Tag Archives: surgery

Pancreatic Pseudocysts: An Uncommon Cause of Painless Jaundice

Posted on by

Medical Student Clinical Pearl by Thomas Camp

 

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. J Vonkeman

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ Pancreatic Pseudocysts: An Uncommon Cause of Painless Jaundice

 

Introduction

It’s 6:30 pm on a Monday evening, and a 52-year-old man presents to the ER with overt jaundice. He says that he’s been feeling great and that he only came in because his coworkers have been teasing him about his changing skin colour.

History and Physical

The patient reports that his skin has been turning yellow for the past week. He denies abdominal pain, nausea, vomiting, weight loss, fever, and fatigue. He also denies any pruritus, bruising, gastrointestinal bleeding, abdominal distension, or mental status changes. On further questioning, he reveals that his stool was pale this morning and that his urine has been unusually dark. Last year he was admitted to hospital for acute pancreatitis, which was thought to be induced by heavy alcohol consumption.

He is unaware of any other medical conditions and does not take any regular medications or herbal supplements. The patient denies any alcohol consumption since his previous admission, any history of IV drug use, and any history of international travel or blood transfusions. He smokes two packs of cigarettes per and there is an extensive family history of gastric cancer.

Physical examination reveals a thin, overtly jaundiced man with scleral icterus and a strong scent of tobacco. His lungs are clear, and his heart sounds are normal. His abdomen is soft and nontender, and there is no evidence of organomegaly or extra hepatic manifestations of liver disease (Figure 1). Ultrasound reveals a distended gallbladder and biliary tree without stones.

Approach to Jaundice

Jaundice is the result of excessive bilirubin levels in the blood, and bilirubin is a product of heme catabolism.2 The differential diagnosis for jaundice is broad but, conceptually, can be divided into pre-hepatic, intra-hepatic, and post-hepatic causes (Figure 2).3

  • Pre-hepatic jaundice is the result of excessive unconjugated bilirubin production, which overwhelms the liver’s ability to conjugate it for excretion. Hemolysis is the most common cause of pre-hepatic jaundice.
  • Intra-hepatic jaundice is the result of either decreased bilirubin uptake or impaired bilirubin conjugation within the liver’s hepatocytes,4 leading to impaired secretion in the bile. Common causes include viral hepatitis, drug toxicity, alcoholic hepatitis, and any of the many conditions leading to cirrhosis.
  • Post-hepatic jaundice is the result of biliary obstruction, which impairs the flow of bile into the duodenum. Gallstones and cancer are the most common cause, but pancreatic pseudocysts, primary sclerosing cholangitis, and bile duct strictures are also possible etiologies.

The distention of the biliary tree, the presence of acholic stools, and dark urine suggests post-hepatic jaundice in this patient.  These are characteristic findings of post-hepatic jaundice because the lack of bilirubin entering the duodenum results in pale stools, and at the same time conjugated bilirubin is water soluble, giving urine a dark colour.3 His age, sex, smoking status, and family history are also significant risk factors for pancreatic cancer, which commonly presents with jaundice.5

 

Work Up

Laboratory investigations reveal conjugated hyperbilirubinemia with a large increase in ALP and a mild increase in ALT. This is a cholestatic pattern of liver injury, which is characterized by a fourfold or greater increase in ALP and absent or mild elevations in the aminotransferases.6,7 In contrast, a hepatocellular pattern of liver injury is characterized by elevated aminotransferases and normal or mildly elevated ALP.6,7

INR and albumin levels are normal, suggesting that synthetic liver function is preserved. Normal hemoglobin levels (that are also stable when compared to the patient’s historical baseline) help exclude hemolysis from the differential. Elevated lipase is worrying for pancreatic cancer but could be explained by obstruction of the pancreatic duct by another cause, for example, gallstones not appreciated on ultrasound.

An urgent CT scan is ordered, and the radiologist comments that there is a complex cystic mass arising from the head of the pancreas that is causing obstruction of the common bile and pancreatic ducts. He notes that underlying malignancy cannot be excluded, and endoscopic retrograde cholangiopancreatography (ERCP) is recommended for further investigation. The patient is referred to gastroenterology and discharged home.

Conclusion 

A week later, ERCP confirms that the mass is in fact a pancreatic pseudocyst. Pancreatic pseudocysts are collections of fluid with a well-defined wall that lack the epithelium required to be classified as true cysts. Classically, they form after an episode of acute pancreatitis, but they are also seen in chronic pancreatitis, in obstruction of the pancreatic duct, and after pancreatic trauma.8 The cyst is drained endoscopically, a technique that is now considered preferable to a percutaneous approach due to its excellent rates of resolution (82-94%).9 The patient’s jaundice resolves over the following weeks and repeat laboratory investigations normalize within two months.

Key Points

  • Categorizing jaundice as pre-hepatic, intra-hepatic, or post-hepatic can provide a useful framework for formulating a differential diagnosis.
  • A fourfold or greater increase in ALP with mild or no elevation in the aminotransferases is characteristic of post-hepatic jaundice.
  • Consider pancreatic pseudocysts in patients presenting with post-hepatic jaundice, especially if they have a recent history of acute pancreatitis.

References

  1. Scott L Friedman M. Clinical manifestations and diagnosis of alcohol-associated fatty liver disease and cirrhosis. In: Post TW, ed. UpToDate. Wolters Kluwer; 2023. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-alcohol-associated-fatty-liver-disease-and-cirrhosis
  2. John S, Pratt DS. Jaundice. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson JL, eds. Harrison’s Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022. http://accessmedicine.mhmedical.com/content.aspx?aid=1197684641
  3. Beckingham IJ, Ryder SD. ABC of diseases of liver, pancreas, and biliary system. Investigation of liver  and biliary disease. BMJ. 2001;322(7277):33-36. doi:10.1136/bmj.322.7277.33
  4. Wolkoff AW. The Hyperbilirubinemias. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson JL, eds. Harrison’s Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022. http://accessmedicine.mhmedical.com/content.aspx?aid=1190492793
  5. Freelove R, Walling AD. Pancreatic cancer: Diagnosis and management. Am Fam Physician. 2006;73(3).
  6. Moseley RH. EVALUATION OF ABNORMAL LIVER FUNCTION TESTS. Medical Clinics of North America. 1996;80(5):887-906. doi:https://doi.org/10.1016/S0025-7125(05)70472-7
  7. Bethea ED, Pratt DS. Evaluation of Liver Function. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson JL, eds. Harrison’s Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022. http://accessmedicine.mhmedical.com/content.aspx?aid=1190492731
  8. Habashi S, Draganov P V. Pancreatic pseudocyst. World J Gastroenterol. 2009;15(1):38-47. doi:10.3748/wjg.15.38
  9. Piraka C, Chen YK. Pseudocyst Drainage: ERCP and EUS Approaches. Tech Gastrointest Endosc. 2007;9(3). doi:10.1016/j.tgie.2007.05.002
Continue Reading

A Case of Spaghetti Wrist: Approach to an Extensive Volar Forearm Laceration in the ED

Posted on by

Medical Student Clinical Pearl by Krystal Stewart

 

 

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. F MacKay

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ A Case of Spaghetti Wrist: Approach to an Extensive Volar Forearm Laceration in the ED

 

Case Presentation

A 13-year-old male presents to the Emergency Department by ambulance, with a deep laceration to his distal volar forearm. The injury occurred at a friend’s house, after tripping on a bong with the shattered glass lacerating his left wrist. The patient was intoxicated by cannabis at the time of arrival and experienced bouts of age regression while attempting to assess and treat him. He is otherwise healthy, with no significant past medical history and is not taking any regular medications. This was an isolated injury; no other lacerations were found on the body, and blood loss at the site of injury was well controlled by the time of arrival at the ED.

