III: GASTROINTESTINAL



RIGHT UPPER QUADRANT PAIN




Cholelithiasis


Presentation


•  Acute, severe, intermittent RUQ pain, +N/V, a/w fatty meals


•  In biliary colic, sxs generally resolve completely in b/w episodes


•  Mild RUQ tenderness but no fever or Murphy’s sign


•  In choledocholithiasis & cholecystitis, sxs will become constant


Evaluation


•  nl labs in biliary colic


•  Biliary colic is a clinical Dx & U/S is not required in ED unless ruling out other Dx, or in pt w/ intractable pain. RUQ U/S spec/sens is 90–95% for stones.


Treatment


•  NSAIDs, opiate analgesics, antiemetics; elective surgical management


Disposition


•  If pain controlled, d/c home w/ surgery f/u to consider cholecystectomy


Pearls


•  80% of stones are of mixed composition w/ cholesterol having the highest concentration


•  RFs include female gender, increasing age & parity, & obesity


Choledocholithiasis


Presentation


•  Biliary colic that becomes constant, often jaundiced


•  Mild RUQ tenderness but no fever or Murphy’s sign


Evaluation


•  Obstructive LFT pattern, U/S shows dilated CBD >6 mm


Treatment


•  ERCP-guided stone removal or cholecystectomy


Disposition


•  Admit medicine


Cholecystitis


Presentation


•  Acute, severe, RUQ pain, that becomes constant, fever, nausea, vomiting


•  RUQ tenderness; Murphy’s sign (arrest of inspiration w/ RUQ palpation), or Sonographic Murphy’s sign (pain w/ palpation of visualized gallbladder w/ U/S probe); fever


Evaluation


•  CBC (elevated WBC ± left shift), LFTs (may be elevated but are often nl), RUQ U/S: The presence of stones, thickened gallbladder wall (>3 mm), & pericholecystic fluid has a PPV of >90%


•  HIDA scan: Used if U/S is equivocal, best sens/spec


Treatment


•  2nd- or 3rd-generation cephalosporin (E. coli, Enterococcus, Klebsiella) broaden coverage if septic


•  Surgical consult for cholecystectomy; may do percutaneous drain if poor surgical candidate


Disposition


•  Admit for surgical management


Cholangitis


Presentation


•  Charcot’s triad: RUQ pain, jaundice, fever (present in 70% of pts)


•  Reynold’s pentad: Charcot’s triad +shock & MS changes (present in 15% of pts)


Evaluation


•  Labs: ↑ WBC, ↑ LFTs, positive blood cultures


•  U/S/CT not very sens; can be suggestive


•  ERCP is diagnostic & can be therapeutic if obstructing stone is found


Treatment


•  Broad-spectrum abx for gram-negative enterics (eg, E. coli, Enterobacter, Pseudomonas): Piperacillin/tazobactam OR ampicillin/sulbactam OR ticarcillin/clavulanate OR ertapenem OR metronidazole + (ceftriaxone OR ciprofloxacin)


Disposition


•  Admission to medicine for IV abx ± ERCP w/ surgery consultation


Pearls


•  80% pts respond w/ conservative mgmt & abx w/ elective biliary drainage


•  20% require urgent ERCP biliary decompression, percutaneous drainage, or surgery


•  5% mortality


EPIGASTRIC PAIN


Pancreatitis


Definition


•  Inflammation of the pancreas


Etiology


•  Alcohol (30%), gallstones (35%), idiopathic (20%) hypertriglyceridemia (TG >1000), hypercalcemia, drugs (thiazides, furosemide, sulfa, ACE-I, protease inhibitors, estrogen), obstructive tumors, infection (EBV, CMV, HIV, HAV, HBV, coxsackievirus, mumps, rubella, echovirus), trauma, post-ERCP, ischemic


Presentation


•  Acute onset epigastric pain radiating to the back, nausea, vomiting


•  Often h/o previous pancreatitis, alcohol abuse, gallstones


•  May be ill appearing, tachycardic, epigastric ttp, guarding, ↓ bowel sounds (adynamic ileus)


Evaluation


•  Increased amylase >3× nl (suggestive but not spec for pancreatitis)


