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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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of thick secretions. X-rays can be done, but airway stabilization takespriority.
Ifx-rays are performed, a steeple sign, much like croup, may be seen. Staphylococ-
cus aureus is most commonly isolated. S. pyogenes, Moraxella catarrhalis, H.influenzae, and anaerobes are also seen. Ampicillin/sulbactam and third-generation
cephalosporins with clindamycin cover most likely causative organisms. Vancomycin should be considered in communities with high rates of methicillin-resistant
S.aureus.
Abscesses
Deep abscesses of the neck are less common causes of acute wheezing, but they have
the potential to be very serious. They are located in the peritonsillar, retropharyngeal, and pharyngomaxillary spaces.
Retropharyngeal abscess affects children 2 to 4 years old. The abscess is usually caused by extension of pharyngeal infection, penetrating trauma, iatrogenic
instrumentation, or a foreign body. Children with this condition present with
fever, drooling, dysphagia, odynophagia, stridor, and respiratory distress. Physical
examination may reveal tender, enlarged cervical lymphadenopathy, cervical spine
range-of-motion limitation, possibly stridor, and wheezing. Diagnosis is made by
lateral neck films, which show bulging in the posterior pharynx (prevertebral soft
tissue more abundant in children during expiration). Treatment utilizes antibiotics such as cephalosporins or antistaphylococcal penicillins. Incision and drainage
treatment is also an option.
Peritonsillar abscess is an infection of the superior pole of the tonsils and is more
common in young teenagers. Fever, severe sore throat, muffled voice, drooling, trismus, and neck pain are typical symptoms. Enlarged tonsils with abscess, cervical
adenopathy, and deviation of the uvula may be obvious on physical examination.
CT scan of the neck is the most helpful diagnostic modality for identifying deep neck
abscesses. The predominant pathogens are S. pyogenes, S. aureus, and anaerobes.
The administration of ampicillin-sulbactam or clindamycin (if penicillin allergic)
for 14 days is appropriate treatment. Drainage of the abscess is indicated as firstline treatment or when antimicrobial agents fail to produce an adequate result.
Serious complications from deep abscesses result from airway obstruction, septicemia, aspiration, jugular vein thrombosis/thrombophlebitis, carotid artery rupture,
and mediastinitis.
CASE CORRELATION
See Case 56 (Wheezing and Asthma).
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COMPREHENSION QUESTIONS
39.1 A 7-month-old infant is brought by her mother to an outpatient clinic
because of a 2-day history of fever, copious nasal secretions, and wheezing. The mother volunteers that the baby has been healthy and has not had
these symptoms in the past. The infant’s temperature is noted to be 100.7 °F
(38.1°C), her respiratory rate is 50 breaths/min, and her pulse oximetry is
95% on room air. Physical examination reveals no signs of dehydration, but
wheezing is heard on bilateral lung fields on auscultation. The infant shows
no improvement after three treatments with nebulized albuterol. Which of
the following is the recommended treatment?
A. Continued nebulized albuterol every 4 hours
B. Antihistamines and decongestants
C. Antibiotics for 7 days
D. Initiate palivizumab
E. Supportive care with hydration and humidified oxygen
39.2 A 9-year-old girl is being seen in your office with fever and difficulty breathing. You are concerned about the diagnosis of epiglottitis. Which of the following is the most accurate statement regarding epiglottitis?
A. The child usually prefers to be in a prone position.
B. The radiographic finding of steeple sign will be present.
C. Every effort should be made to visualize the epiglottis in the office to
confirm the diagnosis.
D. Its diagnosis is decreasing in incidence.
39.3 A 5-year-old child is brought into the office due to the mother’s concern
about difficulty breathing. On examination, the child appears toxic and has a
high fever, cough productive of thick mucopurulent expectorant, and stridor
with wheezing. The child is up to date regarding immunizations. Which of
the following are the most likely condition and causative organism requiring
antibiotic therapy?
A. Epiglottitis due to H. influenzae
B. Tracheitis due to S. aureus
C. Epiglottitis due to S. pyogenes (beta-hemolytic streptococcus group A)
D. Tracheitis due to S. pyogenes (beta-hemolytic streptococcus group A)
E. Retropharyngeal abscess due to S. aureus
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39.4 A 12-year-old girl is brought to the emergency department because of a
severe sore throat, muffled voice, drooling, and fatigue. She has been sick for
the past 3 days and is unable to eat because of painful swallowing. The
parents deny any history of recurrent pharyngitis. The patient still manages
to open her mouth, and you are able to see an abscess at the upper pole of the
right tonsil with deviation of the uvula toward the midline. Examination of
the neck reveals enlarged and tender lymph nodes. Which of the following is
the most appropriate management?
