Category: Gastrointestinal Emergencies

Question Of The Day #95

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

Which of the following is the most likely diagnosis for this patient’s condition?

  • A) Diverticulosis
  • B) Colon malignancy
  • C) Ischemic colitis
  • D) Ulcerative colitis

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #95," in International Emergency Medicine Education Project, July 1, 2022, https://iem-student.org/2022/07/01/question-of-the-day-95/, date accessed: July 7, 2022

Question Of The Day #94

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Administer Platelet transfusion
  • B) IV Vitamin K and IV Fresh Frozen Plasma
  • C) IV Vitamin K only
  • D) Await INR value, and administer IV Vitamin K if INR is greater than 10

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #94," in International Emergency Medicine Education Project, June 24, 2022, https://iem-student.org/2022/06/24/question-of-the-day-94/, date accessed: July 7, 2022

Question Of The Day #93

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

  • A) CT Angiogram of the abdomen and pelvis
  • B) Consult gastroenterology for colonoscopy
  • C) Start IV Pantoprazole infusion
  • D) Administer Packed Red Blood Cells

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #93," in International Emergency Medicine Education Project, June 17, 2022, https://iem-student.org/2022/06/17/question-of-the-day-93/, date accessed: July 7, 2022

Question Of The Day #92

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

  • A) Mesenteric ischemia
  • B) Colon cancer
  • C) Peptic ulcer disease
  • D) Diverticulosis

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #92," in International Emergency Medicine Education Project, June 10, 2022, https://iem-student.org/2022/06/10/question-of-the-day-92/, date accessed: July 7, 2022

Question Of The Day #91

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

  • A) Esophageal varices
  • B) Gastric malignancy
  • C) Peptic ulcer disease
  • D) Gastroesophageal Reflex Disease (GERD)

This patient arrives to the Emergency Department with upper abdominal pain and hematemesis.  He occasionally takes ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), which is a risk factor for GI bleeding. His examination shows tachycardia.  This patient likely has an upper gastrointestinal bleed given his signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding.  

All choices listed above are potential causes of upper GI bleeding, with the exception of GERD (Choice D).  Erosive gastritis and esophagitis can cause an upper GI bleed, but GERD is not a cause of upper GI bleed.  The patient lacks risk factors for esophageal varices (Choice A), such as chronic liver disease, cirrhosis, or alcohol abuse.  Gastric malignancy (Choice B) is possible, but less likely given the patient’s young age and lack of risk factors mentioned in the question stem for gastric malignancy (i.e., prior H. pylori infection, tobacco smoking, chronic gastritis, weight loss, lymphadenopathy, etc.).  The most common worldwide cause of upper GI bleeding is peptic ulcer disease (Choice C).  For this reason, Choice C is the best answer.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #91," in International Emergency Medicine Education Project, June 3, 2022, https://iem-student.org/2022/06/03/question-of-the-day-91/, date accessed: July 7, 2022

Question Of The Day #58

question of the day
~ Joseph Ciano, USA ~ Leave a comment
720 - variceal bleeding

Which of the following is the most appropriate next step in management?   

  • A) 1000mL IV Normal saline
  • B) 1 Unit Packed Red Blood Cells
  • C) IV Ceftriaxone
  • D) IV Pantoprazole

