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Chapter 20 Abdominal and Gastrointestinal Emergencies.

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1 Chapter 20 Abdominal and Gastrointestinal Emergencies

2 National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.

3 National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, presentations, and management of shock associated with abdominal emergencies −Gastrointestinal bleeding

4 National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Acute and chronic gastrointestinal hemorrhage −Liver disorders −Peritonitis −Ulcerative diseases −Irritable bowel syndrome

5 National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Inflammatory disorders −Pancreatitis −Bowel obstruction −Hernias

6 National EMS Education Standard Competencies Abdominal and Gastrointestinal Disorders Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of −Infectious diseases −Gallbladder and biliary tract disorders −Rectal abscesses −Rectal foreign body obstruction −Mesenteric ischemia

7 Introduction GI problems are rarely life threatening. −Can lead to systemic problems if untreated

8 Introduction The number of disorders causing abdominal pain, diarrhea, and nausea is high. −With the exception of septicemia, most GI disorders are not deadly.

9 Introduction Behaviors and characteristics may predispose some people to GI disorders.

10 Anatomy and Physiology Digestion begins in the mouth. −The chewing process is called mastication. −Enzymes in saliva begin the chemical breakdown of food for absorption by the body.

11 Anatomy and Physiology Food reaches the esophagus. −Typically collapsed, allowing air to flow into the lungs instead of the stomach −Dilates when food or liquid travels through it Explains gastric distention during positive-pressure ventilation

12 Anatomy and Physiology The esophagus transports food using peristalsis. The portal vein is intertwined around the esophagus. −Transports venous blood to the liver.

13 Anatomy and Physiology Food travels through the diaphragm to the cardiac sphincter. −Connects the esophagus and the stomach −Controls amount of food that moves up the esophagus

14 Anatomy and Physiology Food then enters the stomach. −Hydrochloric acid breaks down the food even more. −Chyme exits the pyloric sphincter. −Water- and fat- soluble substances are absorbed.

15 Anatomy and Physiology The main function of the GI system is to absorb the digested food. −The duodenum connects the liver, gallbladder, and pancreas to the digestive system. −The pancreas secretes enzymes to assist with digestion and neutralize gastric acid.

16 Anatomy and Physiology The liver: −Produces bile, which breaks down fats −Promotes carbohydrate metabolism −Detoxifies drugs −Completes the breakdown of dead blood cells −Stores vitamins and minerals

17 Anatomy and Physiology The small intestine −Where 90% of absorption occurs −Divided into three sections: Duodenum Jejunum Ileum

18 Anatomy and Physiology Colon (large intestine) −Moves undigested food (feces) to be eliminated from the body

19 Anatomy and Physiology The main role of the large intestine is to complete the reabsorption of water. Bacterial digestion also occurs in the colon. The journey from mouth to anus takes 8 to 72 hours.

20 Scene Size-Up Ensure safety. Look for MOI or NOI. Take standard precautions. Always have equipment for hygiene.

21 Primary Assessment Form a general impression. −Where was the patient found? −What is the patient’s body posture? −Is there an odor?

22 Primary Assessment Airway and breathing −Patient who is vomiting may aspirate. −Open the airway with the appropriate method. −Remove or suction obstructions. −Check for unusual odors

23 Primary Assessment Circulation −Assess skin color, temperature, and moisture. −Determine pulse rate. −Ensure blood pressure reading is accurate. −Take note of amount of blood.

24 Primary Assessment Transport decision −Based on primary assessment −If positive orthostatic vital signs, carefully consider how to move the patient. −Choose the mode of ambulance.

25 History Taking Patients may have a history of issues. −SAMPLE helps you gather information. Changes in bowel patterns or stool Onset of diarrhea, constipation, or nausea/vomiting Recent weight loss Patient’s last meal

26 History Taking

27 Secondary Assessment Detailed abdominal examination −Keep the muscles from flexing. −Check for skin irregularities. Scars Striae © Medical-on-Line Alamy Images

28 Secondary Assessment Asymmetric abdomen could mean: −Tumors −Hernia −Enlarged organs −Pregnancy Check shape of the abdomen.

