CME - Appendicitis - Dx and Presurgical Management.

Update on appendicitis: Diagnosis and presurgical management - Janet H Friday

• Diagnostic tests - overview (what is being done now?)
• Hx, PE, WBC, CRP levels
• MANTRELS score
• Movement of pain to RIF
• Anorexia
• Nausea
• Tenderness in RIF
• Rebound tenderness
• Elevated temperature
• Leukocytosis
• Shift of WBC to left
• Diagnostic imaging
• US,
• IV contrast CT
• Issues with the current diagnostic methods
• MANTREL score has low sensitivity (76-90%) and specificity (50-81%)
• Abdominal CT has the best individual test, but it may be being carried out too rapidly.
• Diagnosing Appendicitis with Ultrasound
• 14 published studies cited including over 10000 children who underwent US scans for evaluation of possible appendicitis
• Sensitivity varied from 50-100%
• Specificity ranges from 88-99%
• Which means negative US scan does not exclude appendicitis unless normal appendix correctly visualized.
• Imaging protocol
• Every patient undergo US before CT scan
• If US inconclusive / negative, CT performed
• This has resulted in 22% of patient CT avoidance.
• Some people may be better off doing US
• Adolescent female - blood supply to ovaries can be obvserved.
• Thin people - easier to visualize internal organs
• Children - CT contraindicated due to radiation
• Diagnosing Appendicitis with CT
• Dx with CT scan has sensitivity of 97%, specificity of 94%^[i]
• Contrast-enhanced CT seem to have a higher reliability than non contrast CT-enhanced CT.
• The issue with CT
• Since the publication of reports of diagnostic accuracy of CT, the CT scans in children has increased seven-folds in US^[ii]
• In one year, 753 patients assessed for appendicitis (2001), where 172 were <18. In this group, 138 (80%) went thru CT scanning for suspected appendicitis, and 62(45%) were negative.
• Unnecessarily CT scans are being performed.
• New clinical decision rule
• Kharbanda et al^[iii]
• Nausea (2 pts)
• Hx of focal right lower quadrant pain (2pts)
• Migration of pain (1pt)
• Difficulty walking (1pt)
• Rebound tenderness (2pts)
• Absolute Neutrophil Count more than 6.75x10­³ (6pts)
• Score up to 5 had a sensitivity (of no appendicitis) of 96%, a negative predictive value of 96%.
• A recursive-partitioning model was created, and the following variables were found to be important
• ANC > 6.75x10³
• Nausea (emesis and anorexia were surrogate variables)
• Maximal tenderness in RLQ.
• When all 3 were absent, the rule had sensitivity of 100% for identifying low-risk patients.
• Presurgical management - analgesics
• According to Kim et al^[iv] and Kokki and associates^[v]
• Analgesic use in children will not affect the diagnostic accuracy of appendicitis.
• Analgesia may be given before surgeon’s examination.
• Use of analgesia may be acceptable especially when waiting for the consultant to arrive.
• Presurgical management - Antibiotics
• 45 published studies of 9576 adults and children with appendicitis who were randomized to be given either antibiotics or placebo before, during, or after appendectomy
• Use of antibiotics were superior to placebo for preventing wound infection and intra-abdominal abscess, regardless of whether perforation has occurred.
• Recent recommendation
• Meropenem
• Imipenem
• Ampicillin, gentamycin, clindamycin (generic)

Take home message - MANTRELS scoring may be outdated - we need to look at ANC values, consider US before CT, can use analgesics, good to use antibiotics presurgically.