On physical examination, pertinent findings consist of the ulnar arterial pulse not being palpable, no sensation throughout the ulnar nerve distribution of the hand, and the flexor carpi ulnaris tendon is visibly torn. Capillary refill was normal, with perfusion being provided solely by the radial artery – which remains intact. Motor examination of the hand was difficult to assess due to patient’s intoxicated state and pain level. The patient felt he was unable to move his hand but was able to wiggle his thumb and index finger.

The on-call plastic surgeon was consulted to assess the defect. The wound was washed out with saline and briefly explored under local anesthetic by the surgeon. Subsequently, the wound was closed with simple interrupted sutures and a volar slab splint was placed on the hand and forearm for temporary stability. The patient was admitted overnight to the pediatric floor to await further exploration in the OR and reparation of the ulnar artery, ulnar nerve, and several flexor tendons.

Anatomical Context

Figure 1: Carpal tunnel anatomy of the volar wrist.1

Clinical Approach

A deep laceration of the distal volar forearm may otherwise be known as the “spaghetti wrist,” due to the number of potential structures that could require repair, including tendons, nerves, and vessels. This term came about from the appearance of lacerated tendons overlying the red background of muscle.2 There lacks a unified classification system for this term in the literature, thus defining a volar forearm laceration and its level of severity as a spaghetti wrist injury is more subjective – with an arbitrary sum of structures lacerated.3

First begin by assessing the patient for hemodynamic instability, if bleeding – apply direct pressure, if it continues a temporary tourniquet may be needed.2 It is important to evaluate for hemorrhagic shock and resuscitation prior to assessment of the hand.2

Vascular status of the hand can be assessed with capillary refill or Doppler ultrasound to each fingertip.2 If the hand is considered well perfused and bleeding is well controlled, surgical exploration can be delayed, as it will take several days for cut tendons, nerves, and vessels to retract.2 If there is concern for arterial laceration, palpation for radial and ulnar pulses would be valuable.

The next important assessment is a focused sensory and motor examination of the hand. Lightly touch at the three sensory areas that represent the cutaneous radial, median ulnar innervation of the hand as demonstrated in Figures 2 and 3.2 Evaluating the extrinsic and intrinsic hand muscle innervation requires a focused motor examination, as demonstrated in Figure 4.2 Have the patient demonstrate a series of hand gestures, the “OK” sign using the index finger and the thumb represents the muscles innervated by the median nerve.2 By abducting the digits, this represents the muscles innervated by the ulnar nerve.2 Lastly, demonstrating a “thumbs up” sign represents the muscles innervated by the radial nerve.2 If there is lack of sensation at a particular sensory distribution and/or lack of ability to demonstrate those representative hand gestures for extrinsic and intrinsic muscle innervation, it should be noted that the associated nerve(s) may be damaged.

To evaluate for any associated injuries to bone, muscle, tendon or ligament, gentle manipulation and palpation is required, along with assessing passive and active range of motion.2 It may also be valuable to assess if there is any ulnar or radial deviation of the wrist.2

 

 

Figure 2: Cutaneous innervation of the volar hand.2

 

Figure 3: Cutaneous innervation of the dorsal hand.2

 

Figure 4: Motor examination of the hand. I: Median nerve, II: Ulnar nerve, III: Radial nerve.2

Management 

Important information to gather on clinical history include the use of anticoagulants, diagnosis of advanced liver disease or diabetes. As the former two impair hemostasis, and the latter may impair wound healing.2 Broad spectrum IV antibiotics may be warranted if the wound is largely contaminated or extensive in size.2 There is a potential risk of contracting tetanus based on the mechanism of injury, thus it is important that the patient has tetanus prophylaxis.2,4An X-ray of the hand and forearm may be necessary if suspicion of a bony fracture.

A consult should be sent to the Plastic Surgery service for further management, including surgical exploration and reparation of any lacerated nerves, tendons, and vessels. These structures begin to retract after injury; thus, it is important that reparation is done within two weeks of injury. If plastic surgeon on call is planning to see the patient in clinic, have the forearm and wrist dorsally splinted at the position of safe immobilisation – wrist in 0-30 degree of extension, MCP joints in 70-90 degrees of flexion and IP joints in full extension.5,6 Once the repair is completed and appropriate hand immobilization has been achieved, the patient should see a designated occupational hand therapist for further patient education and hand rehabilitation.

Prognosis 

The road to recovery largely depends on the patient’s willingness to undergo post-operative rehabilitation and adhere to the regimens set forth by the surgeon and the occupational hand therapist. Age and smoking status may also impact neurologic recovery.5 Nerve regrowth from the site of laceration is a slow process, with approximately 1 mm in growth daily.5 Recovery tends to be functional, with less emphasis on perfection. Ulnar innervation tends to be less predictable in regrowth of intrinsic muscles.5 Possible long-term sequelae include stiffness, neuropathic pain, and cold intolerance.5

Key Points

  • If the hand is de-vascularized, immediate emergency surgery is essential.5
  • If the injury was self-inflicted, a consult to psychiatry is recommended once medically cleared.5
  • Negative prognostic factors include increasing age, low education level, presence of a crush injury.7

Complications

With complex volar forearm lacerations there is the risk of developing acute compartment syndrome post-injury. Diagnosis of acute compartment syndrome is achieved clinically, with signs of swollen and taut muscle compartment(s), pain out of proportion to the injury, or severe pain with passive digital extension.2 Neurological deficits present as a late feature of the syndrome, including paresthesia, paresis and then paralysis.2 Paresthesia is an indicative feature of early nerve ischemia.2 The intra-compartmental absolute pressure may also be measured if suspicious of compartment syndrome – an emergent forearm fasciotomy should be done if greater than or equal to 30 mmHg.2

Post-operative complications may include major deformity of hand due to clawing, ‘anesthetic hands,’ as well as neuromas – being the most cited complication.3 The former two are most likely due to the initial injury rather than a complication from the surgery itself.3 The term ‘clawing’ refers to an ulnar nerve palsy, where the hand will resemble that of a claw hand.8

 

Conclusion

While the Spaghetti Wrist terminology does not have a severity scale, it is intuitively known to be an emergent case with the need for prompt management. Whether the cause of injury was accidental or self-inflicted, the same steps must be taken to ensure that the function of the hand can be salvaged – as the impact on the patient’s physical function and psychological health could be enormous if not managed correctly.

