Acute GIPart 1 and 2

Statistics

• What percentage of patients presenting to emergency departments offer abdominal pain as their chief complaint?

• 31.8% or 5.8 million people (1999-2000)• This number increased to 7 million (2007-2008)• Of the 7 million cases between 2007 and 2008

what percent arrived by ambulance?• 26.9%

CDC.gov

BreakdownAbsorbEliminate

Map Quest• Breakdown

– start = mouth – On ramp = esophagus – Round about = stomach – Exit = pyloris

• Absorb– Enter Country road = Small intestine

• Duodenum• Jejunum• Ileum

• Eliminate– Enter Parkway to large intestine

• Ascending colon• Transverse colon• Descending colon• Sigmoid colon• Rectum

Digestion• Mouth

– Chewing and swallowing (CNS)• Stomach

– Hydrochloric Acid – Pepsin– Intrinsic Factor B12 absorption– Peristalsis outward

• Small intestine– Duodenal secretions

• Amylase, Lipase pancreatic enzymes (bicarbonate)• Bile from liver to gallbladder via common bile duct

– Fat/protein/carbohydrates– Nutrients & Vitamins absorbed

• Large intestine– Ileocecal valve colon– Bacteria breakdown remaining waste– Slow peristalsis water and electrolytes reabsorbed

Case Study

• “After every time I eat a meal within 20 minutes I have the immediately go to the bathroom. I also become very bloated and "gassy" almost nauseous, but never threw up, only go to the bathroom and it goes away until I eat again. At first I thought I was lactose-intolerant (because my sister 22, just developed a severe case out of no where) but it isn't just dairy that causes this, it is with any food. My brother of 25 also suffers from very similar symptoms.”

WebMD Forum

Case Study• A 67 year old male involved in an MVC. Witnesses say he drifted into

oncoming traffic on Ridge Road and struck another vehicle head-on.• He was a restrained driver, there was significant passenger side

compartment intrusion. The passenger, an elderly woman, remains trapped in the vehicle, Mercy Flight is en route to the scene

• The patient is hypotensive with 2 BP readings in the 70’s. His HR is 140. He is still awake, moaning in pain.– Based on Trauma Activation Criteria and Level I Trauma Alert is issued

• An OR is prepped• A cooler of type O negative is prepared• A CT scanner is held• The Trauma Team Assembles

• The patient arrives to ED. – What is you first priority?

• There is no history available– You hang 2 liters of NS via rapid infuser

• You cut his clothing off…– A bedside ultrasound is preformed

• There is “free fluid”

• He vomits• His airway is compromised

• He is intubated

• BP= 60/40• You give 2 units of blood• BP: 70/40• You give 2 more units of blood

– The CT tech yells out “we’re ready”• You suction emesis out of his mouth and then insert an OG tube• Social work enters the room: “I got a hold of his daughter she said

he’s on blood thinners for his DVTs” • BP: 80/60 HR: 130• You take the patient to CT

Group Work• The CT scan reveals a liver laceration. The

patient is taken to the OR. The surgery went well and the damage was repaired. The patient was extubated and is hemodynamically stable. He was transferred to a floor. His sister, the elderly passenger, is still in the ICU.

• You are the nurse assigned to this patient

Before and After

Triage• Anticipate/Coordinate/Evaluate (ACE)– Is this new or old?– Is this expected or unexpected?– What is the patients “normal”?– Is this life threatening?– Can the cause long-term harm?– Is this time sensitive?

• BP/HR/RR/Sat/T + pain score• What are the physiological signs of pain?

Subjective Data• OLDCART• Onset• Location• Duration• Characteristics• Aggravating Factors• Relieving Factors• Treatments

• Focused History– Abdominal Pain– Dyspepsia– Gas– Nausea– Vomiting– Diarrhea– Constipation– Fecal incontinence– Jaundice– Previous GI disease

• http://www.youtube.com/watch?v=UM-HWkbnDfg

Objective: Inspection

InspectionSurface/contour/movement• Scars

– Describe (length/location/character)• Striae

– Pink-purple = Cushings• Dilated veins

– Cirrhosis or inferior vena cava obstruction• Rashes/Lesions • Contour

– Flat/rounded/protuberant– ascites– pregnancy– hernia– distended bladder– AAA– Mass

• Peristalsis– Observe for several minutes if you suspect obstruction – Increased waves with obstruction

• Pulsations– Aortic aneurysm (AAA)

Objective: Auscultation

Auscultation• Listen prior to percussion/palpation• Bowel sounds – one spot RLQ is usually sufficient – 5 to 34 per minute

normal– Altered with diarrhea, intestinal obstruction, paralytic ileus, and peritonitis

• Bruits– Suggest vascular occlusive disease– Listen over aorta, iliac arteries, femoral arteries – May be heard in systole normally, having a bruit in diastole is more

indicative of arterial insufficiency/partial occlusion• Borborygmi

– “stomach grumble” normal in transient waves• Listen for friction rubs over the liver and spleen

