1. “Get in my Belly”Abdominal Emergencies Fred W. Wurster III, AAS, NREMT-P

3. Abdominal Emergencies Anatomy Review Non-hemorrhagic abdominal pain Gastrointestinal hemorrhage Assessments Treatment modalities

4. Abdominal boundaries

5. Peritoneum Abdominal cavity Double-walled structure Visceral and Parietal Separates abdominal cavity into two areas Peritoneal cavity or space Retroperitoneal space

6. Peritoneum

7. Abdominal anatomy

8. Abdominal anatomy

9. GI Structures Primary Mouth/Oral Cavity Pharynx Esophagus (digestive tract between pharynx & stomach) Stomach (hollow digestive organ, receives food from esophagus) Small Intestine (between stomach & cecum, composed of duodenum, jejunum, & ileum) Large intestine (from ileocecal valve to anus, composed of cecum, colon, & rectum)

10. GI Structures Accessory Salivary glands (produce/secrete saliva) Liver (solid organ in RUQ; produces/secretes bile, essential proteins, clotting factors; detoxifies; stores glycogen) Gallbladder (sac located beneath liver, stores/concentrates bile) Pancreas (Endocrine – secretes insulin/Exocrine - secretes digestive enzymes & bicarbonate) Appendix (attached to large intestine, no physiologic function)

11. Major Blood Vessels Aorta Inferior Vena Cava

12. Organs Solid Liver Spleen Pancreas Kidneys Ovaries

13. Organs Hollow Stomach Intestines Gallbladder and bile ducts Ureters Urinary bladder Uterus Fallopian tubes

14. Abdominal quadrants

15. Right Upper Quadrant Liver Gallbladder Duodenum Transverse colon (partial) Ascending colon (partial)

16. Left Upper Quadrant Stomach Liver (partial) Pancreas Spleen Transverse colon (partial) Descending colon (partial)

17. Right Lower Quadrant Ascending colon Appendix Ovary Fallopian tube

18. Left Lower Quadrant Descending colon Sigmoid colon Ovary Fallopian tube

19. Abdominal Pain Visceral Diffuse in nature Stretching of peritoneum of organ capsules by distension or edema Poorly localized Can be perceived at remote locations related to the affected organ’s sensory innervation

20. Abdominal Pain Somatic Sharp in nature Well localized Inflammation of parietal peritoneum or diaphragm Referred Perceived at a distance from the affected organ

21. Non-hemorrhagic Abdominal Pain Esophagitis Inflammation of distal esophagus usually from GERD or hiatal hernia Signs/Symptoms Sub-sternal burning pain (usually epigastric) Pain worsens when laying supine Sometimes temporarily relieved by Nitroglycerine Usually non-hemorrhagic

22. Esophagitis

23. Non-hemorrhagic Abdominal Pain Acute Gastroenteritis Inflammation of stomach and intestine May cause bleeding and ulcers Caused by: Increased acid secretion and biliary reflux Chronic EtOH use/abuse and medication (ASA, NSAIDS) Infections Signs and Symptoms Epigastric pain, usually a burning sensation, tenderness on exam, nausea, vomiting, diarrhea, possible bleeding

24. Peptic ulcer disease Causes craters in mucosa of stomach and/or duodenum (duodenal two-three times more frequent) Four times more likely in males than female Caused by: Infectious disease (Helicobacter pylori (80%)) NSAID use Pancreatic duct blockage Zollinger-Ellison Syndrome

25. Peptic Ulcer Disease Duodenal Ulcer 20 to 50 years old High stress occupations or situations Genetically predisposed Pain when the stomach is empty Pain at night Gastric Ulcer Greater than 50 years old Employed in positions that require physical activity Pain after eating or when stomach is full Usually no pain at night

26. Peptic ulcer Disease Complications Hemorrhage, perforation, progression to peritonitis, scar tissue accumulation, and potentially an obstruction Signs and Symptoms Steady, well-localized pain that is described as burning, gnawing, or hot-rock sensation Relieved by bland, alkaline foods/antacids (BRAN) Increased pain and symptoms with smoking, coffee, stress, spicy foods Changes in stool and skin color

27. Peptic ulcer disease

28. PANCREATITIS Inflammation of the pancreas in which enzymes auto-digest gland Caused by: EtOH (80% of cases) Gallstones obstructing ducts Elevated serum triglycerides Trauma Viral or bacterial infections