29 Secondary Assessment Protuberance may be caused by: −Excessive weight gain −Ascites −Pregnancy −Organ enlargement © Wellcome Images/Custom Medical Stock Photo

30 Secondary Assessment Auscultate for bowel sounds.

31 Secondary Assessment Percuss the abdomen. −The abdomen should sound tympanic. −The upper left and upper right quadrants will sound duller.

32 Secondary Assessment Palpate the abdomen. −Begin farthest away from the pain. −Indent the abdomen wall about 2″ to 4″. −Assess for discomfort, rigidity, and masses.

33 Secondary Assessment Abdominal pain may indicate: −Trauma −Hemorrhage −Infection −Obstruction −Other serious problems Types of pain include: −Visceral pain −Parietal pain (rebound) −Somatic pain −Referred pain

34 Secondary Assessment Rebound tenderness occurs when the peritoneum is irritated. −Once a tender area is found: Depress the skin with your fingertips 2" to 4". Quickly pull your fingers off the abdomen. −An alternative is the Markle heel drop test.

35 Secondary Assessment If there is pain in the right upper quadrant, use Murphy sign to assess for cholecystitis. −Ask the patient to breathe out. −Palpate deeply along the upper right quadrant. −Ask the patient to inhale deeply. −Sharp increase in pain: positive Murphy sign

36 Secondary Assessment Obtain orthostatic vital signs. −Determine the blood pressure and pulse rate. Have the patient change positions and retake. −Significant blood loss may be indicated by: 10-mm Hg drop in blood pressure 10-beat increase in pulse rate

37 Secondary Assessment Many GI diseases affect electrolyte levels. −Use a handheld blood analyzer to test. Ultrasonography and intra-abdominal pressure testing may also be available.

38 Reassessment Routine monitoring includes: −Pulse rate −Electrocardiogram −Blood pressure −Respiratory rate −Pulse oximetry

39 Reassessment Pain medication includes: −Meperidine hydrochloride −Morphine −Ketorolac −Nalbuphine −Fentanyl

40 Reassessment Nausea medications include: −Ondansetron −Diphenhydramine −Hydroxyzine −Promethazine

41 Emergency Medical Care Repeat assessment if patient’s condition suddenly changes dramatically. Do not let patients eat or drink anything.

42 Airway Management Airway concerns include possible aspiration or obstruction due to blood or vomitus. −Place patient so material can drain from mouth. Make sure suction equipment is available. You may need to use a nasogastric tube.

43 Breathing Associated with decreased hemoglobin levels −Administer high-concentration oxygen. −Prevent aspiration. −Auscultate lung sounds.

44 Circulation Concerns: dehydration and hemorrhage −Fluids depend on circulatory perfusion status. Hypotonic solution for stable conditions Isotonic solution for profound dehydration

45 Circulation Hemorrhaging care should be directed at maintaining perfusion of vital organs. −Titrate fluids to a blood pressure of 90 to 100 mm Hg. −If blood pressure cannot be maintained, vasoactive medications may be needed.

46 Specific Abdominal and Gastrointestinal Emergencies The paramedic must have an understanding of many conditions. −In the future, paramedics may be asked to help determine where a patient should be directed. −The more you understand, the more you can educate patients.

47 Specific Abdominal and Gastrointestinal Emergencies

48 Hypovolemia can be caused by: −Dehydration from vomiting and/or diarrhea Electrolyte levels are affected during this process.

49 Specific Abdominal and Gastrointestinal Emergencies Hypovolemia can be caused by (cont’d): −Hemorrhage Potential to be fatal Signs of shock are typically present. Drop in blood pressure indicates significant volume loss

50 Gastrointestinal Bleeding GI bleeding is a symptom, not the disease. −Determine onset and medical history. −Treatment includes: Fluid resuscitation Establish an IV line.

51 Gastrointestinal Bleeding

52 Upper Gastrointestinal Bleeding: Esophagogastric Varices Pathophysiology −Caused by pressure increases in blood vessels surrounding the esophagus and stomach −Blood cannot easily flow through damaged liver. Blood backs up into the portal vessels.

