Ch 19 Gastrointestinal and Urologic Emergencies

peritoneal dialysis (PD)

Fluid circulates within the peritoneal cavity. Urea and other toxins diffuse across the peritoneum into the dialysis fluid, which is then drained from the peritoneum, allowing the peritoneum to essentially function as a kidney. - Large amounts of specially formulated dialysis fluid are infused (and back out of) a large catheter in the abdominal cavity which remains in the cavity for 1 to 2 hours allowing equilibrium.

Colon/Large intestine (GI system)

Food that was not broken down and used as nutrients moves here as waste products. Peristalsis (wave-like contraction of the smooth muscles) moves waste matter through the intestines. Water is absorbed and stool is formed.

The adverse effects of dialysis include?

Hypotension, dysrhythmias, chest pain, muscle cramps, nausea and vomiting, altered mental status, electrolyte imbalances, hemorrhage from the access site, and infection at the access site.

Signs and symptoms of cholecystitis

Pain may steadily increase for hours or may come and go. Commonly produces symptoms about 30 minutes after a particularly fatty meal and usually at night. Other symptoms include nausea and vomiting, indigestion, bloating, gas, and belching.

Signs and symptoms of Esophagitis/GERD

Pain with swallowing and feeling as if an object is stuck in his or her throat. Additional symptoms include heartburn, nausea, vomiting, and sores in the mouth. - In the worst cases = bleeding can occur from the small capillary vessels within the esophageal lining or the main blood vessels.

When assessing the abdomen for the degree of pain and tenderness/rigidity...?

Palpate in a clockwise direction beginning in the quadrant after the one that the patient indicates is tender or painful and ending with the quadrant that the patient indicates is tender or painful -> method to avoiding guarding.

ileus

Paralysis of the bowel, arising from any one of several causes; stops contractions that move material through the intestine. Typically caused by peritonitis. - The retained gas and feces cause abdominal distention (which usually begins after the muscular contractions cease; it refers to swelling). - In the presence of such paralysis, nothing that is eaten can pass normally out of the stomach or through the bowel. The stomach can empty itself only by emesis.

Spleen (additional abdominal organ)

Part of the lymphatic system and plays a significant role in relation to red blood cells and the immune system; assists in the filtration of blood, removes old RBCs, recycles iron, serves as blood reservoir, and produces antibodies.

Signs and symptoms of kidney stones

Patients may initially report vague discomfort in the flank, but the pain can become quite intense and will radiate to the groin. Patients are often agitated and restless as they try to get into a comfortable position to relieve the pain. Nausea or vomiting. Irritation of the ureter may cause a slight amount of blood in the urine (hematuria) before or after the passing of the stone.

Signs and symptoms of cystitis (UTI)

Patients may report blood in urine, an urgency and frequency in urination, and pressure and pain around the bladder. If severe = urethra can become inflamed, causing urinary retention.

Signs and symptoms of pancreatitis

Patients may report that the pain is worse after eating and nausea and vomiting, abdominal distention, and tenderness may accompany the pain. - Complications such as sepsis or hemorrhage can occur (fever + tachycardia revealed in assessment).

Although PD is very effective it carries a small risk of?

Peritonitis which can occur due to bacteria contaminating the dialysis site. The patient may present with abdominal pain, hypotension, fever, nausea, diarrhea, and cloudy dialysis fluid.

Signs and symptoms of hemorrhoids

Presents as bright red blood during defecation, minimal/easily controlled bleeding, itching, small mass on the rectum (which is a clot formed in response to the mild bleeding).

Chronic Kidney Failure (CKD) or End-stage renal disease (ESRD)

Progressive and develops over months and years; it is irreversible. Kidney tissue shrinks and function diminishes such that the patient requires a transplant or dialysis to remove waste products from the bloodstream. - Often caused by diabetes or hypertension. - Treated either with peritoneal dialysis (PD) or hemodialysis.

Liver (GI system)

Secretes bile which aids in the digestion of fats. Also, filters toxic substances produced by digestion, creates glucose stores, and produces substances necessary for blood clotting and immune function.

Pancreas (GI system)

Secretes juice containing enzymes that help break down starches, fats, and proteins (ex: Amylase -> breaks down starches into sugar). Also produces bicarbonate, insulin, and glucagon (bicarbonate -> neutralizes stomach acid in the duodenum and insulin + glucagon -> regulate the levels of the glucose in the bloodstream).

uremia

Severe kidney failure resulting in the buildup of waste products (urea) within the blood. Eventually, brain functions will be impaired.