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[i] Garcia Pena et al Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 1999; 15:1041-1046

[ii] National Caner Institute. Radiation and Pediatric computed tomography: a guide for health care providers. Summer newsletter; 2002 1-4

[iii] Kharbanda AB, Taylor GA, et al A clinical decision rule to identify children at low risk for appendicitis. Pediatrics 2005; 116:709-716

[iv] Kim MK, Strait RT, Sato TT, et. Al. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002; 9:281-287

[v] Kokki H, Lintula H, Vanamo K, et al. Oxycodone vs placembo in children with undifferentiated abdominal pain; a randomized, double-blind clinical trial of the effect of analgesia on diagnostic accuracy. Arch Pediatr Adolesc Med 2005; 159:320-325

TBL - Jaundice and Hepatitis

jaundice / hepatitis

jaundice

Jaundice is a yellowish colouration of the tissue resulting from the deposition of bilirubin

This only happens in the presence of serum hyperbilirubinemia, and is a sign of either

·         Liver disease

·         Hemolytic disorder (less commonly)

The degree of bilirubin elevation can be estimated by PE.

Sclera icterus = at least 51micromol/L (3mg/dL)

May be even green in colour if long-standing (oxidation of bilirubin to biliverdin)

Differential of yellow skin

·         Caretenoderma

·         Quinacrine

·         Phenol exposure

Increased bilirubin occurs when there is an imbalance between the production and clearance of bilirubin.

It may result from

·         Over-production of bilirubin

·         Impaired…

o    Uptake

o    Conjugation

o    Excretion

·         Regurgitation of unconjugated / conjugated bilirubin from damaged hepatocytes / bile ducts.

Initial steps in jaundice patient evaluation

History taking

Some presentation of jaundice are quite characteristic, and such history presentation should warrant a confirmatory  investigations.

·         Fever + nausea + Anorexia (even cigarettes also does not want)

o    Suggestive of viral hepatitis

§  Comfirmation by HepA IgM, Hep B surface antigen, Hep C IgM etc.

·         Pruritis + dark urine + pale stools

o    Suggestive of cholestasis

§  Check by bilirubin study (urobilinogen,

§  Alkaline phosphatase

§  Ultrasound of bile ducts

·         Fatty food triggers colicy pain

o    Suggestive of bile stone causes

§  Ultrasound

§  ERCP

·         Progressive jaundice + fever + chills + rigors (Charcot’s triad)

o    Stone obstructive cholangitis

§  ERCP

§  Ultrasound

·         Jaundice + fever + Conjuctivitis + muscle aches + passage of small and dark urine

o    Leptospirosis

§  Darkfield microscopy

·         Recurrant mild jaundice which worsen with fasting / fever

o    Gilbert syndrome

·         Hematemesis + easy brising, mental confusion, inverted sleep pattern after severe illness like CHF, Shock etc

o    Liver insufficiency causing hepatic encelopathy

§  Liver function tests

Physical examination

Physical examination is often useful, after a sufficient history has been taken from the patient.

History and physical exam should come hand in hand, to provide a solid Differential Diagnosis for us to proceed onto the investigations.

Investigations

·         Full blood count

o    To rule out hemolytic causes

o    Leucocyte – bac. infection

·         Liver biochemistry

o    To rule out hepatocellular causes

·         Bilirubin study

o    Conjugated hyper bilirubinemia

§  Hepatocellular origin

o    Unconjugated
hyper bilirubinemia

§  Over production,

§  Impared hepatic intake

§  Impared conjugation

·         Viral Markers

o    hepatitis viruses

o    EBV

o    CMV

·         Serum alpha-fetoprotein

o    Hepatocellular carcinoma,

o    Germ cell tumors

o    metastatic cancers of the liver.

·         Serum Albumin:

o    low level indicative of chronic liver disease.

·         Prothrombin Time:

o    sensitive indicator of chronic liver disease. Will be prolonged. Vitamin K deficiency must be excluded.

·         Aspartate Aminotransferase:

o    increased in hepatic necrosis, MI, muscle injury, CCF

·         Alkaline Phosphatase:

o    increased in cholestasis(intra/extrahepatic), metastasis of liver, cirrhosis.

