Tag: abdominal pain

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: September 27, 2023

Question Of The Day #39

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Abnormal Right Upper Quadrant

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

  • A) Administer IM Methotrexate
  • B) Order shoulder X-ray
  • C) Consult Obstetrics/Gynecology team
  • D) Administer IM Rho(D) immune globulin (RhoGAM)

This female patient presents to the Emergency department with atraumatic right shoulder pain, generalized abdominal discomfort, and vaginal bleeding.  She is found to have a positive urine pregnancy test and signs of shock on physical exam (hypotension and tachycardia).  The FAST exam (Focused Assessment with Sonography for Trauma) demonstrates free fluid around the liver.  This quick bedside sonographic exam evaluates the right upper quadrant (liver, right kidney, right lung base), left upper quadrant (spleen, left kidney, left lung base), suprapubic area (bladder), and subxiphoid area (view of heart).  The FAST exam is typically used in the setting of trauma to assess for intra-abdominal bleeding, or “free fluid”.  Fluid on ultrasound appears black, or anechoic.  In the setting of trauma or presumed hemorrhagic shock, free fluid is assumed to be blood.  The hepato-renal recess, also known as Morrison’s pouch, is the most common site for fluid to be seen on a FAST exam.  For this reason, the right upper quadrant should always be viewed first during a FAST exam if there is concern for hemorrhagic shock.  The patient’s right upper quadrant FAST view is annotated below.

This patient is in shock with free fluid in her right upper quadrant FAST view.  In the setting of a pregnancy of unknown origin, shock, and abdominal free fluid, a ruptured ectopic pregnancy is assumed to be the diagnosis.  A cystic adnexal structure and a uterus without a gestational sac can also be noted on ultrasound.  Ectopic pregnancy can present with mild symptoms ranging from abdominal pain and vaginal bleeding to signs of shock with hemoperitoneum as in this patient.  Risk factors for ectopic pregnancy include prior ectopic pregnancies, prior tubal surgeries, prior sexually transmitted infections, tobacco smoking, and use of an intrauterine device (IUD).  Initial Emergency department treatment should include volume resuscitation with blood products, pre-operative laboratory testing, and prompt OB/GYN consultation (Choice C).  Patients who are unstable, show signs of shock, or have large ectopic pregnancies are treated operatively.  Patients with stable vital signs, small ectopic pregnancies, and minimal symptoms are treated medically with Methotrexate (Choice A).   This patient’s hemodynamic instability makes Methotrexate contraindicated in her treatment course.  The patient’s atraumatic shoulder pain is likely from free fluid in the right upper quadrant, causing referred pain to the shoulder from diaphragmatic irritation.  A shoulder X-ray (Choice B) is not indicated in this patient.  Rho(D) immune globulin (RhoGAM) (Choice D) is an important treatment to provide in Rh-negative mothers with ectopic pregnancy.  RhoGAM is indicated in maternal-fetal hemorrhage in order to prevent the maternal immune system from attacking fetal Rh-positive cells in future pregnancies.  RhoGAM is indicated in Rh-negative mothers, not Rh-positive mothers.  The question does not indicate the mother’s blood type or Rh status, however, RhoGAM is not the best initial treatment.  Treatment of the hemorrhagic shock and OB/GYN consultation are the best next steps.  Correct Answer: C

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #39," in International Emergency Medicine Education Project, May 14, 2021, https://iem-student.org/2021/05/14/question-of-the-day-39/, date accessed: September 27, 2023

Question Of The Day #38

question of the day
~ Joseph Ciano, USA ~ Leave a comment
251 - Gallbladder stone with thickened wall
Which of the following is the most likely cause for this patient’s condition?
  • A) Biliary colic
  • B) Acute cholecystitis
  • C) Gastritis
  • D) Pancreatitis

This patient presents to the emergency department with upper abdominal pain, nausea, and vomiting. The physical exam demonstrates fever, tachycardia, and focal right upper quadrant abdominal tenderness. Differential diagnoses to consider include cholecystitis, choledocholithiasis, cholangitis, hepatitis, pancreatitis, and ruptured peptic ulcer. The ultrasound image provided shows a thickened gallbladder wall (>4mm) and a gallstone present. See the labeled image below.

