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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Angiodysplasia is sometimes associated with aortic stenosis. It is characterized by painless
bleeding, from mild to massive; signs of bleeding can range from brisk hematochezia to occult
blood loss leading to iron-deficiency anemia. Many patients are elderly with a history of
cardiac disease, especially aortic stenosis. “Hematochezia” refers to the passage of gross
blood per rectum. Recent transfusion guidelines are more liberal and recommend giving
packed RBC transfusions at hemoglobin <7 and hemoglobin <8–9 in those with cardiac
disease.
Brisk colonic hemorrhage due to angiodysplasia responds to endoscopic electrocoagulation. In
high-risk patients unable to be controlled by endoscopy, selective arterial catheterization
should be performed for deliberate embolization. Vasopressin is rarely necessary and should
be avoided in a patient with cardiac disease because it causes vasospasm. Most cases of GI
bleeding stop spontaneously. If massive bleeding continues, subtotal colectomy, laser therapy,
or electrocoagulation is indicated. Fresh frozen plasma is used with coagulopathy.
Aortic stenosis with bleeding from angiodysplasia has been called Heyde’s syndrome. A
possible mechanism by which aortic stenosis may lead to the development of angiodysplasia is
through the development of an acquired form of von Willebrand disease (vWD). Acquired
vWD is thought to result from mechanical disruption of von Willebrand multimers during
turbulent passage through the narrowed valve and from a von Willebrand factor interaction
with platelets that triggers platelet clearance.
In patients with recurrent bleeding due to AVM and aortic stenosis, an aortic valve replacement
should be done to prevent recurrent bleeding.
Final Diagnosis
Lower GI bleed
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Case 5
Chief Complaint
Confusion and irritability
History and Physical Examination
A 73-year-old woman with insulin-requiring diabetes mellitus is brought to the emergency
department by her family for a flu-like illness earlier in the week and because she has not
been eating well. Over the past 24 hrs she has “not been herself,” with marked irritability
and confusion. This morning she was difficult to awaken. There is no history of fever,
neck stiffness, or focal neurologic deficits. She is on no other medications. She is
currently lying on a stretcher and is difficult to arouse.
Vital signs are T 37.8° C (100.0° F), BP 105/72 mm Hg, pulse 110/min, and respirations
16/min. Her pupils are equal, round, and reactive to light and accommodation. She has
normal heart sounds and tachycardia. Her lungs are clear and examination of the abdomen
is benign. Changes consistent with venous stasis are evident in the extremities. Neurologic
exam is nonfocal; there are no gross deficits; however, she is unable to follow commands.
Differential Diagnosis
Hypoglycemia1.
Acute delirium2.
Drug overdose3.
Cerebrovascular accident4.
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Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
Assessment
Hypoglycemia is a relatively common complication of therapy with insulin and oral
hypoglycemic agents. It should be thought of first when seeing a diabetic patient with change in
mental status. Other common symptoms include irritability, tremulousness, diaphoresis, seizure,
stupor, and coma. Meningitis is unlikely in the absence of fever and neck stiffness. Stroke
usually presents with a focal deficit rather than a generalized delirium, as seen in this patient.
CCS NOTE
Sepsis syndrome
5.
Measurement of blood glucose by finger stick
Serum electrolytes
CBC
Blood glucose 35 mg/dL
Serum electrolytes: normal
CBC: normal
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Treating an unstable patient is always more important on the CCS than doing a specific
diagnostic test. Giving glucose to a disoriented person is more important than waiting
for specific diagnostics.
Further Management Plan/Results
Discussion
In diabetic patients, the most common causes of hypoglycemia are as follows:
Diagnosis is easy to establish and the condition must be corrected promptly.
In non-diabetic patients, there are several possible causes:
Treatment with IV dextrose (50 mL of 50% dextrose should be given initially). Avoid
oral administration in patients who are not alert
1.
If patient does not recover after the administration of glucose, consider thyroid function
tests, vitamin B12 level, lumbar puncture, toxicology screen, and CT scan of the head
2.
Blood cultures: no growth3.
Urine cultures: no growth4.
Change in dietary habits without an appropriate change in medication
Increase in metabolic demands (e.g. increase in physical activity)
Medication overdose
New onset renal failure
Insulinoma
Severe liver disease
Alcohol intoxication
Adrenal insufficiency
255
CLINICAL PEARL
Insulinoma also causes elevated insulin levels and elevated c-peptide, but is rare.
