controls bleeding
- Alcohol and smoking can affect the severity
What is Cholecystitis caused by?
- Obstruction of the cystic duct leading from the gallbladder to the duodenum, usually by gallstones
How are gallstones formed?
Gallstones are formed by either increased production of bile or decreased emptying of the gallbladder
Gallbladder
- Stores bile
- If blockage is present, the patient may experience severe pain
What is positive Murphy sign?
- Have patient breather deeply while pressing deeply on the RUQ near costal margin
- If the patient stops the inspiration suddenly due to pain-positive Murphy’s sign
What are the s/s of cholecystitis?
- Fever
- Jaundice
- Tachycardia
Risk Factors of cholecystitis
- females
- older people
- Caucasians
- Overweight or recent extreme weight loss
- Classic patient: fair, obese, female, and 50
Appendicitis
- Accumulation of material
- Usually feces
- Organ is obstructed, pressure may build
- Flow of blood and lymph fluid decreases
- Hinders ability to fight infection
- May eventually result in rupture, peritonitis, sepsis, and death
What are the risk factors of appendicitis?
- Adolescents have the highest incidence of appendicitis
- Number of cases drop as age increases
- Elderly individuals have a higher mortality rate
- Males are slightly more prone
Diverticular Disease
Fibre
- Western societies tended to eat less dietary fibre
- More solid tools
- Increased intraluminal pressures
- Bulges in the colon wall
- Diverticula- small outcropping turn into pouches
- Feces become trapped in these pouches
- Bacteria
- Scarring, adhesions, and fistulas occur due to infections
Pancreas
- Produces several enzymes that help break down the food
- If the duct carrying these enzymes become blocked, the enzymes are activated
- Breaks down the protein and fat of the pancreas itself
- Autodigestion of the pancreas begins
What are the risk factors of pancreatitis?
- Increased alcohol consumption
- Gallstones
- Medication reactions
- Trauma
- Cancer
- Very highly triglyceride levels
- Can occur suddenly or may persist over months
- Can have recurrent attacks
What is ulcerative colitis caused by?
- Generalized inflammation of the colon
- Unclear what cause the chronic inflammation
- Genetics, stress and autoimmunity have be speculated to contribute
- Causes thinning of the wall of the intestine
- Weakened, dilated colon prone to infections by bacteria and bleeding
What are the risk factors of ulcerative colitis?
- Disease of the young (between 15 and 30)
- Equidal incidence among men and women
- Strong hereditary component 20% of people have a family member with it
- More prevalent in Caucasians and people of jewish decent
Crohn Disease
- May affect the entire GI tract
- Immune system attacks the GI tract
- Most likely site of inflammation is the ileum
- Scarred, narrow, stiff, and weakened portion of the small intestine
Risk factors of Crohn Disease
- Most between the ages of 20 and 30
- Men are diagnosed as often as women
- People of Jewish descent have an increased incidence
- May have a genetic component
Acute Gastroenteritis (Stomach Flu)
- Present with diarrhea, nausea, and vomiting
- Bacterial, viral, and parasitic organisms
- Can run its course in 2 to 3 days or continue for several weeks
- C-diffcile
- Norwalk virus (most common cause in adults)
- Rotavirus (most common cause in children)
- Salmonella
- E coli
Cholera
- Type of acute gastroenetritis
- Relatively unknown in Canada
- Frequently encountered in the developing world
Acute Hepatitis
- Caused by one of several viruses: A, B, C, D, and, E
- In Canada: A, B, and C
- Hepatitis is a general term referring to inflammation of the liver
What are other causes of Acute Hepatitis?
- Epstein-Barr virus (from herpes family in adolescents causes mono)
- Cytomegalovirus (herpes family)
- Certain bacterial infections
- Liver cancer
How is hepatitis A and E transmitted?
- A and E move by the fecal-oral route
How is hepatitis B, C, and D transmitted?
- B, C, and D are transmitted by person-to-person contact (sexual intercourse or blood to blood contact)
What are the symptoms of hepatitis infection?
- Abdominal pain
- Vomiting
- Fever
- Jaundice
*Time for initial infection to emergence of symptoms can range from 14-180 days
What is included in you scene assessment for GI?
- Scene safety
- Mechanism of injury or nature of illness
- Personal protective equipment and routine precautions
Scene Safety
- Paramount concern for all types of calls
- No specific concerns related to patients with GI emergencies
- Patient’s will often need some type of assistance with hygiene
- Additional resources
What additional resources should you include for GI emergencies calls?
- Extra gloves, masks, gowns
- Change of uniform
- Suction equipment
- Extra linens, blankets, wash rags, towels
- Adult and child diapers
Mechanism of injury or nature of illness
- Contributes to initial impression
- Most calls for GI problems will not involve multiple patients
- If you are called for multiple patients in one building consider a biological or chemical agent
Personal protective equipment (PPE) and routine precautions
- Gloves
- May need to manage vomit, diarrhea, and soiled patient clothing
- Gowns are helpful
- Masks can help with noxious odors
What should be included in your initial assessment?
