Acute Appendicitis
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Transcript of Acute Appendicitis
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Acute AppendicitisAcute Appendicitis
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EpidemiologyEpidemiology
• The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.
• Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.
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PathophysiologyPathophysiology
• Acute appendicitis is thought to begin with obstruction of the lumen
• Obstruction can result from food matter, adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase intraluminal pressure
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PathophysiologyPathophysiology
• Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.
• With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.
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PathophysiologyPathophysiology
• Increased pressure also leads to arterial stasis and tissue infarction
• End result is perforation and spillage of infected appendiceal contents into the peritoneum
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PathophysiologyPathophysiology
• Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th thoracic vertebral level.
• This pain is generally vague and poorly localized.
• Pain is typically felt in the periumbilical or epigastric area.
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PathophysiologyPathophysiology
• As inflammation continues, the serosa and adjacent structures become inflamed
• This triggers somatic pain fibers, innervating the peritoneal structures.
• Typically causing pain in the RLQ
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PathophysiologyPathophysiology
• The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.
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PathophysiologyPathophysiology
• Exceptions exist in the classic presentation due to anatomic variability of the appendix
• Appendix can be retrocecal causing the pain to localize to the right flank
• In pregnancy, the appendix ca be shifted and patients can present with RUQ pain
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PathophysiologyPathophysiology
• In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.
• Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate
• Multiple anatomic variations explain the difficulty in diagnosing appendicitis
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HistoryHistory
• Primary symptom: abdominal pain
• ½ to 2/3 of patients have the classical presentation
• Pain beginning in epigastrium or periumbilical area that is vague and hard to localize
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HistoryHistory
• Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting
• As the illness progresses RLQ localization typically occurs
• RLQ pain was 81 % sensitive and 53% specific for diagnosis
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HistoryHistory
• Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific
• Anorexia is the most common of associated symptoms
• Vomiting is more variable, occuring in about ½ of patients
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Physical ExamPhysical Exam
• Findings depend on duration of illness prior to exam.
• Early on patients may not have localized tenderness
• With progression there is tenderness to deep palpation over McBurney’s point
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Physical ExamPhysical Exam
• McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS
• Rovsing’s: pain in RLQ with palpation to LLQ
• Rectal exam: pain can be most pronounced if the patient has pelvic appendix
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Physical ExamPhysical Exam
• Additional components that may be helpful in diagnosis: rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectal
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Physical ExamPhysical Exam
• Psoas sign: place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive.
• Obturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive
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Physical ExamPhysical Exam
• Fever: another late finding.
• At the onset of pain fever is usually not found.
• Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture
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DiagnosisDiagnosis
• Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy
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DiagnosisDiagnosis
• Women of child bearing age need a pelvic exam and a pregnancy test.
• Additional studies: CBC, UA, imaging studies
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DiagnosisDiagnosis
• CBC: the WBC is of limited value.
• Sensitivity of an elevated WBC is 70-90%, but specificity is very low.
• But, +predictive value of high WBC is 92% and –predictive value is 50%
• CRP and ESR have been studied with mixed results
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DiagnosisDiagnosis
• UA: abnormal UA results are found in 19-40%
• Abnormalities include: pyuria, hematuria, bacteruria
• Presence of >20 wbc per field should increase consideration of Urinary tract pathology
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DiagnosisDiagnosis
• Imaging studies: include X-rays, US, CT
• Xrays of abd are abnormal in 24-95%
• Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air
• Abdominal xrays have limited use b/c the findings are seen in multiple other processes
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DiagnosisDiagnosis
• Graded Compression US: reported sensitivity 94.7% and specificity 88.9%
• Basis of this technique is that normal bowel and appendix can be compressed whereas an inflamed appendix can not be compressed
• DX: noncompressible >6mm appendix, appendicolith, periappendiceal abscess
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DiagnosisDiagnosis
• Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter
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DiagnosisDiagnosis
• CT: best choice based on availability and alternative diagnoses.
