mark bromley emergency medicine pgy-3. overview cases approach – work-up appendicitis dealing...
TRANSCRIPT
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Mark BromleyEmergency Medicine PGY-3
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Overview
Cases Approach – Work-up Appendicitis
Dealing with surgeons Mesenteric Ischemia ABD films SBO
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Case
21 ♂ with ABD pain onset ~ 24h
Pain Peri-umbilical Escalating to 8/10
Fevers/Chills Emesis x 3 this AM
OE: 38.1 oC 16 85 122/81 ABD:
Diffuse peri-umbilical No Rebound/Guard
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Case
PMHx: WellPSHx: None
Meds: NilAllergies: NKDA
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Approach
Anatomic
Systems
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Work-up
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Case
Order your work-up Morphine 2.5-5mg IV for pain
Return in 1-2h Comfortable Pain – now in RLQ
Tender at McBurneys
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Appendicitis - Classic
Pain Vague peri-umbilical pain that localizes to
the RLQ (McBurney’s) …↑ over 12 to 24h period Pain lasting more than 36h is rare – or
perfed Febrile Anorexic Elevated WBC Rosvings, Psoas, Obturator
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Signs
Psoas sign With pt supine, flex hip against resistance
by pushing down against knee -- pain = +ve
Obturator sign Passively flex hip & knee and internally
rotate leg at the hip -- pain = +ve
Rosvings sign press down in LLQ then release suddenly -
pain = + ve
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Differentiate into 3 groups
1. High suspicion for appendicitis – need for immediate surgery i.e. classic presentation
2. Intermediate suspicion for appendicitis – no clear-cut need to go to OR yet Atypical presentation
3. Low suspicion for appendicitis
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Appendicitis
Expedient diagnosis Non-ruptured - - - - - - - - - - - Mortality
0.6% Ruptured - - - - - - - - - - - - - - Mortality
5%
…the blood was clotted …nurses are sure the lab dropped it
Surgeon wants a WBC before seeing11
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Appendicitis – Role of WBC Methods:
prospective consecutive case series All patients presenting to the ED in whom the
diagnosis of appendicitis was the attending physician’s primary consideration
Patient temperature as taken in the ED, initial total WBC count, and discharge diagnosis.
Results: N=293 wbc > 10 (+LR) 1.59 (-LR) 0.46 wbc > 12 (+LR) 2.70
Fever > 37.2oC (+LR) 1.30 (-LR) 0.8212
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Liklihood Ratio
likelihood ratio, is the ratio of the maximum probability of a result under two different hypotheses
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Probability of ↑WBC with Appy---------------------------------------- =
LRProbability of ↑WBC w/o Appy
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Probability of ↑WBC with Appy____________________
Probability of ↑WBC w/o Appy
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Design: Random assignment of vignettes with different presentation formats of
diagnostic test accuracy. Setting:
Auditorium at a continuing medical education conference. Participants: 183 physicians. Intervention:
After estimating probabilities of 6 common illnesses described in patient vignettes, physicians
Results: post-test probability estimates deviated to a small and similar extent
from Bayes-based estimates in the groups informed by sensitivity and specificity or
likelihood ratios. An inexact numerical graphic led physicians to come closer to Bayes-
based estimates in the PE and chronic obstructive pulmonary COPD vignettes
some physicians estimated lower illness probabilities after a positive test result if it was accompanied by a low test accuracy value.
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Likelihood Ratios
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Odds and Probability
…only works with odds
I’ll give you twenty to one odds 20:1probability = 20/total (21) = 95% chance
Forty to sixty odds = 40:60 = 40/60 = 0.66
probability = 40/total (100) = 40% chance
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Likelihood Ratios
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Likelihood Ratio % chance this guy has an appy = 0.4
(40%) Convert that to odds (pretest) 0.4/0.6 = 4/6 = 2/3
(2/3) x 3 = 6/3 = 2 Convert back to probability (posttest) 2/3 = 0.67 (67%)
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Likelihood Ratios
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Likelihood Ratio
As a rule (+) LR > 10 (-) LR <0.1
…useful
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Case
Resident comes down and sees the patient
…hmm, didn’t do a rectal? Wow. hmmm….
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Appendicitis - Rectal
Why do we do a rectal exam? Should we do a rectal exam? Looking for other diagnoses
PR bleeding Peri-anal disease Mass in the vault
Does everyone need a rectal?