This cirrhotic patient presents to the Emergency Department with epigastric pain after an episode of hematemesis at home.  His initial vital signs are within normal limits.  While waiting in the Emergency Department, his clinical status changes.  The patient has a large volume of hematemesis with hypotension and tachycardia.  This patient is now in hemorrhagic shock from an upper gastrointestinal bleed and requires immediate volume resuscitation.  The most common cause of upper gastrointestinal bleeding is peptic ulcer disease, but this patient’s cirrhosis history and large volume of hematemesis should raise concern for an esophageal variceal bleed.  IV Pantoprazole (Choice D) is a proton pump inhibitor that helps reduce bleeding in peptic ulcers, but it does not provide benefit in esophageal varices.  Volume repletion is also a more important initial step than giving pantoprazole.  IV Ceftriaxone (Choice C) helps reduce the likelihood of infectious complications in variceal bleed patients.  This has a mortality benefit and is a recommended adjunctive treatment.  However, rapid volume resuscitation is a more important initial step.  IV crystalloid fluids, like normal saline (Choice A), are helpful in patients with hypovolemic shock (i.e., dehydration, vomiting), distributive shock (i.e., sepsis, anaphylaxis), and obstructive shock (i.e., tension pneumothorax, etc.).  Hypovolemic shock due to severe hemorrhage (hemorrhagic shock) requires blood products, not crystalloid fluids which can further dilute blood and cause coagulopathy.  Administration of packed red blood cells (Choice B) is the best next step in management in this case.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #58," in International Emergency Medicine Education Project, October 8, 2021, https://iem-student.org/2021/10/08/question-of-the-day-58/, date accessed: July 7, 2022

Question Of The Day #40

question of the day
~ Joseph Ciano, USA ~ 1 Comment

Which of the following is the most appropriate next step in management for this patient?

  • A) Administer IV Vancomycin
  • B) Order CT scan of the abdomen and pelvis
  • C) Consult gastroenterology for emergent colonoscopy
  • D) Administer IV Metronidazole and Ciprofloxacin

This elderly patient presents to the emergency department with left lower abdominal pain, constipation, and anorexia. The exam shows fever, tachycardia, and marked left lower quadrant tenderness. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The most likely diagnosis for this patient is diverticulitis based on the location of the pain. Features of diverticulitis include left lower quadrant pain, nausea, vomiting, change in bowel habits (diarrhea or constipation), anorexia, fever, and leukocytosis. Right-sided diverticulitis is more common in patients of Asian descent, so these patients may alternatively present with right lower quadrant pain. Treatment for acute diverticulitis includes antibiotics, bowel rest, hydration, increased dietary fiber, and pain management.

Other potential diagnoses to consider for this patient include perforated diverticulitis, abdominal abscess, colitis, bowel obstruction, malignancy, AAA, urinary tract infection, ureterolithiasis, and soft tissue infections. The best next step in the management of this patient is to treat empirically for an abdominal infection with IV hydration, antipyretics, and antibiotics. Sepsis from a gastrointestinal source requires antibiotics that cover both gram-negative and anaerobic bacteria. IV Vancomycin (Choice A) is helpful for skin infections, soft tissue infections, MRSA (Methicillin-resistant Staph aureus) infections, or other infections from gram-positive organisms. Vancomycin would not include coverage for a gastrointestinal source. IV Metronidazole covers anaerobic bacteria, and Ciprofloxacin covers gram-negative bacteria. This makes Choice D the best antibiotic choice for this patient. Other options include IV ampicillin-sulbactam, ampicillin and metronidazole, piperacillin-tazobactam, ticarcillin-clavulanate, or imipenem. A CT scan on the abdomen and pelvis (Choice B) should be performed on this patient (ideally with PO and IV contrast). However, IV hydration and antibiotics are a more important initial step to address the patient’s sepsis. CT scanning is recommended for first-time diverticulitis episodes or if there are alternative diagnoses on the differential. Patients with a history of recurrent diverticulitis who present to the Emergency department with uncomplicated acute diverticulitis are able to be treated empirically with oral antibiotics in the outpatient setting. Ill-appearing patients, have no prior history of diverticulitis or have possible alternative diagnoses should get CT imaging. Emergent colonoscopy (Choice C) is not indicated as part of the Emergency department management of acute diverticulitis. In fact, colonic inflammation or inflamed diverticuli are contraindications to colonoscopy (increased risk of bowel rupture). Correct answer: D

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #40," in International Emergency Medicine Education Project, May 21, 2021, https://iem-student.org/2021/05/21/question-of-the-day-40/, date accessed: July 7, 2022

Approach to Jaundice in the Emergency Department

~ Maryam Bagherzadeh, Canada ~ Leave a comment

A 50-year-old male presents to the emergency department (ED) with nausea and vomiting, diminished appetite, and recent changes in his skin color, which he describes as turning “yellow.” This seemed to have worsened over the past few weeks, after which he began to worry and presented to the ED.