·         Ȣ-Glutamyl Transpeptidase:

o    increases with alcohol consumption and drugs i.e. phenytoin

imaging

·         Ultrasound Imaging

o    Bile duct imaging

o    Gallstones?

o    Hepatic mets?

o    Pancreatic mass?

·         CT Scan

o    Abdominal malignancy?

o    Masses in abdomen?

·         Endoscopy (ERCP)

o    Bile duct opening

o    Bile duct obstruction

algorhythm of jaundiced patient (from Harrison 16th ed)

summary of Digital Rectal Exam.

This is the Summary of Digital Rectal Exam.

it is a component of GI, and should be done during semester 3.

flow of events;

1. GIEP - Emphasis on Explanation
2. positioning of patient and getting ready
3. put gloves on.
4. inspection of the perianal area
5. insert finger
6. palpation of the anal canal
7. assess anal tone
8. extract finger and wipe perianal area, put blanket back.
9. inspect your finger,
10. dispose glove
11. report
12. thank patient, leave room

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Explanation

Digital Rectal Exam is an opportunity where we're required to show high levels of professionalism in presenting the patient with sufficient explanation, and asking for consent.

basically what you're going to do is sticking your finger up the patient's ass.

(in your explanation, it is referred to as "the back-passage".)

therefore, the patient should (MUST) be given sufficient good reason for it to be done.

explain throughly - about what you're going to do - how it may feel - how it will be done discreetly - how the patient will be provided with chaperon if she deemed so

Good morning, my name is --------, i am a - year medical student.
Today, I will be carrying out a digital rectal exam on you.
this will involve me inserting my finger through your back-passage, to feel for any irregularities.

during the course of this examination, you may feel as if you're passing motion.

you may feel uncomfortable, but should it cause any pain, please do not hesitate to stop me.

if you feel uncomfortable, you may ask for a cheperon.

Is that fine for you?

something like that. the patient may ask several questions like "why do I have to do this" or "is it really necessary" but we need to use our common sense (if we have one) or empathy skills (as if we have one) on this.

think - what if you were required to go through this DRE? would you be satisfied with what you said?

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Positioning of patient

now that we have convinced the patient to face his doom, we need to instruct the patient to position him/herself for a suitable position.

the position is called a left lateral decubitus. basically the patient will lie like a fetal position on the bed, back-passage towards you, hugging his/her knee.

now, in IMU, we're only going to talk to the butt (the Digital Rectal model) so what you're really doing is explaining to the butt where to move, as you reposition it yourself.

Could you please lie flat, shift to my side, then turn to your left? please hug your knees, thank you.

now that you have the butt in place, you will have to carefully expose the butt to reveal the back-passage ONLY. there is a penis stuck on the rectal model. cover it. the model needs some privacy. (and no i am not joking. it is to minimize the patient's embarrassment.)

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put on your gloves.

put on your gloves. both hands. disposable gloves.

Q - why disposable and not sterile gloves?

A - since when was the rectum sterile? and disposable gloves are cheaper.

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inspection

before you stick your finger in - hold your horses.

you need to inspect the perianal area.

inspect for;

• anal orifice - is it patent?
• anal tone - is it normal / Lax? (the model has a lax anal tone (gaping anal) - he may have a spinal cord injury, not surprising since he has no upper body)
• any piles/hemorrhoid
• anal fissures
  (the model may have an anal fissure due to repeated manhandling by medical students. comment on it, the examiner will be pleased to know that we actually look at things, and realize how we abuse our models.)
  (if you find a fissure in a real patient, feel sorry for him/her. this is going to hurt.)
• warts
• ulcerations
• extra orifice, fistula, etc
• surgical scars
• swelling
• discolouration

and so on.

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Insertion of the finger

now you finally get to insert your finger. but there are several steps you must take, to ensure that the patient won't be scared/in pain/scarred for life.