•  Increased lipase >2.5× nl


•  If severe: ↑ WBC, ↑ BUN, ↑ glucose, ↓ HCT, ↓ calcium (see Ranson criteria)


•  CT scan: 100% spec but low sens. Not required; should be obtained only to r/o cx (acute fluid collection, pseudocyst, necrosis, abscess)


•  Abdominal U/S: May be used to evaluate for gallstones, CBD dilatation or pseudocyst


Treatment


•  Aggressive IV fluids; NPO initially, but early enteral nutrition if tolerated


•  IV analgesia (risk of sphincter of Oddi spasm w/ morphine is unsupported), antiemetics


•  Prophylactic abx have unclear benefit; may use for severe necrotizing pancreatitis


•  Surgery required only for débridement of infected necrosis, or cholecystectomy if 2/2 stone


Disposition


•  Admission for supportive care if severe or not tolerating PO


•  Several scoring systems exist to help determine floor vs. ICU. Ranson criteria widely used (see below) but limited evidence to support utility (Crit Care Med 1999;27(10)2272).




LOWER QUADRANT/PELVIC PAIN


Appendicitis


Definition


•  Inflammation of the appendix


History


•  Classically, dull vague periumbilical pain which then migrates to the RLQ & becomes sharp & localized


•  Nausea, vomiting, anorexia, fever


•  Greatest at 10–30 y of age but can occur at any time


Physical Findings


•  RLQ (McBurney’s point) tenderness, localized rebound & guarding


•  Psoas sign: Pain w/ active flexion against resistance or passive extension of the right leg


•  Obturator sign: Pain w/ internal rotation of the flexed right hip


•  Rovsing sign: RLQ pain w/ palpation of the LLQ


Evaluation


•  Labs: Leukocytosis (not sens or spec); cannot r/o w/ nl WBC. Check hCG.


•  U/S: Less sens than CT but high spec. Consider esp in children.


•  Abdominal CT w/ IV ± oral or rectal contrast (94% sens & 95% spec)


•  MRI is a useful modality in pregnancy


•  In cases w/ strong clinical e/o appendicitis & low suspicion of alternate etiology, it may be reasonable to proceed w/ laparoscopy w/o imaging


Management


•  Abx: Cefoxitin, cefotetan, fluoroquinolone/metronidazole, OR piperacillin–tazobactam


•  Admission for surgical removal


Pearl


•  Patients at extremes of age are more likely to have atypical presentations & present w/ perforated appendicitis. Very thin young patients may have nl CT w/ appendicitis.


Hernia


Definition


•  Defect in the abdominal wall that allows protrusion of abdominal contents


•  Reducible hernia: Can be pushed back in


•  Incarcerated hernia: Cannot be reduced


•  Strangulated hernia: Incarcerated hernia w/ vascular compromise (ischemia)


History


•  Bulging mass in inguinal area, femoral area, or scrotum (men)


Physical Findings


•  Painful mass in abdominal wall or groin


•  Strangulated: Tender, fever, ± cellulitis, blue discoloration or associated peritonitis


Evaluation


•  If concern for strangulated hernia, consider CBC, lactate


•  CT scan required if concern for strangulated hernia


Management


•  Attempt reduction w/ generous analgesia/anxiolysis, pt in Trendelenburg


•  If easily reduced, d/c w/ analgesic, stool softener, & surgery f/u


•  If not reducible or if strangulated, start abx & surgical admission for operative intervention


Pearl


•  Be cautious about reducing a hernia that has been irreducible by the patient for more than 12 h & is difficult to reduce in the emergency department b/c bowel may be compromised. Consult surgery for these cases; may need observation.


Diverticulitis


Definition


•  Inflammation of diverticulum (sac-like protrusion in the wall of the bowel)


•  Complicated diverticulitis: Associated perforation, obstruction, abscess, or fistula


Presentation


•  LLQ pain, fever, nausea, constipation


•  Mild LLQ tenderness, 50% of pts have heme-positive stool


•  Complicated may have peritonitis, septic shock


Evaluation


•  Clinical Dx if mild sxs & typical presentation


•  Labs: Increased WBC (increased in 31–64% of patients)


•  CT only needed if concern for complicated diverticulitis. Oral contrast may reveal pericolonic inflammation/stranding, abscess, or free air if perforation present.


