Gastrointestinal Symptoms

Gastrointestinal disorders are common in military operations of all types. Your ability to recognize and accurately assess, treat and or refer for treatment is crucial. Early diagnosis and treatment will reduce the amount of time that soldiers are unable to do their jobs due to illness.

(1) Provides the body with water, electrolytes, and other nutrients used by cells

(2) Specialized to ingest food, break it down, propel it through the gastrointestinal (GI) tract, absorb nutrients across the wall of the lumen of the GI tract, and absorb water and salts while eliminating waste

(b) Saliva contains a digestive enzyme called salivary amylase that begins chemical breakdown of carbohydrates

(a) Food taken into the mouth is chewed (masticated) by the teeth to physically break it up to facilitate swallowing and processing

(c) The pharynx elevates to receive the food from the mouth. As the pharyngeal muscles contract, the upper esophageal sphincter relaxes, the esophagus opens, and the food is pushed into the esophagus.

(d) During this time the epiglottis tips posteriorly to close the entrance of the airway to prevent aspiration

(1) The muscular canal, about 24 cm long, extending from the pharynx to the stomach

(2) Begins in the neck at the inferior border of the cricoid cartilage, opposite the sixth cervical vertebra

(3) Descends to the cardiac sphincter of the stomach in a vertical path with two slight curves

(6) Muscular contractions in the esophagus occur in peristaltic waves, pushing the food toward and through the cardiac sphincter and into the stomach

(1) Structure - layered muscular tube that is lined with mucous membranes that contains thousands of gastric glands

(2) Function - primary storage and mixing chamber for ingested food (digestion of food is not a major function of the stomach)

(a) Gastric glands secrete hydrochloric acid, intrinsic factor, gastrin and pepsinogen that are thoroughly mixed with the secretions of the stomach to produce a semisolid mixture called chyme

(b) Movements resembling peristalsis slowly force chyme toward the pyloric sphincter, through the pyloric opening and into the duodenum

(a) Begins at the pyloric sphincter of the stomach, coils through the central and inferior part of the abdominal cavity, and eventually opens into the large intestine

(b) Peristaltic contractions move the chyme through the small intestine toward the ileocecal valve, where the chyme enters the cecum

(c) When the cecum distends from the chyme, the sphincter closes, causing the rate of chyme movement to slow preventing material from returning to the ileum from the cecum

(b) Extends from the ileum to the anus and is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum

(b) Very vascular organ that receives a blood supply from two sources, the hepatic artery and portal vein

(2) Function - plays a major role in iron metabolism, plasma-protein production, detoxification of drugs and other substances circulating in plasma, and numerous other biochemical pathways

(ii) Bile contains no digestive enzymes, but it dilutes stomach acid and emulsifies fats. Most bile salts are reabsorbed in the ileum and carried back to the liver in the blood. Other bile salts are lost in the feces

(b) Metabolism - helps maintain a normal blood glucose concentration, involved in fat and protein metabolism, and stores vitamins and minerals

(d) Blood protein production - albumin, fibrinogen, globulin, and clotting factors are produced and released into the circulation by the liver

(1) Structure - pear-shaped sac about 7-10 cm (3-4 in.) long. Located in a depression on the posterior surface of the liver and usually hangs from the anterior inferior margin of the liver.

(a) A retroperitoneal gland about 12-15 cm (5-6 in.) long and 2.2 cm (1 in.) thick

(b) Lies posterior to the greater curvature of the stomach and is connected, usually by two ducts, to the duodenum

(a) Is both an exocrine gland that secretes pancreatic juice and an endocrine gland that secretes hormones (for example, insulin) into the blood

(b) Insulin is secreted in the pancreatic islets and is essential to the bodies cells in processing glucose

(c) Pancreatic juice is the most important digestive juice. It contains digestive enzymes, sodium bicarbonate, and alkaline substances that neutralize the hydrochloric acid in the juices entering the small intestine.