• In one study, CT had greater sensitivity, accuracy, -predictive value
• Even if appendix is not visualized, diagnose can be made with localized fat stranding in RLQ.
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DiagnosisDiagnosis
• CT appears to change management decisions and decreases unnecessary appendectomies in women, but it is not as useful for changing management in men.
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Special PopulationsSpecial Populations
• Very young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosis
• High index of suspicion is needed in the these groups to get an accurate diagnosis
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TreatmentTreatment
• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and preoperative antibiotics
• Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation
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TreatmentTreatment
• There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage
• One sample monotherapy regimen is Zosyn 3.375g or Unasyn 3g
• Also, short acting narcotics should be used for pain management
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DispositionDisposition
• Abdominal pain patients can be put in 4 groups
• Group 1: classic presentation for Acute appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed appendicitis- benefit from imaging and 4-6h observation with surgical consult if serial exam changes or imaging studies confirm
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DispositionDisposition
• Group 3: remote possibility of appendicitis- observe in ED for serial exams; if no change and course remains benign patient can D/C with dx of nonspecific abd pain
• Patients are given instructions to return if worsening of symptoms, and they should be seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
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DispositionDisposition
• Group 4: high risk population(including elderly, pediatric, pregnant and immunocomprimised)- require high index of suspicion and low threshold for imaging and surgical consultation
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Ileitis, Colitis, and Ileitis, Colitis, and DiverticulitisDiverticulitis
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Crohn DiseaseCrohn Disease
• Chronic granulomatous inflammatory disease of the GI tract.
• Can involve any part of GI tract from mouth to anus
• Ileum is involved in majority of cases
• Confined to colon in 20%
• Terms:regional enteritis, terminal ileitis, granulomatous ileocolitis
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Crohn DiseaseCrohn Disease
• Etiology and pathogenesis are unknown.
• Infectious, genetic, environmental factors have been implicated.
• Autoimmune destruction of mucosal cells as a result of cross-reactivity to antigens from enteric bacteria.
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Crohn DiseaseCrohn Disease
• Cytokines,including IL and TNF have been implicated in perpetuating the inflammatory response.
• Anti-TNF(remicade) drugs have shown efficacy in treating Crohn disease
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Crohn DiseaseCrohn Disease
• Epidemiology: peak incidence is 15-22 years old with a second peak 55-66years
• 20-30% increase in women
• More common in European
• 4 times more common in Jews than non-Jews
• More common in whites vs blacks
• 10-15% have family hx
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Crohn DiseaseCrohn Disease
• Pathology: most important is the involvement of all layers of the bowel and extension into mesenteric lymph nodes
• Disease has skip areas between involved areas
• Longitudinal deep ulcers and cobblestoning of mucosa are characteristic
• These result in fissures, fistulas, and abscesses
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Crohn DiseaseCrohn Disease
• Clinical features: variable and unpredictable
• Abd pain, anorexia, diarrhea, and weight loss are present in most cases
• 1/3 of patients develop perianal fissures or fistulas, abscesses, or rectal prolapse
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Crohn DiseaseCrohn Disease
• Patients may present with lat complications including:
• Obstruction, crampy abd pain, obstipation, intraabdominal abscess with fever
• 10-20% have extraabdominal features such as: arthritis, uveitis, or liver disease
• Crohn’s should also be considered when evaluating FUO
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Crohn DiseaseCrohn Disease
• Clinical course and manifestation depends of anatomic distribution.
