ABDOMINAL PAIN
Approach
• Assess nature of pain: Location, acute or chronic, constant or intermittent, relation to
eating, associated sxs such as fever, nausea, vomiting, dysuria, change in bowel habits
• Always ask about previous abdominal surgeries
• Labs depend on presentation. Consider: CBC, BMP, UA, LFTs, lipase, hCG, lactate
• In the elderly, low threshold to evaluate for AAA w/ bedside U/S & ACS w/ EKG
RIGHT UPPER QUADRANT PAIN
Cholelithiasis
Presentation
• Acute, severe, intermittent RUQ pain, +N/V, a/w fatty meals
• In biliary colic, sxs generally resolve completely in b/w episodes
• Mild RUQ tenderness but no fever or Murphy’s sign
• In choledocholithiasis & cholecystitis, sxs will become constant
Evaluation
• nl labs in biliary colic
• Biliary colic is a clinical Dx & U/S is not required in ED unless ruling out other Dx, or
in pt w/ intractable pain. RUQ U/S spec/sens is 90–95% for stones.
Treatment
• NSAIDs, opiate analgesics, antiemetics; elective surgical management
Disposition
• If pain controlled, d/c home w/ surgery f/u to consider cholecystectomy
Pearls
• 80% of stones are of mixed composition w/ cholesterol having the highest
concentration
• RFs include female gender, increasing age & parity, & obesity
Choledocholithiasis
Presentation
• Biliary colic that becomes constant, often jaundiced
• Mild RUQ tenderness but no fever or Murphy’s sign
Evaluation
• Obstructive LFT pattern, U/S shows dilated CBD >6 mm
Treatment
• ERCP-guided stone removal or cholecystectomy
Disposition
• Admit medicine
Cholecystitis
Presentation
• Acute, severe, RUQ pain, that becomes constant, fever, nausea, vomiting
• RUQ tenderness; Murphy’s sign (arrest of inspiration w/ RUQ palpation), or
Sonographic Murphy’s sign (pain w/ palpation of visualized gallbladder w/ U/S
probe); fever
Evaluation
• CBC (elevated WBC ± left shift), LFTs (may be elevated but are often nl), RUQ U/S:
The presence of stones, thickened gallbladder wall (>3 mm), & pericholecystic fluid
has a PPV of >90%
• HIDA scan: Used if U/S is equivocal, best sens/spec
Treatment
• 2nd- or 3rd-generation cephalosporin (E. coli, Enterococcus, Klebsiella) broaden
coverage if septic
• Surgical consult for cholecystectomy; may do percutaneous drain if poor surgical
candidate
Disposition
• Admit for surgical management
Cholangitis
Presentation
• Charcot’s triad: RUQ pain, jaundice, fever (present in 70% of pts)
• Reynold’s pentad: Charcot’s triad +shock & MS changes (present in 15% of pts)
Evaluation
• Labs: ↑ WBC, ↑ LFTs, positive blood cultures
• U/S/CT not very sens; can be suggestive
• ERCP is diagnostic & can be therapeutic if obstructing stone is found
Treatment
• Broad-spectrum abx for gram-negative enterics (eg, E. coli, Enterobacter, Pseudomonas):
Piperacillin/tazobactam OR ampicillin/sulbactam OR ticarcillin/clavulanate OR
ertapenem OR metronidazole + (ceftriaxone OR ciprofloxacin)
Disposition
• Admission to medicine for IV abx ± ERCP w/ surgery consultation
Pearls
• 80% pts respond w/ conservative mgmt & abx w/ elective biliary drainage
• 20% require urgent ERCP biliary decompression, percutaneous drainage, or surgery
• 5% mortality
EPIGASTRIC PAIN
Pancreatitis
Definition
• Inflammation of the pancreas
Etiology
• Alcohol (30%), gallstones (35%), idiopathic (20%) hypertriglyceridemia (TG >1000),
hypercalcemia, drugs (thiazides, furosemide, sulfa, ACE-I, protease inhibitors,
estrogen), obstructive tumors, infection (EBV, CMV, HIV, HAV, HBV, coxsackievirus,
mumps, rubella, echovirus), trauma, post-ERCP, ischemic
Presentation
• Acute onset epigastric pain radiating to the back, nausea, vomiting
• Often h/o previous pancreatitis, alcohol abuse, gallstones
• May be ill appearing, tachycardic, epigastric ttp, guarding, ↓ bowel sounds (adynamic
ileus)
Evaluation
• Increased amylase >3× nl (suggestive but not spec for pancreatitis)
• Increased lipase >2.5× nl
• If severe: ↑ WBC, ↑ BUN, ↑ glucose, ↓ HCT, ↓ calcium (see Ranson criteria)
• CT scan: 100% spec but low sens. Not required; should be obtained only to r/o cx
(acute fluid collection, pseudocyst, necrosis, abscess)
• Abdominal U/S: May be used to evaluate for gallstones, CBD dilatation or pseudocyst
Treatment
• Aggressive IV fluids; NPO initially, but early enteral nutrition if tolerated
• IV analgesia (risk of sphincter of Oddi spasm w/ morphine is unsupported),
antiemetics
• Prophylactic abx have unclear benefit; may use for severe necrotizing pancreatitis
• Surgery required only for débridement of infected necrosis, or cholecystectomy if 2/2
stone
Disposition
• Admission for supportive care if severe or not tolerating PO
• Several scoring systems exist to help determine floor vs. ICU. Ranson criteria widely
used (see below) but limited evidence to support utility (Crit Care Med
1999;27(10)2272).
LOWER QUADRANT/PELVIC PAIN
Appendicitis
Definition
• Inflammation of the appendix
History
• Classically, dull vague periumbilical pain which then migrates to the RLQ & becomes
sharp & localized
• Nausea, vomiting, anorexia, fever
• Greatest at 10–30 y of age but can occur at any time
Physical Findings
• RLQ (McBurney’s point) tenderness, localized rebound & guarding
• Psoas sign: Pain w/ active flexion against resistance or passive extension of the right
leg
• Obturator sign: Pain w/ internal rotation of the flexed right hip
• Rovsing sign: RLQ pain w/ palpation of the LLQ
Evaluation
• Labs: Leukocytosis (not sens or spec); cannot r/o w/ nl WBC. Check hCG.
• U/S: Less sens than CT but high spec. Consider esp in children.
• Abdominal CT w/ IV ± oral or rectal contrast (94% sens & 95% spec)
• MRI is a useful modality in pregnancy
• In cases w/ strong clinical e/o appendicitis & low suspicion of alternate etiology, it
may be reasonable to proceed w/ laparoscopy w/o imaging
Management
• Abx: Cefoxitin, cefotetan, fluoroquinolone/metronidazole, OR piperacillin–tazobactam
• Admission for surgical removal
Pearl
• Patients at extremes of age are more likely to have atypical presentations & present
w/ perforated appendicitis. Very thin young patients may have nl CT w/ appendicitis.
Hernia
Definition
• Defect in the abdominal wall that allows protrusion of abdominal contents
• Reducible hernia: Can be pushed back in
• Incarcerated hernia: Cannot be reduced
• Strangulated hernia: Incarcerated hernia w/ vascular compromise (ischemia)
History
• Bulging mass in inguinal area, femoral area, or scrotum (men)
Physical Findings
• Painful mass in abdominal wall or groin
• Strangulated: Tender, fever, ± cellulitis, blue discoloration or associated peritonitis
Evaluation
• If concern for strangulated hernia, consider CBC, lactate
• CT scan required if concern for strangulated hernia
Management
• Attempt reduction w/ generous analgesia/anxiolysis, pt in Trendelenburg
• If easily reduced, d/c w/ analgesic, stool softener, & surgery f/u
• If not reducible or if strangulated, start abx & surgical admission for operative
intervention
Pearl
• Be cautious about reducing a hernia that has been irreducible by the patient for more
than 12 h & is difficult to reduce in the emergency department b/c bowel may be
compromised. Consult surgery for these cases; may need observation.
Diverticulitis
Definition
• Inflammation of diverticulum (sac-like protrusion in the wall of the bowel)
• Complicated diverticulitis: Associated perforation, obstruction, abscess, or fistula
Presentation
• LLQ pain, fever, nausea, constipation
• Mild LLQ tenderness, 50% of pts have heme-positive stool
• Complicated may have peritonitis, septic shock
Evaluation
• Clinical Dx if mild sxs & typical presentation
• Labs: Increased WBC (increased in 31–64% of patients)
• CT only needed if concern for complicated diverticulitis. Oral contrast may reveal
pericolonic inflammation/stranding, abscess, or free air if perforation present.
