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.
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
With vascular compromise.Pathophysiology
Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed. epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.
Increased pressure also leads to arterial stasis and tissue infarction End result is perforation and spillage of infected appendiceal contents into the peritoneum
This pain is generally vague and poorly localized.
. which enter at the 10th thoracic vertebral level.Pathophysiology
Initial luminal distention triggers visceral afferent pain fibers. Pain is typically felt in the periumbilical or epigastric area.
innervating the peritoneal structures.Pathophysiology
As inflammation continues. the serosa and adjacent structures become inflamed This triggers somatic pain fibers. Typically causing pain in the RLQ
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.
the appendix ca be shifted and patients can present with RUQ pain
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.
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
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
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
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
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
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
voluntary guarding. muscular rigidity. tenderness on rectal
Additional components that may be helpful in diagnosis: rebound tenderness.
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
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
Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy
Women of child bearing age need a pelvic exam and a pregnancy test. Additional studies: CBC. UA. imaging studies
CBC: the WBC is of limited value. Sensitivity of an elevated WBC is 70-90%. But. but specificity is very low. +predictive value of high WBC is 92% and ±predictive value is 50% CRP and ESR have been studied with mixed results
bacteruria Presence of >20 wbc per field should increase consideration of Urinary tract pathology
UA: abnormal UA results are found in 1940% Abnormalities include: pyuria. hematuria.
CT Xrays of abd are abnormal in 24-95% Abnormal findings include: fecalith. appendiceal gas.Diagnosis
Imaging studies: include X-rays. US. and free air Abdominal xrays have limited use b/c the findings are seen in multiple other processes
. blurred right psoas. localized paralytic ileus.
Graded Compression US: reported sensitivity 94.7% and specificity 88. periappendiceal abscess
.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.
perforations may be missed due to return to normal diameter
Limitations of US: retrocecal appendix may not be visualized.
CT: best choice based on availability and alternative diagnoses.
. -predictive value Even if appendix is not visualized. In one study. accuracy. CT had greater sensitivity. diagnose can be made with localized fat stranding in RLQ.
but it is not as useful for changing management in men.
CT appears to change management decisions and decreases unnecessary appendectomies in women.
Very young. 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
. pregnant. very old.
given IVF. and preoperative antibiotics Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation
Appendectomy is the standard of care Patients should be NPO.
enterococci and gram(-) intestinal flora coverage One sample monotherapy regimen is Zosyn 3.375g or Unasyn 3g Also.Treatment
There are multiple acceptable antibiotics to use as long there is anaerobic flora. short acting narcotics should be used for pain management
benefit from imaging and 46h observation with surgical consult if serial exam changes or imaging studies confirm
Abdominal pain patients can be put in 4 groups Group 1: classic presentation for Acute appendicitis. but not diagnosed appendicitis.prompt surgical intervention Group 2: suspicious.
and they should be seen by PCP in 12-24 h Also advised to avoid strong analgesia
. 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.Disposition
Group 3: remote possibility of appendicitisobserve in ED for serial exams.
pregnant and immunocomprimised).require high index of suspicion and low threshold for imaging and surgical consultation
Group 4: high risk population(including elderly. pediatric.
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.Crohn Disease
Chronic granulomatous inflammatory disease of the GI tract. granulomatous ileocolitis
. terminal ileitis.
. Autoimmune destruction of mucosal cells as a result of cross-reactivity to antigens from enteric bacteria.Crohn Disease
Etiology and pathogenesis are unknown. environmental factors have been implicated.
Cytokines.including IL and TNF have been implicated in perpetuating the inflammatory response. Anti-TNF(remicade) drugs have shown efficacy in treating Crohn 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 nonJews More common in whites vs blacks 10-15% have family hx
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. and abscesses
Clinical features: variable and unpredictable Abd pain. anorexia. and weight loss are present in most cases 1/3 of patients develop perianal fissures or fistulas. or rectal prolapse
obstipation. uveitis. or liver disease Crohn¶s should also be considered when evaluating FUO
. intraabdominal abscess with fever 10-20% have extraabdominal features such as: arthritis.Crohn Disease
Patients may present with lat complications including: Obstruction. crampy abd pain.
30% involves only small bowel. 30% only colon.Crohn Disease
Clinical course and manifestation depends of anatomic distribution. and 50% involves both
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
Dermatologic complications: erythema nodosum and pyoderma gangrenosum Ocular: episcleritis and uveitis Hepatobiliary: pericholangitis. chronic hepatitis. cholangiocarcinoma. pancreatitis. primary sclerosing cholangitis. gallstones
arteritis Other: anemia. myeloplastic disease. osteomyelitis. hyperoxaluria leading to nephrolithiasis.Crohn Disease
Vascular: thromboembolic disease. vasculitis. malnutrition. osteonecrosis
or the skin
. cecum.Crohn 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. another ileal segment.
amount of pain or weight loss GI bleed is common. but only 1% develop life threatening hemorrhage.Crohn Disease
Fistulas should be suspected when there is a change in bowel movement frequency. Toxic megacolon occurs in 6% of patients and results massive GI bleed 50% of the time
thrombocytopenia. liver failure. diarrhea.