Signs of acute cholecystitis on ultrasound include a thickened gallbladder wall, pericholecystic fluid (anechoic (black) fluid around gallbladder), the presence of a gallstone (hyperechoic (white) with posterior shadowing), sonographic Murphy sign (tenderness when the transducer is pressed into gallbladder), and a dilated gallbladder. This patient has some but not all sonographic signs of cholecystitis. However, the age, obese body habitus, fever, and location of the pain support a diagnosis of acute cholecystitis (Choice B). Treatment of acute cholecystitis involves IV hydration, parenteral pain management and antiemetics, IV antibiotics, and surgical consultation for cholecystectomy. Biliary colic (Choice A) is less likely given the ultrasound findings and fever on exam. If the patient’s vital signs were normal and the ultrasound showed gallstones with no other sonographic signs of cholecystitis, biliary colic would be more likely. Gastritis (Choice C) does not cause fever or the sonographic signs illustrated above. Gallstones are the most common cause of pancreatitis (Choice D), but there is focal tenderness over the gallbladder in the right upper quadrant. Additional findings, such as an elevated lipase level, pain that radiates to the back, or a history of alcohol abuse would make pancreatitis a more likely diagnosis. Correct Answer: B

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #38," in International Emergency Medicine Education Project, May 7, 2021, https://iem-student.org/2021/05/07/question-of-the-day-38/, date accessed: September 27, 2023

Question Of The Day #37

question of the day
~ Joseph Ciano, USA ~ Leave a comment
25.1 - obstruction volvulus coffee bean 1

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

  • A) CT scan of the abdomen and pelvis
  • B) Emergent surgical consultation for colectomy
  • C) Emergent surgical consultation for detorsion
  • D) IV Ciprofloxacin and IV Metronidazole

This elderly male patient presents to the emergency department with generalized abdominal pain and distension. 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 abdominal X-ray demonstrates a “coffee bean sign” and dilated loops of the large bowel (note haustra of the large bowel). The image supports the diagnosis of sigmoid volvulus, a type of large bowel obstruction that necessitates prompt surgical consultation in the Emergency department. Risk factors for sigmoid volvulus are elderly age, constipation, poor mobility, and residence in a long-term care facility. If left untreated, volvulus can result in intestinal ischemia, necrosis, perforation, and peritonitis. Sigmoid volvulus is most often treated with manual intestinal detorsion through flexible sigmoidoscopy or rectal tube. Cecal volvulus is more common in younger patients, and requires surgical bowel resection or cecopexy (fixing the cecum to the abdominal wall).

The abdominal X-ray provided is sufficient to make the diagnosis of volvulus. A CT scan of the abdomen and pelvis (Choice A) is not necessary for this patient. Surgical consultation is the next best step. IV antibiotics (Choice D) are indicated in volvulus if there are signs of intestinal perforation, necrosis, or peritonitis. The question stem indicates that although the abdomen is tender and distended, the abdomen is soft. This makes peritonitis and the need for antibiotics less likely. Surgical consultation for colectomy (Choice B) would be correct if the patient had cecal volvulus or if there were signs of bowel necrosis. Surgical consultation for bowel detorsion (Choice C) is the best next step for this patient with sigmoid volvulus. Correct Answer: C

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #37," in International Emergency Medicine Education Project, April 30, 2021, https://iem-student.org/2021/04/30/question-of-the-day-37/, date accessed: September 27, 2023

Question Of The Day #36

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely diagnosis of this patient’s condition?
  • A) Incarcerated inguinal hernia
  • B) Strangulated Spigelian hernia
  • C) Fournier’s gangrene
  • D) Strangulated inguinal hernia

