Gastroenterology “A Cute Abdomen” Dr Baxter Larmon Professor UCLA School of Medicine

Gastroenterology“A Cute Abdomen”

Dr Baxter LarmonProfessor

UCLA School of Medicine

Incidence of GI/GU Disorders

Every year about 62 million people are diagnosed with a gastrointestinal disorder.

The incidence and prevalence of most digestive diseases increase with age, although there are exceptions.

Morbidity & Mortality of GI/GU Disorders

In 1992, GI disorders cost nearly $107 billion in direct health care expenditures.

Currently, GI disorders result in nearly 200 million sick days,

50 million visits to a physician, 16.9 million days lost from school, 10 million hospitalizations, And nearly 200,000 deaths per year.

General Pathophysiology

General Risk FactorsExcessive Alcohol ConsumptionExcessive SmokingIncreased StressIngestion of Caustic SubstancesPoor Bowel Habits

EmergenciesAcute emergencies usually arise from

chronic underlying problems.

Etiology of Pain

InflammationForeign chemicalBacterial contaminationStimulation of nerve endings.Irritation

Stretching, distention, bleeding

Visceral vs. SomaticVisceral pain

Caused by stimulation of autonomic nerve fibers that surround a hollow viscus

Cramping or gas typeGenerally diffuse drill

Somatic painProduced by Bacterial or chemical irritation

of autonomic nerveGuardingDon’t want to moveSuperficial

Solid Organs

Dull and steady in nature.More localized.Bleeding

Within capsule,Rupture;

Hollow Organs

Colicky, crampy, dull, or gassy,Typically intermittent.Diffuse and poorly localized.Path of a tube.The place where the patient is

feeling the most pain may not be the most tender on palpation.

Hollow OrgansUsually associated with

nausea, vomiting, tachycardia,diaphoresis;

Bleedingwithin the organ itself;

Referred PainDefinition

Pain in area removed from tissue that caused the pain

Caused by visceral fibers that synapse in the spinal cord

Causesame spinal segment,skin has more receptors,unable to distinguish,

Referred Pain

NOT ALL ABDOMINAL PAIN IS OF ABDOMINAL ETIOLOGY.

General Assessment

Scene Size-up & Initial AssessmentScene clues.Identify and treat life-threatening

conditions.Focused History & Physical Exam

Focused HistoryObtain SAMPLE History.Obtain OPQRST History.

Associated symptomsPertinent negatives

General AssessmentPhysical Exam

General assessment and vital signs

Abdominal assessmentInspection, Auscultation, and

Palpation, PercussionCullen’s Sign: Discoloration

around the umbical areaGrey-Turner’s Sign:

Discoloration in the flank area

Let’s Review aPhysical Exam

of the Abdomen

General Treatment

Maintain the airway.Support breathing.

High-flow oxygen or assisted ventilations.

Maintain circulation.Monitor vital signs and cardiac

rhythm.Establish IV access.Transport in position of comfort.

Specific Illnesses

The Gastrointestinal System Upper

Gastrointestinal Tract

Lower Gastrointestinal Tract

Liver Gallbladder Pancreas Appendix

CausesPeptic Ulcer DiseaseGastritisEsophagitisDuodenitis

Upper Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding Etiology

ETIOLOGY PERCENTPeptic Ulcer 45Gastric erosions 23Varices 10Mallory-Weiss Tear 7 Esophagitis 6Duodenitis 6Other 2

Signs & SymptomsGeneral abdominal discomfortHematemesis and melenaClassic signs and symptoms of shock Changes in orthostatic vital signs

TreatmentFollow general treatment guidelines.

Begin volume replacement using 2 large-bore IVs.

Differentiate life-threatening from chronic problem.

Upper Gastrointestinal Bleeding

Esophageal Varices

CausePortal

HypertensionChronic alcohol

abuse and liver cirrhosis

Ingestion of caustic substances

Esophageal Varices

Signs & SymptomsHematemesis, DysphagiaPainless BleedingHemodynamic InstabilityClassic Signs of Shock

TreatmentFollow General Treatment Guidelines.

Aggressive Airway ManagementAggressive Fluid Resuscitation

Acute Gastroenteritis

CauseDamage to Mucosal GI Surfaces

Pathologic inflammation causes hemorrhage and erosion of the mucosal and submucosal layers of the GI tract.

Risk FactorsAlcohol and tobacco useChemical ingestionSystemic infections

Acute Gastroenteritis

Signs & SymptomsRapid Onset of Severe Vomiting and

DiarrheaHematemesis, Hematochezia, MelenaDiffuse Abdominal PainClassic Signs of Shock

TreatmentFollow General Treatment Guidelines.Fluid Volume Replacement.Consider Administration of Antiemetics.

Peptic Ulcers

PathophysiologyErosions caused

by gastric acid.Terminology based

on the portion of tract affected.

Causes:Alcohol/Tobacco UseH. pylori

Peptic Ulcers

Signs & SymptomsAbdominal PainObserve for signs of hemorrhagic

rupture.Acute pain, hematemesis, melena

TreatmentFollow general treatment guidelines.Consider administration of histamine

blockers and antacids.

PathophysiologyBleeding distal to the ligament of

TreitzCauses

DiverticulosisColon lesionsRectal lesionsInflammatory bowel disorder

Lower Gastrointestinal Bleeding

Signs & SymptomsDetermine acute vs. chronic.Quantity/color of blood in stool.Abdominal painSigns of shock.

TreatmentFollow general treatment guidelines.

