Patient presents with severe RUQ abdominal pain 2 days status post laparoscopic cholecystectomy. What is the workup?

Check LFTs and obtain abdominal CT or ultrasound. Must exclude biloma (from biliary leak) and common bile duct stricture, two known complications of lap chole.


Source

Townsend: Sabiston Textbook of Surgery, 18th ed.

Can cunnilingus cause intraabdominal free air?

Yes. There are several case reports.

Mechanism

Other causes of nonsurgical pneumoperitoneum include pneumothorax, spontaneous bacterial peritonitis, peritoneal dialysis, postpartum coitus, vaginal douching, postlaparatomy, postparacentesis.


Source

Cotton, B. et al. "Pneumoperitoneum from Orogenital Insufflation: An Incidental Finding Resulting in Nontherapeutic Celiotomy" J Trauma. 2005.

For how many days after intraabdominal surgery can pneumoperitoneum be detected on plain x-ray?

3-4 days. Intraabdominal free air seen well beyond this should raise concern regarding a pathological process and not be attributed to the surgery.


Source

Brant, W. and Helms, C. Fundamentals of Diagnostic Radiology. 2007.

Barium is bad for perforated bowel because it can cause peritonitis. Is it bad for a perforated esophagus?

No. Barium is inert in the chest and is used for a contrast esophagram to diagnose a perforated esophagus particularly when the initial study using gastrograffin (which unlike barium will not obscure visualization during endoscopy) is non-diagnostic. 


Source

Townsend: Sabiston Textbook of Surgery, 18th ed

Marx: Rosen's Emergency Medicine, 7th ed

Which of the following statements is false regarding acute pancreatitis?

1. The degree of elevation of serum lipase or amylase at admission predicts the severity of disease.
2. Hemoconcentration and failure of hematocrit to decrease at 24 hours are important predictors of severe pancreatitis.
3. It is best to delay abdominal CT imaging 2-4 days after admission if the diagnosis of acute pancreatitis can be made on the basis of elevated pancreatic enzymes and characteristic abdominal pain because CT at admission may underestimate severity of necrosis.  

Answer: 1 is false.


Source

Cheema, N. and Aldeen, A.  "Acute Pancreatitis"  ACEP News.  Dec 2010.

Which patients with diarrhea should be started on empiric antibiotic therapy? Which antibiotic?

Patient's with any of the following characteristics should be started on a fluroquinolone for three to five days.

• travelers' diarrhea
• signs and symptoms  of invasive bacterial diarrhea such as fever and bloody diarrhea (EXCEPT in cases of suspected or proven infection with enterohemorrhagic E. coli which often presents with bloody diarrhea, abdominal pain and tenderness but little or no fever.  In these cases antibiotics may precipitate HUS)
• elderly/immunocompromised 

Source

Wanke, C.  "Approach to the adult with acute diarrhea in developed countries"  Up to Date. 2 June 2010.

Once in the stomach, most ingested foreign bodies will pass spontaneously. However, there are notable exceptions which should be removed. What are they?

• sharp and pointed objects (associated with perforation rates 15 - 35%)
• objects longer than 5 cm 
• objects wider than 2 cm
• magnetS (pleural) or magnet with metal object 

Source

Felman: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed. 

What is the sensitivity of abdominal CT for intraabdominal "badness" in patients > 18 y/o who present with acute non-traumatic abdominal pain?

89%

With "badness" defined as those ailments needing treatment within 24 hours.


Source

Lameris, W. et al. "Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study" BMJ. March 2009.

Name a potential treatment option for recurrent Clostridium difficille infection which is refractory to usual antibiotic therapies?

Fecal transplant. I'm not kidding. Check it out: click here.


Silverman, M. et al. "Success of Self-Administered Home Fecal Transplantation for Chronic Clostridium difficile Infection" Clinical Gastroenterology and Hepatology. May 2010.

Choose your own adventure.

It's 3 AM, 5 hours into your overnight shift and you're seeing your 18th patient of the night, a 58 y/o male with history of cirrhosis and esophageal varicies who presents with large amounts of hematemesis. HR 130. BP 70/palp.

You intubate, start octreotide/protonix drip, place cordis and transfuse blood. GI is 30 minutes out. Despite above, BP continues to decrease. What is your next move?

What finding on CT is pathognomonic for chronic pancreatitis?

Calcifications within the pancreatic ducts.


Source

Nair, R. et al. "Chronic Pancreatitis" American Family Physician. 1 Dec 2007.

Which patients should have a stool culture?

• severe diarrhea (passage of six or more unformed stools per day)
• diarrhea of any severity that persists for longer than a week
  
• fever
• bloody diarrhea
  
• multiple cases of illness that suggest an outbreak
  

Stool cultures are not routinely recommended in most cases of watery diarrhea or traveler's diarrhea.


Source

DuPont, H. "Bacterial Diarrhea" New England Journal of Medicine. 15 Oct 2009.

Name two thoracic complications that may ensue from bowel perforation that results as a complication of colonoscopy.

Depending on the site of colonic perforation, air from the insufflated bowel can enter into either the peritoneum or retroperitoneum.

1. If air enters the peritoneum, gas can traverse from here through small fenestrations in the diaphragm and enter the pleural space along a pressure gradient causing a pneumothorax. Aside from minute diaphragmatic fenestrations, there is a subset of patients who have undiagnoosed diaphragmatic defects which allow the direct transmission of air into the thorax.

