Topic 3-4

Q- Tommy Jackson 18 years old presented to ED with pain in his right lower abdomen started 5 hours ago while playing Tennis. His pain worsens when standing straight and gets better when bending forward. Denise has any other symptoms of fever, chills, burning urination, nausea, or vomiting.

Physical exam.

GI: On inspection of abdomen, scaphoid without distension, visible peristalsis, visible pulsations, no bulging of the umbilicus, or any signs of inflammation or herniation. On auscultation, normal bowel sounds without bruits or hums. On light palpation, tenderness on light palpation and severe pain on deep palpation with questionable rebound tenderness and a patient grimace on percussion indicating tenderness. There is tenderness on deep palpation at the tip of the 12th rib and a positive Chapman's reflex at that point denotes appendix origin. I could not elicit any McBurney’s point tenderness, Rovsing’s sign, psoas sign, obturator sign cannot be performed in this simulation.

Genitourinary: There are small non-tender, mobile inguinal nodes that denote infection/ inflammation of the surrounding structures including appendicitis. No inguinal hernia or varicocele identified.

Diagnostic tools selected:

1. I would select to do a CBC to see any leukocytosis with an elevated neutrophil count which is diagnostic in these patients' presenting with acute right-sided lower quadrant pain for possible acute appendicitis. CBC- Leukocytosis with WBC OF 17,900 with a neutrophil count-66%. The sensitivity and specificity of leukocytosis were found to be 76% and 12.5 respectively and overall diagnostic accuracy is 56%, and leukocytosis is a helpful investigation to support the diagnosis of acute appendicitis (Vaidya, Lamture, Ramteke, Mundada, Gajbhiye, & Yeola, 2020). Right blower quadrant tenderness left shift of neutrophils, and leukocytosis were the most common symptoms on presentation of acute appendicitis (Shchatsko, Brown, Reid, Adams, Alger, & Charles, 2017).

2. BMP to rule out any uncontrolled diabetes with ketoacidosis/KKNK present with acute abdomen, any underlying electrolyte, fluid imbalances, and kidney problems. BMP: unremarkable. in this patient

3. Urine analysis: To rule out any urinary infection which shows unremarkable.

4. X-ray KUB: To rule out any obstruction with dilated intestine, rupture of bowels with free fluid or air, large masses, or any fractures of the bony structures. In this patient it was unremarkable.

5. CT abdomen/pelvis: - to rule out any acute infection and inflammation, masses, obstruction in the abdomen and its organs and viscera and pelvic organs. In this patient CT showed sigmoid colon, bladder and ureters are in normal appearance. The cecum is enlarged and there is a small fluid collection. Cecal swelling denotes appendicitis and the fluid collection possibly an abscess formation. According to Yardimci, et al, (2017), appendiceal diverticulitis patients may have peri-appendiceal extraluminal loculated fluid, peri-appendiceal stranding, and a larger diameter of the appendix.

Reference.

Yardimci, A. H., Bektas, C. T., Pasaoglu, E., Kinaci, E., Ozer, C., Sevinc, M. M., ... & Kilickesmez, O. (2017). Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations. Japanese journal of radiology, 35(5), 225-232. Retrieved from https://link.springer.com/article/10.1007/s11604-017-0625-z

Vaidya, V. P., Lamture, Y. R., Ramteke, H., Mundada, A., Gajbhiye, V., & Yeola, M. (2020). Reliability of Leukocytosis in Diagnosing Acute Appendicitis. Journal of Evolution of Medical and Dental Sciences, 9(32), 2274-2279. Retrieved from https://go.gale.com/ps/i.do?id=GALE%7CA633840130&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=22784748&p=AONE&sw=w&userGroupName=anon%7Ea8e8521d

Shchatsko, A., Brown, R., Reid, T., Adams, S., Alger, A., & Charles, A. (2017). The utility of the Alvarado score in the diagnosis of acute appendicitis in the elderly. The American Surgeon, 83(7), 793-798. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/000313481708300740

 

Q-2

You are assessing a patient who has presented to the emergency department with an acute onset of abdominal pain. List three differential diagnoses that would lead to immediate surgical consultation. Support your answer with two or three peer-reviewed resources.

Acute appendicitis (AA) –In acute appendicitis patient may present with fever, feeling ill, pain in the right lower quadrant, nausea, vomiting. The lab test will show leukocytosis and US abdomen, or CT abdomen may show inflamed appendix with stranding around the appendix and other findings associated with it. A higher level of WBC is very suggestive of AA along with findings on physical examination and is proven histopathologically had a WBC higher than 11x 103/mm (Özdemir, Özdemir, Sunamak, & Cambaztepe, 2018).

Acute pancreatitis-In acute appendicitis patients may present with mild abdominal pain or epigastric pain with SIRS symptoms. Lab findings with leukocytosis, amylase, and lipase, and lipid panel will be high. CT abdomen will show acute pancreatitis, necrosis, abscess, etc. The patient may be very ill if not treated early with high morbidity and mortality. The patient may present with DKA coupled with elevated serum blood sugar, hypertriglyceridemia, elevated amylase, or lipase to make an early diagnosis of acute pancreatitis and initiate timely management will reduce morbidity and mortality (Timilsina, Timilsina, Mandal, Paudel, & Gayam, 2019).

