Discussion w9 652

Q-1

Pancreatitis

Presentation

Severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forward or assumes the fetal position and worsens with deep inspiration and movement. The patient will also complain of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake.

Etiology

Several etiologic factors have been described for acute pancreatitis, but in 10% to 20% of cases an etiologic factor is idiopathic. The presence of microlithiasis or biliary sludge accounts for 80% of idiopathic pancreatitis. In the US, gallstones followed by alcohol intake are responsible for 80% to 90% of cases of acute pancreatitis. The most common cause worldwide is alcohol consumption (Chatila, Bilal & Guturu, 2019).

Common Differential Diagnosis

Myocardial infarction, hepatitis, cholecystitis, viral gastroenteritis, abdominal aortic aneurysm, intestinal obstruction, peptic ulcer disease, cholangitis, choledocholithiasis, cholecystitis (Chatila, Bilal & Guturu, 2019).

Diagnostic Work-Up

Abdominal pain is the most common symptom I encounter all the time in the Emergency Department together with nausea, vomiting and anorexia. A detailed history is important in narrowing down numerous differentials of abdominal pain. Patients may present with agitation and confusion, and in severe distress. They may give a history of anorexia, nausea, and vomiting with poor oral intake (Chatila, Bilal & Guturu, 2019). The most common presenting symptom is mid-epigastric or left upper quadrant pain that radiates to the back, sometimes band distribution, often straight through middle back; many patients describe it as being “stabbed with a knife”, worsens with movement, and is alleviated when assuming the fetal position such as bent over, with spine, hips, and knees flexed. Any patient with an acute abdomen should have a complete blood count with differential and a blood chemistry including renal, liver, and pancreatic function tests. Mild leukocytosis with left shift and elevated hematocrit as a result of dehydration or low hematocrit as a result of hemorrhage can be seen (Chatila, Bilal & Guturu, 2019). Elevated levels of serum lipase or amylase (>3 upper limit of normal) support, but are not pathognomonic for, the diagnosis of acute pancreatitis. Serum lipase and amylase have similar sensitivity and specificity. Early and serial C-reactive protein (CRP) testing is used in acute pancreatitis as an indicator of severity and progression of inflammation (Chatila, Bilal & Guturu, 2019). MRCP is generally used in patients with renal insufficiency, in whom the use of CT with intravenous contrast is discouraged. CT is the best initial modality for staging acute pancreatitis and detecting complications; however, for serial examinations, MRCP is gaining favor due to better imaging of biliary and pancreatic stones, as well as better characterization of solid versus cystic lesions. ERCP is an endoscopic technique for visualization of the bile and pancreatic ducts. ERCP is a sensitive and specific diagnostic tool in acute pancreatitis. ERCP shows details of the pancreatic ductal anatomy including strictures, rupture, and pseudocysts (Chatila, Bilal & Guturu, 2019).

Treatment Plan

Intravenous hydration with lactated ringer’s or normal saline is essential. Pain control with opioids may reduce the need for multimodal analgesia. Ketorolac, a nonsteroidal anti-inflammatory drug, can be used in patients with intact renal function. It should not be used in older patients because of the risk of adverse gastrointestinal effects (Chatila, Bilal & Guturu, 2019). Oral nutrition should resume as soon as pain and any nausea and/or vomiting begin to subside. Nausea and/or vomiting is a presenting symptom in 70% to 80% of patients. Ondansetron is the most commonly used antiemetic. Magnesium should be replaced, if necessary; low levels are commonly seen in alcoholic patients (Chatila, Bilal & Guturu, 2019).

Preventive Measures

The most important aspect of prevention is patient education. Eating a balanced, low-fat diet, maintaining adequate triglyceride control, and decreasing the amount of alcohol intake, preferably to zero, may help to decrease the incidence of recurrent acute pancreatitis. Data now highlight the substantial correlation between cigarette smoking and recurrent acute pancreatitis. Therefore, patients should be strongly encouraged to abstain completely from tobacco use (Chatila, Bilal & Guturu, 2019).

Referrals

Gastroenterologist, surgeon, infectious disease specialist when it progresses to infection such as acute necrotizing pancreatitis (Koziel et al., 2018).

Presentation in Adult vs Geriatric Patients

Acute pancreatitis in the elderly is more commonly of gallstone etiology; it is also more likely to have an atypical clinical presentation, making recognition more difficult. In acute necrotizing pancreatitis, the elderly patient has an increased risk of complications including multisystem failure and for this reason, such patients should be more carefully monitored and aggressively treated (Koziel et al., 2018).