References

  1. Hansen JT, Netter FH. Netter’s Clinical Anatomy. 2nd Philadelphia, PA: Saunders/Elsevier; 2010.
  2. Thai JN, Pacheco JA, Margolis DS, et al. Evidence-based Comprehensive Approach to Forearm Arterial Laceration.West J Emerg Med. 2015;16(7):1127-1134. doi:10.5811/westjem.2015.10.28327
  3. Koshy K, Prakash R, Luckiewicz A, Alamouti R, Nikkhah D. An Extensive Volar Forearm Laceration – The Spaghetti Wrist: A Systematic Review.JPRAS Open. 2018;18:1-17. Published 2018 Jul 11. doi:10.1016/j.jpra.2018.06.003
  4. Bae C, Bourget D. Tetanus. In:StatPearls. Treasure Island (FL): StatPearls Publishing; August 19, 2022.
  5. Meals CG, Chang J. Ten Tips to Simplify the Spaghetti Wrist.Plast Reconstr Surg Glob Open. 2018;6(12):e1971. Published 2018 Dec 12. doi:10.1097/GOX.0000000000001971
  6. Dobson P, Taylor R, Dunkin C. Safe splinting in hand surgery.Ann R Coll Surg Engl. 2011;93(1):94. doi:10.1308/003588411×12851639108033
  7. De M, Singhal M, Naalla R, Dave A. Identification of Prognostic Factors in Spaghetti Wrist Injuries.J Hand Surg Asian Pac Vol. 2021;26(4):588-598. doi:10.1142/S2424835521500569
  8. Lane R, Nallamothu SV. Claw Hand. In:StatPearls. Treasure Island (FL): StatPearls Publishing; January 8, 2023.
Continue Reading

A Case of Boerhaave Syndrome

Posted on by

Medical Student Clinical Pearl by Jillian Allan

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. R Goss

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ JAllan A Case of Boerhaave Syndrome

 

Case Presentation

44-year-old male presents to the ER with a 5-hour history of retrosternal chest pain and recent onset shortness of breath. He was out drinking the previous night and has been profusely vomiting since 5am.

Differential Diagnosis

A variety of conditions may present in this fashion:

  • GERD/Gastritis/ Esophagitis/Gastric ulcer
  • Pneumothorax
  • Aortic dissection
  • Acute pancreatitis
  • ACS/MI
  • Cannabis hyperemesis syndrome
  • Esophageal rupture

History and Physical

Upon arrival to the ER, he is hemodynamically unstable: tachycardic (125), hypotensive (90/58) and febrile (38.2 C). His O2 sats are 86% on RA. He has no history of gastroesophageal reflux or other relevant medical conditions. He does not use cannabis.

On examination, his abdomen is soft, he is tender in the left upper quadrant and diffusely across his chest wall. Breath sounds are decreased on the leftIn addition, he has bilateral supraclavicular crepitus on palpation and a positive Hamman’s crunch (mediastinal crackling, synchronous with the heartbeat) on auscultation. His neck is becoming increasingly distended, and you have noticed a change in phonation since his arrival.

Etiology 

Boerhaaves syndrome is most commonly caused by profuse vomiting but can also be the result of anything that increases esophageal pressure such as weightlifting, seizures, abdominal trauma, locally invasive cancers/infections, childbirth, or compressed air injuries.7

Pathophysiology 

  • Esophageal perforations are classified into 3 groups:
    • Cervical esophagus: can present with neck tenderness, dysphagia, or dysphonia
    • Thoracic esophagus: presents with severe back pain, pleuritic, chest or epigastric pain, inability to lie supine. Most common area for perforation.
    • Intra-abdominal esophagus: Peritonitis

 

  • Severity of perforation tends to depend on the location of rupture, with intrathoracic esophageal ruptures leading to more devastating outcomes.
    • Intrathoracic rupture results in contamination of the thoracic cavity with gastric contents, which can lead to chemical mediastinitis, infection and mediastinal necrosis.6
    • Barogenic rupture of the cervical esophagus has a more benign course, as the spread of contamination to the mediastinum is slow and attachments of the esophagus to the prevertebral fascia limit the lateral dissemination of esophageal flora.6

Evaluation

  • Diagnosis is established through a computed tomography (CT) scan of the chest or contrast enhanced esophagram. Contrast should be water soluble (gastrografin) to avoid mediastinal contamination with barium contrast.
    • CT: Findings suggestive of esophageal rupture include esophageal wall edema and thickening, peri-esophageal fluid, mediastinal widening, and free air/fluid within the pleural spaces, retroperitoneum, or lesser sac.6
    • Radiography: Plain films may also demonstrate air in the soft tissues of the prevertebral space. Other indications can include pleural effusion, hydropneumothorax, mediastinal widening or subdiaphragmatic air.6 While thoracic and cervical radiography can aid in diagnosis, they cannot exclude or confirm esophageal rupture and should not routinely be performed to diagnose this condition. However, a plain radiograph may be performed, and mediastinal air found incidentally when the diagnosis had not been suspected.
    • Esophagram: Reveals the location and extent of perforation of the esophagus by the extravasation of the contrast medium.6
  • Endoscopy should be performed with caution due to the risk of further esophageal damage.

Case Continued

Laboratory results showed elevated leucocytes at 12.9 x 109/L (normal 4.5-11.5) and an elevated C-reactive protein level but were otherwise unremarkable.

An erect chest radiograph and urgent CT was done, which showed the “V” sign of Naclerio, a V shaped collection of air along the mediastinum and diaphragm, indicating pneumomediastinum (Fig.1a).2 An urgent contrast CT confirmed the radiograph findings, showing pneumomediastinum and left hydropneumothorax (Fig. 1b).2

 

Figure 1. Boerhaave syndrome in a 44-year-old man. (A) Chest radiograph showing Naclerio’s V sign, demonstrating air outlining the mediastinal borders (arrows), indicating pneumomediastinum. (B) Chest CT showing pneumomediastinum and left hydropneumothorax.2

  

Esophageal perforation was confirmed with a contrast esophagram, which showed leakage from the lower esophageal sphincter into the left pleural space.

 

Figure 2. Contrast esophagram showing esophageal rupture at lower esophageal sphincter with leakage into the left pleural space.1

Treatment and Management

  • Mainstay of treatment includes volume resuscitation, broad-spectrum antibiotic coverage, and surgical evaluation.
  • 3 treatments options: conservative, endoscopic, or surgical
    • Conservative: typically reserved for small or contained ruptures.
    • Endoscopic: stent placement to prevent fistula formations or seal esophageal leaks.
    • Surgical: primary esophageal repair via open thoracotomy vs VATS (video-assisted thoracoscopic surgery) with fundic reinforcement- which is the gold standard of treatment if within 24 hours.7

Case Conclusion

The patient underwent an emergency VATS procedure which revealed a small tear in the lower esophagus, which was successfully repaired with sutures and a pleural patch. The patient made an uneventful recovery and was discharged on postoperative day 6.

Summary of Key Points

References

  1. Calvin S.H. Ng, Wilfred L.M. Mui and Anthony P.C. Yim. Barogenic esophageal rupture: Boerhaave Syndrome. CAN J SURG December 01, 2006 49 (6) 438-439;
  2. Chew, Fatt Yang; Yang, Su-Tso. Boerhaave Syndrome. CMAJ 2021 September 27;193:E1499. doi:10.1503/cmaj.202893.
  3. Kassem MM, Wallen JM. Esophageal Perforation And Tears. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532298/
  4. Kukuruza K, Aboeed A. Subcutaneous Emphysema. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542192/
  5. Rawla P, Devasahayam J. Mallory Weiss Syndrome. [Updated 2022 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538190/
  6. Triadafilopoulos, G. Boerhaave Syndrome: Effort rupture of the esophagus. In: UpToDate, Waltham, MA. (Accessed on October 29th, 2022).
  7. Turner AR, Turner SD. Boerhaave Syndrome. [Updated 2021 Dec 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430808/
Continue Reading

A Meeting with the Curb: Review of Lip Laceration Repair

Posted on by

Medical Student Pearl by Nick Ellingwood

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. B Ramrattan

Copy Edited by Dr. J Vonkeman

Pdf Download:  EMSJ NEllingwood Review of Lip Laceration Repair

Case Presentation

A 68-year-old female presents to the ED with facial trauma. She tells you that she was walking in a parking lot trying to remember where she parked when she suddenly tripped over a curb and scraped her face on the asphalt. She remembers the event and did not lose consciousness. She denies any nausea/vomiting, headache, or blurry vision. She arrived at the ED by EMS who say that her GCS has remained 15. She tells you that she is a healthy individual other than her diabetes for which she takes Metformin and Ozempic. She does not smoke or drink alcohol. She tells you numerous times during your history that she is very worried about her lip injury and how it will look after it heals.

