“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 organ’s 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

• Pain when the stomach is empty

• Pain at night

• 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

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)• Cullen’s sign (peri-umbilicial discoloration)• Nausea, vomiting, fever

Cholecystitis

• Gall bladder inflammation, usually secondary to gallstones (90% of cases)

• Risk factors (Five F’s)• 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

(Murphy’s 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:• McBurney’s sign – pain on palpation of RLQ• Aaron’s sign – Epigastric pain upon palpation of

RLQ• Rovsing’s 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

Crohn’s 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

Crohn’s 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.

Crohn’s 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

“left-sided 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 30’s to 50’s

• 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-WeissSyndrome

• 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-WeissSyndrome

Mallory-weisssyndrome

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• Marfan’s 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