The patient’s vital signs are normal. His physical exam is positive for icteric sclerae, jaundice in the face and chest, and hepatomegaly. He is not tender to palpation on the abdomen. The rest of his exam is otherwise normal.

Introduction

Jaundice is not a diagnosis, but a clinical manifestation of an underlying problem, specifically elevated serum bilirubin. Patients with Jaundice present with yellow discoloration of the skin, mucous membranes, and sclera. They can present to the ED with Jaundice in isolation or along with other symptoms. It is the Emergency Physician’s task to evaluate the patient, find the underlying cause, order the appropriate investigation and decide whether the patient requires admission to the hospital and consultation with other physicians.

Normal physiology of bilirubin metabolism

Bilirubin is the end product of heme metabolism. This occurs in three phases: pre-hepatic, hepatic, and post-hepatic phases. Approximately 75-80% of bilirubin comes from the catabolism of red blood cells. Initially, this bilirubin is unconjugated, which is insoluble in water and soluble in fat. Therefore, unconjugated bilirubin can easily cross the blood-brain barrier and the placenta [1].

Unconjugated bilirubin is actively transported to the liver by albumin and is conjugated by the enzyme glucuronosyltransferase. Subsequently, conjugated bilirubin is either stored in bile in the gallbladder or excreted through the biliary tract, where it eventually reaches the intestines and is excreted from the body [1,2].

Pathophysiology and differential diagnosis

The classic definition of jaundice is a serum bilirubin level greater than 2.5 to 3 mg per dL (42.8 to 51.3 µmol per L), with a clinical presentation of yellow skin and sclera [1]. As described in the above section, bilirubin metabolism occurs in three phases, and dysfunction of any of these steps can lead to jaundice.

Pre-hepatic causes

Unconjugated hyperbilirubinemia or elevated levels of unconjugated bilirubin before it reaches the liver can lead to jaundice. This can occur due to excessive heme metabolism from increased red blood cell breakdown (hemolysis) and the saturation of enzymes that conjugate it. A few underlying etiology for this include hemolytic anemia, sickle cell anemia, spherocytosis, glucose-6-PD deficiency, hemolytic uraemic syndrome, and transfusion reaction [1,3].

Hepatic causes

Any process that impacts liver functioning can lead to jaundice. Some of the hepatic causes of jaundice in adults include viral hepatitis, chronic alcohol consumption, autoimmune diseases such as primary biliary cirrhosis, genetic disorders such as Gilbert syndrome, hereditary metabolic defects such as Dubin-Johnson syndrome, and some drugs that can lead to drug-induced liver disease such as acetaminophen, oral contraceptives, estrogenic and anabolic steroids [4-6].

Post-hepatic causes

Any process that instigates post-hepatic obstruction can lead to jaundice due to elevated levels of conjugated bilirubin. Some of these include cholelithiasis leading to obstruction of the biliary duct system, biliary tract tumors, biliary duct strictures, and jaundice secondary to pancreatitis [1, 7].

History and physical examination

A good history and physical examination of patients presenting with jaundice to the ED is key in their diagnosis.

On history, the patient should be asked about alcohol and drug use, recent travel, sexual contact with a person with known or suspected hepatitis, recent tattoos or body piercings, and previous biliary surgery. A focused review of systems should also be conducted. For example, a history of fever and viral symptoms can point towards viral hepatitis, while the presence of constitutional symptoms such as weight loss and night sweat may point towards a malignancy [8].

