Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies Study Guide for the CEN
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General Information
Since there are four main areas covered by these questions, you can imagine they take up a considerable portion of the CEN: 12% of the exam. Information about all of these areas is covered, including the assessment and treatment of related emergencies.
Gastrointestinal
The gastrointestinal system encompasses the patient’s entire digestive tract from their mouth to their anus. Patients can experience a variety of conditions due to infection, trauma, or inflammatory diseases. These conditions can be acute or chronic and, if left untreated, some can be life-threatening.
Acute Abdomen
An acute abdomen is a sudden onset severe abdominal condition that requires immediate treatment. Common causes of an acute abdomen include appendicitis, abdominal aortic aneurysm, perforated peptic ulcer, peritonitis, ovarian torsion, acute pancreatitis, peritonitis, perforated diverticulum, lacerated spleen or liver, and ischemic bowel.
Assessment
The key symptom of an acute abdomen is sudden onset severe abdominal pain and nausea and vomiting. Bowel sounds will likely be few or absent on auscultation, and the patient may demonstrate rebound tenderness and guarding if peritonitis is present. Depending on the severity of the patient’s condition, the patient may experience shock, either septic (in the event of infection) or hypovolemic (in the event of trauma) shock and may display hypotension, tachycardia, decreased urine output, abnormally low or elevated temperature, altered mental status, and elevated lactic acid. A FAST (Focused Assessment with Sonography in Trauma) ultrasound can be used to visualize any internal bleeding or large collections of fluid in the abdomen. A CT scan of the abdomen can also be used to diagnose the specific cause of the patient’s condition.
Treatment
The primary treatment is prompt surgical intervention to treat the cause of the patient’s acute abdomen. The specific surgical procedure will vary depending on the underlying cause of the procedure. If the patient has experienced infection from a perforated diverticulum or peptic ulcer, they will require long-term intravenous antibiotic administration. A patient who has experienced blood loss from a liver or spleen laceration or ruptured abdominal aortic aneurysm will likely require packed red blood cells, fresh frozen plasma or cryoprecipitate. The patient will receive copious fluid replacement, likely with an isotonic fluid, and may require the use of vasopressors to maintain adequate blood pressure. If the patient has had a gastrointestinal issue, they may require an nasogastric tube for several days to decompress the stomach and allow for bowel rest until healing begins.
Appendicitis
Appendicitis is an inflammation of the appendix that can be caused by viral, bacterial, or parasitic infections. It can also occur when stool obstructs the appendix. If the appendix becomes inflamed enough, it can perforate and leak secretions into the patient’s abdominal cavity.
Assessment
Appendicitis presents with sudden onset of right lower quadrant pain, right flank pain, periumbilical pain, or epigastric pain. Nausea or vomiting can be present, as can loss of appetite, irregular bowel habits, and flatulence. The psoas and obturator signs indicate muscle irritation in the psoas and obturator internus muscles, respectively, both of which overlay the appendix. Some rebound tenderness can be present if a patient is experiencing peritonitis after a perforated appendix. Fever and general malaise can present after 24 hours. Appendicitis is definitively diagnosed using an abdominal CT scan.
Treatment
The primary treatment of the appendix is surgical removal. This can usually be accomplished laparoscopically using several small incisions. However, if the appendix is perforated, the patient may need to have an open appendectomy using one larger incision. A patient can possibly discharge home the same day if their appendectomy is laparoscopic. If their appendix has perforated, the patient will need to remain in the hospital for a minimum of several days to receive intravenous antibiotics postoperatively to prevent the spread of infection.
Peritonitis
Peritonitis is inflammation of the peritoneum, a thin membrane between the abdominal wall and the abdominal organs. It can be primary from an infection of the lymph or blood, or secondary due to perforation or trauma of the gastrointestinal tract.
Assessment
The key symptom of peritonitis is sudden onset diffuse abdominal pain. When the healthcare provider palpates the patient’s abdomen, they will experience rebound tenderness (Blumberg’s sign). Other symptoms include abdominal rigidity, fever in the case of an infection, nausea and vomiting, paralytic ileus, and tachycardia. The diagnosis is made in the presence of an elevated white blood cell count (more than 15,000), paracentesis, culture of the abdominal fluid or blood withdrawn in the paracentesis, and abdominal X-ray or CT scan.
Treatment
Peritonitis is treated by addressing the underlying cause. In the case of infection, the patient will receive broad-spectrum intravenous antibiotics, and in the case of gastrointestinal trauma or perforation, an exploratory laparoscopy to fix the underlying trauma. The patient will also receive intravenous fluids and electrolyte replacements as indicated by lab results.
