iTunes or Listen Here

5MinSono has a great 5 minute videocast on the ultrasound diagnosis of pneumoperitoneum.

Core Content

We cover gastropathies and peptic ulcer disease (PUD) using Rosen’s Emergency Medicine (9th ed) Chapter 79 and Tintinalli’s Emergency Medicine (8th ed) Chapter 78  as guides.

Rosh Review Emergency Board Review Questions

A 67-year old man with chronic osteoarthritis complains of gnawing and burning in the epigastric area that is occasionally accompanied by nausea and vomiting. His current BMI is 26 and he is physically active. What is the most probable cause for these symptoms?

A. Cholelithiasis

B. Gastric carcinoma

C. Nonsteroidal anti-inflammatory drug induced gastritis

D. Peptic ulcer disease

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[toggle title=”Answer” state=”closed”] C. Nonsteroidal anti-inflammatory drug (NSAID) therapy is the first line treatment in osteoarthritis, however chronic NSAID use can often destroy the gastric mucosa leading to hemorrhage, erosions and ulcers. NSAIDs such as naproxen and ibuprofen are the most common agents associated with acute erosive gastritis. A long-term prospective study found that patients with arthritis who were older than 65 years and regularly took low-dose aspirin were at increased risk for dyspepsia severe enough to necessitate the discontinuation of NSAIDs. This suggests that better management of NSAID use should be discussed with older patients in order to reduce NSAID-associated upper GI events. COX -2 inhibitors, such as celecoxib, are an alternate therapy to NSAIDs. Other common agents that cause gastritis include alcohol and Helicobacter pylori. The mainstay treatment of erosive gastritis is to refrain from the offending agent. The gold standard for diagnoses of gastritis is an upper GI endoscopy.

Symptomatic cholelithiasis (A) is often seen in populations who have risk factors for gallstones, which include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. This patient does not portray the colicy pain associated with gallstones. Patients with gastric cancer (B) often present with weight loss, dysphagia, postprandial fullness and loss of appetite. Gastric cancer is multifactorial involving both inherited predisposition and environmental factors. Environmental factors implicated in he development of gastric cancer include diet, Helicobacter pylori, previous gastric surgery, pernicious anemia, chronic atrophic gastritis and radiation exposure. Smoking and smoked meats also have a high correlation with gastric cancer. Peptic ulcer disease (D) is a complication of chronic gastritis and can present in a similar manner as gastritis. Peptic ulcers include both gastric and duodenal ulcers. Peptic ulcers present with gnawing or burning sensation that occur after meals. Common risk factors include H. pylori infection and ingestion of NSAIDs. An upper GI endoscopy must be performed to visualize the ulcers. Biopsy is indicated if ulcers are seen on endoscopy in order to rule out Helicobacter pylori. Active ulcers associated with NSAID use are treated with an appropriate course of proton pump inhibitor (PPI) therapy and the cessation of NSAIDs. For patients with a known history of ulcer and in whom NSAID use is unavoidable, the lowest possible dose and duration of NSAID and co-therapy with a PPI is recommended.

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A 55-year-old man presents with severe abdominal pain and tenderness on examination that began acutely approximately 12 hours prior to arrival. His X-ray is shown below. What is the most appropriate next step?

A. Computed tomography scan of the abdomen and pelvis

B. Nasogastric tube insertion

C. Observation and serial abdominal exams

D. Surgical consultation

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D. The X-ray demonstrates free air under the diaphragm representing a perforated viscus within the intraabdominal cavity. The presence of free air is an indication for an emergent surgical consultation for repair. The emergency provider should administer broad-spectrum antibiotics covering aerobic and anaerobic organisms along with intravenous fluid resuscitation.  

A CT scan of the abdomen and pelvis (A) is indicated if the X-ray does not reveal evidence of free air and the patient has ongoing pain and tenderness requiring a diagnosis. Some perforations will not show on plain films, and as time progresses, the area of perforation may wall off and not show on X-ray. A nasogastric tube (B) is not indicated in the management of a patient with a perforated viscus. Observation and serial abdominal exams (C) are not sufficient for a patient with a perforation.  

A patient presents with hematemesis. What test is most likely to determine the etiology of the bleeding?