The physical examination should comprise vital signs and a complete abdominal examination, assessing for right upper quadrant tenderness, ascites, hepatomegaly, splenomegaly, and ascites [9]. Additionally, the physical examination should focus on evaluating encephalopathy by looking for asterixis and changes in mental status and underlying liver disease by assessing for bruising, spider angiomas, gynecomastia, and palmar erythema [1, 8-9]. Lastly, it is important to remember that the presence of painless jaundice and an abdominal mass may point towards obstruction from a malignancy.

Investigations

Laboratory assessment

First line serum testing should include a complete blood count (CBC) to check for hemolysis, bilirubin level with fractionation, aminotransferases (AST and ALT) to assess for hepatocellular injury (although these may be normal in chronic liver disease), alkaline phosphatase, prothrombin time and/or international normalized ratio, albumin, and protein to assess for liver synthetic function. If these tests come back normal, further tests may be needed to identify the underlying cause of the patient’s jaundice, such as hepatitis serology, autoimmune markers, and investigation for acetaminophen levels [1,8].

Imaging

The majority of diagnostic imaging will be done outside of the ED. However, emergency physicians can conduct initial ultrasound screening to assess for bile duct dilation, biliary obstruction, and the presence of cholelithiasis. A CT scan can also be ordered to assess for intraparenchymal liver and pancreas disease [1,8]. Outside of the ED, investigation with Endoscopic Retrograde Cholangio-Pancreatography (ERCP), Magnetic Resonance Cholangio-Pancreatography (MRCP), and a liver biopsy may be warranted.

Management

In the ED, emergency physicians are often involved in the initial investigation of a patient with jaundice in ruling out life-threatening conditions and to decide whether a patient should be discharged or admitted for further management. For example, physicians should first assess medical emergencies that can present with jaundice, such as ascending cholangitis, acute hepatic failure, and massive hemolysis. Timely diagnosis, resuscitation, treatment initiation, and emergent consultation of these conditions are critical in the ED. Additionally, patients with elevated AST/ALT levels should be admitted if there are any signs of sepsis, coagulopathy, altered mental status, and intractable pain and vomiting. The presence of hepatocellular injury, coagulopathy, and altered mental status may point towards fulminant liver failure and may require acute fluid resuscitation and hemodynamic monitoring in an acute care setting [10]. Otherwise, depending on the underlying cause of a patient’s jaundice, surgical, gastroenterological or interventional radiological consultation may be required in an outpatient setting.

References and Further Reading

  1. Roche, S. P., & Kobos, R. (2004). Jaundice in the adult patient. American family physician, 69(2), 299-304.
  2. Wolfson, A. B., Hendey, G. W., Ling, L. J., Rosen, C. L., Schaider, J. J., & Sharieff, G. Q. (2012). Harwood-Nuss’ clinical practice of emergency medicine. Lippincott Williams & Wilkins.
  3. Sackey K. (1999). Hemolytic anemia: part 1. Pediatr Rev, 20,152-8.
  4. Pasha, T. M., & Lindor, K. D. (1996). Diagnosis and therapy of cholestatic liver disease. Medical Clinics of North America, 80(5), 995-1019.
  5. Schramm, C., Kanzler, S., Zum Büschenfelde, K. H. M., Galle, P. R., & Lohse, A. W. (2001). Autoimmune hepatitis in the elderly. The American journal of gastroenterology, 96(5), 1587-1591.
  6. Lewis, J. H. (2000). Drug-induced liver disease. Medical Clinics, 84(5), 1275-1311.
  7. Custis, K., Brown, C., & El Younis, C. M. (2000). Common biliary tract disorders. Clinics in Family Practice, 2(1), 141-154.
  8. Fargo, M. V., Grogan, S. P., & Saguil, A. (2017). Evaluation of jaundice in adults. American family physician, 95(3), 164-168.
  9. Winger, J., & Michelfelder, A. (2011). Diagnostic approach to the patient with jaundice. Primary Care: Clinics in Office Practice, 38(3), 469-482.
  10. Vaquero, J., & Blei, A. T. (2003). Etiology and management of fulminant hepatic failure. Current gastroenterology reports, 5(1), 39-47.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to Jaundice in the Emergency Department," in International Emergency Medicine Education Project, May 17, 2021, https://iem-student.org/2021/05/17/approach-to-jaundice/, date accessed: July 7, 2022