Treatment
• Mild: PO metronidazole + (quinolone or TMP-SMX), OR amoxicillin–clavulanate
• Severe: NPO, IV fluids, IV ampicillin–sulbactam OR piperacillin–tazobactam OR
ceftriaxone/metronidazole OR quinolone/metronidazole OR carbapenem
• Surgery is required if medical therapy fails, free air is present, large abscess that can’t
be drained percutaneously, & recurrent dz (≥2 episodes)
Disposition
• If mild, d/c w/ abx, cathartic, analgesia w/ GI f/u. If severe, admit.
Pelvic Inflammatory Disease/Tubo-ovarian Abscess
Definition
• Polymicrobial infection of the upper female genital tract commonly a/w sexually
transmitted organisms (gonorrhea, chlamydia), but not exclusively
• Cx include abscess, perihepatitis (Fitz-Hugh–Curtis), sepsis, chronic pain, increased
risk of ectopic pregnancy, infertility
History
• Women w/ lower abd pain, vaginal d/c, dysuria, dyspareunia, nausea ± fevers
• RFs: Age <25, multiple sexual partners, unprotected sex, h/o PID, IUD placement in
the last month, recent instrumentation of the cervix, douching, smoking
Physical Findings
• Lower abdominal tenderness, cervical d/c, cervical motion tenderness, adnexal
tenderness/fullness
• Clinical exam has sens of 50–75%; presentation is often atypical
Evaluation
• Labs: Always check pregnancy test; cervical cultures, UA, CBC (not sens)
• Abdominal CT or pelvic U/S only required if TOA is suspected (unilateral tenderness
or palpable mass, systemically ill)
Treatment (CDC. MMWR 2012;61:581)
• Low threshold for empiric tx: Minimum criteria in sexually active young women or
others at risk are pelvic pain & cervical, uterine or adnexal tenderness
• Outpt: Ceftriaxone 250 mg IM × 1 + doxycycline for 14 d
• Consider adding metronidazole for anaerobes, esp if recent gynecologic
instrumentation
• Azithromycin is considered insufficient for PID; may be used in isolated cervicitis or
2nd line
• If severe PCN allergy, options are hospitalization or azithromycin 2 g AND
levofloxacin
• Inpt: (Cefotetan or cefoxitin) + doxycycline OR clindamycin + gentamicin
Disposition
• Admit if toxic appearing, severe vomiting, failure to outpt therapy, pregnancy,
immunocompromised, young age, poor f/u w/i 72 h
• Discharged pts need f/u in 3 d to ensure sx resolving. Partners should be referred for
rxn.
Pearls
• Given ↑ resistance to antibiotic regimens, CDC updates recommendations frequently
• PID in pregnancy is rare but does happen; alternative diagnoses should be considered
DIFFUSE PAIN
Abdominal Aortic Aneurysm
Definition
• Dilation of the abdominal aorta (true aneurysm, involves all layers of the vessel wall)
History
• Older patient w/ low back pain, abdominal pain, or flank pain (may mimic renal
colic), syncope
Physical Findings
• Pulsatile mass (often not present)
• Ruptured AAA: Hypotension, abdominal tenderness, decreased femoral pulses
mottling, decreased urine output due to obstructive uropathy
• Extension into SMA/IMA/celiac arteries leads to bowel ischemia
• Extension to renal artery leads to renal failure, colic, may cause obstructive uropathy
• Extension to spinal arteries causes neuro deficits, specifically T10–T12 spinal ischemia
• Extension to iliac vessels causes peripheral limb ischemia
Evaluation
• Abdominal CT or U/S only if hemodynamically stable
• Bedside U/S may reveal enlarged aorta & free fluid
Treatment
• Stable, nonruptured: Surgical or endovascular repair required if >5.5 cm (1%/y risk
of rupture if >5 cm) or rapidly growing; usually arranged as outpt
• Unstable or ruptured: Immediate surgical repair, allow permissive hypotension (SBP
90 s)
Disposition
• Surgical admission for ruptured AAA or vascular sequelae
Pearls
• RFs: Smoking, HTN, hyperlipidemia, age ≥65 y, male (5×), FH
• 50% mortality if AAA is ruptured at presentation
Small Bowel Obstruction
Definition
• Mechanical obstruction of nl intestinal transit leading to bowel dilation
History
• Diffuse, colicky abdominal pain, nausea, vomiting, abdominal distension, h/o
abdominal surgeries/prior obstructions/hernia, obstipation
Physical Findings
• Diffuse abdominal tenderness, distension, high-pitched bowel sounds
Evaluation
• Supine & upright abdominal x-rays (47–76% sens): Multiple air–fluid levels, >3 cm
small bowel dilation, more than 3 mm small bowel wall thickening
• Abdominal CT (64–100% sens) can be diagnostic & used to characterize the
obstruction (level, severity, cause)
Treatment
• NPO, bowel rest, gastric decompression w/ NGT placement
• IV fluids, analgesia, antiemetics
• Surgical consultation
Disposition
• Surgical admission
Large Bowel Obstruction/Volvulus
Definition
• Mechanical obstruction of the large bowel
• Volvulus: LBO caused by twisting of the large bowel on itself (10% of cases)
History
• Insidious onset of diffuse, colicky abdominal pain, constipation, N/V
Physical Findings
• Diffuse abdominal tenderness, distension, bowel sounds present early
Evaluation
• Supine & upright abdominal x-rays: Dilated large bowel. In volvulus: Single dilated
loop of large bowel (80% sens for sigmoid volvulus, 50% sens for cecal volvulus).
• Abdominal CT w/ rectal contrast: Oral contrast should be avoided
Treatment
• IV fluids & correction of electrolyte abnormalities
• Rectal tube & NGT for relief of sxs
• Surgical consultation for likely operative reduction (particularly for cecal volvulus)
Disposition
• Surgical admission
Pearls
• Sigmoid volvulus most common in ill, debilitated elderly patients, or patients w/
psychiatric/neurologic disorders
• Cecal volvulus common in young adults, classically marathon runners
Perforated Viscus
Definition
• Perforation of hollow viscus leading to abdominal free air, intraluminal spillage
History
• Acute onset, severe abdominal pain, worse w/ movement, anorexia, vomiting
Physical Findings
• Acute peritonitis: Rigidity, tap tenderness, rebound, hypotension, sepsis
Evaluation
• Supine & upright abdominal x-rays: Free air seen (70–94% sens)
• Abdominal CT: Definitive study but not required for operative management
Treatment
• Immediate surgical consult
• Abx: Ampicillin–sulbactam OR cefotetan OR ampicillin/flagyl/gentamicin
Disposition
• Surgical admission
Pearl
• Chronic steroids can mask sxs
Mesenteric Ischemia
Definition
• Insufficient perfusion of the mesentery & intestine
• Etiologies: SMA embolism (50%), transient hypoperfusion (25%), SMA thrombosis
(10%), venous thrombosis (10%), focal segmental ischemia of the small bowel (5%)
History
• RFs: Age, AF, vascular dz (coronary, peripheral), CHF (↓ forward flow)
• May have h/o prior abdominal angina: Postprandial pain, food aversion
• Acute typical presentation is persistent abdominal pain, anorexia, vomiting, bloody
stools
Physical Findings
• Ill appearing, pain out of proportion to exam, tachycardia, fever, occult blood in
stools. Late signs include peritonitis, shock.