• 30% involves only small bowel, 30% only colon, and 50% involves both
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Crohn DiseaseCrohn Disease
• Recurrence rate is as high as 50% for those responding to medical management
• Rate is even higher for those requiring surgery
• Incidence of hematochezia and perianal disease is higher when the colon is involved
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Crohn DiseaseCrohn Disease
• Dermatologic complications: erythema nodosum and pyoderma gangrenosum
• Ocular: episcleritis and uveitis
• Hepatobiliary: pericholangitis, chronic hepatitis, primary sclerosing cholangitis, cholangiocarcinoma, pancreatitis, gallstones
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Crohn DiseaseCrohn Disease
• Vascular: thromboembolic disease, vasculitis, arteritis
• Other: anemia, malnutrition, hyperoxaluria leading to nephrolithiasis, myeloplastic disease, osteomyelitis, osteonecrosis
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Crohn DiseaseCrohn Disease
• Complications: >75% of patients will require surgery within the first 20 years
• Abscesses present with pain and tenderness, but may also have palpable masses or fever spikes
• Most common fistula sites are between ileum and sigmoid colon, cecum, another ileal segment, or the skin
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Crohn DiseaseCrohn Disease
• Fistulas should be suspected when there is a change in bowel movement frequency, amount of pain or weight loss
• GI bleed is common, but only 1% develop life threatening hemorrhage.
• Toxic megacolon occurs in 6% of patients and results massive GI bleed 50% of the time
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Crohn DiseaseCrohn Disease
• Complications can also arise from the treatment of the disease
• Sulfasalazine, steroids, immunosuppressive agents, and antibiotics can cause leukopenia, thrombocytopenia, fever, infection, diarrhea, pancreatitis, renal insufficiency, liver failure.
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Crohn DiseaseCrohn Disease
• Incidence of malignancy is 3 times higher in Crohn disease than in general population
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Crohn DiseaseCrohn Disease
• Diagnosis: history, Upper GI, air-contrast barium enema and colonoscopy
• Characteristic radiologic findings in small intestine include: segmental narrowing, destruction of normal mucosal pattern, and fistulas.
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Crohn DiseaseCrohn Disease
• Colonoscopy is most sensitive for patients with colitis
• Useful for detecting mucosal lesions, defining extent of involvement, occurrence of colon ca.
• Abd CT is most useful for acute presentation
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Crohn DiseaseCrohn Disease
• Findings of bowel wall thickening, mesenteric edema, local abscess formation suggest Crohn disease.
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Crohn DiseaseCrohn Disease
• Differential Dx: lymphoma, ileocecal amebiasis, sarcoidosis, deep chronic mycotic infections involving GI tract, GI TB, Kaposi’s sarcoma, campylobacter, Yersinia, ulcerative colitis, C.diff, ischemic colitis.
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Crohn DiseaseCrohn Disease
• Tx: relief of symptoms, induction of remission, maintenance of remission, prevention of complications, optimizing timing of surgery, and maintenance of nutrition
• Since the disease is virtually incurable, emphasis should be placed of relief of symptoms and preventing complications
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Crohn DiseaseCrohn Disease
• Initial ED management: focus on severity of attack, identifying possible complications such as obstruction, hemorrhage, abscess, toxic megacolon.
• CBC, electrolytes, BUN/creatinine, and type and cross if appropriate
• Plain films may be useful for obstruction, perforation or toxic megacolon
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Crohn DiseaseCrohn Disease
• Initial Tx: NPO, IVF resuscitation and correction of electrolytes
• NG decompression if indicated, broad spectrum atbx(ampicillin or a cephalosporin, aminoglycoside, and flagyl) should be used for suspected fulminant colitis or peritonitis
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Crohn DiseaseCrohn Disease
• IV steroids: hydrocortisone 300mg qd, methylprednisone 48mg qd, or prednisolone 60mg qd should be used for severe disease
• Sulfasalazine 3-4g qd can be effective for mild-moderate cases, although it has many toxic side effects
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Crohn DiseaseCrohn Disease
• Oral steroids are reserved for severe disease-prednisone 40-60mg qd
• Immunosuppressive drugs:
6-MP or azathioprine are useful for steroid alternatives, healing fistulas, or in patients with contraindications to surgery
Response to immunosuppressant agents takes 3-6 months
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Crohn DiseaseCrohn Disease
• Flagyl and Cipro have been shown some improvement in perianal complications and fistulous disease.