53 Upper Gastrointestinal Bleeding: Esophagogastric Varices Assessment −Initial presentation Fatigue Jaundice Anorexia Pruritus Abdominal pain −When the varices rupture: Abrupt discomfort in the throat Severe dysphagia Vomiting bright red blood Signs of shock

54 Upper Gastrointestinal Bleeding: Esophagogastric Varices Management −General management guidelines Accurate assessment of blood loss −In-hospital treatment includes: Stopping the bleeding Aggressive fluid resuscitation Possible endoscopy

55 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Pathophysiology −Junction between the esophagus and the stomach tears Generally due to severe vomiting

56 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Assessment −Bleeding may be light to severe. −In extreme cases, patients will have: Signs and symptoms of shock Epigastric abdominal pain Hematemesis Melena

57 Upper Gastrointestinal Bleeding: Mallory-Weiss Syndrome Management −Aimed at determining the extent of blood loss −In-hospital management may include: Volume resuscitation Endoscopy Attempt to repair the tear

58 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Pathophysiology −Erosion of the mucous that lines the stomach and duodenum −Typically occurs over weeks, months, or years −Variety of causes Infection with Helicobacter pylori Erosive gastritis

59 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Assessment −Burning or gnawing pain in the stomach Disappears after eating, but returns hours later −Other common symptoms may include: Vomiting Belching Heartburn

60 Upper Gastrointestinal Bleeding: Peptic Ulcer Disease (PUD) Management −Assess blood loss and manage hypotension. −Monitor orthostatic vital signs. −In-hospital management includes: Acid neutralization Reduction therapies Endoscopy if needed

61 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Pathophysiology −Sphincter between the esophagus and stomach opens, allowing stomach acids to travel up −Can cause a burning sensation within the chest −Over time it can cause damage to the esophageal wall and possible bleeding.

62 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Assessment −Signs and symptoms Heartburn Coughing or difficulty swallowing Bleeding, resulting in hematemesis and melena

63 Upper Gastrointestinal Bleeding: Gastroesophageal Reflux Disease Management −Treatment focuses on decreasing acidity. Antacids, proton pump inhibitors, H 2 blockers −Symptoms can be confused with myocardial infarction.

64 Lower Gastrointestinal Bleeding: Hemorrhoids Pathophysiology −Swelling and inflammation of blood vessels around the rectum −Caused by increased rectal pressure or irritation

65 Lower Gastrointestinal Bleeding: Hemorrhoids Assessment −Signs and symptoms: Hematochezia Rectal itching Small mass on rectum

66 Lower Gastrointestinal Bleeding: Hemorrhoids Management −Prehospital management is supportive. −Obtain orthostatic vital signs. −In-hospital management may include creams. −Prevention includes eating a high-fiber diet.

67 Lower Gastrointestinal Bleeding: Anal Fissures Pathophysiology −Linear tears in the mucosal lining near and in the anus

68 Lower Gastrointestinal Bleeding: Anal Fissures Assessment −Painful defecation Management −Place dressing over anus. −Do NOT pack fissure or anus.

69 Acute Inflammatory Conditions Inflammation helps white blood cells destroy or seal off an invading agent. Localized inflammation will cause localized signs and symptoms.

70 Acute Inflammatory Conditions If bacteria moves into the bloodstream, sepsis occurs. −The body responds with a generalized inflammatory response. −Autoimmune condition: the body attacks and kills its own cells for no defined reason.

71 Cholecystitis and Biliary Tract Disorders Pathophysiology −Inflammation of the gallbladder Choleangitis—inflammation of bile duct Cholelithiasis—stones in the gallbladder Cholecystitis—inflammation of the gallbladder Acalculus cholecystitis—inflammation without gallstones

72 Cholecystitis and Biliary Tract Disorders Pathophysiology (cont’d) −May arise from decreased flow of biliary materials −Patient may present with: Murphy sign Nausea/vomiting Jaundice

73 Cholecystitis and Biliary Tract Disorders Assessment −After eating a fatty meal, severe upper right quadrant abdominal pain develops. Management −Pain medications: meperidine and morphine −Medication for nausea is often necessary.

