Puja Chopra PGY-1 Emergency Medicine

Puja Chopra PGY-1 Emergency Medicine
Bowel! Puja Chopra PGY-1 Emergency Medicine

Case History: 50 yo male complains of periumbilical and left lower quadrant abdominal pain that began earlier that day. Intermittent and crampy pain, accompanied by anorexia and vomiting Normal BM yesterday No History of this pain has had prior abdominal surgery

…continued Physical Exam: Afebrile
Moderate distress due to his abdominal pain Bowel sounds present Abdomen: mildly distended with periumbilical tenderness but no rebound

Small Bowel Obstruction

Background 15% of hospital admissions for an acute abdomen 5% mortality (compared to 60% mortality in 1900) 30% mortality rate when strangulation occurs Death occurs most often in elderly patients or those with significant co-morbidities The overall accuracy of diagnosis of Small Bowel Obstruction on first presentation is as low as 50% Greater time that is elapsed in diagnosing a SBO the more: pain the patient is in, more possible need for ICU and greater duration of hospital stay and increased mortality.

Definitions: Mechanical obstruction: Simple Obstruction:
Physical barrier to the flow of intestinal contents Simple Obstruction: Partial or complete occlusion, proximal intestinal distention, no compromise to blood flow Closed Loop Obstruction: Obstruction at two sequential sites, twisting around an adhesion or hernia, higher risk of ischemia Mechanical obstruction: when there is a physical barrier to the flow of intestinal contents Simple obstruction: when the flow of intestinal contents is partially or completely occluded at one or more points, thus leading to proximal intestinal distention, but there is no compromise in the intestinal flow of blood Closed-loop obstruction: implies that a segment of bowel is obstructed at two sequential sites, usually by a motion of twisting around an adhesion or hernia. This has a higher risk of ischemia Strangulation: when there is compromised vascular supply to the obstructed area. Neurogenic obstruction: also known as an adynamic illeus and this is the case when the flow of intestinal contents is halted due to a slowing in the gut motility. When intestinal peristalsis fails, there is dilation of the involved intestinal tract. This condition is commonly seen with abdominal surgery but may also be seen with several other causes:

Strangulation: Adynamic Illeus
Vascular compromise to the obstructed area Adynamic Illeus Disturbance in gut motility leading to a failure in flow of intestinal contents. Etiologies: abdominal trauma, infection (retroperitoneal, pelvic, intrathoracic), laparotomy, narcotics and other meds, metabolic disease (hypoK), renal colic, MSK inury

Etiology Extraluminal Causes (Most common) Intrinsic Causes:
Adhesions Post pelvic surgery, appendectomy, colorectal surgery Hernia Cancer Intrinsic Causes: Congenital (stenosis, atresia) Neoplasm Infection from chrones/colitis Intuscception Intraluminal Causes: Gallstones Foreign body Barium

Most likely to lead to strangulation:
Most common cause: Adhesions Most likely to lead to strangulation: Hernia Table II in this study, demonstrates that there were 194 surgical cases, of which it was found that. 49 patients had strangulated SBO and of those the most common etiology was a hernia (45% vs 27%) The average time from symptom onset to surgery was 3.5 days in a non strangulated bowel and 5.8 days in a strangulated bowel This study didn’t find any significant differences in clinical and signs to distinguish strangulation from non strangulation but they did find that strangulated bowel had a 14.3% palpable mass compared to 4.1% in simple obstruction

Loss of ability to reabsorb fluid and electrolytes: dehydration
Pathophysiology Obstruction to intestinal contents occurs: proximal bowel distention, accumulation of fluid and intestinal contents Distention triggers peristalsis above and below the obstruction: early you may have diarrhea Distention triggers fluid release from epithelial secreatory cells perpetuating dilation Loss of ability to reabsorb fluid and electrolytes: dehydration Increased intraluminal pressure, obstruction of lymphatics and capillary flow: edema with eventual loss of mucosal blood supply Increased bacterial proliferation in the small intestine (e coli, streptococcus faecalis, klebsiella)

Clinically History: Colicky abdominal pain q4-5minutes
Abdominal pain is worse with a proximal obstruction Nausea and vomiting Later: obstipation and constipation Be aware of the pain that changes from intermittent and colicky to constant and severe: intestinal ischemia and perforation History: Colicky abdominal pain q4-5minutes Abdominal pain is worse with a proximal obstruction Nausea and vomiting Later: obstipation and constipation Be aware of the pain that changes from intermittent and colicky to constant and severe: intestinal ischemia and perforation

Physical Exam: Inspection: surgical scars, distended hernia, distended abdomen, peristalsis Auscultation: early: you may hear high pitched bowel sounds, later you may hear no bowel sounds Percussion: Tympany Palpation: Masses Look for any peritoneal signs

Positive predictive value: will indicate how often the disease is present is the symptom is found\
This study was designed to limit the number of abdominal radiographs that were taken, because diagnostic insecurity leads to so many xrays that usually don’t tell you any information that helps in the diagnosis or lead to improvement in immediate treatment. Purpose: Which variables from the medical history and physical examination support the diagnosis of bowel obstruction and to analyse whether these data can lead to a reduction in the number of plain radiographs They took the variables with the highest sensitivity and combined them

According to this paper, as radiological examination is the only technique that reliably excludes obstruction it is overused. Six common variables of diagnostic help, increasing the probability of bowel obstruction Abdominal Distention History of Constipation Age greater than 50 Previous abdominal surgery Vomiting Increased bowel sounds The then choose the six variables with the highest sensitivity and did a logistic regression analysis coming to the conclusion that if patients presented with any two of the six common symptoms then abdominal radiographs should be done to look for obstruction, Combining any two of the six most common variables that are of diagnostic help increases the probability of a correct diagnosis by at least three fold, and combination of three increases the diagnostic probability fivefold. If two of the six symptoms found most often in our patients were present the highest combined positive predictive value was 34% The study shows that the intrinsic value of plain radiographs alone are not useful, however when combined with certain hx and px aspects it becomes more usefull

Leukocytosis: common in both SBO and strangulation
Abnormal electrolytes secondary to vomiting and dehydration Lactic acid: aid to diagnosing ischemia Couldn’t find any papers on the labs to aid in the diagnosis

Complications of SBO Hypovolemia Intestinal ischemia and infarction
Peritonitis Sepsis Respiratory distress (due to diaphragm elevation) Reoccurrence Aspiration pneumonia Perforation

Imaging

Plain Films 1. Normal small bowel gas pattern:
Absence of small bowel gas or small amounts of gas with up to four variably shaped non-distended loops of small bowel (less than 2.5 cm in diameter) 2. Abnormal but non-specific gas: One loop of borderline or mildly distended small bowel (2.5 to 3 cm), with three or more air-fluid levels. Normal colonic gas pattern 3. Probable SBO: Multiple gas or fluid filled loops of dilated small bowel with a moderate amount of colonic gas 4. Definite SBO: Dilated gas or fluid filled loops of small bowel in the setting of a gasless colon Show a small bowel obstruction 50 to 60% of the time and in another 20 to 30% demonstrate findings consistent with a small bowel obstruction Sensitivity: 66%, specificity: 50%

Supine Supine: dilated gas filled small bowel proximal to the obstruction and paucity of air in the large bowel Distended small bowel has a diameter of 3 cm The valvulae of small bowel can look like a stack of coins

Upright: Fluid and gas within the bowel lumen create air/fluid levels Multiple different air/fluid levels will give a step-ladder appearance and broad air/fluid levels are seen in a mechanical obstruction When the intestine contains more fluid than gas on the upright you may see a string of pearls sign. Small pockets of air are trapped under the valvulae conniventes in the upright position

Limitations to Abdominal Radiography
Negative and non-specific illeus patterns do not exclude the diagnosis Can be too early thus the colon size and small bowel size are similar Can be too proximal and thus only a small segment is dilated Can be too fluid filled to see dilation The abdominal xray can be non diagnostic in partial or early small bowel obstruction, where there is less disparity in distention between the small and large bowel, obstructed bowel is filled with fluid and thus not visable on radiographs and proximal small bowel obstruction such that only a short segment of bowel dialates.

