Grand Rounds Recap 10.19.22
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Treatment and Complications of Inflammatory Bowel Disease WITH Dr. Hajdu
Inflammatory bowel disease: collection of relapsing and remitting diseases involving chronic inflammation in the gastrointestinal tract
Major subtypes
Crohn’s disease
Ulcerative Colitis
Indeterminate Colitis
Why should we care?
1.6 million people with IBD in the US
Among the top five GI disorders in terms of healthcare expenditure
Rising rates of ED utilization
Significant morbidity, long-term consequences
Ulcerative Colitis
Diffuse and continuous mucosal inflammation
Affects mucosa and submucosa
Symptoms: diarrhea, hematochezia, tenesmus, abdominal pain
Limited to the colon
Involves the rectum but can track proximally
Crohn’s Disease
Contiguous or patchy areas of transmural inflammation (“skip lesions”)
Symptoms based upon location of inflammation
Terminal ileum: abdominal pain and/or distention, loose bowel movements, weight loss, malabsorption
Colonic: hematochezia, diarrhea, abdominal pain
Perianal: pain with defecation or sitting, increased drainage, rarely hematochezia
Treatment of IBD
Usually treated outpatient
Treated with combination of medications +/- surgery
Corticosteroids: systemic vs rectal formulations
Aminosalicylates: 5-ASA
Traditional immunomodulators
Methotrexate
Azothioprine
6-mercaptopurine
Tacrolimus
Biologic DMARDS
Complications of IBD: Intestinal
IBD flare
Gastrointestinal bleeding
Infectious colitis
Fulminant colitis
Perianal or perirectal abscess or fistulizing disease
Small bowel obstruction
Intra-abdominal abscess
Intestinal perforation
Toxic megacolon
Complications of IBD: extraintestinal
Skin: erythema nodosum, pyoderma gangrenosum, oral ulcers
MSK: arthritis, ankylosing spondylitis, osteoporosis
Hepatobiliary: cholelithiasis, autoimmune hepatitis, primary sclerosising cholangitis, fatty liver
Vascular: thromboembolic events, DVT
Ocular: uveitis, episcleritis/scleritis
Renal: nephrolithiasis (calcium oxalate stones)
Hematologic: iron deficiency anemia, anemia of chronic disease
Evaluation: History and Chart Review
Symptoms: stool frequency/day, presence of blood in stool, nausea/vomiting, systemic symptoms
Disease phenotype: predominant location & behavior of disease
Assessments from GI or general surgery
Prior hospitalizations or surgeries
Medication regimens: immunomodulators, current/recent steroid use & dose
Endoscopies
Imaging: CT, MRI
Physical Exam
Abdominal examination
Rectal or external GU exam
Signs of extra-intestinal or systemic manifestations
Laboratory Work-up
CBC, BMP, LFTs, Lipase, UA, CRP
Stool studies*
Fecal calprotectin
C. difficile toxin
Lactate and blood cultures*
+/- other labs to rule out additional disease processes
Imaging
Not all patients need imaging
Indicated if:
Acute abdomen
Concern for surgical emergency
Concern for intraabdominal infection
Perianal disease with concern for systemic or deeper infection
CT scans, MRI, ultrasound
Management
Hydration
Antiemetics
Analgesia
Antibiotics for infections
Consultations
Gastroenterology, general surgery
Procedural vs surgical intervention
Steroids
Immunomodulating agents
Disposition
Discharge
Mild to moderate flares
No signs of toxicity
Reassuring vitals, labs, imaging
Tolerating oral intake
Admission
Severe flares
>6 blood bowel movements, high CRP, low albumin, anemia
Inability to tolerate PO
Abnormal labs, signs of systemic toxicity
Surgical emergencies
Case 1: Ulcerative colitis flare
Antibiotics are indicated when:
Fulminant colitis with concerns of sepsis
Highly suspected infectious colitis
Intra-abdominal infection including toxic megacolon, bowel perforation, intra-abdominal abscess
Are steroids indicated?
