GI DISORDERS

1.Acute abdominal pain

2.Nausea and vomitting

Dr.Prasanth A
Acute abdominal pain
• VISCERAL PAIN
• Visceral pain result from stimulation of autonomic unmyelinated nerves invested in the
visceral peritoneum surrounding internal organs
• Distention of hollow organs by fluid or gas and capsular stretching of solid organs by
edema, blood, masses, or abscesses are the most common stimuli.
• Crampy, dull, or achy pain. it can be either steady or intermittent (colicky).
• The visceral afferent nerves follow a segmental distribution.
• As intraperitoneal organs are bilaterally innervated, intraperitoneal visceral pain is felt in
the midline.
• Appendix wall - T10 - peri umbilical region
• PARIETAL PAIN
• Irritation of myelinated fibers that innervate the parietal peritoneum.
• Since Parietal afferent signals are sent from a specific area of peritoneum, parietal pain can be
localized to the dermatome superficial to the site of the painful stimulus.
• As the underlying disease process evolves, the symptoms of visceral pain give way to the signs
of parietal pain, causing

1. tenderness,

2. guarding,

3. rigidity and

4. rebound tenderness
• Patients with peritonitis generally prefer to remain immobile.
• REFERRED PAIN
• Felt at a location distant from the diseased organ.
• Referred pain patterns are also based on developmental embryology.
• Usually perceived in the same side as the involved organ.
• E.g. ureter and testis
• HISTORY

• Clear description of the pain OP2QRST2

• onset,
• provocative/palliative factors,
• quality,
• radiation,
• associated symptoms,
• timing,
• what the patient has taken for the pain).
• PHYSICAL EXAMINATION
• INSPECTION

• signs of distention (ascites, ileus, obstruction, volvulus),

• obvious masses (hernia, tumor, aneurysm, distended bladder),
• surgical scars (adhesions),
• ecchymoses (trauma, bleeding diathesis),
• stigmata of liver disease (spider angiomata, caput medusa).
• PALPATION
• Middle 3 fingers, painful area last, flex the knee
• Voluntary guarding
• Rigidity
• Involuntary guarding
• Rebound tenderness
• Pelvic examination in females with low abdominal pain in reproductive age group
• Males with lower abdominal pain - hernia, testicle, prostate examination
• Rectal examination - detection of grossly bloody, maroon, or melanotic stool
• PERCUSSION
• Liver dullness in MCL
• Fluid thrill wave

• AUSCULTATION
• Bowel sounds are nonspecific diagnostic signs.
• Decreased/ increased bowel sounds.

• Use location of pain to generate DD’s

• DIAGNOSTIC IMAGING
• X-ray
• Inguinal region needs to be included in abdominal X-ray
• limit plain abdominal X-ray to screening for
1. obstruction,

2. sigmoid volvulus,

3. perforation,

4. severe constipation

• Radiographic evidence of small bowel obstruction may be seen 6 to 12 hours before symptoms
develop.

• Upright chest X-ray sensitivity for small amounts of free air is only about 30%.
ULTRASOUND
• Abdominal US examination can visualize the
• gallbladder,
• pancreas, kidneys and ureters,
• urinary bladder volume,
• aortic dimensions.
• Not useful for diagnosis of small or large bowel disorders.
• The detection of free air or appendicitis by US is operator dependent and limited by
patient obesity and bowel gas.
• US is the preferred modality for the evaluation of biliary tract disease.
POCUS

• Abdominal resuscitative POCUS involves rapid assessment for

• free intra-abdominal fluid (FAST),
• abdominal aortic aneurysm,
• cardiac/inferior vena cava status.
• Abdominal diagnostic POCUS studies are focused urinary tract and biliary evaluations.
Abdomino pelvic CT

• CT scanning include noncontrast studies, or PO, PR, and/ or IV contrast.