Bowel Perforation
A bowel perforation is a tear in the bowels that allows gastrointestinal contents to leak into the patient’s abdominal cavity. This can cause a life-threatening infection, causing the patient to develop peritonitis and then sepsis as the infection reaches the bloodstream. Causes of bowel perforations include trauma, surgical error, cancer, ischemia, inflammation, infection, inflammation such as diverticulitis, chemotherapy, radiation, and obstruction.
Assessment
The primary symptom is sudden onset severe abdominal pain. The patient will be febrile and will present with nausea and vomiting. The patient may experience rebound tenderness if peritonitis is present. The patient’s abdomen will be rigid or swollen. If the patient has become septic, they will have hypotension, tachycardia, an abnormally high or low temperature, elevated lactic acid and white blood cell count, and decreased urine output. The bowel perforation can be diagnosed using an abdominal CT scan or X-ray.
Treatment
Surgical repair of the bowel perforation should take place immediately as an emergent surgery. The patient will receive intravenous fluids and broad-spectrum antibiotics to treat the infection. A nasogastric tube may be inserted for bowel rest, and the patient will be maintained as NPO or on a clear liquid diet to allow the bowel to heal before resuming a normal diet.
Cyclic Vomiting Syndrome
Cyclic vomiting syndrome is a disorder characterized by repeated episodes of vomiting without any apparent physical cause. It can be found in both children and adults. Patients can go days, weeks, or months between episodes, which are interspersed with symptom-free periods.
Assessment
The patient will experience three or more episodes of vomiting that start at approximately the same time and have approximately the same duration. Immediately before the episode begins, the patient will become diaphoretic and severely nauseated. Other symptoms include:
- diarrhea
- abdominal pain
- headache
- retching or dry heaves
- light sensitivity
Diagnostic tests will be used to rule out other gastrointestinal illnesses that cause similar symptoms. These tests include endoscopies, CT scan, abdominal ultrasound, motility studies, and lab tests to check for thyroid and other metabolic disorders.
Treatment
There is no specific treatment for cyclic vomiting. Children commonly grow out of the disorder as they mature. Medications provided to help ease symptoms include antiemetics, antidepressants, proton pump inhibitors, anticonvulsants, and pain medication. In extremely severe cases or prolonged episodes, patients may receive intravenous fluids to prevent dehydration. Patients generally learn to identify their specific triggers and avoid them. Common triggers are allergies, stress, lack of sleep, alcohol, chocolate, caffeine, cheese, anxiety, overexercising, and eating too much or too little.
Bleeding
Gastrointestinal bleeding occurs in the upper (esophagus, stomach, or duodenum) or lower portion (jejunum, ileum, colon, rectum, or anus) of the gastrointestinal tract. It can occur for many different reasons, which include anticoagulant medications, a stomach ulcer, GERD, gastritis, C. difficile, cancer, viral infection, trauma, diverticulitis and diverticulosis, and inflammatory bowel diseases like Crohn’s and ulcerative colitis.
Assessment
The most obvious signs of gastrointestinal bleeding will be blood in the patient’s stool or vomit. If the blood in the stool is from the upper GI system, it will appear dark or tarry because it is partially digested. If it is from the lower GI system, it will appear bright red. If the bleeding is severe enough, the patient will also display signs of acute anemia including hypotension, fatigue, dizziness, fainting, tachycardia, and decreased urine output. An upper endoscopy (for the upper GI system), balloon enteroscopy (for the small intestine) or colonoscopy (for the colon, rectum, and anus) will be used to diagnose the specific area of the gastrointestinal bleed. Other imaging to be performed includes gastrointestinal X-rays, CT scans, and fecal occult blood testing to check for microscopic traces of blood in the stool that aren’t visible to the naked eye. A CBC should be performed to check for anemia or any signs of infection.
Treatment
The treatment varies depending on the underlying cause of the GI bleed. An acute spot of GI bleeding like a stomach ulcer can be cauterized or have a clip placed on the blood vessel that supplies blood flow to the ulcerated area to control bleeding. A patient taking anticoagulants will be asked to stop them. Proton pump inhibitors help to protect the patient’s stomach. If the source of bleeding cannot be located using a scope, the patient may require an exploratory laparoscopy to identify and control the source of the bleeding. The patient may require a blood transfusion if their anemia is severe enough.
Cholecystitis
Cholecystitis is an acute inflammation of the gallbladder due to obstruction of the bile duct by gallstones. It can also lead to pancreatitis due to obstruction of the pancreatic duct. It is most common in women 20-40 years old who are overweight, but also occurs in pregnant patients, the elderly, and diabetic patients.
