Get in my Belly

Abdominal Emergencies
Fred W. Wurster III, AAS, NREMT-P

Abdominal Emergencies
Anatomy Review
Non-hemorrhagic abdominal pain Gastrointestinal hemorrhage

Assessments
Treatment modalities

Abdominal boundaries

Peritoneum
Abdominal cavity
Double-walled structure
Visceral and Parietal

Separates abdominal cavity into two areas

Peritoneal cavity or space Retroperitoneal space

Peritoneum

Abdominal anatomy

Abdominal anatomy

GI Structures
Primary
Mouth/Oral Cavity Pharynx Esophagus (digestive tract between pharynx & stomach) Stomach (hollow digestive organ, receives food from
esophagus)

Small Intestine (between stomach & cecum, composed of

duodenum, jejunum, & ileum)

Large intestine (from ileocecal valve to anus, composed of

cecum, colon, & rectum)

GI Structures
Accessory
Salivary glands (produce/secrete saliva) Liver (solid organ in RUQ; produces/secretes bile, essential
proteins, clotting factors; detoxifies; stores glycogen)

Gallbladder (sac located beneath liver, stores/concentrates

bile)

Pancreas (Endocrine secretes insulin/Exocrine - secretes

digestive enzymes & bicarbonate)

Appendix (attached to large intestine, no physiologic

function)

Major Blood Vessels

Aorta
Inferior Vena Cava

Organs
Solid
Liver Spleen Pancreas Kidneys Ovaries

Organs
Hollow
Stomach Intestines Gallbladder and bile ducts Ureters Urinary bladder Uterus Fallopian tubes

Abdominal quadrants

Right Upper Quadrant

Liver
Gallbladder Duodenum

Transverse colon (partial)

Ascending colon (partial)

Left Upper Quadrant

Stomach
Liver (partial) Pancreas

Spleen
Transverse colon (partial) Descending colon (partial)

Right Lower Quadrant

Ascending colon
Appendix Ovary

Fallopian tube

Left Lower Quadrant

Descending colon
Sigmoid colon Ovary

Fallopian tube

Abdominal Pain
Visceral
Diffuse in nature Stretching of peritoneum of organ capsules by distension or edema Poorly localized Can be perceived at remote locations related to the affected organs sensory innervation

Abdominal Pain
Somatic
Sharp in nature Well localized Inflammation of parietal peritoneum or diaphragm

Referred
Perceived at a distance from the affected organ

Non-hemorrhagic Abdominal Pain

Esophagitis
Inflammation of distal esophagus usually from GERD or hiatal hernia Signs/Symptoms
Sub-sternal burning pain (usually epigastric) Pain worsens when laying supine Sometimes temporarily relieved by Nitroglycerine Usually non-hemorrhagic

Esophagitis

Non-hemorrhagic Abdominal Pain

Acute Gastroenteritis
Inflammation of stomach and intestine May cause bleeding and ulcers Caused by:
Increased acid secretion and biliary reflux Chronic EtOH use/abuse and medication (ASA, NSAIDS) Infections

Signs and Symptoms

Epigastric pain, usually a burning sensation, tenderness on exam, nausea, vomiting, diarrhea, possible bleeding

Peptic ulcer disease

Causes craters in mucosa of stomach and/or duodenum (duodenal two-three times more frequent)
Four times more likely in males than female Caused by:
Infectious disease (Helicobacter pylori (80%)) NSAID use Pancreatic duct blockage Zollinger-Ellison Syndrome

Peptic Ulcer Disease

Duodenal Ulcer
20 to 50 years old High stress occupations or situations Genetically predisposed

Gastric Ulcer
Greater than 50 years old Employed in positions that require physical activity Pain after eating or when stomach is full Usually no pain at night

Pain when the stomach is empty

Pain at night

Peptic ulcer Disease

Complications
Hemorrhage, perforation, progression to peritonitis, scar tissue accumulation, and potentially an obstruction

Signs and Symptoms

Steady, well-localized pain that is described as burning, gnawing, or hot-rock sensation Relieved by bland, alkaline foods/antacids (BRAN) Increased pain and symptoms with smoking, coffee, stress, spicy foods Changes in stool and skin color

Peptic ulcer disease

PANCREATITIS
Inflammation of the pancreas in which enzymes auto-digest gland
Caused by:
EtOH (80% of cases) Gallstones obstructing ducts Elevated serum triglycerides Trauma Viral or bacterial infections