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Patients and Methods: 100 consecutive adults admitted to the emergency surgical unit with
acute abdominal pain Following DRE, patients completed an anonymous questionnaire The house officer conducted the rectal examination at admission and also
completed an evaluation sheet
Results: A working diagnosis of acute appendicitis in 38 patients and
gastroduodenal, pancreatobiliary pathology in 24 patients was made DRE did not alter clinical diagnosis or initial management in any patients Routine DRE did not detect any unrelated pathology 93 wanted to know why rectal examination was required 78 patients rated the DRE as uncomfortable 43 were willing for DRE as a routine 54 patients preferred to have the DRE at the time of other bowel tests
rather than at emergency admission
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Patients 1204 consecutive patients admitted to hospital with RLQ pain 1028 had a rectal examination on admission Main outcome measures - Odds ratio for each symptom and sign related to final diagnosis Results of multiple logistic regression analysis for acute appendicitis
Results Right sided rectal tenderness (odds ratio 1.34, p<005) RLQ tenderness (odds ratio 5.09) Rebound tenderness (3.34) Guarding (3.07) Muscular rigidity in the abdomen (5.03)
In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance
Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis.
No other unexpected diagnoses were established, and no useful additional
Conclusion If patients presenting with pain in the RLQ of the abdomen are tested for rebound
tenderness then rectal examination does not give any further diagnostic information
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Case
The resident agrees – this sure looks like appendicitis.
But the boss would like some imaging.
…thoughts?
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Ultrasound (Graded Compression) Test Characteristics
Sensitivity 75-90%, Specificity 86-100% Pros
No radiation, safe in kids, pregnant pts Can identify alternate Dx esp. in female pts
Cons Difficult for us to get Operator-dependant Limited in obese pts or with ↑ bowel gas Identifies alternate Dx less often than CT Painful
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CT scan
Test characteristics Sensitivity 90-100%, specificity 91-99%
Pros Identifies alternate Dx more often than U/S Fast & accessible in our practice setting
Cons Radiation dose (~100 CXR’s) Delay time to surgery Multiple techniques in literature: controversial
as to which is best but all ~90-100% sensitive Less accurate in pts w/ little intraabdominal fat
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CT vs U/S
2 prospective RCT’s of U/S vs CT CT more sensitive & specific than U/S
94-97% sensitive vs. 76 – 100% for U/S 100% specificity vs. 76-90% for U/S
More alternate Dx identified by CT
Horton et al. Am J Surg 2000; 179: 379-81Walker et al. Am J Surg 2000; 180: 450-55
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CT vs U/SMethods: 120 consecutive pts 8-81 yo w/ ?appy who
were too well to go to OR but too ill to simply D/C
Did focused CT w/ rectal contrast & U/S w/in 1 hr
Gold standard - pathology or clinical f/u x 6m
Results: CT: 95% sensitive, 89% specific U/S: 87% sensitive, 74% specific CT identified 14 alternate Dx vs. 9 for U/S U/S missed 2/3 of pts w/ perforation
*Pickuth et al. Suspected acute appendicitis: Is ultrasonography or computed tomography the preferred imaging technique? Eur J Surg. 2000; 166: 315-19
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Does imaging change mgmt? 2 studies of CT in pts w/ ? appendicitis
comparing Tx plan before & after access to results of scans
Results: CT changed disposition in 27 – 59% of pts Prevented d/c of ~3% pts w/ appendicitis Prevented negative laparotomy in 3-13% Alternate Dx in 11-20%
…yesFrank et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med 2002; 23: 1-7
Rao et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Eng J Med. 1998; 338: 141-6
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Bottom line
Group 1 Appendectomy regardless of imaging
result Group 2
Image Group 3
Clearly instructed when to return for re-evaluation
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Appendicitis - Mgmt
Hydration Antibiotics
Ancef/Flagyl (surgical wound) Fluroquinalone/Flagyl (gram(-) rods /
anaerobes) Surgery
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Case
65 ♂ with ABD pain
Diffuse ABD pain 8/10 Rapid onset Opiod resistant
N/V/D Watery stools x 3
OE: 104 20 145/67 37.2 ABD: Diffuse tenderness - no rebound/guard Rectal: Normal (-) FOB
PMHx: HTN/DMII/smoke/AFIB/MI x3
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Approach
Differential
