Chapter 8

Mechanical p. 318

Abdominal organs, with the exception of the aorta, are not sensitive to mechanical stimuli such as cutting or tearing Abdominal organs and membranes ARE sensitive to stretching and distention which activate nerve endings in both hollow and solid structures. Capsules surrounding organs like the liver, spleen, and gallbladder contain pain fibers that are stimulated by stretching if these organs swell.

Clinical insight p. 318

Abdominal pain in a pregnant patient, other than the pain caused by contractions, is usually considered serious, until proven otherwise

Clinical insight p. 319

The description of pain is important for determining hollow versus solid organ cause, or aortic cuse versus other causes of adbominal pain, as is the progression of the pain (e.g. intermittent progressing to steady or generalized to specific)

Important Note p. 334

The focus of assessment is not to discriminate between possible causes of abdominal pain. Rather, the focus is to determine the probability of a life threat.

Table 8-1 Abdominal Pain from Extraabdominal causes: Signs and Symptoms p. 321

The following 7 flash cards are the signs and symptoms and what extraabdominal causes these indicate

Left Hypochondriac Region

The left hypochondriac region contains the pancreas and the spleen with referred pain from the left pleural space pancreas and spleen

More about pancrease secretions

The pancreas secretes digestive enzymes and controls blood sugare levels through the iproduction of insulin.

Important Note p. 333

The patient who has complained of abdominal pain and then progresses to unresponsiveness must be considered to have a threat to life until proven otherwise

Clinical Insight p. 327

The presence of postural hypotension in the prescence of an abdominal complaint (which may NOT be described as "pai") is highly suggestive of acute blood loss from a ruptured organ such as the liver oir spleen, a tubal pregnancy or a leaking aortic aneurysm.

Right Iliac Region

The right iliac region contains the ascending colon and the appendix and in the female a right ovary and fallopian tube. Appendix, Overies and Fallopian Tues

peritoneum p. 317

The serous membrane that lines the abdominopelvic cavity and helps subdivide tha abdomen vertically : The parietal peritoneum covers the outer wall The visceral peritoneum covers internal organs.

Umbilical and Hypogastric Regions

The umbilical region contains the small intestine, large intestine, and aorta with referred pain from the appendix. The hypogastric region contains the bladder and aorta with referred pain from intestinal obstruction. Together these regions are often referred to as the central abdomen with several disease states manifesting pain in this area. Small Intestine, Large Intestine, Aorta, Pain referred to the umbilical and hypogastric regions

Peritoneum p. 318

Traction, or tension, on the peritoneum caused by adhesions, distention of the common bile duct or forceful peristalsis resulting form intestinal obstructions generally causes pain. Exception: In pregnancy by the third trimester, the peritoneum is no longer sensitive to stretching; therefore, the response to stimuli that would normally produce pain is blunted. Conditions: cholelithiasis (gallstones) and appendicitis in pregnant women have the potential to be serious.(They may go a long time and feel no pain)

aneurysm p. 330

aneurysm is a weakened dilated area of the wall of a vessel

peritoneal space p. 317

anterior portion of the abdomen

peristalsis p. 317

rhythmic contractions that move substances through hollow organs or tubes

Viscera p. 317

the internal organs

Quadrants and regions are useful because...

there is a known relationship between superficial anatomical landmarks and the locations of underlying organs.

referred pain p. 319

visceral pain felt at some distance from a diseased or affected organ (e.g. pain from an ovarian cyst felt in the shoulder or neck). This occurs when the brain misinterprets the pain as originating from a cutanious nerve that innervates an area that is in fact at a site other than the affected organ

Parietal pain p. 319

~Arises from the parietal peritoneum. ~More localized and intense than visceral pain ~Never fibers in the parietal peritoneum travel with associated peripheral nerves to the spinal cord and sensation of pain most frequently corresponds to skin dermatomes T6 and L1 that are innervated by those segments of the spinal cord. ~Parietal pain is localized to one side or the other because at any particular point the parietal peritoneum is unnervated from only one side of the nervous system.

Parietal Pain described p. 319

~Sharp and constant. ~Patients often feel beter in fetal position with knees drawn up. ~This relaxes the parietal peritoneum and reduces pain. ~Any activity that moves the peritoneum like coughing, deep breathing, or lying flat with legs outstretched will produce pain. ~The characteristics of parietal pain are sometimes seen as signs of peritoneal irritation and frequently occurs after visceral pain.

