Critical Concepts in

Gastrointestinal Alterations
Ms.
Azmat Jehan Khan
RM, RN,BScN, MScN
Assistant Professor
AKUSONAM
 Objectives
Life threatening Gastrointestinal Emergencies

Blunt
Trauma
Abdominal
Injuries
Penetrating
Trauma

Acute Gastro-
Intestinal (GI)
Bleeding
Abdominal Anatomy
 Pelvic vascular
Abdominal Cavity plexus, femoral
arteries, femoral
veins, pelvic
Bowel, spleen, skeletal
liver, stomach, & structures,
gall bladder reproductive
organs
Peritoneal
Pelvic Space
Space

Retroperitoneal
Kidney, ureter, bladder, Space
reproductive organs, inferior
vena cava, aorta, pancreas,
duodenum, & rectum
 Structures and Functions of the GI Systems

 The GI tract is a tube approximately 30 feet ( 9m) long.

 Made up of four common layers ( Mucosa, Sub mucosa, muscle,
and serosa). In the esophagus the outer coat is fibrous tissue rather
than serosa).
 The GI tract is innervated by the parasympathetic and the
sympathetic branches of the autonomic nervous system (e.g.
peristalsis is increased by parasympathetic stimulation and
decreased by sympathetic stimulation).

 The GI tract and accessory organs receive approximately

25% to 30% of the cardiac out put.
 Abdominal Trauma
 Abdominal trauma is regularly encountered in the emergency
department
 One of the leading cause of death and disability
 Identification of serious intra-abdominal injuries is often
challenging
 Many injuries may not manifest during the initial assessment
and treatment period

Epidemiology:
 Epidemiology Peak incidence Abdominal Trauma 15 - 30yr
 More than 1.5 Lac people die/year as a result of injuries by motor
vehicle accident , fall, suicide and homicide
 Injury accounts for 10% of all deaths, 3rd leading cause of trauma
death
 Abdominal Trauma (cont’…)

Causes of Mortality:
 Delayed resuscitation
 Inadequate volume
 Inadequate diagnosis
 Hemorrhage (early) due to:
• Solid organ injury:
• (Liver, Pancreas, Spleen, Kidneys, Ovaries)
• Hollow organ injuries:
• (Stomach, Small/ Large Intestines, Appendix, Gall Bladder,
Bladder, Uterus, Aorta, Common Bile Duct, Fallopian Tubes)
• Abdominal vascular injuries
• Pelvic fractures
 Perforation (late)
 Delayed surgery
 Types of Abdominal Trauma
1. Blunt/Closed Trauma
 (Domestic Violence, falls, motor vehicle accidents, or severe
blows to the abdomen. Endoscopic /Laparoscopic surgical
procedures, blood vessels, bowel, & reproductive organs, heimlich
manoeuvre)
2. Penetrating/ Opened Trauma (slightly higher mortality rate
Second most common cause of abdominal injury)
 -Stab wound
 -Gun shot (cause 95% of penetrating abdominal injury)
 Blunt Abdominal Trauma
Blunt Abdominal Trauma (BAT)
 Most common type in children
Causes:
 Motor Vehicle Collision (MVC)
 Bicycle injuries (handlebar)
 Falls
 Non-accidental trauma (NAT)
Organs Injured
 Spleen (40-55%)
 Liver (35-45%)
 Small Bowel (5-10%)

ATLS, 7th Edition, 2004

Spleen Anatomy

Grade 5 Splenic laceration

 Blunt Injury (cont’…)
1. SPLENIC INJURY:
Most common intra-
abdominal organ to
injured (40-55%)
Cause: Left lower rib
fractures
Management:
 Conservative management: -
Hemodynamic stability,
Monitoring Serial abdominal
Examinations

 Operative Management:
 Splenorrhaphy: Major
Laceration
 Partial Splenectomy
 Total Splenectomy
Liver Anatomy

Grade 4 Liver laceration

 Blunt Injury (cont’…)

2. LIVER INJURY:
Liver is the largest organ in
abdomen 2nd most common
organ injured (35-45%)
Cause: Venous bleeding 85%
of all patients with blunt
hepatic trauma

Management:
 Suturing:
 Simple suture
 Deep mattress suture
Laceration
 Omental flap to cover
the laceration
 Surgery:
 Liver Transplantation
Pancreatic Anatomy
 Blunt Injury (cont’…)
3. PANCREATIC INJURY:
Rare 10-20% of all abdominal
injury
Cause: Crush , Direct blow to
abdomen & Seat belt,
associated with Duodenal
injury, Vascular injury &
liver injury
Diagnosis: Difficult, High
index of suspicion CT Scan is
helpful Serum amylase is a
poor indicator
Management:
 Grade I and II injuries best
treated with hemostasis +/-
external drainage
 Grade III injuries treated with
distal Pancreatectomy
 Grade IV and V injuries
treated managed with
surgical management.
Blunt Injury (cont’…)

