Gastrointestinal

  • Appendicitis
  • Cholangitis
  • Cholelithiasis
  • Diverticulitis
  • Gastroenteritis

Appendicitis

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

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Deep Dive

Credit: Finger Splint by Ali kumar
Video Credit: Osmosis


Cholangitis

  • 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
Video Credit: Details Medical

*Deep Dive: Cholangitis: Pearls and Pitfalls (emDOCs)



Cholelithiasis

  • 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.
Video Credit: Osmosis

*Deep Dive: Cholelithiasis (Merck Manual)



Diverticulitis

  • 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.)
Video Credit: Armando Hasudungan

*Deep Dive: Diverticulitis (Merck Manual)



Pancreatitis

  • 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
Video Credit: Armando Hasudungan

*Deep Dive: Acute Pancreatitis (REBEL EM)


Brandon Simpson, PA-C
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