A hernia is an abnormal defect in the abdominal wall through which intra-abdominal contents (i.e., bowel) can protrude. About 10% of the population experiences hernias at one time during their lifetime. Hernias can cause symptoms that range from mild discomfort to severe pain with signs of bowel obstruction, perforation, necrosis, or peritonitis. The most common type of hernia is the inguinal hernia located along the inguinal crease. Other hernias include the femoral hernia, obturator hernia, Richter hernia, internal hernias, and ventral hernias (umbilical, incisional, Spigelian hernia types). Hernias are further classified as reducible, incarcerated (firm, painful, nonreducible), or strangulated (firm, severely painful, nonreducible, overlying skin redness or crepitus, signs of bowel necrosis or obstruction).

This patient has a right inguinal hernia on exam with overlying skin redness, severe tenderness, and signs of intestinal obstruction (vomiting, constipation, abdominal distension). This should raise concern over a strangulated hernia, which is a surgical emergency. Treatment includes IV hydration, IV antibiotics, and prompt surgical consultation for operative management. The patient’s inguinal hernia is not incarcerated (Choice A), the hernia is strangulated. A Spigelian hernia (Choice B) is located along the lateral ventral abdomen along with the rectus abdominal muscle. Spigelian hernias have a high rate of incarceration compared to other hernias. This patient’s hernia is located along the inguinal crease, not the ventral abdominal wall. Fournier’s gangrene is a severe necrotizing fasciitis of the perineum. Although early Fournier’s gangrene may lack subcutaneous emphysema and marked skin redness, the location and other historical details make a strangulated inguinal hernia a more likely diagnosis. Choice D is the correct answer.

Correct Answer: D

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #36," in International Emergency Medicine Education Project, April 23, 2021, https://iem-student.org/2021/04/23/question-of-the-day-36/, date accessed: September 27, 2023

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: September 27, 2023

Question Of The Day #35

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod35
29.2 - small bowel obstruction 2
Which of the following is the most likely cause for this patient’s condition?
  • A) Malignancy
  • B) Adhesions
  • C) Diabetic ketoacidosis
  • D) Delayed gastric emptying

This patient presents to the emergency department with generalized abdominal pain, nausea, vomiting, and constipation. The physical exam demonstrates tachycardia and a distended and diffusely tender abdomen. The patient has three prior abdominal surgeries. The upright abdominal X-ray shows multiple dilated loops of small bowel with air-fluid levels. The information provided by the history, physical exam, and diagnostic imaging collectively supports a diagnosis of small bowel obstruction.

Small bowel obstruction (SBO) is a mechanical blockage to forward flow through the intestines. The majority of SBOs are caused by post-operative scar tissue formation (adhesions), but other causes include hernias, intra-abdominal malignancies, foreign bodies, and Crohn’s disease. Symptoms include intermittent colicky abdominal pain, abdominal distension, nausea and vomiting, and constipation. Some patients may be able to pass stool and flatus early in the timeline of an SBO or if the obstruction is partial, rather than complete. Typical exam findings in SBO are a diffusely tender abdomen and high-pitched bowel sounds. Findings of abdominal rigidity, guarding, or fever should raise concern about possible intestinal perforation, peritonitis, or intestinal necrosis. Diagnosis is made clinically in combination with diagnostic imaging, such as abdominal X-rays, CT scanning, or ultrasound. CT scans have better sensitivity and specificity in diagnosing an SBO than Xray. Abdominal ultrasound is more sensitive and specific in diagnosing SBO than CT scan, but this test requires a skilled practitioner to get high-quality results. Treatment of SBO involves IV hydration, surgical consultation for possible operative intervention, pain medications, antiemetics, and electrolyte repletion. Nasogastric tube placement for gastric decompression is helpful in patients who have marked abdominal distension, intractable vomiting, or have risks for aspiration (i.e. altered mental status).