A. Analgesics for pain
B. Oral antibiotics
C. Nebulized racemic epinephrine
D. Incision and drainage of the abscess
E. Tonsillectomy and adenoidectomy
ANSWERS
39.1 E. Bronchiolitis is the most likely diagnosis in this case. There is no established treatment for bronchiolitis except for supportive management of the
patient’s symptoms. Because the infant did not respond to an albuterol trial
(answer A), there is no justification for continuing its use. Antihistamines
and decongestants (answer B), as well as antibiotics (answer C), are not effective. Palivizumab (answer D) is not helpful in the acute setting.
39.2 D. The incidence of epiglottitis has markedly reduced since the introduction
of the Hib vaccine. Children with epiglottitis are more likely to be in the
tripod position than prone (answer A). The steeple sign (answer B) is seen
in croup; the thumb sign is seen in epiglottitis. Visualization of the epiglottis should preferentially occur in an operating room (not in the office, as in
answer C), where immediate intubation or tracheostomy can occur.
39.3 B. Tracheitis matches the symptom description and is usually caused by
S.aureus. Group A streptococci (answer C) is now the leading cause of
epiglottitis, but the symptom constellation is more likely due to tracheitis;
a patient with epiglottitis is usually sitting still and drooling. Because of
H. influenzae type B immunizations, this organism is now a rare cause of
epiglottitis (answer A). Retropharyngeal abscess (answer E) usually presents
insidiously with neck pain with swelling, fever, dysphagia, and drooling.
39.4 D. This patient is suffering from peritonsillar abscess, which is a surgical
emergency since the upper airway can be compromised. Of the choices
listed, treatment with incision and drainage is the most appropriate. Tonsillectomy (answer E) is only indicated if there are confirmed cases of
recurrent pharyngitis and peritonsillar abscess. Answer A (analgesics for
pain) is an important consideration but secondary to treatment of the
abscess. AnswerC (nebulized racemic epinephrine) is useful for conditions
such as croup (bronchiolitis). Oral antibiotics (answer B) is not appropriate
for peritonsillar abscess.
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CLINICAL PEARLS
» Sufficient airflow is required for the airway to produce a wheezing sound.
» Disappearance of wheezing in a patient who initially presents with
wheezing is an ominous sign that suggests complete blockage of the airway or imminent respiratory failure.
» Bronchiolitis is the most common lower respiratory disease of infants and
the most common reason for hospitalization for infants younger than
1year.
» Never perform a blind finger sweep of a foreign object aspirated in any
patient, and especially in an infant or child, since this maneuver can push
the object further down the airway.
» Epiglottitis and tracheitis are medical emergencies that require the
ability to rapidly secure airways.
REFERENCES
Mapelli E. Sabhaney V. Stridor and drooling in infants and children. In: Tintinalli JE, Stapczynski S,
Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide. 8th ed. New York, NY: McGraw Hill; 2016: Chap. 123 [e-version].
Smith DK, McDermott AJ, Sullivan JF. Croup: diagnosis and management. Am Fam Physician.
2018;97(9):575-580.
Smith DK, Seales S, Budzik C. Respiratory syncytial virus bronchiolitis in children. Am Fam Physician.
2017;95(2):94-99.
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CASE 40
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A 28-year-old woman presents to your office with a chief complaint of abdominal
discomfort, bloating, and constipation intermittently over the last 10 years.
While her symptoms have waxed and waned, they have never worsened. She
describes her abdominal pain as diffuse, dull, and crampy, and she often finds
relief after a bowel movement. She denies radiation of pain, nausea, vomiting,
fever, chills, weight loss, heartburn, hematemesis, hematochezia, or melena. Over
the last 3 months, she reports abdominal cramping 12 to 15 times per month and
has a hard bowel movement every 2 to 3 days with a sensation of incomplete
evacuation. She has tried over-the-counter stool softeners and laxatives, with only
minimal improvement. She has no significant past medical history and denies
tobacco, alcohol, or illicit drugs. Her family history is negative for gastrointestinal
(GI) disease, and she reports that her parents and siblings are healthy. She is
currently engaged and reports moderate stress in preparing for the wedding. Her
vital signs and general physical examination are unremarkable. Her abdomen
has normal bowel sounds and mild tenderness on diffuse palpation without
rebound, rigidity, or guarding. There is no hepatomegaly and no palpable masses.
