Rosen & Barkin's 5-Minute Emergency Medicine Consult (773 page)

Read Rosen & Barkin's 5-Minute Emergency Medicine Consult Online

Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
6.7Mb size Format: txt, pdf, ePub
ADDITIONAL READING
  • Dahl AA. Vitreous Hemorrhage in Emergency Medicine.
    Medscape Reference
    . February 2013.
  • Gerstenblith AT, Rabinowitz MP.
    The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease.
    6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  • Hollands H, Johnson D, Brox AC, et al. Acute-onset floaters and flashes: Is this patient at risk for retinal detachment?
    JAMA
    . 2009;302(20):2243–2249.
  • Leveque T. Approach to the patient with acute visual loss. In: DS Basow, ed.
    UpToDate.
    Waltham, MA: UpToDate; 2013.
  • Lorente-Ramos RM, Armán JA, Muñoz-Hernández A, et al. US of the eye made easy: A comprehensive how-to review with ophthalmoscopic correlation.
    Radiographics
    . 2012;32(5):E175–E200.
See Also (Topic, Algorithm, Electronic Media Element)
  • Central Retinal Artery Occlusion (CRVA)
  • Central Retinal Venous Occlusion (CRVO)
  • Retinal Detachment
  • Visual Loss
CODES
ICD9
  • 250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
  • 362.16 Retinal neovascularization NOS
  • 379.23 Vitreous hemorrhage
ICD10
  • E13.39 Oth diabetes mellitus w oth diabetic ophthalmic complication
  • H35.059 Retinal neovascularization, unspecified, unspecified eye
  • H43.10 Vitreous hemorrhage, unspecified eye
VOLVULUS
Ronald E. Kim
BASICS
DESCRIPTION
  • Axial twist of a portion of the GI tract around its mesentery causing partial or complete obstruction of the bowel
  • Often associated with other GI abnormalities
  • In pediatric setting, infants typically involved:
    • Abnormal embryonic development
  • Can be precipitated by pathologic distention of the colon
  • Blood supply may be compromised by venous congestion and eventual arterial inflow obstruction, leading to gangrene of the bowel and potential infarction
ETIOLOGY
  • 3rd most common cause of colonic obstruction (10–15%) following tumor and diverticular disease
  • Epidemiology:
    • 0–1 yo: 30%
    • 1–18 yo: 20%
    • Over 18 yo: 50%
  • Often associated with other GI abnormalities
  • Cecum (52%):
    • More common in young adults, < 50 yr old
    • Due to improper congenital fusion of the mesentery with the posterior parietal peritoneum, causing the cecum to be freely mobile in varying degrees
    • Associated with increased gas production (malabsorption and pseudo-obstruction)
    • Can be seen in pregnancy and after colonoscopy
  • Sigmoid (43%):
    • More common in:
      • Elderly
      • Institutionalized
      • Chronic bowel motility disorders (Parkinson)
      • Psychiatric diseases (schizophrenia)
    • Due to redundant sigmoid colon with narrow mesenteric attachment
    • Associated with chronic constipation and concomitant laxative use
  • Transverse colon and splenic flexure (5%)
  • Gastric volvulus (rare) associated with diaphragmatic defects
Pediatric Considerations
  • Midgut volvulus:
    • Due to congenital
      malrotation
      in which the midgut fails to rotate properly in utero as it enters the abdomen
    • Entire midgut from the descending duodenum to the transverse colon rotates around its mesenteric stalk, including the superior mesenteric artery
    • Common in neonates (80% <1 mo old, often in 1st week; 6–20% >1 yr old)
    • Males > females, 2:1
    • Sudden onset of bilious emesis (97%) with abdominal pain
    • May have previous episodes of feeding problems/bilious emesis
    • In children >1 yr old, associated with failure to thrive, alleged intolerance to feedings, chronic intermittent vomiting, bloody diarrhea
    • Constipation
    • Mild distention, since obstruction higher in GI tract
    • May not appear toxic based on degree of ischemia
DIAGNOSIS
SIGNS AND SYMPTOMS
History
  • Infants: Vomiting in 90%:
    • May be bilious
  • Older children and adults: Variable and often insidious:
    • 80% with chronic symptoms; weeks to months to years
  • Bowel obstruction secondary to volvulus:
    • Colicky, cramping abdominal pain (90%)
    • Abdominal distention (80%)
    • Obstipation (60%)
    • Nausea and vomiting (28%)
  • Cecal volvulus:
    • Highly variable; intermittent episodes to sudden onset of pain and distention
  • Sigmoid volvulus:
    • Vomiting uncommon
    • More insidious onset
    • Abdominal pain/distention, nausea, and constipation
  • Gastric volvulus:
    • Triad of Borchardt: Severe epigastric distension, intractable retching, inability to pass nasogastric tube (30% of patients)
Physical-Exam
  • Presence of gangrenous bowel:
    • Increased pain
    • Peritoneal signs: Guarding, rebound, and rigidity
    • Fever
    • Blood on digital rectal exam
    • Tachycardia and hypovolemia
  • Cecal volvulus:
    • Distended abdomen
    • Often a palpable mass in the left upper quadrant/midabdomen
Pediatric Considerations
  • Child will appear well with normal exam early in clinical course
  • 70% present with chronic symptoms
  • 40% of neonates with bilious vomiting will require a surgical intervention
  • Hematochezia, abdominal distention or pain, and shock indicate ischemia/necrosis
ESSENTIAL WORKUP
  • CBC, BMP, UA
  • Plain abdominal radiograph
  • Upper GI series (best initial exam for children)
  • CT abdomen/pelvis with IV contrast (optimal for adults)
  • Barium enema
  • US
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • May give clues as to the presence of gangrenous bowel, but normal lab values do not exclude the diagnosis
  • CBC:
    • Leukocytosis (WBC >20,000) suggests strangulation with infection/peritonitis.
  • Electrolytes, BUN, creatinine, glucose:
    • Anion gap acidosis due to lactic acidosis
    • Prerenal azotemia due to dehydration
  • Urinalysis:
    • Elevated specific gravity and ketones
Imaging
  • Plain abdominal radiograph:
    • Suggestive but often inconclusive
    • Diagnostic finding present in <70% of cases
    • Sigmoid volvulus: Inverted U-shaped loop of dilated colon arising from the pelvis
    • Cecal volvulus—dilated and displaced:
      • Cecum in the left abdomen (kidney shaped), often with dilated loops of small bowel
  • CT scan:
    • “Whirl” sign in cecal volvulus
    • May be useful in sigmoid volvulus to determine extent of obstruction
  • Upper GI series (best for duodenum, but operator dependent):
    • Abrupt ending or corkscrew tapering of contrast seen (75%)
    • Subtle findings (25%)
  • Barium enema:
    • “Bird’s beak” deformity at the site of torsion
    • Perform cautiously because of perforation risk
    • Beware of false positives with infants who normally have inadequately fixed cecums
  • US (specific but not sensitive):
    • Abnormal position of the superior mesenteric vein (anterior or left of SMA)
    • “Whirlpool” sign of volvulus: Vessels twirled around the base of the mesentery
    • 3rd part of duodenum not in normal retromesenteric position (between mesenteric artery and aorta)
Pediatric Considerations
  • Diagnosis of midgut volvulus:
    • Duodenum lies entirely to the right of the spine on plain films
    • “Double-bubble” sign on an upright film due to distended stomach and proximal duodenal loop
    • Established by upper GI swallow: Coiled spring/corkscrew appearance of jejunum in the right upper quadrant
    • Plain x-ray normal or equivocal in 20% of cases
ALERT
  • Evaluate any child with signs/symptoms of obstruction (including bilious vomiting and abdominal pain) for malrotation, even if he or she appears nontoxic
  • Delay in diagnosis >1–2 hr results in gangrenous bowel, necessitating large resection and leading to permanent parenteral nutrition with its associated complications

Other books

Conagher (1969) by L'amour, Louis
My Hollywood by Mona Simpson
The Other Slavery by Andrés Reséndez
Royal Protocol by Christine Flynn
Little Dog Laughed by Joseph Hansen