The most common cause of SBO is adhesions (Choice B), not malignancy (Choice A). Diabetic ketoacidosis (Choice C) can present with abdominal pain, nausea, and vomiting. However, DKA becomes more likely when the glucose is elevated over 250mg/dL. The presence of air-fluid levels and dilated small bowel on X-ray imaging also supports SBO over DKA. Delayed gastric emptying (Choice D) is the cause of gastroparesis, a diagnosis that can also present as nausea and vomiting. The other signs, symptoms, and imaging results make SBO a more likely diagnosis than gastroparesis.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #35," in International Emergency Medicine Education Project, April 16, 2021, https://iem-student.org/2021/04/16/question-of-the-day-35/, date accessed: September 27, 2023

iEM Image Feed: Viscus perforation

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

A 35 years old previously healthy gentleman presented to the Emergency Department with a sudden-onset severe and diffuse abdominal pain which started an hour ago. Chest X-ray was ordered; what do you see?

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR
887.1 - viscus perforation

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

887.2 - viscus perforation

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Viscus perforation," in International Emergency Medicine Education Project, April 14, 2021, https://iem-student.org/2021/04/14/viscus-perforation/, date accessed: September 27, 2023

Question Of The Day #34

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod34

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

  • A) CT scan of abdomen/pelvis with IV contrast
  • B) Ultrasound of the appendix
  • C) MRI of abdomen/pelvis
  • D) IV Piperacillin-Tazobactam

This patient is pregnant in the first trimester presenting to the Emergency department with right lower quadrant pain. Any first trimester pregnant patient with abdominal pain should be evaluated for ectopic pregnancy. Other causes of this symptom include ovarian torsion, ovarian cyst rupture, pelvic inflammatory disease, tubo-ovarian abscess, urinary tract infection, ureterolithiasis, colitis, or appendicitis. An intra-uterine pregnancy is confirmed on transvaginal ultrasound which excludes ectopic pregnancy from the differential. Ovarian pathologies are also investigated on the ultrasound and are not discovered. 

Another common diagnosis based on the patient’s pain location, young age, and markedly tender abdomen is acute appendicitis. The most common presenting symptom in appendicitis is right lower quadrant pain. Other signs include fever, anorexia, nausea, or vomiting.  Pregnant women may present with back or flank pain, rather than right lower quadrant pain, as the uterus may displace the appendix in the abdomen. There is no single symptom or laboratory test that can reliably exclude the diagnosis of appendicitis. The gold standard test for acute appendicitis diagnosis is a CT scan of the abdomen with IV contrast dye. PO or PR contrast are additionally used in some institutions based on preference and protocols.  In children, appendiceal ultrasound is performed first to avoid excessive radiation exposure and financial cost. CT scanning (Choice A) is similarly avoided in first-trimester pregnancy to diagnose appendicitis, although it is the test of choice in non-pregnant adults. MRI imaging of the abdomen and pelvis (Choice C) is another diagnostic option for pregnant patients, but this is not recommended until an ultrasound is performed. IV antibiotics (Choice D) may be needed to treat appendicitis or other abdominal infections, but this patient lacks a definitive diagnosis or signs of sepsis or shock which would support emergent antibiotics. The best next step to further evaluate the cause of this patient’s symptoms is conducting an appendiceal ultrasound (Choice B). If this study is non-conclusive or is not available, an MRI should be performed. 

Emergency department treatment for acute appendicitis is IV antibiotics, IV hydration, and surgical consultation for appendectomy. Immediate surgery may be avoided in patients who present several days after symptom onset or with a ruptured appendix. These cases are treated with IV antibiotics, IV hydration, bowel rest, and close monitoring.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #34," in International Emergency Medicine Education Project, April 9, 2021, https://iem-student.org/2021/04/09/question-of-the-day-34/, date accessed: September 27, 2023

Question Of The Day #33

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod33
AAA CT scan possible rupture

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

  • A) Surgical consultation
  • B) IV Vancomycin and Piperacillin-Tazobactam
  • C) Endotracheal intubation
  • D) IV Heparin

This elderly male patient presents to the emergency department with abdominal pain. 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 a 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 syncopal event and signs of shock should raise concern for a more serious etiology of the patient’s symptoms. The CT image provided shows a dilated aorta filled with contrast dye and a large surrounding intra-luminal thrombus. An infrarenal abdominal aorta measuring over 3cm is considered aneurysmal. This patient’s abdominal aorta measures approximately 7cm from outer wall to outer wall using the scale provided on the right-hand side of the image. The green measurement line in the image below shows the size of the aorta from outer wall to outer wall (includes thrombus).

