Rosen & Barkin's 5-Minute Emergency Medicine Consult (174 page)

FOLLOW-UP

• Patients with severe abdominal pain, nausea, and emesis
  
• Neurologically impaired, elderly, morbidly obese who cannot be cleaned out in the ED or home
  
• Bowel obstruction/peritonitis
  

• No co-morbid illness requiring admission
  
• Pain free
  
• Adequately cleaned out
  

GI follow-up for further evaluation and treatment

Primary care or GI follow-up for patients with longstanding constipation

• Advise patients regarding appropriate dietary and lifestyle changes to decrease incidence of constipation.
  
• Perform thorough history and physical exam to exclude significant medical or surgical etiologies for constipation.
  

• Doody DP, Flores A, Rodriguez LA. Evaluation and management of intractable constipation in children.
  Semin Colon Rectal Surg
  . 2006;17(1):29–37.
  
• Ford AC, Talley NJ. Laxatives for chronic constipation in adults.
  BMJ.
  2012;345:e6168.
  
• Leung L, Riutta T, Kotecha J, et al. Chronic constipation: An evidence-based review.
  J Amer Board of Fam Med
  . 2011;24(4):436–451.
  
• Talley N. Differentiating functional constipation from constipation-predominant irritable bowel syndrome: Management implications.
  Rev Gastroenterol Disord
  . 2005;5(1):1–9.
  
• Wexner SD, Pemberton JH, Beck DE, et al., eds.
  The ASCRS Textbook of Colon and Rectal Surgery
  . Springer; 2007.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abdominal Pain
  
• Bowel Obstruction
  

CODES

• 564.00 Constipation, unspecified
  
• 564.09 Other constipation
  
• 564.8 Other specified functional disorders of intestine
  

BASICS

• Irritant:
  
  • Immediate eczematous eruption (superficial inflammatory process primarily in epidermis)
    
  • Most common type of dermatitis
    
  • Trigger substance itself directly damages the skin resulting in nonimmunologic inflammatory reaction with erythema, dryness, cracking, or fissuring
    
  • Usually owing to repeated exposure to mild irritant (e.g., water, soaps, heat, friction)
    
  • Lesions itch or burn:
    
    • Usually gradual onset with indistinct borders
      
    • Most often seen on hands
      
    • May see vesicles or fissures
      
    • Dry, red, and rough skin
      
    • Common irritants include cement, hair dyes, wet diapers, rubber gloves, shampoos, frequent hand washing
      
• Allergic:
  
  • Delayed (type IV) hypersensitivity reaction (requires prior sensitization)
    
  • Allergen-induced immune response
    
  • Local edema, vesicles, erythema, pruritus, or burning
    
  • Usually corresponds to exact distribution of contact (e.g., watchband)
    
  • Onset usually within 12–48 hr with prior sensitization; may take 14–21 days for primary exposure
    
  • Common sources: Nickel, gold, neomycin, bacitracin, preservatives, fragrances, dyes, poison ivy
    
• Photocontact:
  
  • Interaction between an otherwise harmless substance on the skin and UV light
    
  • Common sources: Shaving lotions, sunscreens, sulfa ointments, perfumes.
    

• Allergic contact dermatitis is less frequent in children, especially infants, than in adults
  
• Major sources of pediatric contact allergy:
  
  • Metals, shoes, preservatives, or fragrances in cosmetics, topical medications, and plants
    
  • Diaper dermatitis: Prototype for irritant contact dermatitis in children
    
• Circumoral dermatitis: Seen in infants and small children; may result from certain foods (irritant or allergic reaction)
  

• Irritant (80% of contact dermatitis), e.g.:
  
  • Soaps, solvents
    
  • Chemicals
    
  • Certain foods
    
  • Urine, feces
    
  • Diapers
    
  • Continuous or repeated exposure to moisture (hand washing)
    
  • Course paper, glass, and wool fibers
    
  • Shoe dermatitis: Common; identify by lesions limited to distal dorsal surface of foot usually sparing the interdigital spaces
    
• Allergic:
  
  • Plants, poison ivy, oak, sumac (rhus dermatitis):
    
    • Most common form of allergic contact dermatitis in North America
      
    • Direct: Reaction to oleoresin urushiol from plant
      
    • Indirect: Contact with pet or clothes with oleoresin on surface or fur or in smoke from burning leaves
      
    • Lesions may appear up to 3 days after exposure with prior sensitization (12–21 days after primary exposure) and may persist up to 3 wk
      
    • Fluid from vesicles is not contagious and does not produce new lesions
      
    • Oleoresin on pets or clothes remains contagious until removed
      
  • Cement (prolonged exposure may result in severe alkali burn)
    
  • Metals (especially nickel)
    
  • Solvents, epoxy
    
  • Chemicals in rubber (e.g., elastic waistbands) or leather
    
  • Lotions, cosmetics
    
  • Topical medications (e.g., neomycin, hydrocortisone, benzocaine, paraben)
    
  • Some foods
    
  • Ability to respond to certain antigens is probably genetically determined
    
• Photodermatitis:
  
  • Inflammatory reaction from exposure to irritant (frequently plant sap) and sunlight
    
  • Typically no response in absence of sunlight
    

DIAGNOSIS

• Date of onset
  
• Time course
  
• Pattern of lesions
  
• Relationship to work
  
• Pruritic or not
  
• Mucosal involvement
  
• Exposure to new products (e.g., lotions, soaps, and cosmetics), foods, medications, and jewelry
  

• Special attention to character and distribution of rash
  
• Acute lesions:
  Skin erythema and pruritus:
  
  • May see edema, papules, vesicles, bullae, serous discharge, or crusting
    
• Subacute:
  Vesiculation less pronounced
  
• Chronic lesions:
  May see scaling, lichenification, pigmentation, or fissuring with little to no vesiculation; may have characteristic distribution pattern
  

No specific tests in ED are helpful.

No specific tests in ED are helpful

• Patch testing:
  
  • Generally not done in ED; refer to allergist/immunologist
    
• When tinea is suspected, may use Wood lamp for fluorescence
  

• Atopic dermatitis: Associated with family history of atopy
  
• Seborrheic dermatitis: Scaly or crusting “greasy” lesions
  
• Nummular dermatitis: Coin-like lesions
  
• Intertrigo: Dermatitis in which skin is in apposition (axillae, groin area)
  
• Infectious eczematous dermatitis: Dermatitis with secondary bacterial infection, usually
  Staphylococcus aureus
  
• Cellulitis: Warm, blanching, painful lesion
  
• Impetigo: Yellow crusting
  
• Scabies: Intensely pruritic, frequently interdigital with tracks
  
• Psoriasis: Silvery adherent, scaling, lesions well delineated, affecting extensor surfaces, scalp, and genital region
  
• Herpes simplex: Groups of vesicles, painful, burning
  
• Herpes zoster: Painful, follows dermatomal pattern
  
• Bullous pemphigoid: Diffuse bullous lesions
  
• Tinea: Maximal involvement at margins, fluoresces under Wood lamp
  
• Pityriasis alba: Discrete, asymptomatic, hypopigmented lesions
  
• Urticaria: Pruritic raised lesions (wheal) frequently with surrounding erythema (flare)
  
• Acrodermatitis enteropathica: Vesiculobullous lesion of hands and feet, associated with failure to thrive, diarrhea, and alopecia
  
  • Due to zinc deficiency
    
• Dyshidrotic dermatitis (eczema)
  
  • Drug rash
    
  • Stevens–Johnson syndrome (SJS)
    
  • Toxic epidermal necrolysis (TEN)
    
  • Erythema nodosum (EN)