1. lubricate your index finger - not the whole hand, you're not FISTING the patient -
2. place your index finger (NOT MIDDLE) on the anal margin (just posterior to the anal orifice), with your other fingers clenched. the other hand is lightly pulling on the buttock of the patient. wait for the anal sphincter to relax.
   (your hands must be clenched since if your hands are splayed, you may grab some... stuff)
3. once the anal sphincter relaxes, pass your index finger into the anal canal into the rectum.

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ask the patient to squeeze your finger to assess anal sphincter tone.

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1. sweep the mucosa through 360 deg. checking for any masses, stricture, points of tenderness.
2. identify the prostate in men, and uterine cervix in women.
   the Prostate should form a rubbery, firm swelling about a size of a large nut. run the finger on each of the lateral lobes, and feel for the medial sulcus - which is a faint depression running vertically between each lateral lobe.
   In carcinoma of the prostate, the prostate becomes hard, lobes become irregular and nodular, and thee is distortion or loss of median sulcus.

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1. gently pull out the finger.
2. assure the patient that its all done,
3. wipe the anal region.
4. cover the model.
5. tell the patient it is over, and be careful to roll to supine position as they're near the end of the bed.
6. look at the finger that was inserted. if in doubt, wipe onto a tissue.
   comment for presence of pus, blood, or mucus.

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report after you have disposed the glove.

people won't want you to fling that finger about while you're reporting.

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thank the patient, wash hands, leave.

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summary of Oral Examination station

Summary of Mouth station (learnt in semester 2)

its quite tedious.

you'll need a torchlight.

you'll need a torchlight.

you'll need a torchlight.

(that is how much you need a torchlight)

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to-do list

1. GIEP
2. Wash hands
3. Inspection of the exterior mouth
4. inspection of the vestibules
5. inspection of oral proper
6. inspection of teeth
7. inspection of tongue, tongue maneuver and inspection of mucosa
8. inspection of lingal frenulum
9. inspection of the oropharynx
10. inspection of tonsils
11. check for halitosis, fetor hepaticus etc.
12. report, thank SP, wash hands and leave

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Exterior mouth

• any deformities of lips, and opening of mouth
  (cleft lips, microstoma etc)
• presence/absence of angular stomatitis
• note if there is any scars, swelling, or discolouration.
• discolouration may be cyanosis
• presence/absence of herpes labialis (herpes ulcer on lips)

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Vestibules

(Use Tongue depressor & Torch Light.)

ask patients to pull the lips up and down. either that, use a glove.

• check for any ulcers in the vestibules. most commonly apthous ulcers.
• check the opening of the salivary glands. (Parotid opening is at the opposite of 2nd molar teeth. sublingual and submandibular glands are underneath the tongue)
  Check for presence, any inflammation, blockage etc.
  http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi?book=cm&part=A3627&blobname=ch119f6.jpg

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Oral Proper (use torch light & tongue depressor)

• check for any ulcers.
• check the palates. check for presence of cleft-palate, and rash (SLE) etc.

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Teeth

• Check Dental hygene.
• any extraction of tooth? (predisposes to I.E.)
• count number of teeth. there should be 32.

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tongue

when you check the tongue, do not just check the surface. ask patient to move the tongue left right, up, so as to check all the surface. the leukoplakia may be at the side of the tongue, etc.

• check hydration status
• check for any discolourataion (may be cynosis, or leukoplakia)
• check for swelling / glossitis (vit B12 deficiencies)
• check surfaces for any vegitation. (candida, lichen etc)

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lingal frenulum

This is the place where skin discolouration can be seen most clearly in the mouth.

• check for jaundice, paller and cyanosis.
• check the opening of the submandibular and sublingual salivary glands.
• check for anything else; like leukoplakia or ulcers.

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Oropharynx

ask the patient to say "ah...." while holding the tongue down with the tongue depressor. you should be able to view the back of the throat, the uvula, and tonsils (if inflamed)

• check the back of throat for inflammation (redness, swelling, etc)
• check uvula. is it central?
• check palatine tonsils. is it visible? if so, is it inflamed?

