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Appendicitis
- Inflamed appendix
Clinical Presentation
- Abdominal pain
- Beginning periumbilical and moving toward the RLQ
- Increasing in severity
- Pain with any movement
- Nausea and vomiting
- Fever
Physical Exam Findings
- Abdominal tenderness even to light palpation
- Rebound tenderness
- Tenderness over McBurney’s point – located on the right side of the abdomen one third of the way from the anterior superior iliac spine to the umbilicus
- Obturator sign – pain with flexion and internal rotation of the right hip
- Psoas sign – pain with either passive right hip extension or active right hip flexion
Labs & Studies
- CBC with an elevated WBC count
- U/S
- CT
Treatment
- Pain medication
- Appendectomy
- Most often performed laparoscopically
- Keep patient NPO pre op
- IV antibiotics are given pre op
Celiac disease
- Autoimmune disease which causes an inflammatory reaction to the protein gluten. This reaction causes damage to the villi of the small intestine which results in poor absorption of nutrients.
- Family history is a strong indicator
Clinical Presentation
- Abdominal pain
- Cramping
- Bloating
- Diarrhea
- Constipation
- Anorexia
- Fatigue
- Weight loss
- In children
- Failure to thrive
- Failure to grow
Labs & Studies
- CBC
- Iron panel
- Folic acid
- B12
- Ca
- Vitamin D
- Anti-tissue transglutaminase antibody (tTG) and anti-endomysial antibody (EMA) are not diagnostic but are used to screen patients and help with decision making.
- Endoscopic biopsy of the small intestine is diagnostic
- Atrophy of the villous
- Increased epithelial cells
- Crypt hyperplasia
Treatment
- Gluten free diet results in intestinal healing within weeks
- Patient must avoid all wheat products
Intussusception
- An intussusception is when a portion of the bowel telescopes into another portion of the bowel
- This can lead to ischemia and bowel perforation.
- Typical age range is 3 months to 6 years
Clinical Presentation
- Abdominal pain
- Initially sudden sharp pain that recurs about every 20 minutes
- Later with ischemia, pain becomes constant
- Child holding knees to chest
- Palor
- Lethargy
- Currant jelly stool – this is secondary to ischemia in the bowel
Labs, Studies and Physical Exam Findings
- Sausage shaped abdominal mass may be palpable
- Fecal occult blood test is likely positive
- U/S
- Target sign
Treatment
- Air contrast enema will reduce most cases
- Surgical repair may be necessary
Volvulus
- Volvulus is a twisting of the bowel on itself causing ischemia
- This is a true emergency
Clinical Presentation
- Acute abdominal pain
- Abdominal distention
- Vomiting
- Signs of shock
Labs, Studies and Physical Exam Findings
- Diffusely tender abdomen
- Rigid or distended abdomen
- Possibly an abdominal mass
- Plain abdominal x-ray – may show air fluid levels due to obstruction or a loop of bowel over the liver
- CT scan with oral contrast
Treatment
- Surgical consult!! Typically with a resection of the affected area
Obstruction (small and large bowel)
Causes
- Hernia
- Foreign body
- Stenosis
- Stricture
- Intussusception
- Volvulus
- Fecal impaction
- Abscess
- #1 cause of small bowel obstruction is adhesions following abdominal surgery
- #1 cause of large bowel obstruction is carcinoma
Clinical Presentation
- Postprandial bloating
- Intermittent crampy abdominal pain
- Loud borborygmi (bowel sounds)
- Vomiting
- “Constipation” – the inability to pass stool or flatus
Labs, Studies and Physical Exam Findings
- Abdominal tenderness is possible
- Early obstruction may have
- Peristaltic waves
- High pitched bowel sounds
- Late obstruction
- Peristaltic waves stop
- Bowel sounds quite down and stop
- CBC
- BMP
- Plain abdominal x-ray
- Dilated loops of bowel
- Air fluid levels – stepladder appearance
- Free air
- Contrast CT is study of choice
Treatment
- Pain medication
- IV fluids
- Nasogastric tube to decompress the bowel
- Surgical intervention may be necessary
