02 gastroenterology

Gastroenterology

Dutchess Community College EMS

General Pathophysiology
General Risk Factors






Excessive Alcohol Consumption
Excessive Smoking
Increased Stress
Ingestion of Caustic Substances
Poor Bowel Habits

Emergencies


Acute emergencies usually arise from chronic
underlying problems.


Abdominal Pain
Types






Visceral
Somatic
Referred
Hemorrhagic
Non-hemorrhagic

Causes




Inflammation
Distention
Ischemia

General Assessment
Scene Size-up & Initial Assessment
Scene clues.
 Identify and treat life-threatening conditions.



General Assessment
Focused History & Physical Exam
Obtain SAMPLE History.
 Obtain OPQRST History.
 Associated symptoms
 Pertinent positives and negatives
 Previous history of same event
 Nausea/ vomiting
 Change in bowel habits/ stool






Constipation, Diarrhea

Weight loss

General Assessment


Physical Exam
General assessment and vital signs
 Appearance
 Posture
 Level of consciousness
 Apparent state of health
 Skin color
 Vital signs
 Inspect, Auscultate, Percuss, Palpate, abdomen
 Female abdominal exam
 Male abdominal exam



General Treatment
Airway and ventilatory support
 Maintain

an open airway
 High flow oxygen

Circulatory support
 Electrocardiogram
 Monitor

blood pressure


General Treatment
Pharmacological interventions
Consider initiating intravenous line
 Avoid intervention which mask signs and
symptoms


Non-pharmacological interventions
Nothing by mouth
 Monitor LOC
 Monitor vital signs
 Position of comfort



General Treatment
Transport consideration
Persistent pain for greater than six hours
requires transport
 Gentle but rapid transport


Psychological support
All actions reflect a calm, caring, competent
attitude
 Keep patient and significant others informed of
your actions



The Gastrointestinal System
Upper
Gastrointestinal
Tract
Lower
Gastrointestinal
Tract
Liver
Gallbladder
Pancreas
Appendix

Upper GI Tract


Upper Gastrointestinal Bleeding
Signs & Symptoms





General abdominal discomfort
Hematemesis and melena
Classic signs and symptoms of shock
Changes in orthostatic vital signs

Treatment


Follow general treatment guidelines.




Begin volume replacement using 2 large-bore IVs.

Differentiate life-threatening from chronic problem.

Esophageal
Anatomy


Upper Gastrointestinal Bleeding
Causes
Peptic Ulcer Disease
 Gastritis
 Rupture of Varicies
 Mallory-Weiss Tear
 Esophagitis
 Duodenitis



Peptic Ulcers
Pathophysiology




Ulcerative disorder
Acid-pepsin formation
Loss of protective effects







Gastric mucosa
Bicarbonate ions
Prostoglandins

Terminology based on the portion of tract affected.
Causes:
NSAID Use
Alcohol/Tobacco Use
H. pylori

Benign Ulcer


Stomach Ulcer with Bleeding


Use of ASA / NSAIDS, smoking
These NSAIDs can penetrate the lining of
the stomach and release substances that
damage cells. NSAIDs and smoking also
block natural chemicals called
prostaglandins that can help repair those
cells. Using NSAIDS regularly for a long
time, such as for arthritis pain, especially
adds to this problem.

NSAID Erosion


Helicobacter pylori
A bacterium called Helicobacter pylori
causes most ulcers - about 80-85% of
duodenal ulcers and 60-80% of gastric
ulcers. The bacteria can spread into the
mucus lining that usually protects the
stomach and small intestine from digestive
acids, damaging it in the process.


Helicobacter Pylori
Initiating Inflammation


Peptic Ulcers
Symptoms
Gnawing or burning pain
 In the abdomen between sternum and navel
 Can be a dull ache or strong hunger pains
 The elderly may not feel symptoms at all



Pain from Ulcers
Gastric ulcers


strike at any time of the day, but it's usually
worst after eating a meal, up to three hours
later.

Duodenal ulcers


typically shows up when the stomach is empty at night or between meals. It may last for a
number of weeks and then temporarily go
away. Food or antacids can often relieve this
kind of pain.