Evaluation
• Early surgical eval
• Labs: May be nl, increased WBC/amylase/LDH/lactate (late), metabolic acidosis
• Abdominal x-ray: nl prior to infarction, “thumbprinting” of the intestinal mucosa later
• Abdominal CT: Colonic dilation, bowel wall thickening, pneumatosis of the bowel wall
• CT angiography: More sens than CT alone
• Angiography: Gold standard
Treatment
• IV fluids, avoid pressors if possible
• Abx: Ampicillin/gentamicin/metronidazole OR piperacillin/tazobactam OR
levofloxacin/flagyl
• Intra-arterial thrombolysis or embolectomy for arterial embolism
• Anticoagulation for arterial & venous thrombosis & embolic dz
Disposition
• Surgical admission
Pearl
• 20–70% morality; improved if Dx made prior to infarct
Spontaneous Bacterial Peritonitis
Definition
• Infection of the ascitic fluid in patients w/ severe chronic liver dz
History
• Fever, abdominal pain, new or worsening ascites, hepatic encephalopathy
Physical Findings
• Stigmata of liver failure, diffuse abdominal pain, ascites
Evaluation
• Labs: PT/INR, PTT, platelets prior to paracentesis
• Paracentesis: >250 PMN, blood:ascites pH gradient >0.1, culture
Treatment
• Abx: Cefotaxime 2 g IV OR levofloxacin 750 mg IV; if prior quinolone prophylaxis,
add vancomycin
• Albumin 1.5 g/kg at Dx & 1 g/kg for 3 d shows survival benefit
Disposition
• Medical admission
Pearls
• 70% GNR (E. coli, Klebsiella), 30% GPC (S. pneumoniae, Enterococcus)
• Clinical signs may be unreliable; have low threshold for paracentesis
• Occurs in 20% of cirrhotics
INFLAMMATORY BOWEL DISEASE (ULCERATIVE COLITIS AND CROHN’S
DISEASE)
Definition
• Ulcerative colitis (UC): Idiopathic inflammation of the colonic mucosa
• Crohn’s dz (CD): Idiopathic transmural inflammation of the GI tract
History
• Women, 20–30 y/o, weight loss, vomiting, abdominal pain/diarrhea (grossly bloody
in UC) that flares w/ emotional stress, infections, acute illness, pregnancy, abx,
withdrawal from steroids
Physical Findings
• Diffuse abdominal tenderness (focal RLQ tenderness in CD), heme-positive stools 20%
of pts have extraintestinal sxs, perianal dz (seen in CD); fissures, fistulas, abscess,
rectal prolapse
Evaluation
• Labs: Low HCT (from chronic blood loss), increased WBC, hypokalemia (from
diarrhea)
• Plain abdominal x-ray: If perforation, obstruction, or toxic megacolon suspected
• Abdominal CT: May r/o cx (eg, abscess, obstruction, fistula)
• Outpt colonoscopy: If Dx not known & once acute flare resolved
Treatment
• IV fluids, bowel rest, surgical consult, steroids, ± mesalamine
Disposition
• Admit for severe dz or acute complication
NAUSEA AND VOMITING
Definition
• The sensation of or act of ejecting stomach contents through the mouth
Approach
• Common sxs of many dz processes (eg, intra-abdominal dz, metabolic derangements,
toxic ingestions, neurologic dz)
• Careful attention to ROS, PMH, previous abdominal surgeries
• Labs: Consider CBC, BMP, UA, LFTs, lipase, hCG
• Treat underlying cause: Antiemetics (eg, ondansetron, promethazine), IVF if not
taking PO
Gastroenteritis
Definition: Irritation of the GI tract causing vomiting AND diarrhea usually caused by
infections (viruses, bacteria, bacterial toxins, parasites) or due to medications or diet
History: Vomiting AND diarrhea, ±fever
Physical Findings: nl exam or mild diffuse abdominal ttp, tachycardia, dehydration
Evaluation: Consider BMP if clinical concern for significant electrolyte derangement
Management: Supportive care, antiemetics. IVF if not taking PO. Home when
tolerating PO.
Pearl: Viral & bacterial toxins (food poisoning) are most common & typically resolve
w/o tx in 48 h
Hyperemesis Gravidarum
Definition: Nausea & vomiting that result in weight loss or failure to gain weight
History: Pregnancy (1st trimester, usually week 8–12), nausea, vomiting, inability to
PO
Physical Findings: Tachycardia, dehydration
Evaluation: Labs: Electrolytes, UA; often have ketosis & electrolyte derangements
Treatment: IV fluids (w/ dextrose), antiemetics (ondansetron, metoclopramide), Vit B6
Disposition: Home if tolerating PO
GASTROINTESTINAL BLEED
Definition
• Bleeding from the GI tract
Approach
• Hemodynamically unstable patients should get 2 large-bore IVs (14–18 gauge), early
transfusion of PRBC as well as FFP & Vit K if impaired coagulation
• ROS, PMH, previous GIB, alcohol use, liver dz
• Labs: CBC, BMP, LFTs, lipase, coagulation studies, type & screen
UPPER GI BLEED
Approach
• Glasgow–Blatchford score was designed to predict need for transfusion or urgent
endoscopy. A score of zero identifies low-risk pts who can safely be discharged w/
outpt f/u (JAMA 2012;307(10):1072; Lancet 2000;356(9238):1318).
Bleeding Peptic Ulcer Disease (PUD) or Gastritis
Definition
• Inflammation or ulceration of the stomach or duodenal lining caused by H. pylori
infection (80% of duodenal ulcers & 60% gastric ulcers), NSAIDs (15–30%), ASA,
alcohol, malignancy, smoking, stress, gastrinoma, anticoagulants, other medications
History
• Epigastric abdominal pain worse w/ food (gastric ulcer) or relieved by food (duodenal
ulcer). If bleeding ulcer/gastritis: Black tarry stool, coffee ground emesis
Physical Findings
• Epigastric tenderness, melena or heme-positive stools, peritonitis or back pain if
perforated
Evaluation
• Upright CXR for free air if perforation suspected
• Labs: CBC, LFTs, coagulation panel, elevated BUN; H. pylori serology (90% sens)
• NG tube not routinely indicated; may help GI to determine emergent vs. delayed EGD
Treatment
• For nonbleeding gastritis/PUD: All patients should start PPI or H2B. May use antacids,
Maalox for sx relief. Empiric H. pylori tx not recommended.
• For bleeding or e/o cx: IVF resuscitation, PRBC if indicated, start IV proton pump
inhibitor empirically (omeprazole 80 mg IV bolus, then drip)
• Emergent EGD if hemodynamically unstable (vs. surgical intervention in severe cases)
Disposition
• If ongoing bleeding, Blatchford >0, high risk: Admit for EGD
Variceal Bleeds
Definition
• Bleeding from esophageal or gastric varices (present in 40–60% of cirrhotics) due
portal HTN (10–30% of UGIB)
History
• Bright red hematemesis, diffuse abdominal pain, nausea
Physical Findings
• Stigmata of liver failure (jaundice, spider angiomas, ascites, caput medusae), Ill-
appearing hypotension, tachycardia, melena
Evaluation
• Labs: CBC, LFTs, coagulation panel, type & cross
Treatment
• Place 2 large bore IVs, initiate IV fluid resuscitation, PRBC if anemic or active
bleeding
• Octreotide bolus & drip; often start IV PPI empirically for PUD until EGD confirms
etiology
• Antibiotic prophylaxis for SBP if ascites present (ceftriaxone or levofloxacin)
• Emergent EGD if hemodynamically unstable, may need emergent TIPS if still bleeding
• Balloon tamponade w/ Minnesota or Blakemore tube if exsanguinating (after
intubation)
Disposition
• Usually ICU admission
Pearls
• 30% bleed rate in 1st year, 70% rebleed rate, 30% mortality from the 2nd bleed
• Do not underestimate history: May not appear sick initially but can decompensate
quickly
Mallory–Weiss Tear
Definition
• Tears in the mucosal membrane of the distal esophagus caused by retching against a
closed glottis (10% of UGIB)
History
• Specks of bright red blood in emesis or mild hematemesis after forceful retching
Physical Findings
• Most have no physical findings, mild tachycardia
Evaluation
• Upright CXR if hemodynamically unstable to evaluate for subcutaneous or mediastinal
air for Boerhaave syndrome (complete esophageal rupture)
Treatment
• Antiemetics, PO challenge
Disposition
• D/c w/ outpt EGD
Pearl
• Boerhaave syndrome can result from forceful emesis but pts are usually ill-appearing
w/ shock & require surgical management. Consider barium swallow if high suspicion.
Aortoenteric Fistula
Definition
• Fistula b/w the aorta & GI tract, most commonly in duodenum
History
• H/o AAA, aortic graft (usually >5 y), may have sentinel bleed or large-volume GIB
Physical Findings
• Rapid GIB, hemodynamic collapse
Evaluation
• CBC, type & cross, emergent surgical consult, CT scan if stable
Treatment
• IV fluid resuscitation, PRBC if indicated (use uncrossed blood if unstable)
• Surgical repair
Disposition
• Surgical ICU admission
Pearl
• Mortality directly related to time to the OR
LOWER GI BLEED
Bleeding Diverticulosis
Definition: Bleeding diverticula (33% of LGIB), 50% are from ascending colon
History: Sudden onset, painless bright red rectal bleeding initiated by urge to defecate
Physical Findings: nl abdominal exam, BRBPR, no etiology found on rectal exam
Evaluation: Labs: CBC, LFTs, coagulation panel, type & cross
Treatment: IV fluid resuscitation, PRBC if indicated
Disposition: Admit for colonoscopy
Colorectal Cancer
Definition
• Cancer of the colon or rectum (19% of LGIB)
History
• Chronic blood in stool, change in bowel habits, anorexia, weight loss, lightheaded
Physical Findings
• Pale, heme occult positive stools
Evaluation
• Labs: CBC, LFTs, coagulations; CT if concern for obstruction or significant bleeding
Treatment
• IV fluid resuscitation, PRBC if indicated
• Surgical consultation if significant bleeding (rare)
Disposition
• If stable, d/c for outpt colonoscopy/oncology w/u
Colonic Angiodysplasia
Definition: Enlarged, fragile blood vessels, usually in cecum or proximal ascending
colon (8% of LGIB)
History: >60 y/o, small frequent bleeds
Physical Findings: nl abdominal exam, BRBPR or heme occult positive stools
Evaluation: CBC, coagulation panel
Treatment: IV fluid resuscitation, PRBC if indicated; endoscopic cautery or IR
embolization
Disposition: Admit for observation & colonoscopy
Hemorrhoids
Definition
• Dilated or bulging veins of the rectum & anus. Internal hemorrhoids may prolapse &
become incarcerated (irreducible) or strangulated (ischemic).