Differential Diagnosis in the field p. 322

Only occasionally will a disease process exhibit such classic signs and symptoms that a specific diagnosis will be mistakable. Most cases require a careful history and complete physical may narrow the problem to suspected : bleeding, obstruction, sepsis or irritant isolated to a particular area of organ type. IMPORTANT NOTE ****These determinations , along with mental status , cardiovascular status, and respiratory status, that will determine probability of immediate, potential or no life threat...and if patient is critical, unstable, potentially unstabel, or table (CUPS)

Right and Left Lumbar Regions

Organs in thiese regions include the kidneys and their associated ureters. Kidneys and Ureters

Left Iliac Region

Organs in this region include the descending colon (large intestine) and in the female, the left ovary and fallopian tube) Most of the pain from diseases affecting the large intestine is referred to umbilical or hypogastric region. However, certain specific conditions may localize pain in either the right or the left iliac region, such as diverticulitis which localizes pain in the left ilac region.

Epigastric Region

Organs in this region include the stomach and pancreas with refered pain from the heart and appendix Stomach, Pancreas, Pain referred to the Epigastric Region from the heart(which is on the dome of the region) and Vagus nerve bundle

To help describe the location of findings: Regions (9) Figure 8-2 (b) p. 317

These include: 1. right hypochondriac region 2. epigastric region, 3. left lower hypochondriac region 4. right lumbar region, 5. unbilical region, 6. left lumbar region 7. right iliac region, 8. hypogastric region, 9. left iliac region See figure 8-2 (b) p. 317.

Productive cough and fever with diffuse abdominal pain but o localized abdominal tenderness

Pneumonia

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Productive cough and fever with diffuse abdominal pain but no localized abdominal tenderness

Pneumonia

Extraabdominal Problems that may refer pain to abdomen p. 320-322 Pneumoia

Pneumonia can lead to diffuse abdominal pain but there is no localized abdominal tenderness. A productive cough and fever may also be present

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused History Pain

Poorly localized, diffuse pain(generally felt near the midline in the epigastric, umbilical, or hypogastric region)-- --Visceral organs (hollow or solid) Localized, intense ipain (localized to one side) ------ Parietal peritoneum, generally corresponds to the associated dermatomes Pain felt at some distance from the affected organ or from the location of abdominal tenderness-----Referred pain (originating in visceral organs but felt in another area) see fig. 8-5

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Vital Signs Pulse and blood pressure

Pulse and blood pressure ----Orthostatic hypotension or tilt test-----rising from a supine position causes dizziness and/or nausea, rapid change in skin color, disappearance of radial pulse, increase in pulse 20 bpm, drop in systolic BP 10 mmHg -------Hypotension (shock); blood loss

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Vital Signs Respiration

Rapid - Blood or fluid loss or low tidal volume (shock) Shallow - Pain, peritoneal irritation, or compression of diaphragm

To help describe the location of findings: Quadrants (4) Figure 8-2 (a) p. 317

The abdominal area is divided into 4 quadrants: 1. the right upper quadrant (RUQ), 2. the left upper quadrant (LUQ), 3. the right lower quadrant (RLQ) and 4. the left lower quadrant (LLQ) (Figure 8-2a p. 317) These terms and their abbreviation are commonly used in clinical discussions.

Clinical Insight p. 333

The action of being up and walking around suggests that a perfusing blood pressure is present

Anatomy, Physiology, and Pathophysiology p. 315

The basis for understanding the characteristics of abdominal pain is in the anatomy, physiology, and pathophysiology Abdominal organs are suspended within the abdominal cavity (Fig. 8-1) p. 316 The abdominal cavity has two essential functions: 1. protection of organs from the accidental bumping and jostling that occurs during daily activity such as walking, jumping, running 2. Permitting organs to expand and contract without distrupting surrounding tissues or organ functions

Solid Organs p. 318

Kidneys, liver, ovaries, pancreas, spleen

Fig. 8-5 the gallbladder, systic duct, common hepatic duct, common bile duct, and pancreatic duct. p. 325

Labeled parts

Chief complaint p. 315

Location and characteristics indicate possible origin All individuals react differently according to factors Age - Infants and children may be unable to localize their discomfort and they have diseases not seen in adults Tolerance - Obese or elderly patients tend to tolerate pain better Preexisting conditions - Neuropathy such as that which occurs with diabetes can mask intraabdominal pathology, as can alcohol and certain medications escpecially steroids. Perception - What is perceived as severe pain to one person may not be to another Mental State - Hysteria tends to exaggerate pain, and emotional pain tends to worsen physical pain

The degree of threat to life p. 322

i.e., if the condition is an immediate life threat, a potential life threat, or ot a life threat