Reference:

Chatila, A. T., Bilal, M., & Guturu, P. (2019). Evaluation and management of acute pancreatitis. World Journal of Clinical Cases, 7(9), 1006-1020. doi:10.12998/wjcc.v7.i9.1006

Koziel, D., Gluszek-Osuch, M., Suliga, E., Zak, M., & Gluszek, S. (2018). Elderly persons with acute pancreatitis – specifics of the clinical course of the disease. Clinical Interventions in Aging, Volume 14, 33-41. doi:10.2147/cia.s188520

Q-2

Diverticula are small mucosal herniations of the colon and are typically asymptomatic. It is associated with a low-fiber diet, obesity, constipation, and advanced age (>50 years) (Vagheft-Davari et al., 2020). Diverticulitis is a chronic, low-grade inflammation along the wall of the large intestine, which may be due to invasion of aerobic/anaerobic bacteria of the diverticula, chronic inflammation, and common risk factors, such as smoking, NSAID use, inflammatory bowel disease (IBD), and ETOH use. Patients with diverticulitis will have symptoms of abdominal pain, typically in the LLQ, change in bowel habits of both diarrhea and constipation, nausea, vomiting, and bloating/gas (Chaney, 2018). In right-sided diverticulitis, patients would report right lower quadrant tenderness, which may mimic acute appendicitis. Other symptoms may include urinary symptoms, such as dysuria, urgency, and frequency secondary to bladder irritation from the inflamed adjacent sigmoid colon. Assessment findings include rebound tenderness, low-grade fever, abdominal distention, and signs of peritoneal infection/inflammation. A palpable mass may be present at the LLQ which would require an abdominal CT.

A CT scan images the presence of diverticulitis and complicated diverticulitis, such as abscess, obstruction, fistula, or perforation (Vagheft-Davari et al., 2020). A colonoscopy can be done; however, it is contraindicated in acute diverticular episodes due to the increased risk of perforation. Depending on complications, patients with diverticulitis may have leukocytosis, electrolyte abnormalities due to vomiting or diarrhea, and elevated SED rate (Chaney, 2018).

Patients will require complete bowel rest with NPO status, hydration, broad-spectrum antibiotics. Recommended antibiotic therapy includes metronidazole with a third-generation cephalosporin or aminoglycosides (Vagheft-Davari et al., 2020). However, aminoglycosides should be avoided in geriatrics as nephrotoxicity may occur.

Certain foods including seeds, nuts, corn, and popcorn should be avoided as they may become lodged in the diverticula producing diverticulitis. Patients should incorporate a high-fiber diet, increase physical activity, and avoid the use of NSAIDs.

Differential diagnosis includes appendicitis, IBD, colon cancer, and irritable bowel syndrome. In patients with IBS, the abdomen can appear distended and patients would report tenderness of the lower abdominal quadrants, typically the left lower quadrant, bloating, and constipation, diarrhea, or both (Berens et al., 2019).

A referral should be made out to a gastroenterologist and in severe complications, a surgical consult should be made if there's an indication of carcinoma, perforation/drainage, or bowel obstruction and necessary for colon resection or colostomy.

 

References

Berens, S., Rainer, S., Baumeister, D., Gauss, A., Eich, W., & Tesarz, J. (2019). Does symptom activity explain psychological differences in patients with irritable bowel syndrome and inflammatory bowel disease? Results from a multi-center cross-sectional study. Journal of Psychosomatic Research, 126, 109836. https://doi.org/10.1016/j.jpsychores.2019.109836

Chaney, A. (2018). Diverticulitis. In A. Holier (Ed.). Clinical Guidelines in Primary Care (3rd ed.). Lafayette, LA: Advanced Practice Education Associates, Inc.

Vaghef-Davari, F., Ahmadi-Amoli, H., Sharifi, A., Teymouri, F., & Paprouschi, N. (2020). Approach to acute abdominal pain: Practical algorithms. Advanced Journal of Emergency Medicine, 4(2), 29. https://doi.org/10.22114/ajem.v0i0.272

Q-3

Infectious Diarrhea.

The typical presentation of traveler’s diarrhea is infectious diarrhea is a sudden onset of abdominal cramps, anorexia, and watery diarrhea usually last 3 days to 2 weeks, and onset may occur within the first 3-5 days of visiting a poor resource-poor area, nausea, vomiting, bloody stool diarrhea, fever, bloating, excessive thirst, frequent diarrhea. Fatigue, lethargy and electrolyte imbalance, and signs of hypovolemia and even shock depend on the degree of dehydration from diarrhea.