Pelvic examination is unremarkable, and anorectal examination reveals normal
sphincter tone, no masses, and guaiac-negative stool.
▶ What is the most likely diagnosis?
▶ What is the first step in diagnostic evaluation?
▶ What are the recommended treatments for this condition?
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ANSWERS TO CASE 40:
Irritable Bowel Syndrome
Summary: A 28-year-old woman presents with
A several-year history of intermittent crampy abdominal pain and constipation
Denial of any constitutional symptoms or bloody stools
Unremarkable past medical history and family history
Unremarkable physical examination, including abdominal and pelvic examinations
Most likely diagnosis: Irritable bowel syndrome, constipation predominant subtype
(IBS-C).
First step in diagnostic evaluation: After conducting a thorough history and physical, in the absence of “alarm signs or symptoms,” no diagnostic testing needs to be
performed.
Recommended treatments: Education; reassurance; lifestyle modifications, including tracking of IBS symptoms with a food diary, an elimination diet, regular exercise,
minimizing environmental and psychosocial stressors; appropriate pharmacotherapy.
ANALYSIS
Objectives
1. Describe the epidemiology, clinical manifestations, and pathophysiology of
IBS. (EPA 1, 12)
2. Learn the diagnostic approach to IBS and rationale for ordering diagnostic
studies based on symptom subtype and presence or absence of alarm features.
(EPA 3)
3. Review current therapeutic strategies in the patient with IBS. (EPA 4)
Considerations
This is a young woman with a long-standing history of crampy abdominal pain and
constipation. She denies any “alarm features,” including fever, weight loss, bloody
stools, or severe abdominal pain, and she denies recent antibiotic use. She has no
family history of GI disorders and no physical examination findings of concern.
The chronicity, lack of alarm symptoms, and lack of worsening of symptoms coupled with her age suggests a functional gastrointestinal disorder (FGID), such as
IBS. Education about IBS, reassurance about lack of organic pathology, guidance
on dietary modifications and physical activity, strategies to reduced psychosocial
stressors, and options for pharmacotherapy should be discussed.
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APPROACH TO:
Irritable Bowel Syndrome
DEFINITIONS
FUNCTIONAL GASTROINTESTINAL DISORDER: Poorly understood and
often misdiagnosed GI conditions with varied mechanisms of pathophysiology,
clinical presentations, and provisions of management with an absence of identifiable organic function.
IRRITABLE BOWEL SYNDROME: An FGID characterized by chronic abdominal pain and change in form and frequency of stool.
ROME IV: The Rome Foundation is a worldwide organization of scientists and
clinicians that classifies and critically appraises the science of GI function and dysfunction. Rome IV criteria are current guidelines for the diagnosis and treatment
of FGIDs.
CLINICAL APPROACH
Pathophysiology
The prevalence of IBS is approximately 5% to 20% of the North American population, accounting for a large proportion of GI complaints seen by both primary care
providers and gastroenterologists. IBS affects women 1.5 to 3 times more often
than men and has a peak incidence from age 20 to 39 years, although any age group
can be affected.
Several models to explain the pathophysiology of IBS have been proposed, as
IBS appears to be associated with a combination of host and environmental factors.
Host factors include alterations in GI motility, microbial flora, and gut mucosal
barriers; visceral hypersensitivity; dysregulation of the brain-gut axis; and increased
reactivity to stressors. Environmental factors include a history of enteric infections
and/or antibiotic use, a history of physical or sexual abuse, or other psychosocial
stressors.
The Rome IV criteria were developed to aid clinicians in accurate and appropriate diagnosis of IBS in the absence of organic pathology (Table 40–1). Clinicians
Table 40–1 • ROME IV DIAGNOSTIC CRITERIA FOR IRRITABLE BOWEL
SYNDROME
Recurrent abdominal pain, on average, at least 1 d/wk in the last 3 months, associated with two or
more of the following criteria:
• Related to defecation
• Associated with a change in the frequency of stool
• Associated with a change in form (appearance) of stool
Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
Data from Drossman, DA, ed. Rome IV: Functional Gastrointestinal Disorders, 4th ed. 2016. Copyright © The Rome
Foundation. All rights reserved.