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Ischemic bowel - etiology Embolic
LA LV Cardiac Valves
SMA is most susceptible to embolism Multiple emboli Concomitant vasoconstriction occurs
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Ischemic bowel - etiologyThrombotic Arterial
Acute event Chronic intestinal ischemia from progressive
atherosclerosis Involves multiple vessels
Venous venous thrombosis →mesenteric venous flow → bowel wall
edema, fluid efflux into lumen ↓BP ↑ blood viscosity
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Risk FactorsHypercoagulable states Portal hypertensionAbdominal infections Blunt abdominal trauma PancreatitisSplenectomyMalignancy in the portal region
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Ischemic bowel - etiology Non-occlusive etiology
systemic illness → systemic shock → ↓CO
cocaine → vasospasm Venous thrombosis → ↓ venous return →
interstitial swelling of bowel wall → ↓ arterial flow
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Mesenteric Ischemia – clinical ABD pain
rapid onset severe out of proportion to exam
N/V/D forceful bowel evacuation
Risk factors AFIB CHF peripheral vascular disease hypercoagulability
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Ischemic bowel - diagnostics Labs (non-specific)
Lactate WBC INR/PTT
Imaging Plain films (nonspecific late findings – not
useful) Thumbprinting Pneumatosis intestinalis Portal venous gas
CT Angiography
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CT scan
sensitivity 64-100% specificity 89-94%
Evidence of ischemia in bowel wall & mesentery
Evidence of clot in SMA First investigation done routinely here
If suspect mesenteric ischemia let radiology know
Good but not good enough If CT is negative & high pre-test probability
you need an angiogram
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Ultrasound
Doppler can determine major obstruction to flow in venous & arterial systems Dilated, tubular vessels with echogenic material (clot) Abnormal flow
Limitations Studied primarily in venous thrombosis & chronic
mesenteric ischemia Unsure how it performs for acute mesenteric ischemia Only good for more proximal blockages Has limitations inherent to all U/S exams
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Angiography
Gold standard (~90% sens) Diagnostic and therapeutic
Infuse vasodilators into SMA (papaverine) Angioplasty
Drawbacks Time-consuming Risks of contrast & invasive procedure Expensive
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Angiography: Early vs Late Angiography → early in pts w/o peritonitis & ↑
suspicion Can buy time (papaverine) Can aid in surgical decision making
Surgical: embolectomy, thrombectomy, endarterectomy, bypass graft
Non-surgical: angioplasty
Early (before peritonitis) angio & intervention ↓ mortality 70-90% → 10%
Down side: ↑ negative angios Associated risks & costs
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Angiography: When to say no Contraindications:
1. Unstable hypotensive pts on vasopressors
Difficult to differentiate b/w occlusive & non-occlusive etiologies
Can’t infuse vasodilators
2. Pts w/ peritonitis Delays surgery
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Case
32 ♀ with nausea and vomiting Abdominal pain
periumbilical and crampy paroxysms of pain q 4-5 min abdominal distension
Vomiting q 30 min BM none x 48h
PMHx Crohns – dx in 1997 - resection 2002, 2007
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Crohn’s
Extra-intestinal manifestations Skin manifestations
erythema nodosum, pyoderma gangrenosum
Peripheral arthritis (asymmetric involvement of larger joints)
Ankylosing spondylitis and sacroiliitis Aphthous ulcers Ocular manifestations (eg, episcleritis, recurrent
iritis, uveitis) Amyloidosis and thromboembolic manifestations Liver
elevation of enzyme levels Cholangitis Autoimmune chronic active hepatitis, and cirrhosis
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Comparisons of Crohn's and UC
Crohn's Ulcerative colitis
Terminal ileum involved Commonly Seldom Colon involvement sually Always Rectum involvement Seldom Usually Peri-anal disease Common Seldom Bile duct involvement No ↑ in PSC Higher rate Distribution of Disease Patchy (Skip lesions) ContinuousEndoscopy Deep geographic ulcers
Continuous ulcer Depth of inflammation May be transmural Shallow,
mucosal Fistulae Common Seldom Stenosis Common Seldom Surgical cure Often Cured by
colectomy Smoking risk for smokers ↓risk for smokers
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Complications of Crohn’s
Perforation Fistula Adhesions - obstruction Deficiency / Malabsorption
Protein Vitamins
Abscess Megacolon Steroids
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Abdominal Films
What are they good for?