On exam, she is alert and oriented to person, place, and time. She has an abrasion over her nasal bridge and a laceration at the midline of her lower lip which is approximately 1.5cm deep extending all the way through the vermillion. Her upper right incisor is chipped. She is tender over her nasal bone. Her pupils are equal and reactive, and she has normal extra-ocular movements. She has normal facial sensation and strength and there is symmetrical rise of the uvula. There is no battle sign, hemotympanum, or periorbital bruising. You quickly test her sensation and strength is all her extremities which is normal.

Figure 1: Similar lip laceration as the patient in this case. (Benjamincousinsmd.com)

Associated Injuries

Before repairing a lip laceration, associated injuries must be considered. Common associated injuries include dental fractures, LeFort fractures, nasal bone fractures and jaw fractures.1 Much less common, but can’t miss, associated injuries include intracranial bleed, basal skull fracture, or orbital floor fractures.

Impression/Plan

Given that she is older than 65 years old, you can’t rule out a head injury based of the Canadian CT Head Rule. However, given the mild mechanism of injury and the lack of signs/symptoms of intracranial pathology you decide to forego a CT head and turn your attention to the lip laceration.

Background

When repairing a lip laceration, extra vigilance is needed to ensure proper cosmetic appearance and to preserve the functionality of the lips. It is often one of first facial features people look at when talking to someone and therefore, minimal scarring and good aesthetic are often very important to patients presenting with these lacerations. The lips are also important in tactile sensation, phonation, and mastication.

Evaluation

Lip lacerations are almost always repaired with primary closure because of the difference in aesthetic outcome between primary and secondary closure. Secondary closure may be appropriate in patients with a delayed presentation, signs of infection (erythema, drainage of pus), or contamination in the wound.1 Evaluation of the laceration includes location, length, depth, involvement of the vermillion border and presence of contamination or foreign bodies. Make sure to examine the internal and external lip as partial thickness without vermillion border involvement could be managed conservatively.

Figure 2: Anatomy of the superficial and deep structures of the lips (UpToDate, 2023)1

Anesthesia

Local anesthesia is often avoided in lip lacerations as it can cause swelling which will contort the laceration making it more difficult to maximize the cosmetic appearance. In young children, conscious sedation is needed as they will not stay still for the repair even if they are anesthetized. In adults, infraorbital nerve blocks are used for upper lips lacerations and mental nerve block are used for lower lip lacerations. These nerve blocks provide excellent anesthesia and the landmarking for these blocks are relatively simple. The supraorbital foramen, infraorbital foramen and mental foramen are lined up in a midsagittal plane (See figure 3). Another way to landmark the mental foramen is to find the midpoint between the alveolar crest of the second premolar and the inferior border of the mandible.2 When the mental foramen is located, inject 2-3cc of 1% lidocaine with epinephrine and bicarbonate approximately 1cm under the skin towards the mental nerve. If your laceration is at the midline, then bilateral mental nerve blocks will be needed. Next, wait 15-20 minutes to allow for the anesthetic to take full effect before starting the repair.

Figure 3: Anatomical location of the supraorbital foramen, infraorbital foramen, and mental foramen. (Can J Anesth/J Can Anesth 56, 704–706 (2009).)2

Laceration Repair

Once the laceration is fully anesthetized, you can irrigate the wound and thoroughly examine the laceration. You need to rule out any foreign bodies in the lip through palpation as teeth fragment may not be initially visualized. If in doubt, a lateral XRay may rule out any teeth fragments in the lips as they are radiopaque. You may need to get an extra set of hands to help evert the lip when closing the inner lip portion of the laceration. The most important suture in this repair is the suture at the vermillion border as lining up the vermillion border perfectly will yield the best cosmetic result.3,4Some clinicians prefer to close the inner and outer fibrofatty junction before the vermillion border, whereas some will put their first suture at the vermillion border before closing the deeper tissues. After these steps, you simply need to bring the rest of the lacerations back together. Most clinicians will use either 4-0 or 5-0 absorbable sutures for their deep sutures then 5-0 or 6-0 absorbable sutures for the superficial sutures depending on the anticipated tension on the wound when closed.

Aftercare

The main considerations for aftercare of wounds are tetanus, prophylactic antibiotics, and follow-up.

  • A tetanus booster should be given to patients who are unsure as to when their last dose was or if it has been greater than 5 years since their last Tdap.
  • The evidence of prophylactic antibiotic treatment for lip lacerations is lacking. One study by Steele et al showed that there may be a benefit to prophylactic antibiotics in full thickness lip lacerations such as our case, but their results were not statistically significant.5 The face in general is such a highly vascularized area that if the patient is healthy and not taking any immunosuppressants medications, then the risk of infection is low, and antibiotics are not needed. Irrigation with salt water 2-3x/day is sufficient.
  • Lastly, simple lip lacerations that were repaired in the ED with satisfactory results don’t need Plastics follow-up. If the lip is quite disfigured and you are worried about the cosmetic results, then these patients should be seen by Plastics either in the ED or within 24 hours. Follow-up after several days or more should be avoided as the laceration will already be in the healing stage. This would make any revision and/or alteration to cosmetic results difficult.

References

  1. Hollander, J., & Weinberger, L. (2022, September). Assessment and management of lip lacerations. UpToDate.
  2. Tsui, B.C.H. Ultrasound imaging to localize foramina for superficial trigeminal nerve block. Can J Anesth/J Can Anesth 56, 704–706 (2009).
  3. Espinosa MC, Hohman MH, Sivam S. Oral and Maxillofacial Surgery, Facial Laceration Repair. [Updated 2023 May 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  4. Armstrong, B. Denise. “LACERATIONS OF THE MOUTH.” Emergency medicine clinics of North America 18.3 (2000): 471–480. Web.
  5. Steele, Mark T et al. “Prophylactic Penicillin for Intraoral Wounds.” Annals of emergency medicine 18.8 (1989): 847–852. Web

 

Continue Reading

Understanding Urachal Anomalies

Posted on by

 

Medical Student Pearl by Alexander MacPherson

MD Candidate, Class of 2024

Dalhousie University New Brunswick

Reviewed by Dr. B Ramrattan

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ Understanding Urachal Anomalies by AMacpherson

 

Case Presentation

17-year-old male presents to the emergency room with what he tells you is a pop bottle amount pus-like fluid discharging from his belly button. He appears well and said that this has happened before, but it was never in this amount. He and his family members are, however, concerned as to what may be causing this unusual presentation. Patient denies any past abdominal surgeries or piercings.