• Medically resistant or moderate cases may benefit from anti-TNF(Remicade) 5 mg/kg IV
• Cellcept, etanercept, thalidomide, IL therapy may also be beneficial
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Crohn DiseaseCrohn Disease
• Diarrhea can be controlled using imodium, lomotil, or questran
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Crohn DiseaseCrohn Disease
• Disposition: patients with signs of fulminant colitis, peritonitis, obstruction, significant hemorrhage, dehydration, electrolyte/fluid imbalance should be hospitalized under the care of a surgeon or gastroenterologist
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Crohn DiseaseCrohn Disease
• Patients with chronic disease can be discharged home as long as there are no serious complications.
• Alterations in maintenance therapy should be discussed with GI
• Close follow up should be secured.
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Ulcerative ColitisUlcerative Colitis
• Chronic inflammatory disease of the colon.
• Inflammation is more severe from proximal to distal colon
• Rectum is involved in nearly 100%
• Characteristic symptom is bloody diarrhea
• Etiology remains unknown
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Ulcerative ColitisUlcerative Colitis
• Epidemiology: similar to Crohn disease
• More prevalent in US and northern Europe.
• First degree relatives have 15 fold increase for UC and 3.5 fold increase for Crohn disease
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Ulcerative ColitisUlcerative Colitis
• Pathology: involves mucosa and submucosa
• Mucosal inflammation and formation of crypt abscesses, epithelial necrosis, and mucosal ulceration
• Early stages mucosa membrane appears finely granular and friable
• Severe cases show large oozing ulcerations and pseudopolyps
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Ulcerative ColitisUlcerative Colitis
• Clinical features:• Mild: <4 bm per day, no systemic symptoms,
and few extraintestinal manifestations. (account for 60% of all UC patients)
• Severe: frequent bm’s, anemia, fever, wt loss, tachycardia, low albumin, frequent extraintestinal manifestations. (accounts for 15% of all patients and 90% of mortality)
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Ulcerative ColitisUlcerative Colitis
• Moderate: manifesations are less severe and respond well to treatment. Typically have left sided colitis, but can have pancolitis.
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Ulcerative ColitisUlcerative Colitis
• Characterized by: intermittent attacks of acute disease with remission between attacks
• Unfavorable prognosis and increased mortality is seen with higher severity and extent of disease, short interval between attacks, and onset of disease after 60
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Ulcerative ColitisUlcerative Colitis
• Extraintestinal complications: arthritis, ankylosing spondylitis, episcleritis, uveitis, pyoderma gangrenosum, erythema nodosum, liver disease(similar to that found in Crohn disease)
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Ulcerative ColitisUlcerative Colitis
• Complications: hemorrhage, toxic megacolon, perirectal abscesses and fistulas, colon ca, perforation
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Ulcerative ColitisUlcerative Colitis
• Dx: lab findings are nonspecific.
• Diagnosis is made by Hx of abd cramps and diarrhea, mucoid stools, stool negative for ova/parasites, negative stool cultures
• confirmation of disease by colonoscopy showing granular, friable, ulceration of the mucosa, and sometimes pseudopolyps
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Ulcerative ColitisUlcerative Colitis
• Differential Dx: similar to that of Crohn disease.
• Also be aware of STD’s when confined to the rectum
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Ulcerative ColitisUlcerative Colitis
• Treatment:
• Severe UC: IV steroids, fluid replacement, electrolyte correction, broad spectrum atbx(amp and clindamycin or flagyl)
• Cyclosporine has been advocated for steroid refractory cases
• NG for toxic megacolon just as in crohn disease
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Ulcerative ColitisUlcerative Colitis
• Mild to moderate: majority of cases can be treated as outpatient with daily prednisone 40-60mg
• Active proctitis, proctosigmoiditis, and left side colitis can be treated with 5-aminosalicylic acid enemas or topical steroid preparations
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Ulcerative ColitisUlcerative Colitis
• Treatment is very similar to Crohn disease
• Other supportive measures include metamucil or other bulking agents
• Anti-diarrheals should be used with caution in case of toxic megacolon
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Ulcerative ColitisUlcerative Colitis
• Disposition:Fulminant attacks should be hospitalized for aggressive IVF and elctrolyte correction.
