14.5 Abdominal, Gastrointestinal & Hepatobiliary Emergencies

14.5 Abdominal, Gastrointestinal & Hepatobiliary Emergencies

Abdominal pain is one of the highest-volume medical complaints in Canadian paramedicine and one of the lowest-yield for a field diagnosis. CPCF Appendix A foundational knowledge #2 and #4 require the PCP to understand gastrointestinal and hepatobiliary structure, function, and pathology; the examinable skill is not naming the organ but separating the patient who is bleeding, perforating, or becoming septic from the patient who is not.

Why Abdominal Pain Localizes Badly

The transition from visceral to parietal pain is clinically important: it means the process has reached the peritoneum. A patient who has stopped writhing and is now lying rigidly still has not improved.

Classic referred patterns worth memorizing:

• Diaphragmatic irritation → shoulder tip pain (Kehr's sign) — splenic rupture, ruptured ectopic pregnancy, perforated viscus
• Biliary → right scapula or right shoulder
• Pancreatic → straight through to the back, often relieved by sitting forward
• Renal colic → flank to groin, loin to groin
• Appendicitis → periumbilical first, then localizing to the right lower quadrant as the parietal peritoneum becomes involved

The Presentations That Kill

[!CAUTION] Three groups present atypically and account for most missed abdominal catastrophes: older adults (blunted pain, absent fever, masked tachycardia from beta blockers), people with diabetes (autonomic neuropathy blunts pain), and immunosuppressed patients (no fever, no peritonism). In these patients, treat vital-sign trends and the story as more reliable than the abdominal examination.

Hepatobiliary Disease: What the Failing Liver Does to Your Patient

The liver synthesizes clotting factors and albumin, metabolizes drugs and ammonia, and processes bilirubin. Failure produces a predictable cluster the PCP must recognize:

• Coagulopathy — reduced synthesis of clotting factors means these patients bleed, and bleed badly, from minor causes. Combine that with oesophageal varices and a small tear becomes catastrophic.
• Portal hypertension and varices — dilated, thin-walled oesophageal and gastric veins that rupture without warning. Massive haematemesis in a patient with known liver disease is a true airway and haemorrhage emergency.
• Ascites — splints the diaphragm, reduces functional residual capacity, causes breathlessness, and creates a route for spontaneous bacterial peritonitis.
• Hepatic encephalopathy — accumulated ammonia produces confusion, a flapping tremor (asterixis), and progressive obtundation. It is a diagnosis of exclusion in the field: check the blood glucose, consider infection, gastrointestinal bleeding, and sedatives, and do not attribute altered mentation to liver disease without ruling out the reversible causes.
• Impaired drug metabolism — standard doses of sedatives, opioids, and benzodiazepines are relatively overdoses.
• Jaundice — check sclerae in good light, and in patients with darker skin tones examine the sclerae and the oral mucosa rather than relying on skin colour.

Biliary colic and cholecystitis classically follow a fatty meal, with right upper quadrant pain radiating to the right scapula, nausea, and vomiting. Fever and persistent pain suggest cholecystitis rather than simple colic; jaundice with fever and rigors suggests ascending cholangitis, which is a sepsis emergency.

Pancreatitis — usually gallstones or alcohol — produces severe epigastric pain boring through to the back, relieved by sitting forward, with profound vomiting and very large third-space fluid losses. Hypovolaemia can be severe despite an unremarkable abdomen.

Assessment: A Structured Approach

1. History first, and take it seriously. OPQRST plus: onset in relation to food, vomiting and its content (bile, blood, faeculent), last bowel movement and flatus, stool colour (black, red, pale), urinary symptoms, last menstrual period and pregnancy possibility, previous abdominal surgery, alcohol, NSAIDs, anticoagulants, and weight loss.
2. Look at the patient before the abdomen. Are they still or writhing? Colour, sweat, breathing pattern, mentation.
3. Vital signs with trends, including a postural check where safe, temperature, and blood glucose.
4. Inspect for distension, scars, bruising (flank or periumbilical ecchymosis suggests retroperitoneal bleeding), hernias, and visible pulsation.
5. Palpate gently, in quadrants, starting away from the pain. Note guarding, rigidity, rebound, and masses. Palpate a suspected aneurysm once, lightly, or not at all.
6. Do not delay transport for a complete examination in an unstable patient.

Prehospital Management

• Position of comfort — usually knees flexed; sitting up if vomiting or short of breath; left lateral if actively vomiting with a reduced level of consciousness.
• Airway protection and suction for haematemesis; this is an airway emergency before it is a gastrointestinal one.
• Oxygen titrated to saturation, not given reflexively.
• Nothing by mouth, since most of these patients are heading for imaging or theatre.
• Fluids within scope for hypovolaemia and shock.
• Analgesia. The old teaching that analgesia masks the surgical abdomen is obsolete; adequate analgesia improves examination quality and is an F1 and H3 obligation.
• Antiemetics where authorized.
• Keep the patient warm. Shock plus an exposed abdomen equals rapid heat loss.
• Document precisely: pain character and migration, the exact appearance of vomit and stool, the last oral intake, and the trend in vital signs. These details drive the receiving team's decisions.