CT Recommended when abdo xrays are non diagnostic
Detecting signs of ischemia and closed loop obstruction When patients have failed conservative treatment Can detect etiology – thus useful in patients that have not had previous surgery

In addition to being more sensitive and specific for a small bowel obstruction CT scans can also give you the etiology of the obstruction in 75% of cases and can be used to detect signs of bowel ischemia and closed-loop obstructions. In a high grade obstruction CT scans can have a sensitivity of 90 to 96% and specificity of 96% with an accuracy of 95% When studying high and low grade obstructions CT scans have a sensitivity of 63% and specificty of 78% (Megibow et al, 1991) Dilated loops of small bowel Collapsed distal bowel Transition zone (this is the most realiable sign, whereby you can see small bowel loops dilated proximally and collapsed loops distal, it has a sensitivity of 95% and specificity of 90%) Small bowel feces sign Obstructing lesion visualized Signs of ischemia: thickened bowel wall, ascities, peritoneal fluid, the target sign (trilaminar appearance of bowel due to IV contrast enhancement of the mucosal layer) Advantage of CT over abdo xrays: the diagnosis does not depend on the colapse of the colon, CT can detect fluid filled small bowel that is not seen on xray Small bowel feces sign: enteric contents within obstructed bowel undergo digestion and develop feces like air stippling – this sign is suggestive but not specific for obstruction

CT for Ischemia Ischemia: sensitivity is 70% Bowel wall thickening
Mesenteric edema Ascites – bloody Infarcted bowel: poorly enhancing and paper-thin bowel wall and gas Strangulating small bowel obstruction. CT scan shows distended small bowel loops (S). The small bowel wall is thickened and demonstrates the target sign (arrows), findings that are consistent with submucosal edema. Hemorrhagic fluid within the mesentery (H) and peritoneal cavity fluid (F) are also seen. Hemorrhagic infarct was confirmed surgically

Ultrasound Not commonly performed as it is operator depenedent and not immediately avaible in the ED and results are limited when examining gas containing structures. Also not used frequently is barium contrast as patients have an inability to ingest large amounts of barium and the time taken to ingest the contrast

?Strangulation Fevang et al. Early operation or conservative management of patients with small bowel obstruction Strangulation diagnosed by physical signs and symptoms including fever, leukocytosis, peritonitis, tachycardia or metabolic acidosis is correct only 45% of the time

Strangulation vs Simple
The study prospectively assessed patients presenting with a CT- confirmed diagnosis of SBO my measuring various clinical, lab and radiological parameters. Aim: devise and validate a score for predicting the risk of strangulated SBO Inclusion: all CT confirmed SBO (dilated small bowel, with distal collapse) Exclusion: large bowel obstruction, incarcerated abdominal wall hernia, post op ileus (within a month), IBD, radiation induced intestinal fibrosis, peritoneal carcinomatosis Surgery for strangulated small bowel has a high mortality rate if the surgery is delayed for more than 36 hours, Six factors correlate with surgical outcome: Abdominal guarding CRP level 75 or greater Leucocyte count 10 or more Presence of at least 500 cc of free intrabdo fluid Reduced wall contrast enhancement on CT

Patients with a score of 4 or more had 100% risk of undergoing small bowel resection
At least 3 predicted need for surgery with a sensitivity of 67.7 and pecificity of 90.8 Needs validation Small bowel resection was rarely performed on patients with a score of 1 or less but was always necessary in patients with a score of at least 4

Study: regression analysis of CT and clinical findings to identify predictive risk factors for small bowel strangulation in patients presenting with an acute intestinal obstruction Method: they went back and looked at all patients that were diagnosed as having a small bowel obstruction and then taken to the OR…then classifying those patients having either strangulation or not strangulation. They then did a univariate and multivariate analysis to look for independent predictors of small bowel strangulation. On analysis of reasons sited for going to the OR the following were found: imaging results in 64% of patients with confirmed straunglating and 80% in non strangulated. (imaging contributed to the decision to proceed to operation in the majority of cases, which further suggests that diagnostic uncertainty is the norm in patients with SBO, thereby leading the surgeon to obtain objective radiologic findings before exploration) Clinical deterioration Lack of clinical improvement with conservative management History of multiple episodes of acute SBO Severe pain Peritonitis Preop acidosis was considered an important indicator of bowel compromise and thus estimated from serum bicarb values which were known in all, a bicarb less

On univariate analysis other factors that made one think of strangulation were:
Hypotension Acidosis Elevated BUN But when put in multivariate analysis this was not proven

Management IV fluid rehydration Bowel decompression – NG
Symptom control – Analgesia, Antiemetics Surgery vs conservative Factors that favor early surgical exploration: Clinical signs of bowel compromise (fever, tachycardia, leukocytosis and peritonitis) Incarcerated hernia Complete SBO (obstipation) No prior history of bowel surgery Factors that favor initial conservative therapy: History of bowel resection or abdominal surgery History of IBD Prior radiation therapy

Reoccurrence There is about a 50% reoccurrence rate after the first small bowel obstruction Gowen GF, 2003 There is an 81% reoccurrence rate after 4 obstructive episodes Fevang et al., 2004

Case 2

The lifetime risk of requiring surgery for appendicitis is 7%
Anatomy: The appendix is a hollow muscular tube, that rises from the posterior medial surface of the cecum, it is approximatley 3 cm below the iliocecal valve and has an average length of about 10 cm. The appendix receives innervation from the superior mesenteric plexsus, which consists of the vagus nerve as well as sympathetic nerves. The afferent fibers that carry visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of the 10th vertebrae and as a result these pain is referred to the umbilical area

The various positions of the appendix are conveniently categorized into the following locations:
paracolic (the appendix lies in the right paracolic gutter lateral to the cecum), retrocecal (the appendix lies posterior to the cecum and may be partially or totally extraperitoneal), preileal (the appendix is anterior to the terminal ileum), postileal (the appendix is posterior to the ileum), promontoric (the tip of the appendix lies in the vicinity of the sacral promontory), pelvic (the tip of the appendix lies in or toward the pelvis), and subcecal (the appendix lies inferior to the cecum).