74 Appendicitis Pathophysiology −Fecal and other matter builds up in appendix. −Build-up of pressure will eventually cause the organ to rupture, resulting in: Peritonitis Sepsis Death

75 Appendicitis Assessment −Stages of presentation Early—periumbilical pain, nausea, vomiting Ripe—pain in lower right quadrant Rupture—decrease in pain (decrease in pressure) −Evaluate for peritonitis with Dunphy sign.

76 Appendicitis Management −Assess for septicemia. −Volume resuscitation Use dopamine if crystalloids are not effective. −Administer pain and antinausea medications.

77 Diverticulitis Pathophysiology −Diverticulum: weak area in the colon that begins to have pockets (diverticula) −Diverticulosis: condition of having diverticula −Diverticulitis: Inflammation of diverticuli

78 Diverticulitis Pathophysiology −A diet low in fiber creates more solid stool. −If feces gets trapped in diverticula, inflammation and infection occur and may cause: Scarring Adhesions Fistula

79 Diverticulitis Assessment −Signs and symptoms include: Abdominal pain, usually localized on the left lower abdomen Classic infection signs Constipation or diarrhea

80 Diverticulitis Management −Ensure severe infection is not present. −Patients may need fluids and/or dopamine. −In-hospital treatment includes: Antibiotics Liquid diet Surgery

81 Pancreatitis Pathophysiology −Inflammation of the pancreas −Occurs when the tube carrying enzymes becomes blocked, leading to autodigestion −Can occur suddenly or over many months −May be single or episodic attacks

82 Pancreatitis Assessment −Signs and symptoms may include: Sharp pain in the epigastric area or right upper abdomen Pain radiating to the back Muscle spasms

83 Pancreatitis Assessment (cont’d) −Internal hemorrhage may be indicated by: Cullen sign Grey-Turner sign © Wellcome Trust/Custom Medical Stock Photo

84 Pancreatitis Management −Directed by general management guidelines −Assess for signs of severe hemorrhage. −Meperidine is the choice for pain management.

85 Ulcerative Colitis Pathophysiology −Generalized inflammation of the colon −Causes a thinning of the intestinal wall and a weakened rectum −Peaks between ages 15 and 25 years and 55 and 65 years

86 Ulcerative Colitis Assessment −Signs and symptoms may include: Gradual onset of bloody diarrhea Hematochezia Mild to severe abdominal pain Skin lesions

87 Ulcerative Colitis Management −Determine the degree of hemodynamic instability. −Administer fluids, if necessary. −Follow the general management guideline.

88 Irritable Bowel Syndrome (IBS) Pathophysiology −Patients often show: Hypersensitivity of bowel pain receptors Hyperresponsiveness of the smooth muscle Psychiatric disorder connection

89 Irritable Bowel Syndrome (IBS) Pathophysiology (cont’d) −Hyperresponsiveness can cause spasm. Can cause constipation and bloating or diarrhea −Typically begins during childhood −Can be triggered by various stimuli

90 Irritable Bowel Syndrome (IBS) Assessment −You will typically be called when the patient is having a flare-up of symptoms. Management −Mainly supportive −Assessment should include the patient’s mood.

91 Crohn Disease Pathophysiology −Involves the entire GI tract −A series of attacks leaves a scarred, narrowed, and weakened portion of the small intestine. Can cause bowel obstruction

92 Crohn Disease Assessment −Signs and symptoms may include: Rectal bleeding Weight loss Skin disorders

93 Crohn Disease Management −Prehospital care should focus on general management guidelines, including: Volume resuscitation Control of nausea and pain

94 Acute Infectious Conditions GI infection occurs when contaminated food is ingested or when the GI tract ruptures. −People that have a difficulty combating infection: Immunocompromised Very old Very young

95 Acute Infectious Conditions Damage may allow contents to be released into surrounding tissues. −The body will begin to defend itself. −If the infection continues, it may leave the GI system and enter the bloodstream. This is known as sepsis.

