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)
• Disposition
  • All patients with confirmed appendicitis will need to be admitted. Consult general surgery early.

Pearls

• Appendicitis is a clinical diagnosis if the patient has a convincing history and physical exam. Do not delay consulting surgery for confirmatory imaging.
• There is growing evidence that antibiotics alone may be sufficient for uncomplicated appendicitis, but approximately 27% of these patients will ultimately have to undergo appendectomy within a year anyway.

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
• Disposition
  • Admission is required with gastroenterology and general surgery consultation. ICU admission may be required if signs of sepsis are present.

Pearls

• Acute cholangitis has a near 100% mortality rate. Initiate antibiotics as early as possible.
• Although RUQ ultrasound is effective for identifying cholelithiasis and cholecystitis, CT with IV contrast is preferred for the diagnosis of choledocolithiasis and cholangitis. 

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.
• Disposition
  • Stable patients with no evidence of cholecystitis, cholangitis, or pancreatitis can be discharged with a referral to general surgery.

Pearls

• Ultrasound is the preferred imaging modality for diagnosis of cholelithiasis and cholecystitis, but CT imaging w/ IV contrast is required if your suspicious for choledocolithiasis or cholangitis.
• Pain from gallstones is usually transient. If the pain is lasting greater than 6 hours, this main be a sign of complicated gallstone disease.

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.)
• Disposition
  • Mild, uncomplicated cases of diverticulitis can be discharged as long as they can tolerate PO and have access to close follow-up.
  • Provide referral to gastroenterology for colonoscopy (performed after acute episode has resolved)

Pearls

• Although patients typically present with LLQ pain, patients of Asian descent more commonly present with RLQ pain.
• It has traditionally been taught that patients should avoid corn, nuts, and popcorn to decrease incidence of diverticulitis, though there is no evidence to support this. 

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
  • (+) Grey-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
• Disposition
  • Chronic pancreatitis or mild acute cases w/o evidence of biliary disease can be discharged with follow-up in 24-48 hours
  • Admission is required for patients with severe symptoms or unable to tolerate PO fluids.
    • Consult general surgery for ruptured pseudocyst or evidence of concomitant biliary disease

Pearls

• Gallstones and alcohol are the most common causes of pancreatitis, but can also be caused by hyperlipidemia, scorpion venom, medications, and hypercalcemia.
• The Bedside Index of Severity in Acute Pancreatitis (BISAP) score can be used to help risk stratify these patients. It is more sensitive and specific than the traditional scoring systems (Ranson criteria, APACHE II)

Deep Dive

• Acute Pancreatitis (REBEL EM)