Acute Gastroenteritis
Causative organisms
Rotavirus, Norwalk virus, and many others
Parasites




Protozoa giardia lamblia
Crypto sporidium parvum
Cyclosporidium cayetensis

Contracted via fecal-oral transmission, contaminated
food and water
Cyclosporidium reported to be contracted by
swimming in contaminated waters

Causative organisms
Bacteria







Escherichia coli
Klebsiella pneumonia
Enterobacter
Campylobacter jejuni
Vibrio cholera
Shigella




Not part of normal intestinal flora

Salmonella


Not part of normal intestinal flora

Modes of transmission
Fecal-oral
Ingestion of infected food or non-potable water

Susceptibility and resistance
Travelers into endemic areas are more susceptible
Populations in disaster areas, where water supplies
are contaminated, are susceptible
Native populations in endemic areas are generally
resistant

Signs & Symptoms
Rapid Onset of Severe Vomiting and Diarrhea
 Hematemesis, Hematochezia, Melena
 Diffuse Abdominal Pain
 Classic Signs of Shock



Gastroenteritis
Similar to Acute Gastroenteritis


Long-Term Mucosal Changes or Permanent
Damage.
Primarily due to microbial infection.
 More frequent in developing countries.



Gastroenteritis
Patient management and protective measures
EMS personnel - do not work when ill if your job
involves patient contact
Environmental health and development/ availability
of clean water reservoirs, food preparation and
sanitation
Disaster workers and travelers to endemic areas
must be vigilant in knowing the sources of their
water supplies or drink hot beverages that have been
brisk-boiled or disinfected

Gastroenteritis
Patient management and protective measures
Health care workers treating gastroenteritis patients
must be careful to avoid habits that facilitate fecaloral/ mucous membrane transmission, observe BSI
and effective hand washing
Selected organisms may be sensitive to antibiotics
Epidemic treatment is normally symptomatic


Erosive Gastritis
LESIONS


Esophageal Varices
Cause


Increased Portal Hypertension
Chronic alcohol abuse and liver cirrhosis
 Ingestion of caustic substances


Result


Esophagitis with erosion


Esophageal Varices
Signs & Symptoms





Hematemesis, Dysphagia
Painless Bleeding
Hemodynamic Instability
Classic Signs of Shock

Treatment


Follow General Treatment Guidelines.



Aggressive Airway Management
Aggressive Fluid Resuscitation


Varicies


Inverted esophagus on post
showing varicies


Esophagitis


Erosive Esophagitis


Mallory-Weiss Tear
A tear in the lower end of the esophagus
Caused by severe vomiting.
Common in alcoholics.
May also be caused by increased pressure in
the abdomen from coughing, hiatal hernia,
or childbirth.


Mallory Weiss Tear


Lower GI Tract


Lower Gastrointestinal Bleeding
Pathophysiology
Bleeding distal to the ligament of Treitz
 Causes


Diverticulosis
 Colon lesions
 Rectal lesions
 Inflammatory bowel disorder



Lower Gastrointestinal Bleeding
Signs & Symptoms
Determine acute vs. chronic.
 Quantity/color of blood in stool.
 Abdominal pain
 Signs of shock.


Treatment




Establish IV access with large-bore catheter(s).

Lesions


Ulcerative Colitis
Pathophysiology


Causes Unknown

Signs & Symptoms




Abdominal Cramping
Nausea, Vomiting,
Diarrhea
Fever or Weight Loss

Treatment


Follow general
treatment guidelines.


Ulcerative Colitis


Irritable Bowel Syndrome (IBS)*
Pathophysiology


Patients often show:
Hypersensitivity of bowel pain receptors
 Hyperresponsiveness of the smooth muscle
 Psychiatric disorder connection


Pathophysiology (cont’d)


Hyperresponsiveness can cause spasm.


Can cause constipation and bloating or diarrhea

Typically begins during childhood
 Can be triggered by various stimuli


Assessment


You will typically be called when the patient is
having a flare-up of symptoms.

Management
Mainly supportive
 Assessment should include the patient’s mood.


Crohn’s Disease
Pathophysiology


Inflammatory disorder


Small bowel, Large bowel

Increased suppressor T-cell activity
 Damages Intestinal submucosa
 Lesions
 Fissures and Fistulas




Can affect the entire GI tract.



Hypertrophy and fibrosis of underlying muscle.

