Module 2: Emergencies of Abdominal and Gastrointestinal System Disorders PDF

Module 2: Emergencies of Abdominal and Gastrointestinal System Disorders This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. ...

Module 2: Emergencies of Abdominal and Gastrointestinal System Disorders This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Objectives Upon completion of this chapter, the paramedic student will be able to: 1. Label a diagram of the abdominal organs. 2. Describe the function of the abdominal organs. 3. Outline the prehospital assessment of a patient complaining of abdominal pain. 4. Distinguish between pain characteristics in abdominal pain. 5. Describe general prehospital management techniques for a patient complaining of abdominal pain. 6. Describe signs and symptoms, complications, and prehospital management for the following abdominal and gastrointestinal disorders: gastrointestinal bleeding, acute and chronic gastroenteritis, ulcerative colitis, diverticulosis, appendicitis, peptic ulcer disease, bowel obstruction, Crohn’s disease, pancreatitis, hemorrhoids, cholecystitis &, esophagogastric varices. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Overview Anatomically and functionally, the digestive system can be divided into the tubular gastrointestinal (GI) tract, or alimentary canal, and accessory digestive organs. The organs of the GI tract include the oral cavity, pharynx, esophagus, stomach, small intestine, and large intestine. The accessory digestive organs include the teeth, tongue, salivary glands, liver, gallbladder, and pancreas. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Functions of the Digestive System 1. Ingestion: Occurs when materials enter digestive tract via the mouth 2. Mechanical processing: – Crushing and shearing “makes materials easier to propel along digestive tract”. 3. Digestion: – Is the chemical breakdown of food into small organic fragments for absorption by the body. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  4. Secretion: – Is the release of water, acids, and enzymes ✔ by the digestive tract ✔ by the digestive organs 5. Absorption: – Movement of organic substrates, electrolytes, vitamins, and water into the bloodstream. 6. Excretion: – Removal of waste products from body fluids This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  INGESTION PROPULSION MECHANICAL DIGESTION Swallowing Chewing Peristalsis Churning Segmentation CHEMICAL DIGESTION ABSORPTION Enzyme action Blood Lymph By Active transport Passive transport This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Assessment of the Patient With Acute Abdominal Pain ❑ When caring for a patient with abdominal pain, the paramedic should begin the primary survey by ensuring that the scene is safe. ❑ Determine whether the patient’s abdominal pain is a result of trauma or a medical condition. This distinction may be evident from the initial scene survey. The nature of the pain also may become evident through information obtained from the patient, family, or bystanders. ❑ The paramedic should inspect the nearby area for medication bottles and signs of alcohol or other drug use, as they may offer clues to the cause of the patient’s condition. ❑ After addressing life threats identified in the primary survey, assessment of the patient with acute abdominal pain begins with a thorough history focused on the chief complaint. ❑ The paramedic should assess and document baseline vital signs and perform a systematic physical examination. This examination helps the paramedic identify abdominal This PDF document was edited with Icecream PDF Editor. emergencies, Upgrade to PRO to remove watermark. including those indicating the development of shock or the need for immediate transport for surgical intervention.  History When obtaining a history of abdominal pain, the paramedic should attempt to identify the location and type of pain and any associated signs and symptoms. The mnemonic OPQRST or a similar method can help the paramedic organize this information. Sample questions that might be included in the OPQRST evaluation include the following: Onset. Was the onset of pain sudden? What were you doing when it started? Provocation/palliation. What makes the pain better? What makes the pain worse? Does a sitting or lying position affect your discomfort? Does a deep breath increase the pain? Does the pain change after you eat or drink? Quality. What does the pain feel like? Is it sharp, dull, burning, tearing? Region/radiation. Where is the pain located? Does it travel (radiate) to another area of the body, or does it stay in the same place? Severity. Is the pain mild, moderate, or severe? What is the degree of discomfort on a scale of 0 to 10 (with 10 being the worst)? Time. When did the pain begin? Is it constant or intermittent? If intermittent, how long does the pain This PDF document was edited with Icecream PDF Editor. episode last? Upgrade to PRO to remove watermark.  