. immunosuppressive agents. fever. renal insufficiency. pancreatitis.Crohn Disease
Complications can also arise from the treatment of the disease Sulfasalazine. steroids. infection. and antibiotics can cause leukopenia.
Incidence of malignancy is 3 times higher in Crohn disease than in general population
Diagnosis: history. air-contrast barium enema and colonoscopy Characteristic radiologic findings in small intestine include: segmental narrowing. Upper GI. destruction of normal mucosal pattern. and fistulas.
occurrence of colon ca.Crohn Disease
Colonoscopy is most sensitive for patients with colitis Useful for detecting mucosal lesions. defining extent of involvement. Abd CT is most useful for acute presentation
local abscess formation suggest Crohn disease.
. mesenteric edema.Crohn Disease
Findings of bowel wall thickening.
Yersinia. campylobacter. ulcerative colitis.diff. GI TB. deep chronic mycotic infections involving GI tract.
. ileocecal amebiasis. C. ischemic colitis. Kaposi¶s sarcoma.Crohn Disease
Differential Dx: lymphoma. sarcoidosis.
induction of remission. emphasis should be placed of relief of symptoms and preventing complications
Tx: relief of symptoms. optimizing timing of surgery. prevention of complications. maintenance of remission. and maintenance of nutrition Since the disease is virtually incurable.
perforation or toxic megacolon
. identifying possible complications such as obstruction. hemorrhage. BUN/creatinine. toxic megacolon. CBC. abscess.Crohn Disease
Initial ED management: focus on severity of attack. electrolytes. and type and cross if appropriate Plain films may be useful for obstruction.
aminoglycoside. and flagyl) should be used for suspected fulminant colitis or peritonitis
Initial Tx: NPO. broad spectrum atbx(ampicillin or a cephalosporin. IVF resuscitation and correction of electrolytes NG decompression if indicated.
although it has many toxic side effects
. methylprednisone 48mg qd.Crohn Disease
IV steroids: hydrocortisone 300mg qd. or prednisolone 60mg qd should be used for severe disease Sulfasalazine 3-4g qd can be effective for mild-moderate cases.
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
IL therapy may also be beneficial
. etanercept. thalidomide.Crohn 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.
Diarrhea can be controlled using imodium. or questran
obstruction. dehydration. significant hemorrhage. peritonitis. electrolyte/fluid imbalance should be hospitalized under the care of a surgeon or gastroenterologist
Disposition: patients with signs of fulminant colitis.
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.
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
First degree relatives have 15 fold increase for UC and 3.Ulcerative Colitis
Epidemiology: similar to Crohn disease More prevalent in US and northern Europe.5 fold increase for Crohn disease
and mucosal ulceration Early stages mucosa membrane appears finely granular and friable Severe cases show large oozing ulcerations and pseudopolyps
Pathology: involves mucosa and submucosa Mucosal inflammation and formation of crypt abscesses. epithelial necrosis.
anemia. low albumin.Ulcerative Colitis
Clinical features: Mild: <4 bm per day. fever. and few extraintestinal manifestations. (account for 60% of all UC patients) Severe: frequent bm¶s. wt loss. no systemic symptoms. frequent extraintestinal manifestations. (accounts for 15% of all patients and 90% of mortality)
Typically have left sided colitis. but can have pancolitis.Ulcerative Colitis
Moderate: manifesations are less severe and respond well to treatment.
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. and onset of disease after 60
. short interval between attacks.
pyoderma gangrenosum.Ulcerative Colitis
Extraintestinal complications: arthritis. erythema nodosum. liver disease(similar to that found in Crohn disease)
. episcleritis. ankylosing spondylitis. uveitis.
colon ca. perirectal abscesses and fistulas.Ulcerative Colitis
Complications: hemorrhage. toxic megacolon. perforation
Diagnosis is made by Hx of abd cramps and diarrhea. friable. negative stool cultures confirmation of disease by colonoscopy showing granular. ulceration of the mucosa.Ulcerative Colitis
Dx: lab findings are nonspecific. mucoid stools. and sometimes pseudopolyps
. stool negative for ova/parasites.
Also be aware of STD¶s when confined to the rectum
Differential Dx: similar to that of Crohn disease.
fluid replacement. 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
Treatment: Severe UC: IV steroids. electrolyte correction.
proctosigmoiditis. and left side colitis can be treated with 5aminosalicylic acid enemas or topical steroid preparations
Mild to moderate: majority of cases can be treated as outpatient with daily prednisone 40-60mg Active proctitis.
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
Disposition:Fulminant attacks should be hospitalized for aggressive IVF and elctrolyte correction. Instructions on when to return should be given
. Complications should be managed with appropriate surgical or GI consult Mild-moderate: may be discharged with close follow up secured.
Inflammatory bowel disorder with membrane-like yellowish plaques of exudate overlie and replace necrotic intestinal mucosa
severe medical illness. post-operative and antibiotic associated Risk factors: recent atbx.Pseudomembranous Colitis
Epidemiology: Clostridium Difficile. GI surgery. advancing age Transmission: direct contact and objects
.spore forming obligate anaerobic bacillus 3 types: neonatal.