- Forming a general impression
- Odour
- Airway patency
- Breathing
- Circulation
- Pain or hemorrhage
- Orthostatic vital signs
- Gross bleeding
Forming a general impression
- Positioning of pt (fetal position can relive symptoms)
- Location- where is the pt?
Odour
- Smell of the room
- Noxious odor from stool
Airway patency
- More pertinent concern
- Vomiting pt may aspirate
- Open the airway
- Remove or suction any obstructions
- Bowel obstruction may cause breath to smell like feces
Breathing
- Rarely affected
- Systemic complication
- Suspect aspiration if breathing is affected
Circulation
- Skin color, temp, and condition
- Heart rate
- Peripheral pulses
Pain or hemorrhage
- Blood volume begins to drop
- Epinephrine and norepinephrine are released to compensate for lower blood pressures
- Vasoconstriction, increased HR
- Pain stimulate similar responses
Orthostatic Vital Signs
- Help determine the extent of bleeding
- Recline in a position of comfort
- Accurate BP and HR
- Have the patient sit or stand, wait a min or two, then repeat the BP and HR measurements
Gross bleeding
- Not usual to find large amounts of blood
- Take note of the amount of blood lost
- Volume estimation can be difficult, especially in the toliet
Handling Smells
- The sense of smell is the most acute for about a min
- By then 50% of the intensity of an odour is lost
- Due to the olfactory nerve becoming tired of sending the same signal
- Try to stay in the environment for 2-5 mins
- The smell may be less noticeable
What focused history/ physical examination would you do on an unstable patient
- Head-to-toe examination
- DCAP-BTLS examination
- Major effects from GI disease typically relate to the nervous, cardiovascular, and resp systems
Examining the abdomen
- Can be uncomfortable
- Respect pt’s privacy; protect from onlookers
- Maintaining straight legs and arms over the head can result in flexed abdominal muscles
- Try to distract pt with conversation
What should we look for on the skin?
- Irregularities
- Scars from trauma or previous surgery
- Stretch marks
Shape of the abdomen
- Symmetry
- Round
- Protuberant (ascites and/or liver failure)
- Scaphoid (concave) from malnutrition
Listening to bowel sounds
- Listening to bowel sound is not accurate (osculate)
- One location is usually all that is needed, RLQ
- Normal sounds- gurgles and glicks 5-30 times a min
- Borborygmi- growling, indicates strong contractions of the intestines
- Hyperperistalsis- enhanced bowel sounds. Can be heart in early stages of bowel obstruction as bowel tries to overcome obstruction
- Decreased bowel sounds
- Absence of bowel sounds
Palpate the abdomen
- Place your hand flat on the wall of the abdomen
- Begin in the quadrant farthest from the complaint
- With your hand sitting on the wall of the abdomen, raise your wrist so that you indent the abdominal wall with your fingers about 5 to 10 cm
- Presence of rigidity, comfort, or masses
- If pt flexes due to feeling ticklish may be difficult to assess, try to distract with conversation
Assessing the Abdomen
- Ask patient to breath with an open mouth
- Much harder to hold the stomach contracted with mouth breathing
- When pt exhales the abdomen typically relaxes
Focused History and Physical Examination- Pain
- Often a finding of importance with GI patients
- Can indicate trauma, hemorrhage, infection, or obstruction
- Determine the OPQRST of the complaint
- Somatic patients
- Visceral pain
- Rebound tenderness
- Examination goal is to have the peritoneum vibrate
Somatic pain
- found in skin and deep tissues, well localized
ex. cut your skin you experience somatic pain, or stretch your muscles too far during exercise
Visceral pain
- comes from organs
What are some questions to ask?
- When does the patient have pain?
- Does it increase with palpation?
- Is there pain when not being touched?
Rebound tenderness
- suggestive of serious and potential life threatening pathology
- Occurs when peritoneum is irritated due to either hemorrhage or infection
How do we check for rebound tenderness?
- We depress the skin about 5 to 10cm then quickly pull your fingers off the abdominal wall
- Speed in essential
Assessment of abdomen
- Abdomen should be smooth when palpated
- Any presence of bumps or masses may signal the presence of:
- Engorged liver
- Bowel distension
- Aortic aneurysm
- Tumors
SAMPLE History
- Elicit the relevant current and past medical history
What should you monitor enroute?