Assessment
Cholecystitis presents with sudden onset severe right upper quadrant pain. The pain can radiate through to the back and cause pain around the right shoulder blade. Other symptoms include leukocytosis, fever, nausea and vomiting, jaundice, a positive Murphy’s sign (tenderness when palpating the gallbladder) and altered mental status or confusion. In the early stages, the patient may notice several occurrences of right upper quadrant pain that are triggered by eating fatty foods and resolve spontaneously. Cholecystitis is diagnosed using an abdominal ultrasound or CT scan, which will reveal thickening of the gallbladder walls in the presence of a positive Murphy’s sign, or a HIDA scan, which will show delayed gallbladder filling.
Treatment
The primary intervention is a cholecystectomy or surgical removal of the gallbladder via a laparoscopic or open approach. If the patient shows signs of sepsis or ascending cholangitis, intravenous antibiotics will be administered. The patient will receive antispasmodic agents like glycopyrrolate for biliary colic and vomiting, as well as anti-nausea medication and analgesics (note that opioids increase the pressure in the sphincter of Oddi).
Cirrhosis
Cirrhosis is a chronic liver disease in which fibrotic tissue begins to replace normal liver tissue, gradually impairing liver function. There are three primary causes for cirrhosis: alcoholism, post-necrotic changes as a result of viral hepatitis, and biliary from chronic biliary obstruction and cholangitis.
Assessment
Note that cirrhosis can be compensated or decompensated. Compensated cirrhosis presents with non-specific symptoms like indigestion, ankle edema, abdominal pain, palmar erythema, fever, epistaxis, an enlarged liver, and an enlarged spleen. Uncompensated cirrhosis occurs when the liver function has been so severely affected that it can no longer make proteins and clotting factors, and portal hypertension occurs. Portal hypertension will lead to jaundice and abdominal ascites, as well as esophageal varices.
The patient’s general electrolyte levels will be decreased. Generalized edema can also occur due to the lack of albumin. Petechiae occur due to a lack of vitamin K. Hepatic encephalopathy and altered mental status can occur in the final stages due to elevated ammonia levels. To diagnose cirrhosis, the patient will have blood work performed including CBC, liver function tests, electrolyte testing, and diagnostic testing (such as an abdominal ultrasound or CT scan) to rule out other conditions such as liver cancer, gallstones, or hepatitis A, B, and C. A liver biopsy is used to confirm the presence of cirrhosis.
Treatment
There is no specific treatment for cirrhosis; instead, treatment is guided by the symptoms that the patient experiences. A patient with ascites or severe edema will be prescribed a potassium-sparing diuretic such as spironolactone or triamterene. Colchicine will help to reduce fibrotic changes. Dietary supplements and vitamins help to address vitamin and electrolyte deficiencies. In end-stage liver disease, the only treatment left is a liver transplant, which requires immunosuppression to prevent organ rejection.
Diverticulitis
Diverticular disease describes a small pouch in the bowel lining that protrudes through the muscle layer and can occur anywhere in the GI tract. Roughly 20 percent of people develop inflammation in a pouch when food or bacteria become trapped, which is known as diverticulitis. This inflammation can lead to an abscess, bowel obstruction, perforation, fistula, or bleeding.
Assessment
Diverticulitis usually presents with steady pain in the left lower abdominal quadrant, change in bowel habits (either constipation or diarrhea), tenesmus, and a paralytic ileus from perforation or intra-abdominal irritation. Nausea and vomiting can be present as well. If a fistula into the bladder is present, the patient may experience recurrent UTIs and dysuria. Diverticulitis is diagnosed using an abdominal CT, which will show a thickened bowel wall, diverticula in the colon, and increased soft tissue density. Blood work is normal in many instances. If the diverticulitis is severe or a perforation has occurred, the patient will have leukocytosis, elevated serum amylase, and pyuria if a urine culture is performed (only if a fistula is also present).
Treatment
The initial treatment for diverticulitis is the administration of intravenous antibiotics and intravenous fluids to rehydrate the patient. They should receive anti-nausea and analgesic medications as needed. The patient should be NPO initially to allow for bowel rest/recovery and an NG tube may be required if an ileus occurs. If diverticulitis occurs repeatedly, the patient may undergo a surgical resection of the area of the intestine that contains the diverticula.
Esophageal Varices
Esophageal varices are dilated blood vessels found in the submucosa of the esophagus, usually toward the distal end. They occur as a result of cirrhosis in the liver, which causes the portal vein to become obstructed and blood to back up in the esophageal veins. The tissue in the esophageal vessels is usually very fragile, meaning that a life-threatening hemorrhage can occur if they tear or burst.