Note: The abdomen is divided into four quadrants by imaginary lines crossing at the umbilicus — the Right Upper Quadrant (RUQ), Left Upper Quadrant (LUQ), Right Lower Quadrant (RLQ), and Left Lower Quadrant (LLQ)

(1) Inspection: check for scars, bruising, rashes, dilated veins, umbilical hernia or abdominal distention (swelling)

(2) Auscultation: listen for bowel sounds. An arterial bruit (a vascular murmur like sound) may be heard and is always abnormal. Bowel sounds may be present, hyperactive, or absent. If sounds are not heard in five minutes of continuous auscultation, consider them absent.

(3) Percussion: begin to percuss the liver down from the right upper chest. Liver dullness begins around the 5th or 6th rib extending down to the costal (rib) margin. Liver length is usually less than 15 cm.

(4) Palpation: palpate superficially (lightly) and deeper in all quadrants with the patients knees bent to relax the abdominal wall muscles. Assess for tenderness in all 4 quadrants. (will add picture for students)

(a) RUQ: palpate for the liver during inspiration, usually not palpated. If enlarged, you will feel the edge of the liver as it passes beneath the fingers.

(c) RLQ and LLQ: palpate for tenderness (pain increased by pressure). Check for involuntary guarding (tightness of the abdomen), and for rebound tenderness by quickly releasing pressure from the abdomen. Check for peritoneal irritation using the heeltap test.

(5) Rectal Exam: with the patient standing while bending at the waist or curled on his/her side and using a glove and lubricant, slowly insert your index finger. Check the prostate anteriorly (in males) and obtain a stool specimen for blood and test using the hemocult test. This may be outside the scope of 91W.

(f) ALWAYS include cardiac and respiratory examination when performing an abdominal examination

(g) ALWAYS consider whether a male or female genital examination by a M.D./P.A. may be required for complete assessment for the patient. All patients with abdominal pain require genital exam.

(a) Somatic pain – Sharp, localized pain that originates in the peritoneal walls. Often described as a stabbing or burning pain

(b) Visceral pain – Poorly localized pain that originates in the walls of hollow organs. Often described as a vague, dull or cramping pain

Identify and manage specific gastrointestinal illness

Upper Gastrointestinal (GI) Disease

(1) Gastroenteritis: an acute syndrome characterized by inflammation of the stomach and intestinal tract. Viral or bacterial infections are the most common cause of acute gastroenteritis

(a) Signs and symptoms

(i) Nausea, vomiting and diarrhea-may be mild or severe

(ii) Fever- may or may not be present

(iii) Abdominal cramping. Normal to increased bowel sounds

(iv) Rectal examination may show blood in the stool

(v) May become dehydrated if fluid loss is severe

(b) Treatment:

(i) Rest

(ii) Correct fluid loss- either orally or with IV hydration

(iii) If vomiting is severe, control with an antiemetic, either orally or by intravenous injection at direction of physician. Contraindicated with invasive organisms.

(iv) Refer to a MD/PA for further care, especially when fever, severe abdominal pain or rectal blood is present

(2) Upper GI Bleeding

(a) The vomiting of blood (hematemesis), passage of black tarry stool (melena), or occult chronic bleeding from the GI tract

(b) Caused by a number of factors such as: cancerous tumors, peptic ulceration, erosive gastritis, and esophageal varices

(c) Signs and symptoms: the manifestations of GI bleeding depend on the source, rate of bleeding, and underlying or coexistent disease. Patients with chronic blood loss may present with symptoms and signs of anemia (e.g., weakness, easy fatigability, pallor, chest pain, and dizziness) or chronic rectal bleeding.

(d) Treatment

(i) Hematemesis or melena is a medical emergency

(ii) Fluid resuscitation and treatment for shock are indicated

(iii) Refer to a PA/MD for more definitive care

(iv) Evacuate as soon as possible

(3) Peptic Ulcer Disease: erosion of the lining of the stomach or duodenum as a result of gastric acid hyperacidity

(a) Risk factors- stress, diet, alcohol, caffeine, drugs (ASA, NSAIDs), tobacco, H. Pylori infection and heredity

(b) Signs and symptoms

(i) Epigastric pain 45-60 minutes after a meal

(ii) May be nocturnal — becoming most severe between midnight and 0200 hrs.