The diagnosis for this patient is a ruptured abdominal aortic aneurysm (AAA). This condition carries a high mortality and is often lethal without prompt surgical intervention (Choice A). Administration of blood products is helpful if there are signs of hemorrhagic shock as in this patient. Antibiotics, like IV Vancomycin and Piperacillin-Tazobactam (Choice B), are not helpful in the management of this diagnosis. Endotracheal intubation (Choice C) is needed prior to operative intervention, but Emergency department management should focus on volume resuscitation and close communication with the surgical team for operative repair. IV Heparin (Choice D) may be beneficial in acute mesenteric ischemia from an embolic etiology (i.e. Atrial fibrillation), but anticoagulation would worsen this patient’s hemorrhagic shock.

AAAs can present to the Emergency department without any symptoms and be discovered incidentally on imaging or on physical exam as a pulsatile abdominal mass. Other presentations include severe back pain (the abdominal aorta is retroperitoneal) and circulatory shock. Rupture of a AAA can be large and result in rapid decompensation and death, or bleeding can be contained in the retroperitoneal space with transiently stable vital signs. Risk factors for AAA formation are male sex, tobacco use, hypertension, increased patient age, Marfans syndrome, or Ehlers-Danlos syndrome. The diagnosis of AAA is clinical and includes the use of bedside aortic ultrasound or CT aortic angiogram imaging. Treatment for AAA depends on aortic size and patient symptoms. Operative repair is indicated for any AAA over 5.5cm diameter in men, over 5.0cm diameter in women, or any size if there are signs of shock or concern for AAA rupture.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #33," in International Emergency Medicine Education Project, April 2, 2021, https://iem-student.org/2021/04/02/question-of-the-day-33/, date accessed: September 27, 2023

Question Of The Day #32

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod32

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

  • A) Administer IV midazolam
  • B) Order CT scan of abdomen/pelvis
  • C) Consult surgery team
  • D) Order IV hydration

This patient has intermittent epigastric abdominal pain with nausea and vomiting that radiates to the back. He has a history of alcohol abuse, but lacks tremors or tongue fasciculations to demonstrate signs of active alcohol withdrawal. Laboratory testing reveals pre-renal acute kidney injury (BUN/Creatinine ratio >20), elevated liver function tests with a hepatocellular pattern (AST>ALT in 2:1 ratio), and a markedly elevated lipase.  This information supports a diagnosis of acute pancreatitis. Administration of IV midazolam, a benzodiazepine, would be an appropriate next step if the patient had signs or symptoms of alcohol withdrawal. Alcohol withdrawal can begin as early as 6 hours after refraining from alcohol intake in a chronic alcohol user.  Information regarding alcohol intake is not provided in the question, but objective clinical signs indicating withdrawal are not present on exam. Ordering a CT scan of the abdomen and pelvis (Choice B) is not required in making the diagnosis of acute pancreatitis.  A CT scan can be helpful if you are considering an alternative diagnosis (i.e. AAA, abdominal abscess, etc) or if there is concern for sepsis or fulminant pancreatitis. 

