Gastrointestinal bleeding can occur anywhere in the gastrointestinal tract and may cause bright-red blood or black, “coffee ground” material in vomitus as well as bright-red blood in stools or black, tarry stools.
LESSON OUTLINE
Upper gastrointestinal bleeding may be variceal (usually from portal hypertension) or nonvariceal bleeding (usually from esophageal or duodenal erosion). Variceal bleeding may cause weakness, low- grade fever, right upper quadrant pain, and hypotension. Nonvariceal bleeding may cause
hematemesis, melena, pallor, and hypovolemia.
o Initial management of upper gastrointestinal bleeding calls for oxygen, fluids, cardiac monitoring, pulse oximetry, catheterization, and gastric lavage.
o Tests include complete blood count, blood urea nitrogen, creatinine, coagulation, radiography, and electrocardiography.
o Endoscopy can identify the site of upper gastrointestinal bleeding and control bleeding.
Medications and surgery may also be used to stop the bleeding.
o Complications include aspiration, pneumonia, respiratory failure, and hypovolemic shock.
Lower gastrointestinal bleeding may result from hemorrhoids, diverticula, angiodysplasia, colonic polyps, and colon cancer. Its cardinal sign is hematochezia. Other manifestations include abdominal pain, painless bleeding, hypovolemia, and diarrhea.
o Management of severe lower gastrointestinal bleeding requires hospitalization for fluid resuscitation, diagnosis, and treatment. Once stable, the patient may undergo colonoscopy, radionuclide imaging, or mesenteric angiography.
o Anticipate endoscopic therapy and treatment for diverticula, angiodysplasia, and hemorrhoids. Surgery may be needed for exsanguination.
In gastroesophageal reflux disease, reflux of gastric contents into the esophagus causes mucosal damage. Typical symptoms include heartburn, chest pain, regurgitation, and dysphagia. Other manifestations may include chest pain; nocturnal choking; sleep apnea; recurrent pneumonia or ear, nose, and throat infections; loss of dental enamel; and chronic halitosis.
o When gathering the history, ask about medications, disorders, and foods that may lead to gastroesophageal reflux disease.
o After eliminating more serious disorders, ED management includes antacids, histamine2- receptor antagonists, and proton pump inhibitors.
LESSON OUTLINE
Appendicitis usually results from obstruction of the appendiceal lumen and can lead to rupture into the peritoneum.
o Signs and symptoms include abdominal pain (especially the classic pain at McBurney’s point), nausea, vomiting, malaise, anorexia, tachycardia, chills, and fever.
o Testing may include white blood cell count, ultrasonography, computed tomography, and urinalysis.
o Definitive therapy for appendicitis is surgery. Complications can include perforation, peritonitis, and abscess formation.
Acute cholecystitis involves inflammation of the gallbladder and is usually associated with gallstone disease. The phrase “fair, fat, fertile, flatulent, 40- or 50-year-old female” summarizes the major risk factors for gallstone development.
o The primary symptom is sudden, epigastric or right upper quadrant pain, usually after eating fried or fatty foods. Other manifestations may include low-grade fever, tachycardia, nausea, vomiting, flatulence, jaundice, and weight loss.
o A wide range of tests may be ordered, including complete blood count, urinalysis, serum electrolyte and other levels, radiography, ultrasonography, computed tomography, and hepatobiliary iminodiacetic acid scanning.
o Definitive treatment for cholecystitis is surgery. Interventions may include administration of crystalloids, antiemetics, opioids, and antibiotics; nasogastric tube insertion; and monitoring of vital signs and fluid intake and output.
Acute pancreatitis is an acute inflammation of the pancreas. Although the exact cause is unknown, it is characterized by the release of activated digestive enzymes into the pancreas and surrounding tissues. This causes tissue damage in the pancreas and nearby structures and may lead to systemic inflammatory response syndrome.
o A clinical hallmark of pancreatitis is abdominal pain that originates in the epigastric region and radiates to the back. Other signs and symptoms include abdominal and rebound
tenderness, guarding, nausea, vomiting, abdominal distention, low-grade fever, tachycardia, hypotension, tachypnea, and hypoactive or absent bowel sounds.
o Besides serum amylase and lipase levels and other blood tests, the patient may undergo radiography, ultrasonography, and computed tomography.
o Management calls for nothing-by-mouth status; administration of fluids, electrolytes, antiemetics, analgesics, and antibiotics; nasogastric tube insertion, and frequent monitoring.
When diverticula become inflamed, diverticulitis develops. Inflammation occurs when fecal matter becomes trapped in the pouches, causing trauma to the intestinal lining. Infection commonly results.
o Signs and symptoms include persistent pain in the left lower quadrant, cramping, constipation, and (with infection) fever, chills, nausea, and vomiting.
o Tests may involve complete blood count, urinalysis, abdominal and barium enema radiography, and computed tomography.
Bowel obstruction may be partial or complete and mechanical (as from intussusception) or
nonmechanical (as in paralytic ileus). The most common cause is adhesions from abdominal surgery.
o Signs and symptoms vary with the obstruction’s location. Abdominal pain may be severe, colicky, crampy, intermittent, and wavelike. Other findings may include abdominal
distention, tenderness, and rigidity; constipation; hyperactive and hypoactive bowel sounds (above and below the obstruction, respectively); fever; tachycardia; hypotension; nausea;
and vomiting.
o Tests include complete blood count and other blood tests, arterial blood gas analysis, radiography, and computed tomography.
o Management includes administration of fluids, electrolytes, and antibiotics; monitoring of abdominal changes, pain, and fluid intake and output; gastric tube insertion; and preparation for surgery.
o Life-threatening complications include peritonitis, bowel strangulation or perforation, renal insufficiency, aspiration, hypovolemia, and intestinal ischemia or infarction.
Acute gastroenteritis is an inflammation of the stomach and intestinal lining caused by viral, protozoal, bacterial, or parasitic agents.
o Signs and symptoms may include nausea, vomiting, diarrhea, abdominal cramps, hyperactive bowel sounds, fever, headaches, and anal excoriation from diarrhea.
o Laboratory tests may include complete blood count, electrolyte levels, and stool cultures.
o Treatment requires identifying the causative agent and resting the gastrointestinal tract.
Expect to replace fluid and electrolytes and administer antiemetics. As soon as diarrhea subsides, start the modified BRAT diet, with bananas, rice, applesauce, and toast.
PRECEPTOR EXERCISES
Discuss the following questions with your preceptor: