CHAPTER 34. Gastrointestinal Emergencies
Amy Herrington
Gastrointestinal (GI) emergencies vary from minor problems to more serious, potentially life-threatening problems. Complaints of a GI nature are a common reason for visits to the emergency department (ED). Clinical indications of a problem in the GI system include heartburn, nausea, vomiting, constipation, diarrhea, bloating, chest pain, abdominal pain, and blood in stool or vomitus. This chapter focuses on those conditions seen most often in the ED. A brief review of anatomy and physiology is followed by discussion of specific GI conditions (e.g., gastroenteritis, GI bleeding, bowel obstruction, diverticulitis, gastroesophageal reflux disease [GERD], appendicitis, cholecystitis, and pancreatitis). Trauma of the GI system is discussed in Chapter 24.
ANATOMY AND PHYSIOLOGY
Normal GI function requires ingestion of nutrients and fluids and is followed by elimination of waste products formed from metabolic actions. Major organs and structures of the GI system are the esophagus, stomach, intestines, liver, pancreas, gallbladder, and peritoneum.
Esophagus
The major function of the esophagus is movement of food. The esophagus, a straight, collapsible tube approximately 25 cm long and up to 3 cm in diameter, extends from the pharynx to the stomach. Distinct esophageal layers are the mucous membrane, submucosa, and muscular layer. Secretions from mucous glands spread throughout the submucosa keep the inner lining moist and lubricated. Striated muscle in the upper esophagus is gradually replaced by smooth muscle in the lower esophagus and GI tract. The upper esophageal sphincter is at the proximal end of the esophagus, and the lower esophageal sphincter (LES) (also called the cardiac sphincter) is at the distal junction of the esophagus and stomach. The LES prevents regurgitation from the stomach into the esophagus.
Stomach
The stomach is a J-shaped organ located below the diaphragm between the esophagus and small intestine. Stomach functions include food storage and combining food with gastric juices. Limited absorption occurs in the stomach before the movement of food into the small intestine. Recognized regions of the stomach are the pylorus, fundus, body, and antrum. The pyloric sphincter controls food movement from stomach to duodenum. Distinct layers of the stomach wall are outer serosa, muscular layer, submucosa, and mucosa. The mucosal layer contains multiple wrinkles called rugae that straighten as the stomach fills to accommodate more volume. Completely relaxed, the stomach holds up to 1.5 L. 8 Gastric juices containing pepsin, hydrochloric acid, mucus, and intrinsic factor are secreted by glands in the submucosa. These agents begin food breakdown. Acids in the stomach maintain the pH of gastric juices at 1.0.
Intestines
The small intestine is a tubular organ extending from the pyloric sphincter to the proximal large intestine. Secretions from the pancreas and liver complete the digestion of nutrients in chyme—the semiliquid mixture of food and gastric secretions. The small intestine absorbs nutrients and other products of digestion and transports residue to the large intestine. Segments of the small intestine are the duodenum, jejunum, and ileum. The duodenum attaches to the stomach at the pyloric sphincter in the retroperitoneal space and represents the only fixed portion of the small intestine. The duodenum is approximately 25 cm long and 5 cm in diameter. The jejunum and ileum are mobile and lie free in the peritoneal cavity.
Segments of the large intestine are the cecum, colon, rectum, and anal canal. The large intestine is approximately 1.5 m long, beginning in the lower right side of the abdomen where the ileum joins the cecum. The colon is divided into ascending colon, transverse colon, descending colon, and sigmoid colon. Primary functions of the large intestine are absorption of water and electrolytes, formation of feces, and storage of feces.
Liver
The liver, located in the right upper quadrant of the abdomen, is divided into right and left lobes. Functional units of the liver called lobules contain sinusoids and Kupffer cells. Each lobule is supplied by a hepatic artery, sublobular vein, bile duct, and lymph channel. The liver is extremely vascular; approximately 1450 mL of blood flow through the liver each minute. Sinusoids in lobules act as a reservoir for overflow of blood and fluids from the right ventricle. A thick capsule of connective tissue known as Glisson’s capsule covers the liver. The liver is involved in hundreds of metabolic functions, including metabolism of nutrients, gluconeogenesis, and drug metabolism. Production of bile is a major function of the liver; 600 to 1200 mL of bile are secreted each day. Bile is essential for digestion and absorption of fats and fat-soluble vitamins and excretion of bilirubin and excess cholesterol. Bilirubin is an end product of hemoglobin destruction.
Pancreas
The pancreas is a lobulated organ behind the stomach that contains endocrine and exocrine cells. The organ is divided into the head, body, and a thin, narrow tail. Cells in the islets of Langerhans secrete insulin and regulate glucose levels. Exocrine cells called pancreatic acini secrete pancreatic juices for digestion of fats, carbohydrates, proteins, and nucleic acids. Pancreatic enzymes (i.e., lipase and amylase) enter the intestines through the pancreatic duct at the same juncture as the bile duct from the liver and gallbladder. Pancreatic and bile ducts join at a short dilated tube called the ampulla of Vater. A band of smooth muscles called the sphincter of Oddi surrounds this area and controls exit of pancreatic juices and bile.
Gallbladder
The gallbladder is a pear-shaped sac located in a depression on the inferior surface of the liver. The organ’s main functions are the collection, concentration, and storage of bile. Maximum volume is 30 to 60 mL; however, input from the liver can reach 450 mL over 12 hours. Concentration of bile in the gallbladder can be 5 to 20 times that of bile in the liver. 5 Bile is 80% water, 10% bile acids, 4% to 5% phospholipid, and 1% cholesterol. 8
Peritoneum
The peritoneum is a serous membrane covering the liver, spleen, stomach, and intestines that acts as a semipermeable membrane, contains pain receptors, and provides proliferative cellular protection. Technically, all abdominal organs are behind the peritoneum and therefore are retroperitoneal; however, the liver, spleen, stomach, and intestines are suspended into the peritoneum and considered intraperitoneal organs. Omenta are folds of peritoneum that surround the stomach and adjacent organs. The greater omentum drapes the transverse colon and loops of small intestine. It is extremely mobile and spreads easily into areas of injury to seal off potential sources of infection. The lesser omentum covers parts of the stomach and proximal intestines but is not as movable as the greater omentum.
The peritoneum is permeable to fluid, electrolytes, urea, and toxins. Somatic afferent nerves sensitize the peritoneum to all types of stimuli. In acute abdominal conditions the peritoneum can localize an irritable focus by producing sharp pain and tenderness, voluntary or involuntary abdominal muscle rigidity, and rebound tenderness.
PATIENT ASSESSMENT
Assessment of a patient with a GI emergency should initially focus on airway, breathing, and circulation (ABCs) with the primary survey completed before the focused assessment. Determination of chief complaint, social and medical history, reason for seeking treatment, and treatment before arrival follows the initial assessment. Information may be obtained from the patient, family members, significant other, friends, emergency medical services personnel, or previous medical records. Historical assessment should include questions related to gynecologic and genitourinary (GU) symptoms because many gynecologic or GU conditions cause abdominal pain, nausea, and vomiting. Information related to food intake and alcohol consumption should be obtained during assessment of patient history.
Evaluate the patient for abnormal skin color, abdominal wall abnormalities, pain, and alterations in bowel patterns. Abdominal pain is a common chief complaint in the ED that may be caused by an acute event or related to a chronic process. Abdominal pain may be visceral, somatic, or referred.
Visceral pain is caused by stretching of hollow viscus and is described as cramping or a sensation of gas. Pain intensifies, then decreases, and is usually centered at the umbilicus or below the midline. Diffuse pain makes localization of pain difficult. Diaphoresis, nausea, vomiting, hypotension, tachycardia, and abdominal wall spasms may be present. Conditions associated with visceral pain are appendicitis, acute pancreatitis, cholecystitis, and intestinal obstruction.
Somatic pain is produced by bacterial or chemical irritation of nerve fibers. Pain is sharp and usually localized to one area. A patient may be found lying with legs flexed and knees pulled to the chest to prevent stimulation of the peritoneum and subsequent increase in pain. Associated findings include involuntary guarding and rebound tenderness.
Referred pain occurs at a distance from the original source of the pain and is thought to be caused by development of nerve tracts during fetal growth and development. Biliary pain can be referred to the subscapular area, whereas a peptic ulcer and pancreatic disease can cause back pain.
Individual and cultural variations in expressions of pain must be considered when assessing abdominal pain. Each person reacts differently—older adult patients may not exhibit the same level of pain as younger patients; men may hide pain because expression of pain is not considered masculine in many cultures. Conversely, dramatic expression of pain may be expected in some cultures. Emergency nurses must remember that pain is a symptom—not a diagnosis. Interventions should focus on identification and treatment of the source of pain.
A systematic approach is recommended for assessment of abdominal pain. The PQRST mnemonic can be used to obtain appropriate historical information and identification of essential characteristics of pain. Provocation—Is there an action or movement that increases or changes the pain? Quality or character of pain—Is the pain sharp, dull, intermittent? Radiation or referral of pain—Does the pain stay in the right lower quadrant or move to the left lower quadrant as well? Using an age-appropriate pain scale such as a numeric rating of 0 (no pain) to 10 (worst pain ever) can identify the intensity or Severity of the pain. Question the patient regarding how long the pain has lasted to determine the Time of pain onset. It is important to consider the anatomy of the patient and to correlate the location of pain with the organ or system located in that region. For example, right lower quadrant pain in a female is often associated with ovarian or appendix conditions. The next step would be evaluating the descriptive information using the mnemonic discussed earlier. Final diagnosis would occur following serial examinations and diagnostics to evaluate or rule out each organ of potential disease or injury.
Another common finding with most GI emergencies is nausea and vomiting. Specific treatment varies with the underlying cause and physician preference. Abdominal assessment uses a sequence of inspection, auscultation, percussion, and palpation. Patient position should be noted because patients assume positions of comfort. Observe facial expression for signs of discomfort. Note skin color, temperature, and moisture. Inspect the abdominal wall for pulsations, movement, masses, symmetry, or surgical scars.
Auscultate bowel sounds in all four quadrants, determining frequency, quality, and pitch. Normal bowel sounds are irregular, high-pitched gurgling sounds occurring 5 to 35 times per minute. Decreased or absent bowel sounds suggest peritonitis or paralytic ileus, whereas hyperactive bowel sounds associated with nausea, vomiting, and diarrhea suggest gastroenteritis. Frequent, high-pitched bowel sounds may occur with bowel obstruction. Vascular sounds such as venous hums or bruits are abnormal findings. Auscultation should always be done before palpation because palpation may create false bowel sounds. The presence of hypoactive or hyperactive bowel sounds can be found in patients without abdominal pathologic processes. Thus bowel sounds must be evaluated in association with other abdominal findings such as guarding and tenderness with palpation. Factors such as stress and last food intake can affect bowel sounds.
Percussion is performed in all four quadrants. Dull sounds occur over solid organs or tumors, whereas tympanic sounds occur over air masses. Dull sounds may also be heard over a distended bladder or an area of bowel distended with stool. Tympany is the predominant sound heard when percussing the abdomen.
Palpation is the last step in abdominal assessment. Begin palpation away from painful sites, noting areas of tenderness, guarding, or rigidity. Assess for abnormal masses and rebound tenderness.
Concurrent findings such as fever and chills are usually found with bacterial infection, appendicitis, or cholecystitis. Other signs associated with pain are nausea, vomiting, and anorexia. Intractable vomiting or feces in emesis suggest bowel obstruction. Blood in emesis occurs with gastritis or upper GI bleeding. Assess bowel patterns for abnormalities such as diarrhea or constipation, noting stool color and consistency. Diarrhea can occur with gastroenteritis; black, tarry stools suggest upper GI bleeding; and clay-colored stools are found with biliary tract obstruction. Fatty, foul-smelling, frothy stools occur with pancreatitis.
SPECIFIC GASTROINTESTINAL EMERGENCIES
Infection, structural abnormalities, or pathologic processes may cause GI emergencies. Heredity and lifestyle also play a role. For example, excessive alcohol consumption can lead to GI bleeding, cirrhosis, or esophageal varices. Regardless of cause, nontraumatic GI emergencies are a common occurrence in any ED—ranging from minor inconvenience to life-threatening problems.
Gastrointestinal Bleeding
Bleeding can originate anywhere in the GI tract and can occur at any age. Bleeding is functionally categorized by location—upper or lower GI bleeding. Upper GI bleeding is more common in males, whereas lower GI bleeding is seen more often in females. Symptoms associated with bleeding in the GI tract include bright-red blood and/or black, “coffee grounds” material in vomitus, as well as bright-red blood from the rectum and/or black, tarry stools. Bleeding stops spontaneously in the majority of hospitalized patients.