Extraabdominal Problems that may refer pain to abdomen p. 320-322 AMI

AMI may be accompanied by diffuse abdominal pain, or more commonly, indigestion. Palpation may worsen indigestion due to an ulcer but usually has no effect on the indigestion due to AMI

Diffuse pain p. 339

Peritonitis Early appendicitis Bowel obstruction Intestinal Ischemia Aortic aneurysm Gastroenteritis Pancreatitis Diabetic ketoacidosis Sickle cell crisis

Summary of Treatment p. 342 IV fluids PART 2

**Note The drug of choice in the field is dopamine. The dosage is based on μg/kg/min with 5 - 10 μg/kg/min as a usual starting dose, titrated to systolic prssure Sepsis may also affect alveolar and capillary wall permeability, causing pulmonary edema. Thus, positive-pressure ventilations along with fluids are often necessary. Positive pressure ventilations along with fluids are often necessary. Dehydration with third spacing of fluid is a significant finding with sepsis.

How to determine if the pain in the abdomen radiates from another site p. 336-8

1. Inspection of abdomen(look for distention/absence of distention) and inspection of color. 2. Auscultation Commonly done in hospital setting, is not recommended for short transport times in the field because: *not quiet enough for the amount of time it takes *Treatment does not depend on this Ausculation of chest is recommended. 3. Palpation of abdomen if it does not increase comfort of patient (first do no harm). Start far from pain. Watch for tenderness. REBOUND palpation is not recommended.

Physical exam should accomplish 3 things p. 335-6

1. Is the patient critical/threat to life or potentially unstable 2. Determine a high or low probability for involvement of a specific organ or the presence of a specific condition like bleeding, infection or obstruction 3. Determine what treatment is appropriate

Table 8-3 Pain Referred to Abdominal Regions p. 324 Pain in these areas 1. Right hypochondriac Region 2. Epigastric region 3. Left hypochondriac region 4. Umbilical and hypogastric regions

1. May be caused by/referred from Pleuritis or pneumonia in the right pleural cavity 2. Cardiac condition: appendicitis 3. Pleuritis or pneumonia in the left pleural cavith 4. Obstruction of the intestine

3 mechanisms for abdominal pain p. 318

1. Mechanical 2. Inflammatory 3. Ischemic

Summary of Treatment p. 340 The pneumatic antishock garment (PASG)

Suggested for treating abdominal bleeding, especially abdominal aortic aneurysm. The garment helps stabilize the aneurysm by exerting circumferential pressure. NOTE ***The use of this device is highly controversial

Acute Abdominal Pain Chapter 8 p. 314-343 Topics covered: When chief complaint is abdominal Pain, Anatomy, physiology and pathophysiology, differential diagnosis, assessment, and treatment

A common Chief complaint Presenting symptom for a number of diseases Always a symptom of intraabdominal pathology Treatment is primarily aimed at supporting vital functions, making the patient as comfortable as possible and transporting him to the hospital

Differential Diagnosis p. 322

A differential diagnosis determined in the field takes on a far different meaning that the differential diagnosis determined in a hospital setting. In the field differential diagnosis for abdominal pain is frequently limited to determining two things: 1. the degree of threat to life 2. A suggested organ type

More Stomach Description p. 325 Gastric glands secrete hydrochloric acid, enzymes, and intrinsic factor ) a substance that makes possible the absorption of vitamin B12

A muscular, sac-like organ , shaped like an expanded J. It is located primarily in the epigastric region of the abdominopelvic cavity. The outer surface is covered by the peritoneum, which is continuous with a pair of mesenteries, the greater omentum ( a site for fat deposit that protects the abdominal organs), and the lesser omentum. The stomach is lined with mucous cells that secrete mucus to protect the lining from acids, enqymes and abrasive materials it contains

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused History Pain

Abdominal pain with signs and symptoms commonly associated with extraabdominal causes (e.g. chest pain, dyspnea) - Referred pain (originating outside the abdomen but felt as abdominal pain) See Table 8-5 Sudden onset of pain (severe enough to cause fainting) - Perforated visceral organ, ruptured aneurysm Onset during or caused by physical activity or coughing- - Hernia; pulled muscle; ruptured spleen (especially with history of mononucleosis) This pain has happened before - Complication of chronic condition (e.g. perforated ulcer, diverticulitis)

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused Physical Exam Auscultation of chest:

Abnormal breath sounds (wheezing, crackles or rales, rhonchi) with abdominal pain.-----Primary problem outside the abdomen (e.g. pneumonia) Wheezing with abdominal distention -------Abdominal distention exerting pressure on diaphragm and lungs

Ascites p. 324

Accumulation of serous fluid from the liver that accumulates in the abdominal cavity.

