HEGAZY SURGERY

1. Gastroenterology
“A Cute Abdomen”
Dr Baxter Larmon
Professor
UCLA School of Medicine

2. Incidence of GI/GU Disorders
 Every year about 62 million people are
diagnosed with a gastrointestinal
disorder.
 The incidence and prevalence of most
digestive diseases increase with age,
although there are exceptions.

3. Morbidity & Mortality of GI/GU
Disorders
 In 1992, GI disorders cost nearly $107 billion
in direct health care expenditures.
 Currently, GI disorders result in nearly 200
million sick days,
 50 million visits to a physician,
 16.9 million days lost from school,
 10 million hospitalizations,
 And nearly 200,000 deaths per year.

4. General Pathophysiology
 General Risk Factors
 Excessive Alcohol Consumption
 Excessive Smoking
 Increased Stress
 Ingestion of Caustic Substances
 Poor Bowel Habits
 Emergencies
 Acute emergencies usually arise from
chronic underlying problems.

5. Etiology of Pain
 Inflammation
 Foreign chemical
 Bacterial contamination
 Stimulation of nerve endings.
 Irritation
Stretching, distention, bleeding

6. Visceral vs. Somatic
 Visceral pain
 Caused by stimulation of autonomic nerve
fibers that surround a hollow viscus
 Cramping or gas type
 Generally diffuse drill
 Somatic pain
 Produced by Bacterial or chemical irritation
of autonomic nerve
 Guarding
 Don’t want to move
 Superficial

7. Solid Organs
 Dull and steady in nature.
 More localized.
 Bleeding
Within capsule,
Rupture;

8. Hollow Organs
 Colicky, crampy, dull, or gassy,
 Typically intermittent.
 Diffuse and poorly localized.
 Path of a tube.
 The place where the patient is
feeling the most pain may not be
the most tender on palpation.

9. Hollow Organs
 Usually associated with
nausea,
vomiting,
tachycardia,
diaphoresis;
 Bleeding
within the organ itself;

10. Referred Pain
 Definition
 Pain in area removed from tissue that caused
the pain
 Caused by visceral fibers that synapse in the
spinal cord
 Cause
 same spinal segment,
 skin has more receptors,
 unable to distinguish,

11. Referred Pain
 NOT ALL ABDOMINAL PAIN IS
OF ABDOMINAL ETIOLOGY.

12. General Assessment
 Scene Size-up & Initial Assessment
 Scene clues.
 Identify and treat life-threatening
conditions.
 Focused History & Physical Exam
 Focused History
Obtain SAMPLE History.
Obtain OPQRST History.
 Associated symptoms
 Pertinent negatives

13. General Assessment
Physical Exam
General assessment and vital
signs
Abdominal assessment
Inspection, Auscultation, and
Palpation, Percussion
Cullen’s Sign: Discoloration
around the umbical area
Grey-Turner’s Sign:
Discoloration in the flank area

14. Let’s Review a
Physical Exam
of the
Abdomen

15. General Treatment
 Maintain the airway.
 Support breathing.
 High-flow oxygen or assisted
ventilations.
 Maintain circulation.
 Monitor vital signs and cardiac
rhythm.
 Establish IV access.
 Transport in position of comfort.

16. Specific Illnesses
 The
Gastrointestinal
System
 Upper
Gastrointestinal
Tract
 Lower
Gastrointestinal
Tract
 Liver
 Gallbladder
 Pancreas
 Appendix

17.  Causes
Peptic Ulcer Disease
Gastritis
Esophagitis
Duodenitis
Upper Gastrointestinal Bleeding

18. Upper Gastrointestinal Bleeding
Etiology
ETIOLOGY PERCENT
Peptic Ulcer 45
Gastric erosions 23
Varices 10
Mallory-Weiss Tear 7
Esophagitis 6
Duodenitis 6
Other 2

19.  Signs & Symptoms
 General abdominal discomfort
 Hematemesis and melena
 Classic signs and symptoms of shock
 Changes in orthostatic vital signs
 Treatment
 Follow general treatment guidelines.
 Begin volume replacement using 2 large-bore
IVs.
 Differentiate life-threatening from chronic
problem.
Upper Gastrointestinal Bleeding