(iii) Pain, described as burning, may be relieved by food or antacid intake

(iv) Epigastric tenderness, occult blood on rectal exam if the ulcer is bleeding

(v) UGI or endoscopy confirms the diagnosis

(i) Restriction of coffee, tea, cola, alcohol, aspirin, NSAIDs and tobacco

(ii) Antacids: 30 ml P.O. 1 and 3 hours after meals and at bedtime, Cimetidine (Tagamet) 400 mg P.O. BID or 800 mg P.O. at bedtime.

(iii) Refer to MD/PA for full evaluation

(4) Esophageal varices: An esophageal varix is a dialated vein of the esophagus. Primary causes of esophageal varices are alcohol consumption, portal hypertension, and the ingestion of caustic substances.

(a) Signs and symptoms: the physical findings in esophageal varices are:

(i) Hematemesis with bright red blood

(ii) Dysphagia (difficulty swallowing)

(iii) Burning or tearing sensation as the varices continue to bleed, irritating the lining of the esophagus

(iv) May exhibit classic signs of shock, including tachycardia, tachypnea and cool diaphoretic skin

(b) Treatment:

(i) Two large bore IV’s

(ii) Treatment for shock and immediate evacuation to a definitive care facility

(5) Esophageal reflux: "Gastroesophageal Reflux Disease" (GERD) is a term applied to the symptoms of tissue damage caused by the reflux of gastric contents (usually acidic) into the esophagus

(a) Signs and symptoms

(i) Heartburn, burping, regurgitation — worse when lying down, frequently severe substernal pain, occurring 30 — 60 minutes after eating

(ii) May manifest as laryngitis, chronic cough due to aspiration of gastric contents

(iii) The physical exam is usually normal

(iv) Cardiac disease MUST be ruled out prior to a diagnosis of reflux esophagitis is given

(b) Treatment:

(i) Weight reduction if obese

(ii) Avoid eating near bedtime

(iii) Antacids after meals and at bedtime

(iv) Avoid tobacco, alcohol and caffeine

(v) Elevation of the head of the bed with 6 inch blocks helps

(vi) Avoid large meals

(vii) Tagament, Zantac, and Prilosec are oral medications to be used to reduce acid reflux

Lower Gastrointestinal (GI) Disease

(1) Constipation: considered if defecation is delayed for days beyond the patients normal, or if the stools are unusually hard, dry, and difficult to move

(a) Signs and symptoms: difficulty or straining on defecation, occasionally with abdominal cramping. Usually no severe pain, nausea, vomiting or blood in stools. Normal bowel sounds on physical examination. Usually has no bleeding on hemoccult rectal exam.

(b) Treatment: increase intake of water and fiber (fruits, bulky vegetables, and bran cereals. Daily exercise. Metamucil 2 tsp. in water or juice 2 —3 x qd Milk of Magnesia 2 tsp. at Hs Bisacodyl (Dulcolax) 10 — 15 mg orally or suppository one rectally at hs, Fleets enemas.

(2) Diarrhea: frequent passage of unformed watery bowel movements. May be due to viral, bacterial or parasitic infections

(a) Four basic mechanisms of diarrhea

(i) Increased intestinal secretion

(ii) Decreased intestinal absorption

(iii) Increased osmotic load

(iv) Abnormal intestinal motility

(b) Signs and symptoms

(i) Frequent, loose or watery stools

(ii) Change in consistency

(iii) Bloody (refer to Colitis) or nonbloody

(iv) Mucus

(v) Pus

(vi) Fatty materials, oil, grease (stools will float if high in fat)

(vii) Character and volume

* Describe the stools appearance: watery, bloody, or black and tar-like?

* How long does it last? Number of bowel movements per day?