Chest pain with "indigestion"

Acute myocardial infarction (apply ECG monitor)

Dyspnea with "indigestion"

Acute myocardial infarction (apply ECG monitor)

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Chest pain with "indigestion"

Acute myocardial infarction (apply ECG monitor)

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Dyspnea with "indigetstion"

Acute myocardial infarction (apply ECG monitor)

Severe, collicky pains that suggest intestinal obstruction

Addictive drug use

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Sever, colicky pains that suggest intestinal obstruction

Addictive drug use

Anorexia

Anorexia is a loss of appetite

Table 8-2 Patterns of Findings for specific abdominal organs p. 323 Liver - Largest abdominal organ. Left lobe extends to the midclavicular line of the left hypochondria region. Normally the liver in an adult is not palpable int the field.

Any liver disease: Steady, dull pain. Possible bleeding tendencies,noticed as bruising; jaundice to skin or sclera Inflamed (hepatitis): Enlarged with mild pain and tenderness in right hypochondriac region, jaundice of the sclera, preceded by flu-like symptoms (i.e., vomiting, diarrhea, chills, fever) Chronic liver disease (cirrhosis): Dyspnea rather than pain, ascites Ruptured Capsul: Pain referred to right neck and shoulder

Hollow Organs p. 318

Aorta, appendix, bladder, common bile duct, fallopian tubes, gallbladder, large intestine or colon, rectum, small intestine, stomach, ureters, uterus

Left Lower Quadrant Pain p. 339

Appendicitis Ectopic pregnancy Ovarian cyst incarcerated hernia regional ileitis kidney stone bowel obstruction Pelvic inflammatory disease

Right Lower Quadrant Pain p. 339

Appendicitis Ectopic pregnancy Ovarian cyst incarcerated hernia regional ileitis kidney stone bowel obstruction Pelvic inflammatory disease

Appendicitis p. 331

Appendicitis is inflammation of the appendiz

Parietal Pain examples: p. 319

Appendix - at first it may be described as intermittent and dull, arising from the umbilical region. (This is visceral pain from distention of the appendix) As time goes on and bacteria penetrate the wall of the appendix, pain more closely resembles parietal pai. It becomes sharper, constant and localized to the righ lower quadrant with the patient more comfortable if knees are drawn up. This localization of pain reflects dermatome distribution.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Spleen - normally cannot be palpated due to posterior location

Enlarged or irritation: Steady, dull pain. May radiate to left neck and shoulder. Ruptured: Sharp, intense pain, lets up, then recurs, increases in intensity, radiates to left neck and shoulder; syncope, postural hypotension.

Clinical Insight p. 326

Because injury to alveolar membranes of the lungs (usually on the left side) may occur with pancreatic disease, lung sounds may include wheezing or crackles

Clinical Insight p. 331

Because of its ability to wriggle and twist, an inflamed appendix may be located more to the posterior or more to the left than normal. This may cause atypical description of appendicitis,

Special Note p. 340

Because the abdomen tends to be a site for referred pain, the ECG should be monitored in older patients and diabetic patients. Look for associated weakness and or breathlessness especially on exertion and initiate ECG monitoring. Diabetic patients should also have a blood sugar evaluation. If pain in abdomen took for other signs of diabetic ketoacidosis like rapid respiration with an acetone or fruity odor, history of polyuria, tachycardia and poor skin turgor. Pulse oximetry can be useful to assess respiratory function; however it does not serve as a substitute for good respiratory assessment and is inaccurate in shock states.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Small Intestine and Large intestine - Part 2

Bowel Obstruction: Begins with intermittent, crampy or colicky pain. If unrelieved, distention and peritoneal irritation with increasingly intense, steady, poorly localized pain. Patient may lie in fetal position. Shallow respirations; pain worsened by coughing or deep breathing. Inflamed pockets in colon wall (dirverticulitis): Dull pain tenderness on palpation. If perforated spillage of contents into peritoneal space,k causing steady, sharp pain and signs of peritoneal irritation. Early pain is poorly localized and referred to hypogastric region; later pain becomes localized, commonly to lower left quadrant. Diarrhea, fever, bleeding (from occult to massive) may be present

Spinal or CNS disease p. 322

Can produce pain referred to the abdomen. The most common cause is radiculitis (inflammation of spinal nerve roots), of which herpes zoster, or shingles is the best-known example. This pain is usually chronic rather than acute. In the case of shingles pain may precede the appearance of the ras.

