Tuesday Advanced Cases

Advanced Cases – Complications of IBD!

Allison Cash M.D.

HPI

  • 42 year old male with history of Crohn’s
  • Presented with 5 days LLQ pain, fevers, chills, diarrhea
  • Denied hematochezia/melena, vomiting

Physical Exam

  • BP 136/82  | Pulse 77  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 16  | SpO2 98%
  • Exam: patient uncomfortable appearing, LLQ pain with no rebound or guarding

Work-up

  • CBC, BMP unremarkable
  • CT A/P with bowel wall thickening and multiple pericolonic abscesses

Hospital Course

  • Patient admitted to surgery and started on IV Zosyn
  • IR consulted for abscess drainage
  • Transitioned to oral Augmentin, diet advanced, discharge home

IBD complications pearls

References:

  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.
  2. Maaser C, Sturm, et al. European Crohn’s and Colitis Organisation [ECCO] and the European Society of Gastrointestinal and Abdominal Radiology [ESGAR] ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019 Feb 01;13(2):144-164.
Friday Board Review

Board Review by Dr. Edward Guo (Edited by Dr. Parikh)

A 30 year old male with a history of cardiac arrest with ischemic encephalopathy status post tracheostomy and gastrostomy placement presents from a long-term care facility for a feeding tube problem. His nurse was bathing and performing dressing changes when the patient’s gastrostomy tube fell out. He has otherwise had no fever or vomiting, and his last bowel movement was earlier today. Vital signs are within normal limits. On exam, he appears comfortable. Patient is non-verbal and does not follow commands. There is a patent gastrostomy stoma in his left upper quadrant with no surrounding erythema or drainage. Old charts state that general surgery created the gastrostomy 6 weeks ago with a 16-french tube. Which of the following is the most appropriate initial management?

A: Consult General Surgery for gastrostomy tube replacement

B: CT abdomen and pelvis

C: insert a 14-french gastrostomy tube

D: insert a 16-french gastrostomy tube

Answer: Insert a 16-french gastrostomy tube

Artificial stomas are at risk for premature closure if the tube has been accidentally removed. Closure may begin quickly (within hours) depending on how mature the tract is. It is important for the emergency physician to be knowledgeable of the maturity of different surgical stomas and when consultation is necessary. In general, gastrostomy tracts mature after 2 to 3 weeks and then afterward can be replaced in the emergency department. Using the previous size tube is preferred to prevent leakage around the tract with a smaller diameter tube. CT of the abdomen and pelvis is unlikely to change management given the patient is asymptomatic. If the gastrostomy tract is immature or a 16-french tube is difficult to insert, then it would be indicated to consult general surgery for replacement. Do not attempt to push through resistance due to the risk of creating a false tract. In that case, attempting to insert a smaller size tube is advised to keep the original tract patent.

Type of Surgical StomaTime to Mature
Tracheostomy7 to 10 days
Gastrostomy2 to 3 weeks
Cystostomy (suprapubic)4 to 6 weeks (little evidence, varies based on provider)

References:

Witting MD. Gastrointestinal Procedures and Devices. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
Buscaglia  JM: Common issues in PEG tubes—what every fellow should know. Gastrointest Endosc 64: 970, 2006. [PubMed: 17140906]

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 27 year old male presents for a right shoulder injury. He was attempting to break up a fight between his dogs when his right arm was pulled and he felt a “pop” in his right shoulder. He has been unable to move his right shoulder since and there is severe pain that is worse with movement. His vitals are within normal limits. On exam, the right upper extremity is neurovascularly intact. There is an obvious deformity of the right shoulder with severely reduced range of motion. An x-ray is performed and shown below. What’s the diagnosis?

