Contributor: Adam Barkin, MD Educational Pearls: Internal hernias, when bowel herniates through iatrogenic or congenital defect in mesentery, represent 1-6% of all small bowel obstructions Mortality of strangulated internal hernias is over 50% due to bowel necrosis and sepsis Intermittent symptoms presenting with nausea, vomiting, abdominal pain, abdominal distension Increased risk in patients with gastric…
Read Morethe invisible bleed Chief Complaint: Hematemesis HPI: 43-year-old woman with a history of gastroparesis and seizures suddenly vomited blood about 4 hours prior to arrival to the ED. She has never vomited blood like this before. She describes copious hematemesis with clots. She has a history of esophagitis with mild hematemesis several years in the…
Read MoreContributor: Sam Killian, MD Educational Pearls: Patients with cirrhosis and ascites are frequently evaluated for spontaneous bacterial peritonitis, an infection of the ascites fluid that is not from a surgically treated source Fever, abdominal pain, and altered mental status should all raise clinical suspicion in a patient with ascites Fluid from paracentesis may show increased…
Read MoreContributor: Ricky Dhaliwal, MD, JD Educational Pearls: Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence NItroglycerin too has very limited evidence but a much better adverse event profile Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally Nothing beats upper endoscopy for…
Read MoreContributor: Erik Verzemnieks, MD Educational Pearls: INR measures the clotting cascade including factors II, VII, IX, and X Coumadin most commonly elevates the INR, and it is used to monitor the anticoagulant’s effectiveness Liver failure can cause a similar elevation in the INR due to lack of synthesis of factors II, VII, IX, X An…
Read MoreContributor: Peter Bakes, MD Educational Pearls: Necrotizing Enterocolitis (NEC) Presents in the first few days of life (often in the NICU) to 3 weeks old Risk factors include prematurity, excess feeding, neonatal sepsis Pneumatosis Intestinalisis on abdominal xray caused by bacterial translocation into the bowel wall Treated with NG tube, bowel rest and surgical resection…
Read MoreContributor: Jared Scott, MD Educational Pearls: Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy Convulsions with gastroenteritis is a known entity to cause seizures in infancy Predominantly occurs in ages 6 months to 3 years Occur with diarrheal episodes No electrolyte abnormalities associated with the seizure nor severe dehydration Seizures tend to come in…
Read MoreContributor: Aaron Lessen, MD Educational Pearls: Pyogenic liver abscesses can be caused by Intra-abdominal infection progressing to peritonitis which then drains into liver Bacteremia leading to hematogenous spead and seeding Local biliary infection with contiguous spread Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or…
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pneumatosis intestinalis Chief Complaint: Generalized Weakness HPI: 55-year-old male with a past medical history of hypertension, diabetes mellitus type II, hypothyroidism and testicular cancer in remission presents to the Emergency Department with the chief complaint of shortness of breath and generalized weakness. He reports he was in his normal state of health the day prior….
Read MoreContributor: Sam Killian, MD Educational Pearls: Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients Symptoms may include abdominal pain, fever, and/or altered mental status Paracentesis is diagnostic test of choice. Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture Treatment is typically…
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