Pancreatitis
May lead to
Peritonitis, pseudocyst formation, hemorrhage, necrosis, secondary diabetes

Signs and Symptoms

Mid-epigastric pain radiating to back Worsened by food and EtOH consumption Grey-Turner sign (flank discoloration) Cullens sign (peri-umbilicial discoloration) Nausea, vomiting, fever

Cholecystitis
Gall bladder inflammation, usually secondary to gallstones (90% of cases)
Risk factors (Five Fs)
Fat, fertile, febrile, fortyish, and female Heredity, diet, BCP use

Acalculus cholecystitis
Burns, sepsis, diabetes, multiple organ systems failure

Chronic cholecystitis (bacterial infection)

Cholecystitis
Signs and Symptoms
Sudden pain, often severe and cramping, in RUQ that radiates to right shoulder Point tenderness under right costal margin (Murphys sign) Nausea and vomiting Associated with fatty food intake History of similar episodes Can be relieved by nitroglycerin

Cholecystitis

Appendicitis
Inflammation of vermiform appendix
Usually secondary to obstruction by fecalith May occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis Signs and Symptoms
Classic: Peri-umbilical pain RLQ pain/cramping, guards upon palpation Nausea, vomiting, low-grade fever Patient found right lateral recumbant in fetal position

Appendicitis
Signs and Symptoms:
McBurneys sign pain on palpation of RLQ Aarons sign Epigastric pain upon palpation of RLQ Rovsings sign Pain LLQ upon palpation of RLQ Psoas sign Pain when patient extends right leg while lying on left side and/or flexes legs while supine

Ruptured appendix - true emergency, temporary relief from pain followed by peritonitis

appendicitis

Appendicitis

Bowel obstruction
Blockage of intestine
Caused by
Adhesions (secondary to surgery) hernias, neoplasms volvulus intussusceptions impaction

Bowel Obstruction
Pathophysiology
Fluid, gas, and air collect near obstruction site causing the bowel to distend impeding blood flow/halting absorption. Water and electrolytes collect in bowel lumen leading to hypovolemia. Bacteria from the gas above the obstruction causes further distension and the distension extends proximally. Finally necrosis and/or perforation occur at the site of the obstruction

Bowel Obstruction
Signs and Symptoms
Severe, intermittent, crampy pain High pitched tinkling bowel sounds Abdominal distension Nausea and vomiting Decreased frequency of bowel movements Change in bowel (semi-liquid or pencil-thin stool) If severe enough can have feces in vomitus

Hernia
Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal)
Often secondary to increased intra-abdominal pressure (coughing, lifting, straining) Can progress to ischemic bowel (strangulated hernia) Signs and symptoms:
Pain increased with abdominal pressure Inguinal hernia may be palpable in groin or scrotum

Crohns Disease
Idiopathic inflammatory bowel disease
Occurs anywhere from mouth to rectum 35-45%: small intestine, 40%: colon

Hereditary
High risk groups: caucasian females, Jews, persons under high stress

Crohns Disease
Pathophysiology
Mucosa of GI tract becomes inflamed and granulomas form invading the submucosa. Muscular layer of the bowel become fibrotic and hypertrophied. All of this causes an increased risk for bowel obstruction, perforation, or hemorrhage.

Crohns disease

Diverticulitis
Diverticula
Pouches in the colon wall Typically found in older people Usually asymptomatic Related to diets with inadequate fiber

Causes:
Diverticula traps feces and becomes inflamed Occasionally causes bright red rectal bleeding Rupture of diverticula can lead to peritonitis and sepsis

Diverticulitis
Signs and Symptoms
Usually left-sided pain May localize to LLQ commonly referred to as leftsided appendicitis Alternating constipation and diarrhea Bright red blood in stool Fever

Diverticulitis

Hemorrhoids
Small masses of veins in anus/rectum
Most frequently develop when patients are in 30s to 50s Most are idiopathic, can be associated with pregnancy, portal hypertension, lengthy driving, constipation Bright red bleeding with pain upon bowel movement May become infected and inflamed

Peritonitis
Inflammation of abdominal cavity lining
Signs and symptoms
Generalized pain, tenderness Abdominal rigidity Nausea, vomiting Absent bowel sounds Patient is resistant to movement