Etiology of the traveler’s diarrhea from ingestion of contaminated food and water and the bacterial causative organism may primarily Escherichia coli, campylobacter jejuni, shigella, salmonella, Aeromonas, Pseudomonas, and Vibrio cholera (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019). Some of the viral causes can be norovirus (cruise ships), rotavirus (children) and parasite causes may be giardia lamblia (hikers and campers from freshwater streams), cryptosporidium, entamoeba histolytica, Cyclospora (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019). Nosocomial causes such as C-difficile diarrhea, Klebsiella oxytoca is associated with antibiotic-associated hemorrhagic colitis, staph aureus, bacillus cereus, clostridium perfringens, B. cereus, Vibrio cholera.

Common differential diagnosis was acute gastroenteritis, food poisoning, traveler’s diarrhea, c-difficile infection, shigellosis, amoebiasis salmonellosis, antibiotic-associated colitis, Malaria, malabsorption syndrome, appendicitis, proctitis, intestinal obstructions, colitis, diverticulitis, intestinal obstruction (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019).

Typical diagnostic work-up-to rule inflammatory and noninflammatory causes detailed history of duration, >2 weeks considered chronic diarrhea. Stool for culture thiosulfate-citrate-bile salts- sucrose (TCBS) or tellurite-taurocholate- gelatin (TTG) agar, latex agglutination tests for rotavirus and PCR for norovirus, immunofluorescence-based rapid antigen detection assays or standard microscopy for giardiasis, stool for ova and parasites, stool for occult blood (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019). Other general tests such as CBC, BMP, ESR, CRP to evaluate for infectious process and hydration status.

Treatment plan- Administration of oral rehydration solution, Pedialyte, lytren or flavored mineral water, and saltine crackers for watery diarrhea Without fever or blood in the stool or enteric symptoms. Bismuth subsalicylate 30 ml or 2 tablets every 30 minutes for 8 doses or loperamide 4 mg initially followed by 2 mg after the passage of each unformed stool not to exceed 16 mg per day for 2 days if its non-infectious cause (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019). Prophylactic empiric antibacterial such as fluoroquinolones or a macrolide such as erythromycin or azithromycin while pending stool culture and antispasmodic agents (Kasper, Hauser, Jameson, Fauci, Longo, Loscalzo, 2019). Oral administration of vancomycin, fidaxomicin, or metronidazole 500 mg TID X 10 days and for recurrent c-diff infection (CDI) tapering doses of vancomycin or pulse dosing every other day for 2-8 weeks without metronidazole. For severe complicated or fulminant CDI may present with signs of obstruction without diarrhea, then work for acute abdomen needs to be done including cautious sigmoidoscopy or colonoscopy pr colectomy is indicated. Retention enema with vancomycin through colostomy or ileostomy with iv metronidazole is been tried. Probiotics are an ideal intervention to manage acute infectious diarrhea and their efficacy strictly related to strains and indications (Vecchio, Buccigrossi, Fedele, & Guarino, 2019), and it is beneficial in antibiotic-associated colitis.

Preventative measures- Travelers to prevent diarrheal disease by eating only hot, freshly cooked food, by avoiding raw vegetables, salads, and unpeeled fruits, and by drinking only boiled or treated water and avoiding ice. Bismuth subsalicylates for prophylaxis for diarrhea of 525 mg four times a day. Prophylactic antibiotics generally not recommended for prevention except for immunocompromised or high risk for morbidity from GI infection. Vaccination against common bacterial and viral infection against rotavirus and S. Typhi and V. cholerae are available.

Appropriate referrals in complicated infection Gastroenterologist, infectious disease specialist, and referral to surgery in the complicated acute abdomen are mandated and rehabilitation therapy for severe debility management. Screening tools/diagnostic specific scales tools in patients with diarrhea need to be screened for an infectious cause especially those who are burdened and immunocompromised and additional information that would be important to the geriatric population. Elderly patients in long-term care institutions 50 % of the infectious diarrhea institutions are due to C-difficile and the older population is more prone to develop infectious diarrhea as well as the complications with infectious diarrhea due to comorbidity as well as frailty.

Reference

Kasper, D.L., Hauser, S.L., Jameson, J.L., Fauci, A.S., Longo, D.L., Loscalzo, J.L. (2019). Harrison’s principles of internal medicine. New York: McGraw Hill.

Vecchio, A. L., Buccigrossi, V., Fedele, M. C., & Guarino, A. (2019). Acute infectious diarrhea. In Probiotics and Child Gastrointestinal Health (pp. 109-120). Springer, Cham. Retrieved from https://link.springer.com/chapter/10.1007/5584_2018_320