History
• Bright red coated stool/toilet paper/dripping into the bowl, pain w/ defecation
(external hemorrhoids), h/o hard stools/constipation/prolonged sitting
Physical Findings
• External hemorrhoids are visible on eversion of the anal orifice, internal hemorrhoids
are visible at 2-, 5-, & 9-o’clock (when prone) w/ anoscopy, unless prolapsed
Evaluation
• CBC only if significant blood loss suspected or concerning underlying condition
Management
• Generally outpt w/ stool softener (Colace, Senna), Sitz baths (15 min TID & after
BMs), suppositories for symptomatic relief
• Acute thrombosis (<48 h since onset of pain) can be excised at bedside in ED
• If prolapsed hemorrhoid is incarcerated w/ signs of strangulation, consult surgery
• All patients over 40 should be referred for colonoscopy to exclude concurrent
malignancy
Pearl
• Does not cause anemia
DIFFICULTY SWALLOWING
Definition
• Dysphagia is difficulty swallowing, odynophagia is pain w/ swallowing
Approach
• Nature: Time course, progressive (solids to liquids), localization (upper vs. lower
esophagus)
• ROS, PMH, hx or FH of GI disorders or neurologic disorders
• Labs: CBC, BMP
• Studies: Barium swallow or EGD for structural/mechanical lesions; motility studies
Esophageal Food Impaction/Foreign Bodies
Definition
• Food or FB stuck in esophagus (70% lodge at the lower esophageal sphincter)
History
• Sensation of food (often meat) or FB stuck in the esophagus, retching, unable to
swallow secretions, h/o esophageal stricture, scleroderma, or dysmotility
Physical Findings
• Respiratory distress (if at upper esophageal sphincter), drooling
Evaluation
• CXR (may show dilated esophagus w/ air–fluid level or FB)
Treatment
• Smooth muscle relaxants: Glucagon 2 mg IV (30–60% success rate), nitroglycerin SL,
calcium channel blockers, benzodiazepines
• Endoscopy if medications as unsuccessful, if a dangerous object is present (batteries,
sharp object), or FB doesn’t pass w/i 12–24 h
Disposition
• If tolerating PO, d/c w/ outpt EGD
DIARRHEA
Definition
• Frequent, watery stools. Specifically, >3 loose stools/day OR >250 mL water in
stool/day.
Approach
• Nature: Bloody, mucus present, duration, frequency, volume; recent travel or abx
• Labs: Consider BMP for electrolyte derangement; consider CBC, LFTs, heme occult
Infectious Diarrhea
History
• Diarrhea ± blood/fever, recent ingestion of meats/poultry/dairy/shellfish/sea
food/unrefrigerated food, sick contacts, recent travel (last 6 mo), antibiotic use
• Invasive bacterial enteritis is a clinical Dx: Fever, blood in stool, tenesmus, abd pain
Physical Findings
• Dehydration, mild abd tenderness. If invasive: Heme-positive stool, fever.
Evaluation
• Labs: Increased WBC (Salmonella), low WBC (Shigella), eosinophilia (parasites)
hypokalemia, metabolic acidosis
• Stool culture, fecal WBC & O&P appropriate if ill appearing, severe diarrhea, extremes
of age, chronic, or immunocompromised
Treatment
• IV fluid resuscitation if needed, electrolyte repletion
• Abx: TMP-SMX, ciprofloxacin or azithromycin (recent travel, ill appearing, fever,
immunocompromised), OR metronidazole (C. difficile, Giardia, E. histolytica)
• Antimotility agents may be used for traveler’s diarrhea
• Constipating diet (BRAT: Bananas, rice, applesauce, toast) for a short time
Disposition
• Admit if unable to keep up w/ volume loss or toxic
Pearl
• Significant abdominal pain in not common & should be evaluated further
Irritable Bowel Syndrome
Definition: Disorder of the colon: Causes cramping, bloating, diarrhea, constipation (F
> M)
History: Must have recurrent abdominal pain >3 d/mo over the last 3 mo. Plus 2 or
more of the following: Improvement w/ defecation, onset w/ change in frequency of
stools, onset w/ change in form of stools. No constitutional sxs.
Physical Findings: May have mild lower abdominal tenderness, heme-negative stools
Treatment: Fiber for constipation, antimotility for diarrhea, antispasmodics (Bentyl)
for pain
Disposition: D/c, outpt management
Pearl: Dx of exclusion. Unlikely if age of onset >35 or associated constitutional sxs.
CONSTIPATION
Definition
• Reduced frequency of stool (<3/wk), &/or difficult passage of hard stool
Approach
• Nature: Duration, severity, character of stool, pain, fever, medication use, prior
episodes
Simple Constipation (Including Stool Impaction)
History
• Poor diet, decreased fluid/fiber intake, decreased mobility, constipating medications
Physical Findings
• Firm stool in the rectal vault, palpable stool on abd exam, minimal abd ttp
Evaluation
• Abdominal x-ray or CT if need to r/o obstruction, or to confirm Dx in high-risk pt
Treatment
• Manual disimpaction if needed
• Colace, mineral oil, magnesium citrate, enema (esp in elderly)
• Natural bulking agents (Metamucil) when constipation resolves
Disposition
• Home
Rectal Foreign Body
History
• FB insertion usually during sex play or iatrogenic
Physical Findings
• FB in rectum on exam or anoscopy
Evaluation
• Abdominal x-ray to eval location/shape
Treatment
• Removal w/ forceps traction while the patient bears down. Impacted object may cause
proximal vacuum suction; can pass foley around object to break vacuum seal & use
balloon to pull back on object.
• Removal in OR if unsuccessful or if sharp object w/ risk of perforation
Disposition
• Home if removed
Pearl
• Procedural sedation may be needed to sufficiently dilate anus to remove FB in ED
JAUNDICE
Definition
• Yellowing of the skin as a result of elevated bilirubin (>3 mg/dL)
Approach
• Duration, associated pain, fever, recent travel, h/o liver dz or alcohol abuse
• Labs: CBC, BMP, UA, LFTs, lipase, ±ammonia if MS changes, paracentesis if ascites
Cirrhosis
Definition
• Fibrosis & nodular regeneration resulting from hepatocellular injury
• Etiologies include alcohol, viral hepatitis (esp HCV), autoimmune hepatitis,
hemochromatosis, Wilson dz, α1-antitrypsin deficiency, biliary tract dz, vascular dz
(Budd–Chiari syndrome, right-sided CHF, constrictive pericarditis), nonalcoholic fatty
liver dz, malignancy (usually metastatic)
History
• Abdominal pain, jaundice, pruritus, abdominal distension
Physical Findings
• Liver: Enlarged palpable liver or shrunken nodular
• Signs of liver failure: Jaundice, spider angioma, palmar erythema, gynecomastia,
asterixis, encephalopathy
• Signs of portal HTN: Splenomegaly, ascites, caput medusae
Evaluation
• New onset: LFTs, BMP, CBC (for anemia, thrombocytopenia), INR (to evaluate
synthetic function), abdominal U/S if pain, tenderness, or fever present to r/o acute
biliary dz or if concern for Budd–Chiari, paracentesis if new-onset ascites
• Exacerbation/decompensation of known cirrhosis: Labs to evaluate for electrolyte
derangements, new coagulopathy. Paracentesis to r/o SBP if fever, abdominal pain,
tenderness, new hepatic encephalopathy, GIB, significant leukocytosis, renal failure.
Treatment
• Directed at treating cx
• Hepatic encephalopathy (failure of liver to detoxify ammonia & other agents): Protein
restriction, lactulose (goal 2–4 stools/d)
Disposition
• Admit if decompensated (increasing ascites/edema despite compliance w/ outpt
regimen), pulmonary edema, renal failure, hypotensive, encephalopathic, febrile
Pearl
• Cx: Portal HTN (ascites, varices), encephalopathy, hepatorenal syndrome,
hepatopulmonary syndrome, infections (relative immunosuppression), HCC
Acute Liver Failure
Definition
• Acute hepatic dz often w/ coagulopathy & encephalopathy
• Fulminant liver failure is when encephalopathy occurs <8 wk since onset of 1st sx
• Common etiologies: Viral hepatitis, drugs (40% acetaminophen), toxins (mushrooms),
Reye’s syndrome, vascular (Budd–Chiari, CHF), autoimmune hepatitis, idiopathic
(20%)
History
• Abdominal pain, jaundice, toxic ingestion, nausea, vomiting, malaise, confusion
Physical Findings
• Jaundice, abdominal tenderness, enlarged liver, encephalopathy, pulmonary edema,
GIB (decreased clotting factors, DIC)
Evaluation
• Labs: CBC (anemia, thrombocytopenia), PT/INR, BMP (electrolytes, renal function),
acetaminophen level, viral serologies
• Paracentesis if ascites (32% have SBP)
Treatment
• Treat underlying causes (eg, acetaminophen w/ NAC)
• If etiology unclear have low threshold for NAC regardless of acetaminophen level
• Abx: Broad-spectrum (Vancomycin + 3rd-generation cephalosporin)
• Coagulopathy/GIB: Vit K, FFP, platelets, cryoprecipitate if active hemorrhage
• Cerebral edema: Consider ICP monitoring, mannitol, barbiturates
Disposition
Admit medicine. ICU if fulminant, hypotensive, or GIB.