Treatment


•  Mild: PO metronidazole + (quinolone or TMP-SMX), OR amoxicillin–clavulanate


•  Severe: NPO, IV fluids, IV ampicillin–sulbactam OR piperacillin–tazobactam OR ceftriaxone/metronidazole OR quinolone/metronidazole OR carbapenem


•  Surgery is required if medical therapy fails, free air is present, large abscess that can’t be drained percutaneously, & recurrent dz (≥2 episodes)


Disposition


•  If mild, d/c w/ abx, cathartic, analgesia w/ GI f/u. If severe, admit.


Pelvic Inflammatory Disease/Tubo-ovarian Abscess


Definition


•  Polymicrobial infection of the upper female genital tract commonly a/w sexually transmitted organisms (gonorrhea, chlamydia), but not exclusively


•  Cx include abscess, perihepatitis (Fitz-Hugh–Curtis), sepsis, chronic pain, increased risk of ectopic pregnancy, infertility


History


•  Women w/ lower abd pain, vaginal d/c, dysuria, dyspareunia, nausea ± fevers


•  RFs: Age <25, multiple sexual partners, unprotected sex, h/o PID, IUD placement in the last month, recent instrumentation of the cervix, douching, smoking


Physical Findings


•  Lower abdominal tenderness, cervical d/c, cervical motion tenderness, adnexal tenderness/fullness


•  Clinical exam has sens of 50–75%; presentation is often atypical


Evaluation


•  Labs: Always check pregnancy test; cervical cultures, UA, CBC (not sens)


•  Abdominal CT or pelvic U/S only required if TOA is suspected (unilateral tenderness or palpable mass, systemically ill)


Treatment (CDC. MMWR 2012;61:581)


•  Low threshold for empiric tx: Minimum criteria in sexually active young women or others at risk are pelvic pain & cervical, uterine or adnexal tenderness


•  Outpt: Ceftriaxone 250 mg IM × 1 + doxycycline for 14 d


•  Consider adding metronidazole for anaerobes, esp if recent gynecologic instrumentation


•  Azithromycin is considered insufficient for PID; may be used in isolated cervicitis or 2nd line


•  If severe PCN allergy, options are hospitalization or azithromycin 2 g AND levofloxacin


•  Inpt: (Cefotetan or cefoxitin) + doxycycline OR clindamycin + gentamicin


Disposition


•  Admit if toxic appearing, severe vomiting, failure to outpt therapy, pregnancy, immunocompromised, young age, poor f/u w/i 72 h


•  Discharged pts need f/u in 3 d to ensure sx resolving. Partners should be referred for rxn.


Pearls


•  Given ↑ resistance to antibiotic regimens, CDC updates recommendations frequently


•  PID in pregnancy is rare but does happen; alternative diagnoses should be considered


DIFFUSE PAIN


Abdominal Aortic Aneurysm


Definition


•  Dilation of the abdominal aorta (true aneurysm, involves all layers of the vessel wall)


History


•  Older patient w/ low back pain, abdominal pain, or flank pain (may mimic renal colic), syncope


Physical Findings


•  Pulsatile mass (often not present)


•  Ruptured AAA: Hypotension, abdominal tenderness, decreased femoral pulses mottling, decreased urine output due to obstructive uropathy


•  Extension into SMA/IMA/celiac arteries leads to bowel ischemia


•  Extension to renal artery leads to renal failure, colic, may cause obstructive uropathy


•  Extension to spinal arteries causes neuro deficits, specifically T10–T12 spinal ischemia


•  Extension to iliac vessels causes peripheral limb ischemia


Evaluation


•  Abdominal CT or U/S only if hemodynamically stable


•  Bedside U/S may reveal enlarged aorta & free fluid


Treatment


•  Stable, nonruptured: Surgical or endovascular repair required if >5.5 cm (1%/y risk of rupture if >5 cm) or rapidly growing; usually arranged as outpt


•  Unstable or ruptured: Immediate surgical repair, allow permissive hypotension (SBP 90 s)


Disposition


•  Surgical admission for ruptured AAA or vascular sequelae


Pearls


•  RFs: Smoking, HTN, hyperlipidemia, age ≥65 y, male (5×), FH


•  50% mortality if AAA is ruptured at presentation


Small Bowel Obstruction


Definition


•  Mechanical obstruction of nl intestinal transit leading to bowel dilation


History


•  Diffuse, colicky abdominal pain, nausea, vomiting, abdominal distension, h/o abdominal surgeries/prior obstructions/hernia, obstipation