Assessment
Esophageal varices are asymptomatic until they tear or burst. If that happens, the patient will experience vomiting with bright red blood, dark stool, and signs of hypovolemic shock (tachycardia, hypotension, decreased urine output, altered mental status, etc). Esophageal varices can be diagnosed using an esophagogastroduodenoscopy, CT scan, MRI, or capsule endoscopy (when the patient swallows a pill with a small camera in it and it travels through the digestive system and takes pictures).
Treatment
In the case of rupture, prompt treatment is key. The patient will require emergent fluid replacement and blood transfusion. IV vasopressin, somatostatin, and octreotide all decrease venous pressure and help with vasoconstriction/clotting. Esophagogastric balloon placement using Sengstaken-Blakemore or Minnesota tubes can help to temporarily tamponade bleeding vessels, but should not be left in place for more than 24 hours due to the risk of esophageal ulceration. For a more long-term solution, the patient’s gastroenterologist can inject individual varices with sclerosing agents and/or ligate them using an endoscope. Transjugular intrahepatic portosystemic shunting creates a connection between the systemic and portal venous system to reduce portal hypertension and thus reduce the pressure in the esophageal vessels.
Foreign Bodies
A foreign body is any inedible object that a patient has swallowed or inserted through their anus into their digestive tract and is unable to be removed. Examples include a toddler who swallows a penny or a patient who inserts a bottle of Rogaine into their rectum.
Assessment
The symptoms vary depending on the object and where it is located. A toddler may be able to easily pass a penny without symptoms as long as it traveled to their stomach without causing respiratory distress. A toddler who swallows a battery may have severe burns in their stomach or esophagus and will be in severe distress and experience severe nausea/vomiting. A patient who has inserted an object rectally may experience abdominal pain, pressure, cramping, and constipation. Most foreign objects can be located on X-ray or via endoscopy or colonoscopy.
Treatment
The only treatment for a foreign body is to remove it. Ideally, it can be removed through an endoscopy or colonoscopy. If not, a surgical removal is needed, along with a possible bowel resection and temporary ostomy placement. In some cases, small objects can pass independently.
Hepatitis
Hepatitis is an acute or chronic inflammation of the liver that causes organ damage and impairs liver function. Causes of hepatitis include viruses (types A, B, C, D, and E), heavy alcohol use, toxins, and autoimmune dysfunction.
Assessment
Some patients with hepatitis will be asymptomatic. The patients who experience symptoms may notice fever, fatigue, jaundice, joint pain, clay or light-colored bowel movements, abdominal pain, decreased appetite, nausea and vomiting, and dark urine. Hepatitis is diagnosed through blood work, including a CBC, liver function tests, and hepatitis tests. An abdominal CT scan or MRI may be performed, and a liver biopsy is sometimes required to evaluate the degree of liver damage and determine the underlying cause.
Treatment
The treatment for hepatitis varies depending on the cause. Anti-nausea medications will likely be provided to help with nausea and vomiting. Most cases of viral hepatitis resolve with rest and intravenous fluids; hepatotoxic medications should be avoided. Antiviral medications may be administered if the case is particularly severe to help prevent permanent liver damage. If the patient consumes alcohol, they should immediately stop to allow their liver to recover. Treating toxins is primarily supportive care such as rest and intravenous fluids, but certain toxins such as an acetaminophen overdose can be treated with acetylcysteine. If severe liver damage occurs, the patient may need to receive a liver transplant.
Intussusception
Intussusception occurs when part of the intestine telescopes or slides into a neighboring part of the intestine. This can cause a mechanical obstruction or compromise blood flow to the intestine, resulting in necrosis. The cause is usually unknown, although it sometimes happens after a viral infection, cancer, or recent intestinal surgery. It usually involves the small intestine instead of the large intestine.
Assessment
Symptoms include sudden onset crampy abdominal pain, nausea and vomiting, decreased bowel sounds, bloating, and blood in stool. If the condition is not identified early, their condition can then progress to necrosis of the intestine, which can cause symptoms of peritonitis and eventual sepsis. Because the symptoms are vague, diagnosis can be challenging, and imaging is usually required to confirm the final diagnosis. Types of imaging include abdominal CT scan (the most accurate) and abdominal ultrasound (less sensitive). X-rays are usually ineffective at showing intussusception.
Treatment
The only treatment is surgical intervention to move the intestine and restore blood flow and the flow of intestinal contents. If part of the intestine has started to necrose, an intestinal resection may be required as well. Prompt treatment and identification is key to restoring intestinal position before the tissue has started to necrose.
Obstructions
Bowel obstruction occurs when there is a mechanical blockage in the intestine that disrupts the flow of food. This can be due to adhesions, intestinal narrowing, complete occlusion, or a paralytic ileus in which peristalsis stops. It can occur in patients of all ages but is most common in older patients or those with a history of extensive abdominal surgeries.
Assessment
Symptoms include abdominal rigidity, distension, and pain; nausea and vomiting; respiratory distress (if distended loops of bowel start pressing on the diaphragm); dehydration; constipation; and sepsis/shock if the obstruction causes a bowel perforation to occur. The most accurate diagnostic method for bowel obstruction is a CT scan, although gas-filled loops of bowel and retained stool from constipation will sometimes show on X-ray.
Treatment
Treatment methods for a small bowel obstruction include strict NPO status, inserting a nasogastric tube, administration of IV fluids/rehydration, analgesics and anti-nausea medications, walking, and addressing any electrolyte abnormalities. If bowel rest has been ineffective after several days or the patient begins to demonstrate signs of an acute abdomen or peritonitis, surgical intervention will be required. Sometimes an intestinal resection will be required, but in other cases, the surgeon is able to lyse adhesions causing the blockage. Each case is different.
Pancreatitis
Pancreatitis is inflammation of the pancreas that can be acute or chronic. It is most commonly caused by a gallstone blockage in the bile duct which causes digestive enzymes produced in the pancreas to instead irritate the pancreas. Heavy alcohol use also increases the risk of pancreatitis. Less commonly, pancreatic cancer and trauma to the pancreas can also cause pancreatitis.
Assessment
In acute pancreatitis, symptoms include sudden onset severe upper abdominal pain that radiates to the back and extreme tenderness in the upper abdomen, nausea and vomiting, fever, and tachycardia. In the case of chronic pancreatitis, the patient may experience abdominal pain that worsens after eating; oily, foul-smelling stools; and unintentional weight loss. Diagnostic blood work includes amylase and lipase levels, which will usually be elevated to three times the normal range if pancreatitis is present. A CBC and CMP will also be drawn. Imaging includes ultrasound, CT scan, and MRI.
Treatment
Rest, analgesics, anti-nausea medications, and IV fluids/rehydration usually allow pancreatitis to resolve without further intervention. If the cause of the pancreatitis is due to bile duct obstruction, an endoscopic cholangiopancreatography to remove the offending stone is needed, and the patient will require a cholecystectomy as well. The patient should be encouraged to abstain from all alcohol use to prevent further pancreatic irritation. The patient may be required to take supplemental digestive enzymes as well if the pancreatitis has damaged the pancreas to the point where its long-term function is negatively impacted.
Gastrointestinal Trauma
Gastrointestinal trauma describes any acute injury to the abdomen or abdominal organs due to physical trauma. In the United States, this is most commonly caused by motor vehicle accidents. Organs affected can include the intestines, kidneys, spleen, or liver.
Assessment
The patient will present with abdominal pain. Depending on the nature of the injury, the abdominal pain can be diffuse or localized. The patient may have tenderness over the entire abdomen or a localized quadrant of the abdomen. If intraperitoneal hemorrhage or retroperitoneal hemorrhage is present, the patient may develop a circular ecchymosis around their navel known as the Cullen sign. If severe abdominal bleeding is present, the patient will present with signs of hypovolemic shock. The patient may have a seat belt mark (severe bruising across their lower abdomen and chest) if a seat belt was worn. The quickest diagnostic exam is a FAST exam—a Focused Assessment with Sonography for Trauma to assess for the presence of fluid within the abdomen. An abdominal CT scan will offer a more in-depth assessment of abdominal injuries, but takes longer than a FAST exam. Every minute matters if the patient is unstable. A CBC and CMP should be drawn as well.
Treatment
The treatment depends on the severity of the trauma. The options are either rest and monitoring or surgery. Lacerations to an organ are graded at a severity scale of I (mild) to IV (severe). A patient with a grade II splenic laceration, for instance, would be kept on bed rest and have serial hemoglobins (likely q6 hours) drawn to monitor their bleeding, along with q2-4 hour vitals if no other major injuries are present. A patient with a grade IV splenic laceration would have emergent surgery and a splenectomy if the surgeon is unable to control the hemorrhage. A perforated bowel would also require emergent surgery. Sometimes injuries will become apparent hours or days later after the initial trauma. The patient may require a blood transfusion if their hemorrhage is severe.
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