Pearl
Survival 10–50%
RECTAL PAIN (PROCTALGIA)
Approach
• Nature: Duration, consistency of stools, bleeding, fevers
Anal Fissure
Definition: Superficial tear of the anoderm that begins just below the dentate line
History: H/o passage of hard stools, sharp pain w/ defecation, blood on toilet paper
Physical Findings: Visible fissure, painful. If not midline, eval for cancer, HIV, IBD,
STDs.
Management: Sitz baths (warm baths 15 min 3×/d), high-fiber diet, lidocaine jelly
FEVER
Background
• Temp >100.4°F/38°C
• Caused by response to bacteria, viruses, inflammation; ↑ metabolic rate, meds
• Distinct from hyperthermia (caused by exogenous factors)
Approach
• Careful hx: COLDER, associated sxs (N/V, diarrhea, cough, abd pain, rash, AMS)
• Eval directed by pt hx & sx localization
• Assess VS for significant abnormalities that may indicate serious infection (↓ BP, ↑ HR)
• If immunosuppressed (HIV/AIDS, elderly, malnourished, chronic steroids, DM) or
neutropenic, more intensive eval & testing: CBC, Chem, UA & cx, CXR; consider blood
cx & admission
• Intermittent/relapsing fever, FUO, or occurring after foreign travel: Consider travel-
related infectious etiologies, endocarditis
ENDOCARDITIS (Arch Intern Med 2009;169(5):463)
History
• RFs: IVDU, congenital or acquired valvular dz, prosthetic valves, structural heart dz,
HD, indwelling venous catheters, cardiac surgery, bacteremia, chronic alcoholism,
previous endocarditis
• Difficult to Dx 2/2 nonspecific sx (lethargy, weak, anorexia, low-grade temp), or
negative w/u
Findings
• Fever (96%), new murmur (48%), CHF (32%), splenomegaly (11%), petechiae
• Classic physical exam findings
• Roth spots (2%): Exudative, edematous retinal lesions w/ central clearing
• Osler nodes (3%): Violaceous tender nodules on toes & fingers
• Janeway lesions (5%): Nontender, blanching, macular plaques on soles & palms
• Splinter hemorrhages (8%): Nonblanching, linear, reddish-brown under nails
• Septic emboli (mitral valve vegetations)
Diagnosis
Evaluation
• EKG, CBC, Chem, coags; CXR, ↑ ESR/CRP (nonspecific), ≥2 blood cx
• Typically Staph or Strep species; also gram-negative bacilli, Candida (prosthetic)
• Echo for vegetations or valve ring abscesses; TEE more sens than TTE
Treatment
• Hemodynamic stabilization if valve rupture, can present w/ acute pulmonary edema
cultures
• Immediate abx in suspected cases, preferably after blood cultures (see table)
Disposition
• Admit w/ continuous telemetry & IV abx, ICU if hemodynamic compromise
Pearls
• Infection of endothelium of heart (including but not limited to valves)
• Consider cardiac surgery consultation for refractory CHF, fungal endocarditis,
recurrent septic emboli, conduction disturbance, persistent sepsis, aneurysm rupture of
sinus of Valsalva, kissing infection of anterior mitral leaflet w/ aortic valve
endocarditis
• Mortality w/ native valve dz: ∼25%; prosthetic valve higher
• Worse prognosis if involves aortic valve, DM, S. aureus (30–40%)
• Left-sided endocarditis (mitral 41%, aortic valve 31%) most common
• IVDU: Tricuspid valve endocarditis; rheumatic valve dz: Mitral, then aortic valve
ABSCESS
Approach
• ↓ activity of infiltrated local anesthetic agents b/c of the low pH of abscess area;
consider regional nerve or field blocks + IV procedural sedation/analgesia
• Gram stain & wound cx rarely necessary for skin or perirectal abscesses
• Cx from intra-abdominal, spinal, or epidural abscesses usually sent from OR to guide
therapy
• Pharyngeal abscess cx can also help tailor antibiotic therapy
• In diabetic, immunocompromised, w/ systemic sxs, septic, obtain labs & blood
cultures, start IVF & abx & admit for IV abx
SOFT TISSUE
Cutaneous Abscess (Clin Infect Dis 2005;41(10):1373)
History
• ↑ pain, tenderness & induration, usually w/o h/o fever or systemic tox
• Disruption of skin from trauma or penetrating injury, often pt cannot recall injury
• H/o IVDA/skin popping, prior MRSA abscesses
Findings
• Exquisitely tender, soft, fluctuant mass surrounded by erythema
• Most commonly Staph species, often polymicrobial
Evaluation
• Blood work rarely needed unless appear systemically ill; US may help w/ localization
• Culture from abscess only if tx w/ abx, severe infection, systemic illnesses, failed
initial tx
Treatment
• No abx indicated in healthy hosts unless cellulitis, fever, immunosuppression, failed
I&D
• I&D w/ regional nerve or field block ± procedural sedation
• Create elliptical incision to prevent premature wound closure
• Break up loculations in abscess cavity w/ hemostat
• Consider irrigate & pack w/ 1/4-in gauze × 48 h (24 h if cosmetically important)
• If surrounding cellulitis, nafcillin 2 g IV q4h, cefazolin 1 g IV q8h, or cephalexin PO
• If for complicated abscess: Clindamycin, Bactrim, tetracycline, linezolid, vancomycin
Disposition
• D/c w/ wound care instructions, 2-d f/u
• Warm soaks TID × 2–3 d after removal of packing to allow continued wound
drainage
Pearl
• Can develop essentially anywhere: Furuncle, acne, skin breakdown, insect bites
• Routine packing of abscesses after I&D is controversial
Paronychia
History
• Pain & swelling lateral to nail edge; superficial infection of epithelium
• No inciting injury but can be secondary to contaminated nail care instruments or
trauma
Findings
• Purulent collection lateral to nail bed w/ minimal surrounding erythema
• Most commonly Staph or Strep species but can have mixed aerobic & anaerobic flora
Evaluation
• No labs necessary
Treatment
• No abx indicated in healthy hosts
• Digital block w/ 1% lidocaine with or without epinephrine in each web space of
affected digit
• #11 blade scalpel to lift cuticle from nail on affected side & express purulent material
Disposition
• D/c w/ wound care instructions, 2-d f/u
• Warm soaks to finger TID × 2–3 d to allow complete drainage
Pearls
• Often h/o manicure/pedicure, nail biting
• If recurrent or chronic paronychia, consider Candida infection
• May spread to pulp space of finger (felon) or deep spaces of hand, tendon if neglected
Pilonidal Cyst
History
• Painful, tender abscess in alar cleft, often in obese or hirsute individuals
• More prevalent in males; fever & systemic tox very rare
Findings
• Painful, localized abscess in natal cleavage/midline sacrococcygeal region, 4–5 cm
posterior to anal opening; surrounding erythema & fluctuance
• Mixed flora: Staph or Strep species, anaerobic cocci, mixed aerobic & anaerobic flora
Evaluation
• No labs necessary unless systemically ill
Treatment
• Same as for cutaneous abscess, I&D
• Surgical referral for excision of follicle & sinus tract after acute episode subsides
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
Pearls
• High recurrence rate (40–50%) unless follicle surgically removed
• Thought to be caused by hair penetrating into subcutaneous tissues creating abscess
Bartholin Gland Cyst/Abscess
History
• Severe localized pain in labia caused by obstructed Bartholin duct
• Difficulty walking & sitting secondary to pain
• Fever & signs of systemic tox are rare
Findings
• Painful, tender, cystic mass on inferior lateral margin of vaginal introitus, often w/
purulent drainage from sinus tract
• Typically anaerobes, MRSA, also Staph, Strep, & E. coli species, chlamydia, gonorrhea
Evaluation
• Culture for chlamydia, gonorrhea
Treatment
• I&D through mucosal surface, place Word catheter ×48 h
• Sitz baths TID for the 1st 2–3 d to assist drainage
• Gyn f/u for consideration of marsupialization to prevent recurrence
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
Pearl
• Recurrence rate still 5–15% after marsupialization; consider gyn malignancy
PERIRECTAL Abscesses (Int J Colorectal Dis 2012;27:831)
History
• Pain & swelling in rectal area w/ defecation & often w/ sitting down or walking
• High fever & signs of systemic tox are rare
• Pts often have h/o Crohn dz, obesity, DM, or PID
Findings
• Rectal exam essential to ensure abscess localized outside of anal sphincter & to
identify upper extent of abscess
• Typically E. coli species, Enterococcus, Bacteroides species, S. aureus, MRSA
Figure 4.1.