Bowel injury:
Most common bowel injuries :
 Duodenal hematomas
 Small bowel perforation
 Duodenal hematoma or rupture found in:
Bowel injury associated with:
Poor outcome (sepsis  death) predictors:
 Delay in diagnosis of >8 hours
Management:
Explore Laparotomy with Primary Repair
History: Blunt Trauma
 Mechanism of injury
 Identification & treatment of life threatening
 Force, location
 Associated symptoms
 Pain, vomiting, hematuria,
hematochezia (blood in
stool), dyspnea,
respiratory distress
 Emergency Care
 Motor vehicle collision
 Speed,
 Location,
 Seat Belt,
 Patient Position,
 Status Of Passengers
Initial Assessment and Resuscitation Primary
survey:
conditions.
 Airway , with cervical spine precautions
 Breathing
 Circulation
 Disability
 Exposure
 I V fluids
 Control external bleeding
 Dressing of wounds
 Protect organs with a sterile dressing
 Stabilize an impaled object in place
 Give high flow oxygen
 Immobilize the patient with a fractured
pelvis
 Keep the patient warm
 Analgesics
 Secondary Survey General &Systemic Examination:
 Identify all injuries
 Special attention to:
 Back
 Bleeding
 Perforation
AMPLE History
 A : Allergy
 M : Medications
 P : Past medical history
 L : Last meal
 E : Event - What happened
 Inspection
1. Laceration Abrasion Entry/Exit wounds
2. Abdomen distended: blood, inflammation
3. Seat Belt Sign(SBS)
4. Handlebar mark
5. Cullen’s Sign: Bluish discoloration around
umbilicus due to hemoperitoneum Severe
pancreatitis.
6. Grey-Turner’s Sign (late): (occurs 6-24 hours
after onset) Bluish discoloration of the flanks
Retroperitoneal Hematoma, hemorrhagic
pancreatitis.
 Assess for pelvic stability
 Penile, vaginal, perineal, and rectal
evaluation
 Presence of blood
Auscultation
1. Bowel sounds in the thoracic cavity (Diaphragmatic rupture)
2. Decreased bowel sounds

Percussion

1. Tympanic (ileus, free air)

2. Ballance’s Sign: Dullness on percussion of the left upper
quadrant ruptured spleen
 Palpation
 Mass -Tenderness
 Signs of peritonitis
 Abdominal tenderness
 Right/left lower costal margin tenderness
 Flank tenderness

1. Kehr’s sign: Acute Referred pain, in the tip of the left shoulder due to
the presence of blood or other irritants in the peritoneum when a person
is lying down and the legs are elevated. A classical symptom of a ruptured
spleen (Splenic injury, free air, intra-abdominal bleeding).
 Investigations

 Focused Assessment with Sonography in Trauma (FAST) :1996, Can,

Cost effective, Four different views- Pericardiac, Perihepatic, Perisplenic,
Peripelvic space

 Plain X-Ray Chest & Abdomen, CT Scan

 Paracentesis: Four quadrant aspiration of abdomen A Positive tap –
blood, air, bile stained fluid
 Diagnostic Peritoneal Lavage
 Diagnostic Laparoscopy
 Ultrasound
 Diagnostic Peritoneal Lavage
 Amount of warmed Ringer’s
lactate for lavage:
 10 ml/kg in a child
 1 liter in an
adolescent/adult
 Gram stain with bacteria
 Aspiration of gross blood,
GI contents,
Penetrating Abdominal Trauma
 Gunshot
 Stab wound
 Penetrating Abdominal Trauma
Common Organs:
 Small Intestine (29%)
 Liver (28%)
 Colon(23%)
 Patients with deep penetrating injuries always require surgery
 Gunshot Wounds
Types of Gun: handguns, rifles, and
shotgun
Degree of injury depends:
 Amount of kinetic energy imparted
by the bullet to the victim
 Mass of the bullet and the square
of its velocity
 Distance
Type of Wound:
 Type I Wounds: long range
(>7 yards) , a penetration of
subcutaneous tissue
 Type II Wounds: distance of 3
to 7 yards and may create a
large number of perforated
structures.
 Type III Wounds: occur at
close range (<3 yards) and
involve a massive destruction
of tissue
 Stab Wound
Type of Weapon:
 Knives, Ice pick, pens, coat hangers, screwdrivers, and broken bottles.
 Most commonly in the upper quadrants, the left more commonly (20% )
 The incidence varies with the direction of entry into the peritoneal cavity
 The liver, followed by the small bowel, is the organ most often damaged
by stab wounds.
Intervention: Never try to replace organs, cover with moist gauze, then
sterile dressing. Transport immediately
 Types of GI Bleed