Bowel perforation with peritonitis. The patient presents with acute colicky or wave-like pain increasing intensity with abdominal distension, ill-looking, tachycardia, hypertension, and then hypotension, fever, nausea, and vomiting. Abdomen gets rigid and board-like with guarding in peritonitis, associated with sepsis or septic shock. Abdominal pain is classically colicky due to an increase in motility to overcome obstruction and later replaced by reduced peristalsis and dilation, pain becomes intense and untreatable with analgesics in case of ischemia or perforation (Catena, De Simone, Coccolini, Di Saverio, Sartelli, & Ansaloni, 2019). Other features may be nausea and vomiting in small bowel obstruction with abdominal distension with peritonism sign is associated with ischemia/peritonitis and/or perforation. CT with IV contrast is superior to that of conventional abdominal radiography and ultrasound with higher sensitivity and specificity and the ability to provide additional information about the etiology and alternative diagnosis (Catena, De Simone, Coccolini, Di Saverio, Sartelli, & Ansaloni, 2019).

Reference.

Özdemir, H., Özdemir, Z. Ü., Sunamak, O., & Cambaztepe, F. (2018). Which one in the diagnosis of acute appendicitis: Physical examination, laboratory, or imaging? A retrospective analysis in the light of pathological results. Electronic Journal of General Medicine, 15(2). Retrieved from https://doi.org/10.29333/ejgm/81764

Timilsina, S., Timilsina, S., Mandal, A., Paudel, R., & Gayam, V. (2019). Triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis: severity of acute pancreatitis may correlate with the level of hypertriglyceridemia. Cureus, 11(6). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695235/

Catena, F., De Simone, B., Coccolini, F., Di Saverio, S., Sartelli, M., & Ansaloni, L. (2019). Bowel obstruction: a narrative review for all physicians. World Journal of Emergency Surgery, 14(1), 1-8. Retrieved from https://wjes.biomedcentral.com/articles/10.1186/s13017-019-0240-7

Q-3

Acute Cholecystitis

In the case of acute onset of abdominal pain, Acute Cholecystitis is one of the most common causes for pain that is severe in the abdomen (Correa & Spiegleman, 2018). The recommened and most appropriate mangement is a CT scan of the abdomen to confirm, then when positive, an immediate consultation to surgery for a laprascopic cholecystectomy (Correa & Spiegleman, 2018). The only situation where the lap chole can be postponed is when the patient is acutely ill and considered a poor surgical canidate such as in a septic shock situation (Correa & Spiegleman, 2018). In these cases, placement of a temporary percutaneous drainage catheter is appropriate until the patient has been stabilized (Correa & Spiegleman, 2018).

Acute Appendicitis

Another common cause of acute abdominal pain is Acute Appendicitis. In this case the patient will present with acute abdominal pain, and the first steps to perform would be to make the patient NPO and obtain a CT of the abdomen (Kulvatunyou et al., 2021). Once the scan is positive, the next step is immediate surgical consultation, and preperation of the gold standard of a laproscopic appendectomy or secondary, an open appendectomy (Kulvatunyou et al., 2021). Preference would be up to the surgeon, and collaboration is important in this scenario as there is a question of whether or not to initiate prophylactic antibiotic treatment (Kulvatunyou et al., 2021).

Acute Bowel Perforation

In the case of bowel perforation, the patient presets severly and acutely ill, with severe abdominal pain (Adiwinata et al., 2020). Just like in any other presentation of acute severe abdominal pain, the first step is to get a CT of the abdomen (Adiwinata et al., 2020). The CT is the scan of choice as it can detect free air but also dectect the location of the perforation which greatly helps the surgeon in this case (Adiwinata et al., 2020). Once the CT scan comes back positive immediate surgical consult is required for possible laproscopic vs open colon resection (Adiwinata et al., 2020). However, in this case, if a patinet is hemodynamically unstable, then stablization is priority followed by exploratory laprotomy which is the surgical procedure of choice in this scenario (Adiwinata et al., 2020).

References:

Adiwinata, R., Rotty, L., Tendean, M., Waleleng, B. J., Gosal, F., Rotty, L., Winarta, J., & Waleleng, A. (2020). Bowel Obstruction and Perforation as Emergency Presenting Sign of Colorectal Cancer with Peritoneal Carcinomatosis: A Case Report and Review. Indonesian Journal of Gastroenterology, Hepatology & Digestive Endoscopy, 21(3), 235–240.

Correa, C. & Spiegelman, S. (2018). A Case of Acute Cholecystitis. Journal of Education and Teaching in Emergency Medicine, 3(1), 11–12. https://doi-org.lopes.idm.oclc.org/10.21980/J8405Q

Kulvatunyou, N., Zimmerman, S. A., Adhikhari, S., Joseph, B., Gries, L., Tang, A. L., & Rhee, P. (2021). The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis. Journal of Surgical Research, 260, 293–299. https://doi-org.lopes.idm.oclc.org/10.1016/j.jss.2020.11.018