Crohn’s Disease
Signs and Symptoms


Difficult to differentiate.


Clinical presentations vary drastically.

GI bleeding, nausea, vomiting, diarrhea.
 Abdominal pain/cramping, fever, weight loss.



Crohn’s
Disease


Diverticulitis*
Pathophysiology
Diverticulum: weak area in the colon that
begins to have pockets (diverticula)
 Diverticulosis: condition of having diverticula
 Diverticulitis: Inflammation of diverticuli


Diverticulitis*
Pathophysiology
A diet low in fiber creates more solid stool.
 If feces gets trapped in diverticula,
inflammation and infection occur and may
cause:


Scarring
 Adhesions
 Fistula


Diverticulitis*
Assessment


Signs and symptoms include:
Abdominal pain, usually localized on the left lower
abdomen
 Classic infection signs
 Constipation or diarrhea


Diverticulitis*
Management
Ensure severe infection is not present.
 Patients may need fluids and/or dopamine.
 In-hospital treatment includes:


Antibiotics
 Liquid diet
 Surgery


Bowel Obstruction
Pathophysiology
Mechanical
 Non-mechanical
 Lesions
 Obturation of the lumen
 Small/ large bowel
 Adhesions
 Hernias



Bowel Obstruction
Intussusception


Bowel Obstruction
Volvulus


Bowel Obstruction
Adhesions


Bowel Obstruction
Pathophysiology


Other Causes


Foreign bodies, gallstones, tumors, bowel infarction

Signs & Symptoms





Decreased Appetite, Fever, Malaise
Nausea and Vomiting
Diffuse Visceral Pain, Abdominal Distention
Signs & Symptoms of Shock

Treatment




Accessory Organ Diseases
GI Accessory Organs
Liver
 Gallbladder
 Pancreas
 Vermiform Appendix



Appendicitis
Pathophysiology
Inflammation of the vermiform appendix.
 Obstruction of appendiceal lumen
 Ulceration of appendiceal mucosa


Viral
 Bacterial


Frequently affects older children and young adults.
 Lack of treatment can cause rupture and
subsequent peritonitis.



Appendicitis
Signs & Symptoms



Nausea, vomiting, and low-grade fever.
Pain localizes to RLQ
(McBurney’s point).

Treatment


Follow
general
treatment
guidelines.


Cholecystitis
Pathophysiology
Gall Stones in Cystic Duct
 Inflammation of the Gallbladder
 Cholelithiasis
 Chronic Cholecystitis






Bacterial infection

Acalculus Cholecystitis
Burns, sepsis, diabetes
 Multiple organ failure



Cholecystitis
Signs & Symptoms


URQ Abdominal Pain


Murphy’s sign

Nausea, Vomiting
 History of Cholecystitis


Treatment




Pancreatitis
Pathophysiology
 Inflammation of the Pancreas
 Classified

as metabolic, mechanical, vascular, or
infectious based on cause.
 Common causes include alcohol abuse,
gallstones, elevated serum lipids, or drugs.
 Injury or disruption of pancreatic ducts or acini
 Leaked enzymes


Pancreatitis
Signs & Symptoms


Mild Pancreatitis
Epigastric Pain, Abdominal Distention,
Nausea/Vomiting
 Elevated Amylase and Lipase Levels




Severe Pancreatitis
Refractory Hypotensive Shock and Blood Loss
 Respiratory Failure



Hepatitis
Pathophysiology


Injury to Liver Cells




Typically due to inflammation or infection.

Types of Hepatitis
Viral hepatitis (A, B, C, D, and E)
 Alcoholic hepatitis
 Trauma and other causes




Risk Factors


Hepatitis
Signs & Symptoms







Acute/ chronic onset
URQ abdominal tenderness
Loss of appetite, nausea/vomiting, weight loss, malaise
Fatigue, Headache, Photophobia
Clay-colored stool, jaundice, scleral icterus
Pharyngitis, Cough

Treatment




Use PPE and follow BSI precautions


Hemorrhoids
Pathophysiology




Mass of swollen veins in anus or rectum.
Increased portal vein pressure
Mucosal surface




Thrombosis
Infection
Erosion

Signs & Symptoms



Limited bright red bleeding and painful stools.
Consider lower GI bleeding.