- Heart rate, ECG, BP, RR, and pulse oximetry
- If GI bleeds, assess for signs of shock
- Determine the effect of treatment
- Monitor pain level
- Repeat the assessments as if for a new patient where there is a dramatic change
Not necessary to diagnose the specific causes of a pt’s abdominal pain in order to appreciate that the pt is in a serious condition
Gastrointestinal Bleeding Assessment
Presentation
- Variable
- Reflects the presence of a number of diseases
Medical history
- May provide important information
- Gathering information on how symptoms have
progressed is important
- Medications may irritate the GI tract
- NSAIDS are bad for the GI
How much bleeding has occurred
- Most important component of the physical
examination
- Focus assessment on evaluation for shock
- Need to determine if the patient is compensating
for the fluid loss
- Orthostatic vital signs are the key to gauging the
degree of fluid loss.
Esophageal Varices Assessment
- Initially patient may show subtle signs of liver disease
- Once there is a variceal bleed, the presentation is quite dramatic
- Throat discomfort, copious amounts of vomiting with bright red blood, hypotension, shock
- If the bleeding is less severe, then hematemesis and melena predominate
Mallory-Weiss Syndrome Assessment
- Due to repeated vomiting
- In women, may be associated with hyperemesis gravidarum (more dramatic morning sickness)
- Extent of bleeding can range from very minor to severe
Hemorrhoids Assessment
- Bright red blood rectal bleeding
- Hematochezia
- Usually minimal and easily controlled
- Patient may overreact as blood loss looks worse in toilet
- May experience itching and a small mass on the rectum
Peptic Ulcer Disease Assessment
Classic sequence:
- Burning or gnawing pain in the abdomen
- Subsides or diminishes after eating
- Reemerges 2 to 3 hours later
- Nausea, vomiting, belching, and heartburn are common
- Gastric bleeding can occur.
Cholecystitis Assessment
- Severe right upper quadrant pain after large or fatty meals.
- Fever and tachycardia from inflammation of the gallbladder wall
Appendicitis Assessment
- Periumbilical (around umbilicus) visceral pain that migrates to the right lower quadrant
- Rebound tenderness suggest possible perforation of the appendix with peritonitis
- Additionally may develop:
- Anorexia
- Nausea
- Fever
Diverticular Disease Assessment
- Abdominal pain
- Tends to be localized to the left side of the lower abdomen
- Classic signs of infection
Fever, malaise (don’t want to do anything), body aches, chills, nausea, and vomiting
Pancreatitis Assessment- pain
- Tends to be localized to the epigastric area or right upper abdomen
- Can be sharp and may be quite severe
- May also experience nausea, vomiting, fever, tachycardia, hypotension, and muscle spasms in the extremities
Pancreatitis Assessment- Greatest cause for alarm
- Internal hemorrhage from erosion of nearby blood vessel
- Advanced autodigestion
- Hemodynamic instability may be present.
- Grey Turner sign and Cullen sign represent retroperitoneal bleeding
Ulcerative Colitis Assessment
- Bloody diarrhea and abdominal pain
- Other signs and symptoms include joint pain and skin lesions, from autoimmune response
- May experience fever, fatigue, and loss of appetite
Crohn Disease Assessment
- Recurrent flares of abdominal pain
- Rectal bleeding, weight loss, diarrhea, arthritis, skin problems, and fever may also be present
- Bleeding tends to be small amounts over a long period of time
- Chronic bleeding can cause anemia
- May experience repeated episodes of mild to severe signs and symptoms
Gastroenteritis Assessment
- Vomiting and diarrhea
- Inflammation of the intestines
- Blood, mucous, or pus in the stool
- Abdominal cramping
- Fever, nausea, and anorexia
- Dehydration and hemodynamic instability if diarrhea continues (asking if they can keep anything down)
Acute Hepatitis Assessment
Different etiologies often associated with the same signs and symptoms
- First phase
- Joint aches
- Weakness and fatigue
- Fever
- Nausea and vomiting
- Abdominal pain
- Anorexia
- Second phase
- Symptoms of liver failure
- Acholic stools- absence of bile, pale or clay
coloured) - Darkening of the urine
- Jaundice
- Abdominal pain in the right upper quadrant and an enlarged liver
- Depending on the disease progression, total liver failure may be only days away
Bowel Obstruction Assessment
- Strictures- causes narrowing usually from scar tissue or tumor
- Varies according to the underlying cause
- Signs include abdominal pain and fullness
- Diarrhea initially
- Peristalsis increases as an attempt to overcome the obstruction
- Constipation may eventually result
- Nausea and vomiting are common in later stages
- Emesis and the pt’s breath having a fecal odor
- Eventually perforation of the bowel may occur (causing septic shock peritonitis)
General Management Guidelines
- Often little can be done
- Prehospital care for the effects of the disease
- Extreme amounts of pain, dehydration, hypotension, or extreme nausea
What are the main goals of general management guidelines?
- Maintain routine precautions and PPE
- Manage the ABCs
- Manage the patient’s pain and nausea.
