Abdominal / GI Emergencies

Gastroenteritis

Loose Stools

Contagious causes: Shigella, Giardia, Salmonella, Rotavirus, Clostridium, Staphylococcus aureus

• Rapid onset, elevated temperature, increased bowel sounds
  Request stool tests for ova and parasites, culture, white blood cells, and complete blood count.
  Use anti-nausea medications, pain relievers, and medications to reduce bowel activity.
• Examples: Lomotil, Levsin, Reglan
  Follow a clear fluid diet.

Gastritis

Stomach Inflammation

• Triggers: NSAIDs, alcohol, corticosteroids, contaminated food
• Acute Symptoms: Nausea, vomiting, diarrhea, upper abdominal discomfort, loss of appetite
• Chronic Symptoms: Ulcer formation, bleeding, anemia, risk of peritonitis
• Pain Relief: Often improves with eating
• Onset: Can be sudden or develop gradually
• Management:
  • Rule out cardiac causes
  • Possible use of a nasogastric tube (NGT)
  • Keep patient NPO (nothing by mouth)
  • Administer anti-nausea medications
  • Use H2 receptor antagonists and proton pump inhibitors (PPIs)

Upper GI Bleed

• Main Cause: Bleeding ulcers (responsible for about two-thirds of cases)
  • Other Triggers: Alcohol consumption
  • Symptoms:
    • Vomiting bright red blood or black, tarry stools (melena) due to blood interacting with stomach acid

Ulcer

Discomfort may worsen with eating or during fastingDuodenal ulcers: Pain typically occurs after meals, with potential bleeding but usually no vomiting of blood

Management:

• Use of antacids, antiemetics, and pain relievers
• Dietary Adjustments:
  • Follow a bland diet
  • Opt for low-fiber foods to avoid irritation

Lower GI Bleed

• Common Causes: Ulcerative colitis, tumors, polyps, cecal ulcers, ruptured hemorrhoids, diverticular bleeding
  • Symptom: Bright red blood per rectum (BRBPR)
  • Treatment:
    • Fluid resuscitation
    • Possible surgical intervention

Bowel Obstruction

• Potential Causes: Severe constipation, scar tissue (adhesions), tumors, bowel paralysis (ileus), telescoping bowel (intussusception), twisted intestine (volvulus)
  • Risk Factor: History of abdominal surgery
  • Symptoms: Signs of sepsis, abdominal tightness, vomiting
  • Management:
    • Use of a nasogastric tube (NGT)
    • Keep patient NPO
    • Intravenous fluids (IVF)
    • Surgery may be required

GERD (Gastroesophageal Reflux Disease)

• Symptoms: Burping, burning sensation, feeling of a lump in the throat
  • Treatment:
    • Proton pump inhibitors (PPIs), H2 receptor antagonists, GI cocktail
  • Lifestyle Modifications:
    • Avoid spicy foods, caffeine, and peppermint
    • Consider weight loss and quitting smoking
  • Additional Notes:
    • Can worsen asthma symptoms
    • Alendronate (Fosamax) can irritate the esophagus; patients should sit upright for at least 30 minutes after taking it

Pyloric Stenosis

• Location: Lower stomach outlet is narrowed or blocked
  • Main Symptom: Forceful vomiting
  • Physical Exam: May feel an olive-shaped mass in the abdomen

Pancreatitis

• Causes: Gallstones, excessive alcohol consumption
  • Pain Characteristics:
    • Sharp, deep pain in the left upper quadrant (LUQ)
    • Often starts suddenly
    • May be accompanied by vomiting
    • Can have wet lung sounds in the lower left lung (LLL)

Cholecystitis

• Possible Symptom: Yellowing of the skin or eyes (jaundice)
• Physical Exam Sign: Murphy’s sign – pain on inhalation while pressing on the upper right abdomen

Appendicitis

• Pain Location: Lower right abdomen (RLQ), worsens with movement
  • Pain starts around the belly button and moves to the RLQ within 24 hours
• Physical Exam Signs:
  • Psoas sign: Patient lies on their left side with legs straight. Examiner extends the patient’s right thigh backward.
  • Markle sign: Pain felt when the patient stands on tiptoes and then drops to their heels, jarring the body.
  • Rovsing sign: Pressing on the lower left abdomen (LLQ) causes pain in the RLQ.
  • McBurney’s Point: Pain located two-thirds of the way between the belly button and the front of the hip bone.