Evaluation
• Lab studies unnecessary unless systemically ill
• DM or immunocompromised should have Chem, CBC
• CT/MRI if concern for intersphincteric or supralevator or postanal abscess or fistula
Treatment
• ED I&D of superficial abscesses outside the anal verge w/ visible indurated area
• Pain control; I&D extremely painful, procedural sedation often needed
• If abscess is only identified on rectal exam & no induration visible, refer to surgery for
I&D under general anesthesia
• DM or immunocompromised pts should undergo I&D in OR to ensure full drainage
• Pack w/ Vaseline gauze ×48 h, Sitz baths TID for 1st 2–3 d to assist drainage
• No abx for healthy host w/ superficial abscess
• Consider abx for immunocompromised, prosthetic device/valve, incomplete I&D
• Levofloxacin 500 mg QD (ampicillin 1 g + gentamicin 80 mg q8h) + metronidazole
500 mg q8h, consider vancomycin
Disposition
• D/c w/ wound care instructions, 2-d wound care f/u
• Admit diabetic & immunocompromised for IV abx
Pearls
• 35–50% treated w/ I&D or spontaneous drainage will develop chronic anal fistula
• Bilateral tenderness raises possibility of “horseshoe” abscess
INTRACRANIAL ABSCESS
History
• Caused by contiguous spread (sinus, ear, dental), hematogenous seeding from distant
infection, (endocarditis) or post-CNS surgery/penetrating trauma
• HA (70–90%), fever (50%), meningismus, photophobia, sz (30%), vomiting (25–50%),
AMS
• Subacute time course (vs. meningitis or encephalitis)
Findings
• Focal neuro deficits, low-grade fever, obtundation (mass effect), sz, AMS, nuchal
rigidity (25%), papilledema (10–50%)
• Wide variety of organisms depending on method of entry, 1/3 polymicrobial
Evaluation
• Blood cultures, CBC (WBC nonspecific), Chem, coags
• CT scan w/ & w/o IV contrast; MRI more sens for cerebritis, posterior fossa lesions
• CSF findings nonspecific, avoid LP
Treatment
• Emergency neurosurgical consult for drainage in OR; airway management, sz tx
• Early IV abx w/ good CSF penetration, tailored to likely pathogen
• Start broad-spectrum IV abx: Ceftriaxone 2 g + vancomycin 1 g + metronidazole 500
mg
• Corticosteroids ONLY for tx of cerebral edema: Decadron 10 mg IV × 1 then 4 mg q6h
Disposition
• Neurosurgical intervention for operative washout, 6–8 wk IV abx then 4–8 wk PO abx
Pearls
• Mortality 24–27%, unless abscess ruptures into ventricular system (mortality 80%)
• Morbidity from residual neuro deficits, new sz from scar tissue or neuropsych Δ (50%)
SOFT TISSUE INFECTIONS
Approach
• Careful hx, associated sxs (V/D, cough, abd pain, AMS), progression
• Check blood sugar if diabetic
• Assess VS for significant abnormalities that may indicate serious infection (↓ BP, ↑ HR)
• If immunosuppressed (HIV/AIDS, elderly, malnourished, chronic steroids) or
neutropenic, more intensive eval & testing: CBC, Chem, UA & cx, CXR; consider blood
cx & admission
• If recent foreign travel: Consider travel-related infectious etiologies
DERMATOLOGIC
Cutaneous/Subcutaneous Cellulitis (Clin Infect Dis 2005;41(10):1373)
History
• Often no h/o broken skin; ± local trauma, recent surgery, FB
• May report fever, chills, malaise
Findings
• Warm, blanching erythema & tenderness to palpation, mild to moderate swelling
• ± distal skin disruption (eg, tinea pedis b/w toes w/ cellulitis of anterior shin)
Evaluation
• If elevated BS, check Chem, UA; Rule out abscess clinically or with bedside ultrasound
• Consider blood cultures, CBC w/ differential, chemistries, CRP, CPK in systemically ill
pts
• Bacterial cultures of inflamed area not indicated; only 10–50% positive
• Most often caused by Strep or S. aureus (including MRSA); can be from metastatic
seeding
Treatment
• If LE cellulitis, recommend rest & elevation × 48 h, crutches if needed
• PO abx: cephalexin 500 mg PO QID, dicloxacillin 500 mg PO QID, or Augmentin 500
mg PO TID
• IV abx: Cefazolin, ceftriaxone, nafcillin
• If PCN allergic: clindamycin 500 mg PO QID, or azithromycin 500 mg PO × 1, then
250 mg PO × 4 d, levofloxacin 500 mg QD × 5 d
• If diabetic or immunocompromised, use broader coverage abx
• Consider MRSA coverage: Vancomycin, gentamicin, tetracyclines, Bactrim, rifampin,
Daptomycin, linezolid
• Pain control w/ NSAID/APAP; if severe pain consider necrotizing infection
• Wound débridement if infected, contaminated or devitalized wound
• Surgery consult if aggressive/necrotizing infection/gas in soft tissue
Disposition
• D/c w/ PO abx & 24–48 h f/u, strict return instructions
• Admit if signs of systemic infection, DM, immunocompromise, failure of outpt tx
Pearls
• Due to inflammation of dermal & subcutaneous tissue due to nonsuppurative bacteria,
infection does not involve fascia or muscles
• Consider Doppler vascular studies in single limb w/ diffuse swelling, posterior calf or
medial thigh to rule out DVT
• Mark border w/ permanent ink, write time & date
Erysipelas
History
• Extremes of age, obesity, DM, CHF, postop, nephrotic syndrome at higher risk
• Acute onset pain, erythema, induration
• Initial fever & chills followed by painful rash 1–2 d later
• May have systemic sxs: Myalgias, arthralgias, nausea, HA
Findings
• Skin painful superficial, indurated, raised; erythema w/ sharply demarcated border
• Irregular erythema w/ lymphangitis, may see desquamation, dimpling, vesicles, LAD
• 70–90% found on lower extremities, 5–20% on face, 5–6% on upper extremity
Evaluation
• None indicated unless toxic appearing
Treatment
• PCN G, amoxicillin, cefazolin 1 g IV q8h or azithromycin 500 mg PO
• PCN allergic: Azithromycin, clindamycin, levofloxacin
Disposition
• D/c w/ PO abx & analgesics, elevate affected area, 24–48 h f/u, strict return
instructions
Pearls
• Typically caused by group A β-hemolytic streptococcus; involves dermis, hypodermis,
& lymphatics
• More superficial than cellulitis
• Recurrence rate 10–40%
Staphylococcal Scalded Skin Syndrome (SSSS) (Am J Clin Dermatol
2003;4(3):165)
History
• Young children <5 yr, rare in adults, fairly rapid progression of prodromal sore
throat, conjunctivitis, fever, malaise to painful red skin w/ sloughing
Findings
• No mucous membrane involvement (vs. TEN)
• Erythematous cellulitis followed by acute exfoliation: Bullae, vesicles → large sheets of
skin loss resulting in scalded-appearing skin
• General malaise, fever, irritability, tenderness to palpation, does not appear severely
ill
Evaluation
• None indicated unless systemically ill
• Positive Nikolsky sign (epidermis separates when pressure applied)
Treatment
• Similar to burns (IVF, topical wound care, burn consult)
• Most recover w/o abx but still recommended: Nafcillin, vancomycin, clindamycin
Disposition
• Admit for burn care, IVF; consider ICU
Pearls
• Caused by exfoliative exotoxins of S. aureus, reports of MRSA
• Separation of epidermal layers vs. more severe TEN (necrosis at level of basement
membrane)
• Prognosis: Children (4% mortality) often w/o significant scarring; adults (60%
mortality)
Toxic Shock Syndrome (TSS)
History
• Multiple sxs: Prodrome, pain at site of infection (out of proportion to findings), fever,
chills, N/V, abd pain, watery diarrhea, myalgias, arthralgias, pharyngitis, HA, AMS
• Recent surgery, infrequently changed packing (tampons, nasal packing)
Findings
• Clinical Dx w/ findings from all organ systems:
• Temp >38.9°C, ↓ BP (shock/hypovolemia), rash
• “Sandpaper” diffuse, macular rash initially on trunk → spread to arms, legs, palms,
soles → flaking full-thickness desquamation, 5–12 d after onset
• Involvement of 3 organ systems (see table)
Evaluation
• CBC w/ differential, Chem, UA, LFTs, coags, cultures (blood, urine, throat)
Treatment
• Remove tampon or packing if still in place, drain abscesses if present; burn care
• Aggressive resuscitation, pressors if needed, Foley catheter to monitor urine output