Facts 7% lifetime risk of developing appendicitis
In the ED, 25% of patients younger than 60 yo with acute abdominal pain have appendicitis In the ED, 4% patients older than 60 yo with acute abdominal pain have appendicitis Incidence of perforation: 20% 15 to 35% negative laparotomy rate, rises to 45% in females. Although the incidence of perforation is about 20%, there is an increased rate of perforation in the elderly (almost 60 to 70%) and this is because of a few different factors: Rate of a perforated appendix within elderly is actually close to 60-70%, and this is because of the fact that elderly…. Significant delay in seeing medical attention Non-specificity of the presenting signs and symptoms Lack of febrile response Fewer laboratory abnormalities such as the elevated wbc Children are also at an inceaesd risk in perforation: due to the frequent delays in seeing a physician for abdominal pain.

Etiology: Appendiceal obstruction may be caused by fecaliths, calculi, lymphoid hyperplsai, infectious processes, benign or malignant tumors

Localized inflammatory process that gives peritoneal findings
Acute obstruction (usually secondary to an appendicolith but also can be due to calculus, tumor, parasite or enlarged lmyph node) Acute obstruction will lead to a rise in intraluminal pressure, and mucosal secreations become such that they cannot be drained. This resulting distention will stimulate the visceral affernt pathways and results in a dull poorly localized pain Abdominal cramping may also occur as a result of hyperperistalisi As the intraluminal pressure exceeds the venous pressure leading to necrosis and ischemia of the appendiz Bacteria and polymorphic cells will then invade the appendiceal wall With time the appenix will swell and pain becomes localized to RLQ Luminal distention produces a visceral pain sensation experienced by the patient as periumbilical pain (sympathetic afferent fibers carry pain from the superior mesenteric plexsus that arrive at the spinal cord at the level of the 10th verebrae) As the distention continues there is subsequent impairment of lympathatic and venous drainage leading to mucosal ischemia Localized inflammatory process that gives peritoneal findings

Typical Presentation Occurs in ????% of cases
History: Clinical –The typical presentation occurs in only 50 to 60% of cases Based on pathophys: Initally patients first note a vague, poorly localized epigastric or periumbilical discomfort or pain which is usually not very severe and patients often think of it as gastric upset. Patients can often have a downward urge in which they feel that a bowel movement should make the pain better – this pain reaches its pain max in 4 hours and then migrates to the RLQ Within 4 to 12 hours patients will note nausea, anorexia, vomiting Mild fever Over 12 to 24 hours the patients pain increases in intensity and localizes to the RLQ Atypical presentations occur for a variety of reasons, classic migration of periumbilical pain to the right lower quadrant occurs by an inflammed appendix, in cases of the retrocecal or pelvic appendicitis this site may not become irritated. Extremes of age, pregnant or immunosupressed also all give you an atypical presentation

Three Findings With a high positive likelihood ratio
RLQ pain: Sensitivity: 81% Specificity: 53% LR+: 7.31, LR-: 0.20 Rigidity: Sensitivity: 27% Specificity: 83% LR+: 3.76, LR-: 0.82 - Migration: Sensitivity: 64% Specificity: 82% LR+: 3.18, LR-: 0.50 Does this patient have appendicitis: Bottom line: Three findings show a high positive likelihood ratio and when present are the most usefull for identifying pateitns that are most increased likelihood of having appendicitis. Right lower quadrant pain LR 8 Rigiditiy 4.0 Migration of initial periumbilical pain to the RLQ 3.2 There are many signs that proved to be helpful in ruling out appendicitis: Absense of RLQ pain LR 0.2 Presence of similar previous pain LR 0.3

…Ruling out appendicitis?
Signs with Powerful Negative Likelihood Ratios: Absence of RLQ pain LR-: 0.20 Presence of similar previous pain LR-: 0.50 Lack of migration of pain Nothing in particular can be used to rule out appendicitis, but there are many signs that are helpful in ruling out appendicitis:

Other Symptoms Symptom Sensitivity Specificity LR+
Pain before vomiting 100% 64% 2.76 Fever 67% 79% 1.94 Anorexia 68% 36% 1.27 Vomiting 51% 45% 0.92 Nausea 58% 37%

Other Signs… Sign Sensitivity Specificity LR+ Rebound tenderness 63%
69% 1.10 to 6.30 Guarding 74% 57% 1.65 to 1.78 Rectal tenderness 41% 77% 0.83 to 5.34 Psoas sign 16% 95% 2.38

McBurney’s Point On a straight line from the ASIS to the umbilicus, mcburney’s point is 2/3 the distance from the umbilicus: Only 35% of patients have an appendix that lies within 5 cm of this point, and thus sensitivity is 50-94%, specificity is 75-86%

Rovsing Sign A sign related to the rebound tenderness test, press deeply and evenly in the left lower quadrant and then release pressure suddenly. The presence of tenderness in the right lower quadrant during palpation is referred to as rebound tenderness in the right lower quadrant Sensitivity 22 to 68% Specificity 58 to 96%

Psoas Sign With the patient in the supine position, ask the patient to lift the thigh against your hand placed just above the knee, or with the patient in the left lateral decubitus position extend the patients right leg at the hip. Increased pain with either maneuver is a positive sign and indicated irritation of the psoas muscle by an inflammed appendix. Passive extension of the ilipsoas muscle with hip extension causes RLQ pain Sensitivity 13 to 42% Specificity 79 to 97% Indicitive of a retrocecal appendix –

Obturator Sign Irritation of the obturator internus muscle from an inflamed pelvic appendix This is performed by flexing the hip and the knee and then internally rotating the hip, doing this will elicit right lower quadrant pain suggesting appendicitis with a sensitivity of 8% and specificity of 94%

The goal in this paper was to reduce the negative appendectomy rate without increasing the risk of perforation. Retrospective chart review of 305 patients with appendicitis They assigned a diagnotic weight: adding the joint probability of a positive test to the joint probability of a negative test. The joint probaility was found by dividing the total number of patients by those with a positive test and those with a negative test. In this paper a score of 5 to 6 is compatible with an acute appendicitis, 7 to 8 means probable appendicitis 9 to 10 means very probable appendicitis

The things in this score had the highest diagnostic weight in patients with surgery proven appendicitis