History SAMPLE history (signs and symptoms, allergies, medications, past medical history, last meal or oral intake, and events before the emergency). Other important elements of a patient history include any recent illness and past significant medical history. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Location and Type of Abdominal Pain To assess a specific disorder, the paramedic can seek to relate the anatomic location of GI organs and structures to the origin of the pain. Next TABLE lists locations of abdominal pain and possible causes of illness associated with them. The types of abdominal pain that may result from chronic or acute episodes may be classified as visceral, somatic, or referred This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Visceral Pain ▪ Visceral pain (or organ pain) is caused by the stimulation of autonomic nerve fibers that surround an organ. It can also be caused by compression and inflammation of solid organs and by distention or stretching of hollow organs or the ligaments. ▪ The patient usually describes the pain as cramping or gas-type pain. It may vary in intensity, increasing to severe and then subsiding. Visceral pain generally is diffuse, so it is difficult to localize. ▪ Often the pain is centered at the umbilicus or lower in the midline. ▪ Visceral pain often is associated with other symptoms of autonomic nerve involvement, such as tachycardia, diaphoresis, nausea, or vomiting. ▪ Common causes of visceral abdominal pain include early appendicitis, pancreatitis, cholecystitis, and intestinal obstruction This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Somatic Pain ▪ Somatic pain is produced by bacterial or chemical irritation of nerve fibers in the peritoneum (peritonitis). ▪ somatic pain usually is constant and localized to a specific area. Patients often describe the pain as sharp or stabbing and generally are hesitant to move about. They may lie on the back or side with the legs flexed to prevent additional pain stemming from stimulation of the peritoneal area. ▪ Other physical signs in patients with acute abdominal pain are presented in next TABLE ▪ Common causes of somatic pain are appendicitis and an inflamed or perforated viscus (ulcer, gallbladder, or small or large intestine) This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Referred Pain ▪ Referred pain is pain in a part of the body considerably removed from the tissues that cause the pain. ▪ This type of pain arises when branches of visceral fibers synapse in the spinal cord with the same second-order neurons that receive pain fibers from the skin. When these pain fibers are stimulated intensely, pain sensations spread. ▪ The patient experiences the pain in areas distant from the source. A knowledge of referred pain is important because many visceral ailments cause no symptoms except referred pain (FIGURE). ▪ For example, cardiac pain may be referred to the neck and jaw, shoulders, and pectoral muscles and down the arms; biliary pain to the right subscapular area; renal colic to the genitalia and flank area; uterine and rectal pain to the lower back; and a leaking aortic aneurysm to the lower back or buttocks. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. FIGURE: Referred pain. A, Anterior view. B, Posterior view  Common causes of acute abdominal pain There are several mnemonics that can be used to remember possible, common causes of acute abdominal pain. One such method is BAD-GUT-PAINS. Bowel obstruction Appendicitis Diverticulitis, diabetic ketoacidosis, diarrhea drug withdrawal Gastroenteritis, gallbladder disease/stones/obstruction/ infection Urinary tract obstruction (stone), infection (pyelonephritis/ cystitis) Toxins Pneumonia, pleurisy, pancreatitis, perforated bowel/ulcer Abdominal aneurysm Infarcted bowel, infarcted myocardium, Inflammatory bowel disease (IBD) This PDF document was edited with Icecream PDF Editor. Splenic Upgrade to PRO rupture/infarction, sickle cell crisis to remove watermark.  Signs and Symptoms Although numerous signs and symptoms may be associated with acute abdominal pain, the following, along with possible causes, are commonly noted: 1. Nausea, vomiting, anorexia ❑ Appendicitis ❑ Biliary tract disease ❑ Gastritis ❑ Gastroenteritis ❑ High intestinal obstruction ❑ Pancreatitis 2. Diarrhea ❑ Inflammatory process (gastroenteritis( This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Signs and Symptoms 3. Constipation ❑ Dehydration ❑ Obstruction ❑ Medication-induced decreased intestinal motility (codeine, morphine) 4. Change in stool color ❑ Biliary tract obstruction (clay-colored stools) ❑ Lower intestinal bleeding (black, tarry stools) 5. Chills and fever ❑ Appendicitis ❑ Bacterial infection ❑ Cholecystitis This PDF document was edited with Icecream PDF Editor. ❑ Pyelonephritis Upgrade to PRO to remove watermark.  Vital Signs ▪ Vital sign assessment should include evaluation and documentation of the patient’s blood pressure, pulse rate , respiratory rate, temperature, and skin condition (color, moisture, temperature, and turgor). ▪ The presence or absence of orthostatic pulse and blood pressure changes should be noted if possible. Rising from a recumbent position to a sitting or standing position, with an associated fall in systolic pressure (after 1 minute) of 10 to 15 mm Hg and/or a concurrent rise in the pulse rate (after 1 minute) of 10 to 15 beats/min, indicates significant volume depletion and a decrease in perfusion status. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Physical Examination ❑ Inspection, auscultation, percussion, and palpation ❑ If a life-threatening illness is suspected, rapid stabilization and transport of the patient are the first priorities. Further examination can be completed en route This PDF document was edited with Icecream PDF Editor. to the receiving hospital. Upgrade to PRO to remove watermark.  In the initial patient encounter, the paramedic should note the position in which the patient is lying. As stated previously, many patients with abdominal peritoneal irritation lie on the side. The knees often are flexed and pulled in toward the chest. Inspection Other visual clues that may indicate abdominal pain are skin color, facial expressions and the presence or absence of voluntary movement. The paramedic should remove the patient’s clothing (while ensuring privacy) and inspect the abdominal wall for bruises, scars, ascites, abdominal distention, or abdominal masses. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Auscultation ▪ Determining the presence or absence of bowel sounds by auscultation usually is performed as part of the assessment in the emergency department. However, if auscultation is to be done in the field, the paramedic should auscultate the abdomen as appropriate given the time and noise level of the surroundings to determine whether bowel sounds are absent. Note that it can be difficult to hear these sounds in the often-noisy field or ambulance setting. Auscultation should always precede palpation and percussion, because these procedures may alter the intensity of bowel sounds. ▪ An increase in the number, duration, or intensity of bowel sounds indicates the possibility of gastroenteritis or intestinal obstruction. A considerable decrease in the number and intensity of bowel sounds (or their absence) may indicate peritonitis or ileus (with obstruction of the intestine). This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Percussion If time permits, a general assessment of tympany and dullness by percussion may be performed. This evaluation is intended to detect the presence of fluid, air, or solid masses in the abdomen. The paramedic should use a systematic approach and move from side to side or clockwise. Tympany is the major sound that should be noted during percussion because of the normal presence of air in the stomach and intestines; dullness should be heard over organs and solid masses. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  The paramedic should begin palpation of the abdomen gently and avoid the painful area until the remainder of the abdomen has been examined. Palpation The paramedic should note signs of rigidity or spasm, tenderness or masses, and the patient’s facial expressions, as they may provide clues to the severity of the pain. In addition, the paramedic should identify the abdomen as soft or rigid. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Patients with acute abdominal pain or GI bleeding cannot be managed effectively in the prehospital setting. Most require extensive evaluation in the emergency Managemen department, including laboratory analysis, radiologic imaging, fluid and medication therapy, and perhaps t of the surgical intervention. Patient With an The role of the paramedic, therefore, is to support the patient’s airway and ventilatory status; to perform and Abdominal document an initial patient assessment, including a thorough history; to monitor vital signs and cardiac Emergency rhythm; to initiate intravenous (IV) therapy for fluid replacement or fluid resuscitation; to administer analgesics and antiemetics per protocol; and to transport the patient for evaluation by a physician. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ❖ Abdominal emergencies can result from inflammation, infection, and obstruction. Some disorders may be associated with upper GI bleeding—for example, lesions, peptic ulceration, and esophageal varices. ❖ Other disorders may be associated with lower GI Specific bleeding—for example, colonic lesions, diverticulosis, Still other disorders, such as pancreatitis and Abdominal cholecystitis, more often are associated with acute abdominal pain in the absence of bleeding. Emergencies ❖ The specific GI disorders include GI bleeding, acute and chronic gastroenteritis, IBD (ulcerative colitis and Crohn disease), diverticulosis, appendicitis, peptic ulcer disease, bowel obstruction, pancreatitis, esophageal varices, hemorrhoids, cholecystitis, acute hepatitis, and hereditary hemochromatosis. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ It can range from chronic blood loss to a massive, life-threatening hemorrhage, which may be difficult to control. Although many bleeding episodes resolve spontaneously, evaluation by a physician to identify the bleeding site is crucial to help prevent a recurrence. ▪ Bleeding from the GI tract can be classified by site of origin as upper or lower GI bleeding. ▪ The most common causes of upper GI bleeding are gastric or duodenal ulcers and variceal rupture (eg, esophageal varices that result from GI Bleeding underlying chronic liver disease, such as cirrhosis). Other causes of upper GI bleeding are esophagitis, gastritis, or Mallory-Weiss syndrome (an esophageal laceration that usually results from repeated vomiting or retching) ▪ Tumors or cancers of the esophagus or stomach may also cause bleeding. ▪ Factors that may aggravate upper GI bleeding include use of nonsteroidal anti-inflammatory drugs (NSAIDs), chronic liver disease, blood-thinning medications and underlying medical conditions such as renal disease, This PDF document was edited with Icecream PDF Editor. hypertension, and cardiorespiratory diseases Upgrade to PRO to remove watermark.  ▪ The most common cause of lower GI (colon) bleeding is diverticulosis. Other causes include colon cancers, and IBDs, such as ulcerative colitis and Crohn disease. ▪ lower GI bleeding may be either mild or brisk and difficult to control. Complaints often associated with such bleeding include cramping abdominal pain, diarrhea (which may be bloody), nausea, vomiting, and changes in the patient’s stool and bowel habits. ▪ The seriousness of GI bleeding depends on the acuity and the source of the blood loss. Mild chronic GI blood loss may present without any noticeable bleeding but result in an iron-deficiency anemia. Affected patients often are unaware that they are bleeding and may or may not notice small amounts of blood with their bowel movements. ▪ Patients with severe cases of chronic or acute bleeding can have signs of anemia, such as weakness, pallor, dizziness, shortness of breath, or angina. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Hematemesis (bloody vomitus). This vomit may be red or may have a dark, coffee ground–like appearance. ▪ Blood in the stool could present as bright red, dark, or black and tarry; the presentation depends on the location of the bleeding source. ▪ A black, tarry stool (melena) often indicates an upper GI source of bleeding. ▪ Bright red blood from the rectum (hematochezia) after a bowel movement usually signifies a bleeding source close to the rectal opening. conditions such as rectal cancers arteriovenous malformations, and infections also can cause this type of bleeding. Pre-hospital care for patients with active and severe GI bleeding includes airway monitoring and management, provision of emotional support, administration of This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. high-concentration oxygen  ✔ In the prehospital setting, GI bleeding often cannot be controlled by the paramedic. In some cases, hypotension can be protective, because a reduced blood pressure can minimize blood loss. NOTE ✔ Medical direction may recommend that the patient’s systolic blood pressure be maintained between 80- and 90-mm Hg (permissive hypotension) until the patient has been delivered to the emergency department for definitive care. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Gastroenteritis This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Acute Gastroenteritis ❑ Acute gastroenteritis is inflammation of the stomach and intestines accompanied by the sudden onset of vomiting and diarrhea. ❑ Acute gastroenteritis may be caused by bacterial or viral infection, parasites (eg, organisms that cause “traveler’s diarrhea,” Giardia lamblia and Cyclospora cayetanensis, which are reported to be transmitted through ingestion of contaminated water), chemical toxins, and other conditions such as allergies, lactose intolerance, and immune disorders. ❑ The inflammation causes hemorrhage and erosion of the mucosal layers of the GI tract and can alter the way water and nutrients are absorbed. ❑ Infectious acute gastroenteritis usually is transmitted through the fecal–oral route and by ingestion of infected food or contaminated water. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ❑ Infectious acute gastroenteritis also can arise among travelers in endemic areas and in populations in disaster areas where water supplies are contaminated. ❑ Acute gastroenteritis often is abrupt and violent in onset. Patients rapidly lose fluids and electrolytes through constant vomiting and diarrhea. The resulting fluid loss and dehydration may be especially severe in children, older adults, and immunosuppressed people. ❑ Hypokalemia, hyponatremia, acidosis (from prolonged diarrhea), or alkalosis (from prolonged vomiting) may develop. ❑ Treatment mainly is supportive, consisting of IV fluid replacement, sedation, bed rest, and medications to control vomiting and diarrhea. Bacterial causes of gastroenteritis can be treated with antibiotic therapy. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ❑ Chronic gastroenteritis results from inflammation of the stomach and intestines, which can produce long-term changes or damage to the gastric mucosa. This condition usually is due to microbial infection, or chronic use of alcohol, aspirin, and NSAIDs. Chronic ❑ Signs & symptoms of chronic gastroenteritis include: ▪ Epigastric pain, nausea and vomiting (which may gastroenteriti be severe), fever, anorexia, mucosal bleeding s (erosive gastritis), and epigastric tenderness on palpation. In severe cases, patients may be experiencing hypovolemia and shock. ❑ The condition is treated with dietary regulation, medications (antibiotics, antacids), and fluid replacement or fluid resuscitation if hypovolemia or This PDF document was edited with Icecream PDF Editor. dehydration occurs. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ❑Inflammatory Bowel Disease (IBD) Inflammatory is a general term that describes two conditions—ulcerative colitis Bowel and Crohn disease—that cause Disease chronic inflammation of the digestive tract. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Ulcerative colitis is an IBD affecting the large intestine. It is characterized by ulceration of the mucosa of the intestine, usually in the rectum and lower part of the colon but sometimes over the entire colon. ▪ The inflammation makes the colon empty often (causing diarrhea). In addition, the ulceration Ulcerative causes bleeding and produces pus. Colitis ▪ Ulcerative colitis can occur at any age, although it most often starts between ages 15 and 30 years or, less often, between ages 50 and 70 years. ▪ The disorder may be related to the way the immune system reacts to a virus or bacterium that causes chronic inflammation in the intestinal wall. Other possible causes include allergies to This PDF document was edited with Icecream PDF Editor. certain foods (eg, lactose intolerance) and Upgrade to PRO to remove watermark. environmental and psychological factors.  ▪ The most common signs and symptoms of ulcerative colitis are abdominal pain, fatigue, weight loss, anorexia, and bloody diarrhea with or without mucus ▪ Symptoms may be mild or more severe. Some patients with the disease have remissions that last for months or years, though the symptoms eventually return in most individuals. ▪ After evaluation by a physician and stabilization of the condition, ulcerative colitis usually is managed with steroids, electrolytes, antibiotics, immunotherapy, and dietary regulation. Few patients require surgery, although surgical removal of the diseased colon may be indicated in severe cases. ▪ Prehospital care is directed to provide airway, ventilatory, and circulatory support to manage hypovolemia and shock. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Crohn disease is a chronic IBD that usually affects the ileum" The last part of the small intestine" , the colon, or both, but may occur anywhere in the GI tract from the mouth to the anus. ▪ Crohn disease may occur in individuals of all ages but is primarily a disease of young adults. Crohn ▪ The inflammation associated with Crohn disease may cause blockage of the intestine: The disease Disease tends to thicken the intestinal wall with swelling and scar tissue, narrowing the passage. ▪ Other complications associated with Crohn disease include arthritis, skin problems, inflammation of the eyes or mouth, kidney stones, gallstones, and other diseases of the liver and biliary system This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Crohn disease can be difficult to diagnose, because its symptoms are similar to those of ulcerative colitis. ▪ Crohn disease is characterized by frequent attacks of diarrhea, severe abdominal pain, nausea, fever, chills, weakness, anorexia, and weight loss. ▪ Patients with Crohn disease are frequently hospitalized. Once their condition has been stabilized, the disease may be managed with antibiotics, steroids, and antimotility agents" drugs used to alleviate the symptoms of diarrhea" in an attempt to induce This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. remission, as well as dietary regulation. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Diverticulosis ▪ A diverticulum is a sac or pouch that develops in the wall of the colon (FIGURE). ▪ Diverticula are a common development with older age and are associated with diets low in fiber. ▪ Diverticular outpouchings (a condition known as diverticulosis) tend to develop because of the high pressure in the contracting sigmoid colon that regulates movement of stool into the rectum. ▪ The outpouchings are most common at the weakest point in the colon wall—on the left side, just above the rectum. As a diverticulum expands, it develops a thin wall compared to the rest of the colon. Subsequently, bacteria may seep through and cause infection This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Most patients with diverticula are completely symptom-free, but as many as 25% experience diverticulitis when one or more diverticula become obstructed with fecal matter. ▪ Mild complications of diverticulitis include irregular bowel habits (alternating constipation and diarrhea), fever, and lower left quadrant pain. ▪ Diverticulitis tends to