QUALITY P. 335

Can you Describe the Pain

Assessment of abdominal pain p. 322

If associated signs and symptoms indicate a possible extraabdominal cause of abdominal pain, ask questions and look for environmental clues to determine whether the patient has any known or suspected disease or condition. Previous history is usually very important. Although it may be impossible to know exactly the origin of the abdominal pain, a through assessment, including history and physical exam, will always be the best basis for treatment decisions.

Summary of Treatment p. 340 IV treatment

Depending on the problem, IV access may be appropriate, but do not delay transport to get a line. IV access can be obtained en route. If internal bleeding is a high probability ensure that administration of IV fluids does not cause disruption of clot formation.(This can happen when systolic pressure is above 100) In the case of an abdominal aortic aneurysm, high systolic pressures may increase the likelihood of complete rupture. In this case suggestions are to keep systolic pressure between 70-100 mmHg using mental status as a guide.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Vomiting with diffuse abdominal pain

Diabetes (check blood glucose level)

Vomiting with diffuse abdominal pain

Diabetes (check blood glucose level)

Extraabdominal Problems that may refer pain to abdomen p. 320-322 Diabetes

Diabetes (in particular, diabetic ketoacidosis) can lead to diffuse abdominal pain with vomiting, probably caused by high potassium levels Wide spread smooth muscle contractions affect the small intestine have been blamed

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused Physical EXam Inspection

Distention: obstruction;collection of gas, fluid Bluish discoloration at naval or flank: Bleeding in retroperitoneal space

Clinical Insight p. 339

Dizziness or weakness when getting up suggests that orthostatic hypotension is present

RADIATION p. 335

Does the pain go anywhere? *radiation often occurs along the distribution of the nerves of thesame spinal segment. *Gallbladder -beneath right scapula * Diaphragmatic irritation from blood or pus can be felt in the region of either shoulder or both shoulders. *Renal pain radiates to the region of the groin *In older patients severe pain beginning in the midback and rapidly spreading to the abdomen is characteristic of an aortic aneurysm.

Drug Addicts p. 321

Drug addicts suffering withdrawal symptoms may have sever colicky pains that suggest intestinal obstruction

Ectopic Pregnancy p. 332

Ectopic pregnancy is a pregnancy in which the ovum is implanted in an area outside the uterus, usually in a fallopian (tubal pregnancy).

pain in hollow organs p. 319

Edema and vascular congestion from inflammation may also cause an obstruction or irritation of the lining of membranes lining the walls. Obstruction or irritation of the lining of hollow organs frequently stimulates contractions and peristalsis. The resulting pain is often described as crampy or colicky. In gastroenteritis, increased peristalsis of the small or large intestine ay also trigger diarrhea. If obstruction is not relieved, intermittent pain may become constant.

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Scene size up and initial assessment Patient's position

Fetal - parietal pain Supine - Visceral pain Up, pacing, can't get comfortable - Hollow organ obstruction (e.g. kidney stone, gallstone)

Abdominal quadrants

Figure 8-2 (a) p. 317

Abdominal regions

Figure 8-2 (b) p. 317

Common areas of referred pain p. 321

Figure 8-4 Common areas of referred pain

Skin dermatomes p.320

Figures 8-3 Skin dermatomes p. 320

Summary of Treatment p. 340 Ventilation

For patients who have complained of abdominal pain and are now unresponsive, assist ventilations with a bag-valve-mask and a reservoir at 15 lpm and tracheally intubate patient if appropriate. If patient is awake, apply a nonrbreather mask with a flow rate of 15 lpm

Tilt Test p. 339

For: orthostatic or postural hypotension: Pulse and blood pressure taken when the patient is supine are compared with measurements when the patient rises to a sitting or standing position. Internal bleeding or severe fluid loss is indicated by a rapid change in skin color, dizziness or nausea, disappearance of the radial pulse, an increase in pulse of 20 beats or a drop in blood pressure of 10 mmHg

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Gallbladder - Located under the right lobe of the liver, the gallbladder is also surrounded by the liver capsule. The gallbladder stores and concentrates bile necessary for digestion of fat.

Gallstone obstructing common bile duct Intermittent, crampy or colicky pain occurring 30-60 minutes after eating. Can radiate left to right or be localized at gallbladder or anywhere along length of bile duct. If localized, radiates to right scapula or to the back between the scapulae. Patient cannot get comfortable, may pace.

