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Hernias
- The movement of an organ through the wall which normally contains it
- Reducible hernia – the hernia sac may be pushed back into place
- Incarcerated hernia – the hernia sac may not be pushed back into place
- Strangulated hernia – a hernia whose blood supply has been cut off
- Inguinal hernias make up about 75% of all abdominal hernias
- Indirect inguinal hernias are the most common – hernia sac enters the inguinal ring through a congenital defect.
- Direct inguinal hernias protrude through a weakening in the fascia of hesselbach’s triangle
- Femoral hernias have a high rate of strangulation
- Umbilical hernias
- Incisional hernias
- Hiatal hernias
Clinical Presentation
- A lump where there shouldn’t be a lump.
- Pain
Labs, Studies and Physical Exam Findings
- Abdominal films may show air fluid levels but are not really helpful
- U/S with doppler
- CT is the study of choice in most cases
Treatment
- If inflamed a broad spectrum antibiotic is appropriate
- Reducible hernia
- Elective surgical correction
- Incarcerated hernia
- NPO
- Narcotics
- Ice
- If reduction possible monitor patient
- Surgical repair
- Strangulated hernia
- Surgical emergency
Infectious Diarrhea
- Causes
- Viruses
- Norovirus
- Rotavirus
- Bacterial
- Campylobacter
- Clostridiodies difficile
- Escherichia coli
- Salmonella
- Shigella
- Staphylococci
- Vibrio cholerae
- Parasites
- Giardia
- Entamoeba histolytica
- Sources of infection
- Contaminated food
- Contaminated water
- Person to person
- Viruses
Clinical Presentation
- Diarrhea
- Vomiting
- Abdominal Cramps
- Fever
- Headache
Labs, Studies and Physical Exam Findings
- A good history is very important
- Dehydration
- Rapid heart rate
- Loss of skin elasticity
- Dry mucous membranes, the mouth, throat, nose, and eyelids
- Low blood pressure
- Thirst
- Muscle cramps
- Stool sample
- Cultures normally necessary, but it depends on the situation
- Microscopic exam if parasites suspected
- CBC
- BUN/CR
Treatment
- Prevention
- Wash hands
- Cook meat thoroughly
- Do not contaminate food or water with feces
- Fluids
- Electrolyte replacement
- Antibiotics only indicated for severe symptoms
- Ondansetron for nausea and vomiting
Rotavirus and Norovirus
- These two combine to be the most common cause of infectious diarrhea
- The rotavirus vaccine has been very effective in decreasing cases
Campylobacter
- Gram negative
- Watery diarrhea
- Bloody diarrhea is possible
- May cause bacteremia
- Relatively common cause of infections diarrhea
- Azithromycin if necessary Clostridiodies difficile
- Risk factors
- Long hospital stay
- Living in a care facility
- Antibiotics change gut flora predisposing patients to a C. diff infection
- Cephalosporins
- Penicillins
- Clindamycin
- Fluoroquinolones
- Diagnosis confirmed with stool testing
- Glutamate dehydrogenase antigen test
- C. difficile toxin antigen test
- PCR for the toxin gene
- Vancomycin or fidaxomicin can be used as treatment in severe cases
Escherichia coli
- Gram negative
- Most common organism responsible for travelers diarrhea
Salmonella enterica
– Gram negative rod
– May cause Typhoid or gastroenteritis
– May have bloody or purulent diarrhea
Shigellosis
- Gram negative, facultative anaerobe, rod
- Fecal-oral route
- This is often found in day care centers, nursing homes, refugee camps, and other places where conditions are crowded and sanitation is poor
- Patients with HLA-B27 may develop reactive arthritis
- Signs and Symptoms
- Presence of blood, pus, or mucus in stools
- Severe abdominal pain
- Fever
- Tenesmus (urgency to defecate)
Staphylococci
- Gram positive in clusters
- Food poisoning
- Caused by toxins produced by the bacteria
- Symptoms begin 30 minutes to 8 hours after eating contaminated food
Vibrio cholera
- The Ghost Map by Steven Johnson
- Vibrio cholerae – Gram negative
- Common in places with poor sanitation and crowding
- Toxin produced by the bacteria results in hyper-secretion of water and chloride.
- “Rice water stool” diarrhea and lots of it! 10-20 liters (3-5 gallons) per day!
- Cholera dipstick tests
- Fluids!!
Giardia
- Flagellated protozoan
- Major source of transmission is from drinking contaminated water including water from fresh streams that appears to be clean.
- Treat with tinidazole or metronidazole
Amebiasis
- Entamoeba histolytica
- Treat with tinidazole or metronidazole