Treatment


General treatment guidelines.

Rectal Abscess*
Pathophysiology


Caused when the ducts carrying mucus to the
rectal area become blocked


Allows bacteria to grow and spread to the anus

Rectal Abscess*
Assessment


Symptoms may include:
Rectal pain that increases with defecation
 Rectal drainage
 Constipation


Management


Focus on keeping the patient comfortable.

Acute Infectious Conditions*
GI infection occurs when contaminated
food is ingested or when the GI tract
ruptures.


People that have a difficulty combating
infection:
Immunocompromised
 Very old
 Very young


Acute Infectious Conditions*
Damage may allow contents to be released
into surrounding tissues.
The body will begin to defend itself.
 If the infection continues, it may leave the GI
system and enter the bloodstream.




This is known as sepsis.

Hernia*
Pathophysiology
Organ/structure protrusion into adjacent cavity
 To check for an inguinal hernia:


Place fingers on lower abdomen.
 Instruct patient to cough.
 Weakness in abdominal wall will present as bulging.


Hernia*
Pathophysiology (cont’d)


Caused by any condition that causes intraabdominal pressure:
Obesity
 Standing for long periods
 Straining during bowel movements
 Chronic obstructive pulmonary disease


Hernia*
Assessment


Four types
Reducible
 Incarcerated
 Strangulated
 Incisional


Hernia*
Management
Focus on supportive measures.
 Pain management
 Assess for sepsis


Rectal Foreign Body Obstruction*
Pathophysiology


Originates from upper GI tract or anal insertion

Assessment
Presents with sudden rectal pain with
defecation
 Determine if the rectum has been perforated.


Rectal Foreign Body Obstruction*
Management
Do NOT attempt to remove object.
 Prehospital management should be limited to
patient comfort.


Treat with analgesia if indicated.
 Closely monitor vital signs.


Mesenteric Ischemia*
Pathophysiology
Interruption of the blood supply to the
mesentery
 Can be caused by:


Arterial embolism
 Thrombosis
 Profound vasospasm


Assessment
Gradual or sudden onset
 Symptoms include:


Severe pain with ill-defined location
 Nausea, vomiting, and diarrhea
 Possible blood in stool


Management
Patients require rapid transportation.
 Monitor closely.
 Check vitals for signs of sepsis.
 Fluid resuscitation in cases of shock
 Give analgesics as needed.


Gastrointestinal Conditions in
Pediatric Patients*
GI complaints are common in children.


Prolonged vomiting, diarrhea, or bleeding can
lead to severe changes in sodium and potassium
levels.

Pediatric Patients*
Congenital GI
anomalies
Gastrochisis:
portions of the GI
system lie outside
the abdominal wall
© M. Ansary/Custom Medical Stock Photo



Pediatric Patients*
Congenital GI
anomalies (cont’d)


Intestinal
malrotation:
intestines rotated
incorrectly during
development

Pediatric Patients*
Congenital GI
anomalies (cont’d)


Pyloric stenosis:
hypertrophy of the
pyloric sphincter of
the stomach

GI bleeding can
occur in children.

Pediatric Patients*
Careful assessment is critical.
Check skin turgor, pulse rate, and peripheral
pulse status.
 Severe fluid loss may cause diminished LOC.






Standard fluid resuscitation: 20 mL/kg isotonic fluid

Get a detailed medical history from the parent.

Pediatric Patients*
Patients may have a gastrostomy tube.
If dislodged, place a sterile dressing over it.
 If clogged, talk about ways to clear the tube.
 If the blockage cannot be easily managed, turn
off the feeding, clamp the tube, and transport.


Older Adults*
GI diseases more prevalent in older adults
Abdominal pain can also be a symptom of a
cardiac condition.
Obtain a thorough history and physical exam.
 Consider a 12-lead ECG.
 Monitor vital signs.


Prevention Strategies*
Many behaviors can
prevent or limit
severity of GI
diseases.

Gastroenterology Review
General Pathophysiology, Assessment, and
Management
Specific Illnesses
Upper Gastrointestinal Diseases
 Lower Gastrointestinal Diseases
 Accessory Organ Diseases



QUESTIONS ?


02 gastroenterology

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02 gastroenterology