CMPP -- Acute Intestinal Issues (II)

Intussusception

invagination of part of the intestine into itself; "telescoping"

abdominal emergency of early childhood

cause of intestinal obstruction in infants 6-36 months of age

Intussusception is the most common...

idiopathic

cause of intussusception in children

pathologic

cause of intussusception in adults

ileocecal junction

Intussusception most commonly occurs at what part of the small intestine?

idiopathic, viral gastroenteritis season, URI, AOM

factors that can contribute to the presence of intussusception

sudden severe abdominal pain/craping

episodic ever 15-20 min

inconsolable crying

+/- vomiting

presentation of intussusception

currant jelly stool

presentation of stool in intussusception

sausage-shaped mass

what is observed on the abdomen in intussusception

ultrasound

what is the method of choice to detect Intussusception?

abdominal x ray

what imaging study can be done to evaluate for perforation?

hydrostatic (saline/contrast) or pneumatic pressure enema

performed under sonographic or fluoroscopic guidance

what is the diagnostic and therapeutic means for reducing an Intussusception

release of inflammatory substances

bacterial translocation

why might one observe a fever after treatment of Intussusception?

12-24 hours (NG tube if N/V)

some institutions will observe a pt in the hospital for how long after tx?

evidence of peritonitis or perforation

patient is too unstable to attempt non-operative treatment

patient fails non-operative tx

when is surgery indicated for Intussusception

Appendicitis

inflammation of the vermiform appendix which is located at the base of the cecum near the ileocecal valve (where taeniae coli converge on the cecum)

base of the cecum, direction the appendix is pointing (retrocecal, pelvic)

the attachment of the appendix is ALWAYS at the __________, however, the _______ can vary from patient to patient

occurs in 2nd-3rd decade of life

periumbilical abdominal pain and then localizes to RLQ, tenderness at McBurney's point (1/3 distance of ASIS to umbilicus)

other common symptoms include anorexia and N/V (after onset of pain)

classic presentation of appendicitis

indigestion, flatulence, bowel irregularity, generalized malaise, diarrhea, dysuria/frequency

atypical presentation of appendicitis

fecaliths

calculi

lymphoid hyperplasia

infection

tumor

what can cause initial inflammation of the appendiceal wall

fecaliths

most common cause of initial inflammation of the appendiceal wall in adults

lymphoid hyperplasia (response to bacteria/viruses)

most common cause of initial inflammation of the appendiceal wall in teens

perforation and contained abscess/generalized peritonitis

appendicitis can lead to what complication?

obstruction --> ischemia --> perforation --> abscess/peritonitis

how does obstruction of the appendix lead to infection

increased intraluminal pressure results in thrombosis and occlusion of the blood supply

engorgement stimulates visceral nerves T8-T10

how does obstruction during appendicitis lead to periumbiilcal pain?

inflammation and translocation of bacteria causes recruitment of neutrophils to area

local irritation of surrounding parietal peritoneum

how does inflammation during appendicitis lead to RLQ pain?

low grade fever

McBurney's point tenderness

findings on PE for one with appendicitis

Rosving's sign

RLQ pain upon palpation of LLQ

Psoas sign

pain in the RLQ with passive hip extension; more associated with RETROCECAL appendix

Obturator sign

more associated with a pelvic appendix; relies on fact that inflamed appendix lays along the right obturator internus muscle; when patients' right hip and knee are flexed and internally rotated -- results in RLQ pain

mild leukocytosis

laboratory findings with appendicitis

CT of abdomen and pelvis with IV and PO contrast

imaging study of choice for appendicitis

enlarged diameter with occluded lumen

appendiceal wall thickening

periappendiceal fat stranding

appendicolith

absence of air in lumen

findings on CT for one with appendicitis

cannot tolerate CT or in children

when is ultrasound indicated for one with appendicitis?