Upper Gastrointestinal Bleeding
Upper GI bleeding refers to blood loss between the upper esophagus and duodenum at the ligament of Treitz. Bleeding is categorized as variceal or nonvariceal. 10 The risk for death is greater with variceal bleeding because of the occurrence of massive hemorrhage in these patients. Gastroesophageal varices are enlarged, venous channels that are dilated by portal hypertension. The common causes of portal hypertension in the United States are alcoholic liver disease and chronic active hepatitis. 8 As portal hypertension increases, varices continue to enlarge and eventually rupture, causing hemorrhage. Systemic manifestations of cirrhosis vary depending on the stage of the disease. Early symptoms include generalized weakness and fatigue; intermittent low-grade fevers; ankle edema; right upper quadrant abdominal pain; and various (GI) symptoms, including anorexia, nausea and vomiting, dyspepsia, and changes in bowel pattern. As the disease progresses, jaundice, mental status changes, muscle wasting, weight loss, ascites, epistaxis, spontaneous bruising, and hypotension may occur. 6 It is during this later stage that GI bleeding becomes prevalent. Bleeding from varices requires immediate intervention and close observation following initial control of bleeding. The risk for rebleeding is high until the varices are obliterated.
Nonvariceal bleeding occurs because of the disruption of esophageal or gastroduodenal mucosa with ulceration or erosion into an underlying vein or artery. Ulcerations or erosions occur when hyperacidity, pepsin, or aspirin inhibit mucosal prostaglandins and overwhelm protective factors of the esophagus (i.e., esophageal motility, salivary secretions, and the LES) and gastric mucosa (i.e., mucus, rapid epithelial renewal, and tissue mediators). Peptic ulcer disease, an infectious process caused by Helicobacter pylori, renders the underlying mucosa more vulnerable to gastric acid damage by disrupting the mucosal layer and initiating an inflammatory response that perpetuates tissue damage. Peptic ulcer disease may account for more than 50% of upper GI bleeding cases. 2 Other causes of upper GI bleeding include drug-induced erosions and severe or prolonged retching and vomiting such as with bulimia. Mallory-Weiss syndrome occurs from longitudinal tears or lacerations in the distal esophagus and proximal stomach. 18 The lacerations may result in bleeding from submucosal arteries. This syndrome is usually associated with severe retching. Mallory-Weiss syndrome has also been reported in patients with a history of straining with stools, coughing, lifting, and grand-mal seizures. Patients with a hiatal hernia are at greater risk for Mallory-Weiss syndrome.
Clinical signs and symptoms of GI bleeding are variable. Hematemesis, the vomiting of blood or coffee grounds–like material, confirms upper GI bleeding. Abdominal pain, nausea, vomiting, hematemesis, or melena (black, tarry stools) can be present. Other presenting symptoms may include pallor, dizziness, weakness, and lethargy. Signs of hypovolemia such as tachycardia, orthostatic hypotension, and syncope may also occur. Mental confusion, jaundice, or ascites are often observed in patients associated with variceal bleeding.
Management begins with maintenance of the ABCs. Administer high-flow oxygen via nonrebreather mask for patients with hemodynamic compromise or indicators of hypovolemic shock. Fluid replacement begins with normal saline or lactated Ringer’s solution followed by blood (packed red blood cells [PRBCs] or whole blood) replacement if the patient’s condition does not improve. Using a cardiac monitor and continuous pulse oximetry is recommended for patients with significant blood loss or bright-red bleeding. Older adult patients can experience myocardial infarction secondary to ischemia caused by hypovolemia. Monitor vital signs and level of consciousness for signs of hemodynamic compromise. A nasogastric tube is inserted for gastric lavage with saline solution to remove blood clots. Lavage also serves to clear the GI tract, which facilitates endoscopy. A urinary catheter is inserted to monitor output and fluid status.
Determine if the patient has a history of nonsteroidal antiinflammatory drug or aspirin use, and alcohol or liver disease. Baseline laboratory studies include complete blood count (CBC), type and crossmatch, electrolytes, blood urea nitrogen (BUN), creatinine, and serum glucose. Normal creatinine level with increased BUN suggests bleeding with breakdown of blood in the gut or dehydration. Liver function and coagulation studies are also recommended to rule out coagulopathies or liver disease. An upright chest radiograph can provide valuable information if perforation is suspected; however, this is not feasible if significant hemodynamic compromise is present. An electrocardiogram should be obtained to assess for dysrhythmias or cardiac ischemic changes related to blood loss.
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