Right Upper Quadrant Pain p. 339

Gallstones Pancreatitis Perforated Ulcer Hepatitis Liver abscess Right kidney stone Right kidney infection Herpes Zoster (shingles) Myocardial Infarction Right lung pneumonia/pleuritis

Biochemical mediators of the inflammatory response p. 319

Histamine, prostaglandins, bradykinin, and serotonin, stimulate organ nerve endings and produce abdominal pain. The edema and vascular congestion that accompany chemical bacterial or viral inflammation also cause painful stretching of organs and organ walls.

TIME p. 335

How long ago did this pain start? How long did the attack last? (if a severe pain attack suddenly lets up, it may be the calm before the storm as in appendicitis or perforated ulcer)

A suggested organ type p. 322

I.e. if the pain is typical of a hollow organ or a solid organ.

Abdominal pain p. 319

Identified as visceral, parietal (somatic), or referred

Summary of Treatment p. 340 IV fluids PART 1

If dehydration is suspected IV access and admin of a fluid bolus of 250-500 ml may be sufficient and it can also manage an elevated temperature. Crystalloids such as normal saline (0.9% NaCl) and lactated Ringer's are recommended. When hypotension is severe and uncorrected by crystalloid admin and sepsis is suspected, treatment may include pharmacologic therapy

Clinical Insight p. 327

If swelling of the spleen has been gradual, there may not be a classic complaint of "pain" rather, the description will be an "ache" or a "stitch" in the side.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Small Intestine and Large intestine- Part 1

Inflamation of gastroentestinal tract (gastroenteritis), may be specified as inflammation of the intestine (enteritis or inflammatory bowel disease) also known by its location along the intestinal tract (ileitis, colitis); Intermittent, crampy or colicky pain, possible with diarrhea and vomiting resulting in dehydration. Food poisoning: Sudden onset within 2-8 hours of ingesting contaminated food. Usually begins iwth nausea, vomiting, cramping, colicky, intermittent pain, followed by diarrhea, possible bloody. Resultant blood loss, dehydration, electrolyte imbalance.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Appendix

Inflammation (appendicitis): May begin with intermittent, dull pain in umbilical region, becoming more localized and intense with possible signs of peritoneal irritation. Nausea, vomiting, anorexia, and fever may be present. Ruptured appendix: Possible sudden relief of pain, soon followed by sharp, severe, constant pain worsened by movement.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Kidneys and Ureters

Inflammation of kidney: Dull, steady pain localized to the affected side, posterior. Difficult or painful urination may or may not be present (especially in the elderly) if infection involves bladder. Kidney stone obstruction of ureter: Sharp, intermittent, crampy or colicky pain localized to one side, intensifying if no relieved. May radiate the length of the ureter or to the groin. Blood may be present in the urine.

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Stomach - A muscular, sac-like organ , shaped like an expanded J.

Inflammation of stomach lining (gastritis) and stomach ulcers (peptic ulcer disease): Both cause localized, steady, burning pain in epigastric region. Vomiting may be bloody. Perforated ulcers: Bleeding and spillage of stomach contents with signs of peritoneal irritation. Pain may be pronounced on the left or right (side where perforation occurs).

Cholecystitis p. 324

Inflammation of the gallbladder

Summary of Palliation of Pain p. 342

May systems are using pharmacologic pain relief methods, such as nitrous oxide, morphine, or fentayl. if pain is present. Midazolam (Versed) does not relieve pain but does relieve anxiety. Promoting patient comfort is important BUT use of pain relief measures mandates complete assessments and thorough study of the pharmacologic agens used. USE MEDICAL DIRECTION AND LOCAL PROTOCOL.

Focused History and physical Exam is to focus to determine the probabilities of an immediate threat to life and to clarify the organ system that is probably involved. Use mnemonics like OPQRST to get information about pain p. 334-335

O - onset P - palliation/provocation Q - quality R- Radiation S - Severity T - Time Associated Symptoms or patterns of onset must be looked at as well.

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Scene size up and initial assessment Enlarged abdomen

Obstruction or fluid collection (ascites or blood)

SEVERITY p. 335

On a scale of 1-10 with 10 the worst How bad is the pain? Sudden and sever is more serious especially if associated with syncope or hypotension

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Ovaries and Fallopian Tubes

Ovarian inflammation or cyst: Dull, constant piain localized to one side. Ruptured ovarian cyst: Pain may lessen, then become severe, poorly localized, with signs of peritoneal irritation. May radiate to either side of neck or shoulder. Fallopian tube blockage or rupture (due to ovum growing in tube):L Intermittent, crampy, colicky pain, recurring as severe, intense, and constant after rupture, with radiation to either side of neck or shoulder.