Rule out Obstruction Perforation Foreign Body
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Obstruction
Small Bowel 1. Distended loops of bowel proximal to
obstruction Intramural width > 3cm
2. Multiple intra-luminal air fluid levels more distal obstruction → more gas-fluid levels
3. Discrepancy b/w bowel size proximal/distal to obstruction
4. Obstruction →→ Intramural gas 2o to ischemia
This is a late poor prognostic sign
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Case
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MATERIALS AND METHODS. A blinded retrospective analysis was done on 78 pts
who underwent plain abdominal radiography, CT, and enteroclysis to assess for suspected SBO.
The findings at enteroclysis and the clinical outcomes were used as standards of reference.
RESULTS Plain film radiography for SBO sens: 69% (44/64)
specificity 57% (8/14). Overall accuracy of plain film radiography was 67%
(52178).
CT sensitivity 64% (41/64) and specificity 79% ( I 1/ 14)
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Abdominal Films
What are they good for?
Rule out Obstruction Perforation Foreign Body
Skip Films59
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Abdominal Films - FB
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Abdominal Films - FB
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Abdominal Films
What are they good for?
Rule out Obstruction Perforation Foreign Body
Skip Films62
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Air may be trapped anteriorly in the cupola of the diaphragm
permitting visualisation of the undersurface of the central portion of the diaphragm
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Crescent sign
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Double Wall sign Gas-relief sign Air is present on both sides of the intestine
(usually requires > 1L of free air)
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Rigler’s sign
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Supine
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Supine FilmsSupine Films
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69supine
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Supine FilmsSupine FilmsSupine FilmsSupine Films
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Supine Films
Double Blind Retrospective Supine films from 44 cases of pneumoperitoneum
were randomly interspersed among supine films from 87 control subjects without free air
One or more of these signs were present (59%) Right-upper-quadrant gas sign (41%) Rigler's sign (32%) Falciform ligament and football signs (2%)
11 false-positive cases (13%)
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SBO - case
32 ♀ with nausea and vomiting Abdominal pain
periumbilical and crampy paroxysms of pain q 4-5 min abdominal distension
Vomiting q 30 min BM none x 48h
PMHx Crohns – dx in 1997 - resection 2002, 2007
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SBO - pathophysiology
Swallowed air and gas from bacterial fermentation accumulates
Bacterial overgrowth occurs in the proximal small bowel the contents of which are normally nearly sterile emesis can become feculent due to bacterial overgrowth
The bowel wall becomes oedematous Normal absorptive function is lost Fluid is sequestered in the bowel lumen ↑ secretion of fluid into the lumen of the proximal bowel ↑ transudative loss of fluid into the peritoneal cavity
Dehydration → tachycardia, oliguria, azotemia, and hypotension
Emesis → loss of Na, K, H, and Cl
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SBO - Treatment
Degree of dehydration Need for surgery – timing of surgery
Partial vs Complete “…never let the sun rise or set on a
SBO!"
IV access – fluid resuscitation Non-operative
NG tube76
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Case
42 female presents with diarrhea PMHx
Dental Surgery 2 weeks ago Recent travel to mountains ?questionable
water
Diarrhea Onset ~ 4-5 days ago Large volume – watery Tried some immodium - ?helped a little
No N/V ABD pain
Diffuse generalized abdominal pain77
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Thoughts? Differential? Work-up?
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C. difficile 1978 C. difficile identified as the causative pathogen Implicated Abx
Clindamycin Penicillins Cephalosporins
Any antibiotic can predispose to C. diff colonization Risk Factors
Abx Broad spectrum Abx Multiple Abx Increased duration
Advanced Age Gastric Acid Suppression
Protective Factors Neonates
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C. Difficile pathogenesis
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C. Difficile - presentation
Typical Watery diarrhea
Onset durring Abx course or 10-15d post Abd cramping Fever (low grade) Leukocytosis OE: Abd tenderness Colonoscopy:
patchy erythema → pseudomembranous colitis
Atypical Protein losing enteropathy Involvement in IBD Extra colonic involvement
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C. Difficile - treatment
IV, O2, Monitor Fluid resuscitation Discontinue antibiotics
∆ to less associated abx Infection control – contact precaution Avoid opiates / loperimide Metonidazole Vancomycin (PO)
Probiotics Intermittent therapy
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Case
Pt is admitted under hospitalist (capped) You see the patient 3 handovers later
Diarrhea has slowed Abd distension Altered sensoriumOE:
Vitals: 120 107/42 19 38.1 Distended tender lower ABD No peritoneal signs
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Toxic Megacolon - Diagnosis
Radiographic dilation of colon (>6cm)
PLUS 3 of: Fever > 38 HR > 120 WBC > 10.5 Anemia
PLUS 1 of: Dehydration Altered Sensorium Hypotension Electrolyte disturbances
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Toxic Megacolon – pathophysiology Nitric Oxide → generated by
macrophages/inflamed smooth muscle → inhibitor of smooth muscle tone
Inflammation Extension → paralyzes smooth muscle
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Toxic Megacolon - Treatment
Goals: Reduce colitis severity Restore colonic motility Decrease likelihood of perforation
Medical Mgmt Bowel Rest / NG decompression D/C anti-motility agents
Opiates, Anticholinergics Abx ?Steroids
Surgical Mgmt Colectomy
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Thank you!