Recent Blog Posts By Maryam Bagherzadeh

iEM Image Feed: Gallbladder Stone

iem image feed
~ iEM Education Project Team ~ Leave a comment

A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria. Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.

Her temperature is 37ºC, blood pressure: 110/70 mmHg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder (positive Murphy’s sign). Rectal exam normal, stool is hemoccult negative for blood. Pertinent lab values: glucose 110 mg/dl, alkaline phosphatase 120 U/L, alanine aminotransferase (ALT) 25 U/L, aspartate aminotransferase (AST) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.

The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.

79 - gall bladder stone

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Gallbladder Stone," in International Emergency Medicine Education Project, April 21, 2021, https://iem-student.org/2021/04/21/iem-image-feed/, date accessed: July 7, 2022

Question Of The Day #20

question of the day
~ Joseph Ciano, USA ~ Leave a comment
cod20
608 - Figure3 - pericardial effusion - ECG

Which of the following is the most appropriate next investigation for this patient’s condition?

  • A) Arterial blood gas
  • B) Bedside cardiac sonogram
  • C) Chest radiography
  • D) CT pulmonary angiography

This patient’s EKG demonstrates alternating amplitudes of QRS complexes, a phenomenon known as electrical alternans. This is caused by the heart swinging back and forth within a large pericardial effusion. The patient is tachycardic and borderline hypotensive, which should raise concern over impending cardiac tamponade. The next best investigation to definitively diagnose a large pericardial effusion with possible tamponade would be a cardiac sonogram (Choice B). This investigation could also guide treatment with pericardiocentesis in the event of hemodynamic decompensation and the development of obstructive shock. Other EKG signs of a large pericardial effusion are diffusely low QRS voltages and sinus tachycardia. Chest radiography (Choice C) may show an enlarged cardiac silhouette in this case and evaluate for alternative diagnoses (i.e. pneumothorax, pleural effusions, pneumonia, atelectasis), however, cardiac echocardiography is the best next investigation. CT pulmonary angiography (Choice D) would demonstrate the presence of a pericardial effusion along with differences in cardiac chamber size indicative of tamponade. Still, bedside cardiac sonogram is a faster test that prevents a delay in diagnosis. Sending a potentially unstable patient for a CT scan may also be dangerous. Arterial blood gas testing (Choice A) has no role in diagnosing pericardial effusion or cardiac tamponade. Correct Answer: B

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #20," in International Emergency Medicine Education Project, November 6, 2020, https://iem-student.org/2020/11/06/question-of-the-day-20/, date accessed: July 7, 2022

Question Of The Day #19

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod19
52 - Perforated Viscus

Which of the following is the most likely cause of the patient’s condition?

  • A) Pulmonary embolism
  • B) Pancreatitis
  • C) Peptic ulcer disease
  • D) Gastroesophageal Reflux Disorder