Hemorrhagic Abdominal Problems

Gastrointestinal Hemorrhage
Intraabdominal Hemorrhage

Esophageal Varices
Dilated veins in esophageal wall
Occurs secondary to hepatic cirrhosis, common to alcohol abusers Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins

Esophageal Varices
Portal Hypertension
Hepatic scarring slows blood flow Blood backs up in portal circulation Pressure rises Vessels in portal circulation become distended

Signs and Symptoms

Hematemesis (usually bright red) Nausea, vomiting Hypovolemia Melena

Esophageal varices

Mallory-Weiss Syndrome
Longitudinal tears at the gastroesophageal junction
Occur as a result of prolonged, forceful vomiting or retching Common in alcoholics May be complicated by presence of esophageal varices

Mallory-Weiss Syndrome

Mallory-weiss syndrome

Peptic Ulcer Disease

Ulcer erodes through blood vessel
Massive hematemesis Melena may be present

Aortic Aneurysm
Localized dilation due to weakening of aortic wall
Usually older patients with a past history of hypertension, atherosclerosis May occur in younger patients secondary to:
Trauma Marfans syndrome

Usually occurs just above aortic bifurcation and may extend to one or both iliac arteries

Aortic Aneurysm
Signs and Symptoms
Unilateral lower quadrant pain, low back pain or leg pain May be described as tearing or ripping pain/sensation Pulsatile palpable mass usually above umbilicus Diminished pulses in lower extremities Unexplained syncope, often after bowel movement Evidence of hypovolemic shock

Aortic aneurysm

Ectopic Pregnancy
Any pregnancy that takes place outside of uterine cavity
Most common location in fallopian tube Pregnancy outgrows tube, causing tube wall to rupture Hemorrhage into pelvic cavity occurs

Suspect in females of child-bearing age with abdominal pain and/or unexplained shock
When was the patients LMP?

Ectopic Pregnancy
Ectopic pregnancy does NOT necessarily cause a missed period

Ectopic pregnancy

Ectopic pregnancy

Assessment of acute abdomen

History
Where do you hurt?
Try to pinpoint or have patient pinpoint

What does pain feel like?

Steady pain = inflammatory process Cramping pain = obstructive process

Onset of pain?
Sudden = perforation or vascular occlusion Gradual = peritoneal irritation, distension of hollow organ

history
Does the pain travel anywhere?
Gallbladder = angle of right scapula Pancreas = straight through to back Kidney/ureter = around flank to groin Heart = epigastrium, neck/jaw, shoulders, upper arms Spleen = left scapula, shoulder Abdominal aortic aneurysm = low back pain, radiating to one or both legs

History
How long have you been hurting?
> 6 hours = increased probability of surgical significance

Nausea and/or vomiting?

How much and how long
Consider hypovolemia

Blood or coffee ground emesis

Any blood in GI tract = emergency until proven otherwise

Urine changes?
Change in frequency, color, or odor; or increased urgency,

History
Bowel movements?
Change in bowel habits? Change in color? Change in odor?
Bright red Melena (black, tarry, and foul-smelling) Dark (suspect bleeding)

History
Last menstrual period?
Abnormal bleeding? In females, lower abdominal pain = gynecological problem until proven otherwise In females of child-bearing age, lower abdominal pain = ectopic pregnancy until proven otherwise

Physical exam
Position and general appearance
Still refusing to move = inflammation or peritonitis Extremely restless = obstruction

Gross appearance of abdomen

Distended Discolored Consider possible third spacing of fluid

Physical exam
Vital Signs
Tachycardia = more important sign of volume loss than a falling blood pressure Rapid shallow breathing = possible peritonitis Consider performing a tilt test

Bowel sounds
Auscultate before palpating Listen for 1 minute in each quadrant Absent sounds= possible peritonitis, shock High pitched tinkling sounds = possible bowel obstruction

Physical exam
Palpation
Palpate each quadrant Palpate area of pain last Do not check rebound tenderness in prehospital setting All abdominal tenderness is significant until proven otherwise

Management
Oxygen by NRM
IV of Lactated Ringers or Normal Saline Solution Keep patient warm

Monitor vital signs

Monitor EKG Consider MI with pain referred to abdomen in patients under 30 years old Keep patients NPO

Management
Treat pain per protocols (some believe that masking/treating pain is wrong)
Give a thorough report to receiving facility For aortic aneurysm considering taking patient to hospital that is capable of CT surgery