29. Pancreatitis May lead to Peritonitis, pseudocyst formation, hemorrhage, necrosis, secondary diabetes Signs and Symptoms Mid-epigastric pain radiating to back Worsened by food and EtOH consumption Grey-Turner sign (flank discoloration) Cullen’s sign (peri-umbilicial discoloration) Nausea, vomiting, fever

30. Cholecystitis Gall bladder inflammation, usually secondary to gallstones (90% of cases) Risk factors (Five F’s) Fat, fertile, febrile, fortyish, and female Heredity, diet, BCP use Acalculus cholecystitis Burns, sepsis, diabetes, multiple organ systems failure Chronic cholecystitis (bacterial infection)

31. Cholecystitis Signs and Symptoms Sudden pain, often severe and cramping, in RUQ that radiates to right shoulder Point tenderness under right costal margin (Murphy’s sign) Nausea and vomiting Associated with fatty food intake History of similar episodes Can be relieved by nitroglycerin

32. Cholecystitis

33. Appendicitis Inflammation of vermiform appendix Usually secondary to obstruction by fecalith May occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis Signs and Symptoms Classic: Peri-umbilical pain  RLQ pain/cramping, guards upon palpation Nausea, vomiting, low-grade fever Patient found right lateral recumbant in fetal position

34. Appendicitis Signs and Symptoms: McBurney’s sign – pain on palpation of RLQ Aaron’s sign – Epigastric pain upon palpation of RLQ Rovsing’s sign – Pain LLQ upon palpation of RLQ Psoas sign – Pain when patient extends right leg while lying on left side and/or flexes legs while supine Ruptured appendix - true emergency, temporary relief from pain followed by peritonitis

35. appendicitis

36. Appendicitis

37. Bowel obstruction Blockage of intestine Caused by – Adhesions (secondary to surgery) hernias, neoplasms volvulus intussusceptions impaction

38. Bowel Obstruction Pathophysiology Fluid, gas, and air collect near obstruction site causing the bowel to distend impeding blood flow/halting absorption. Water and electrolytes collect in bowel lumen leading to hypovolemia. Bacteria from the gas above the obstruction causes further distension and the distension extends proximally. Finally necrosis and/or perforation occur at the site of the obstruction

39. Bowel Obstruction Signs and Symptoms Severe, intermittent, “crampy” pain High pitched tinkling bowel sounds Abdominal distension Nausea and vomiting Decreased frequency of bowel movements Change in bowel (semi-liquid or pencil-thin stool) If severe enough can have feces in vomitus

40. Hernia Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal) Often secondary to increased intra-abdominal pressure (coughing, lifting, straining) Can progress to ischemic bowel (strangulated hernia) Signs and symptoms: Pain increased with abdominal pressure Inguinal hernia may be palpable in groin or scrotum

41. Crohn’s Disease Idiopathic inflammatory bowel disease Occurs anywhere from mouth to rectum 35-45%: small intestine, 40%: colon Hereditary High risk groups: caucasian females, Jews, persons under high stress

42. Crohn’s Disease Pathophysiology Mucosa of GI tract becomes inflamed and granulomas form invading the submucosa. Muscular layer of the bowel become fibrotic and hypertrophied. All of this causes an increased risk for bowel obstruction, perforation, or hemorrhage.

43. Crohn’s disease

44. Diverticulitis Diverticula Pouches in the colon wall Typically found in older people Usually asymptomatic Related to diets with inadequate fiber Causes: Diverticula traps feces and becomes inflamed Occasionally causes bright red rectal bleeding Rupture of diverticula can lead to peritonitis and sepsis

45. Diverticulitis Signs and Symptoms Usually left-sided pain May localize to LLQ – commonly referred to as “left-sided appendicitis” Alternating constipation and diarrhea Bright red blood in stool Fever

46. Diverticulitis

47. Hemorrhoids Small masses of veins in anus/rectum Most frequently develop when patients are in 30’s to 50’s Most are idiopathic, can be associated with pregnancy, portal hypertension, lengthy driving, constipation Bright red bleeding with pain upon bowel movement May become infected and inflamed