Answer: Anterior shoulder dislocation

  • Anterior dislocations of the shoulder are the most common type, approximating 99%. The mechanism typically occurs from forced abduction and external rotation. 
  • Exam will show a “squared off” appearance of the normal round contour of the shoulder and guarding of the arm in slight abduction and external rotation. The axillary nerve, which provides sensation to the proximal arm and shoulder, is most commonly injured.
  • Diagnosis is obtained with plain radiographs. A scapular “Y” view shown on the right can help confirm anterior vs posterior in unclear cases.
  • Treatment of simple cases involves closed reduction in the ED. There are various methods which can be achieved with or without sedation.
    • Examples that do not require sedation: Cunningham, Davos, Fares,
    • Examples that typically require sedation: Kocher, Traction-Countertraction
    • Complications include recurrent dislocations (most common) and bony injuries such as Hill-Sachs and Bankart lesions

References:

Bjoernsen L, Ebinger A. Shoulder and Humerus Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Friday Board Review

Board Review by Dr. Guo (Edited by Dr. Parikh)

A 40 year old female with a history of kidney stones with a left ureteral stent placed 2 years ago presents for urinary pain associated with increased urge and frequency. She denies fever or flank pain. It does not feel similar to her previous kidney stones. Vital signs are within normal limits. On exam, she is comfortable appearing and has mild suprapubic tenderness to palpation. Point-of-care pregnancy test is negative. Urinalysis results with 3+ leukocyte esterase, 2+ nitrites, and 105 WBCs/HPF. Which of the following is the appropriate management of this patient’s condition?

A: Admit for IV antibiotics

B: Consult urology for stent removal

C: CT of the abdomen and pelvis

D: Discharge with oral antibiotics

Answer: discharge with oral antibiotics

This patient is presenting with findings consistent with acute cystitis, a urinary tract infection localized to the bladder. Urinalysis findings with elevated leukocyte esterase, nitrites, and WBCs with clinical symptoms are supportive of the diagnosis. Treatment of minor urinary tract infections in patients with ureteral stents is oral antibiotics and do not require stent removal. If pyelonephritis or systemic infection with a ureteral stent is suspected, consultation with urology, IV antibiotics, and radiographic imaging to determine the location of the stent is warranted. 

References:

Askew KL. Urinary Tract Infections and Hematuria. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Josephson EB, Azan B. Complications of Urologic Procedures and Devices. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Wednesday Image Review

What’s the Diagnosis? By Jake Barr, MS3

The patient is a 40-year-old male with no past medical history who presents with concerns of a rash on his hands. He states that the lesions appeared two days ago, but had a fever, muscle aches, and pruritis two days before that. He does not have a history of hives or contact dermatitis. He does not take any medications, but states he recently developed “cold sores.” His temperature is 100.6oF, but his other vitals are within normal limits. The cutaneous rash is demonstrated below. When looking in his mouth, blistering lesions are also present. What the diagnosis and management?

Answer: Erythema Multiforme

  • Erythema multiforme is the result of a T-cell mediated hypersensitivity reaction resulting in a characteristic pruritic, targetoid papules, with a hazy-center, and surrounding erythematous rings.
  • 90% of cases are associated with infectious etiologies, with HSV-1 being most common in adults and Mycoplasma pneumonia in children.
    • Remaining 10% are due to drugs (NSAIDs, antiepileptics, antibiotics), malignancy, and autoimmune diseases. Their mechanism of rash formation is unknown.
  • There are two specific subtypes:
    • Erythema multiforme minor: rash without mucosal involvement or constitutional symptoms
    • Erythema multiforme major: rash with mucous membrane involvement and constitutional symptoms (fever, malaise, myalgias etc.)
  • Diagnosis is often clinical, but immunofluorescence can be helpful if uncertain.
    • PCR testing for both HSV and Mycoplasma pneumoniae should be done if suspected.
  • Treatment is mostly symptomatic, and the rash is usually self-limited.
    • Antihistamines are useful for pruritis.
    • Systemic steroids maybe be used, but the impact on long-term outcomes and symptom duration is unclear.
    • Acyclovir may be used to prevent recurrent HSV infections.
    • Macrolides may be used in Mycoplasma pneumoniae is suspected.

References:

  1. Baluzy Matthew, Karaze Tallib. Maculopapular Rashes. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recvFPlc0BmXxYuzp/Maculopapular-Rashes#h.til8vwjxmfh6. Updated June 21, 2023. Accessed January 24, 2024.
  2. Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol. 2012;51(8):889-902. doi:10.1111/j.1365-4632.2011.05348.x
  3. Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019;100(2):82-88.
  4. J. Brady W, Pandit A, R. Sochor M. Generalized Skin Disorders. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed January 24, 2024. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180403
  5. DermNet. https://dermnetnz.org/topics/erythema-multiforme-images