Observation/ Investigation Surgical consult
Suspected Appendicitis Alvarado Score Sensitivity: 92.77% Specificity: 58.18% 1-4 5-6 7-10 The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult Y. Pouget-Baudry , S. Mucci , E. Eyssartier , A. Guesdon-Portes , P. Lada , C. Casa , J.-P. Arnaud , A. Hamy ∗ Endocrine and gastrointestinal surgery service, CHU of Angers, 4, rue Larrey, Angers cedex, France Available online 11 June 2010 low score < 4: PPV = 61.82%, NPV = 79.21%; (about 80% of patients with a negative alvarado score are correclty diagnosed) • high score > 6: PPV = 89.16%, NPV = 41.33%; • sensitivity of the test is 92.77% • specificity of the test is 58.18%. Evaluation of the Alvarado score in the diagnosis of acute appendicitis.Shrivastava UK, Gupta A, Sharma D.Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi AbstractAcute appendicitis may simulate many other acute abdominal illnesses and the exact diagnosis is important for the proper management. The present study was undertaken to evaluate the role of the Alvarado score in the diagnosis of a patient with suspected appendicitis. The study was carried out on 100 patients operated with a presumptive diagnosis of acute appendicitis on the basis of clinical grounds. Alvarado scoring was done in all these patients preoperatively by different personnel. Discriminant analysis of the Alvarado score of all the patients was done to determine the cut-off value in an Indian set-up. The positive and negative predictive values of the Alvarado score were 77.6% and 52.4%, respectively. It is more effective in men and children, with a predictive value of 84% and 92.8%, respectively. Discriminant analysis revealed a cut-off value of > or = 6 rather than the original value of > or = 7. The sensitivity of the Alvarado score increased from 69.2% to 92% with the new cut-off value of > or =6. The Alvarado scoring system can be used in surgical emergency departments to diagnose acute appendicitis. In women, additional investigations may be required to confirm the diagnosis. The original cut-off value given by Alvarado may be changed in the Indian set-up to increase sensitivity. Discharge Observation/ Investigation Surgical consult PPV = 61.82%, NPV = 79.21%; PPV = 89.16%, NPV = 41.33% The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult Y. Pouget-Baudry et al. 2010

…but the WBC is normal…they can’t have appendicitis?
Sensitivity of wbc: 80 to 90% (thus 10% of patients with an appy can have a normal wbc) Specificity about 55%

Imaging In 50 to 60% of patients the diagnosis of appendicitis can be made clinically Alvarado score 4-6 ….you can wait and watch, or image

Plain Xray Findings: Right lower quadrant appendicolith (1% chance of seeing this) Localized right lower quadrant ileus Loss of the psoas shadow Free air Deformity of the cecum RLQ soft tissue density Xray above: appendicolith and dilated cecum

Plain X-ray In a prospective study of 104 patients, with right lower quadrant pain suspicious of appendicitis the plain abdo xray only changed management 6% of the time. Study design: Surgeons were given a prospective questionnaire before hand that asked what they thought the diagnosis was and a therapeutic option. Following which they had a chest/abdo xray and then another questionnaire was given…asking the surgeon their clinical diagnosis and management plan. The abdo xray changed the initial diagnosis in only six cases, two of them the diagnosis of appy was changed to ureteral obstruction after the xray showedd the calculus Both of these patients tested positive for blood In 4 of the other patients with non specific abdo pain, they were changed into the category of appendicitis based on an appendiceal fecalith and ileus located in the RLQ

Sensitivity of 28% Specificity of 76%
Our investigation has shown that plain abdominal radiographs show some combination of nonspecific findings about as often in patients with appendicitis as in those without appendicitis, and they infrequently make a specific and correct diagnosis of an abnormality. Plain Films: Should only be done: bowel obstruction or gi perforation, or urinary symptoms and you think they may have a calculi is thought to be likely

Ultrasound Used to help confirm the diagnosis of suspected appendicitis Sensitivity: 86% Specificity: 81%

CT Used to help confirm the diagnosis of suspected appendicitis
Sensitivity: 95% Specificity: 94% Rectal contrast: best but usually not tolerated Oral contrast: leads to a delay, may not be tolerated IV: not recommended Unenhanced CT: sensitivity of 88 to 96%, specificity of 91 to 98% and diagnostic accuracy of 94 to 97% Limited ability to diagnose other abdominal pathology potentially diminishing the role of examination in patients in whome there is diagnostic uncertainty

Benefit of imaging Thanks to Jay green
Diagnostic accuracy increasing without changing the perforation rates. With performing the appendiceal CT there is a drop in the negative appendectomy rate from 20% to 7% But why do we care: 5 to 15% of complications rates exist due to removal of a normal appendix. Infectious: wound infections, pulmonary infections and UTI. 1.3% risk of small bowel obstrucion in the series with the longest followup

Perforation Perforation with resultant peritonitis, abscess and portal phylebitis Perforation: occurs in 10 to 30% of patients, higher in elderly and children CT scans have reduced the rate of perforation from 22% to 14% Risk of perforation is highest 36 hours after symptom onset and factors associated with this are those that perf are usually delayed in presenting to the hospital. Study: In 244 patients, the overall risk of rupture was 16%, Patients that were younger than 6 yo old had a risk of rupture of 60% and those that were older than 65 yo had a risk of rupture of 58%. This is comparable to 13% in those 6 to 64 yo. The risk of rupture was negligible within the first 24 hours of untreated symptoms, rose during 24 to 36 hours and then trippled among patients who had not yet been treated by 36 hours after symptom onset. Having a ct scan or ultasound was associate with a longer time to treatment but they don’t tell us if those increased the risk of perforation.

Treatment Analgesia Opioid: NSAIDs:
The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment. Manterola et al. Systematic Review: Analgesia in patients with acute abdominal pain The Cochrane Collaboration. Published by John Wiley & Sons, Ltd NSAIDs: Retrospective chart review case controlled suggesting that NSAIDs delays treatment Frei et al. Is early analgesia associated with delayed treatment of appendicitis? American Journal of Emergency Medicine (2008) A prospective randomized double blond- crossover design Group A – mg/kg of morphiene IV and then after 30 minutes was given placebo. Gropu B was the total opposite, first placebo (with IV saline) and then next morphinene). They were examined by a surgery resident 30 minutes after the first medications 34 participants, those receiving morphiene did not have a significant change in their physical examination May not be true for NSAIDs one retrospective study that showed NSAIDs was associated with a delay in treatment of appendicitis and the complications rates (absess, perforation and gangrene is higher with delay in treatment) Early analgesia is defined as given within two hours of initial examination

IV Fluid Perioperative Antibiotics:

Acute mesenteric ischemia:
Rare but devastating with a mortality of 60 to 90% Factors associated with high mortality: Atypical clinical presentations Subacute nature of symptom progression Lack of predisposing disease Diagnostic difficulties leading to delayed surgical intervention Studies have shown that 50 to 75% of patients with mesenteric artery thrombosis had prior symptoms of chronic ischemia and 33 to 75% of patients have a history of a fib

There are three major midline branches of the abdominal aorta that supply the abdominal organs:
Celiac artery: supplies the foregut including: esophagus, stomach, proximal duodenum, liver, gallbladder, pancreas and spleen SMA: distal duodenum, jejunum, ileum colon to splenic flexure IMA: decending sigmoid colon and rectum The mesenteric circulation will receive about 20 to 30% of cardiac output at rest, and this can increase to 50% post meal…this blood supply is to satisfy the absorption function of the intestine, but also will serve as a resvior that can shunt blood to vital organs in times of stress…this shunting can sacrifice the mesenteric circulation

Mesenteric Arterial Embolism:
50% of ischemia More common in women Age greater than 70 years old Commonly involves the SMA Risk factors: Post MI with a mural thrombus Congestive heart failure Valvular heart disease (rheumatic, non bacterial endocardtitis) Arrythmia (a fib) Aortic aneursyms or dissection Coronary angiogram Mesenteric Arterial Thrombosis: 25% Usually due to thrombosis of the SMA Risk Factors: Older age Hypertension Coronary artery disease/athroscelrosis Nonocclusive Mesenteric Ischemia: 20% of cases Low flow states leading to mesenteric vasoconstriction Vasoactive medications: pressors RF: Cardiovascular disease with low flow state (CHF, cardiogenic shock, post bypass, arrythmia) Hypotension (shock) Drug induced vasoconstriction (digoxin, vasopressors, cocaine) Mesenteric Vein Thrombosis: 5 to 10% of cases 60% of these patients have a history of DVT Hypercoagulable states: polycythemia vera, sickle cell disease, anti-thrombin III deficiency, cancer, protein C and S deficiency, estrogen therapy, pregnancy Inflammatory conditions: pancreatitis Trauma