– Tumor/infection/infarction

Objective: Percussion

Percussion• Helps determine the amount and distribution of

gas• Identifies masses (solid or fluid filled)• Liver/spleen boarders• Tympany + dullness – Check all 4 quadrants– Tympany = gas– Typanitic = intestinal obstruction

• Dullness = fluid/feces– Can be related to a mass in the abdomen

Objective: Palpation

Palpation

• Light palpation– Superficial, relaxes patient, identify areas of pain

• Deep palpation– Can delineate abdominal masses

• Peritoneal Inflammation– Have the patient cough, ask where it hurts, use one finger to

touch– Rebound tenderness = peritoneal inflammation

• “does it hurt more when I push down or let go?”• “did the pain get worse with the bumps in the road”

• Be aware of referred pain

Specialty Exams• Percussing to establish the liver boarders• Palpating the liver boarders– Hooking technique

• Percussing the spleen• Palpating the spleen• Palpating the kidneys• CVA (costal vertebral angle) tenderness

Referred Pain

Acute GIPart 2

Jason Morgan RN, BSRoberts Wesleyan

InspectionSurface/contour/movement• Scars

– Describe (length/location/character)• Striae

– Pink-purple = Cushings• Dilated veins

– Cirrhosis or inferior vena cava obstruction• Rashes/Lesions • Contour

– Flat/rounded/protuberant– ascites– pregnancy– hernia– distended bladder– AAA– Mass

• Peristalsis– Observe for several minutes if you suspect obstruction – Increased waves with obstruction

• Pulsations– Aortic aneurysm (AAA)

Auscultation• Listen prior to percussion/palpation• Bowel sounds – one spot RLQ is usually sufficient – 5 to 34 per minute

normal– Altered with diarrhea, intestinal obstruction, paralytic ileus, and peritonitis

• Bruits– Suggest vascular occlusive disease– Listen over aorta, iliac arteries, femoral arteries – May be heard in systole normally, having a bruit in diastole is more

indicative of arterial insufficiency/partial occlusion• Borborygmi

– “stomach grumble” normal in transient waves• Listen for friction rubs over the liver and spleen

– Tumor/infection/infarction

Percussion• Helps determine the amount and distribution of

gas• Identifies masses (solid or fluid filled)• Liver/spleen boarders• Tympany + dullness – Check all 4 quadrants– Tympany = gas– Typanitic = intestinal obstruction

• Dullness = fluid/feces– Can be related to a mass in the abdomen

Palpation

• Light palpation– Superficial, relaxes patient, identify areas of pain

• Deep palpation– Can delineate abdominal masses

• Peritoneal Inflammation– Have the patient cough, ask where it hurts, use one finger to

touch– Rebound tenderness = peritoneal inflammation

• “does it hurt more when I push down or let go?”• “did the pain get worse with the bumps in the road”

• Be aware of referred pain

Nursing Process• Define this condition• What physical exam findings would you

expect?• What subjective data/complaints would you

expect?• What’s the plan for your patient?• What are your nursing diagnoses?• What would you teach your patient?

Content Overview

1. Appendicitis2. Intestinal Obstruction3. Esophageal varices4. Peptic ulcers5. Pancreatitis6. Upper/lower GIB7. Peritonitis/NG tubes8. Diverticulitis

http://www.youtube.com/watch?v=9RFYqH4DnHU

Acute Abdomen

• Severe pain• Rigid, board-like on exam• Muscle spasms r/t peritoneal irritation• DX problem– Peritonitis– Bowel rupture– Bleeding

• Testing • Aggressive pain management - OR

Assessment findings of common disorders

• Right lower quadrant (RLQ)– Appendicitis– Perforated duodenal

ulcer• Cecal volvulus• Strangulated hernia

– Left lower quadrant (LLQ)• Ulcerative colitis• Colonic diverticulitis

– Right upper quadrant (RUQ)• Liver hepatitis• Acute hepatic congestion• Biliary stones, colic• Acute cholecystitis• Perforated peptic ulcer

– Left upper quadrant (LUQ)• Splenic trauma• Pancreatitis• Pyloric obstruction

Appendicitis

Appendicitis

• Assessment:– Severe sudden

epigastric pain– Pain increases w/

movement, breathing– Pain may radiate to

shoulder or back– Indigestion– Acute Abdomen– Psoas sign– Obturator sign

• Vital signs?