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Incarcerated Hernia - Case 52 ♂ with pain, edema → scrotum nausea, vomiting, and low-grade
fever
…if you listen bowel sounds in the scrotal sac
inguinal mass can be palpated separately from the testes
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Incarcerated Hernia - Mgmt Trendelenburg posn with an ice to the groin Sedation Slow, gentle pressure to reduce the hernia
If the hernia cannot be reduced or strangulation is suspected (fever, overlying cellulitis, peritonitis) fluid resuscitation broadspectrum Abx emergent surgical consultation
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Hernia (non-incarcerated) Patients who have a hernia on
routine exam or
who have had the hernia reduced and are without symptoms of incarceration or strangulation
Refer for out pt surgical repair
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Hernia - Peds
Fun Facts Inguinal hernias occur ~ 10-20/1000 live births Prematurity and low birth weight ↑ risk ♂:♀ 4:1 → ↑ ♀ incarceration Most common indication for surgery < 2 yrs
Presentation Abdominal or inguinal pain, an inguinal or scrotal mass, nausea,
vomiting, and low grade fever
Mgmt Attempt reduction if the child appears well Analgesia, sedation Trendelenburg position Slow gentle pressure
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Diverticulitis - case
65 ♂ presents with bloating and LLQ pain Stool:
↓ freq no change in caliber/consistency
OE: 37.5 87 135/24 18 ABD: soft tender LLQ. No rebound/guard Rectal: FOB positive
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Hb: 146 WBC: 10.6 Urine: clean Bili/ALT/ALP/Lipase: N
Imaging CT Barium Enema / Non-contrast Enema US Endoscopy Plain Films
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CT scan: Evaluates the colon and surrounding
structures Diagnose diverticulitis Evaluate the extent of the disease
Peri-colonic fat Thickening of bowel wall > 4mm Free air Abscess
Guide perc drainage Our guy:
Multiple diverticuli Local inflammation
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Diverticulitis
Colon is penetrated by vasa recta (vessels)
Site of penetration is weak Diverticula form 2o to ↑ itracolonic
pressure
Assymptomatic Obstructed → inflammation → microperf
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Diverticulitis
Uncomplicated Peri-colonic fat inflamation
Complicated Fistula Abscess Adjacent obstruction → mass effect
(abscess)
→ stricture
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Diverticulitis – Mgmtuncomplicated Oral Abx x 7-10 days*
Septra DS BID and flagyl 500 mg q6h Cipro 500 mg BID and flagyl 500 mg q6h Amoxicillin/clavulanate 500/125 mg TID
Diet Liquid High-fiber (↓ recurrence)
Pain NSAIDs / opiods
Admission Unable to tolerate PO Poor social support / compliance / Follow-up
*Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA (eds): The Sanford Guide to Antimicrobial Therapy, 34th ed. Hyde Park, Vt, Antimicrobial Therapy, Inc, 2004.
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Diverticulitis – MgmtComplicated IV Abx*
Mild to Moderate Infection Ticarcillin/clavulanate 3.1 gm IV q6h Ampicillin/sulbactam 3 g IV q6h Ciprofloxacin 400 mg IV q6h and flagyl 500 mg IV q6h
Severe Infection Ampicillin, 2 g IV q 6 hr, and metronidazole, 500 mg IV q 6 hr, and
gentamicin, 7 mg/kg q 24 hr, or ciprofloxacin, 400 mg IV q 12 hr Trovafloxacin, 300 mg IV once a day Imipenem, 500 mg IV q 6 hr
NPO – bowel rest Surgical Mgmt
Peritonitis Perforation Sepsis resistant to medical mgmt Fistula Strictures
*Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA (eds): The Sanford Guide to Antimicrobial Therapy, 34th ed. Hyde Park, Vt, Antimicrobial Therapy, Inc, 2004.