96 Acute Gastroenteritis Pathophysiology −Conditions involving infection with fever, abdominal pain, diarrhea, nausea, and vomiting −Can be caused by various organisms Typically enter via the fecal-oral route

97 Acute Gastroenteritis Assessment −Symptoms may show anywhere from several hours to several days from contact −Can last two or three days, or several weeks

98 Acute Gastroenteritis Assessment (cont’d) −Signs and symptoms may include: Diarrhea of various types Nausea and vomiting Anorexia −Assess for dehydration, hemodynamic instability, and electrolyte imbalance.

99 Acute Gastroenteritis Management −Determine the degree of fluid deficit. −Obtain orthostatic vital signs. −Analgesic and antiemetic medications −Teach patients about safe food and water use.

100 Rectal Abscess Pathophysiology −Caused when the ducts carrying mucus to the rectal area become blocked Allows bacteria to grow and spread to the anus

101 Rectal Abscess Assessment −Symptoms may include: Rectal pain that increases with defecation Rectal drainage Constipation Management −Focus on keeping the patient comfortable.

102 Liver Disease: Cirrhosis Pathophysiology −Early liver failure, which may be hallmarked by: Portal hypertension Deficiencies with coagulation Diminished detoxification

103 Liver Disease: Cirrhosis Assessment −First stage may include: Weakness and fatigue Nausea and vomiting Anorexia Pruritus

104 Liver Disease: Cirrhosis Assessment (cont’d) −2nd stage may include: Alcoholic stools Dark urine Icteric conjunctiva Ascites Enlarged liver Courtesy of Dr. Thomas F. Sellers/Emory University/CDC

105 Liver Disease: Cirrhosis Assessment (cont’d) −Common blood tests: Aminotransferases Alkaline phosphatase Albumin Bilirubin

106 Liver Disease: Cirrhosis Management −Prehospital care should be supportive. −Involves bleeding control and medication −Use lower ends of medication dose range.

107 Liver Disease: Hepatic Encephalopathy Pathophysiology −Brain impairment due to diminished liver function −Underlying causes: Increased levels of ammonia Diminished cellular energy supplies Change in blood-brain barrier permeability

108 Liver Disease: Hepatic Encephalopathy Assessment −Can range from mild memory loss to coma −May be precipitated by: Infection Renal failure GI bleeding Constipation

109 Liver Disease: Hepatic Encephalopathy Management −Mainly supportive −Ensure that LOC status is not from other cause. Check blood glucose levels. Assess for trauma and overdose. Take a medical history.

110 Obstructive Conditions Intestines are unable to move material through the digestive tract. −Two main reasons: Paralysis of the intestines Intestinal lumen diameter compromise

111 Small-Bowel Obstruction Pathophysiology −Most often caused by post-operative adhesions −Other causes include: Cancer Crohn disease Hernias Foreign bodies

112 Small-Bowel Obstruction Assessment −Signs and symptoms may include: Crampy and intermittent abdominal pain Initial diarrhea, nausea, and vomiting Increased pressure Constipation

113 Small-Bowel Obstruction Management −Monitor blood pressure, and perform volume resuscitation. −Administer dopamine as needed. −Consider using a nasogastric tube. −Antiemetics are indicated.

114 Large-Bowel Obstruction Pathophysiology −Caused by either mechanical obstruction or colon dilation −Imaging studies determine the location and extent of obstruction. Once located, can be easily treated

115 Large-Bowel Obstruction Assessment −Signs and symptoms may include: Nausea and vomiting Distended abdomen Absent bowel sounds Peritonitis signs if bowel has ruptured

116 Large-Bowel Obstruction Management −Same as for small bowel obstruction

117 Hernia Pathophysiology −Organ/structure protrusion into adjacent cavity −To check for an inguinal hernia: Place fingers on lower abdomen. Instruct patient to cough. Weakness in abdominal wall will present as bulging.

118 Hernia Pathophysiology (cont’d) −Caused by any condition that causes intra- abdominal pressure: Obesity Standing for long periods Straining during bowel movements Chronic obstructive pulmonary disease

119 Hernia Assessment −Four types Reducible Incarcerated Strangulated Incisional

120 Hernia Management −Focus on supportive measures. −Pain management −Assess for sepsis

121 Rectal Foreign Body Obstruction Pathophysiology −Originates from upper GI tract or anal insertion Assessment −Presents with sudden rectal pain with defecation −Determine if the rectum has been perforated.