Upper GI bleed Mid-intestinal bleed Lower intestinal

arising from the arising from distal bleed
esophagus, stomach, or duodenum to ileocecal arising from
proximal duodenum valve colon/rectum
• Hematochezia
• positive stool blood • Melena
• Spectrum: bright red
• Occult blood in • Very dark, tarry, blood, dark red,
stool pungent stool maroon
• Does not provide • Usually suggestive • Usually suggestive
any localizing of UGI origin (but of colonic origin
information can be small (but can be UGI
• Indicates slow pace, intestinal, proximal origin if brisk
usually low volume colon origin if slow pace/large volume)
bleeding pace)
 Acute U.G.I. Bleeding
Cause:
1. Chronic Peptic Ulcer Disease- most
common (50% of GI bleed)
 Duodenal Ulcers: 29% will re-bleed in
10% of cases within 24-48h
 Gastric Ulcers: 16% more likely to re-
bleed
 Stomal Ulcers: <5%
2. Erosive Gastritis, Esophagitis,
Duodenitis:
causes are (alcohol), NSAID’s
3. Esophageal and Gastric Varices:
causes by portal hypertension
4. Mallory-Weiss Syndrome: longitudinal
mucosal tear in the cardio-esophageal
region caused by repeated vomiting
 Acute U.G.I. Bleeding (cont’…)

Assessment:
1. Active/recent bleeding history (24 hrs), then hospitalized.
2. If Small Amount, admit for observation, because CVS can compensate
3. History helps in diagnosing the cause of the hemorrhage, eg: long
history of indigestion, or previous hemorrhage from ulcers.
4. Liver Disease  severe, recurrent bleeding (if from varices)
5. Splenomegaly  portal hypertension
6. 85% stop bleeding during 48 hrs
7. Risk factors:
 Age (60 +)
 Amount of Blood Lost
 Continuing Visible Blood Loss.
 Signs of Chronic Liver Disease
 Classical Clinical Features of Shock
 Acute UGIB: Prognostic Indicators
NASOGASTRIC STOOL MORTALITY RATE
ASPIRATE COLOR (%)
Clear Red, brown, or black 10

Coffee Grounds Brown or black 10

Red 20

Red Blood Black 10

Brown 20

Red 30

Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

 Investigations: Acute U.G.I. Bleeding
1. Hb, PCV
2. CBC
3. Blood glucose
4. Platelets, coagulation
5. Urea, creatinine, electrolytes
6. Liver biochemistry
7. Acid-base state
8. Imaging: chest & abdominal X ray, US, CT
 Management: A.U.G.I. Bleeding
Immediate Management:
*Emergency management
-History + exam.
-Monitor: HR & BP /30 min
-Blood sample: Hb, urea,
electrolytes, grouping & cross-
matching
-I.V. access
-Bld transfusion in case of
1. shock
2. Hb <10 g/dl
-Urgent endoscopy
-Surgery if require
Shock Management:
Airway: OET,
oropharyngeal airway.
Give oxygen
Breathing: support
respiratory function
Monitor: RR, ABGs, chest
X ray
Circulation: expand
circulating volume: blood,
colloids, crystalloids
support CVS function:
vasodilators
Monitor: skin color, Temp.,
urine flow, BP, ECG
Drug Therapy
-Acid suppression
(intragastric pH > 4)
-Histamine 2 Receptor
Antagonists (H2RAs)
-Ranitidine (Zantac)
-Famotidine (Pepcid)
Proton Pump
Inhibitors (PPIs)
-Pantoprazole (Protonix)
-Lansoprazole (Prevacid)
-Esomeprazole (Nexium)
-Test for H. pylori. Tx =
amoxicillin,
clarithromycin, and PPI
-Limit NSAID use
 Lower GI Bleed
Causes
1. Diverticular Disease (large intestine
or colon, become inflamed,
unknown cause)
2. Angio-dysplasia (small vascular
malformation of the gut)
3. Inflammatory Bowel Disease (a
group of inflammatory conditions of
the colon and small intestine)
4. Ischemic Colitis (inflammation and
injury of the large intestine result
from inadequate blood supply)
5. Infective Colitis
6. Colorectal Carcinoma
 Investigation: L.G.I. Bleeding
 Can be investigated once bleeding has stopped
 In the actively bleeding patient consider:
 Colonoscopy - can be difficult
 Selective mesenteric angiography (superior mesenteric artery)
 Requires continued bleeding of >1 ml/minute
 Management: L.G.I. Bleeding
 Resuscitation
 Most bleeding ceases
 Colonscopy - early
 UGI source
 If bleeding persists perform endoscopy to
exclude upper GI cause
 Proceed to Laparotomy and consider on-table
lavage
 If right-sided angio-dysplasia perform a right
hemicolectomy
 If source of colonic bleeding unclear perform a
subtotal colectomy and end-ileostomy
 5% Mortality
on-table lavage
38 4/2/2018