Should be prescribed by or in consultation with the patient’s gastroenterologist
Steroid use in IBD is associated with increased morbidity and mortality
Use with caution
Case 2: Small bowel obstruction in a patient with Crohn’s disease
Caused by strictures
Inflammatory → improve with medical therapy
Fibrostenotic → need procedural/surgical intervention
Bowel obstruction in patients with ulcerative colitis raises suspicion for malignancy
Imaging considerations
CT with IV contrast preferred in ED
KUB can be used as screening
If CT unavailable, consider trans-abdominal ultrasound
Case 3: Perianal disease
More common in Crohn’s disease than ulcerative colitis
Symptoms: persistent, blood tinged or purulent, malodorous discharge, +/- pain with defecation or sitting
Therapeutics & disposition
Well-appearing:
Discharge
Outpatient surgery referral
Antibiotics: ciprofloxacin + metronidazole
Analgesia, sitz baths, lidocaine
Ill appearing
Admit
Urgent surgical consultation
IV antibiotics: ciprofloxacin + metronidazole, zosyn
Analgesia, IVF
CPC: Appendicitis WITH Drs. Gobble and Urbanowicz
Acute appendicitis
Epidemiology
Most common abdominal emergency in the general population and the third most common indication for abdominal surgery in the elderly patient.
Pathogenesis
Obstruction of appendiceal lumen
Lymphoid hyperplasia
Fecolith
Obstruction = distention, bacterial overgrowth, ischemia, and inflammation
If untreated
Necrosis, gangrene and perforation occur
Historical features
Peri-umbilical, colicky pain becoming sharp and migrating with R iliac fossa
Initial pain = referred pain from visceral innervation of midgut
Localized pain = inflammation of parietal peritoneum
Loss of appetite prominent feature
Constipation and nausea often present
Vomiting rarely feature in simple appendicitis
May indicate perforation
Patients at extremes of age present with subtle clinical signs
Anatomy/Exam
A retrocecal appendix (about 75% of individuals) will present with RLQ pain with tenderness on exam.
The Psoas muscle is irritated in this position, leading to hip flexion and exacerbation of the pain on hip extension (posas stretch sign)
For an appendix that is subcecal or pelvic ( about 20% of individuals) suprapubic pain and urinary frequency may predominant
Diarrhea may be present as a result of irritation of the rectum
Abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right
Microscopic hematuria and leukocytes may be present on UA
Pre-ileal and post-ileal appendicitis (5%)
Traditional signs and symptoms may be lacking
Vomiting and diarrhea may be more prominent
Alvarado and Ohmann Scores may help stratify likelihood for appendicitis
Imaging
Ultrasound
Sensitivity 86%, Specificity 81%
Diameter > 6mm
CT
Sensitivity 94%, Specificity 95%.
MRI
Growing use in pediatric population with reported test characteristics similar to CT
Management
Pre-operative antibiotics
Reduce and prevent formation of abdominal abscesses and superficial wound infection rates
Early Surgical consultation
After 26h, avg rate of perforation 16-26%
Increases 5% every subsequent 12h period
Non-operative management
Evidence has demonstrated longer hospital stay, increased readmission rates, increased recurrence with non-operative management
Appendicitis in the Elderly
Higher mortality rate
Delayed and atypical presentations
1/5 will present after 3 days of symptoms
5-10% after 1 week
Less than 1/3 have fever, anorexia, RLQ pain, or leukocytosis
25% have no RLQ pain at all
More likely than other age groups to have complicated appendicitis
18-70% compared to 3-29% for patients <65 yo
Increased rate of perforation from vascular sclerosis and narrowing of lumen from fibrosis
Hand Injuries in the Community WITH Dr. Betz
Rules of two:
Two views
Two joints: image the joint above and below a long bone
Two sides: compare the other side if unsure of pathology
Two abnormalities: look for a second abnormality
Two occasions: compare current film and old films
Two visits: repeat films before and after procedures
Two specialist: if possible obtain a formal radiology report
Two examination modalities: consider additional imaging if needed
Physical examination
ROM: extension/flexion (MCP/PIP/DIP)
Flexor digitorum profundus (DIP)
Flexor digitorum superficialis (PIP)
Bony Tenderness
Phalanx, metacarpals
Snuff box tenderness, ttp ulnar deviation, axial loading
Scapholunate ligament
Hook of the hamate
Thumb IP, valgus laxity at 30 degrees
Neurovascular Funciton
Radial pulse, capillary refill
Medial (+recurrent median nerve), radial, ulnar nerve (sensation/motor)
Dominant hand, occupational history
To transfer or not to transfer?