A. CT scan of the abdomen and pelvis

B. Nasogastric tube lavage

C. Right upper quadrant ultrasound

D. Upper endoscopy

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Upper endoscopy is the modality that is most likely to identify the culprit lesion in a patient with upper gastrointestinal bleeding (UGIB). UGIB is a common presentation caused by a variety of pathologies including gastritis, esophageal varices, peptic ulcer disease, Mallory-Weiss tears, arteriovenous malformations and Boerhaave’s syndrome. Of these causes, peptic ulcer disease is the most common. Regardless of the etiology, endoscopy represents the best modality for diagnosis. It allows direct visualization of the esophagus, stomach and first two sections of the duodenum. Additionally, it allows for interventions to be performed if active bleeding or stigmata of recent bleeding are found.

CT scan of the abdomen and pelvis (A) is limited in its ability to give a diagnosis. Nasogastric tube lavage (B) may show the presence of blood in the upper GI tract but cannot differentiate between causes. Right upper quadrant ultrasound (C) may give information about the patient including the presence of cirrhosis but cannot give a specific diagnosis as the cause.

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References

1. Nazerian P, Tozzetti C, Vanni S. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Critical ultrasound journal. 7(1):15. 2015. [pubmed]

iTunes or Listen Here

Dr. Salim Rezzaie of RebelEM wrote a blog post on HUGS – Haloperidol for Gastroparesis.  This study had significant methodologic limitations but provides some interesting insight into a practice that many providers have adopted – using haloperidol for gastroparesis. A tiny RCT by Roldan and colleagues also looked at this practice and found promising results, although the study was very small.  Haloperidol has also been used in cannabinoid hyperemesis but literature on this is limited to case reports/series. 

Core Content

We review biliary colic, cholecystitis, and cholangitis using Tintinalli (8th ed) Chapter 79 and Rosen’s Emergency Medicine (9th ed) Chapter 80 as guides.

Rosh Review Emergency Board Review Questions

A 60-year-old woman presents with two days of right upper quadrant abdominal pain constant in nature and associated with subjective fever, nausea, and vomiting. Vital signs are temperature of 38.1°C, heart rate 87, blood pressure 140/80 mm Hg, respiratory rate 14, and oxygen saturation of 99% on room air. Her abdomen is soft with right upper quadrant tenderness and a positive Murphy’s sign. Which of the following tests is most sensitive and specific in diagnosing this patient’s condition?

A. Computed tomography scan with intravenous contrast

B. Hepatobiliary iminodiacetic acid (HIDA) scan

C. MRI with gadolinium

D. Ultrasound

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This patient has suspected acute cholecystitis and requires an imaging study for confirmation. Hepatobiliary iminodiacetic acid (HIDA) scanning is considered the most sensitive and specific test for diagnosing acute cholecystitis. IDA is administered intravenously, taken up by hepatocytes, and excreted into the bile canaliculi. Failure to obtain an outline of the gallbladder within one hour proves cystic duct obstruction and, in the appropriate clinical setting, confirms the diagnosis of acute cholecystitis. Visualization of the gallbladder and common duct within one hour has a high negative predictive value. A HIDA scan is usually obtained when the ultrasound study is equivocal.

Computed tomography scan with intravenous contrast (A) can identify cholecystitis with a reported sensitivity of 92% and specificity of 99%. It is most useful in cases of emphysematous and hemorrhagic cholecystitis. MRI with gadolinium (C) provides similar diagnostic yield to CT scan. Ultrasound (D) is most useful in the ED setting because it is a quick, noninvasive test. Its sensitivity and specificity, however, are lower than a HIDA scan’s for pathology-confirmed cholecystitis. Ultrasound findings and a clinical exam consistent with acute cholecystitis are highly predictive, and many such patients will undergo cholecystectomy without further diagnostic testing.

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References:

1. Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017; 35(8):1118-1120. [pubmed]
2. Roldan CJ, Chambers KA, Paniagua L, Patel S, Cardenas-Turanzas M, Chathampally Y. Randomized Controlled Double-blind Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. Acad Emerg Med. 2017; In Press[pubmed]
3. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003; 289(1):80-6. [pubmed]
4. Jain A, Mehta N, Secko M. History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Acad Emerg Med.. 2017; 24(3):281-297. [pubmed]
5. Hwang H, Marsh I, Doyle J. Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital.   J Surg. 2014 Jun; 57(3): 162–168. [pubmed]