48. Peritonitis Inflammation of abdominal cavity lining Signs and symptoms Generalized pain, tenderness Abdominal rigidity Nausea, vomiting Absent bowel sounds Patient is resistant to movement

49. Hemorrhagic Abdominal Problems Gastrointestinal Hemorrhage Intraabdominal Hemorrhage

50. Esophageal Varices Dilated veins in esophageal wall Occurs secondary to hepatic cirrhosis, common to alcohol abusers Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins

51. Esophageal Varices Portal Hypertension Hepatic scarring slows blood flow Blood backs up in portal circulation Pressure rises Vessels in portal circulation become distended Signs and Symptoms Hematemesis (usually bright red) Nausea, vomiting Hypovolemia Melena

52. Esophageal varices

53. Mallory-WeissSyndrome Longitudinal tears at the gastroesophageal junction Occur as a result of prolonged, forceful vomiting or retching Common in alcoholics May be complicated by presence of esophageal varices

54. Mallory-WeissSyndrome

55. Mallory-weisssyndrome

56. Peptic Ulcer Disease Ulcer erodes through blood vessel Massive hematemesis Melena may be present

57. Aortic Aneurysm Localized dilation due to weakening of aortic wall Usually older patients with a past history of hypertension, atherosclerosis May occur in younger patients secondary to: Trauma Marfan’s syndrome Usually occurs just above aortic bifurcation and may extend to one or both iliac arteries

58. Aortic Aneurysm Signs and Symptoms Unilateral lower quadrant pain, low back pain or leg pain May be described as tearing or ripping pain/sensation Pulsatile palpable mass usually above umbilicus Diminished pulses in lower extremities Unexplained syncope, often after bowel movement Evidence of hypovolemic shock

59. Aortic aneurysm

60. Ectopic Pregnancy Any pregnancy that takes place outside of uterine cavity Most common location in fallopian tube Pregnancy outgrows tube, causing tube wall to rupture Hemorrhage into pelvic cavity occurs Suspect in females of child-bearing age with abdominal pain and/or unexplained shock When was the patients LMP?

61. Ectopic Pregnancy Ectopic pregnancy does NOT necessarily cause a missed period

62. Ectopic pregnancy

63. Ectopic pregnancy

64. Assessment of acute abdomen

66. history Does the pain travel anywhere? Gallbladder = angle of right scapula Pancreas = straight through to back Kidney/ureter = around flank to groin Heart = epigastrium, neck/jaw, shoulders, upper arms Spleen = left scapula, shoulder Abdominal aortic aneurysm = low back pain, radiating to one or both legs

67. History How long have you been hurting? > 6 hours = increased probability of surgical significance Nausea and/or vomiting? How much and how long Consider hypovolemia Blood or coffee ground emesis Any blood in GI tract = emergency until proven otherwise Urine changes? Change in frequency, color, or odor; or increased urgency,

68. History Bowel movements? Change in bowel habits? Change in color? Change in odor? Bright red Melena (black, tarry, and foul-smelling) Dark (suspect bleeding)

69. History Last menstrual period? Abnormal bleeding? In females, lower abdominal pain = gynecological problem until proven otherwise In females of child-bearing age, lower abdominal pain = ectopic pregnancy until proven otherwise

70. Physical exam Position and general appearance Still refusing to move = inflammation or peritonitis Extremely restless = obstruction Gross appearance of abdomen Distended Discolored Consider possible third spacing of fluid

71. Physical exam Vital Signs Tachycardia = more important sign of volume loss than a falling blood pressure Rapid shallow breathing = possible peritonitis Consider performing a “tilt” test Bowel sounds Auscultate before palpating Listen for 1 minute in each quadrant Absent sounds= possible peritonitis, shock High pitched tinkling sounds = possible bowel obstruction

72. Physical exam Palpation Palpate each quadrant Palpate area of pain last Do not check rebound tenderness in prehospital setting All abdominal tenderness is significant until proven otherwise

73. Management Oxygen by NRM IV of Lactated Ringers or Normal Saline Solution Keep patient warm Monitor vital signs Monitor EKG – Consider MI with pain referred to abdomen in patients under 30 years old Keep patients NPO

74. Management Treat pain per protocols (some believe that masking/treating pain is wrong) Give a thorough report to receiving facility For aortic aneurysm considering taking patient to hospital that is capable of CT surgery