• Complications should be managed with appropriate surgical or GI consult
• Mild-moderate: may be discharged with close follow up secured. Instructions on when to return should be given
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Pseudomembranous ColitisPseudomembranous Colitis
• Inflammatory bowel disorder with membrane-like yellowish plaques of exudate overlie and replace necrotic intestinal mucosa
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Pseudomembranous ColitisPseudomembranous Colitis
• Epidemiology:
• Clostridium Difficile- spore forming obligate anaerobic bacillus
• 3 types: neonatal, post-operative and antibiotic associated
• Risk factors: recent atbx, GI surgery, severe medical illness, advancing age
• Transmission: direct contact and objects
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Pseudomembranous ColitisPseudomembranous Colitis
• Pathophysiology: 10-25% of hospital patients are colonized
• Diarrhea in recently hospitalized person should suggest C.difficile
• Broad spectrum atbx such as clindamycin, cephalosporins, amp/amox- alter gut flora and allow C.difficile to flourish
• However any atbx can lead to C.difficile
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Pseudomembranous ColitisPseudomembranous Colitis
• C. difficile produces
• toxin A enterotoxin
• toxin B cytotoxin
• Toxins interact and produce the colitis and associated symptoms
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Pseudomembranous ColitisPseudomembranous Colitis
• Clinical features: from frequent mucoid, watery stools to profuse toxic diarrhea(>20-30 stools/day), abdominal pain, fever, leukocytosis, dehydration, hypovolemia
• Stool exam may reveal fecal leukocytes
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Pseudomembranous ColitisPseudomembranous Colitis
• Complications: severe electrolyte imbalance, hypotension, anasarca from low albumin, toxic megacolon, bowel perforation
• Onset is typically 7-10 days after starting atbx therapy
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Pseudomembranous ColitisPseudomembranous Colitis
• Extraintestinal complications are rare, but include: arthritis, visceral abscesses, cellulitis, necrotizing fasciitis, osteomyelitis, prostheitc device infection
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Pseudomembranous ColitisPseudomembranous Colitis
• Diagnosis: hx of diarrhea that develops during or within 2 weeks of atbx treatment.
• Confirmed by stool for C.difficile toxin and colonoscopy
• Most labs use ELISA to detect C.difficile toxins even though there are many other modes
• 5-20% of patients require more than one stool to diagnose
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Pseudomembranous ColitisPseudomembranous Colitis
• Treatment: d/c atbx, supportive IVF, electrolyte correction, flagyl 250 mg qid, or vancomycin 125-250mg po qid(alternative regimen)
• 25% of patients will respond to supportive measures only
• Severely ill patients should hospitalized
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Pseudomembranous ColitisPseudomembranous Colitis
• Relapses occur in 10-20% of patients
• Use of anti-diarrheals should be avoided
• Surgery or steroids are rarely needed
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Pseudomembranous ColitisPseudomembranous Colitis
• Disposition:• Severe diarrhea, symptoms that persist
despite outpatient management, or those with systemic response(fever, leukocytosis, severe abdominal pain) should be hospitalized
• Suspected perforation, toxic megacolon or failure to respond to medical treatment need a surgical consult
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Pseudomembranous ColitisPseudomembranous Colitis
• For patients who are discharged whom: good oral intake must be encouraged. Flagyl or vancomycin are equally effective for treatment.