All patients who present to the emergency department with chest pain should be evaluated for the top life-threatening conditions causing chest pain. Some of these include myocardial infarction, pulmonary embolism, esophageal rupture, tension pneumothorax, cardiac tamponade, and aortic dissection. Many of these diagnoses can be ruled-out or deemed less likely with a detailed history, physical exam, EKG, and sometimes imaging and blood testing. This patient presents with vague, burning chest pain, nausea, and tachycardia on exam. Pulmonary embolism (Choice A) is hinted by the patient’s tachycardia, but the patient has no tachypnea or risk factors mentioned for PE. Additionally, the chest X-ray findings demonstrate an abnormality that can explain the patient’s symptoms. Pancreatitis (Choice B) and Gastroesophageal reflux disorder (Choice D) are also possible diagnoses, especially with the location and description of the patient’s pain. However, Chest X-ray imaging offers an explanation for the patient’s symptoms. The patient’s Chest X-ray demonstrates the presence of pneumoperitoneum. In the presence of NSAID use, this radiological finding raises concern over a perforated viscus from advanced peptic ulcer disease (Choice C). Peptic ulcer disease (PUD) is most commonly caused by Helicobacter pylori infection, but NSAIDs, iron supplements, alcohol, cocaine, corrosive substance ingestions, and local infections can cause PUD. PUD is a clinical diagnosis which can be confirmed visually via endoscopy. The treatment for PUD includes initiation of a proton pump inhibitor (H2-receptor blockers are 2nd line), avoiding the inciting agent, and H.pylori antibiotic regimens in confirmed H.pylori cases. The treatment for a perforated peptic ulcer with pneumoperitoneum is IV fluids, IV antibiotics, Nasogastric tube placement, and surgical consultation for repair.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #19," in International Emergency Medicine Education Project, October 30, 2020, https://iem-student.org/2020/10/30/question-of-the-day-18-2/, date accessed: July 7, 2022

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Question Of The Day #11

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod 11

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) IV antihypertensives and cardiothoracic consultation
  • B) IV heparin
  • C) Pericardiocentesis
  • D) IV Fluids, antibiotics, and surgical consultation

IV antihypertensives and CT surgery consultation (Choice A) would be the best treatment for a patient with aortic dissection. This diagnosis is characterized by severe tearing chest pain that radiates to the back, along with hypertension. Risk factors include tobacco smoking, uncontrolled hypertension, trauma (i.e. rapid deceleration), and connective tissue diseases (i.e. Marfan syndrome). Other than chest pain with radiation to the back, this patient lacks the other risk factors for aortic dissection, making Choice A less likely. IV heparin (Choice B) would be the correct choice for the treatment of pulmonary embolism and acute coronary syndrome (i.e. NSTEMI). Both of these diagnoses are possible, but a chest CT scan with PO water-soluble contrast is not the gold standard for diagnosing PE or ACS. A CT Pulmonary angiogram is ideal for PE diagnosis, and an EKG along with troponin levels are ideal for ACS diagnosis. Pericardiocentesis (Choice C) is the treatment for cardiac tamponade. The patient’s vitals show no evidence of obstructive shock, and there is no history of penetrating chest trauma, pericardial effusion, end-stage renal disease, HIV, lupus, cancer, or other risk factors for cardiac tamponade. Choice D outlines the best course of action to take in a patient with esophageal rupture, which is the disease described in the question stem. This condition can occur spontaneously after forceful vomiting causing high pressures in the esophagus (Boerhaave syndrome). In this situation, the chest pain typically begins after the onset of vomiting. Other etiologies of esophageal rupture include deceleration injuries and penetrating trauma (i.e. gunshot wounds, iatrogenic via esophagogastroduodenoscopy (EGD)). A “Hamman’s Crunch”, subcutaneous emphysema, fever, and signs of shock can be seen on exam. Diagnosis is confirmed by an esophagram or a CT scan of the chest with water-soluble oral contrast (i.e. Gastrograffin). Esophageal rupture is a life-threatening diagnosis as esophageal contents can spill into the mediastinum, causing mediastinitis and septic shock. The treatment is typically surgical with the repair of the perforated segment and drainage of fluid collections. Correct Answer: D  

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Nickson, C. (2019) Oesophageal Perforation. Life in the Fast Lane. Accessed August 17, 2020. https://litfl.com/oesophageal-perforation/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #11," in International Emergency Medicine Education Project, September 4, 2020, https://iem-student.org/2020/09/04/question-of-the-day-11/, date accessed: July 7, 2022