Physical Exam

  • Vitals: HR 70, BP 118/78, RR 14, T 37.3°C
  • Tenderness in the periumbilical region
  • Discharge of whitish, mucus-like liquid.
  • Red, dome shaped swelling at centre of umbilicus.

Differential Diagnosis [1]

  1. Urachal anomaly
  2. Abscess
  3. Benign lesion (hamartomas, pyogenic granulomas etc.)
  4. Primary malignancy (urachal adenoma, melanoma, squamous cell carcinoma and basal cell carcinoma).
  5. Metastatic lesion
  6. Omphalitis

Common Clinical Findings of Urachal Anomalies [1]

Urachal anomalies when found in children typically present with:

  • Umbilical drainage
  • Abdominal pain
  • Abnormal appearance of the umbilicus, with a palpable mass
  • Infection
  • Incidental finding

Urachal anomalies when found in adulthood typically present with:

  • Hematuria
  • Pain
  • Dysuria
  • Incidentally

Investigations

  • The primary investigation for a urachal anomaly is through Imaging.
    • Most urachal remnants are diagnosed via abdominal ultrasonography.
    • CT abdomen, MR abdomen and Voiding Cystourethrography (VCUG) are also used to detect and diagnose urachal anomalies and to confirm that there are no associated genitourinary tract abnormalities. [1,2].
  • Our patient received an ultrasound and went on for a CT abdomen to confirm the diagnosis of urachal cyst.

Treatment

  • Surgical resection seems to be the most definitive way to manage and prevent the return of symptoms. It is also important to note that adults presenting with urachal anomalies are at a considerable progressive risk for cancer and if not removed should undergo routine screening.
  • Early removal of urachal remnants at first diagnosis are deemed to be best at preventing future morbidity by some studies, while others recommend that children who are experiencing asymptomatic lesions do not benefit from prophylactic excision [1,2,3]
  • Our patient was referred to general surgery and the urachal cyst was excised.

Background on Urachal Anomalies

During embryologic development the allantois has a connection to the apex of the fetal bladder. This connection is called the urachus and allows for fetal bladder emptying [4]. In a normally developing fetus, the bladder descends into the pelvis. This decent of the bladder stretches the urachus and its lumen is eventually obliterated. The now obliterated urachus is a fibrous cord that is called the median umbilical ligament and continues to be connected to the umbilicus and the bladder. This process, like any other, can be disrupted [5].

The disruption can be divided into several urachal anomalies based on the amount of and where the residual tissue is located (Figure 1):

  1. Patent urachus: A complete failure of closure of the lumen forming a tubular connection between the bladder and umbilicus. Allows for urine to drain through the umbilicus.
  2. Bladder diverticulum: Extra tissue present at the bladder end but does not continue to the umbilicus.
  3. Umbilical polyp: Extra tissue and patency at the umbilical end that does not continue to the bladder.
  4. Urachal cyst: An area of patency in between the bladder and umbilicus that does not communicate with either [1,4].

Figure 1. Urachal anomaly types. Accessed from UpToDate [6]

An Important Note on Malignancy

  • Although there have been no reports of urachal adenocarcinoma in the urachal anomalies resected from children a longitudinal study by Ashley et al (2007) found that 51% of those resected from adults showed evidence of malignancy. It was also determined that age >55 and hematuria were the strongest predictors for malignancy [2].
  • A comprehensive review performed by Gleason et al (2013) however determined that urachal anomalies are more common that previously reported and that the number needed to excise to prevent one case of urachal adenocarcinoma was 5,721 [3]

References

  1. Palazzi, D. L., & Brandt, M. L. (2021, August 27).Care of the umbilicus and management of umbilical disorders. UpToDate. Retrieved April 16, 2022, from https://www.uptodate.com/contents/care-of-the-umbilicus-and-management-of-umbilical-disorders
  2. Ashley RA, Inman BA, Routh JC, Rohlinger AL, Husmann DA, Kramer SA. Urachal anomalies: a longitudinal study of urachal remnants in children and adults. J Urol. 2007 Oct;178(4 Pt 2):1615-8. doi: 10.1016/j.juro.2007.03.194. Epub 2007 Aug 16. PMID: 17707039.
  3. Gleason JM, Bowlin PR, Bagli DJ, Lorenzo AJ, Hassouna T, Koyle MA, Farhat WA. A comprehensive review of pediatric urachal anomalies and predictive analysis for adult urachal adenocarcinoma. J Urol. 2015 Feb;193(2):632-6. doi: 10.1016/j.juro.2014.09.004. Epub 2014 Sep 16. PMID: 25219697.
  4. Briggs KB, Rentea RM. Patent Urachus. [Updated 2021 Jun 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557723/
  5. Naiditch, Jessica A.; Radhakrishnan, Jayant; Chin, Anthony C.(2013). Current diagnosis and management of urachal remnants. Journal of Pediatric Surgery, 48(10), 2148–2152.        doi:10.1016/j.jpedsurg.2013.02.069
  6. Retrieved from: https://www.uptodate.com/contents/image?imageKey=PEDS%2F79324&topicKey=PEDS%2F5009&search=urachal+cyst+infection&rank=1%7E150&source=see_link

Continue Reading

Under pressure: Anorectal abscesses… to drain or not to drain?

Posted on by

Resident Clinical Pearl

Victoria Landry

iFMEM R3

Reviewed by Dr. J Mekwan

Copy Edited by Dr. J Vonkeman

PDF Download: EMSJ Anorectal Abscess by VLandry

Case

A 57yo male presents to the emergency department with complaints of a lump near his rectum and pain with sitting which developed over the past week. He is afebrile with normal vital signs. He tells you that about 6 months ago this same thing occurred and drainage was attempted in the ED but was unsuccessful. A colorectal surgeon subsequently drained it successfully under local anesthetic in clinic later the same day. He has had no recurrence of symptoms until the past week. He smokes and has hypertension controlled with medication but is otherwise healthy.

He denies pain with defecation and has not had any rectal bleeding nor changes in bowel habits. He feels otherwise well and denies fevers or chills.

On exam you find a tender firm mass in the subcutaneous tissue lateral to his rectum on the left side. There is minimal overlying erythema and no fluctuance.

Key Point #1: Always do a Digital Rectal Exam

  • Palpate in all directions to localize area of tenderness1
  • Should be unremarkable after you get past the anal verge2 – if tenderness, mass, induration past anal verge, do a CT scan to assess for deeper abscess

You think back to your perirectal anatomy and recall the spaces where abscesses can develop.

