Gastrointestinal

Key Concepts to Remember

Cullen’s Sign:

• Description: Bruising around the umbilical area, indicating intraperitoneal bleeding.

Grey-Turner’s Sign:

• Description: Bruising on the flank, a sign of retroperitoneal bleeding.

Kehr’s Sign:

• Description: Sharp pain in the left shoulder due to diaphragm irritation, often associated with abdominal injury.

Abdominal Trauma

• Signs:
  • Umbilical bruising: Suggests intraperitoneal hemorrhage.
  • Flank bruising: Indicates retroperitoneal bleeding.

Abdominal Compartment Syndrome (ACS)

• Characteristics: Can occur without noticeable distention.
• Common Triggers: Trauma, emergency abdominal surgeries, massive fluid resuscitation.
• Effects of Increased Intra-Abdominal Pressure (IAP):
  • Reduced cardiac output.
  • Increased systemic vascular resistance (SVR).
  • Decreased renal perfusion and venous return.

Monitoring: Bladder pressure measurement.

• Normal: 0–5 mmHg.
• Hypertension: >12 mmHg.
• Decompression laparotomy required: >20 mmHg.
• Fatal threshold: >25 mmHg.

Prevention for IAP > 12 mmHg:

• Elevate the head of bed < 20° or use reverse Trendelenburg.
• Manage pain and agitation.
• Loosen tight clothing.
• Avoid hypervolemia.
• Use NGT with low intermittent wall suction (LIWS).
• Check for bowel impaction.

Esophageal Varices

• Cause: Portal hypertension, often linked to liver disease.
• Treatment:
  • Endoscopy with banding or sclerotherapy.
  • Esophageal balloon (Sengstaken-Blakemore tube):
    • Inserted nasally or orally.
    • Inflated to compress blood flow and stop bleeding.
    • Caution: Airway obstruction if displaced—scissors must be kept bedside to deflate the balloon immediately.

Bowel Infarction

• Cause: Decreased blood supply to mesenteric vessels, potentially leading to necrosis, perforation, or peritonitis.
• Treatment: Gastric decompression via NGT and bowel resection if needed.

Bowel Obstruction

• Small Bowel: Sharp, intermittent pain, early vomiting, high-pitched bowel sounds.
• Large Bowel: Dull pain, late vomiting, low-pitched sounds, abdominal distention.
• Progression: Hyperactive bowel sounds early, hypoactive or absent late.
• Treatment: NGT, fluid replacement for hypovolemia, and pain management.

Bowel Perforation

• Signs: Rigid abdomen, rebound tenderness, absent bowel sounds.
• Treatment: Antibiotics after cultures and urgent surgery.

Liver Failure

Chronic Liver Failure:

• Common Cause: Alcohol use disorder.
• Key Considerations: Avoid lactated Ringer’s solution to prevent lactic acidosis.

Ammonia Levels:

• Elevated ammonia (NH3) can lead to encephalopathy and increased ICP.
  • Management:
    • Lactulose to lower ammonia.
    • Neomycin or rifaximin to reduce gut bacteria.

Acute Liver Failure:

• Cause: Acetaminophen overdose.
• Treatment: N-acetylcysteine (Mucomyst).

Labs in Liver Failure:

• Increased: AST, ALT, bilirubin, NH3.
• Decreased: Albumin, protein, blood glucose.

Symptoms: Altered mental status, asterixis, ascites, jaundice, renal failure (hepatorenal syndrome).

Acute Pancreatitis

• Cause: Pancreatic inflammation and autodigestion.
• Symptoms:
  • Boring pain radiating across quadrants.
  • Nausea, vomiting, rigid abdomen, absent bowel sounds.
  • Hemorrhagic signs: Cullen’s (umbilicus) and Grey-Turner’s (flank).
• Complications:
  • Left lobe atelectasis, left pleural effusion, ARDS.
  • Systemic inflammatory response syndrome (SIRS).
• Labs: Elevated amylase, lipase, glucose; decreased calcium.

Management:

• NGT, fluid/electrolyte therapy, pain control (morphine), PPIs, H2 blockers.

Spleen Injury

• Cause: Typically blunt abdominal trauma.
• Signs of Rupture: Kehr’s sign, abdominal distension, absent bowel sounds.
• Treatment: Supportive care and monitoring for sepsis.

Nutrition

Enteral Nutrition

• Benefits: Preferred over TPN, prevents malabsorption.
• Timing: Initiate within 24–48 hours.
• Key Points:
  • Bowel sounds and resolved ileus are not prerequisites.
  • Confirm tube placement via x-ray.
  • Keep the head of the bed elevated >30°.

Total Parenteral Nutrition (TPN)

• Timing:
  • Begin after 7 days if the patient was previously well-nourished.
  • Start immediately if malnourished.