Routine Precautions and PPE
- Essential due to the high likelihood of coming in contact with infectious agents
- Be prepared to deal with large amounts of vomit, feces, and blood
- Equipment
- Gloves/gowns/eye protection/surgical mask
- Towels and washcloths
- Extra linen
- Absorbent pads
- Emesis basin
- Disposable basin
- Biohazard bags
- Sterile water for irrigation
Airway
- Aspiration or obstruction of the airway due to vomit or blood
- These complications are rare
- Effective positioning
- Portable suctioning
Breathing
- Often associated with decreased hemoglobin due to bleeding
- Be liberal in delivering oxygen
- Oxygen masks can cause some patients to experience a sense of confinement
- Monitor patients to make sure they can get the mask off quickly if they start to vomit
Administer fluids
- One or two large bore intravenous cannulas
- Degree of hemodynamic instability combined with evidence of pulmonary edema
- If the patient is hypotensive, a rapid bolus of 10 to 20 ml/kg of an isotonic crystalloid
Maintain peripheral perfusion
- Check LOA- GCS of 15
- Normal mentation
- Skin condition
- Presence of a radial pulse (if gone their BP is usually around 80)
- Should all be adequate for to allow for perfusion of the brain, kidneys and other vital organs
Pain Management
- Controversial subject (NSAIDS causes bleeding in the stomach, masks the pain they are in)
- System protocols should provide guidance.
- Should be a priority
- Hypotension is a contraindication
- Medications for abdominal pain:
- Morphine
- Ketorolac
- NSAID
- Fentanyl
- Medications for nausea
- Dimenhydrinate
- Hydroxyzine
- Promethazine
Gastrointestinal Bleeding Managment
- Directed at maintaining perfusion of vital organs
- Internal hemorrhage cannot be controlled in the prehospital setting
- Volume replacement is critical
- Hemodilution can be a side effect of aggressive volume replacement
EsophageaL Varices Management
- Follow general guidelines.
- Accurate assessment of the extent of blood loss is critical.
- Volume resuscitation and aggressive suctioning of the airway
Mallory-Weiss Syndrome Management
- Directed at determining the extent of blood loss
- May be dehydrated from repeated vomiting
- In hospital treatment includes possible repair of any damage
- Most resolve spontaneously
Hemorrhoid Management
- Largely supportive
- In isolation, more of an inconvenience than a life-threatening condition
- Rarely, some patients suffer severe lower GI bleeds.
- The majority resolve in 2 to 3 days.
- Conservative management
- Surgical removal (rarely)
Peptic Ulcer Disease Management
- Accurately assess the extent of blood loss
- Prepare to manage any hypotension
- Orthostatic vital signs are critical.
- In hospital treatment includes acid neutralization and antibiotic therapy for H pylori can prevent new cases from occurring
Cholecystitis Management
- Directed at making the patient comfortable
- Treating hypovolemia
- Morphine and meperidine(narcotic)
- IV fluids
- Gravol
- In hospital treatment may include antibiotics and surgical removal of gallbladder
Appendicitis Management
- Remain vigilant for signs of perforation or septic shock
- Be prepared to use dopamine if crystalloids are not effective
- In hospital treatment includes antibiotics and surgical removal of appendix
Diverticular Disease Management
- Directed at making the patient comfortable
- Examine closely for severe infection.
- May need large amounts of fluids and/or dopamine due to sepsis
- In hospital treatment includes antibiotics, liquid diet and possible surgery
Pancreatitis Management
- Follow general guidelines.
- Pay special attention to signs of severe hemorrhage.
- Fluid resuscitation
- In hospital treatment includes GI rest, analgesia
Pancreas can not be removed
Ulcerative Colitis Management
- Determine the degree of hemodynamic instability
- Look for signs of shock
- Provide supportive prehospital care and follow general management guidelines
- In hospital treatment includes anti-inflammatory medications, antibiotics,
- Eventually removal of diseased sections of their colon
Crohn Disease Management
- Follow general management guidelines
- Volume resuscitation may be necessary
- Measures to control nausea and pain are commonly needed
- In hospital treatment includes medications to stop inflammation and creating environment where GI tract can heal itself
- If severe surgical resection of portions is needed
Acute Gastroenteritis Management
- Follow general management guidelines
- Degree of fluid deficit
- Patients often feel markedly better after rehydration.
- Analgesic and antiemetic medications
- In hospital treatment includes rehydration, and antibiotics if bacterial or parasitic
- Best prevention is education on safe food and water use
Acute Hepatitis Management
- Supportive
- Follow general management guidelines
- Two important areas to focus on are:
- Infection control and medication administration
- Limit contact with bodily fluids
- Hep B can stay in dried blood for a week
- Liver detoxifies medication.
- Drugs given may remain active within the body
for longer than anticipated - Consider lower doses and at longer intervals
- Drugs given may remain active within the body