* Do you have cramping associated with the bowel movement

(i) Can be caused by nerves, viral, or bacterial infection

(ii) Nocturnal diarrhea may suggest organic disease of the bowel

(iii) Toxic substances

(iv) May be found in family history of GI disorders

(v) Different food or water as in history of travel

(vi) Poor water or food sanitation or poor hygiene (Food Poisoning)

(vii) Sexual transmission

(viii) May have fever associated with dehydration

(ix) Determine circumstances surrounding the onset

* Acute diarrhea - usually caused by infection; chronic may be caused by systemic illness; intermittent by psychological factors: Did it begin rapidly or gradually?; Were you under any stress at the time of onset?; What foods did you eat before it began?; Have you recently changed your diet?; Any travel history? Camping? Deployment?

* Chronic: when do you last recall not having the symptom?

* Intermittent: How long do intervals between episodes last?; Does diarrhea alternate with constipation?

(d) Treatment

(i) Dictated by cause when known

(ii) Clear liquids for 24 hours, then diet as tolerated

* Replacing lost fluid and electrolytes is the most important therapeutic measure in acute diarrhea

* If patient is significantly dehydrated, start IV fluid

* If patient is not vomiting and mild dehydration: oral rehydration

(iii) Avoidance of agents that worsen diarrhea:

* Caffeine

* Dairy products

* Raw fruits and vegetables

(iv) Kaopectate indicated only if illness and diarrhea continues

(v) May give Lomotil or Imodium if no blood in stool or no fever

(vi) If febrile or blood in stool, refer to MD/PA for antibiotic therapy and lab studies

(vii) Withhold food for 24 hrs — clear liquid diet only, force clear liquids. Kaopectate liquid: 2 tbs. after each loose bowel movement (or 2 tbs.). Refer to MD/PA if not improved.

(3) Lower GI Bleeding

(a) Signs and symptoms: Hematochezia (passage of bright red rectal blood), melena (dark or black tarry stool). 10% of hematochezia is due to an UGI bleed (Fast transit of blood)

(b) Caused by a number of factors: colitis, malignancy, anorectal disease, inflammatory bowel disease, hemorroids

(i) Hematochezia and melena are medical emergencies

(ii) Initiate two Large Bore IV’s

(iii) Fluid resuscitation and treatment for shock are indicated

(iv) Referral to an MD/PA for definitive management

(v) Evacuate as soon as possible

(4) Colitis: the term colitis applies to inflammatory diseases of the colon (e.g. ulcerative, granulomatous, ischemic, radiation, infectious colitis or irritable bowel syndrome)

(a) Signs and symptoms: bloody diarrhea of varied intensity and duration is interspersed with asymptomatic intervals. Usually an attack begins insidiously, with increased urgency to defecate, mild lower abdominal cramps, and blood and mucus in the stools. However, an attack may be acute and fulminant, with sudden violent diarrhea, high fever, signs of peritonitis, and profound toxemia. Some cases develop following a documented infection (e.g., amebiasis, bacillary dysentery).

(b) Treatment: dependent on diagnosis. Initial onset to be considered a medical emergency. Refer to MD/PA for management

(5) Appendicitis: obstruction of the appendix by a fecalith, inflammation, foreign body or tumor

(a) Signs

(i) Classic presentation: Anorexia and pain in the epigastric or periumbilical area of the abdomen that evolves into pain in RLQ over 8 hours, often, signs and symptoms do not follow classic presentation

(ii) Nausea, diarrhea, and vomiting may accompany pain. Occasionally, constipation is present. The pain is moderately severe and after several hours localizes to the RLQ

(iii) Acute abdomen

(iv) Patient often will point precisely to the RLQ area of pain (positive McBurney’s sign)

(b) Symptoms

(i) Abdominal tenderness

(ii) Fever may be present

(iii) Decreased bowel sounds if perforated

(iv) Rebound tenderness

(v) Rovsing sign (peritoneal irritation producing right lower quadrant pain with palpation of the left lower quadrant)

(vi) Psoas sign (pain with active flexion against resistance or passive extension of the right hip)

(vii) Obturator sign (pain with passive internal rotation of the flexed right hip)