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DiverticulitisDiverticulitis
• Acute inflammation of the wall of a diverticulum and surrounding tissue
• Caused by either a micro- or macroperforation
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DiverticulitisDiverticulitis
• Epidemiology:
• Acquire disease of the colon has become common in industrialized nations
• Approximately 1/3 of population will acquire diverticuli by age 50 and 2/3 by age 85
• Rare <20 years
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DiverticulitisDiverticulitis
• Diverticulitis is estimated in 10-25% of people with known diverticulosis
• Incidence increases with age
• Only 2-4 % are < 40
• Diverticulitis in younger age is associated with more complications requiring surgical intervention
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DiverticulitisDiverticulitis
• Frequency is slightly higher in men, the incidence is on the rise in women
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DiverticulitisDiverticulitis
• Pathophysiology:
• Cause is not known
• Low residue diets have been implicated
• Acute complications: Inflammation(and associated complications) and Bleeding
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DiverticulitisDiverticulitis
• Inflammation is the most common complication of diverticulosis
• Mechanism was thought to occur when fecal material was inspissated in the neck of a diverticulum, resulting in bacterial proliferation, mucous secretion, and distention
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DiverticulitisDiverticulitis
• More commonly, it results from high pressure in the colon, erosion of diverticulum wall, microperforation, and inflammation.
• Free perforation can occur with generalized peritonitis, but is uncommon
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DiverticulitisDiverticulitis
• Other complications: obstruction and fistula formation between the bladder and diverticulum
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DiverticulitisDiverticulitis
• Clinical Features: most common symptom is pain.
• Described as steady, deep discomfort in the LLQ
• Other complaints: change in bowel habit, tenesmus, dysuria, frequency, UTI, distention, nausea, vomiting,
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DiverticulitisDiverticulitis
• Presentation may be indistinguishable for acute appendicitis
• Diverticulitis should always be considered in patient >50 with abdominal pain
• Perforation is characterized by sudden lower abdominal pain progressing general abdominal pain
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DiverticulitisDiverticulitis
• Physical exam: frequently fever of 38 C, localized abdominal tenderness, voluntary guarding, rebound, rectal tenderness on left side, possibly occult blood +,
• As always, Pelvic should be done with female
• Watch for signs of peritonitis or perforation
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DiverticulitisDiverticulitis
• Diagnosis: typically suspected by Hx and physical
• Abdominal plain films can show partial SBO, free air, extraluminal air
• CT is procedure of choice. Demonstrates inflammation of pericolic fat, diverticula, thickening of bowel wall, peridiverticular abscess
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DiverticulitisDiverticulitis
• Barium enema can be done, but are insensitive and may cause perforation due to the introduction of barium at high pressures
• Routine labs include: CBC, electrolytes, BUN/creatinine, UA
• Sigmoidoscopy and colonoscopy are performed only after inflammation has decreased
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DiverticulitisDiverticulitis
• Differential Dx:
• Similar to that of appendicititis, Crohn disease, UC, and C.difficile colitis
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DiverticulitisDiverticulitis
• Treatment:
• NPO, IVF, electrolyte correction, NG for obstruction, Broad spectrum atbx, observation for complications
• Outpatient management includes liquids only for 48 hours and oral antibiotics(Cipro, flagyl, bactrim, ampicillin)
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DiverticulitisDiverticulitis
• Disposition:
• Patients without signs of peritonitis or systemic infection maybe treated as outpatients with careful follow up arranged. Should be instructed to return for fever, increasing pain, unable to tolerate po.
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DiverticulitisDiverticulitis
• If patient shows signs of systemic infection, perforation or peritonitis then they should be hospitalized with a surgical consult
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Questions:Questions:
• 1. With a retrocecal appendix, the pain of acute appendicitis may localize to the right flank. (True or false)
• 2. Outpatient antibiotics is the standard treatment of acute appendicitis. (True or False)
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Questions:Questions:
• 3. Special populations of people that may have delayed diagnosis of acute appendicitis due to atypical presentation include:
• A.) very young patients• B.) elderly patients• C.) AIDS patients• D.) Pregnant patients• E.) all of the above
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Questions:Questions:
• 4. Crohn disease can involve:
• A.) any part of the GI tract(from mouth to anus
• B.) colon only
• C.) esophagus only
• D.) small intestine only
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Questions:Questions:
• 5. Ulcerative colitis and Crohn disease are both considered types of inflammatory bowel disease. (True or False)
• Answers: 1T, 2F, 3E, 4A, 5T