Diverticulitis

• Pain Location: Often described as “appendicitis on the wrong side” because the pain is in the lower left abdomen (LLQ) instead of the RLQ
  • More common in older adults (over 50)
  • Pain is usually dull and aching
  • Possible Symptom: Blood in the stool
• Treatment Options:
  1. Augmentin
     • Immediate Release (IR): 875 mg every 8-12 hours for 4-10 days
     • Extended Release (ER): 2,000 mg every 12 hours for 4-10 days
  2. Ciprofloxacin: 500 mg every 12 hours for 7-10 days
     • Combined with Metronidazole: 500 mg every 8 hours for 7-10 days

Summary of Conditions Affecting the Lower Abdomen

DEFINITION

• UC – Inflammation limited to the large intestine and rectum
• Crohn’s – Chronic inflammation impacting scattered areas throughout the digestive tract, from mouth to anus
• IBS – A functional disorder affecting bowel movements without structural damage
• Celiac Disease – Autoimmune response triggered by gluten consumption

Anatomical Distribution

• UC – Affects only the colon
• Crohn’s – Can affect any part of the GI tract; has skip lesions
• IBS – Affects the colon
• Celiac Disease – Primarily affects the small intestine

Presentation

• UC – Bloody diarrhea, proctitis, tenesmus, weight loss
• Crohn’s – Alternating diarrhea and constipation, crampy or steady abdominal pain, perianal issues (fistulas, ulcers, skin tags), weight loss
• IBS – Recurrent crampy abdominal pain relieved by defecation, no weight loss
• Celiac Disease –
  • Infancy: Failure to thrive
  • Older children: Delayed growth, malnutrition
  • Adults: Variable symptoms, possible weight loss, nutrient deficiencies, higher osteoporosis risk

Histology

• UC – Mucosal inflammation, crypt distortion, cryptitis, crypt abscesses, loss of goblet cells
• Crohn’s – Inflammation in the submucosa or full thickness, deep ulcers, fistulas, patchy changes, granulomas
• IBS – Normal histology
• Celiac Disease – Subtotal villous atrophy

Risk Factors

• UC – Equal in males and females, ex-smokers, HLA-DR103
• Crohn’s – Equal in males and females, higher risk in Ashkenazi Jews, CARD 15/NOD-2 mutation
• IBS – More common in young females, possible history of PTSD, anxiety, or previous gastroenteritis
• Celiac Disease – More common in females, associated with autoimmune disorders (HLA-linked), insulin-dependent diabetes, thyroid disorders

IBS

• A condition related to gastrointestinal motility and spasms
• Elevated ESR
• HIGH FIBER DIET recommended
• Associated with mental health issues like depression and anxiety

Treatment

• Mesalamine suppositories: for mild to moderate ulcerative colitis or Crohn’s disease
• Oral sulfasalazine: for inflammatory bowel diseases
• Left-sided ulcerative colitis: treatment involves a combination of oral and rectal aminosalicylates

Crohn’s Disease

Characterized by abdominal pain, diarrhea, and weight loss

• Affects all layers of the bowel (unlike UC, which only impacts the mucosa and submucosa)
• Can involve the entire gastrointestinal tract and presents with skip lesions

Bone Density Changes in Celiac Disease

Low Bone Density:

• Common in young females and older individuals of both sexes

Normal Bone Density:

• Seen in young men and middle-aged adults

Diets by Diagnosis

• IBS: Avoid sorbitol (which causes gas bubbles) and refrain from drinking water with meals
• Esophagitis: Steer clear of spicy foods, all alcoholic beverages, and opt for small, frequent meals
• GERD: Stick to small, low-fat meals
• Pancreatitis: Avoid alcohol and caffeine
• Cholecystitis: Follow a low-fat diet

Esophageal Varices

Portal hypertension due to cirrhosis leads to congestion

• Symptoms: Dull pain, signs of hemorrhage
• Treatment: Vitamin K, vasopressors, octreotide (Sandostatin)

Mallory-Weiss Tear

Tear in the esophagus caused by forceful vomiting

• Up to 70% of cases linked to heavy alcohol use, and it can also occur in individuals with bulimia
• Increased risk of severe bleeding when combined with esophageal varices