Life/limb threatening
Compartment syndrome
High pressure injection injury
Arterial injury
High morbidity if missed or if diagnosis is delayed
Scaphoid fracture
Rolando/Bennett Fracture
Perilunate/Lunate dislocation
Gamekeeper’s Thumb
Scapholunate dissociation
Fight Bite
Flexor tenosynovitis
Moderate morbidity if missed
Flexor tendon injury
Mallet finger
Jersey finger
Reasons to call a hand consultant in the community:
Planning to admit
< 48h follow up
Difficult reduction
Specific concern about follow up, splint, need to get in urgently
Other cases to call a hand surgeon:
Flexor tendon laceration
Splint in flexion, follow up in 24 hours
Extensor tendon laceration
Splint in extension, follow up within 2-3 days
Except – MCP and PIP joint injuries may need to be seen sooner
Mallet finger
Splint in extension, follow up 24-48 hours
Jersey finger
Splint in flexion, follow up in 24-48 hours
If having difficulty reducing dorsal or volar PIP dislocations, may be due to entrapment by volar plate or lateral bands
Fingertip amputation
Revision amputation indicated in adults with exposed bone and the ability to rongeur bone proximally without compromising bony support to nail bed
Secondary healing appropriate if no bone or tendons are exposed, <2cm skin loss, or in all cases for children
Lunate/perilunate dislocation
Some argue that immediate operative treatment of perilunate/lunate dislocations result in better functional outcome
Closed Reduction technique
Finger traps, elbow at 90 degrees of flexion
Hand 5-10 lbs traction for 15 minutes
Reduced through wrist extension, traction, and flexion of wrist
Apply sugar tong splint
Needs immediate consultation
Taming the SRU: Traumatic Aortic Injuries WITH Dr. Kein
Acute Aortic Rupture
90% at the isthmus
Classic imaging findings
Grading system: I-IV
I = intimal tear
II = intramural hematoma
III = pseudoaneurysm
IV = Rupture
Epidemiology
Found in 10-15% of fatal MVCs
85% mortality pre-hospital
Of 15% who make it to the ED: 99% will die without surgical intervention
Surgical mortality ~30%
30% have no signs of external trauma to the chest
Workup
Nexus Chest Rules
Population: blunt trauma patients age 15+ who are awake, nonintubated, HD stable
No CT indicated if the following are absent:
Rapid deceleration > 40 mph
Distracting injury
Chest wall tenderness
Thoracic spine tenderness
Scapular tenderness
Abnormal CXR
CXR
Normal CXR with NPV > 95%
Widened mediastinum, loss of aortic knob, depression of left mainstem bronchus, deviation of esophagus or NG tube, opacification of aortopulmonary window on CXR concerning for aortic injury
CT with contrast
Airway management with limited mouth opening
Relieve any obstruction if able (jaw wires, braces, etc)
Nasotracheal intubation
Retrograde intubation
Insert needle into cricothyroid membrane, pass wire through needle and search for wire in the oropharynx or nares
Bonfils stylet
Pass preloaded device into the cheek, around molars and rotate to enter the posterior oropharynx. Device should allow for visualization of laryngeal structures.
Cricothyroidotomy
