“Knife, Finger, Bougie” Cricothyrotomy Made Easy
Gastrointestinal Board Review with Dr. Edward Guo
A 40 year old female who works as a nurse aide in a long term rehabilitation center presents for abdominal pain and diarrhea. She describes greater than 3 episodes of loose, watery stool for the past 2 days with no vomiting or fever. Her vital signs are within normal limits. A Clostridium difficile stool toxin PCR is sent and results positive. According to the 2021 Infectious Disease Society of America guidelines, what is the preferred treatment for her condition?
A: IV vancomycin
B: PO fidaxomicin
C: PO metronidazole
D: PO vancomycin
Answer: PO fidaxomicin
The most recent IDSA guidelines for the treatment of non-fulminant Clostridium difficile diarrhea is fidaxomicin. It has shown superiority in preventing recurrence of disease when compared to oral vancomycin. Oral vancomycin or oral metronidazole are acceptable alternatives in non-fulminant disease and generally cost less than fidaxomicin. IV vancomycin is not used in the treatment of C. difficile diarrhea.
| Treatment of Clostridium Difficile Diarrhea in Adults | |
|---|---|
| Initial, non-fulminant | Fidaxomicin preferred PO vancomycin alternative |
| Recurrent, non-fulminant | Fidaxomicin or PO vancomycin |
| Fulminant | PO vancomycin or via NG tube and IV metronidazole |
References:
Stuart Johnson, Valéry Lavergne, Andrew M Skinner, Anne J Gonzales-Luna, Kevin W Garey, Ciaran P Kelly, Mark H Wilcox, Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults, Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044, https://doi.org/10.1093/cid/ciab549
Critically Appraised Topic by Dr. Rudenstein
What’s the Diagnosis? By Dr. Christine Hill
A 76-year-old male with a history of coronary artery disease presents with 3 months of abdominal pain. Patient first experienced nausea, vomiting, diarrhea, chills, and severe right lower quadrant abdominal pain approximately 3 months ago. Patient states the pain improved after several days of rest, a bland diet, and hydration. However, patient reported continued decreased appetite and weight loss of 15-20 pounds over the intervening months. The pain recurred approximately one month ago and did not improve with rest prompting patient to see his primary care physician. Patient was placed on oral amoxicillin–clavulanate and instructed to get a CT scan of the abdomen and pelvis. Patient presented to the emergency department following the CT. Vitals include BP 122/69, HR 60, SpO2 98% on RA, T 97.8F. Patient is well appearing with mild tenderness to palpation in the right lower quadrant.
An ultrasound is performed and shown below. What’s the diagnosis? How is the ultrasound performed? What else should you be considering given this patient’s history?
Answer: Appendicitis
Appendicitis Ultrasound:
Technique
- Probe – Linear probe often works best. Can consider curvilinear probe in those with larger body habitus.
- 1) Ask patient to point area of maximal tenderness and place linear probe on this area
- 2) Apply steady but gradually increasing pressure in this area to displace bowel gas and enable visualization
- 3) Appendix is typically anterior to psoas and iliac vessels and is a blind tubular structure that has no peristalsis
- 4) If not visualized over area of maximal tenderness can track up and down along iliac vessels to look for appendix
Pathologic findings
- 1) Dilation > 6 mm in transverse diameter
- 2) Non-compressible
- 3) May have surrounding edema and fecalith within the appendix
Appendicitis Ultrasound Pearls:
- Appendix can be hard to visualize due to body habitus, bowel gas, or because it is retrocecal. Tips to improve visualization:
- Have patient place right leg crossed over left
- Roll patient into left lateral decubitus
- Appendix can be hard to differentiate from terminal ileum
- Terminal ileum does not have a blind ending
- Terminal ileum will show peristalsis
- Always make sure to visualize the blind ending of the appendix
- Ultrasound “Rules In” appendicitis!
Patient ultimately taken to OR by surgery where appendix was removed and sent to pathology. Given patients presentation of chronic appendicitis couple with weight loss there was concern for appendiceal cancer. Pathology has not returned at this time.
Appendiceal Cancer Facts:
- Cancer of the appendix is observed in <2% of appendiceal specimens
- Most patients are asymptomatic but in those who experience symptoms 30% present with acute appendicitis
- History that should raise suspicion for appendiceal cancer include
- Appendicitis in a patient >50 yrs of age
- Chronic symptoms of appendicitis
- Weight loss and anorexia
References:
https://coreultrasound.com/appendicitis/
Uya, A., & Chaiaza, H. (2021, June 24). Appendicitis. ACEP Symbol. https://www.acep.org/sonoguide/advanced/appendicitis
Osueni A, Chowdhury YS. Appendix Cancer. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555943/
Headaches with Dr. Harwood
Case: A 63 y.o. female with PMH of migraines and chiari malformation presents with headache. Patient reports that for the past 10 days, she has had a right-sided migraine that she describes as similar in quality to her prior migraines but longer-lasting. However, at 2 PM yesterday, she experienced an acute worsening of the severity of her headache – additionally, the pain became bilateral and occipital at this time. The patient reports dizziness, nausea, and photophobia, and her husband states that the patient has been slower to respond to questions for the past day. Denies vomiting, visual changes, or fever.