Target sign

transverse US scan through an inflamed appendix shows an intact echogenic submucosal layer and a fluid-filled lumen

appendectomy

standard of care for appendicitis

to prevent wound infection and development of intra-abdominal abscesses

given 1 hour pre-op

why are prophylactic abx given to one before an appendectomy?

anaerobes (Bacteroides) and gram negative anaerobes (E coli, Enterobacter, Klebsiella, Proteus)

target bugs in prophylactic abx administration for an appendectomy

Cefazolin (any cephalosporin) + Metronidazole (Met-Cef)

Broader agents (Piperacillin-tasobactam (Zosyn)) chosen for severe, complicated cases

prophylactic Abx regimen for appendectomy

Cefazolin (Ancef)

1st generation cephalosporin; only available IM/IV; functions in inhibiting cell wall synthesis

common gram-negatives (E. coli, enterobacter, klebsiella, proteus)

may also cover relevant gram positives (enterococcus)

DOES NOT PROVIDE ANAEROBIC COVERAGE

what does Cefazolin cover?

GI upset, rash, risk of C.diff

side effects of Cefazolin

infection and ileus

complications associated with appendectomy

infection -- simple wound (S. aureus) or intra-abdominal abscess formation

--> more likely for those with perforation prior to OR

most common complication of appendectomy

Diverticulum

a sac-like protrusion in the colon wall; develop at well-defined points of weakness, which correspond to where the vasa-recta penetrate the circular muscle layer of the colon

abnormal colonic motility

important predisposing factor in the development of diverticula

Diverticulosis

the presence of diverticula

diverticulitis

diverticular bleeding

segmental colitis associated with diverticulosis

complications of diverticulosis

left (sigmoid)

most patients in western/industrialized nations have _____-sided diverticulosis

have adequate fiber intake (14 g per 1000 cal)

bowel regularity -- hydration critical!

quit smoking

patient education for diverticular disease

micro/macro perforation of a diverticulum

what is thought to be the underlying cause of diverticulitis?

erosion of diverticular wall by increased intraluminal pressure -- increased inflammation and focal necrosis -- perforation

what is thought to cause micro/macro perforation of a diverticulum?

uncomplicated, recurrent episodes (can lead to scarring, stricture, obstruction)

most diverticulitis is ____, and it is unlikely to cause _______.

no

does each subsequent episode of diverticulitis increase the risk for development of complications?

bowel obstruction, abscess, fistula, or macroscopic perforation

what is associated with complicated diverticulitis?

abdominal pain -- LLQ bc usually sigmoid colon

most common symptom of diverticulitis

N/V

change in bowel habits

sometimes can have urinary urgency, dysuria, increased frequency form sigmoid inflammation

other symptoms associated with diverticulitis

hematochezia (bleeding RARE!)

what is a RARE part of the presentation of diverticulitis

low grade temp

abdominal tenderness to palpation

tenderness/mass on rectal exam (sigmoid abscess)

physical exam findings of diverticulitis

fever not responsive to abx

free perforation

fistula formation

red flags associated with diverticulitis

(abdomen distended and diffusely tender to light palpation, diffuse guarding, rigidity, rebound tenderness, absent bowel sounds)

symptoms associated with free perforation

colovesical fistula

connection between colon-bladder

pneumaturia, fecaluria, dysuria

symptoms of colovesical fistula

Colovaginal fistula

abnormal opening between the colon and vagina

vaginal passage of feces/flatus

symptoms of colovaginal fistula

CT scan with oral and IV contrast

test of choice for diverticulitis

high risk for perforation

why should one avoid a colonoscopy in one with acute diverticulitis

to assess the degree of diverticular disease and rule out malignancy

why should one GET a colonoscopy 6-8 wks after resolution of diverticulitis

conservative management with bowel rest (NPO, low residue diet) and antibiotics

treatment fo symptomatic, uncomplicated diverticulitis

CT showing complicated diverticulitis (frank perforation, abscess, obstruction, or fistulization)

CT showing uncomplicated diverticulitis, but the patient has one or more comorbidities (sepsis, immunosuppression, micro perforation, high fever, etc)

when is diverticulitis made inpatient?