• Abx, may not have impact (toxin-mediated process); tx any identified source
• Nafcillin, vancomycin, clindamycin to suppress bacterial toxin synthesis; linezolid
• High-dosed steroids reported to improve TSS in case reports
• IVIG 400 mg/kg IV (has antibodies to TSS-1 & other exotoxins) for very ill pts w/
pulmonary edema or who require mechanical ventilation may reduce mortality
• Surgical consult if debridable sources of infection
Disposition
• ICU admission
Pearls
• Rate ↓ w/ ↓ in use of superabsorbent tampons
• Caused by inflammatory response to TSST-1 enterotoxin from Strep & Staph species
• Strep: Usually after surgery or trauma; scarlet fever-like rash; 30–70% mortality,
fulminant
• Staph: More indolent, 5% mortality
• Poor prognosis, mortality as high as 70%, 30–50% recurrence, most w/i 2 mo
Necrotizing Fasciitis
History
• H/o mild trauma, often diabetic, PVD, EtOH abuse or nutritionally compromised
• Sudden onset of pain & swelling which progresses to anesthesia
Findings
• Fever, tenderness, erythema, toxic appearing
• Pain out of proportion to exam &/or numbness, crepitus
• Rapidly spreading, progressive erythema/infection of deep fascia w/ secondary
necrosis of subcutaneous tissues, subcutaneous air (due gas-forming organisms)
• Can progress to involvement of deeper layers, causing myositis or myonecrosis
Evaluation
• CBC w/ differential, Chem, UA, CRP, coags
• Plain radiographs less sens than CT in eval of gas w/i soft tissue
Treatment
• Early surgical consult for débridement (definitive tx); hemodynamic support
• Early & broad abx
• Vancomycin 1 g q12h + piperacillin/tazobactam 4 g IV q6h + clindamycin 600 mg
IV q8h
• Consider hyperbaric oxygen tx, IVIG after débridement
Disposition
• ICU admission for surgical débridement, transfer for hyperbaric oxygen therapy
Pearls
• Mortality 20–50%, fatal if untreated
• Mostly S. pyogenes (group A), S. aureus, or mixed Gram + & – bacteria, anaerobes
GENITOURINARY
Fournier Gangrene
History
• Elderly, obesity, diabetic, chronic EtOH abuse, chronic steroids, immunocompromised
• Recent h/o instrumentation, indwelling catheter, perirectal dz, anal intercourse
• Fever, lethargy prodrome
• Rapidly progressing scrotal swelling, pain, erythema, warmth, possible purulent
drainage
Findings
• Intensely tender, swollen, warm scrotum w/o clear fluctuance, pruritic genitalia
• Fever, chills, systemic sxs (tachycardia, ↓ BP), ± crepitus, drainage
• Deep-space infection is often vastly greater than skin involvement would suggest
Evaluation
• CBC w/ differential, Chem, blood & urine cx, CRP, coags
• X-rays may show subcutaneous air; CT will show extent of infection & necrosis
Treatment
• Urology or general surgery consult for wide débridement & drainage
• Hemodynamic support & resuscitation w/ IVF, pressors
• Broad-spectrum abx: Vancomycin, Unasyn, Zosyn, clindamycin; Td prophylaxis
• Consider hyperbaric oxygen tx. IVIG after débridement.
Disposition
• ICU admission for surgical débridement, transfer for hyperbaric oxygen therapy
Pearls
• Mortality of severe infection 50%; early surgical débridement most strongly correlated
w/ outcome
• Polymicrobial (E. coli, Bacteroides, Strep, Staph, anaerobes, enterobacter, fungi)
• Rapid destruction of fascial planes
OPHTHAMOLOGIC (Ophthalmology 2007;114(2):345)
Periorbital/Preseptal Cellulitis
History
• Recent infection of sinuses, periorbital skin, trauma to periorbital area, bites
Findings
• Unilateral eyelid swelling, erythema, warmth, discoloration of skin
• Injected sclera, conjunctival ecchymosis
• No pain w/ or ↓ extraocular movements, no proptosis
Evaluation
• CBC w/ differential, blood cultures, CT scan of orbits to evaluate for orbital extension
Treatment
• Head elevation
• Abx: Ceftriaxone or Unasyn 3 g IV q6h (if need admission) or cephalexin, dicloxacillin,
clindamycin or Augmentin 500 mg PO TID × 10 d if d/c
Disposition
• Admit if appears systemically ill or has other comorbidities
• O/w d/c w/ close ophthalmology f/u (2 d)
Pearls
• Infection of soft tissue of eyelids & periocular region anterior to orbital septum
• Most often caused by Staph & Strep, rarely H. influenzae
• Distinguish from orbital cellulitis: No pain w/ EOM or proptosis in periorbital cellulitis
Orbital Cellulitis
History
• Orbital pain increased w/ extraocular movements, ↓ vision
• Recent infection of sinuses, periorbital skin, trauma to periorbital area, facial trauma
Findings
• Fever, HA, rhinorrhea, malaise
• Proptosis & ophthalmoplegia are cardinal signs
• Unilateral eyelid swelling, erythema, warmth, discoloration of skin
• Injected sclera, chemosis
• Tenderness on gentle globe palpation, ↑ IOP
• ↓ visual acuity, relative afferent pupillary defect, visual field abnormalities
Evaluation
• CBC w/ differential, CT scan of orbits, soft tissue aspirate if possible, blood cultures
Treatment
• Ophthalmology consult, head elevation
• Aggressive tx w/ immediate abx: Vancomycin, Unasyn 3 g IV q6h
Disposition
• Admission for abx
Pearls
• Infection of soft tissues of orbit posterior to orbital septum
• Most common: Strep, Staph, H. influenzae, polymicrobial
• Serious: Venous drainage via communicating vessels w/ the brain (cavernous sinus);
most commonly caused by extension from ethmoid sinuses
• Cx: 1.9% meningitis, permanent ocular mobility, visual acuity impairment
OTOLARYNGOLOGIC
Ludwig Angina
History
• Pts w/ poor dental hygiene, recent dental extraction, tooth abscess, penetrating injury
Findings
• Odynophagia, dysphagia, neck swelling, malaise, fever, stridor, drooling, tongue
protrusion
• Swelling of submandibular/sublingual space feels hard & “board like” or woody
Evaluation
• CBC w/ differential, Chem, UA, blood cultures, coags
• CT scan head & neck
Treatment
• If severe swelling, aggressively ↑ infection, or airway threatening, endotracheal
intubation may be difficult, fiberoptic nasotracheal intubation may be the best initial
approach w/ cricothyrotomy as backup
• Consultation w/ otolaryngologist for admission
• IV abx: PCN, Unasyn, 3rd-generation cephalosporin, carbapenems, clindamycin,
metronidazole
• Add gentamicin in DM, vancomycin in IVDU
Disposition
• Admit to ICU for IV abx, airway watch
Pearls
• Rapidly spreading, firm indurated cellulitis originally intraorally, involves
supramylohyoid & inframylohyoid bilateral w/o abscess or LAD, causing rapid upper
airway obstruction
• Surgical débridement was tx in preantibiotic era; now only if unresponsive to IV abx
or e/o purulent collections
VIRAL INFECTIONS
INFECTIOUS MONONUCLEOSIS
History
• Fever, pharyngitis, lymphadenopathy, HA, rash, nonspecific sxs
• 4–6 wk incubation period, 1–2 wk prodrome: Fatigue, malaise, myalgias, low-grade
temp
Findings
• Low-grade temp, pharyngitis, tonsillitis
• Tender & firm LAD for 1–2 wk, most often postcervical nodes, but can be generalized
• Rash: Papular erythematous on UE, erythema nodosum, erythema multiforme
• Splenomegaly; severe abdominal pain uncommon, may indicate splenic rupture
• May have petechiae, jaundice, hepatomegaly, periorbital edema
Evaluation
• CBC: ↑ WBC, ↑ atypical lymphocytes, ↑ LFTs (bilirubin, AST, ALT); monospot test
Treatment
• Supportive, rest, analgesics, antipyretics
• Corticosteroids if airway edema
Disposition
• Admission rarely indicated; close PCP f/u
• Advise to avoid contact sports or vigorous exercise × 1 mo to prevent splenic rupture
Pearls
• Represents syndrome response to EBV (90% of people have EBV); most cases of mono
caused by EBV but most EBV infections do not result in mono
• Secondary etiology: CMV
• Transmission through saliva; infects epithelial cells of oropharynx & salivary glands
• B lymphocytes become infected → allows viral entry into bloodstream