20. Esophageal Varices
 Cause
 Portal
Hypertension
 Chronic alcohol
abuse and liver
cirrhosis
 Ingestion of
caustic
substances

21. Esophageal Varices
 Signs & Symptoms
 Hematemesis, Dysphagia
 Painless Bleeding
 Hemodynamic Instability
 Classic Signs of Shock
 Treatment
 Follow General Treatment Guidelines.
 Aggressive Airway Management
 Aggressive Fluid Resuscitation

22. Acute Gastroenteritis
 Cause
 Damage to Mucosal GI Surfaces
Pathologic inflammation causes
hemorrhage and erosion of the mucosal
and submucosal layers of the GI tract.
 Risk Factors
Alcohol and tobacco use
Chemical ingestion
Systemic infections

23. Acute Gastroenteritis
 Signs & Symptoms
 Rapid Onset of Severe Vomiting and
Diarrhea
 Hematemesis, Hematochezia, Melena
 Diffuse Abdominal Pain
 Classic Signs of Shock
 Treatment
 Follow General Treatment Guidelines.
 Fluid Volume Replacement.
 Consider Administration of Antiemetics.

24. Peptic Ulcers
 Pathophysiology
 Erosions caused
by gastric acid.
 Terminology based
on the portion of
tract affected.
 Causes:
 Alcohol/Tobacco Use
 H. pylori

25. Peptic Ulcers
 Signs & Symptoms
 Abdominal Pain
 Observe for signs of hemorrhagic
rupture.
Acute pain, hematemesis, melena
 Treatment
 Follow general treatment guidelines.
 Consider administration of histamine
blockers and antacids.

26.  Pathophysiology
 Bleeding distal to the ligament of
Treitz
 Causes
Diverticulosis
Colon lesions
Rectal lesions
Inflammatory bowel disorder
Lower Gastrointestinal Bleeding

27.  Signs & Symptoms
 Determine acute vs. chronic.
 Quantity/color of blood in stool.
 Abdominal pain
 Signs of shock.
 Treatment
 Follow general treatment guidelines.
 Establish IV access with large-bore catheter(s).
Lower Gastrointestinal Bleeding

28. Crohn’s Disease
 Pathophysiology
 Inflammatory bowel
disease, ? Autoimmune
etiology
 Can affect the entire GI
tract.
 Pathologic inflammation:
 Damages mucosa.
 Hypertrophy and fibrosis of
underlying muscle.
 Fissures and fistulas.

29. Crohn’s Disease
 Signs and Symptoms
 Difficult to differentiate.
 Clinical presentations vary drastically.
 GI bleeding, nausea, vomiting, diarrhea.
 Abdominal pain/cramping, fever, weight
loss.
 Treatment
 Follow general treatment guidelines.

30. Diverticulitis
 Pathophysiology
 Inflammation of small
outpockets in the
mucosal lining of the
intestinal tract.
 Common in the elderly.
 Diverticulosis.
 Signs & Symptoms
 Abdominal
pain/tenderness.
 Fever, nausea, vomiting.
 Signs of lower GI
bleeding.
 Treatment
 General treatment
guidelines.

31. Hemorrhoids
 Pathophysiology
 Mass of swollen veins
in anus or rectum.
 Idiopathic.
 Signs & Symptoms
 Limited bright red
bleeding and painful
stools.
 Consider lower GI
bleeding.
 Treatment
 General treatment
guidelines.

32. Bowel Obstruction
 Pathophysiology
 Blockage of the hollow
space of the small or
large intestines
 Hernias

33. Bowel Obstruction
 Pathophysiology
 Occlusion of the
intestinal lumen that
results in blockage
of the normal flow
of intestinal fluids
OR

34. Bowel Obstruction
 Pathophysiology
 Twisting of the bowel

35.  Pathophysiology
 Adhesions
Bowel Obstruction

36. Bowel Obstruction
 Signs & Symptoms
 Decreased Appetite, Fever, Malaise
 Nausea and Vomiting
 Diffuse Visceral Pain, Abdominal
Distention
 Signs & Symptoms of Shock
 Treatment
 Follow general treatment guidelines.