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odours

here, you briefly smell the patient's mouth.

• check for fetor hepaticus - its a sweet, faecal smell. indicating liver failure.

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http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A3627

summary of GI system

summary of GI system.

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summery of events

GIEP

1. wash hands
   
2. General physical examination
   hands
   tremours
   arm
   hair
   eyes
   mouth
   chest
3. inspection of abdomen
   
4. general palpation of abdomen
   Superficial
   Deep
5. organ palpation and percussion
   Liver
   Spleen
   (no kidney)
6. general percussion
7. shifting dullness
8. fluid thrill
9. auscultation
   Abdominal sounds
   Bruits
10. thank, wash hands, leave

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Things we usually forget;

• positioning of patient - you're in deep shit when you complete the P.E just to realize your patient is propped up 45deg. GG.
• patient's legs - are they straight? SP's can be bastards.
• flapping tremour
• gynacomastia
• fetor hepaticus
• axilliary hair loss
• to divide the abdomen into 9 parts - we're expected to regurgitate the 2 horizontal and 2 vertical lines, and name the 9 quadrants before we even touch the patient.
• Warn, Warm and touch patient prior to palpation.
• to LOOK AT THE FACE of patient as we palpate
• whenever eliciting shifting dullness, remember that there are 2 steps to it.
• to expose the patient properly (at least till the ASIS level, by right it is down till the mid-thigh)
• to turn the patient over 90deg (or more, not less) when we attempt to palpate a spleen
• washing hands as we leave - common to all PE station.

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things you should practice

• naming the 9 quadrants of the abdomen.

the abdomen can be divided into 9 regions by using 2 horizontal and 2 vertical planes.
the 2 vertical planes being 2 imaginary planes connecting the left and right mid-clavicular line and mid-inguinal point.
the 2 horizontal planes are the subcostal and transtubercular line, where subcostal being the line connecting the two lowest point of coastal margin, or the 10th rib, and transtubercular line being the line connecting the two illiac tubercules.

• organ palpation - different lecturers will stress on different ponits, but ALL LECTURERS stress on organ palpation technique.
• percussion.

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things we should know (Viva Material)

yellow discolouration of skin is not necessarily due to jaundice.

could also be;

• carotenoderma - from eating too much carotene - spares sclera
• quinacrine (drug) - ask drug history
• exposure to phenols

difference between kidney and spleen

• kidney is BALOTTABLE, spleen is NOT
• NOTCH ON ANTERIOR BORDER - palpable in spleen, not in kidney
• spleen enlarges diagonally towards RLQ, while the kidney enlarges inferiorly
• kidney can be resonant to percussion (d/t overlying bowel), spleen should be DULL
• UPPER EDGE of spleen NOT palpable, upper edge of kidney is
• SPLENIC RUB on auscultation (have patient breath in and out)

Traube’s Space

• triangular area demarcated by xiphisternal line, lower costal margin, Mid Axiliary Line
• tympanic due to the gastric bubble - in splenomegaly, stomach is displaced and region sounds dull (not a specific test)
• False Positives: full stomach, pleural effusion and pneumonia

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extra stuff (if you're interested)

Jaundice can be seen most prominently at the sclera of the eye due to the high elastin content of the sclera (Harrison's pg 261)

long-standing jaundice may cause a Green discolouration of the skin (bilirubin ->biliverdin) (Harrison pg261)

Clinical presentation of chronic renal failure

Mnemonic: RESIN & 8 Pʼs

R Retinopathy
E Excoriations (scratch marks)
S Skin is yellow
I Increased blood pressure
N Nails are brown
P Pallor
P Purpura and bruises
P Pericarditis and cardiomegaly
P Pleural effusions
P Pulmonary oedema
P Peripheral oedema
P Proximal myopathy
P Peripheral neuropathy