Figure 1: Transverse anorectal anatomy3

Figure 2: Longitudinal anorectal anatomy3

 

  Perianal Ischiorectal Intersphincteric Supralevator Postanal
Incidence 40-45% 20-25% 20-25% <5% 5-10%
Location Outside anal verge, red, swollen, fluctuant, easily palpable at anal verge Between rectum and ischial tuberosity, outside sphincters, palpable through rectal wall or lateral to anal verge on buttocks Lower rectum, between sphincters, inferior to levator ani (tender indurated mass in rectum) Above levator ani (tender indurated mass in rectum) Posterior to rectum, Deep to external sphincter, inferior to levator ani
Symptoms Painful perianal mass Buttock pain Rectal fullness, throbbing, worse with defecation Perianal and buttock pain Rectal fullness and pain near coccyx
Fever, ↑WBC No Possibly Possibly Yes Yes
Fistula formation ++ + +++ +++ –
ED I&D Yes Possibly: I&D/needle aspiration only if abscess is superficial and fluctuant No No:

Consult surgery for urgent drainage

 No

Table 1: Types of abscesses3

** caution as mass may be bigger/deeper than anticipated – prudent to defer to surgery for their expertise

Figure 3: Anorectal abscess locations4

Key Point #2: Get a CT scan to define the abscess for any of the following2

  • Unable to see the abscess superficially
  • Patient is unable to tolerate the DRE due to significant pain
  • Induration, bogginess or tenderness in the supralevator space (above the sphincter muscle)
  • If the extent of the abscess is uncertain4

Note: can use POCUS to evaluate location of abscess, but caution against false reassurance as to extent/depth, and safer to rely on palpable fluctuant mass to determine if I&D is safe

 

Figure 4: Perianal abscess on CT1

Management5

  • Simple, isolated, fluctuant perianal abscess4
    • Bedside I&D
    • Goal is to relieve the pus under pressure2
  • Ischiorectal abscess2
    • Can consider I&D only if superficial, but prudent to get a CT first
    • Consult surgery for their expertise
  • Intersphincteric, Supralevator, Postanal
    • CT to define the abscess
    • Consult surgery

Key Point #3: Err on the side of caution

Only do I&D in the ED if the following criteria are met3 [3]

  • Perianal abscess (+/- ischiorectal) is small and superficial
  • Patient
    • Is Well-appearing
    • Is Cooperative
    • Has no complicating factors (DM, immune compromise etc.)

Incision and Drainage of simple perianal abscess2

  • Local anesthetic – lidocaine with epinephrine
    • Infiltrate superficial skin where you will poke with needle
    • occasionally procedural sedation is needed3
  • Needle poke +/- aspiration (18guage) or pinpoint incision over painful region to localize purulent pocket4
  • Inject more local anesthetic2
  • Enlarge the incision
    • Make incision as close to anal verge as possible to minimize the length of any potential fistula2,5,6
    • Cruciate (with trimming of the flaps) or elliptical incision over fluctuant part of abscess is preferred over a linear incision to keep incision open and draining without painful packing2
    • If linear only, will need packing to prevent premature closure
    • Note: loop drainage technique not recommended for I&D in the ED7
  • Break up loculations with finger (increased tactile feedback and better control) or hemostat +/- irrigation with saline7
  • Cover with bulky dressing4
  • Ideally, close follow up until complete healing (up to 8wks) to monitor for recurrence and for fistula formation5
  • Uncomplicated perianal abscesses do not require antibiotics after successful drainage2.

Figure 5: Cruciate incision4

Instruct the patient to WASH8

  • W – warm water sitz baths 5-10min BID-QID PRN, with Epsom salts (start the day after I&D)
    • Water >40°C helps decrease anal canal pressure
  • A – analgesics (NSAIDs, topical 1-2% lidocaine gel)
  • S – stool softeners (PEG, senna)
  • H – high fiber diet +/- fiber supplement
  • Uncomplicated perianal abscesses do not require antibiotics after successful drainage2.

Indications for antibiotics (+/- tetanus +/- admission to hospital with surgical consult)4

  • Surrounding cellulitis
  • Immune compromise
  • Valvular heart disease
  • Diabetes
  • Systemic symptoms (Fever, ill appearing, leukocytosis)
  • Elderly

Note: Send off a wound culture before giving antibiotics

Antibiotic choice5:

  • Systemic: piperacillin-tazobactam
  • Oral: Amoxicillin-clavulanate or Metronidazole + ciprofloxacin

A word on fistulas

  • Fistulas are a connection between two epithelium-lined surfaces, characterized by persistent or recurrent anal drainage. They are seen in Crohn’s, TB, cancer, FB reactions, and as a complication of anorectal abscesses. Treatment is surgical3
  • ~50% of anorectal abscesses form a fistula overtime2
  • Suggest surgical consultation after drainage of perianal abscess as fistula formation is common4
  • Fistulas may be missed on CT scan; MRI is more sensitive for diagnosis2     

Take home points: 

  1. Always do a rectal exam as part of the initial evaluation
  2. Have a low threshold to get a CT scan to define the abscess
  3. Reserve I&D in the ED for perianal abscesses that are visible, superficial and fluctuant

References

  1. Farah, Jennifer, Mason, Jessica, and Werner, Jessie, “Perirectal Abscess & Pilonidal Cyst.” [Online]. Available: https://www.emrap.org/episode/gastro/perirectal
  2. Jhun, Paul and Cologne, Kyle, “Anorectal Infections,” HIPPO EMRAP, vol. 15, no. 9, pp. 17–18, Sep. 2015.
  3. Parrillo, “Anorectal Emergencies,” presented at the EMRAP, Temple University Hospital EM Residency, Feb. 2004. [Online]. Available: https://www.emrap.org/episode/september2004/anorectal
  4. Berberian J.G., & Burgess B.E. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), “Anorectal disorders,” in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e, McGraw Hill, 2020. [Online]. Available: https://accessmedicine-mhmedical-com.ezproxy.library.dal.ca/content.aspx?bookid=2353&sectionid=219642697
  5. Streitz Matthew, Long Brit, “Anorectal Disease,” in CorePendium, Burbank, CA: CorePendium, LLC, 2022. [Online]. Available: https://www.emrap.org/corependium/chapter/reclLjrt5HvPGSIDv/Anorectal-Disease#h.d78nqbylr3x
  6. Bleday, Ronald, Perianal and perirectal abscess. uptodate.com, 2022. [Online]. Available: https://www.uptodate.com/contents/perianal-and-perirectal-abscess
  7. Cavanaugh, Megan and Ormon, Rob, “Anorectal Disorders.” [Online]. Available: https://www.emrap.org/episode/april2011/anorectal
  8. Lipp, Chris, “Anorectal Disorders.” [Online]. Available: https://canadiem.org/crackcast-e096-anorectal-disorders/

 

 

 

 

 

 

 

 

 

 

Continue Reading

Approach to Inguinal and Femoral Hernias in the Emergency Department

Posted on by

Medical Student Pearl

Julia Short

Med 2

DMNB Class of 2025

Reviewed by Dr D Lewis

Copy Edited by Dr. J Vonkeman

PDF Download: EMSJ Approach to Inguinal and Femoral Hernias in the ED by JShort

Case

A 52-year-old male patient presents in the ER with a lump in their right groin. The lump protrudes when they cough and when laying on their left side, although it re-enters the abdomen on its own. You wonder if it could be a femoral or an inguinal hernia, and how to go about differentiating between the two.

Introduction

A hernia is defined as an organ, or part of an organ, that protrudes through the body wall in which it is normally contained. The etiology of a hernia can be due to congenital anatomical malformations or from acquired weakening of the body wall tissues. There are various subtypes of abdominal hernias, while groin hernias consist of inguinal and femoral hernias. Throughout their lifetime, males have a 27 to 43% chance of developing a groin hernia, while females have a 3 to 6% lifetime prevalence1. Although it is much more likely that a groin hernia is inguinal in nature (they account for 96% of groin hernias), it is clinically useful to identify and distinguish between the types of groin hernias. Additionally, there are important clinical features that must not be overlooked when characterizing a groin hernia.