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Table 40–2 • ALARM FEATURES/RED FLAGS WARRANTING FURTHER
WORKUP
Abdominal or rectal mass
Blood in the stool or rectal bleeding
Change in symptom quality
Family history of colon or ovarian cancer, inflammatory bowel disease, or celiac disease
Fever
New onset of symptoms at age 50 or older
Nighttime symptoms that awake the individual
Markers of inflammatory bowel disease
Markers of celiac disease
Recent use of antibiotics
Unexplained anemia
Unintentional or unexplained weight loss
are encouraged to use judicious, cost-effective diagnostic testing when appropriate
and to minimize unnecessary testing.
Irritable bowel syndrome may coincide with other functional disorders, including
fibromyalgia, chronic fatigue, interstitial cystitis, chronic pelvic pain, and chronic
headaches. Conflicting studies suggest that patients with IBS may have higher rates
of depression, anxiety, and posttraumatic stress disorder.
The differential diagnosis of IBS includes celiac disease, GI infection, lactose
intolerance, diverticular disease, inflammatory bowel disease (IBD), colorectal cancer, ischemic colitis, carcinoid tumor, and adverse effects of various drug classes,
including opiates, antidepressants, and calcium channel blockers. Patients should
be asked for the presence of alarm symptoms that may suggest an underlying organic
etiology and warrant further workup or referral to gastroenterology (Table 40–2).
Clinical Presentation
Patients with IBS may complain of recurrent and episodic nonlocalized abdominal pain with a predominant pattern of constipation (IBS-C), diarrhea (IBS-D),
or mixed symptoms of constipation alternating with diarrhea (IBS-M). The pain
often has variable intensity and may be worsened by emotional stress. Patients
often report crampy abdominal pain that does not awaken them from sleep and
can fluctuate over time but is not described as progressive. Other GI symptoms
seen in IBS include the passage of mucus with stool, bowel urgency, abdominal
distention or bloating, or the sensation of incomplete stool evacuation. Up to
50% of patients with IBS also experience upper GI symptoms, including dyspepsia, nausea, gastroesophageal reflux, dysphagia, early satiety, and noncardiac
chest pain.
A thorough history should be obtained using open-ended, nonjudgmental
questions that include review of symptoms outside of GI symptoms and psychosocial components. The physical examination should focus on ruling out organic
pathologic processes that are inconsistent with IBS. Importance should be paid to
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all medications, dietary habits, and environmental stressors that may worsen the
symptoms of IBS.
Treatment
Treatment of IBS is aimed at improving symptoms and quality of life. Treatment
options can be challenging due to the recurrent nature of symptoms and because
some symptoms may be refractory to treatment. As with all functional disorders,
the cornerstone of management is a therapeutic relationship between the provider
and the patient. Clinicians should spend time establishing rapport, listening attentively, and explaining pathophysiology, natural history, and prognosis, including the
chronic nature of IBS. Providers should spend time validating patient concerns and
answering questions, especially at the initial visit. Setting realistic goals for functional improvement, not cure, is helpful for creating structured and purposeful visits for patients.
Initial Therapy. Having patients create a food diary may be useful in associating certain foods to IBS symptoms. A low FODMAP (fermentable oligosaccharide,
disaccharide, monosaccharide, and polyols) is an elimination diet that may provide some symptomatic improvement. Soluble fiber supplementation (eg, psyllium)
may provide some symptomatic improvement in patients with IBS-C, but it also
may cause bloating. Exercise, stress reduction, psychological treatment, and relaxation may also be useful in improving IBS symptoms.
Pharmacologic Therapy. Medications for IBS-C and IBS-D can be found in
Table 40–3.
For abdominal pain, the following medications may be considered:
1. Antispasmodics (eg, dicyclomine, hyoscyamine) are anticholinergic agents
that have demonstrated improvement in IBS-related global symptoms and
abdominal pain. These may be used on an as-needed basis, especially when
pain is mild and infrequent. Side effects include dry mouth, blurred vision,
and dizziness.
2. Tricyclic antidepressants (TCAs) have demonstrated modest improvement in
abdominal pain and global relief and can be considered when pain is more
frequent and severe. TCAs can cause a sedation effect and should be used with
caution in patients with prolonged QT intervals.
3. Probiotics and enteric-coated peppermint oil may be helpful for some individuals in improving bowel symptoms and reducing visceral pain.
4. Selective serotonin reuptake inhibitors (SSRIs) have not been shown to
improve global symptoms or abdominal pain in patients with IBS alone, but
they may be beneficial when depression or anxiety disorders are comorbid
with IBS.
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