Common conditions producing acute abdominal pain

condition	Usual pain characteristics	Possible associated S/S
Appendicitis / meckel’s diverticulitis	Initially periumbilical or epigastric, colicky, later becomes localized to RLQ, often at Mcburney’s. - more medial pain may be meckel’s.	Guarding, tenderness + iliopsoas +obturator sign, RLQ skin hyperesthesia, anorexia, nausea, vomiting - after onset of pain. Low-grade fever + Aaron, Rovsing, Markle and Mcburney signs.
peritonitis	Onset sudden / gradual. Pain generalized / localized, dull / severe and unrelenting. Guarding, pain on inspiration.	shallow respiration with Blumberg, Markle and Balance signs, reduced or absent bowel sounds, nausea and vomit.
Cholecystitis	Severe, unrelenting RUQ or epigastric pain - may be referred to right subscapular area.	RUQ tenderness and rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice
pancreatitis	Dramatic, sudden, excruciating LUQ / epigastric / umbilical pain. May be radiating to back / left shoulder.	Epigastric tenderness, vomiting, fever, shock +grey turner’s sign +Cullen sign - both + after 2-3d.
Salpingitis	LQ pain, worse on left	Nausea vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic exam.
PID (Pelvic Inflammatory Disease)	LQ, increase with activity (PID shuffle)	Tender adnexa and cervix, cervical discharge, dyspareuria
Diverticulitis	Epigastric, radiating down left side of abdomen especially after eating - may be referred to back	Flatulence, borborygmus, diarrhea, dysuria, tenderness on palpation.
Perforated Gastric / Duodenal Ulcer	Abrupt, RUQ, may be referred to shoulders	Abdominal free air and distension with increased resonance over liver, tenderness over epigastrium / RUP
Intestinal obstruction	Abrupt, Severe, colicky, spasmodic, referred to epigastrium, umbilicus	Distension, minimal rebound tenderness, vomiting, visible peristalsis, bowel sounds may be absent (paralytic) / hyperactive (mechanical obstruction)
Volvulus	Referred to hypogastrium and umbilicus	Distension, nausea, vomiting, guarding, sigmoid loop volvulus may be palpable
Bile stone colic	Episodic, severe, RUQ / epigastric lasting 15 min - several hours	RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature
Renal calculi	Intense, Lumber, loin to groin pain, may be episodic	Fever, hematruria, +Kehr sign
Ectopic pregnancy	Lower quadrant, referred to shoulder, with rupture - agonizing	Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses. If ruptured - shock, rigid abd.wall, +Kehr and Cullen signs
Splenic rupture	Intence, LUQ, radiating to Left shoulder, may worsen with foot elevated	Shock, pallor, lowered temperature
IBS (Irritable Bowel Syndrome)	Hypogastric, crampy, variable, infrequent.	May relieve by passage of flatus.

Abdominal signs associated with common abnormalities

Aaron	Pain / distress in area of heart / stomack on palpation of mcburney’s  point.	Appendicitis
Ballance	Fixed dullness to percussion in left flank, and dullness in right flank which disappear on change of position	Peritoneal irritation
Blumberg	Rebound tenderness	Peritoneal irritation, appendicitis
cullen	Ecchymosis around umbilicus	Hemoperitoneum, pancreatitis
Kehr	Abd. Pain radiating to left shoulder	Splenic rupture, Renal calculi, Ectopic pregnancy
Markle (heel jar)	Patient stand with straight knees, then tip-toe - relax to hit heel on floor. - abd. Pain = positive	Peritoneal irritation, appendicitis
mcburney	Rebound tenderness and sharp pain when Mcburney’s point is palpated	Appendicitis
Murphy	Abrupt cessation of inspiration on palpation of gall bladder	Cholecystitis
Romberg-Howship	Pain down the medial aspect of thigh to knees	Strangulated obturator hernia
Rovsing	RLQ pain intensified with LLQ abdominal palpation	Peritoneal irritation; appendicitis.