17 years old girl, previously known healthy, vomited blood!
This is an extremely serious symptom. Although this patient’s vitals were totally in the normal range, actively vomiting blood should warn physicians to act immediately to protect further deterioration in the patient. This may even include early airway protection because we simply do not want them to aspirate any blood. Having a normal vitals with this picture does not mean anything, and should not create a relaxing environment in the treatment/resuscitation bay. Honestly, this patient should go directly to resuscitation bed from the triage.
Steps are straightforward. Protect the airway if necessary, start oxygen like in any other critically ill patient during/for primary evaluation(survey). Open the two large bore IV line, give fluid bolus, order type, and cross, and be ready for any deterioration in the BP and starting blood (ORh-). Obviously, even starting a transfusion earlier may be appropriate. Activating GI team for emergency endoscopy is necessary. However, some institutions may not have this luxury 24 hours. Therefore, other measures such as mechanical compressions with Sengstaken-Blakemore tube and some medications can be an only option. This patients final diagnosis was Variceal Bleeding.
To learn more about management please read two GI bleeding chapters below.
In case you didn’t encounter a 6-year-old patient who swallowed a coin today!
In case you didn’t encounter RUQ pain today!
Sonographic criteria for acute cholecystitis
the presence of gallstones,
thickened gallbladder wall,
sonographic Murphy’s sign,
common duct dilatation.
How many did you see in the ultrasound image except sonographic Murphy’s sign? Feel free to give your answers to comment section at the bottom of the page.
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 mm Hg, 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 which called 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 (A.L.T.) 25 U/L, aspartate aminotransferase (A.S.T.) 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.
An I.V. was established, and the patient received an isotonic fluid bolus. In addition, ketorolac 30 mg I.V. and ondansetron 4 mg I.V. were administered.
Over the course of an hour symptoms resolved. Absent evidence of gallbladder inflammation or infection, she was discharged from the emergency department and referred to a general surgeon for elective cholecystectomy. She was advised that her pain might return but if it is prolonged, is associated with fever or jaundice she is to return to the emergency department.
A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal pain. He felt nauseated and vomited twice. His pain started around the umbilicus, moved to the left side of his abdomen and then become generalized. It peaked the last few hours, and the painkillers did not work. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. The past and family histories were unremarkable. His blood pressure was 100/60 mmHg, pulse rate 120/min, the temperature 37.8°C (100°F), and respiration rate 24/min. Physical examination showed diffuse abdominal tenderness and voluntary guarding. Bowel sounds were not heard.
Bedside ultrasonography (USG) exhibited increased echogenicity of the peritoneal stripe, with corresponding horizontal reverberation artifacts over the liver. Plain chest radiographs confirmed the presence of free abdominal air. Oral intake was stopped, intravenous (IV) catheter was inserted, fluid therapy was started, and cefoperazone sodium was administered intravenously. Blood type and cross, complete blood count and coagulation were ordered. He transferred to the operation theater with the diagnosis of the perforated viscus.
by Ozlem Dikme, Turkey
A previously healthy 22-year-old male was brought to the emergency department (ED) with recently-started abdominal pain. He had not eaten anything since that morning due to loss of appetite. He was nauseated and vomited three times. His abdominal pain started around the umbilicus and epigastric area. His pain increased as it moved towards his right lower quadrant (RLQ). The maximum pain was felt on the right iliac fossa. He had not taken any medication. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. His diet mostly consisted of carbohydrates. The past and family histories were unremarkable. His blood pressure was 120/70 mmHg, pulse rate was 100/min, the temperature was 37.8°C (100°F), and respiration rate was 22/min.
Physical examination showed normal bowel sounds, tenderness and voluntary guarding, particularly over the right iliac fossa. The costa-vertebral angles were not tender. Oral intake was stopped, intravenous (IV) catheter was inserted, blood and urine tests were planned, and fluid therapy was started. The urinalysis was normal. White blood cell (WBC) count was 14,500 with 89% polymorphous and 11% lymphocytes. The ultrasonography (USG) showed a non-compressible tubular structure of 9 mm in diameter at RLQ. He admitted to the surgical ward with the diagnosis of acute appendicitis.
by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley, USA
A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to the Emergency Department (ED) with a complaint of vomiting bright red blood that began prior to arrival. He arrives actively vomiting; a significant amount of blood is noted in his emesis basin. He is now complaining of dizziness and appears pale.
Gastrointestinal bleeding (GIB) can be generalized into two categories based on the site of bleeding. Upper GIB (UGIB) is defined as any bleeding that occurs proximal to the ligament of Trietz near the terminal duodenum. Lower GIB (LGIB) is any bleeding that occurs distal to the ligament extending to the rectum. Most GIB seen in the ED is attributed to UGIB with an incidence of 90 per 100,000 population. LGIB, on the other hand, presents with a rate of 20 per 100,000 population. LGIB is more commonly seen in the elderly but has a wide range of presentations and causes. As a result, the approach to LGIB has been less standardized.
Acute Mesenteric Ischemia
Rabind Antony Charles, Singapore
A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with diarrhea and vomiting. She says the pain is increasingly worse and has failed to respond to paracetamol and charcoal tablets. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. She has no history of laparotomy. She is alert and oriented. However, she is in distress because of her abdominal pain. The pain score is 9 out of 10. Blood pressure: 96 over 56 mmHg, pulse rate: 125 (irregularly, irregular), respiratory rate 20, pulse oximetry: 98% on room air, tympanic temperature: 37.5 degrees Celsius. Heart sounds: (irregular) S1S2 positive. Lungs sounds are bilateral equal and clear. Abdominal exam reveals diffuse tenderness; it is worse in periumbilical region, no guarding, bowel sounds are sluggish. No scars or hernias noted. Per rectal exam: brown stool. ECG is given on the side.