2. If air enters the retroperitoneum a pneumomediastinum can ensue through direct communication.


Source

Zeno, B. et al. "Tension Pneumothorax Following Colonoscopy" Chest. Oct 2005. Supplement.

Appendicitis is like a ticking time bomb. What factors increase the risk of rupture?

Source

Bicknell, N. et al. "How Time Affects the Risk of Rupture in Appendicitis" J Am Coll Surg. v 202, n. 3, March 2006.

What percentage of patients with bright red blood per rectum have a upper GI source of bleeding?

In one small single center study, about 10%. Chances increased if patient had history of upper GI bleeding or was anemic.


Source

Byers, S. DO et al. "Incidence of occult upper gastrointestinal bleeding in patients presenting to the ED with hematochezia" American Journal of Emergency Medicine. 2007.

Is it safe to place a nasogastric tube in a patient who potentially has esophageal varices?

Probably.

From Roberts, "Although variceal rupture has occurred during insertion of instruments into the esophagus, several studies suggest that NG tube passage is generally safe, even in the presence of esophageal varices."

Emedicine suggests that history of varices is a relative contraindication to NG lavage.

Bottom line: Probably safe but don't do the procedure if not absolutely necessary.


Sources

Roberts: Clinical Procedures in Emergency Medicine, 4th ed.

Shlamovitz, G. MD and Shah, N. MD "Nasogastric Tube" Emedicine. http://emedicine.medscape.com/article/80925-overview. 20 June 2008.

Check out what I found ...

I was at work, minding my own business, doing my thing. It was a normal day in the neighborhood: altered mental status (UTI), dysuria (UTI), suprapubic pain (UTI), mixed in with a little shortness of breath (pneumonia) when all of a sudden I came across this ...


A 20-ish year old female with epigastric pain over the past several weeks, worst with eating. Sounded every bit like a little gastritis but my sixth sense inspired me to CT scan her anyway. Glad I did. What is it? How is it treated? Scroll down for answer.

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A bezoar. On CT it appears as a mass with air bubbles which conforms to the confines of the stomach. Turns out the patient liked chewing on her hair and ingested a bit too much. A gastrotomy later, the patient is now doing fine. Smaller bezoars can sometimes be broken up and removed via endoscopy.

Source

Image: http://newyorkmedicaljournal.org/Archives/Parekh4-06.htm

Townsend: Sabiston Textbook of Surgery, 18th ed.

What type of hemorrhoids should be considered for excision in the ED?

• external, not internal hemorrhoids
  
• thrombosed (bluish mass covered by epidermis)
  
• super painful

Without excision, thrombosed external hemorrhoids will generally resolve spontaneously over 1 - 3 weeks.

Source

Roberts: Clinical Procedures in Emergency Medicine, 4th ed.

A few pointers for evaluation of abdominal pain in patients with history of Roux-en-Y gastric bypass ...

• Roux-en-y is the most commonly performed gastric bypass operation for morbid obesity
  
  
• Procedure: 1. Upper stomach divided 2. Upper jejunum divided and distal end (Roux limb) anastamosed to stomach pouch 3. Proximal end of divided jejunum (excluded Roux limb) attached to Roux limb (Image source: Annals of Emergency Medicine, v 47, n 2, Feb 2006)

• Even with significant intra-abdominal pathology, the abdominal examination in the morbidly obese is often unrevealing. Have low threshold for obtaining imaging studies
  
  
• Given the limited volume of the gastric pouch decrease the volume and rate of oral contrast administration.
  
  
• If abdominal CT is normal and patient still having abdominal pain, consider internal hernia causing obstruction of the excluded Roux limb. Consider surgical consult and exploration.

Source

Edwards, E MD et al. "Presentation and Management of Common Post-Weight Loss Surgery Problems in the Emergency Department." Annals of Emergency Medicine. v 47, n 2. Feb 2006.

How good is glucagon at relieving esophageal foreign bodies?

Anywhere from useless to 69% successful depending on the study cited.

A couple caveats to maximizing glucagon's utility:

• Glucagon decreases resting tone of the lower esophageal sphincter. It has no effect on the upper third of the esophagus and minimal effect on the middle third; Hence, foreign bodies stuck in these locations are less likely to be dislodged by glucagon administration.


• Administer 0.25 - 2 mg IV slowly over 1 - 2 minutes (to minimize nausea/vomiting side effect), then 1 minute later give the patient some water to stimulate esophageal peristalsis. If no effect after 20 minutes, can attempt again.


• Contraindications: insulinoma (while glucagon will intially elevate glucose via hepatic glycogenolyss and gluconeogenesis, it will stimulate excessive insulin secretion in this condition), pheochromocytoma (stimulates catecholamine release), Zollinger-Ellison syndrome (stimulates excessive gastric acid production), glucagon hypersensitivity, or sharp esophageal foreign body.


• If glucagon fails, other pharmacologic maneuvers to consider include nitroglycerin, gas forming agents (ex soda)

With the holiday season now in full force, I'm sure the ER will be seeing its fair share of patients with turkey, chicken, beef and other sundry meats stuck in the upper GI tract. Perhaps this info will come in handy. Cheers and Happy Thanksgiving!

Source

Munter, David MD and Heffner, Alan MD. "Esophageal Pharmacologic Maneuvers." Roberts: Clinical Procedures in Emergency Medicine, 4th ed. 2004.

Glucagon: Drug information. Up to Date.