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.
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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.
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.
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