Vitals: BP: 133/90 | Pulse: 71 | Temp: 98.1F | Respiratory Rate: 18 | SpO2: 99%
Exam: Neuro exam is non-focal. Patient appears tired, but responds to questions appropriately.
Clinical Course: Patient is given Tylenol, 10 mg IV Compazine, and 1 L lactated ringers with significant improvement in symptoms. Given change in headache quality from prior migraines and acute worsening of headache, CT Head without contrast ordered.
CT revealed a large hemorrhagic neoplasm in the right frontal region with associated mass effect and 1.2 cm leftward midline shift resulting in obstructive hydrocephalus. Patient subsequently noted to be increasingly somnolent compared to initial presentation. Neurosurgery was consulted who recommended decadron, Keppra for seizure prophylaxis, and admission to the ICU.
Headache Pearls: The majority of headaches are due to primary headaches such as tension headache, migraine, or cluster headache. However, as 18% of patients with chief complaint of headache may be experiencing a secondary headache disorder. Many of these secondary headaches represent life-threatening emergencies such as intracranial bleeding or CNS infection. The SNOOP mnemonic is a helpful tool for remembering “red flag” headache symptoms to identify headache patients who warrant further imaging/laboratory work-up in the ED. Additionally, improvement in symptoms with medication does not decrease the likelihood of a secondary headache disorder.
Systemic: Systemic signs or conditions such as fever, weight loss, immunocompromised, HIV, cancer
Neuro: Neurologic findings including mental status changes, vision changes, seizure, confusion, or focal neuro findings on exam
Onset: Onset that is acute with progression to worst severity within minutes
Older: Older patient (50 y.o. or older) with new headache or a progressive headache
Previous: No history of previous headaches, or in a patient with history of headaches, a change in severity/symptoms/location from prior headaches
Pregnancy: Headache in pregnant or post-partum patient
References:
Ashenburg Nick, Marcolini Evadne, Hine Jason. Approach to Headache. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/rec8eRzSrPsVUiMuV/Approach-to-Headache#h.pq7xksb5a2qy. Updated October 8, 2022. Accessed December 22, 2023.
Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:87–92.
Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697
From the Archives: Acute Signs Board Review with Dr. Christine Collins
A 50 year old male presents with 4 weeks of diarrhea and associated abdominal pain described as cramping. He reports multiple episodes of pale, loose and malodorous stools daily. He recently went fishing. His vitals are as followed: 70 bpm, BP: 125/80, RR 18, PO2: 98%. Temp 37.2. What vitamin deficiency would you worry about in this patient?
A. Vitamin
B. Niacin
C. Vitamin C
D. Riboflavin
Answer: Riboflavin
This patient is presenting with signs and symptoms consistent with giardiasis. Patients can have malabsorption and steatorrhea, and chronic infection can result in deficiency of fat soluble vitamins A, D, E, and K. Malabsorption can also lead to deficiency in Vitamin B12 and folate.
Giardiasis is the most common cause of parasitic diarrheal infection in the US and is transmitted by fecal-oral route. It is associated with streams and daycares. Classic symptoms include, colicky abdominal pain and pale, loose, malodorous stools. Treatment is metronidazole.
References:
Bjoernsen, L. P., & Ebinger, A. (2016). Chapter 159 Foodborne and Waterborne Diseases In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8th ed). New York, NY: McGraw-Hill Education.
Critically Appraised Topic by Dr. Rudenstein
From the Archives: What’s the Diagnosis? By Dr. Loran Hatch
A 62 year old male presents to the ED with 1 week of abdominal distension with associated nausea and vomiting. He has had only 2 small bowel movements in the last week. He denies abdominal pain. On exam, his abdomen is distended and rigid. An obstruction series is obtained and shown below. What’s the diagnosis?
Answer: multiple air-fluid levels concerning for obstruction
- CT A/P obtained (shown below) – diagnosis of Large bowel obstruction
- Most common cause of large bowel obstruction = neoplasm/mass
- Other causes: diverticulitis, sigmoid or cecal volvulus
- Other uncommon causes: adhesions, hernias, IBS, fecal impaction, intraluminal FB, intussusception
- LBO are less common than SBO
- Presenting sypmtoms: abdominal pain/distension, constipation
- CT A/P w/ IV contrast is imaging modality of choice
- Most require surgery
- Ogilvie Syndrome: acute colonic psuedo-obstruction due to loss of sympathetic innervation of colon (no actual mechanical obstruction)
- Usually seen in severely ill patients with multiple comorbidities
- CT shows marked dilatation of the large bowel without any evidence of a marked transition point or obstructing lesion
References:
Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic radiographic and CT findings, etiology and mimics. Radiology. 2015 June;275(3):651-63.
Price TG, Orthober RJ. Bowel Obstruction. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 538-41
Advanced Cases – DKA Emergency!