Distinguishing inguinal from femoral hernias

An important landmark in determining the hernia origin is the inguinal ligament. Inguinal hernias protrude superior to the inguinal ligament, while femoral hernias present inferior to the inguinal ligament (Figure 1). This is because femoral hernias protrude from the femoral ring, located medial to the femoral vein. As a result, in males, femoral hernias will never course into the scrotum. Femoral hernias also present more lateral than inguinal hernias and may be difficult to differentiate from lymph nodes. Although they account for only 3% of all groin hernias, 40% of femoral hernias present as urgent due to bowel strangulation or incarceration1. Females are more likely to develop femoral hernias, while males are more likely to develop inguinal hernias.

Figure 1. Groin anatomy © 2023 UpToDate7

Distinguishing between direct and indirect inguinal hernias

Direct inguinal hernias originate medially, near the pubic tubercle and external inguinal ring. They protrude through Hesselbach’s triangle as a result of weakness in the floor of the inguinal canal. On exam, a bulge near the external (superficial) inguinal ring is suggestive of a direct inguinal hernia. In contrast, indirect inguinal hernias protrude near the midpoint of the inguinal ligament, at the internal (deep) inguinal ring (Figure 2). In males and females respectively, the internal inguinal ring is where the spermatic cord and round ligament exit the abdomen. A bulge in this area therefore suggests an indirect inguinal hernia. This type of hernia is the most common in all ages and sexes, accounting for approximately two thirds of all inguinal hernias2. In males, the indirect hernia often courses into the scrotum, which can be palpated if the patient strains or coughs. In contrast, it is rare for a direct hernia to course into the scrotum.

Figure 2. Anatomical comparison of direct and indirect inguinal hernias © 2020 Dr. Vaibhav Kapoor8

Clinical Approach

General considerations for investigating groin hernias include assessing the symptoms at presentation as well as any “red flag” physical findings. Patients commonly complain of dull or heavy types of discomfort when straining, which resolves when straining stops. Most groin hernias occur on the right side. Common physical findings include a bulge in the groin, which can indicate the type of hernia based on location relative to the inguinal ligament (Figure 3). However, in female or obese patients, the layers of abdominal wall may make the hernia more difficult to locate. In these cases, ultrasound or other imaging is needed to detect hernias. Clinicians should also determine if the hernia is reducible, or if the herniated bowel can be returned to the abdominal cavity when moderate pressure is applied externally.

Figure 3. Locations of femoral and inguinal hernias on examination © 2023 UpToDate7

 

Physical examination has a 76 to 92% sensitivity and 96% specificity for diagnosing groin hernias, although imaging may also be required1,2. Nausea, vomiting, fever, moderate-to-severe abdominal pain, localized tenderness, or bloating may indicate more sinister pathology such as bowel incarceration (when the hernia contents cannot return to the abdominal cavity), strangulation (when the blood supply to the involved bowel section is compromised) or necrosis.

Figure 5. CT images of A) femoral hernia (courtesy of Chris O’Donnell9 and B) inguinal hernia (courtesy of Erik Ranschaert10)

Management

Uncomplicated or asymptomatic hernias in males can be monitored through watchful waiting. Surgical repair is a definitive treatment for inguinal hernias and should be considered for symptomatic or complex hernias. If repair is needed for an uncomplicated inguinal hernia, a laparoscopic repair is recommended. Watchful waiting is not recommended for femoral hernias – these patients should have a laparoscopic repair (when anatomically feasible).

Manual reduction of the hernia can be performed by following the GPS Taxis technique. Taxis is a non-invasive technique for manual reduction of incarcerated tissues in a hernia to the original compartment5. “GPS” is an acronym to remind clinicians to be gentle, be prepared, and be safe when performing taxis5. Conscious sedation with intravenous diazepam and morphine is recommended for the procedure. Consider having an anesthetist present for the procedure if the patient is frail. Provide appropriate early resuscitation by monitoring vital signs, administering oxygen therapy and establishing IV access. Place the patient in Trendelenburg position. Begin the GPS Taxis technique by palpating the fascial defect around the base of the hernia and gently manipulating hernia contents back into the abdominal cavity. Use gentle manipulation pressure over 5-10 minutes until a gurgling sound is heard (indicating successful reduction of bowel).

 

Taxis guided by ultrasound may increase success rates for reduction.

https://sjrhem.ca/taxis-reduction-of-inguinal-hernia/

Figure 4. Colourized clip demonstrating PoCUS assisted Taxis reduction of an inguinal hernia11

 

It should be noted that the major contraindication to performing GPS Taxis is bowel strangulation within the hernia. A rare but serious complication of manual reduction is reduction en masse, when a loop of bowel remains incarcerated at the neck of the hernia after manual reduction6. This can lead to early strangulation, intestinal necrosis, sepsis, organ failure and death. Femoral hernias and indirect inguinal hernias are at higher risk of reduction en masse from manual reduction attempts.

References:

  1. UpToDate – Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults
  2. Hammoud M, Gerken J. Inguinal hernia. StatPearls. 2022 Aug 15.
  3. UpToDate – Overview of treatment for inguinal and femoral hernia in adults
  4. Bates’ Guide to Physical Examination and History Taking, 12th ed. (pdf). Chapter 13: Male Genitalia and Hernias
  5. Pawlak M, East B, de Beaux AC. Algorithm for management of an incarcerated inguinal hernia in the emergency settings with manual reduction. Taxis, the technique and its safety. Hernia, 25, 1253-1258. 2021 May 25.
  6. Yatawatta A. Reduction en masse of inguinal hernia: a review of a rare and potentially fatal complication following reduction of inguinal hernia. BMJ Case Rep. 2017 Aug 7.
  7. UpToDate – Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults
  8. Kapoor, V. Difference between and inguinal and umbilical hernia. 2020. Retrieved from: https://www.drvaibhavkapoor.com/difference-between-inguinal-and-umbilical-hernia.html
  9. Patel, MS. Femoral hernia. Radiopaedia. 2022 Dec 28. Retrieved from: https://radiopaedia.org/articles/femoral-hernia
  10. Fahrenhorst-Jones, T. Inguinal hernia. Radiopaedia. 2022 Apr 12. Retrieved from: https://radiopaedia.org/articles/inguinal-hernia
  11. PoCUS assisted Taxis reduction of an inguinal hernia. Video obtained courtesy of Dr. David Lewis.

Continue Reading

Colovesicular fistula

Posted on by

Approach to diagnosing Colovesicular fistula- A Medical Student Clinical Pearl

Emmanuel Hebert

Med 4, Dalhousie Medicine

Reviewed by Dr. Chris Doiron

Copyedited by Dr. Mandy Peach

Case

54 y/o M presents with a bizarre presenting complaint at 10am Monday morning…

You enter the room to see a man in no apparent distress who tells you that for the past two days something that looks like feces is coming out of his penis. The patient went to the bathroom to urinate Sunday night and noted air coming out of his penis that felt as if he were passing flatus. He then noticed brown foul-smelling liquid upon urinating. There was no blood. He reports no suprapubic fullness, pain with urination, or urgency. He denies any abdominal or pelvic pain. He noted chills Sunday evening which resolved and have not returned after a single dose of acetaminophen 500mg.