High Index of suspicion required

Clinical Need a high index of suspicion
Ischemia of the viscera: leading to pain out of proportion with findings Abdominal pain: 83% Vomiting: 44% Diarrhea: 19.3% GI bleeding: 20.1% Infarction Huang et al. Clinical Factors and Outcomes in Patients with Acute Mesenteric Ischemia in the Emergency Department. July 2003: Acad Emerg Med. Sudden onset of acute abdominal pain severe enough to warrant medical attention – Initially: severe and poorly localized colicky abdominal pain, nausea, vomiting and frequent bowel movements Pain out of proportion with findings: GI bleeding: bloody stools, tarry stools, coffee ground vomitus, hematemsis Chart review of patients with confirmed acute mesenteric ischemia: The following were the most common underlying disorders: Hypertension – 30% Arrythmia – 27% Cerebral vascular diseaes – 19% Signs and symptoms: Abdominal pain: 83% Vomiting: 44% Abdominal distention: 19.3% Diarrhea: 19.3% Hypotension: 12% Abdominal pain: 90% of patients Decreaed or absent bowel souns: 82% Rebound pain: 59% Muscle guarding: 35% Infarction: you’ll find a grossly distended abdomen, absent bowel sounds and very tender to palpation with peritonitis Other things to consider: patients with chronic ischemia or thrombosis may have a histroy of changed bowel habits, weight loss and post prandial pain Acousta et al: Consider this diagnosis in a. abdominal pain that is out of proportion to findings, vomiting and diarrhea, recurrent a fib or an MI etc

Laboratory: Non-specific Aid in diagnosis when suspicious
Normal labs do not exclude ischemia

Sensitivity of 100% Specificity of 44% LR+ of 1.8 Useful to exclude the diagnosis Not specific to intestinal ischemia D-dimer as a marker for early diagnosis of acute mesenteric ischemia: In rats, four groups: laparoscopy with bw 30 minutes after, laparoscopy with bw 7 hours after, SMA ligation with bw 30 min and 7 hours later Reason for doing this study: the fact that when you do see lab samples and elevated lab work…the markers are so non specific that they are due to irreverible cell damage and as a result they are elevated after infarciton occurs But what about D-dimer which is a marker of fibrinolysis secondary to an imbalance in coagulation cascade In their experimental model, it was found that the levels of D-dimer 30 minutes after the ligation of the SMA was significantly higher than that of the group undergoing simple laparotomy. However, the question is how usefull this really is, because of the fact that other intra-abdominal processes such as non ruptured AAA, or pancreatitis can rise the Ddimer levels

Drawbacks of the D-dimer studies is that there is a small sample size (as mesenteric ischemia is uncommon)

Other Tests… LDH Lactate Alpha-GST
Sensitivity 70%, Specificity 42%, LR+ 1.2, LR- 0.7 Lactate Sensitivity 90%, Specificity 44%, NPV 96%, PPV 70 Alpha-GST Sensitivity 72%, Specificity 77%, NPV 86%, PPV 58% ALP (marker of intestinal mucosal ischemia) Sensitivity: 80%, Specificity: 64%, LR+ 2.2, LR – 0.3 Data for lactate: From Murray MJ et al. Serum D-lactate levels as an aid to diagnosing acute intestinal ischemia Data for LDH and ALP: Block et al. Diagnostic accuracy of plasma biomarkers for intestinal ischemia In the end of the day this paper states that there is no marker of diagnosis of intestinal ischemia but there are factors that increase the suspicion of it being present - D-dimer is found to be an unspecific marker for intestinal ischemia, but increased absolute D- dimer values in combination with clinical variables may strengthen the diagnostic utility of the test as a fibrinolytic marker in patients with suspected SMA occulsion.

Predictors of mortality
Bandemia 68.9% sensitive, 74.2% specific Elevated AST 62.1% sensitive, 78.9.% specific Elevated BUN 88.5% sensitive, 39.3% specific Metabolic acidosis: 53.6% sensitive, 85.5.% specific Huang et al. Clinical Factors and Outcomes in Patients with Acute Mesenteric Ischemia in the Emergency Department. July 2003: Acad Emerg Med. Predictors of mortality: Bandemia 68.9% sensitive, 74.2% specific Elevated AST 62.1% sensitive, 78.9.% specific Elevated BUN 88.5% sensitive, 39.3% specific Metabolic acidosis: 53.6% sensitive, 85.5.% specific In all patients diagnosed with mesenteric ischemia comparing those that survived and those that did not survive Huang et al. Clinical Factors and Outcomes in Patients with Acute Mesenteric Ischemia in the Emergency Department. July 2003: Acad Emerg Med.

Plain xrays: non-specific in the diagnosis, and by the time you see some key findings its usually too late…ie bowel infarction has occurred: 26% of these patients have a normal plan film Early nonspecific signs of ischemia: intestinal dilation, gasless abdomen, ileus Later ischemia: wall thickening, valvulae conniventes ie thumb printing, penumatosis intestinalis Ultra-sonography also has no role in the diagnosis of mesenteric ischemia mainly because the study is technically limited by distended air filled bowel loops,

CT scans: usefull and often the first most commonly ordered test as we are trying to distinguish patients eitiology of pain CT findings: Huintestinal bowel-wall thickening with or without wall enhancement Intramural pneumatosis Mesenteric or portal vein gas Mesenteric artery or vein thrombosis CT Sensitivity of 64% to 82% (you should be looking for evidence of ischemia in the bowel wall and mesentery) – use of oral contrast or IV contrast is best The CT is a good investiatigation but is not specific enough, if you are concerned about mesenteric ischemia with a negative CT then the patient should be getting a further work up However Contrast enhanced multidetector CT may be one of the best studies of choice… Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. The meta-analysis showed a pooled sensitivity of 93.3% (95% confidence interval: 82.8%, 97.6%) and a pooled specificity of 95.9% (95% confidence interval: 91.2%, 98.2%).