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Pediatric Issues
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NEC - Case
HPI: 10 day ♂ presents with feeding intolerance and bloody stools Mom also notes abdominal distension, lethargy the bedside nurse notes a decrease in the infant activity level
and temperature instability
PMHx: Ex-36 wk 3 days in SCN - uneventful Some ongoing difficulties with feeding / wt gain – formula fed
OE: 160 60/42 50 35oC Decreased tone – slip through Mottled ABD: distended and tender
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NEC
Most common GI emergency in the neonates
Acute fulminant dz associated with ulceration and necrosis of the distal small intestine and colon
Pathophysiology – poorly understood Infectious – nursery epidemics Prematurity - ↓ after 36wks Enteral alimentation- ↑ metabolic demand Inflamatory mediators -
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NEC - Diagnosis
Radiology Pneumatosis intestinalis Portal venous air Pneumoperitoneum Non-specific
localized dilated loop of bowel thickened loops gasless abdomen
Labs Thrombocytopenia Leukocytosis Electrolyte imbalance Metabolic acidosis Hypoxia or hypercapnia
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NEC - Mgmt
1. Early bowel decompression by NG suction
2. Prompt IV Abx therapy Ampicillin Gentamycin Anaerobic bacterial coverage (clindamycin)
3. Maintain volume/ mesenteric perfusion. NEC is associated with third spacing of fluid into the mesentery Intra-vascular volume supplementation is required to maintain mesenteric
perfusion Follow perfusion of the extremities and urine output (1-2 ml/kg/hour)
4. Except in the milder cases, because of respiratory failure and worsening acidosis, intubation mechanical ventilation is often necessary
5. Pain control is essential → extremely painful disease6. Surgical consultation7. ICU consultation
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Intussusception - case
Hx: 13 month ♀ with profound lethargy A bit snot nosed last week but mom thought she was doing better Earlier today she was quite irritable and was noted to bring her
legs up to her ABD
PMHx - well
OE: AVSS Afeb Child is lethargic ABD distended
Diffuse poorly localized tenderness Not firm
Rectal FOB (-)
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Ultrasound98-100% sensitivity90-100% specificity100% negative predictive value
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Intussusception
lead point causes telescoping of one segment of intestine into another
Edema develops and obstructs venous return
Ischemia of the bowel wall
peritoneal irritation → perforation
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Intussusception - presentation Classic Triad (~30%)1.Abdominal pain2.Vomiting3.Bloody stools
Drawing the legs up to the abdomen Profound lethargy
Dance’s Sign - a sausage-like mass in the RUQ and an empty space in the RLQ representing the displaced cecum
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Intussusception - Mgmt
IV fluids 20 mL/kg NS bolus Repeat PRN
NPO NG tube decompression Ill-appearing or febrile children → ABx
1. Ampicillin 2. Gentamicin3. Clindamycin or metronidazole
Air or hydrostatic barium enema
Surgical intervention if… reduction is unsuccessful perforation occurs
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60 ♂ with DM presenting with back pain 32 ♀ with RLQ pain 5 month ♀ with “colic”
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Which pairing correctly matches the radiological finding with the cause of abdominal pain in infants?
A. Volvulus: Double-bubble sign with associated dilatation and increased gas pattern distal to the volvulus
B. NEC: Asymmetric pattern of gas with dilatation early in the course of illness and subsequent air in bowel wall (pneumatosis intestinalis)
C. HPS: String and pearls sign is seen with a barium upper GI series
D. Intussusception: Proximal colonic dilatation and distal narrowing in barium study
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The most common GI emergency in the neonatal period is necrotizing enterocolitis.
A. TrueB. False
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Diffuse abdominal pain occurs in all of the following except:
A. sickle cell crisis.B. inflammatory bowel disease.C. inguinal hernia.D. diabetic ketoacidosis.
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Which of the following statements is true regarding intussusception?
A. The condition is more common in females.
B. It is the most common cause of intestinal obstruction in children younger than 2 years.
C. Most commonly, the intussusception is ileoileal.
D. Plain films are reliable in diagnosis.122
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Which of the following statements is true of hernias in children?
A. Prematurity and low birth weight increase the risk.
B. They are more common on the left side.
C. They occur more in females.D. Males incarcerate more often.
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Which of the following is/are non-abdominal cause(s) of abdominal pain?
A. Lead poisoningB. Black widow spider biteC. Diabetic ketoacidosisD. Sickle cell pain crisisE. All of the above
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