Ureters (urinary system)

Small (0.2 inch diameter) hollow, muscular tubes in which peristalsis occurs in these tubes to move urine to the bladder; passes from the renal pelvis of each kidney along the surface of the posterior abdominal wall behind the peritoneum .

kidney stones (renal calculi)

Solid crystalline masses formed in the kidney, resulting from an excess of insoluble salts or uric acid crystallizing in the urine; may become trapped anywhere along the urinary tract. - Pressure build-up behind the stone -> swelling in the kidney. Pain is often caused when the stone moves within the ureter; causing a blockage that prevents urine from passing -> stretching and dilating the ureter behind the location of the stone. - May be passed on its own or may have to be surgically removed/broken up.

Kidneys (urinary system)

Solid organs that play an important role in the regulation of the acid-base balance (pH) and BP (associated with this organ's ability to remove sodium chloride from the body). Also rids the body of toxic wastes and control the body's balance of fluid + electrolytes. - Nearly 20% of the output of the blood from the heart passes through here each minute.

Hollow organs include ___ and perforation of these organs cause what?

The gallbladder, stomach, small intestine, large intestine, and urinary bladder; contents will leak and contaminate the abdominal cavity.

Esophagitis/GERD

The lining of the esophagus becomes inflamed by infection or from acids in the stomach (gastroesophageal reflux disease) -> condition in which the sphincter between the esophagus and the stomach opens (allowing for stomach acid to move up into the esophagus), aka acid reflux disease. - 18% of the total population in the U.S.; extremely common - upper GI bleeding

Solid organs include ___ and injury to such organs can cause what?

The liver, spleen, pancreas, kidneys, and ovaries; shock and bleeding because of the amount of blood vessels contained in the organ.

Stomach (GI system)

The main organ of the digestive system, is where gastric juices break down food into a form that can be used by the body.

peritoneum

The membrane lining the walls of the abdominal cavity (parietal) and covering the abdominal organs (visceral).

Signs and symptoms of gastroenteritis

When patients come in contact with contaminated matter, then the patient may experience upset stomach and diarrhea within several hours or several days -> can run its course in 2 to 3 days or continue for several weeks. Diarrhea is the principle symptom in both infectious and noninfectious forms (large dumping type or frequent small liquid stools; may contain blood and/or pus). Abdominal cramping, nausea, vomiting, fever, and anorexia. Dehydration can result. - As volume of fluid loss increases = likelihood of shock.

Signs and symptoms of CKD in patients who are untreated or missed dialysis?

Wide range of symptoms from not feeling well to altered LOC. Later stages = coma and seizures are possible. Additional signs and symptoms include lethargy, nausea, headaches, cramps, and edema in the extremities + face because of fluid imbalance.

hernia

the protrusion of an organ or tissue through an abnormal body opening (where it does not belong). Can occur due to: a congenital defect as around the umbilicus, a surgical wound that has failed to heal properly, or a natural weakness in the area such as in the groin. - Reducible or incarcerated

emesis

vomiting

hematemesis

vomiting blood

Signs and symptoms of AAA

- Pain in the lower quadrants or the lower parts of the back (due to the peritoneum being stripped away from the wall of the abdominal cavity by the hemorrhage). The pain may be severe, sudden, persistent, or constant. It may spread to the groin, buttocks, or legs. A pulsating feeling near the navel may be present. - Patients describe this pain as "tearing, ripping" or "searing" and the patient cannot easily explain the back pain's origin -> back pain = is common when an aneurysm has started to expand + aortic linings begin to tear, and sudden abdominal pain manifests. - If the aneurysm tears + ruptures = massive hemorrhaging + signs of acute peritoneal irritation and shock. - Pale and sweating, a difference in pulse strength in the feet.

A healthy adult forms how many liters of urine everday?

1.5 to 2 liters every day

Gastrointestinal hemorrhage

Bleeding within the digestive tract, symptom of another disease NOT a disease itself. - Can be acute (shorter term, more severe) or chronic (longer duration, less severe). - Can occur in upper or lower GI tract.

Signs and symptoms of PUD

A classic sequence of burning or gnawing pain in the stomach that subsides or diminishes immediately after eating and then reemerges 2 to 3 hours later. Nausea, vomiting, belching, and heartburn are common symptoms. Severe erosion can cause gastric bleeding, resulting in hematemesis and melena. - More serious conditions can cause severe peritonitis and acute abdomen (or perforation - a hole in the abdomen through the wall of the stomach). - Pain is localized in the upper mid-abdomen or upper part of the back.

Abdominal Aortic Aneurysm (AAA)

A condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge/swell. - Common in older people; the typical patient is a male in his late 60's - If the aneurysm is not expanding, the patient will be asymptomatic.

acute abdomen

A condition of sudden onset of pain within the abdomen, usually indicating peritonitis; immediate medical or surgical treatment is necessary.

Gallbladder (GI system)

A hollow pouch located beneath the liver that acts as a reservoir for bile.

