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

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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
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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

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