Podcast #388: Antibiotics for Appendicitis

Author:  Aaron Lessen, MD

Educational Pearls:

  • 5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years
  • Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

 

Editor’s note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #385: Probiotics

Author:  John Winkler, MD

Educational Pearls:

  • Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.
  • Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.
  • Probiotics should not be given as a one-size-fits-all treatment.

 

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Podcast # 348: Steakhouse Syndrome

Author: Don Stader, MD

Educational Pearls:

  • Steakhouse syndrome is an impacted esophageal food bolus.
  • Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
  • Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
  • Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
  • Complications of NTG are hypotension and headache.

 

References

Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.

Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.

Podcast # 331: Oral Rehydration Therapy (ORT)

Author: Nick Hatch, MD

Educational Pearls:

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Podcast # 327: No More Hemoccults

Author: Don Stader, MD

Educational Pearls:

 

  • The use of fecal occult blood tests is falling out of favor in emergency departments
  • These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited
  • They have relatively high false positive and false negative rates
  • Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing

 

References:

Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002

Podcast #307: Guillain-Barre Syndrome

Author: Peter Bakes, M.D.

Educational Pearls:

  • Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness.
  • Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination.
  • Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells.
  • Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure.

References:

Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). “Population incidence of Guillain?Barré syndrome: a systematic review and meta-analysis”

van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). “Guillain?Barré syndrome: pathogenesis, diagnosis, treatment and prognosis”. Nature Reviews Neurology. 10 (8): 469?482.

Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). “Guillain?Barré Syndrome”. New England Journal of Medicine. 366 (24): 2294?2304.

Podcast #301: Biliary Pathology

Author: Don Stader, M.D.

Educational Pearls

  • Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis.
  • Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction.
  • Risk factors for Cholecystitis are the 5 F’s (Fat, Forty, Female, Fertile, Family Hx).
  • Classic symptoms seen in ascending cholangitis are Charcot’s Triad of fever, RUQ pain, and jaundice, or Reynold’s pentad which is more severe and has the addition of
    altered mental status and hypotension.
  • Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder.

References:

Kimura Y, Takada T, Kawarada Y, et al. (2007). “Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines”. J Hepatobiliary Pancreat Surg.

Strasberg, SM (26 June 2008). “Clinical practice. Acute calculous cholecystitis”. The New England Journal of Medicine. 358 (26): 2804?11.

Podcast #289: Cannabinoid Hyperemesis

Author: Dylan Luyten, M.D.

Educational Pearls

  • Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
  • The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
  • Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
  • Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:  Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

Podcast #288: Diarrhea

Author: Peter Bakes, M.D.

Educational Pearls

  • Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks.
  • Look for clues in the history, including  travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history.
  • Irritable Bowel Disease (Crohn’s/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea.
  • Crohn’s always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only.
  • Workup for IBD includes colonoscopy and tissue biopsy.
  • Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha).

References:  https://www.aafp.org/afp/2011/1115/p1119.html

Podcast #285: C Diff

Author: Aaron Lessen, M.D. 

Educational Pearls

  • While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community.
  • One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection.
  • Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors.

References:  Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.