Angiography Who should we do it in and who should we not CTA and MRA

Management 1. Stabilize the patient 2. Antibiotics 3. Heparin
Evidence that survival improved 3. Heparin 4. Vasodilators ? Glucagon 5. Papaverine 6. Surgery IV fluid resucitation Antibiotics: Patients with mesenteric ischemia have a high incidence of postivie blood cultures, in animal studies evidence shows reduce the extent and severity of ischemic injury – no RCT in humans Broad spectrum coverage, gram negative, gram positive and anaerobic: - levofloxacin 500 mg q25 hours and metronidazole 500 mg q6hours - Levoflox 500 mg q24 hours and pip/tazo (3.375 q6h) Heparin: to prevent furthur arterial and treat venous clots Initial loading dosage of 5000 to units and then an infusion of 1000 to 1250U/hour titrating until theres a thromboplastin time of 50 to 70 sec Vasodilators: Glucagon

Glucagon Vasodilator Intestinal vasodilator and hypotonicity to reduce oxygen demand Used if no evidence of peritonitis Studies in rat’s and dogs have shown improved survival No studies in humans

Papaverine Phosphodiesterase inhibitor Improves mesenteric blood flow
Arterial embolic disease or non-occlusive disease Intra-arterial (60 mg bolus and then 60mg/h infusion) Survival improvement by 20 to 50% Increases the concentration of cAMP Reduces vasospasm

Diverticulosis: outpouching of the colonic wall
Diverticulitis: inflammation of the diverticular tissue Complicated diverticulitis: Possible exam question: name all the complications of diverticular disease: 1. abscess formation 2. Intestinal obstruction 3. Fistula formation 4. Perforation Approximatley 10 to 25% of patients with diverticulosis will go on to develop diverticulitis Basic Facts: <10% chance of diverticulitis is your less than 40 50-60% chance of diverticulitis in patients that are greater than 80 year of age Incidence is the same in men and women, with men having a greater chance of bleeding and women having a greater chance of stricuture or abscess formation

Diverticuli form where there is penetration of the bowel wall by the vasa recta, which is usually the weakest point of the bowel wall, and usually involves the mucosa and submucosa through a defect in the muscularis Divertuculi can occur anywhere within the colon, with the most common place in western canada being the sigmoid colon, Occur due to abnormal motility and increased intraluminal pressures as the colon is attempting to process the higher non fiber foods. Theese higher pressures lead to herniation of the colonic mucosa through the intestinal wall at the vasa recta…usually measure about 5 to 20 mm but on the rare occation can be HUGE like 25 cm.

Asymptomatic Diverticulosis
CT scan finds incidental diverculosis Should we do anything? Inverse association between dietary fiber intake and the risk of subsequently developing clinically evident diverticular disease 4 years follow up of men on a high fiber diet. Those that consumed a low fiber, high total fat diet had a 2.35 RR compared to those on a low fiber diet

Symptomatic Uncomplicated Diverticulitis
History: LLQ abdominal pain Better with defecation Worse with eating No rebound No guarding

Symptomatic Diverticuli
History: Low grade fever Left lower quadrant pain Colonic dysfunction (bloating, constipation, diarrhea, mucous per rectum) Signs of obstruction Signs of colovescial fistula Physical Exam: Localized tenderness in the LLQ Guarding and reboud Palpable mss Rosens: Typically presents as left lower quadrant pain and tenderness, pain may be first felt in the hypogastrium before localization to the left lower quadrant. Patients may have referred pain into the scrotum and suprapubic region. These patients may also have other symptoms such as dysuria if they have a colovescial fistula, or they can have signs of obstruction (such as distention, nausea, vomiting). Ask about gas or fecal matter coming from the vagina Clinical triad: LLQ pain, fever and leukocytosis The pain is often associated with a change in bowel habbits (constipation in 50%) and diarrhea (30%), nausea and vomiting is present in 60%, anorexia in 40% and urinary symptoms are present in 10%

Diagnosis History and Physical Exam Laboratory: WBC: can be elevated
Prospective analysis of 226 cases demonstrated that 46% of patients with confirmed diverticulitis had no elevated WBC Urinanalysis Rule out UTI or fistula Tintinalli” Laboratory values are rarely diagnostic for diverticulitis but can aid ruling out or in of other pathology LIVer panal CBC Renal testing

To image or not to image Imaging is recommended to to the high diagnostic inaccuracy and potential for complications Clinical diagnosis: No imaging if age appropriate, left lower quadrant pain and tenderness, no peritoneal irritation or mass on exam Image: Peritonitis – look for complications Atypical presentation Immunocomprimised Clinical deterioration

Plain films: Not for the diagnosis of diverticulitis itself but for the look of complications of diverticulitis Pneumoperitoneum has been found in 11% of patients 30 to 50% of radiographs should have some abnormality No use in the diagnosis of divertuiculitis

Contrast Enema: Sensitivity of 62% to 94% False negative rate of 2 to 15% Double contrast enemas should not be performed in the acute diverticulitis setting given the risk of barium peritonitis, however single contrast water souble enema’s can be used in suspected diverticulitis In a single contrast study the colon is filled with barium which will outline the intestine and reveal large abnormailities Double contrast study the colon is first filled with barium and then the barium is drained out leaving only a think layer of barium on the wall of the colon, the colon is then filled with air – this will provide a good detailed view of the colon. Not to use barium contrast in suspected peritonitis as you can get barium peritonitis so they use water soluble contrast - Not used as much now given the use of CT scans

CT Sensitivity: 93-98% Specificity: 77% Water soluble contrast
orally and IV Pro’s: Therapeutic: percutaneous drainage of abscess (if >4cm) Determine alternate pathology Identify complicated diverticulitis CT scanning: Can be therapeutic in that you are able to put in a percutaenous drain of those absesses that are greater than 4 cm Allows the visualization of adjacent structures and inflammation IV and oral contrast in combination increase the sensitivity to 97% and specificity to 100% The following CT findings: Increased soft tissue densitiy within the pericolic fat indicating inflammation 98% Colonic diverticula (84%) Bowel wall thickening 70% Soft tissue masses (abscessess) 35% In 10% of the cases diverticulitis cannnot be distinugished from carcinoma and thus these patients need to be referred for colonscopy in 6 weeks time

Ultrasonography Sensitivity: 84% to 98% Specificity: 90 to 93% Pros:
Avoids radiation Gyne structures are seen Cons: Patients often acutely tender here compression by probe is uncomfortable Cannot identify perforation/air Obese patient or overlying gas High resolution real time sonography: Study by schwerk et al: evaluated high-resolution real time sonography in the diagnosis of acute and complicated diverticulitis they had 130 patients with a diagnostic accuracy of 97% (. Ultrasonography enabled the diagnosis of diverticulitis with an overall accuracy of 97.7 percent, a sensitivity of 98.1 percent, and a specificity of 97.5 percent. The predictive values of positive and negative ultrasound examinations were 96.2 percent and 98.5 percent, respectively. ) Sensitivity: 84% to 98% Specificity: 90 to 93%

Endoscopy and MRI: Not in the ER

Complicated Diverticulitis
Abscess (15%) Obstruction (10%) Free Perforation (1%) Fistula (2%) Diverticular hemorrhage Abscess: tender abdomen and a tender mass of physical, Persistent fever and leukocytosis despite an adequate trial of appropriate oral antibiotics Free perforation: more common to occur in the first attack of diverticulitis than in subsequent attacks and this is a surgical emergency. Patients have diffuse abdo pain with signs of peritonitis: Fistula: Colovesical fistula’s are the most common (65%), women (risk factor is prior hysterectomy), patients will present with urinary symptoms such as pneumaturia and fecaluria. Polymicrobial urinary tract infections (with this patients on CT scan you’ll see air or contrast within the bladder). Colovaginal fistula: second most common and patients may actually present to their gynecologist first. They would be complaining of abnormal vaginal discharge or passage of air per vagina. Obstruction: Stricutres can develop after repetitive attacks leading to fibrosis within the colonic wall and small bowel can also become adherent Diverticular hemorrhage: this is the most common cause of lower GI bleeds, accounting for almost 30 to 40% of Lower GIB. Clinical features that suggest diverticular hemorrhage include copious bright red or marron blood per rectum and the presence of diverticulosis on previous radiological studies. Exclusion of an upper GI source and exclusion of an alternative colonic source. - NSAIDs increase the risk of a diverticular bleed IF they’ve already bleed, but there is not studies to demonstrate if NSAIDs decrease the risk of diverticular bleed in patients with asymptomatic diverticulosis - Diverticulr bleeds are usually painless and they are not present in the setting of actue diverticulitis