• Testing– Lab work (WBC)– X-ray (free air series)– CT scan – contrast

• Treatment– Surgery (endoscopic)

• Complications– Rupture – SBP

• Nursing Care– PIV– IVF– NPO– OR prep– NG

Intestinal Obstruction

Intestinal Obstruction• Partial or complete obstruction in

the small or large intestine• Impairs absorption

– Electrolyte abnormalities

• Cause– Hernia– Adhesions– Tumor– Paralytic ileus– Neuromuscular disease

• Assessment– Distended ABD– N/V, constipation– Pain– Hyperactive bowel sounds or absent

• Testing– Labs– X-ray– CT scan– U/S

• Treatment– Can be conservative such

as bowel rest– Surgical option

• Nursing Care– IV/IVF/NPO/NG/Pain

medications

Obstruction

SBO = copious vomiting/ hyperactive BSLarge Intestine = uncommon emesis /decrease or absent BS

Esophageal Varices

Esophageal Varices• Risk– Liver disease

• Portal hypertension

– Portal system engorged

• Rupture– High mortality– Vomiting bright red

blood– Hemodynamic

monitoring– Banding via endoscope

• Treatment– Gastric decompression– Sclerotherapy– Endoscopic band ligation– Esophogogastric balloon

tamponade– ETOH withdrawl – Transjugular intrahepatic

portosystemic shunting (TIPS)

Peptic Ulcer

Peptic Ulcer

• HPI– Severe sudden epigastric

pain– Pain increases w/

movement, breathing– Pain may radiate to

shoulder or back– Indigestion– Acute Abdomen

• PMH?• Medications?

• Objective Data– X rays - Free air series– CT– Endoscopy– CBC– Coagulation studies

• PT/PTT• INR

• Treatment– PPI/H2 blocker

Gastric Surgery

Gastric Surgery• Open vs. closed

(laparoscopic)– Indication related to

diagnosis– Maintain NPO status – ABX on-call to OR– Lab work

• CBC• Chemistry panel• Coags• Type and screen

– Pre-op EKG (cardiology clearance)

• POST-OP considerations

Complications◦ Include typical post-op

complications (bleeding, infection, pain, ileus)

◦ Dumping syndrome Rapid emptying into small intestine Water rushes into intestine causing

nausea, diarrhea, sweating, palpitations, syncope

May result in malnutrition, weight loss, inability to travel from home

• With in 30 minutes of eating– Tachycardia– Palpitations– N-V– Dizziness– May be delayed up to 90 minutes

after a meal.

Abdominal Trauma

• Blunt force trauma• Sheering injuries• Rapid deceleration• Penetrating wounds• MVC and pregnancy• Seat Belt sign• Liver/spleen/kidney laceration• Hemodynamic monitoring

Pancreatitis

Pancreatitis • Acute inflammation resulting in auto-digestion

– Inflammation delays enzyme release which damages the organ• Gallstones and alcohol abuse account for 80 to 90% of cases• Assessment

– Sudden onset of sharp, twisting, deep ,upper abdominal pain – Symptoms include anorexia, hypoactive bowel sounds, abdominal distention, as well

as nausea and vomiting. • Management

– IVF – Pain management– NPO (block stimulation of enzymes)– 3 days to 7 weeks for recovery

• ERCP (endoscopic retrograde cholangiopancreatography)– Endoscopic approach to view structures such as the bile duct

• Gallstones can be removed this way

• MRCP – MRI to see biliary tree and pancreatic ducts

GI Bleed

Upper GI BleedCauses◦ Ulcers, varices, trauma, Mallory-Weiss tears, ingestion of foreign

bodies◦ Only 5% GIBs originate in small bowel

Nursing considerations◦ NPO◦ Isotonic IVF, blood products◦ Gastric and airway suction◦ Left lateral (side) decubitus (lying) position◦ Endoscopy within 24h◦ Post endoscopy complications:

Spasm, perforation Decreased BS, abd distension Mediastinis, fever

Lower GI Bleed

Causes– Ulcerative colitis– Diverticulitis– Hemorrhoids– Colon polyps– Cancerous tumors– Crohn's disease– Trauma– Foreign object

insertion / ingestion

Nursing considerations– NPO– Isotonic IVF, blood products– Guiaic stools until LGIB

confirmed– Prep for colonoscopy

• Oral prep• Enemas contraindicated

– Post colonoscopy complications:• Perforation• Decreased BS, abd distension• Infection, fever

Peritonitis

Peritonitis • Inflammation of the peritoneum

– Usually related to bacterial exposure– May be from an injury or trauma– Appendicitis– Perforated ulcer– Diverticulitis– Bowel perforation

• Remedy problem (above)• Watch hemodynamics (shock?)• IVF/ABX• Improvement

– Decrease in temp/HR– ABD softens – (+) BM/flatus– (+)BS

Diverticulitis

Diverticulitis

• A diverticulum is a saclike herniation that extends through the muscle wall of the bowel

• 95% are in the sigmoid colon• When food or bacteria are

retained in the pouches inflammation occurs– Perforation– Abscess formation– Peritonitis – Obstruction

• Typical DX occurs through colonoscopy

• CT scans• X-ray (free-air series)• Labs

– CBC– ESR

• Treatment– PERC drain for abscess– Resection– Colectomy

Review:Nasogastric and Nasointestinal tubes

• Know why the tube is placed• Know how to check placement– What are the gold standards?– What have you been taught in clinical?

• Know the common complications– Nasal breakdown– Low intermittent vs. continuous suction– Aspiration– Discomfort