Physical Findings


•  Diffuse abdominal tenderness, distension, high-pitched bowel sounds


Evaluation


•  Supine & upright abdominal x-rays (47–76% sens): Multiple air–fluid levels, >3 cm small bowel dilation, more than 3 mm small bowel wall thickening


•  Abdominal CT (64–100% sens) can be diagnostic & used to characterize the obstruction (level, severity, cause)


Treatment


•  NPO, bowel rest, gastric decompression w/ NGT placement


•  IV fluids, analgesia, antiemetics


•  Surgical consultation


Disposition


•  Surgical admission


Large Bowel Obstruction/Volvulus


Definition


•  Mechanical obstruction of the large bowel


•  Volvulus: LBO caused by twisting of the large bowel on itself (10% of cases)


History


•  Insidious onset of diffuse, colicky abdominal pain, constipation, N/V


Physical Findings


•  Diffuse abdominal tenderness, distension, bowel sounds present early


Evaluation


•  Supine & upright abdominal x-rays: Dilated large bowel. In volvulus: Single dilated loop of large bowel (80% sens for sigmoid volvulus, 50% sens for cecal volvulus).


•  Abdominal CT w/ rectal contrast: Oral contrast should be avoided


Treatment


•  IV fluids & correction of electrolyte abnormalities


•  Rectal tube & NGT for relief of sxs


•  Surgical consultation for likely operative reduction (particularly for cecal volvulus)


Disposition


•  Surgical admission


Pearls


•  Sigmoid volvulus most common in ill, debilitated elderly patients, or patients w/ psychiatric/neurologic disorders


•  Cecal volvulus common in young adults, classically marathon runners


Perforated Viscus


Definition


•  Perforation of hollow viscus leading to abdominal free air, intraluminal spillage


History


•  Acute onset, severe abdominal pain, worse w/ movement, anorexia, vomiting


Physical Findings


•  Acute peritonitis: Rigidity, tap tenderness, rebound, hypotension, sepsis


Evaluation


•  Supine & upright abdominal x-rays: Free air seen (70–94% sens)


•  Abdominal CT: Definitive study but not required for operative management


Treatment


•  Immediate surgical consult


•  Abx: Ampicillin–sulbactam OR cefotetan OR ampicillin/flagyl/gentamicin


Disposition


•  Surgical admission


Pearl


•  Chronic steroids can mask sxs


Mesenteric Ischemia


Definition


•  Insufficient perfusion of the mesentery & intestine


•  Etiologies: SMA embolism (50%), transient hypoperfusion (25%), SMA thrombosis (10%), venous thrombosis (10%), focal segmental ischemia of the small bowel (5%)


History


•  RFs: Age, AF, vascular dz (coronary, peripheral), CHF (↓ forward flow)


•  May have h/o prior abdominal angina: Postprandial pain, food aversion


•  Acute typical presentation is persistent abdominal pain, anorexia, vomiting, bloody stools


Physical Findings


•  Ill appearing, pain out of proportion to exam, tachycardia, fever, occult blood in stools. Late signs include peritonitis, shock.


Evaluation


•  Early surgical eval


•  Labs: May be nl, increased WBC/amylase/LDH/lactate (late), metabolic acidosis


•  Abdominal x-ray: nl prior to infarction, “thumbprinting” of the intestinal mucosa later


•  Abdominal CT: Colonic dilation, bowel wall thickening, pneumatosis of the bowel wall


•  CT angiography: More sens than CT alone


•  Angiography: Gold standard


Treatment


•  IV fluids, avoid pressors if possible


•  Abx: Ampicillin/gentamicin/metronidazole OR piperacillin/tazobactam OR levofloxacin/flagyl


•  Intra-arterial thrombolysis or embolectomy for arterial embolism


•  Anticoagulation for arterial & venous thrombosis & embolic dz


Disposition


•  Surgical admission


Pearl


•  20–70% morality; improved if Dx made prior to infarct



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Sep 6, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on III: GASTROINTESTINAL

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