Management Symptomatic uncomplicated diverticulitis
All patients had diverticulitis confirmed by ultrasound Included Patietns: Grade 1 inflammation consisting of an inflammed diverticulum, pericolitis, abscess that is less then 2 cm in diameter Excluded patients: Bacteremic patients Those with an abscess greater than 2 cm Evidence of perforation Uncontrolled diabetes, heart failure, renal failure, cancer, anyone that had been on antibiotics within the last twenty-four hours, Treatment regieme: 3 days of sports drink followed by oral hydration with clear fluids and antibiotics for 10 days : cefpodoxime 200 mg bid (third generation cephalosporin) They found that 68 of their 70 patients recovered in 10 days (one was taken out because he was not compliant with meds, and one was brought into the hospital for worsening symptoms) When discharging from the ED: They should be instructed to follow up with their GP in 2 to 3 days or to return to the ED for reoccuring pain, high fevers, nausea and vomiting or abdominal tenderness

Versus…no antibiotics
Controversy Most studies showing symptomatic and complication rates benefit from antibiotics versus just bran Most studies are using rifaximin (which is a poorly systemic absorbed but good locally used antibiotic) Retrospective review of patients in california, Primary outcomes in patients that were discharged from hospital were: 1. to estimate the overall success of treatment and to identify specific groups of patients who may beat risk for treatment failure. Patients included were those that had diverticulitis for the first time ever and had no previous diagnosis of diverticulitis, colon cancer or ibd Treatment failure was considered in patients if they were admitted or relapsed to the emergency department within 60 days Treatement: was oral metronidazole and cipro for 10 days 94% of 693 patients were sucessfully treated There were two predictors of treatment failure: female sex (OR of 3.09) and the presence of free fluid (OR of 3.19). Not statsitically significant but had a higher odds ratio of returning: WBC greater than 18, OR was 2.77, abscess present (OR was 2.25), Perforation present (as CT saying microperforation) (OR 2.47)

Acute Diverticulitis Outpatient Mild symptoms No peritonitis
Able to tolerate a clear liquid diet Close follow-up Return to ED: increasing pain, fever, inability to tolerate oral fluids You need to determine who requires hospitalization: Severity of illness Ability to tolerate oral intake Comorbid disease Outpatient support systems One with mild symptons, no peritoneal signs and the ability to take oral fluids These (patients with mild symptoms, no peritonitis and oral tolerance) should be placed on a clear liquid diet and antibiotics at discharge. Most diverticular abscesses grow mixed aerobic and anaerobic organisms (ecoli, streptococcus, bacteroides) Patients that are discharged home should start to have symptomatic improvement in two to three days at which time the diet can be advanced slowly Antibiotics for a total of seven to 10 days

Acute Diverticulitis Inpatients: Elderly Immunocompromised
Severe comorbidities High fever Significant leukocytosis These patient require bowel rest with either just clear liquids or nothin by mouth. IV fluids and electrolyte balance Within two to four days patients should start to improve with decreasing fever and leukocytosis, at this point you can advance their diet. 15 to 30% of patients require surgery during the hospital admission…especially if they do not respond to pain, fever and leukocytosis with antibiotics

Antibiotics Rosen’s BOX 93-5 INTRAVENOUS ANTIBIOTIC COVERAGE FOR BOWEL FLORA Mild to Moderate Infection Ticarcillin-clavulanate, 3.1 g IV q6h Ampicillin-sulbactam, 3 g IV q6h or Ciprofloxacin, 400 mg IV q12h, and metronidazole, 1 g IV q12h Severe Infection Ampicillin, 2 g IV q6h, and metronidazole, 500 mg IV q6h, and (gentamicin, 7 mg/kg q24h, or ciprofloxacin) 400 mg IV q12h or Imipenem, 500 mg IV q6h

Surgery Emergency: perforation with peritonitis
Non-emergency: fistula, stricture, Elective: Recurrent episodes (greater than 2) Younger than 40 yo (more likely to have severe disease) Initial attack and immunocompromised Patients that are immunocompromised have a higher risk of badness: Perforation 43% vs 14% in non immunocomp Surgery 58% vs 33% Mortality 39% vs 2% Although now surgeons are advocating for more of a case by case approach prior to resection

Reoccurrence Risk Reoccurrence rate varies from 7 to 45% and reoccur within a year Although we say that you should have elective surgery after the second attack, this is being refuted by the fact that people are actually doing okay after the second attack and have a higher rate of surgery complications 2004 paper demonstrated via a decision analysis that performing a colectomy after the fourth attack would result in fewer deaths and colostomies

Large bowel obstruction
Pseudo-obstruction (probably won’t talk about because its more of an inpatient or surgical patient thing rather than those presenting to the ED) This is when patients are found to have an obstruction of the colon and mostly the right sided colon with no evidence of a mechanical obstruction noted. There are several etiologies for a pseudoobstruction: Parkinsons, spinal cord patient, alzhimers, multiple sclerosis, Drugs including antipsychotics, narcotics, antiparkinsoninan drugs, alcohol patients, electrolyte abnormalities, heart failure, MI, stroke, liver failure, actue inflammatory process (acute choecystitis, pancreatitis, pelvic abscess, sepsis), penumonia, trauma (such as a femur fracture). Clinically: Patients will have abdominal pain and nausea and vomiting, they are most notably to have a distended abdomen which can occur on day three to 7 but even also on day 1. Radiography: dialated R colon, you should still see gas within the rest of the colon due to the presence of fecal matter. Patients with fever, change in their pain or tachycardia should cause a red flag because they are more likely to perforate. The most common etiologies are: Cancer (50%) (an infact about 20% of patients with a new diagnosis of CRC will present with an obstruction like symptoms, and obstruction occurs most commonly distal to the splenic flexure and these patients commonly require emergency surgery) Volvulus (15%) Diverticulitis

