Introduction
Symptoms such as abdominal pain; nausea; vomiting; diarrhea; or painful, decreased, or increased urination are some of the most common emergency department (ED) patient complaints. These symptoms can be caused by a variety of gastrointestinal (GI) or genitourinary (GU) conditions of varying severity.
Initial Evaluation
After triage, simple comfort measures should also be offered. Patients who are actively vomiting should be given an emesis bag. Patients with severe pain should be placed on a stretcher. If a patient asks to use the bathroom, the ED technician (EDT) should proactively offer a urine or stool collection cup in anticipation of future physician orders.
The diagnostic testing plan ordered by the ED physician can vary widely. Clinical findings at triage will guide the physician’s workup. For example, fever is often a sign of an infectious process and suggests that testing may include blood cultures, urinalysis, and imaging to try to identify the source of the infection. While awaiting the results of the first round of testing, intravenous (IV) medications can be given for pain and nausea, and fluids can be given to rehydrate the patient without yet knowing the specific cause of the symptoms. All individuals of childbearing age with a uterus should receive a pregnancy test unless the patient is already known to be pregnant. Over time, an astute EDT will be able to anticipate the workup for most patients within the first few minutes of initial assessment.
Brief Overview of the Clinical Assessment of the GI or GU System
Clinical Assessment of the GI System
Physicians will start by taking a history from the patient. There are certain specific questions that are usually asked to help distinguish among the different causes of the complaints. One simple acronym that can be used to outline some of the typical questions is PQRST.
P: Palliating and provocative factors: “What makes the pain better or worse?”
Q: Quality of the pain: “How would you describe the pain?”
R: Radiation: “Does the pain radiate (start in one place and travel to another)?”
S: Severity: “How bad is the pain?”
T: Timing: “How long has this been going on? What were you doing when it started?”
The physician will then do a physical exam. Having the patient get undressed and into a gown is a critical part of obtaining an adequate physical exam, as direct visualization of the skin is necessary and clothing hinders the ability to auscultate or examine the body part in question.
Ill or elderly patients may need help getting changed out of their clothing. The opening of the gown should be facing the back so that the patient’s chest and abdomen are not exposed when they are not being examined, and a patient should be helped to tie their gown in the back. They should be offered a sheet or blanket to feel covered and comfortable.
One notable exception to asking a patient to change is if the patient has come to the ED after a sexual assault. In this case, the patient should be asked to remain in their clothing and to try not to use the bathroom until they are seen by a clinician specifically trained in doing a forensic exam so the best evidence can be collected.
Basic Anatomy of the Abdomen
The organs of the GI and GU systems are predominantly located within or behind the abdominal cavity, (retroperitoneal) the anatomy of which is divided into four quadrants ( Fig. 11.1 ). Note that right and left refer to the patient’s right and left, not the clinician’s. Abdominal pain can be described in terms of its quadrant (e.g., “right lower quadrant pain”). The reason for this is that the location of the pain may correspond to the anatomic location of the diseased organ causing the pain. For example, the appendix is located in the right lower quadrant, where appendicitis pain is often localized. Gallbladder problems present with pain in the right upper quadrant, where the gallbladder is located.
Other common terms that are used to describe the location of pain may include words like epigastric , meaning the upper third of the abdomen; periumbilical , meaning around the belly button; or suprapubic , meaning the pelvic region above the pubic bone. Again, these descriptors often help predict the cause of the patient’s pain. For example, epigastric pain may indicate problems like gastritis or ulcers (described later in this chapter), and suprapubic pain may be caused by a urinary tract infection (UTI).
Focused GI Issues in the ED
GI Bleeding
GI bleeding encompasses complaints of vomiting blood, bleeding from the rectum, or blood seen in the stool, suggesting that there is a source of bleeding from somewhere in the GI tract. GI bleeding can be further categorized as “upper GI bleeding” or “lower GI bleeding.” Upper GI bleeding refers to situations where the point that the bleeding originates from is located in the esophagus, stomach, or the beginning of the small intestine known as the duodenaum. Upper GI bleeding most often presents with vomiting of blood ( Fig. 11.2 ). Blood that has been exposed to stomach acid and other digestive enzymes and then vomited up is often described as a “coffee ground emesis,” because the vomitus has a dark brown/black and granular appearance, similar to coffee grounds. Melena is the name given to black, tarry appearing stools. Similar to coffee ground emesis, the stool appears this way because the blood in the stool has already been partially digested. Melena suggests that the source of bleeding is coming from the upper GI tract because the blood has been acted on by digestive enzymes that are only located in the stomach and intestines.