(viii) Voluntary or involuntary guarding

(ix) Rectal tenderness is common

(6) Diverticular Disease: typically presents with left lower quadrant pain and tenderness, similar to the right-sided pain and tenderness of appendicitis

(a) Signs and symptoms:

(i) Abdominal pain, usually in the left lower quadrant

(ii) Nausea and vomiting

(iii) Constipation

(iv) Diarrhea

(v) Left lower quadrant tenderness, guarding, rebound

(vi) Fever

(vii) General peritonitis with tachycardia, high fever, and sepsis if colonic perforation occurs

(b) Treatment

(i) Diverticular disease is primarily a clinical diagnosis

(ii) Outpatient treatment: bowel rest and broad-spectrum oral antibiotic therapy. Patients are instructed to limit activity and maintain a liquid diet for 48 hours. If symptoms improve, low-residue foods are added to the diet.

(iii) If patient demonstrates signs of toxicity: fever, tachycardia, leukocytosis and severe abdominal pain, intravenous antibiotics are administered (authorized by MD/PA)

(7) Bowel Obstruction: complete arrest or serious impairment of the passage of intestinal contents caused by a mechanical blockage. Mechanical obstruction is divided into obstruction of the small bowel, including the duodenum, and the large bowel. Major causes are hernia and adhesions

(a) Signs and symptoms:

(i) Obstruction of the small bowel is based on a triad of symptoms:

* Abdominal cramps are centered around the umbilicus or in the epigastrium; if cramps become severe and steady, consider strangulation (lack of blood flow to the bowel)

* Vomiting starts early with small-bowel and late with large-bowel obstruction

* Constipation occurs with complete obstruction, but diarrhea may be present with partial obstruction

(ii) Obstruction of the large bowel: symptoms usually develop more gradually than with small-bowel obstruction. Increasing constipation leads to obstipation and abdominal distention. If the ileocecal valve is competent, there may be no vomiting; if it allows reflux of colonic contents into the ileum, vomiting may occur (usually several hours after onset of symptoms). Lower abdominal cramps unproductive of feces are present.

(b) Treatment

(i) A nasogastric tube is inserted and placed on suction

(ii) An inlying bladder catheter helps monitor urinary output

(iii) IV hydration

(iv) Complete obstruction is treated surgically after supportive therapy has been initiated

(v) Bowel obstruction should be considered a surgical emergency. Refer patient to an MD/PA and evacuate immediately

(7) Hemorrhoids: a varicose vein in the lower rectum or anus. Caused by straining at stool, constipation, prolonged sitting and a diet poor in fiber.

(a) Signs and symptoms: itching, irritation and bleeding with bowel movements. Obvious external hemorrhoid or internal hemorrhoids found on rectal examination. Mucoid discharge from rectum

(b) Treatment: high roughage/fiber diet. Sitz bath (sitting in warm water reduces pain and swelling). Metamucil 2 tsp. in water or juice 1-3 times daily. Anusol or Anusol HC suppositories for internal hemorrhoids can be given two-three times a day.

(c) Complications: A thrombosed hemorrhoid is caused by the rupture of a vein, forming a clot in the subcutaneous tissue. A tender bluish mass is visualized. Thrombosed hemorrhoids require evaluation by an MD/PA.

Liver, Biliary Tract and Pancreatic Diseases

(1) Hepatitis

(a) Hepatitis is a liver inflammation that stems from a virus or
hepatotoxic agent

(b) Viral hepatitis is the most common of the serious, contagious
diseases caused by a virus that attacks the liver

(d) Types

(i) Hepatitis A - formerly called infectious hepatitis

* Ranks as most common type of hepatitis

* Highly contagious

* Transmitted primarily in food handled by individuals in the infectious stages of the disease is very contagious and often spread within families

* Public health problems occur from contaminated shellfish after raw sewage releases and accidents as well as, from commercial food handlers

* Acute onset

* No treatment has been shown to alter the disease course

* Immunization: An inactivated hepatitis A vaccine is available, Prophylactic IG may be administered within two weeks after exposure to hepatitis A, Persons traveling to Africa, the Middle East, Central and South America, and Asia should be immunized FEMA team personnel should be offered vaccine if they travel out of the United States

(ii) Hepatitis B - formerly called serum hepatitis; most serious form

* A prominent source of acute/chronic hepatitis and cirrhosis of the liver

NOTE: Tragically, more than 20,000 health care workers contract HBV annually. Studies have indicated that 10 - 40% of health care workers may exhibit evidence of past or present HBV infection.