 

Past Medical History:

Hypertension

Adenocarcinoma of rectum- 2019

Radiation Therapy- 2019

Partial Bowel resection with ileostomy and stoma- 2019

Reversion of ileostomy- 2020

Medications: Coversyl Plus

Allergies: Codeine, penicillin

Physical Examination:

Patient is comfortable and appears well. Vitals: HR 85; Temp 36.5; BP: 125/80; O2Sat99% on RA. Abdominal exam is unremarkable. There is no suprapubic or CVA tenderness on palpation. Pelvic exam reveals a penis with no discharge or tenderness.

 

Initial bloodwork:

  • WBC: 11×10^9/L
  • Hgb: 135
  • Plt: 300×10^9/L
  • Na: 135
  • K: 4.0
  • CRP: 80
  • Lactate: 1.0
  • Creatinine: 100
  • eGFR: N

Urinalysis: Grossly brown with + leukocytes, Nitrite positive and RBCs present

 

What is the differential diagnosis of pneumaturia?

  • Recent urinary tract instrumentation, catheterization.
  • Urinary tract infection with a gas forming organism (emphysematous cystitis).
  • Emphysematous pyelonephritis (rare) [1]
  • Colovesicular  and enterovesicular Fistula as a result of complicated Diverticulitis, Crohn’s Disease or Carcinoma of the Colon or Bladder

Colovesicular Fistula

Colovesicular and enterovesicular fistulas are defined as connections between the enteric lumen and the bladder. [2] There are many ways that tissue can develop a fistula but in the enteric system there are several common etiologies [3]:

  • Diverticulitis: 65–79% of cases
  • Cancer (mostly adenocarcinoma): 10–20%
  • Crohn’s Disease: 5-7%
  • Previous radiation, bowel surgery, perforated peptic ulcer, genitourinary coccidioidomycosis, pelvic actinomycosis, and appendicitis make up the remaining cases.

Symptoms of Colovesicular Fistula

Figure 1: Graphic showing the common symptoms of colovesicular fistula

 

The classic findings of enterovesicular and colovesicular fistulas known as Gouveneur’s Syndrome are suprapubic pain, frequency, dysuria, and tenesmus.

Notwithstanding, pneumaturia, fecaluria and recurrent UTIs are pathognomonic with over 75% of patients presenting with these three findings. [3]

 

Investigations

Urinalysis (U/A) and culture can be useful on initial presentation to help guide diagnosis. In colovesicular fistula, U/A can reveal white blood cells and feces in the urine. Cultures will typically grow bacteria associated with the enteric system with E. coli being the most common pathogen (81% ). [3] (Note: E. coli is a common pathogen in the setting of an uncomplicated UTI thus E. coli growth does not necessarily mean the patient has a fistula)

 

It is important to assess for evidence of sepsis in any patient with suspected colovesicular fistula. If the patient displays signs of fever and/or shock, blood and urine cultures and other labs to guide resuscitation and management are indicated. There are no blood tests that help definitively diagnose a colovesicular fistula.

 

When the clinical suspicion of colovesicular fistula is high, computed tomography (CT) of the abdomen and pelvis with oral/rectal contrast but without IV contrast is indicated. IV contrast is excreted by kidneys and can appear in the bladder confusing the origin of the contrast. Rectal contrast, however, should not appear in the bladder and its presence can help confirm the diagnosis. CT findings indicative of colovesicular fistula include air in the bladder/ureters, visualization of the fistula tract, oral/rectal contrast in the bladder, and bladder thickening adjacent to a thickened loop of bowel. [3]

Point of care ultrasound may identify echogenic material (fecal material), reverberation artifact indicative of gas within the bladder or thickened bowel abutting the bladder though is not generally nor should be considered a modality for the diagnosis of colovesicular fistula.

MRI provides excellent resolution of a fistula tract and potential underlying pathology however, given lack of access and the associated time and financial costs, CT remains the modality of choice for the diagnosis of colovesicular fistula in the emergency department. [3]

Figure 2: CT Abdomen-Pelvis revealing pneumoureter in the left image and the colovesicular tract in the right image.

Management

The definitive management of a colovesicular fistula is surgical repair. Timing is dependent on several factors including hemodynamics at presentation, patient comorbidities, and etiology of the fistula (diverticulitis vs malignancy). In rare cases, conservative management may be considered if the patient is too frail for surgery. Septic patients should be resuscitated as per sepsis guidelines while stable patients should receive broad spectrum antibiotics with ciprofloxacin and metronidazole or amoxicillin-clavulanate being common regimens. Surgical consultation is recommended in all patients after initial resuscitation and imaging. [2]

Back to the case:

CT abdomen-pelvis was performed which showed air in the ureter and bladder as well as a tract connecting the sigmoid colon to the bladder. General Surgery was consulted and Piperacillin/Tazobactam 3.375g IV q6h was started. As the patient was stable, surgery asked that the patient be held in the ED until they could be seen latter in the day.

Two Hours Later

• On reassessment, patient appeared unwell and visibly diaphoretic. He was febrile with a temp of 38.5, a HR of 110 and a BP of 100/70. Repeat labs showed a white count of 14 and a lactate of 2.5.
• Diagnosis of septic shock was made and resuscitation started.
• Surgery was notified who opted to bring the patient to the OR for emergent exploratory laparotomy.

In the OR:

• The bladder was attached to the sigmoid colon via a thick adhesion. The surgeon had difficulty discerning what was bladder and what was intestine.
• Intestine was resected and an ileostomy was placed with stoma.
• Patient tolerated procedure well and was admitted to ICU for monitoring.

Figure 3: Laparoscopic View of bowel adhered to the bladder

 

Key Takeaways

  • Most colovesicular fistulas are the result of complicated diverticulitis.
  • Pneumaturia is highly suggestive for enterovesicular fistula in the absence of recent bladder instrumentation.
  • CT abdomen/pelvis with oral and rectal contrast without IV contrast is the imaging modality of choice.
  • Patients can go from stable to septic shock quickly.
  • The definitive management is surgical [2]

 

References:

 

  1. Youssef S. Tanagho, Jonathan M. Mobley, Brian M. Benway, Alana C. Desai, “Gas-Producing Renal Infection Presenting as Pneumaturia: A Case Report”, Case Reports in Medicine, vol. 2013, Article ID 730549, 3 pages, 2013. https://doi.org/10.1155/2013/730549
  2. Granieri, S., Sessa, F., Bonomi, A., Paleino, S., Bruno, F., Chierici, A., Sciannamea, I. M., Germini, A., Campi, R., Talso, M., Facciorusso, A., Deiana, G., Serni, S., & Cotsoglou, C. (2021). Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence. BMC surgery, 21(1), 265. https://doi.org/10.1186/s12893-021-01272-6
  3. Tomasz Golabek, Anna Szymanska, Tomasz Szopinski, Jakub Bukowczan, Mariusz Furmanek, Jan Powroznik, Piotr Chlosta, “Enterovesical Fistulae: Aetiology, Imaging, and Management”, Gastroenterology Research and Practice, vol. 2013, Article ID 617967, 8 pages, 2013. https://doi.org/10.1155/2013/617967
  4. Kavanagh, P. Neary, J. D. Dodd, K. M. Sheahan, D. O’Donoghue, and J. M. P. Hyland, “Diagnosis and treatment of enterovesical fistulae,” Colorectal Disease, vol. 7, no. 3, pp. 286–291, 2005.

 

 

Continue Reading