
Bowel Perforations



History



Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in…  



* Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms)* Pediatric patients (unable to or scared to mention symptoms)



Exam



Commonly have “peritoneal signs”



* Guarding* Rebound Tenderness* Rigidity



Testing



* CT Scan* X-Ray? (not your primary test, but a common test question will show you an upright chest X-ray and you will see a rim of free air under the diaphragm (should NOT be there in a normal upright X-ray)



Treatment



* Broad spectrum antibiotics* Stat surgical consult



Volvulus



It is common to first learn this as a pediatric condition (Malrotation with Volvulus) however it is common in adults as well. The two most common subtypes are…



* Cecal Volvulus* Sigmoid Volvulus



The history exam and testing plan is the same as with bowel obstruction. The primary difference is that volvulus without ischemia/gangrene is frequently treated with colonoscopy which is a GI CONSULTATION rather than surgical consultation. 



Additional Reading



* Management of colonic volvulus (PubMed)

Bowel Perforation and Volvulus

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* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 19 (MW) Tummy Ache in Child with Diabetes


Phase One: CNS




* Ataxia, Slurred Speech, Confusion, N/V, Seizures




Phase Two: Cardiopulmonary 




* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS




Phase Three: Renal




* Flank pain, Hematuria, Oliguria, Renal Failure




Diagnosis:




* HIGH INDEX OF SUSPICION



* Ethylene Glycol Serum Level



* Elevated Osmolar Gap



* Serial Anion Gap Measurements




Treatment:




* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid



* Hemodialysis



* Consider Bicarb drip, pyridoxine, and thiamine








Further Reading:



 EMCrit Toxic Alcohols





Ethylene Glycol (Deep Dive MW R18)


You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again



Initial Vitals:



HR: 116



BP: 150/70



Temp: 98.8



RR: 26



O2: 85% (Room Air)



Critical Actions:




* Recognize Hypoxemia



* Diagnose Toxic Alcohol Ingestion



* Consult Nephrology Emergent Dialysis



* Administer Fomepizole



* Workup Anion Gap Metabolic Acidosis


Round 18 (MW) Drunk Man Wants Pizza


Hypertensive Emergencies of Pregnancy



PreEclampsia, Eclampsia, HELLP syndrome



Diagnosis: BP >140/90 plus end organ dysfunction 




* Acute Kidney Injury



* Proteinuria



* Thrombocytopenia



* Transaminitis



* Hemolysis



* Pulmonary Edema



* Cerebral Edema / Hemorrhage



* Headache refractory to tylenol



* Visual Changes



* RUQ Pain not attributable to another diagnosis




Treatment




* Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock



* Maintenance Dose: 1g/hr IV



* Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine



* Delivery of fetus and placenta


Bowel Perforation and Volvulus

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