Submitted by Kevin Anderson MD PGY1
HPI
A 63-year-old male with PMH diabetes type 2 and renal failure presents to the ED via EMS with AMS. The patient’s family noted the patient had been feeling ill over the last week, causing him to miss 2 dialysis sessions. Patient has been taking insulin as prescribed. Today, the patient was confused and lethargic with LOC. EMS noted the patient’s blood glucose to be >600.
Vitals HR: 90, BP: 110/70, RR: 30, SpO2: 100%, Rectal Temp: 94F
The patient has peaked T-waves on ECG
Patient is initially given calcium gluconate for suspected hyperkalemia and IVF for suspected Sepsis/DKA. Patient’s labs result:
VBG: pH 6.96, pCO2 20, pO2 41, HCO3 6, K 7.4
BMP: Glucose 1227, BUN 120, Cr 5.90, Na 123, K (hemolyzed), Cl 84, CO2 4, Anion Gap 35
Beta-Hydroxybutyrate: 8.18
Lactate: 2.2
Clinical Course
Patient given additional doses of calcium gluconate for hyperkalemia and IVF for worsening hypotension. Insulin bolus and drip started. Sodium Bicarbonate was given for severe acidosis. Patient started on broad-spectrum antibiotics for sepsis as suspected cause of DKA. Patient was admitted to the ICU for diabetic ketoacidosis and continued to receive insulin until anion gap closed. UTI secondary to urinary retention was identified as the cause of sepsis.
DKA Pearls
Diabetic ketoacidosis is usually secondary to insulin non-adherence or infection DKA is the result of decreased serum insulin, increased gluconeogenesis, accelerated glycogenolysis, and impaired glucose utilization. Utilizing fatty acid metabolism for energy production
Of note, whole-body potassium will be depleted through osmotic diuresis Serum levels may be normal due to large potassium shift into serum- except in patients with renal failure (like this one!) Potassium must be checked and replaced to >3.3 before giving insulin, otherwise patient may go into respiratory arrest, cardiac arrhythmias, or cardiac arrest!
Patients will be tachypneic (Kussmaul respirations), trying to breathe off CO2 to compensate for their metabolic acidosis! AVOID intubating these patients as even seconds of hypoxia will interrupt this crucial compensatory mechanism.
References
Diabetic Ketoacidosis
https://www.emrap.org/episode/icufundamentals/thefulltalk
From the Archives: Peptic Ulcer Disease and Gastritis by Dr. Angela Ugorets and Dr. Karen O’Brien
Peptic Ulcer Disease
Chronic illness, recurrent ulcers in stomach and duodenum most commonly due to H. Pylori and NSAIDs. 10% people in the western world will have this in their lifetime.
Symptoms:
- Burning, gnawing, achy, “empty, hungry” epigastric pain
- Relieved by ingestion of food (usually), milk, antacids (buffers/dilutes gastric acid)
- Worsens after gastric emptying, classically the pain awakens patients at night
- Chronic ulcers can be asymptomatic or cause painless GI bleeding
- NOT (usually) related to PUD: pain after eating, nausea, belching
- “Alarm features” for suspicion of cancer –> need more emergent endoscopy: >50 yo, weight loss, persistent vomiting, dysphagia/odynophagia, GIB, abdominal mass, lymphadenopathy, Family hx
Physical Exam: For uncomplicated PUD, expect benign physical exam +/- epigastric tenderness (not sensitive or specific). VS should be normal.
Workup: Generally includes CBC to rule out anemia from chronic GIB. Consider LFT, lipase, EKG, trop, upright CXR, RUQ US to rule out other etiologist that may present similarly with epigastric pain if indicated. Gold standard for diagnosis is endoscopy.
Treatment:
- Stop NSAIDs
- Proton pump inhibitors: decrease acid secretion from gastric parietal cells, irreversibly bind with H+K+ATPase (proton pump).
- Example: omeprazole, pantoprazole.
- Heal ulcers faster than any other tx.
- H2 receptor antagonists: Inhibit action of histamine on H2 receptor on gastric parietal cells
- Example: famotidine, ranitidine.
- Dose should be adjusted for patients in renal failure.
- Sucralfate: covers ulcer crater, protects it and allows healing, but doesn’t relieve pain as well
- Antacids: buffer gastric acid. Use for breakthrough pain. (Ex: Mylanta, Rolaids, Tums, etc)
Dispo: As long as uncomplicated (no bleed, obstruction, perforation, etc), can be discharged from ED with Rx for meds above and referral to PCP or GI.
Gastritis
- Not the same as PUD
- Acute or chronic inflammation of gastric mucosa (not discrete ulcers)
Causes: ischemia, toxic effects of NSAIDs, steroids, bile, alcohol, H. Pylori, autoimmune processes that destroy gastric parietal cells
Exam: epigastric pain, N/V. Often presents with GIB: hematemesis vs chronic anemia vs melena
References:
Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015 Feb 15;91(4):236-42. PMID: 25955624.
Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009 Oct 24;374(9699):1449-61. doi: 10.1016/S0140-6736(09)60938-7. Epub 2009 Aug 13. PMID: 19683340.