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

Lower Gastrointestinal Bleeding

Crohn’s Disease

Pathophysiology Inflammatory bowel

disease, ? Autoimmune etiology

Can affect the entire GI tract.

Pathologic inflammation: Damages mucosa. Hypertrophy and fibrosis of

underlying muscle. Fissures and fistulas.

Crohn’s Disease

Signs and SymptomsDifficult to differentiate.

Clinical presentations vary drastically.GI bleeding, nausea, vomiting, diarrhea.Abdominal pain/cramping, fever, weight

loss.Treatment

Follow general treatment guidelines.

Diverticulitis Pathophysiology

Inflammation of small outpockets in the mucosal lining of the intestinal tract.

Common in the elderly. Diverticulosis.

Signs & Symptoms Abdominal

pain/tenderness. Fever, nausea, vomiting. Signs of lower GI

bleeding.

Treatment General treatment

guidelines.

Hemorrhoids Pathophysiology

Mass of swollen veins in anus or rectum.

Idiopathic. Signs & Symptoms

Limited bright red bleeding and painful stools.

Consider lower GI bleeding.

Treatment General treatment

guidelines.

Bowel Obstruction

PathophysiologyBlockage of the hollow

space of the small or large intestines

Hernias

Bowel Obstruction

PathophysiologyOcclusion of the

intestinal lumen that results in blockage of the normal flow of intestinal fluids

OR

PathophysiologyOcclusion of the

intestinal lumen that results in blockage of the normal flow of intestinal fluids

OR

Bowel Obstruction

Pathophysiology Twisting of the bowel

Pathophysiology Twisting of the bowel

PathophysiologyAdhesions

Bowel Obstruction

Bowel Obstruction

Signs & SymptomsDecreased Appetite, Fever, MalaiseNausea and VomitingDiffuse Visceral Pain, Abdominal

DistentionSigns & Symptoms of Shock

TreatmentFollow general treatment guidelines.

Accessory Organ Diseases

GI Accessory OrgansLiverGallbladderPancreasAppendix

Appendicitis

PathophysiologyInflammation of the vermiform

appendix.Frequently affects older children

and young adults.Lack of treatment can cause

rupture and subsequent peritonitis.

Cholecystitis

Pathophysiology Inflammation of the

GallbladderCholelithiasisChronic

Cholecystitis Bacterial infection

Acalculus Cholecystitis

Burns, sepsis, diabetes

Multiple organ failure

Pathophysiology Inflammation of the

GallbladderCholelithiasisChronic

Cholecystitis Bacterial infection

Acalculus Cholecystitis

Burns, sepsis, diabetes

Multiple organ failure

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.Viral Hepatitis

A viral inflammatory disease:1. Hepatitis A Virus (HAV),2. Hepatitis B Virus (HBV),3. Hepatitis C Virus (HCV) aka non-A, non-B hepatitis,4. Hepatitis D Virus (HDV) only occurs in individuals

with HBV,5. Hepatitis E Virus (HEV).

CirrhosisInfection

Viral hepatitisToxins

ETOHAltered immune response;Vascular disturbance;

Urology &

Nephrology

Anatomy & Physiology

Ureters Urinary Bladder Urethra Testes Epididymus

and Vas Deferens

Prostate Gland Penis

Inflammatory or Immune-Mediated Disease

Infectious DiseasePhysical ObstructionHemorrhage

General Mechanisms of Nontraumatic Tissue Problems

Differentiating GI and Urologic Complaints

Pathophysiologic Basis of PainCauses of PainTypes of Pain

Visceral painReferred pain

General Pathophysiology, Assessment and Management

Risk Factors Older Patients History of Diabetes History of Hypertension Multiple Risk Factors

Renal and Urologic Emergencies Acute Renal Failure Chronic Renal Failure Renal Calculi Urinary Tract Infection

Renal and Urologic Emergencies

Acute Renal Failure

PathophysiologyPrerenal Acute Renal Failure

Dysfunction before the level of kidneysMost common and most easily reversible

Renal Acute Renal FailureDysfunction within the kidneys

themselvesPostrenal Acute Renal Failure

Dysfunction distal to the kidneys

Acute Renal Failure

AssessmentFocused History

Change in urine outputSwelling in face, hands, feet, or

torsoPresence of heart palpitations or

irregularityChanges in mental function

Acute Renal FailurePhysical Assessment

Altered mental status Hypertension Tachycardia ECG indicative of hyperkalemia Pale, cool, moist skin

Acute Renal Failure

Physical Assessment

Edema of face, hands, or feet

Abdominal findings dependent on the cause of ARF

Renal Calculi

PathophysiologyResults when “too

much insoluble stuff” accumulates in the kidneys.

Stone typesCalcium saltsStruvite stonesUric acidCystine

Renal Calculi

AssessmentFocused History

Severe pain in one flank that increases in intensity and migrates from the flank to the groin

Painful, frequent urination with visible hematuria

Prior history of calculiPhysical Exam

Difficult due to patient discomfortTachycardia with pale, cool, and moist skin

Urinary Tract Infection

PathophysiologyRisk Factors

Increased risk in female or catheterized patients

Sexual activityLower and Upper UTIs

UrethritisCystitisProstatitisPyelonephritisCommunity-acquired vs. nosocomial infections

Urinary Tract Infection

AssessmentFocused History

Abdominal painFrequent, painful urinationA “burning sensation” associated with

urinationDifficulty beginning and continuing to

voidStrong or foul-smelling urineSimilar past episodes

Blarmon@mednet.UCLA.edu