AM Report 11/16/16: RLQ Pain

NuvaRing:

  • Combined (progestin/estrogen) hormonal contraceptive vaginal ring
  • Works by preventing ovulation and inhibition of sperm penetration (via cervical mucosal changes)
  • Used for a 3 week period followed by a “break week;” reported 91% effective with typical use

Appendicitis:

Epidemiology: Most common indication for emergent abdominal surgery in childhood (<14 years old); Males > Females.

Pathophysiology: Non-specific obstruction of the appendiceal lumen (fecal material, undigested food, enlarged lymphoid follicle, etc.)

Clinical Manifestations: Anorexia, periumbilical pain (early) → migration to RLQ (often within 24 hours), vomiting (after onset of pain), fever (24-48 hours after symptoms)

Diagnosis: Clinical diagnosis; various scoring systems to aid treatment (PAS,    Alvarado score, etc.), CBC (leukocytosis), +/- imaging (US vs. CT)

Treatment: Surgical resection

picture1

Pelvic Inflammatory Disease (PID):

Epidemiology: Sexually active females, younger age (15-25 yo), prior STIs, previous PID are all known risk factors; method of contraception also important (barrier is protective)

Pathophysiology: Two stages: Stage 1) acquisition of a vaginal or cervical infection (often STI); Stage 2) direct ascent of microorganism

Clinical Manifestations: Fever, nausea/vomiting, severe pelvic/abdominal pain, abnormal vaginal discharge (75% of cases), unanticipated vaginal bleeding, tenderness on pelvic exam (adnexal tenderness 95% sensitive)

Diagnosis: History/Physical, pregnancy test, CBC (leukocytosis), saline microscopy of vaginal fluid, ESR/CRP, STI testing, UA, +/- imaging

Treatment: Antibiotics against common organisms:

  • Regimen A: ceftriaxone, doxycycline, metronidazole
  • Regimen B: cefoxitin, doxycycline, metronidazole

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Ectopic Pregnancy:

Epidemiology: Increased incidence (4.5/1000 pregnancies in 1970 vs. 19.7/1000 in 1992) attributed to improved diagnostics; more common in women > 35 years old and non-white ethnic groups.

Pathophysiology: Any pregnancy in which the fertilized ovum implants outside the intrauterine cavity (>95% in the fallopian tubes)

Clinical Manifestations: Abdominal pain with spotting ~ 6-8 weeks after the last menstrual period; physical findings include slightly enlarged uterus, pelvic pain with movement of the cervix, and palpable adnexal mass

Diagnosis: History/Physical, pregnancy test, +/- progesterone, US

Treatment: Depends on patient stability:

  1. Expectant management: 68-77% resolve without intervention
  2. Medical management: methotrexate
  3. Surgical resection: salpingectomy via laparotomy

Ovarian Torsion:

Epidemiology: 5th most common surgical emergency in females; primary risk factor is an ovarian mass (particularly >5cm) or pregnancy (20%), can occur at any age – but most common in early reproductive years (median age 28 years)

Pathophysiology: Ovary rotates around both the suspensory and utero-ovarian ligament; rotation results in compression of the ovarian vessels (vein before artery) leading to ovarian edema and eventually ischemia

Clinical Manifestations: Classic presentation: acute onset of moderate-severe pelvic pain (90%), often with nausea/vomiting (47-70%), in a women with an adnexal mass (86-95%); other symptoms include fever (2-20%) and abnormal vaginal bleeding (4%)

Diagnosis: History/Physical, pregnancy test, CBC, pelvic US with doppler

Treatment: Surgical evaluation with detorsion or resection

Yersina Enterocolitica:

Epidemiology: Most often due to consumption of raw or undercooked pork; young individuals more often (75% are 5-15 years old)

Pathophysiology: Following consumption, invasion and penetration occurs in the ileum (M cell) => multiplication in Peyer patches (underlying lymphoid tissue) => mesenteric lymph => node spread => localized infection => systemic infection (rare)

Clinical Manifestations: Fever, abdominal pain, and diarrhea ~ 4-6 days after exposure; pain often localized to the right-side of the abdomen (pseudoappendicitis)

Diagnosis: History/Physical, stool culture for yersinia

Treatment: Supportive care typicially; aminoglycosides and TMP-SMZ if severe

Pyelonephritis:

Definition:

  • Pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal pelvis
  • Cystitis refers to an infection of the lower urinary tract, specifically the bladder

Epidemiology:

  • Women > Men (11.7 vs 2.4 hospitalizations per 10,000 cases)
  • Men > Women (16.5 vs 7.3 deaths per 1000 cases)

 

PID Cystitis Pyelonephritis
Dysuria + + +
Discharge +
Abdominal Pain + + +
Fever + +
Frequency/Urgency + + +
CMT +
CVA +

Pathogenesis:

  • Most renal parenchymal infections result from bacterial ascent through the urethra and urinary bladder
  • In males – prostatitis and prostate hypertrophy (causing urethral obstruction) predispose to bacteriuria

Uncomplicated Pyelonephritis:

  1. Typical pathogen
  2. Immunocompetent patient
  3. Normal urinary anatomy/renal function

Treatment:

Outpatient:

  • Oral fluoroquinolone (i.e. ciprofloxacin)
  • Recommended given low resistance rates (1-3%), absorbed well from the GI tract, excellent kidney penetration
  • Other acceptable options for susceptible organisms include:
  1. Amoxicillin-clavulanate (preferred for pregnancy)
  2. Cephalosporin
  3. Trimethoprim-sulfamethoxazole

Inpatient:

  • IDSA recommends one of three IV therapies:
  1. Fluoroquinolone (i.e. ciprofloxacin)
  2. Aminoglycoside (i.e gentamycin) +/- ampicillin
  3. Extended-spectrum cephalosporin +/- aminoglycoside
  • 7-14 days is effective; but studies suggest that 5-7 is comparable to longer duration in terms of clinical and bacteriologic outcome
  • Therapy with appropriate empiric antibiotics should produce improvement within 48-72 hours; failure should additional testing for an alternative diagnosis

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