Pathophysiology: 10-25% of hospital patients are colonized Diarrhea in recently hospitalized person should suggest C. amp/amox.alter gut flora and allow C.difficile
.difficile Broad spectrum atbx such as clindamycin.difficile to flourish However any atbx can lead to C. cephalosporins.
difficile produces toxin A enterotoxin toxin B cytotoxin Toxins interact and produce the colitis and associated symptoms
hypovolemia Stool exam may reveal fecal leukocytes
. fever. leukocytosis. dehydration. abdominal pain.Pseudomembranous Colitis
Clinical features: from frequent mucoid. watery stools to profuse toxic diarrhea(>20-30 stools/day).
bowel perforation Onset is typically 7-10 days after starting atbx therapy
. hypotension. anasarca from low albumin. toxic megacolon.Pseudomembranous Colitis
Complications: severe electrolyte imbalance.
Extraintestinal complications are rare. prostheitc device infection
. visceral abscesses. necrotizing fasciitis. osteomyelitis. but include: arthritis.
Diagnosis: hx of diarrhea that develops during or within 2 weeks of atbx treatment.difficile toxin and colonoscopy Most labs use ELISA to detect C. Confirmed by stool for C.difficile toxins even though there are many other modes 5-20% of patients require more than one stool to diagnose
electrolyte correction.Pseudomembranous Colitis
Treatment: d/c atbx. flagyl 250 mg qid. supportive IVF. or vancomycin 125-250mg po qid(alternative regimen) 25% of patients will respond to supportive measures only Severely ill patients should hospitalized
Relapses occur in 10-20% of patients Use of anti-diarrheals should be avoided Surgery or steroids are rarely needed
leukocytosis. or those with systemic response(fever.Pseudomembranous Colitis
Disposition: Severe diarrhea. symptoms that persist despite outpatient management. toxic megacolon or failure to respond to medical treatment need a surgical consult
. severe abdominal pain) should be hospitalized Suspected perforation.
For patients who are discharged whom: good oral intake must be encouraged. Flagyl or vancomycin are equally effective for treatment.
Acute inflammation of the wall of a diverticulum and surrounding tissue Caused by either a micro.
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
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
Frequency is slightly higher in men. the incidence is on the rise in women
Pathophysiology: Cause is not known Low residue diets have been implicated Acute complications: Inflammation(and associated complications) and Bleeding
mucous secretion. and distention
. resulting in bacterial proliferation.Diverticulitis
Inflammation is the most common complication of diverticulosis Mechanism was thought to occur when fecal material was inspissated in the neck of a diverticulum.
and inflammation. but is uncommon
. erosion of diverticulum wall. Free perforation can occur with generalized peritonitis.Diverticulitis
More commonly. it results from high pressure in the colon. microperforation.
Other complications: obstruction and fistula formation between the bladder and diverticulum
frequency. tenesmus. distention. deep discomfort in the LLQ Other complaints: change in bowel habit. nausea. vomiting. Described as steady.Diverticulitis
Clinical Features: most common symptom is pain.
. UTI. dysuria.
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
Pelvic should be done with female Watch for signs of peritonitis or perforation
Physical exam: frequently fever of 38 C. voluntary guarding. rebound. rectal tenderness on left side. localized abdominal tenderness. As always. possibly occult blood +.
Demonstrates inflammation of pericolic fat. free air. peridiverticular abscess
. extraluminal air CT is procedure of choice.Diverticulitis
Diagnosis: typically suspected by Hx and physical Abdominal plain films can show partial SBO. diverticula. thickening of bowel wall.
Barium enema can be done. BUN/creatinine. UA Sigmoidoscopy and colonoscopy are performed only after inflammation has decreased
. electrolytes. but are insensitive and may cause perforation due to the introduction of barium at high pressures Routine labs include: CBC.
UC. and C.difficile colitis
Differential Dx: Similar to that of appendicititis. Crohn disease.
bactrim. flagyl. electrolyte correction. IVF. NG for obstruction.Diverticulitis
Treatment: NPO. ampicillin)
. observation for complications Outpatient management includes liquids only for 48 hours and oral antibiotics(Cipro. Broad spectrum atbx.
Disposition: Patients without signs of peritonitis or systemic infection maybe treated as outpatients with careful follow up arranged. increasing pain. Should be instructed to return for fever.
. unable to tolerate po.
If patient shows signs of systemic infection. perforation or peritonitis then they should be hospitalized with a surgical consult
(True or False)
. Outpatient antibiotics is the standard treatment of acute appendicitis. the pain of acute appendicitis may localize to the right flank. (True or false) 2. With a retrocecal appendix.Questions:
) all of the above
3.) Pregnant patients E.) AIDS patients D. Special populations of people that may have delayed diagnosis of acute appendicitis due to atypical presentation include: A.) elderly patients C.) very young patients B.
) small intestine only
4.) any part of the GI tract(from mouth to anus B.) esophagus only D.) colon only C. Crohn disease can involve: A.
5. (True or False) Answers: 1T. 3E. Ulcerative colitis and Crohn disease are both considered types of inflammatory bowel disease. 5T