Archive | November, 2016

Pyelonephritis (quick hits)

8 Nov

submitted by Christina Brown, M.D.

Definition – Ascension of bacteria from lower urinary tract infection (UTI) into the upper pyelourinary tract. Primarily a clinical diagnosis.

 
Epidemiology of Male/female ratio:
• 1:10 in 1st years of life
• 1:5 in children
• 1:50 in reproductive years
• 1:1 in fifth decade and later

 
Bacteriology: Escherichia coli 80–95% predominates.

 
Risk Factors – Recent instrumentation, urinary obstruction, urinary retention, recent pyelonephritis (within 1 yr), anatomic variation, neurogenic bladder, DM, immunosuppression, pregnancy.

 
Signs & Symptoms
– Dysuria, urgency, frequency
– Back, flank, or abdominal pain
– Fever, chills, N/V, Malaise
– CVA Tenderness or suprapubic TTP

 

Pediatric Considerations
– Renal scarring: More common sequelae in young children than in adults.
– Group B streptococci

Geriatrics – AMS, nausea/vomiting, diarrhea, fever may predominate.

Urine Culture: >100,000 colony-forming units (CFU)/mL is (+).

CT Imaging:

Consistent or concerning findings:
• Stranding or inflammation and edema of parenchyma
• Perinephric fluid
• Calculi, obstruction
• Renal/perinephric abscess
• Intraparenchymal gas formation (consistent with emphysematous pyelonephritis)

ED Treatment – 14 days duration
– Oral Antibiotics – Ciprofloxacin, Cefdinir
– PEDS – Amoxicillin, Keflex
– IV Antibiotics – Ceftriaxone, Ciprofloxacin
– PEDS 0-3 months – Amp + Gent, Cefotaxime. 3+ months – Ceftriaxone may be used in place of Cefotaxime.

Additional Pediatric Considerations
All children with 1st episode of pyelonephritis should have urinary tract imaging performed later with pediatrician.

Renal US:
• Within 48 hr if no clinical improvement
• Within 3–6 wk if clinical improvement
Girls 4–10 yr old: Voiding cystogram for UVR w/ pediatrician
Boys 4–10 yr old: Voiding cystourethrogram after urine is sterile and bladder spasm has subsided

Disposition

– Admit septic, unable to tolerate PO intake, immunocompromised.

– If clinically stable, discharge home w/ pediatrician f/u within next 48 hrs with appropriate antibiotic regimen.

 

References:

1. Bitner M, Schaider, J., lfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Pyelonephritis. Rosen & Barkin’s Five Minute Emergency Medicine consult.

2. Piccoli B G, Cresto E, and Ragni F et al.: The clinical spectrum of acute uncomplicated pyelonephritis from an emergency medicine perspective. Int J Antimicrob Agents. 2008; 31(suppl S):S46-S53.

3.  Stunnell H, Buckley O, and Feeney J et al.: Imaging of acute pyelonephritis in the adult. Eur Radiol. 2007; 17:1820-1828.

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Pancreatitis (quick hits)

1 Nov

submitted by Christina Brown, M.D. 

Definition – Inflammation of pancreas due to activation, interstitial liberation, and digestion of gland by its own enzymes. Gallstones and alcohol abuse most common causes.

Acute – Exocrine and endocrine function of gland impaired for weeks-months. Function will return to b/l.

Chronic – Dysfunction progressive and irreversible.

Signs and Symptoms

  • Abdominal pain: 95–100%
  • Epigastric tenderness: 95–100%
  • Nausea and vomiting: 70–90%
  • Low-grade fever: 70–85%
  • Hypotension: 20–40%
  • Jaundice: 30%
  • Grey Turner/Cullen sign: <5%

 

Ranson Criteria – Indicators of morbidity and mortality:

o 0–2 criteria: 2% mortality
o 3 or 4 criteria: 15% mortality
o 5 or 6 criteria: 40% mortality
o 7 or 8 criteria: 100% mortality

Criteria on admission:

• Age >55 yr
• WBC count >16,000 mm3
• Blood glucose >200 mg/dL
• Serum lactate dehydrogenase >350 IU/L
• AST >250 IU/L

 
Diagnostic Evaluation/Labwork

Lipase: Rises within 4–8 hr of pain onset. More reliable indicator of pancreatitis than amylase

Amylase: Levels >3 times limit of normal suggest pancreatitis.

Calcium: Hypocalcemia indicates significant pancreatic injury.

Imaging
Abdominal Series – Most common finding is isolated dilated bowel loop (sentinel loop) near pancreas.

CXR: Pleural effusion

RUQ U/S: Useful if gallstone pancreatitis is suspected.

Abdominal CT indications:

• High-risk pancreatitis (>3 Ranson criteria)
• Hemorrhagic pancreatitis
• Suspicion for pseudocyst
• Diagnosis in doubt

Endoscopic retrograde cholangiopancreatography (ERCP) – Indicated for severe pancreatitis with cholangitis or biliary obstruction

 

 
ED Treatment
Fluid resuscitation

Correct electrolyte abnormalities

• Hypocalcemia (calcium gluconate)
• Hypokalemia occurs with extensive fluid losses.
• Hypomagnesemia occurs with underlying alcohol abuse.

Analgesia, Antiemetics

Antibiotics: Indicated if pancreatic necrosis >30% on abdominal CT

 

DISPOSITION:
Admission Criteria
• Acute pancreatitis with significant pain, nausea, vomiting
• ICU admission for hemorrhagic/necrotizing pancreatitis

Discharge Criteria
• Mild acute pancreatitis without evidence of biliary tract disease and able to tolerate oral fluids
• Chronic pancreatitis with minimal abdominal pain and able to tolerate oral fluids. All discharged mild pancreatitis should have scheduled follow-up within 24–28 hr.

 

References:
Lewis, T. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Pancreatitis. Rosen & Barkin’s 5 minute Emergency Medicine Consult.

Frossard D, Steer M L, and Pastor C M.: Acute pancreatitis. Lancet. 2008; 371:143–152

Heinrich S, Schäfer M, and Rousson V et al.: Evidence-based treatment of acute pancreatitis: A look at established paradigm. Ann Surg. 2006; 243(2):154–168.
Hayerle J, Simon P, and Lerch M M.: Medical treatment of acute pancreatitis. Gastroenterol Clin North Am. 2004; 855–869