Mallory-Weiss tear

A tear in the junction between the esophagus and the stomach causes severe bleeding and potentially death. Primary risk factors = alcoholism and eating disorders. - Upper GI bleeding

Signs and symptoms of diverticulitis

Abdominal pain, usually localized on the left lower quadrant. Classic infection signs include fever, malaise (feeling of discomfort), body aches, chills, nausea, and vomiting. Constipation or diarrhea. Local infections = scar -> tissues stick -> bowel obstruction. Severe cases = infected outcropping burst -> perforation of the affect segment of colon leading to peritonitis, severe infection, and if untreated = septic shock.

(Acute) Gastroenteritis

Acute: comprises a family of conditions revolving around a central theme of infection combined with diarrhea, nausea, and vomiting (bacterial + viral organisms can propagate this infectious condition -> enter the body through the contaminated food or water). - Can also be caused by noninvasive/noninfectious conditions such as adverse reactions to medications, exposure to certain toxins, or chemotherapy.

urinary tract infection

An infection, usually of the lower urinary tract (urethra and bladder), that occurs when normal flora bacteria enter the urethra and grow.

Duodenum (GI system)

Apart of the small intestine and is where digestive juices from the pancreas and liver combine.

Ileum (GI system)

Apart of the small intestine which absorbs the remaining nutrients and also absorbs bile acids so that they can be returned to the liver for future use and vitamin B12 for making nerve cells + RBCs.

Jejunum (GI system)

Apart of the small intestine which plays a major role in the absorption of digestive products. Compromises a large amount of surface area of the small intestine and does much of the work.

Abdominal pain quality in the parietal peritoneum

Because this peritoneum is supplied by nerves from the spinal cord that supply the skin of the abdomen, then this peritoneum can (much like the skin of the abdomen) can perceive pain, touch, pressure, heat, and cold + easily identify/ precisely localize a point of irritation. - Intense, aggravated by movement, severe

melena

Black, foul-smelling, tarry stool containing digested blood.

Lower GI bleeding

Bleeding occurs between the upper part of the small intestine to the anus. Stools are often bright red or maroon in color.

Upper GI bleeding

Bleeding occurs from the esophagus to the upper small intestine. Hematemesis is frequently seen with bright red blood or the appearance of coffee grounds. Bleeding also manifests as melena (tarry, dark stools).

strangulation

Complete obstruction of blood circulation in a given organ as a result of compression or entrapment; an emergency situation causing the death of tissue. - Immediate surgery is required to remove dead tissue and repair the hernia.

Small intestine (GI system)

Consists of the three sections: the duodenum, jejunum, and ileum.

Hemorrhoids

Created by swelling and inflammation of blood vessels or increased pressure surrounding the rectum. Half of the population has at least one by the age of 50 years! - Pregnancy, straining at stool, and chronic constipation = increased pressure. Diarrhea = irritation. - May be internal/high in rectum/not visible = painless, associated with bright red blood, brisk bleeding. - May be external/low in rectum/clearly visible = painful.

Referred pain

Felt in remote areas supplied by the same neuro-segment as the diseased organ (radiation); result of the connection between the body's two separate nervous systems. Pain is felt in an area of the body other than the area where the cause of pain is located. - Well localized and appears with intense visceral stimulus. - Ex: acute cholecystitis may cause pain in the right shoulder because the autonomic nerves serving the gallbladder lie near the spinal cord at the same anatomic level as the spinal sensory nerves that supply the skin of the shoulder.

Diverticulitis

Inflammation in small pockets at weak areas in the muscle walls of the intestines. Localization of pain in the left lower quadrant. Fiber decreases in diet -> stool become solid -> more intestinal contractions -> increases pressure in colon -> bulges in colonic wall result -> small outcroppings turn into pouches (diverticula where feces may be trapped -> bacteria growth = localized inflammation + infection). - MOST common cause of lower GI bleeding in the U.S.

cystitis

Inflammation of the bladder (UTI), especially common in women, is generally caused by bacterial infection. Pain is localized in the lower mid-abdomen (retropubic), Can become a serious health problem if the infection spreads to the kidneys.

cholecystitis

Inflammation of the gallbladder. Localization of constant, severe pain in the right upper quadrant (direct), mid-abdominal region, and may radiate to the right upper back, shoulder area, or flank (referred). Propagated when gallstones form and block the outlet of the gallbladder, causing pain in which the gallbladder can rupture causing inflammation to spread and irritate surrounding structures such as the diaphragm and bowel. - May have a substantial elevation in body temperature.

pancreatitis

Inflammation of the pancreas. Can be caused by an obstructing gallstone, alcohol abuse, and other diseases. Severe pain is localized in the upper abdomen (both quadrants) and may radiate to the back.

peritonitis

Inflammation of the peritoneum. Any foreign material, such as blood, pus, bile, pancreatic juice, or amniotic fluid can cause irritation. - Usually causes ileus. - Pain is diffused throughout the abdominal area.

appendicitis

Inflammation or infection of the appendix and is a frequent cause of acute abdomen. Inflammation can cause the tissues to die and/or rupture, causing abscess, peritonitis, or shock.

guarding

Involuntary muscle contractions (spasm) of the abdominal wall to minimize the pain of abdominal movement; a sign of peritonitis or a perforated ulcer.