 

Diagnosis of pancreatitis is made clinically based on the history and physical exam, risk factors for the disease, and laboratory testing.  Pancreatitis typically presents as upper abdominal pain that radiates to the flanks and back.  Nausea and vomiting are frequent accompanying symptoms. The disease can range from mild symptoms to severe symptoms with pancreatic necrosis, multi-organ failure, shock, and Acute Respiratory Distress Syndrome (ARDS). Serum lipase testing is more specific than amylase for pancreatitis. Lipase is elevated in pancreatitis.  Risk factors for the disease include gallstones, alcohol use, abdominal trauma, recent ERCP, hypertriglyceridemia, pancreatic ischemia, scorpion envenomation, certain viral infections (Mumps, CMV), hypercalcemia, and certain medications (sulfonamides, azathioprine, valproic acid, etc).  The most common cause of first-time pancreatitis is gallstones. A gallbladder ultrasound should always be performed in patients with a gallbladder who present with pancreatitis. A surgical consultation (Choice C) for gallbladder removal would be warranted if this patient had gallstone pancreatitis, but the patient has a history of a cholecystectomy. The likely cause of this patient’s pancreatitis is his alcohol abuse which causes direct pancreatic injury and inflammation. Treatment of pancreatitis includes IV hydration (Choice D), analgesia, antiemetics, and monitoring for electrolyte abnormalities. Avoiding food or liquid intake (NPO) for “pancreatic rest” has been recommended historically for all cases of pancreatitis, however there is not robust evidence to support this practice.  Routine antibiotics are not recommended for acute pancreatitis, unless there are signs of sepsis.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #32," in International Emergency Medicine Education Project, March 26, 2021, https://iem-student.org/2021/03/26/question-of-the-day-32/, date accessed: September 27, 2023

Question Of The Day #31

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod31
CT bowel wall thickness - m

Which of the following is the most likely diagnosis causing this patient’s symptoms?

  • A) Ruptured appendicitis
  • B) Ruptured abdominal aortic aneurysm
  • C) Mesenteric ischemia
  • D) Ureterolithiasis

This elderly female patient presents to the emergency department with acute onset of severe abdominal pain, vomiting, and diarrhea. 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 a 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 patient in this question has pain that is reported as being significantly high in relation to the minimal amount of abdominal tenderness provoked by the physical exam. This finding, known as “pain out of proportion” should raise concern for an ischemic etiology of the patient’s pain.  Ruptured appendicitis (Choice A) is less likely as the patient lacks clinical signs of peritonitis (i.e. diffuse tenderness with guarding, fever, hypotension, signs of shock).  Appendicitis, although not impossible in an elderly individual, is a diagnosis that occurs more often in younger patients. Ruptured abdominal aortic aneurysm (Choice B) typically results in death rapidly from hemorrhagic shock. This patient lacks signs of shock (hypotension, tachycardia, altered mental status), and her aorta on CT scan is not enlarged or aneurysmal (see image below).  Ureterolithiasis (Choice D), or a stone in the ureter, typically manifests as unilateral intermittent flank pain with hematuria. The question stem does not report a history of prior stones, and a first-time stone at an elderly age is not likely. 

Given the patent’s advanced age, her “pain out of proportion”, acute onset, risk factors for thromboembolic disease (Atrial fibrillation), the most likely diagnosis is acute mesenteric ischemia (Choice C). X-ray imaging can be used prior to CT angiogram imaging, but CT imaging is more specific and sensitive in making the diagnosis.  X-ray imaging may show bowel dilation, ileus, or pneumatosis intestinalis (air in bowel wall) in severe cases.  Lactate and D-Dimer testing can be used in the evaluation of these patients, but neither test is specific for mesenteric ischemia and reliable enough to rule out the disease. CT angiogram imaging of the abdomen and pelvis is the gold-standard diagnostic test for mesenteric ischemia.  Early CT findings include bowel wall thickening (seen on this patient’s imaging), dilated bowel, mesenteric edema, or ascites. Late CT findings include pneumoperitoneum, portal venous gas, and pneumatosis intestinalis.  Treatment of acute mesenteric ischemia is fluid resuscitation, broad spectrum antibiotics, surgical consultation, and consideration for anticoagulation.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #31," in International Emergency Medicine Education Project, March 19, 2021, https://iem-student.org/2021/03/19/question-of-the-day-31/, date accessed: September 27, 2023