* Hepatitis B virus is very hardy, the virus’ ability to survive outside its normal environment for an extended period of time demonstrates the need for appropriate application of universal precautions

* Signs and symptoms are vague and can be mistaken for influenza or the common cold (fatigue, gastrointestinal disorders, headaches)

* In prehospital care workers, needle stick injuries, mucous membrane contact and open lesions of the skin are the primary mode

* Needle stick injuries are the most common cause of contraction

* Workers are at risk of HBV infection to the extent they are exposed to blood and body fluids

* Modes of transmission are preventable by the application of engineering controls, proper work practices (universal precautions), and HBV vaccination

* Prophylaxis: Hepatitis B vaccine before exposure and Hepatitis B immune globulin after exposure

(iii) Hepatitis C - formerly called non A, non B hepatitis

* Transmission: transfused blood (most common), body fluids

* Individuals at high risk for developing hepatitis C include: Intravenous drug users, renal dialysis patients, multi-transfused patients, hemophiliacs

* Prevention: clean water supply, safe disposal of human waste, hygienic handling of food, good personal hygiene, and medical prophylaxis includes active immunization with Immunoglobulin (1g)

* Treatment: no specific treatment or drug can kill the hepatitis viruses

(3) Acute pancreatitis: inflammation of the pancreas- alcoholism accounts for 80% of all causes

(a) Signs and symptoms

(i) Abrupt onset of epigastric pain, radiating to back

(ii) Nausea, vomiting, sweating, weakness

(iii) Abdominal tenderness and distention

(iv) Fever

(v) May have a history of previous episodes, often related to alcohol abuse

(vi) Jaundice may occur – may be caused by stones

(b) Treatment:

(i) NPO until patient is pain free

(ii) Nasogastric suction

(iii) IV hydration

(iv) Bed rest

(v) Pain control with narcotics IV (by MD/PA order)

(vi) Refer patient to MD/PA

(vii) Evacuate as soon as possible

(4) Acute Cholecystitis: acute inflammation of the gallbladder wall, usually as a response to cystic duct obstruction by a gallstone

(a) Signs and symptoms

(i) Steady, severe pain and tenderness in the right upper quadrant or umbilical area. Acute attack is often precipitated by a large, fatty meal.

(ii) Nausea and vomiting

(iii) Painful splinting of respiration during deep inspiration and right upper quadrant palpation (Murphy's sign) is frequent

(iv) Fever

(b) Treatment

(i) NPO

(ii) IV hydration

(iii) Pain control with narcotics IV (by MD/PA order)

(iv) IV antibiotics – as directed by MD/PA

(v) Cholecystectomy usually performed 2-3 days after acute episode subsides

(vi) Refer patient to MD/PA

(vii) Evacuate as soon as possible

(5) Cholelithiasis: formation or presence of calculi (gallstones) in the gallbladder.

(a) Signs and symptoms

(i) The clinical consequences of stone formation in the gallbladder are exceedingly variable. Most patients remain asymptomatic for long periods, frequently for life.

(ii) Persistent obstruction usually produces inflammation and acute cholecystitis. Stones in the duct cause colicky pain associated with peristaltic motion.

(b) Treatment: symptomatic gallstones - biliary colic recurs with irregular, pain-free intervals of days or months. Symptomatic patients are at increased risk of developing complications, and cholecystectomy is indicated. Refer to PA/MD and evacuate.

SUMMARY

Gastrointestinal disorders are common and your ability to recognize and accurately assess, treat and or refer for treatment is crucial. Early diagnosis and treatment will reduce the amount of time that soldiers are unable to do their jobs due to illness.