• Noncontrast CT is the preferred imaging modality for the diagnosis of kidney and ureteral
stones. 97% specificity for acute appendicitis.
• PO contrast CT is the imaging modality of choice in many institutions for suspected GI
abscess, perforation, ulceration, fistula or inflammatory bowel disease.
• Rectal contrast CT can identify distal large bowel obstruction.
• IV contrast CT provides superior visualization of bowel mucosa, visceral organs, and
vascular structures. It can identify small and large bowel obstruction and the transition
point.
• It is the initial test of choice for suspected abdominal aortic aneurysm rupture or
mesenteric ischemia
TREATMENT

• Analgesics
• Antiemetics as needed
• NG tube and urinary catheter as needed
• Antibiotics for suspected abdominal sepsis and peritonitis. Endogenous gut flora cause
abdominal infections in the GI or GU tract.
• In all intra-abdominal nongynecologic infections, coverage should minimally be targeted
at anaerobes and facultative aerobic gram-negative bacteria.
 Abdominal compartment syndrome
• Intra-abdominal hypertension -persistent intra-abdominal pressure above 12 mm Hg.
• Abdominal compartment syndrome occurs as increased intra-abdominal pressure, often above
20 mm Hg, causes associated organ dysfunction.
• It is most often seen in critically ill septic, trauma, burn, and postoperative patients who receive
aggressive fluid resuscitation.
• The diagnosis of abdominal compartment syndrome should be considered in the critically ill
unstable patient with a tense abdomen.
• Abdominal compartment syndrome is confirmed by assessing intra-abdominal pressure, which
is most often measured via urinary bladder pressure monitoring.
• Medical management involves
• identification and treatment of the contributing factors of abdominal compartment
syndrome,
• evacuating intraluminal contents,
• improving abdominal wall compliance, and
• optimizing fluid administration and perfusion.
• Surgical decompression is required in patients with severe or refractory abdominal
compartment syndrome.
Nausea and vomitting

• The act of vomiting is divided into three phases: nausea, retching, and actual vomiting.
• During nausea there is an increase in tone in the musculature of the duodenum and
jejunum, with a concomitant decrease in gastric tone; this leads to reflux of intestinal
contents into the stomach.
• Retching is characterized as rhythmic, synchronous contractions of the diaphragm,
abdominal muscles, and intercostal muscles that occur against a closed glottis, without the
expulsion of gastric contents.
• Vomiting is the forceful expulsion of gastric contents through the mouth.
• vomiting is coordinated by the vomiting center located in the lateral reticular formation of
the medulla.
• The efferent pathways from the vomiting center are mainly through
• the vagus,
• phrenic, and
• spinal nerves.
• Afferent signals
• The CTZ area is rich in
• dopamine D2 receptors
• serotonin receptors
• The lateral vestibular nucleus is rich with
• cholinergic
• histamine receptors.
• Serotonin receptors are also widely found in the GI tract. These receptor sites are targets
for the various medications that are used to treat nausea and vomiting.
Clinical features

• Frequency of the episodes and interval between episodes are helpful to gauge the severity
of illness.
• Timing of the vomitting
• Content of the vomitting
• Pain preceding the nausea and vomiting is most particularly associated with an
obstructive process.
• Fever or, possibly, diarrhea suggests gastroenteritis.
• A history of recent weight loss is associated with a malignancy or psychiatric component.
• Any CNS sign may suggest a central cause for the nausea and vomiting.
• Assess vital signs for hypotension and tachycardia.
• Observe skin turgor, mucous membrane hydration, and capillary refill to assess for
dehydration.
• In children, the most useful predictors of significant dehydration (>5% loss of body
weight) are abnormal capillary refill, abnormal skin turgor, absent tears, and abnormal
respiratory pattern
• Abdominal examination
Diagnostic testing
• Based on dds raised by history and physical examination
• CBC and BMP often part of initial evaluation
• Lipase
• Lft, ammonia
• Urinalysis
• Pregnancy test
• US
• CT Abdomen
• CT/MRIbrain
Treatment
• Decreased oral intake with concomitant fluid loss (by vomiting) causes dehydration.
• If the patient is mildly or moderately dehydrated and is able to take oral liquids, a solution
containing sodium, carbohydrate, and water is recommended.
• Patients who are severely dehydrated or in whom intake of oral fluids is not possible or is
contraindicated should be given IV crystalloid solution and electrolyte abnormalities
corrected.
• Placement of a nasogastric tube is not indicated, except in patients with bowel obstruction.
• Antiemetics