recur within the first 5 years after the onset of symptoms. ▪ Definitive care for these patients includes dietary regulation, a high-fiber diet to stimulate daily bowel movements, antibiotic therapy, and, in some cases, surgical repair ▪ Serious complications of diverticular disease are associated with lower GI bleeding, inflammation, abscess formation, strictures, and perforation of the bowel. These complications include massive bright red rectal bleeding (or dark stools if bleeding is from a diverticulum in the right colon). Hemorrhage from a diverticulum can occur rapidly, is often painless, and is the most common cause of massive rectal bleeding in older adults ▪ The hemorrhage often stops spontaneously. However, if the bleeding does not stop, emergency surgery may be necessary This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Appendicitis ▪ Appendicitis is a common abdominal emergency, ,Although this condition may present at any age, most patients are 10 to 19 years old ▪ appendicitis occurs when the passageway between the appendix and the cecum" the first part of the large intestine." becomes obstructed by fecal matter (fecalith). Alternatively, it may be due to inflammation of the area caused by a viral or bacterial infection. ▪ Obstruction of the passageway leads to distention of the appendix. If the condition continues, the inflamed organ eventually develops gangrene and ruptures into the peritoneal cavity. The spilling of its contents typically results in peritonitis. ▪ because of variations in the position of the appendix, the patient’s age, and the degree of inflammation, the clinical presentation of appendicitis can vary dramatically (BOX). This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ The classic presentation of appendicitis is abdominal pain or cramping, nausea, vomiting, chills, low-grade fever, flatulence, and anorexia. At first the pain is periumbilical and diffuse. Later it becomes intense and localized to the right lower quadrant. ▪ The location of the pain can vary, however, based on the location of the tip of the appendix. If the appendix ruptures, the patient’s pain diminishes before peritoneal signs become evident. ▪ The goal of definitive care for appendicitis is surgical removal of the appendix (appendectomy) before the organ ruptures. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Peptic Ulcer Disease ▪ Peptic ulcer disease results from a complex pathologic interaction among the various acidic gastric secretions and proteolytic enzymes and the mucosal barrier in the digestive tract. ▪ As part of digestion, the stomach produces hydrochloric acid and an enzyme called pepsin. From the stomach, food passes into the duodenum, where digestion and nutrient absorption continue. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  ▪ Ulcers can form in the lining of the stomach or the duodenum, where acid and pepsin are present. These sores cause the disintegration and death of tissue. ▪ If the sores are left untreated, massive hemorrhage or perforation may result. ▪ Ulcers can develop at any age but are rare among teenagers and even more uncommon in children. Duodenal ulcers usually occur for the first time between the ages of 30 and 50 years and are more common in men than in women. ▪ The two main causes of peptic ulcer disease This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark. are H. pylori infection and the use of NSAIDs.  ▪ A patient with a peptic ulcer usually is aware of the condition and may use over-the-counter antacids in an effort to relieve the discomfort. ▪ The ulcer pain often relieved by eating, taking antacids, or vomiting. In addition to pain and vomiting of blood, the patient may experience melena as a result of blood passing through the GI tract. ▪ Pre-hospital care for patients with peptic ulcer disease includes obtaining a pertinent history, evaluating for hypotension, and providing circulatory support as needed. ▪ After evaluation by a physician, definitive care may involve antibiotics, antacids, ▪ Some patients with acute peptic ulcer disease require hospitalization for fluid or blood replacement or for surgery if medications are not effective or blood loss continues. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Bowel Obstruction ▪ Bowel obstruction is an occlusion of the intestinal lumen that results in blockage of normal flow of intestinal contents. Bowel obstruction may be caused by an ileus" temporary lack of the normal muscle contractions of the intestines.", a condition in which the bowel does not work properly. ▪ It results from mechanical obstruction, such as hernia ,fecal impaction, polyps, tumors. And ingested foreign bodies, and foreign bodies introduced from the anus ▪ Most bowel obstructions occur in the small bowel (accounting for 20% of all hospital admissions for abdominal complaints) and are caused by adhesions or hernias. This PDF document was edited with Icecream PDF Editor. ▪ Large bowel obstructions most often result from tumors or fecal impactions. Upgrade to PRO to remove watermark.  ▪ Signs and symptoms of intestinal obstruction include nausea and vomiting, abdominal pain, diarrhea, constipation (a late finding), and abdominal distention. ▪ The most significant danger is perforation of the bowel, which may lead to generalized peritonitis and sepsis. An elevated lactate level may signal the onset of sepsis. ▪ A patient with bowel obstruction often has abdominal pain; dehydration may result from vomiting, decreased intestinal absorption, and fluid loss into the lumen and interstitial (bowel wall edema). As the affected portion of the bowel distends, its blood supply is decreased, and the segment becomes ischemic. ▪ Definitive care involves fluid replacement, antibiotics, placement of a nasogastric tube for decompression and, frequently, surgery to correct the obstructing lesion. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Pancreatitis The pancreas also secretes insulin and glucagon into the bloodstream. These hormones help maintain an adequate glucose concentration. When the pancreas becomes inflamed (pancreatitis), it releases pancreatic enzymes into the blood, the pancreatic duct, and the pancreas itself. This causes further inflammation and autodigestion of the gland. Pancreatitis occurs in two stages, acute and chronic. Acute pancreatitis is sudden in onset. It occurs soon after the pancreas becomes damaged or irritated by its own enzymes. Causes: Obstruction by gallstones in the bile duct or by alcohol abuse. Other, less common causes of acute pancreatitis include elevated serum lipids, This PDF document was edited with Icecream PDF Editor. thromboembolism, drug toxicity, infection, and some surgeries. Upgrade to PRO to remove watermark.  Pancreatitis Chronic pancreatitis begins as acute pancreatitis. It becomes chronic when the pancreas becomes scarred. This condition usually results from long-term and excessive alcohol consumption Signs & Symptoms: Severe epigastric pain GIT disturbances: Nausea, vomiting, abdominal tenderness & distention. Fever Tachycardia, and Signs of generalized sepsis and shock This PDF document was edited with Icecream PDF Editor. Management: IV fluids, pain medication, and placement of a nasogastric tube if the Upgrade to PRO to remove watermark. patient is vomiting  Hemorrhoids Hemorrhoids are swollen, distended veins inside the anus (internal) or under the skin around the anus (external). Hemorrhoids are common during pregnancy Pain from hemorrhoids is infrequent unless thrombosis, ulceration, or infection is present Slight bleeding is the most common symptom. Recurrent episodes of bleeding may be significant enough to produce anemia. Definitive care includes dietary modification, stool softeners, tissue fixation techniques, and operative hemorrhoidectomy for severe cases. This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.  Esophagogastric varices Esophagogastric varices arise from obstruction of blood flow to the liver as a result of liver disease. Rupture of the varices can cause hemorrhage and death. They are common in patients with liver disease and often result from portal hypertension caused by cirrhosis of the liver. Varices can rupture. This results in life-threatening hemorrhage. Other causes of esophageal bleeding include esophagitis. Clinically, a patient with esophageal bleeding has bright red hematemesis. The patient also may manifest the classic signs of shock. Therapeutic intervention includes ensuring a patent airway and fluid resuscitation. Definitive care may include placement of a Sengstaken-Blakemore tube to tamponade This PDF document was edited with Icecream PDF Editor. bleeding vessels, surgical ligation of the bleeding varices, or transendoscopic injection of Upgrade to PRO to remove watermark. a sclerosing agent into the bleeding vessels.  Cholecystitis Esophagogastric varices arise from obstruction of blood flow to the liver as a result of liver disease. Rupture of the varices can cause hemorrhage and death. Hemorrhoids are distended veins in the rectoanal area. Cholecystitis is inflammation of the gallbladder. It most often is associated with the presence of gallstones. Risk factors for cholecystitis include female gender, oral contraceptive use, increasing age, obesity, diabetes mellitus, chronic alcohol ingestion, and African American or Asian ethnicity. In 90% of cases, acute cholecystitis is caused by gallstones (composed mainly of cholesterol) in the gallbladder. Patients with gallbladder disease commonly have episodes of pain at night. Generally, the episodes are associated with recent ingestion of fried or fatty foods. Low-grade fever, nausea, & vomiting are common signs & symptoms of cholecystitis , in addition there are shaking chills, jaundice, and acute pancreatitis. This PDF document was edited with Icecream PDF Editor. Treatment may include hospitalization, IV fluid therapy, antibiotics, and placement of a nasogastric tube. Upgrade to PRO to remove watermark. Definitive treatment is surgical removal of the gallbladder.  Thank you This PDF document was edited with Icecream PDF Editor. Upgrade to PRO to remove watermark.