- Appendicitis is acute inflammation of the appendix, most commonly caused by a fecalith
- Periumbilical pain that moves to RLQ pain, +/- fever, +/- nausea/vomiting
- (+) Rovsing sign, (+) Obturator sign, (+) Psoas sign
- Clinical diagnosis for straightforward cases
- Ultrasound and CT can be used to confirm diagnosis
- NPO status (for surgery), fluid resuscitation, analgesia, antiemetics, and antibiotics (ex. ceftriaxone)
- Consult surgery for definitive management (appendectomy)
- Cholangitis is an acute bacterial infection (E. coli) that occurs when there is an obstruction in the bile duct (typically from a gallstone)
- “Charcot triad” (fever, jaundice, RUQ pain)
- “Reynolds pentad” (Charcot triad + hypotension and AMS)
- RUQ ultrasound or CT (initially)
- ERCP is the gold standard
- Treat hypotension/sepsis (IV fluid resuscitation, vasopressors)
- Broad-spectrum antibiotics (ex. Piperacillin-tazobactam + gentamicin)
- Consult GI early
*Deep Dive: Cholangitis: Pearls and Pitfalls (emDOCs)
- 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.
- Usually asymptomatic. If any, symptoms usually transient (< 5 hours)
- RUQ pain, +/- radiation to right scapula, +/- nausea/vomiting
- RUQ ultrasound
- 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.
*Deep Dive: Cholelithiasis (Merck Manual)
- Diverticulitis is inflammation of the the diverticulum, with or without infection. It is almost exclusively left-sided in the US.
- LLQ pain, fever, nausea/vomiting, change in bowel habits
- Abdominal guarding, rigidity, and rebound tenderness
- CT scan (Sn 97%, Sp 100%)
- Antibiotics (ex. metronidazole + ciprofloxacin)
- Surgery for complicated cases (perforation, peritonitis, etc.)
*Deep Dive: Diverticulitis (Merck Manual)
- Pancreatitis is acute inflammation of the pancreas, most commonly caused by gallstones and alcohol consumption.
- Epigastric pain radiating to the back, nausea/vomiting
- (+) Gray-turner sign and (+) Cullen sign in hemorrhagic pancreatitis
- Presence of at least 2 of the following: abdominal pain, lipase 3x the upper limit of normal, and characteristic findings on US or CT
- 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
*Deep Dive: Acute Pancreatitis (REBEL EM)