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused History Pain

Pain Present -Rapid onset (distention of an abdominal organ) No or little pain - Gradual onset (distention of abdominal organ) Steady pain - Solid organs (liver, pancreas, spleen, kidneys, ovaries) Intermittent (crampy, colicky) pain - Hollow organs (stomach, small intestine, large intestine, append rectum, gallbladder, uterus, bladder, common bile duct, ureters, fallopian tubes, aorta)

pain in solid organs p 319

Pain from stretching in solid organs and organ capsules is a steady pain

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Scene size up and initial assessment Patient's color

Pale - Extreme pain and or internal bleeding(shock) Cyanotic - Respiratory or cardiovascular compromise (shock) Mottled - Blood pooling (Shock) Jaundiced - Liver abnormality

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Pancreas - a tadpole shape When large quantities of digestive enzymes pool within the pancreas, the pancreatic secretions begin, literally to digest the pancreas itself.

Pancreatic inflammation (pancreatis): Usually causes peritoneal irritation resulting in sudden, constant, severe pain. Patient feels more comfortable lying still with knees drawn up. Patients look toxic and are extremely ill. Because the pancreas lies in both the peritoneal and the retroperitoneal spaces, pancreatic exudate-containing toxins and activated pancreatic enzymes permeate the retroperitoneum, often including the anterior or pertoneal cavity. This induces a chemical burn and increase in permeability of blood vessels and leads to third spacing, hypovolemia and shock.

Bowel Ischemia or infarction p. 329

Patients with bowel ischemia or infartction may be in extremis, complain of terrible pain, and often writhe in agony.

Measurement of Vital Signs p. 338-9

Respiration, pulse, blood pressure at intervals and compared to baseline. This will help determine blood loss and hypoperfusion, severity of pain and physical changes in the abdominal cavity.

Left Upper Quadrant Pain p.339

Ruptured or distended spleen Duodenal ulcer Pancreatitis Gastritis Gastric ulcer Left kidney stone Left kidney infection Herpes Zoster (shingles) Myocardial Infarction Right lung pneumonia/pleuritis

Organs of the digestive system

See pictorial chart page 316

Organs of the urinary system

See pictorial chart page 316

Intestines and liver, stomach, pancreas

See pictorial charts page 316

Sickle Cell Disease p. 321

Sickle cell disease may be associated with attacks of severe abdominal pain, which may be due to infarction of capillary beds in organs such as the spleen.

Attacks of severe abdominal pain

Sickle cell disease, systemic lupus erythmatosis (SLE)

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Attacks of sever abdominal pain

Sickle cell disease, systemic lupus, erythmatosis (SLE)

Table 8-5 Abdominal Pain: Clues to Underlying Cause and Assessment p. 337 Focused Physical Exam Palpation:

Softness - Lesser severity(softness is normal) Rigidity - Greater severity(inflammation;internal bleeding) Localized tenderness - Involvement of underlying organ Pulsating mass - Aortic aneurysm

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Chronic abdominal pain

Spinal or central nervous system disease (commonly caused by radiculitis, e.g. herpes zoster/shingles

Chronic abdominal pain

Spinal or central nervous system disease (commonly caused by radiculitis, e.g. herpes zoster/shingles)

Special Note p. 340

Treatment for patient with acute abdominal pain is symptomatic. Treat for possible shock, place the patient in a position of comfort, apply oxygen or assisted ventilation as needed, and IV therapy per local protocols. Expedite Transport

Right Hypochondriac Region

Underlying organs in the region include the liver and gallbladder and pain may be refered to this area form the lungs (as in pleuritis or pneumonia) Liver and Gallbladder

Visceral pain in abdominal organ p, 319

Usually felt near the midline in the epigastrium or umbilical region. Visceral pain is poorly localized and is dull rather than sharp. It is diffuse and vague because nerve endings are sparse and multisegmented in abdominal organs. IN hollow organs:Described as crampy or colicky and tend to be dull and intermittent. In solid organs: dull and constant

ONSET p. 334

Was it sudden? What were you doing when it started? Has this pain happened before?

Signs and symptoms of Abdominal Pain Associated with and indicated extraabdominal causes Table 8-1 p. 321 Aorta - Ordinarily, the aorta cannot be palpated; however, sometimes the aneurysm can be felt as a pulsating mass.