122 Rectal Foreign Body Obstruction Management −Do NOT attempt to remove object. −Prehospital management should be limited to patient comfort. Treat with analgesia if indicated. Closely monitor vital signs.

123 Mesenteric Ischemia Pathophysiology −Interruption of the blood supply to the mesentery −Can be caused by: Arterial embolism Thrombosis Profound vasospasm

124 Mesenteric Ischemia Assessment −Gradual or sudden onset −Symptoms include: Severe pain with ill-defined location Nausea, vomiting, and diarrhea Possible blood in stool

125 Mesenteric Ischemia Management −Patients require rapid transportation. −Monitor closely. −Check vitals for signs of sepsis. −Fluid resuscitation in cases of shock −Give analgesics as needed.

126 Gastrointestinal Conditions in Pediatric Patients GI complaints are common in children. −Prolonged vomiting, diarrhea, or bleeding can lead to severe changes in sodium and potassium levels.

127 Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies −Gastrochisis: portions of the GI system lie outside the abdominal wall © M. Ansary/Custom Medical Stock Photo

128 Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d) −Intestinal malrotation: intestines rotated incorrectly during development

129 Gastrointestinal Conditions in Pediatric Patients Congenital GI anomalies (cont’d) −Pyloric stenosis: hypertrophy of the pyloric sphincter of the stomach GI bleeding can occur in children.

130 Gastrointestinal Conditions in Pediatric Patients Careful assessment is critical. −Check skin turgor, pulse rate, and peripheral pulse status. −Severe fluid loss may cause diminished LOC. Standard fluid resuscitation: 20 mL/kg isotonic fluid −Get a detailed medical history from the parent.

131 Gastrointestinal Conditions in Pediatric Patients Patients may have a gastrostomy tube. −If dislodged, place a sterile dressing over it. −If clogged, talk about ways to clear the tube. −If the blockage cannot be easily managed, turn off the feeding, clamp the tube, and transport.

132 Gastrointestinal Conditions in Older Adults GI diseases more prevalent in older adults Abdominal pain can also be a symptom of a cardiac condition. −Obtain a thorough history and physical exam. −Consider a 12-lead ECG. −Monitor vital signs.

133 Prevention Strategies Many behaviors can prevent or limit severity of GI diseases.

134 Prevention Strategies

135 Summary GI illnesses are rarely life threatening, but systemic illnesses can occur if left untreated or undertreated. The structures and functions of the GI system perform digestion, which begins in the mouth and ends in the anus. It is likely you will come in contact with blood or other body fluids. A complete scene size-up requires a survey of PPE.

136 Summary Observe a patient presenting with GI symptoms to form a general impression. Maintain airway and circulation; determine extent of bleeding. Weigh patient stability and risk of injury when deciding on rapid transport. The field impression and gathered information can determine cause of complaint.

137 Summary The secondary assessment should include a physical examination. Orthostatic vital sign changes of 10-beat pulse rate increase and 10-mm Hg drop in blood pressure is a likely sign of significant volume loss. Reassess the patient by monitoring changes in condition.

138 Summary Pain and nausea management can be given to most patients with GI emergencies. Compassionate care and clear documentation are essential parts of delivering excellent patient care. Perform new assessments and examinations if patient condition changes.

139 Summary Perform airway management if necessary. If circulation is compromised by dehydration or hemorrhage, fluid resuscitation is essential. Paramedics must understand GI diseases to educate patients and to perform an increasing level of responsibilities.

140 Summary The four major conditions responsible for abdominal and GI emergencies are: −Hypovolemia −Acute or chronic inflammation −Infection −Obstruction

141 Summary GI tract bleeding is a symptom and can reflect many GI diseases. Pediatric patients face special challenges because of their size, physiology, and possible GI congenital anomalies. Treating older adults with GI emergencies is complicated by comorbidities, multiple medications, and other factors.

142 Credits Chapter opener: © Wellcome Trust/Custom Medical Stock Photo Backgrounds: Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc.; Green—Courtesy of Rhonda Beck Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

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