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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Jan 8, 2021

In this podcast Dr. Todd Elftmann, a general surgeon with Lakeview Clinic and Ridgeview, discusses abdominal surgeries through a case review format.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Recognize the potential for appendicitis and/or cholecystitis.
  • Initiate the appropriate work-up for appendicitis and/or cholecystitis.
  • Create the appropriate referral for appendicitis and cholecystitis.

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

  

SHOW NOTES:

CASE 1: 
The four "Elftmann criteria" include fever, elevated white blood cell count, history of pain or anorexia, and a positive physical exam. Two or more of these findings means a probable appendectomy.  Peritoneal irritation is not a subtle finding and even the most stoic patients will grimace with palpation of the abdomen. Localized pain versus diffuse pain in all four quadrants can help determine if there is a rupture.

Additional work up includes, as always, a good history, plus lab work an x[ray of the abdomen in this case, and finally, a CT scan with oral contrast. The CT is the gold standard and has decreased the number of negative appendectomies to 1-2%. Ultrasound can be used, and is often for pediatric patients, but has limitations. CT scans are more sensitive and specific for appendicitis.

A white blood cell count is included in the lab work-up, but a patient with appendicitis may present with a normal white count. Conservative treatment is possible, but per the literature does have a failure rate, with anywhere from 25-50% of patients still requiring an appendectomy.

A perforated appendix does not guarantee an immediate OR visit. Depending on the patient and the surgeon's comfort level, treatment may include a delayed appendectomy with antibiotics, plus or minus a percutaneous drain if an abscess is present.

IV piperacillin tazobactam would be given as an inpatient, and oral Augmentin as an outpatient along with very close follow-up. For patients with a penicillin allergy, a fluoroquinolone plus metronidazole is appropriate. Surgery could occur approximately 8-12 weeks later after clinical and laboratory improvement.

Stump appendicitis occurs when a patient presents with a classic presentation of an appendicitis, post a previous appendectomy. It happens most commonly with patients who had an appendicolith and the entire base was not removed in the original surgery.

CASE 2: 
Abdominal pain for patients that are pregnant can be complicated. Initial assessment includes a fetal exam, and assuring the viability of the fetus. Further consideration would include using ultrasound instead of CT for reduced radiation exposure.

In this case, a woman presented with right upper quadrant tenderness, fever, and hyperbilirubinemia indicative of cholecystitis. If she had jaundice, this would be Charcot's triad and would indicate cholangitis. Early surgical consultation, especially for a pregnant patient is important. Failed conservative treatment for these patients can have adverse outcomes.

For other work-up modalities, MRCP is an option, but if the patient is already going to the operating room, a cholangiogram can be performed in the OR with GI on standby for an ERCP, thereby eliminating the need for an extra test. MRCP is for patients that are not good operative candidates, and are too acute or sick to tolerate a procedure. A HIDA scan can evaluate whether the cystic duct is open and is good for non-toxic appearing patients where ultrasound is unremarkable or with fever of unknown origin.

The ongoing treatment of cholecystitis whether surgical or nonsurgical depends on the patient and the severity of their illness. It turns out, antibiotic choice for cholecystitis is similar to that of appendicitis with perforation. Antibiotics can range from cefazolin to zosyn or even meropenem. For severely penicillin allergic patients, a fluoroquinolone plus metronidazole can be used. For patients that are higher acuity, whether due to calculous or acalculous cholecystitis, and are not good surgical candidates, a percutaneous drain may be indicated.

Post-cholecystectomy, 85-90% of patients will not notice a change, 10% will report a looser bowel pattern, and 1% of patients will experience severe diarrhea. These patients can be treated with a bile binding medication like cholestyramine.

A key point today, the gallbladder is a surgical disease and Dr. Elftmann recommends early surgical consultation.

Thanks for listening.

 

Sources/Links: 
Evidence for an Antibiotics-First Strategy for Uncomplicated Appendicitis in Adults: A Systematic Review and Gap Analysis. Journal of the American College of Surgeons.  DOI:  http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.009

Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. Journal of the American College of Surgeons.  DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.039

The Scientific Forum presentation, Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at facs.org/clincon2018. 

The Panel Session, The Call Bladder: Dealing with the Acute Gallbladder, was held Monday, October 28 at the American College of Surgeons Clinical Congress 2019 in San Francisco (program, webcast and audio information).

Gallstone size and the risk of gallbladder cancer      https://pubmed.ncbi.nlm.hin.gov/6632129