37. Accessory Organ Diseases
GI Accessory Organs
Liver
Gallbladder
Pancreas
Appendix

38. Appendicitis
 Pathophysiology
Inflammation of the vermiform
appendix.
Frequently affects older children
and young adults.
Lack of treatment can cause
rupture and subsequent
peritonitis.

39. Cholecystitis
 Pathophysiology
 Inflammation of the
Gallbladder
 Cholelithiasis
 Chronic
Cholecystitis
 Bacterial infection
 Acalculus
Cholecystitis
 Burns, sepsis, diabetes
 Multiple organ failure

40. Pancreatitis
 Pathophysiology
 Inflammation of the Pancreas
 Classified as metabolic, mechanical, vascular, or
infectious based on cause.
 Common causes include alcohol abuse, gallstones,
elevated serum lipids, or drugs.Viral Hepatitis
 A viral inflammatory disease:
1. Hepatitis A Virus (HAV),
2. Hepatitis B Virus (HBV),
3. Hepatitis C Virus (HCV) aka non-A, non-B hepatitis,
4. Hepatitis D Virus (HDV) only occurs in individuals
with HBV,
5. Hepatitis E Virus (HEV).

41. Cirrhosis
 Infection
Viral hepatitis
 Toxins
ETOH
 Altered immune response;
 Vascular disturbance;

42. Urology
&
Nephrology

43. Anatomy & Physiology
 Ureters
 Urinary Bladder
 Urethra
 Testes
 Epididymus and
Vas Deferens
 Prostate Gland
 Penis

44.  Inflammatory or Immune-
Mediated Disease
 Infectious Disease
 Physical Obstruction
 Hemorrhage
General Mechanisms of
Nontraumatic Tissue Problems

45.  Differentiating GI and Urologic
Complaints
 Pathophysiologic Basis of Pain
 Causes of Pain
 Types of Pain
Visceral pain
Referred pain
General Pathophysiology,
Assessment and Management

46.  Risk Factors
 Older Patients
 History of Diabetes
 History of Hypertension
 Multiple Risk Factors
 Renal and Urologic Emergencies
 Acute Renal Failure
 Chronic Renal Failure
 Renal Calculi
 Urinary Tract Infection
Renal and Urologic Emergencies

47. Acute Renal Failure
 Pathophysiology
 Prerenal Acute Renal Failure
Dysfunction before the level of kidneys
 Most common and most easily reversible
 Renal Acute Renal Failure
Dysfunction within the kidneys
themselves
 Postrenal Acute Renal Failure
Dysfunction distal to the kidneys

48. Acute Renal Failure
 Assessment
Focused History
Change in urine output
Swelling in face, hands, feet, or
torso
Presence of heart palpitations or
irregularity
Changes in mental function

49. Acute Renal Failure
 Physical Assessment
 Altered mental status
 Hypertension
 Tachycardia
 ECG indicative of hyperkalemia
 Pale, cool, moist skin

50. Acute Renal Failure
 Physical
Assessment
 Edema of face,
hands, or feet
 Abdominal
findings
dependent on
the cause of
ARF

51. Renal Calculi
 Pathophysiology
 Results when “too
much insoluble
stuff”
accumulates in
the kidneys.
 Stone types
 Calcium salts
 Struvite stones
 Uric acid
 Cystine

52. Renal Calculi
 Assessment
 Focused History
 Severe pain in one flank that increases in
intensity and migrates from the flank to the
groin
 Painful, frequent urination with visible
hematuria
 Prior history of calculi
 Physical Exam
 Difficult due to patient discomfort
 Tachycardia with pale, cool, and moist skin

53. Urinary Tract Infection
 Pathophysiology
 Risk Factors
 Increased risk in female or catheterized
patients
 Sexual activity
 Lower and Upper UTIs
 Urethritis
 Cystitis
 Prostatitis
 Pyelonephritis
 Community-acquired vs. nosocomial infections

54. Urinary Tract Infection
 Assessment
 Focused History
Abdominal pain
Frequent, painful urination
A “burning sensation” associated with
urination
Difficulty beginning and continuing to
void
Strong or foul-smelling urine
Similar past episodes

55. Blarmon@mednet.UCLA.edu