02 gastroenterology

Dutchess Community College EMS

Gastroenterology


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 supportMaintain an open airwayHigh flow oxygen

Circulatory supportElectrocardiogramMonitor 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 TractLower Gastrointestinal TractLiverGallbladderPancreasAppendix


Upper GI Tract


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.

Upper Gastrointestinal Bleeding


EsophagealAnatomy


Causes Peptic Ulcer Disease Gastritis Rupture of Varicies Mallory-Weiss Tear Esophagitis Duodenitis

Upper Gastrointestinal Bleeding


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 PyloriInitiating 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 organismsRotavirus, 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 organismsBacteria 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 transmissionFecal-oralIngestion of infected food or non-potable water

Susceptibility and resistanceTravelers into endemic areas are more susceptiblePopulations in disaster areas, where water supplies are contaminated, are susceptibleNative 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 measuresEMS 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 measuresHealth care workers treating gastroenteritis patients must be careful to avoid habits that facilitate fecal-oral/ 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


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.


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

Lower Gastrointestinal Bleeding


Lesions


Ulcerative Colitis

Pathophysiology Causes Unknown

Signs & Symptoms Abdominal Cramping Nausea, Vomiting,

Diarrhea Fever or Weight Loss

Treatment Follow general

treatment guidelines.


Ulcerative Colitis

http://www.drpstokes.com/diseases_02.htm

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


Adhesions

Bowel Obstruction


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



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



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 aciniLeaked 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


Use PPE and follow BSI precautions


HemorrhoidsPathophysiology 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 intra-

abdominal 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.


Congenital GI anomalies Gastrochisis:

portions of the GI system lie outside the abdominal wall

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Congenital GI anomalies (cont’d) Intestinal

malrotation: intestines rotated incorrectly during development


Congenital GI anomalies (cont’d) Pyloric stenosis:

hypertrophy of the pyloric sphincter of the stomach

GI bleeding can occur in children.


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.


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.

Gastrointestinal Conditions in 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.

Prevention Strategies*


Gastroenterology Review

General Pathophysiology, Assessment, and Management

Specific Illnesses Upper Gastrointestinal Diseases Lower Gastrointestinal Diseases Accessory Organ Diseases


QUESTIONS ?

Education

02 gastroenterology