Gastrointestinal

Rapid Review

• Background
  • Appendicitis is acute inflammation of the appendix, most commonly caused by a fecalith
• Signs/Symptoms
  • Periumbilical pain that moves to RLQ pain, +/- fever, +/- nausea/vomiting
  • (+) Rovsing sign, (+) Obturator sign, (+) Psoas sign
• Diagnosis
  • Clinical diagnosis for straightforward cases
  • Ultrasound and CT can be used to confirm diagnosis
• Treatment
  • NPO status (for surgery), fluid resuscitation, analgesia, antiemetics, and antibiotics (ex. ceftriaxone)
  • Consult surgery for definitive management (appendectomy)

Pearls

Deep Dive

• Appendicitis: Pearls and Pitfalls (emDOCs)

Rapid Review

• Background
  • Cholangitis is an acute bacterial infection (E. coli) that occurs when there is an obstruction in the bile duct (typically from a gallstone) 
• Signs/Symptoms
  • “Charcot triad” (fever, jaundice, RUQ pain)
  • “Reynolds pentad” (Charcot triad  + hypotension and AMS)
• Diagnosis
  • RUQ ultrasound or CT (initially)
  • ERCP is the gold standard
• Treatment
  • Treat hypotension/sepsis (IV fluid resuscitation, vasopressors)
  • Broad-spectrum antibiotics (ex. Piperacillin-tazobactam + gentamicin)
  • Consult GI early

Pearls

Deep Dive

• Cholangitis: Pearls and Pitfalls (emDOCs)

Rapid Review

• Background
  • Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 years have gallstones. 
• Signs/Symptoms
  • Usually asymptomatic. If any, symptoms usually transient (< 5 hours)
  • RUQ pain, +/- radiation to right scapula, +/- nausea/vomiting
• Diagnosis
  • RUQ ultrasound
• Treatment
  • Supportive care (rehydration, analgesia)
  • Most can be definitively managed with outpatient elective cholecystectomy. 
  • Surgical consultation from the ED is required if you suspect cholecystitis, cholangitis, or choledolithiasis.

Pearls

Deep Dive

• Cholelithiasis (Merck Manual)

Rapid Review

• Background
  • Diverticulitis is inflammation of the the diverticulum, with or without infection. It is almost exclusively left-sided in the US. 
• Signs/Symptoms
  • LLQ pain, fever, nausea/vomiting, change in bowel habits
  • Abdominal guarding, rigidity, and rebound tenderness
• Diagnosis
  • CT scan (Sn 97%, Sp 100%)
• Treatment
  • Antibiotics (ex. metronidazole + ciprofloxacin)
  • Surgery for complicated cases (perforation, peritonitis, etc.)

Pearls

Deep Dive

• Diverticulitis (Merck Manual)

Rapid Review

• Background
  • Pancreatitis is acute inflammation of the pancreas, most commonly caused by gallstones and alcohol consumption. 
• Signs/Symptoms
  • Epigastric pain radiating to the back, nausea/vomiting
  • (+) Gray-turner sign and (+) Cullen sign in hemorrhagic pancreatitis
• Diagnosis
  • Presence of at least 2 of the following: abdominal pain, lipase 3x the upper limit of normal, and characteristic findings on US or CT
• Treatment
  • Supportive care (IV fluids, analgesia, and nutritional support). Antibiotics required only if there is a clear source of infection.
  • Consult for ERCP/cholecystectomy if related to gallstones

Pearls

Deep Dive

• Acute Pancreatitis (REBEL EM)