Sigmoid Volvulus 859 patients with sigmoid volvulus 83% were males
17% were females (of which 6.3% were pregnant) Mean symptom duration of 39.4 hours Clinical Triad highly suggestive of SV: Abdominal pain (98.7%), asymmetric abdominal distention (96%), obstipation (92.3%) Frequently a disease of the older people, mainly in the 60 to 80’s and this is due to patient having an elongated long redundant segment of sigmoid colon that is attached to the abdominal wall by a narrow strip of mesentery (which is attached to the retroperitoneum) RF: ? High fiber diet ? Chronic constipation Clinically: The most common presenting symtpom is abdominal distention which is acute in onset 20% of patients will have nausea, vomiting and abdominal pain (abdominal pain is usually constant with worsening paroxysms) Most patients will present within 73 hours of the distention onset Some patient have pain on palpation, when there is pain on palpation with peritonitic features you must worry about a perforation Signs to suggest gangrene: significant abdominal pain, fever, lack of power sounds, hypotension, peritonitis, (duration of symptoms does not predict gangrene) They will have a distended tympanatic abdomen Radiology: Plain abdominal xrays are diagnostic in 85% of cases, they will show a sigmoid distention with thinning of the haustra. An inverted U is seen with the apex pointing to the right upper quadrant or to the Left upper quadrant, you may also call this the coffee bean sign Patients with peritonitis should be stabilized and then taken to the OR Patients without peritonitis but the xray shows a distal obstruction should be having a water soluble contrast study or CT with rectal contrast Treatment: Peritonitis: the patient should be taken to the OR Decompression of a sigmoid volvulus may be accomplished with a flexible or rigid sigmoidoscope and the placement of a rectal tube. In a classic study, Ballantyne compiled 19 American series totaling 595 patients and found that sigmoidoscopy, either alone or combined with a rectal tube, successfully reduced the volvulus in 70% to 80% of attempts. Placing the rectal tube in for 48 hours can help reduce the risk of reoccurance. The reoccurrence rate is about 25 to 50% Study above: the sigmoid volvulus was confirmed by non emergency surgery

Sigmoid volvulus has a 7% mortality

Congenital incomplete fusion of the cecal mesentery to the posterior abdominal wall, as a result there is mobile ceca that can lead to a torsion In these patients there is a congenitally incomplete fusion of the cecal mesentery to the posterior abdominal wall and as a result there is mobile ceca that can cause a torsion Persons with less space in the abdomen for the colon to move are predisposed to developing this, these such patients are younger Pregnancy is a risk factor Same clinical triad of abdominal pain, distention and constipation – although in this case 50% of patients have vomiting as a presenting symptom. They will often have constant abdominal pain which becomes worse with peristalsis so an element of colicky nature to it. They will also have nausea, vomiting and obstipation. The abdomen is diffusely tender. Radiology: Single large gas filled segment of bowel, representing the massively distended cecum. Kidney shaped due to the indentation of its inferior surface by the ilocecla vlve Most often in the mid abdomen or the left upper quadrant 98% of abdo radiographys will show caecal dilation Signle airfluid level in 73 to 88% Small bowel dilation in 42 to 55% Absence of gas in the distal colon in 82% Dilated loop of bowel extending from the RLQ upto the LUQ 17% mortality and up to 40% if gangrenous Treatment: Often unable to reduce it endoscopically due to its proximal location These patients will require surgery to detort and fix to the abdominal wall

Complications of Chrones disease
IBD Patients: Will often present with crampy abdominal pain and tenesmus with loose or diarrheal stools. Blood may be present within their stool as well. Patients with chrones disease that present with abdominal pain: Acute inflammation (ie patient has not been compliant with their maintance therapy. Acute obstruction (de novo or secondary to a stricture from a previous surgery) Abscess formation (intra-abdominal absess)..about 25% of patients will have an intraabdominal abscess at some point Peri-anal disease (in fact 24% of patients will initlally present with perianal disease rather than signs and symptoms of chrones disease and this perianal disease can have a lead time of four years before the diagnosis of chrones…skin: ulcer, tags and abscess, fissures, ulcers, stricutres) Strictures are not common in the virgin abdomen more in patients that have had a resection for chrones Extraintestinal manifestations: Musculoskeletal: the most common extraintestinal manifestation. Patients have waxing and waning joint pain and stiffness in association with flares of intestinal disease. The disases is non deforming and often accompanied by skin (erythema nodosum) and eye (uveitis) complications Knee and ankle joints are often affected first but elbows wrists and PIP also are involved Mucocutaneous manifestations: pyoderma gangrenosum and erythema nodum. Pyoderma: leg or arounda s toma: progresses from a papule or pusutle into an ulcer, Erythema nodosum: re-tibial tender subcutaneous nodule with an erythematous or dusky appearnace, ocurs with exacerbation of intestinal disease and improves with treatment of the underlying bowel disease. Aphthous ulcers of the mouth are common in patients with chrons disease Ocular: 6% of crohns disease: episcleritis is the most common, they occur with active disease Scleritis also occurs with active disease and is much more severe Uveitis: headache, deep eye pain, lacrimation, blurred vision and photophhobia, usually bilateral Hepatobilary: Gallstones are present in over 25% of patients with chrohns disease representing a relative risk of 1.8 compared to the general population. Asx elevation in LFT are seen in crohns disease but few of these patients have cirrhosis, Renal: memrbanous nephropathy Prothrombotic: hypercoagulability

Complications of Ulcerative colitis
Clinciallay: diarrhea, rectal bleeding, passage of mucus, tenesmus, urgency and abdominal pain. In more severe cases fever and weight loss. Patients symptoms have been present for weeks to months before they seek medical care, the median time quaoted is usually about 9 months. 1. Rectal bleeding: This ist eh most common symptom in ulcerative colitis

Toxic megacolon: defined as acute colonic dilatation with a transverse colon diameter of greater than 6 cm and loss of haustration in a patient with a severe attack of colitis. Maximal colonic dilatation is most commonly observed in the transverse colon. Occurs as an extension of colonic inflammation beyond the mucosa to the underlying tissues, including the muscularis propria. The colon looses its contractility and thus leads to the accumulation of gas and fluid within the lumen and subsequent colonic dilatation. Risk factors: IBD both chrones and colitis Infectious bowel disease Patients with ulcerative colitis have a 2.5% lifetime risk of developing toxic megacolon Precipitating factors for toxic megacolon include electrolyte imbalance (particularly hypokalemia), use of antimotility drugs including anticholinergic agents and narcotics, and procedures such as barium enema and colonoscopy performed during a severe attack With clinical deterioration, patients can develop fever, tachycardia, hypotension, diffuse abdominal distention and tenderness, and decreased bowel sounds. Other laboratory parameters reflecting progressive severe systemic inflammation include marked leukocytosis, metabolic alkalosis, and electrolyte disturbances. History: Patients may have acute colitis that is refractory to treatment, ie they may have had diarrhea, abdominal pain, rectal bleeding tenesmus, vomiting and fever A careful history may reveal recent travel, antibiotic use, chemotherapy, or immunosuppression. Patients are usually very ill, with the toxic definition including some or all of the following symptoms: High fever Abdominal pain and tenderness Tachycardia Dehydration The diagnostic criteria developed by Jalan et al may be helpful to guide the history of patient suspected of having toxic megacolon (toxic colitis). They are as follows: Radiographic evidence of colonic dilation (usually the colon is greater than 6 cm in the transverse section) and there is a loss of haustra 2. Three of the following: Fever (greater than 38.6) 2. Tachycardia (>120), 3. Leukocytosis (greater than 10.5), anemia 3. One of: Dehydration, altered mental status, electrolyte abnormalities or hypotension

Puja Chopra PGY-1 Emergency Medicine

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