Common causes of upper GI bleeding include peptic ulcer disease, where the ulcer has eroded into a blood vessel; esophagitis (inflammation in the esophageal lining); gastritis (inflammation of the stomach lining); or tears in the lining of the esophagus. The frequent use of medications like aspirin or ibuprofen can predispose people to developing ulcers and stomach inflammation that can lead to GI bleeding. Forceful vomiting can cause tears in the wall of the esophagus called Mallory-Weiss tears. Chronic ethanol use that leads to liver cirrhosis can also cause enlargement of blood vessels in the esophagus (esophageal varices), which can become a source of potentially life-threatening bleeding. Some upper GI bleeding is more worrisome than others. Patients with bleeding suspected to be from a small tear in the esophagus may be discharged home if they remain stable after a period of ED observation. Most other upper GI bleeding conditions require hospitalization. Smoking and alcohol abuse predispose people to inflammation and irritation in the GI system.
Lower GI bleeding refers to bleeding from the rectum and colon and usually presents with either bright or dark red blood, but not melena. Hematochezia refers to bright red blood in the stool. The presence of hematochezia means that the blood is coming from the colon or rectum because it has not been partially digested by the time it passes.
Causes of lower GI bleeding range from the relatively benign to the critical. More benign causes of GI bleeding include bleeding from hemorrhoids (dilated veins near the anus), anal fissures (tears in the skin around the anus), and diverticulosis, a condition in which small bulges form in the wall of the colon and can erode into nearby blood vessels. Another consideration in determining the severity of a lower GI bleed is whether the bleeding is ongoing or not. For example, is blood actively leaking from their rectum, or did it occur one time and then stop? Additionally, patient factors like the use of anticoagulant medications and advanced age are important indicators of what actions need to be taken next. If a patient with suspected GI bleeding needs to move their bowels, ask them to use a bedpan, as the physician team may want to visually inspect the stool.
Gastritis
Gastritis is an inflammation of the stomach lining. People may experience gastritis acutely or chronically. Patients may present with complaints of nausea, vomiting, feeling full after a small meal (early satiety), bloating or belching, and vague epigastric abdominal discomfort. Common causes of gastritis include bacterial infection from Helicobacter pylori ; the frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen or naproxen; or autoimmune disease. Over time, gastritis can lead to ulcerations in the stomach or duodenum that could cause upper GI bleeding. The treatment of gastritis depends on the underlying cause. For those whose symptoms are caused by Helicobacter , antibiotics are needed. Patients using NSAIDs should discontinue their use. Upper endoscopy, a procedure where the physician directly visualizes the stomach and esophagus with a fiberoptic camera, is often performed as an outpatient to help establish the diagnosis.
Appendicitis
Appendicitis is inflammation of the appendix. The appendix is a finger-like, blind-ended tube that projects from the first part of the colon (caecum) . Most commonly, the appendiceal opening is blocked by small piece of stool (fecalith) . Inflammation and infection can then ensue in the appendix, which has become a “closed space.” Patients typically present complaining of pain around the umbilicus (early) or in the right lower quadrant (later). Delay in treatment can lead to a perforated appendix, where infectious contents from within the appendix are released into the peritoneal cavity creating a serious infection. Patients with a ruptured appendix may look very ill and uncomfortable. Their abdomen may be exquisitely tender to the touch or even rigid. In general, patients with suspected appendicitis will get bloodwork and some form of imaging. Ultrasound is the preferred means of imaging in children, whereas computed tomography is preferred in adults. Appendicitis is usually managed with antibiotics and surgical removal of the appendix. Appendicitis may also be managed by treating with antibiotics alone, depending on the patient’s severity and institutional preferences.
Biliary Emergencies
The gallbladder is a small, sac-like organ in the right upper quadrant of the abdomen under the liver. The gallbladder stores bile manufactured in the liver and secreted into the small intestine to help with intestinal fat absorption. The gallbladder stores bile until it is needed, which is then released into the small intestine after meals. Stones can form in the gallbladder, leading to a number of problems. The presence of gallstones is called cholelithiasis . People can have gallstones and have no symptoms for years. Occasionally, a stone may pass out of the gallbladder and impact within the bile ductal system, blocking the release of bile into the intestines. This can cause the sudden onset of severe pain in the right upper quadrant, or epigastrium . Pain from transient passage of a stone is termed biliary colic . If the stone remains lodged in the ductal system, there can be ongoing pain and the risk of serious infection. This is termed choledocholithiasis . When the gallbladder becomes inflamed and infected, this is called cholecystitis . A patient with symptomatic gallstones will need to have the gallbladder removed, the timing of which depends on the patient’s clinical situation. People whose gallbladder has been removed have no symptoms or medical needs resulting from the surgery.
Urinary Retention
The inability to urinate when the bladder is full is called urinary retention. Patients with urinary retention often present with extreme discomfort in the lower abdomen and may appear to have a very distended abdomen. The most common urinary retention scenario is that of an older man with an enlarged prostate that impedes the passage of urine from the bladder. UTI can be either the cause or result of urinary retention in either men or women. Relief of the urinary retention is achieved by placing a catheter through the urethra to drain the urine from the bladder. A “straight catheterization” is when a catheter is inserted only temporarily to drain the bladder and then removed immediately when the bladder is emptied. An “indwelling” catheter is left in place attached to a drainage bag ( Fig. 11.3 ). Sometimes a patient may be discharged with a catheter in place, with a urine collection bag attached to their leg.