Ciprofloxacin/Flagyl for 7-10 days to target gram negative rods and anaerobes

ABX treatment for uncomplicated diverticulitis

amoxicillin-clavulanate (Augmentin)

alternative for Cipro/Flagyl in abx tx of diverticulitis

hepatotoxic

why is Augmentin used less in the acute tx of uncomplicated diverticulitis?

antacids (must be taken 2-4 hours before antacid)

Absorption of Ciprofloxacin is impaired by...

CANNOT BE USED IN PATIENTS UNDER 18 -- interferes with cartilage growth and can cause arthropathy

contraindications to Ciprofloxacin

peripheral neuropathy that may last months or years after taking med

--> occurs in al fluoroquinolones

side effect(s) of Cipro

tendon rupture (risk most significant if > 60 y/o or those taking corticosteroids)

avoid in those with myasthenia gravis -- can make muscle weakness worse

black box warnings for Ciprofloxacin

after absorption, it is broken down by the bacterial to cause a toxic byproduct that effectively kills the bacteria

Flagyl MOA

possible antabuse reaction -- avoid ETOH while on therapy and 72 hours after

metallic taste

Flagyl side effects

Amoxicillin/Clavulanate (Augmentin)

contains amoxicillin and a beta-lactamase inhibitor; effective against gram-positive aerobes, gram-negative aerobes, and anaerobes (Bacteroides)

GI upset

WATCH FOR HEPATIC DYSFUNCTION -- "usually reversible"; more common in elderly, males, or those with prolonged tx; can occur while on tx or several weeks after therapy has been discontinued

side effects of Augmentin

clear liquid diet for several days,, slowly advance diet to low residue (low fiber/low daily) then further advance as tolerated

diet recommendations for one with diverticulitis

increasing pain, fever, or inability to tolerate PO

failure to improve in 2-3 days of Tx

red flags for diverticulitis tx

patients with prior episode of complicated diverticulitis

immunosuppressed patients (increased risk of serious complications from recurrent attacks of diverticulitis)

The American Society of Colorrectal Surgeons guidelines recommend elective surgery to...

6 or more weeks after an episode of acute diverticulitis when all infection and inflammation have resolved

when is elective surgery for diverticulitis performed?

those with uncomplicated diverticulitis without improvement in pain and fever despite 3 days of Abx tx

what diverticulitis patients should we suspect an abscess in?

luminal narrowing secondary to acute inflammation or for compression by neighboring abscess

what can cause obstruction in a diverticulitis patient?

Ceftriazone and Metronidazole

Ampicillin-Sulbactam (Unasyn)

Piperacillin-Tazobactam (Zosyn)

--> given IV until pain/tenderness are resolving -- then can move to PO

common agents used to treat complicated diverticulitis

IV/IM (NOT PO)

Ceftriaxone can only be administered...

some patients develop biliary sludge and symptoms of biliary colic

side effects of Ceftriaxone

gram-positive, gram-negative, anaerobic coverage (so Flagyl not needed)

coverage of Unasyn/Zosyn

primary anastomosis

when surgical management of diverticulitis is done electively __________ can often be achieved

Stage 1: Hartmann's procedure

Stage 2: reversal of colostomy (around 3 months)

two stage procedure for those with diverticulitis

Hartmann's procedure

resection of diseased colon and creation of colostomy with rectal stump

diverticular bleeding (diverticular disease)

what is the most common cause of lower GI bleeding in adults?

hemorrhoids

what is the most common cause of rectal bleeding in those younger than 50?

colon carcinoma

what is the most common cause of lower GI blood loss?

acute onset, PAINLESS, bright red/maroon bleeding per rectum; occasionally can have cramping with urge to defecate; volume of blood loss can lead to hemodynamic instability

clinical presentation of diverticular bleeding

monitor H/H, transfuse if needed

correct coagulopathy if present, hold blood thinners

NPO vs clear liquid diet in case colonoscopy is required

treatment for diverticular bleeding

colonoscopy

nuclear medicine bleeding scan (angiography)

surgical resection

what is diverticular bleeding does not stop with supportive care/resuscitation?