GI Bleeds: Gastrointestinal bleeding is divided into either upper or lower GI bleeding. The dividing point between the 2 is the ligament of Treitz. Bleeding that occurs in the lower GI is generally not passed through the digestive process, and usually presents as frank, bright or dark red, blood at the rectum. Bleeding that is further up may present with melanotic stools. Upper GI bleeding usually undergoes the digestion process to some degree, and presents with coffee ground emesis. The exception being bleeding from esophageal varicies, which presents as profuse, bright red emesis, usually mixed with some degree of partially digested blood.
In general these patients present with obvious bleeding, tachycardia, perhaps dyspnea depending on degree of blood loss, and potentially hypotension. Management is aimed at maintaining a SBP of 90mmHg, conservatively to avoid washout of clotting factors. Oxygen issues can be addressed with supplemental O2.
Acute abdominal pain: Pain in the abdomen is a challenge due to the number of organs and vessels in this one area. In general, the quality of the patient's pain, its location, and radiation, as well as additional symptoms, provide us with an idea of what may be going on. Dull, crampy, or achey pain originates from hollow organs, and is due to distension or inflammation. We see this with bowel issues, appendicitis, cholecystitis, etc. Pain that is sharp typically has its origin in the solid structures of the abdominal wall or organs like the liver. The presence of additional symptoms such as fever, nausea, dyspnea, anorexia, etc, give us further clues as to potential differentials
Appendicitis: Appendicitis occurs due to the obstruction of the appendiceal lumen by fecal material. The appendix houses a great deal of gut bacteria, and this obstruction leads to overproliferation. The result is that the appendix distends, becomes inflamed, and eventually necrotic. If not treated, the appendix will rupture and spill its contents into the peritoneal cavity, leading to peritonitis, sepsis, and potentially death. Symptoms of appendicitis usually begin gradually with dull pain at the umbilicus, that eventually becomes sharp and radiates to the right lower quadrant. This is usually accompanied by fever, nausea, and anorexia. Treatment in the prehospital environment is simply early recognition and management of nausea. Fever may be addressed with passive cooling.
Cholecystitis: This results from the crystallization of bile salts in the common bile duct, forming an obstruction. The effect is that the gallbladder is unable to excrete bile past the blockage, and as a result becomes distended. This causes RUQ pain that may radiate to the right shoulder tip. There is typically fever and nausea associated with this problem, and symptoms usually follow the ingestion of a fatty meal. Treatment involves management of the fever, and addressing nausea.
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