Incarcerated hernia

Is an irreducible hernia in which the contents of the hernial sac are entrapped and can become seriously compressed by the surrounding tissue; eventually comprising the blood supply (strangulation).

Abdominal pain quality in the visceral peritoneum

Is supplied by nerves of the autonomic nervous system such that patients are unable to describe exactly where the pain is localized. Usually irritated first. - Stimulated when distention or contraction of the hollow abdominal organs activates the stretch receptors, described as "deep pain," dull, gnawing, or burning, vague, and presents with secondary autonomic symptoms: sweating, nausea. - Other painful stimulation may be perceived at a distant point on the surface of the body (back or shoulder = referred pain).

Urinary bladder (urinary system)

Located immediately behind the pubic symphysis in the pelvic cavity and is composed of smooth muscle with a specialized lining membrane. A temporary storage reservoir for urine that empties outside of the body through the urethra.

Reducible hernia

Mass that can disappear back into the body cavity which it belongs; can be gently pushed back through the abdominal wall. Pose little risk, patients can live with them for years.

Signs and symptoms of appendicitis

Pain is initially generalized, dull, and diffuse and may center in the umbilical area. Pain later localizes to the right lower quadrant of the abdomen. Can also cause referred pain around the navel. Patients may also report nausea and vomiting, anorexia, fever, and chills. Classic symptom = rebound tenderness.

Esophageal varices

Occur when the pressure with the blood vessels surrounding the esophagus increases, frequently as a result of/ secondary to liver failure. - Esophageal blood vessels eventually drain their blood into the liver, if the liver becomes damaged, and blood cannot flow through it easily, blood begins to back up in these portal vessels -> dilating vessels -> causing the capillary network of the esophagus to leak. - If the pressure begins to build, the vessel walls may fail, causing massive upper GI bleeding and hematemesis. - Industrialized countries: alcohol = main cause of liver damage. - Developing countries: viral hepatitis = main cause of liver damage.

Peptic Ulcer Disease (PUD)

One cause of acute abdomen. The protective layer is eroded, allowing the acid to eat into the organ itself over the course of weeks, months, or even years (stomach + duodenum are especially subject to high levels of acidity). Can be propagated by: infection of the stomach by Helicobacter pylori bacteria and chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (trade = Advil, Motrin), naproxen (trade = Aleve).

The female reproductive system consists of?

Ovaries, fallopian tubes, uterus, cervix, and the vagina.

Acute Kidney Injury (AKI)

Sudden decrease in kidney function. Occurs from a variety of causes: hemorrhage, dehydration, trauma, shock, sepsis, heart failure, medications, drug abuse, and kidneys stones. Very often reversed with prompt diagnosis and treatment!

Signs and symptoms of esophageal varices

Takes two forms (1) initially, the patient shows signs of liver disease: fatigue, weight loss, jaundice, anorexia, edema in the abdomen, abdominal pain, nausea, and vomiting -> gradual disease process takes months to years until the patient reaches a state of extreme discomfort. (2) spontaneous rupture of varices: sudden onset discomfort in the epigastric region or sternum, severe difficulty swallowing, vomiting of bright red blood, hypotension, and signs of shock -> less dramatic bleeding = hematemesis and melena. - Major ruptures = death in a matter of minutes, life-threatening!

The male reproductive system consists of?

Testicles, epididymis, vasa deferentia, seminal vesicles, prostate gland, and penis.

Hemodialysis (HD)

The patient's blood circulates through a dialysis machine that functions in much the same way as the normal kidneys. Long-term patients have a shunt or fistula; a surgically created connection between a vein and an artery in which the patient is connected to the dialysis machine through the shunt or the fistula.

Interventions for treating a patient with an abdominal emergency consists of?

Treatment of shock, providing emotional support, and keeping the patient as comfortable as possible. Administering oxygen if the patient is hypoxemic, cover the patient with a blanket for warmth, and provide gentle transport for the patient without delay. Place the patient in a position of comfort. Maintain and protect the airway.

Signs and symptoms of Mallory-Weiss tear

Violent coughing or vomiting is the principal cause. In women, this syndrome may be associated with severe vomiting related to pregnancy! Can range from minor bleeding (little blood loss) or severe bleeding + to extreme fluid loss. In severe cases, patients experience shock, upper abdominal pain, hematemesis, and melena.