Weakened, dilated area (aneurysm): May present with syncope with or without pain. Usually presents with steady, deep boring or tearing visceral pain in lower back, radiating to lower abdomen or vice versa. Pain may also radiate to one flank or the other or down either leg or both legs. May be felt on palpation as a pulsating mass and may be tender to palpation. May leak, then rupture, causing severe pain. A serious threat to life.

PALLIATION/PROVOCATION P. 334

What makes the pain better? What makes the pain worse?

Associated Symptoms or Pattern of Onset p. 335

What other problems or complaints have you also noticed? This question may help narrow the problems. When vomiting precedes pain and followed by diarrhea, gastroenteritis is probable. Pallor, sweating, fainting are rough guides to severity of pathological process. Presence of of shock is an ABSOLUTE indicator of severity. It is a life threat.

Determining if the condition is potentially life threatening p. 315

You can establish this by: careful history focused physical exam limited number of diagnostic tests can be done in the field (e.g. blood sugar values, 12-lead ECG, and orthostatic blood pressure checks)

Table 8-4 Abdominal Pain: Clues to the Severity of Patient's Condition These are characteristics of abdominal pain and associated signs/symptoms and indicate a serious condition and potential threat to life --a critical, unstable or potentially unstable condition --warranting expeditious care and trans port:

^Sudden onset (potentially unstable) ^Severe pain (may be described as "knife-like") (potentially unstable) ^Pulsating mass present (unstable or potentially unstable) ^Fainting; loss of consciousness (critical or unstable) ^Any signs of shock or internal blood loss (e.g. diminished mental status; pale, moist skin; mottled skin; rapid, shallow respirations; rapid pulse; falling blood pressure) (critical or unstable) ^Orthostatic hypotension or positive tilt test (critical or unstable)

Chron's disease p. 328

a chronic inflammatory disease that can occur anywhere in the digestive tract, usually in the small or large intesting

dermatomes p. 319

areas of the skin innervated by specific spinal cord segments

epithelium p. 328

cells that form the outer surface of the body and the lining of the body cavity and principal tubes and passageways leading to the exterior

Cirrhosis p. 324

chronic liver disease that can have a variety of causes, including nutritional deficiencies, alcohol ingestion, or prior viral or bacterial inflammation

Peptic ulcer disease

formation of a disruption in the mucosa of the stomach or proximal portion of the small intestine.

Diaphragm p. 317

forms the superior dome of the abdominal cavity and the floor of thre chest cavity

inflammatory bowel disease p. 328

disease complex causing chronic inflammation of the small or large intesting; colitis

diverticula p. 329

diverticula are pockets in the walls of an organ

diverticulitis p. 329

diverticulitis inflammation of diverticula. Inflamed diverticula of the colon may perforate, causing spillage into the peritoneal space

diverticulosis p. 329

diverticulosis is the presence of diverticula

mesenteries p. 317

double sheets of peritohneum that support the intestines and contain the blood vessels that supply the intestines

dysuria p. 331

dysuria is painful or difficult urination.

colitis p. 328

inflammation of the colon (large intestine)

Gastritis

inflammation of the gastric mucosa

gastroenteritis p. 328

inflammation of the gastrointestinal tract

iletis p. 328

inflammation of the ileum

enteritis p. 328

inflammation of the intestine

Hepatitis p. 322

inflammation of the liver that can have a variety of causes, including viruses, bacteria, drugs, and toxic agents

hepatitis p. 322

inflammation of the liver that can have a variety of causes, including viruses, bacteria, drugs, and toxic agents.

Crampy, colicky p. 319

intermittent or spasmodic pain

Third spacing

leakage of fluid from the vascular and/or intracellular space into the interstitial space

localized/poorly localized p. 319

localized pain is limited to a definite area; poorly localized pain is diffuse or may be felt in a somewhat different location than the affected organ

Visceral pain p. 319

pain arising from a visceral organ, usually dull and poorly localized

parietal pain p. 319

pain that arises from the parietal peritoneum usually sharp, intense, and localized

retroperitoneal space p. 317

posterior portion of the abdomen

Serous membrane p. 317

prevents friction between adjacent viscera and between the visceral organs and the body wall

Referred pain p. 319-320

~Visceral pain felt at some distance from a diseased or affected organ ~The site is referred pain and usually well localized and felt in skin or deeper tissues that share a central afferent nerve pathway (toward the spinal cord) with affected organs. ~Usually develops as intensity increases ~EX: Gallbladder pain is referred to a scapula or to the back between the scapulae. It may begin as a crampy discomfort in the right upper quadrant and as inflammation worsens, progress to a sharp localized referred pain to the right scapula or between the shoulder blades. See Fig. 8-4 for common areas of referred pain for given organs