• Self-limited; usually spontaneous resolution in 3–4 wk, complete in several months
HIV/AIDS (Emerg Med Clin N Am 2008;26:367)
History
• Fever, fatigue, night sweats, pharyngitis, diarrhea, myalgia/arthralgias, HA, flu-like
sxs
Findings
• Generalized maculopapular rash, oral ulcers (thrush), fever, lymphadenopathy
Evaluation
• CBC: Leukopenia, thrombocytopenia, ↑ LFTs
• ELISA to test for HIV Ab; if + confirm w/ Western blot (VL >100 K in acute
infection)
• PCR to detect viral load, CD4 count
Treatment
• Counseling pre- & post-HIV testing
Disposition
• D/c unless systemically ill, ID f/u for antiretroviral tx
Pearls
• Transmitted through sexual contact (70%), IVDU; mother-to-child transmission
possible during pregnancy or birth
• Untreated HIV → AIDS (CD4 <200) w/ life expectancy of 2–3 yr
RABIES
RABIES ENCEPHALITIS
History
• Possible h/o dog, cat, or other nonrodent (raccoon, skunk, fox, bat) bite or scratch or
rabid-appearing animal (agitated, drooling, unprovoked attack) or bat exposure
• Prodrome lasts 2–10 d; nonspecific fevers, pharyngitis, HA, anorexia, pain, N/V,
anxiety, irritability or paresthesias at site of bite or scratch
Findings
• Hydrophobia, aerophobia, high fevers
• CNS sxs begin 2–7 d after start of prodrome
• 80% hyperactivity (agitation, thrashing, bulbar, & myoclonus), 20% “dumb rabies”
(progressive, ascending, flaccid paralysis w/ intact sensorium, incontinence)
• Progressive autonomic instability: Hyperpyrexia, mydriasis, ↑ lacrimation & salivation
• Late findings: Hypotension, coma, DIC, multisystem organ failure, arrhythmias, &
arrest
• Rapidly progressive encephalopathy
• Paralysis & apnea are terminal events; universally fatal unless pt gets prophylaxis
Evaluation
• Rabies antigen, RNA, rabies-neutralizing Ab titer >1:5 in serum is diagnostic of
infection if not previously vaccinated (4× ↑ in titers diagnostic for vaccinated pts)
• CSF: ↑ protein; slightly ↑ RBC & WBC; Ab titer diagnostic, regardless of vaccine status
• CT head, CSF Gram stain & culture; evaluate for other causes of encephalopathy
Treatment
• Supportive, palliative
• No proven medical tx has been shown to be effective
• Therapeutic coma (ketamine, benzo’s) & antiviral therapy (amantadine, ribavirin)
rarely a/w survival
Disposition
• ICU admission if neuro or resp sxs w/ inpt ID consult
• Notify public health department & animal control center
• Identify others at risk & initiate postexposure prophylaxis if indicated
Pearls
• Caused by Lyssavirus in family Rhabdoviridae
• Dogs are the most commonly infected animals worldwide, but very rare in US &
Canada
• All 3 reported cases of neurologically intact survivors of rabies received rabies vaccine
before onset of sxs
• Human-to-human transmission through corneal transplants (8 cases), organ
transplants (8 cases), airborne through lab work (2 cases), & human bites (1 case)
• Initial ED presentation of active rabies is rare, nonspecific, almost always missed;
universal precautions should be used in all pts w/ unexplained encephalopathy
• Accounts for >35000 deaths/y in developing countries, consider when neurologic sxs
occur after foreign travel (esp South East Asia, Africa, Latin America)
• Nearly always fatal once sxs develop. Prevention is key! Prophylaxis always
successful.
RABIES POSTEXPOSURE PROPHYLAXIS
History
• Report of dog, cat, or other nonrodent (raccoon, skunk, fox, bat) bite or scratch or
rabid-appearing animal (agitated, drooling, unprovoked attack)
• Any contact w/ bat, dead or alive
Findings
• Bite wound or scratch mark, possibly no signs of trauma
Evaluation
• Consider contacting local public health authority to assess rabies exposure risk
Treatment
• Wound care (soap, water, irrigation w/ povidone–iodine solution), débridement of
devitalized tissue, secondary closure, update Tetanus vaccination
• If domestic dog or cat bite, determine vaccination status of animal from owner
• Assess rabies risk & need for HRIG & HDCV (table below)
• HRIG: 20 IU/kg; 1/2 dose at exposure site, 1/2 dose IM in deltoid
• HDCV: 1 mL dose in deltoid in ED. F/u doses given days 3, 7, 14.
• HDCV 5th dose on day 28 if immunocompromised
• Do not stop rabies immunization b/c of mild rxn to vaccine doses
• Pre-exposure prophylaxis for at-risk individuals
• Rabies cases from nonbite exposures > from known bite exposures; consider
prophylaxis for any contact w/ high-risk animals (esp bats)
Disposition
• D/c w/ return instructions, vaccination schedule
TETANUS
History
• Acute onset hypertonia, painful muscular contractions (jaw & neck) & generalized
muscle spasms; lockjaw in 75% of cases
• RFs: Inadequate vaccination status, chronic wound, IVDU
Findings
• Spasms of muscles in close proximity to site of injury, cephalic, lockjaw, risus
sardonicus (characteristic grimace) tetanic sz, respiratory failure
• Autonomic Dysfxn: BP ↑ or ↓, dysrhythmias, cardiac arrest
• Cx include fractures & dislocations
Evaluation
• No spec tests available; clinical Dx
Treatment
• Tx of muscle spasm w/ benzo’s, respiratory support, NG tube for feeding
• Intrathecal antitetanus immunoglobulin hastens clinical improvement
• Abx: Metronidazole, PCN G, or tetracycline
Disposition
• ICU admission
Pearls
• C. tetani is obligate gram-positive nonencapsulated spore forming bacillus, resistant to
heat, desiccation, & disinfectants
• DTaP (diphtheria, tetanus, pertussis; inactivated) vaccine given at 2, 4, & 6 mo,
booster given b/w 15–18 mo & at 4–6 yr; booster recommended q10y or if dirty wound
• Mortality 30–45%; if received tetanus toxoid at sometime in life mortality 6%
• Slow recovery over 2–4 mo, usually complete resolution of sxs
Prevention
• Clean & débride wound as needed
• Pts who have not completed primary immunization series should repeat Td booster in
4–8 wk & 6–12 mo
PARASITIC INFECTIONS
SCABIES
History
• Persistent pruritus, worsen over 2–3 wk; sometimes multiple family members involved
• More common in fall & winter months, worse at night
Findings
• Skin eruption: Elevated thin pink or gray track in skin w/ small vesicle at tip
• Associated intense pruritus b/w web spaces of extremities, genital region, axilla, feet,
buttocks, areola, nipples, abdomen, beneath breasts
• Secondary lesions include urticaria, impetigo, eczematous plaques, pyoderma,
excoriations, cellulitis, & furuncles
Evaluation
• Clinical Dx; burrow ink test, tetracycline fluorescence test, skin scrapings, or shave
biopsy
Treatment
• Symptomatic relief, treat secondary infections & household members, clean clothes
• Permethrin 5% cream most effective; if severe can also give ivermectin, lindane 1%
Disposition
• D/c w/ instructions for household to be treated, decontaminate clothing, bedding
• Exclude from school until treated, topical permethrin usually effective w/i 12 h
Pearls
• Caused by female human mite, S. scabiei
• Skin-to-skin contact, indirect contact through bedding or clothing
• Can lead to long-term colonization of skin by group A Strep
TOXOPLASMOSIS
History
• Immunocompromised (HIV), painless impaired vision
Findings
• Mainly neural & muscular tissue involvement, often asymptomatic
• Nontender isolated cervical or occipital LAD, 4–6 wk
• Congenital: Intracranial calcifications, neonatal hydrocephalus, chorioretinitis,
blindness
• Immunocompromised: HA, confusion, sz, AMS, focal motor deficits, CN abnormalities,
movement disorder
Evaluation
• IgG detection via ELISA
• MRI better than CT to see Toxoplasma brain lesions
Treatment
• Fluid resuscitation, sz tx, airway management
• Nonpregnant: Pyrimethamine + sulfadiazine OR spiramycin OR clindamycin OR
azithromycin OR atovaquone + folic acid; corticosteroids for ocular toxoplasmosis
• Pregnant: Spiramycin + pyrimethamine + sulfadiazine
• AIDS: Pyrimethamine + sulfadiazine (tx & prophylactic)
Disposition
• Depends on sxs