Reactive hypoglycemia occurs following a meal, usually 2–4 hrs after eating. It is due
to an excess of insulin released after glucose stimulation often after gastric resection.
When the diagnosis is in question, an insulin level can be obtained.
Final Diagnosis
Hypoglycemia
Myxedema
Severe malnutrition
Factitious disorder with abuse of insulin or sulfonylureas
If a patient presents with the triad of hypoglycemia, elevated insulin, and low c-
peptide levels, suspect factitious use of insulin.
If a patient presents with hypoglycemia with elevated insulin and c-peptide levels,
check sulfonylurea levels for overdose of sulfonylurea hypoglycemic drugs.
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Case 6
Chief Complaint
“I’m wheezing, and my lips are swollen.”
History and Physical Examination
A 27-year-old woman comes to the emergency department complaining of wheezing and
swelling of the lips. The symptoms began acutely just after eating a chicken-and-nut dish
at a nearby Chinese restaurant. She also complains of tightness in her chest and mild
difficulty breathing. She has no significant past medical history and is not taking any
medications. She had a similar episode a year ago after she had eaten some cookies at a
friend’s house.
Vital signs are T 36.8° C (98.2° F), BP 110/50 mm Hg, pulse 110/min, and respirations
24/min. The patient appears anxious and in mild respiratory distress. She has diffuse
facial erythema and swelling of the lips and tongue. There is no stridor. Her heart has a
regular rhythm and is tachycardic. There is diffuse bilateral wheezing on auscultation. The
remainder of the physical examination is unremarkable.
Differential Diagnosis
Acute anaphylaxis1.
Foreign body aspiration2.
Asthma3.
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Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
Assessment
The onset of wheezing, shortness of breath, facial erythema, and swelling of the tongue are
common manifestations of anaphylaxis. The diagnosis is made easier by the development of
these symptoms occurring shortly after exposure to the causative agent—in this case, nuts.
There are no tests that will determine the specific agent. The most important factor in a case of
acute allergic reaction is evidence of instability, such as dyspnea, hypotension, or signs of
airway obstruction, such as stridor. An allergic reaction characterized only by a rash is much
less dangerous. The presence of wheezing in this case is very worrisome.
Further Management Plan
Pulse oximetry
Oxygen saturation 92%
Epinephrine 1:1000 subcutaneously every 15 minutes until improvement
Supplemental oxygen
Establish IV access and start normal saline
Diphenhydramine intramuscularly or intravenously every 4–6 hrs
IV corticosteroids every 6 hrs
Endotracheal intubation if there is severe airway obstruction secondary to laryngeal edema
that does not rapidly improve with epinephrine
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CCS NOTE
An oximeter alone is sufficient when one is not investigating CO
2
retention and when a
specific A-a gradient is not important. An ABG is important in COPD or Pneumocystis
pneumonia.
CCS NOTE
Oxygen should be administered at the same time as ordering the oximeter in a patient
with shortness of breath. When a test and a treatment are ordered at the same time, the
test reflects the pretreatment state.
Discussion
Anaphylaxis is an acute systemic reaction resulting from the interaction of a foreign antigen
with surface immunoglobulin E located on mast cells and basophils in a previously sensitized
person. This results in the release of histamine, leukotrienes, and other factors that lead to
smooth-muscle contraction causing bronchoconstriction, and smooth-muscle relaxation leading
to vasodilation. Anaphylactic reactions can present with a spectrum of symptoms, and, in the
majority of cases, will develop within one hour of exposure to the offending agent.
Vasodilation results in the leakage of plasma into the extravascular space, which may result in
urticaria and angioedema, hypovolemia and shock, pulmonary edema, obstruction of the upper
Albuterol inhalers in patients who are wheezing
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airway, and cardiac arrhythmias. The most critical issue in anaphylaxis is whether or not the
person’s airway is obstructed and if their BP is low. IV fluids must be given with the
epinephrine at the beginning if the BP is low.
The systems most frequently affected are the skin, lungs, GI tract, and cardiovascular system.
The diagnosis is generally easily made if the symptoms occur shortly after exposure to the
causative agent. If not, the diagnosis may be more difficult and can be confused with such
diagnoses as a vasovagal episode, foreign body aspiration, and cold urticaria.
Countless substances can cause anaphylactic reactions, but the most common offenders are
drugs, insect stings, and food substances, such as peanuts and fish. Because anaphylaxis may be
rapidly fatal, the most important step in management involves a rapid assessment of the
patient’s airway, breathing, and cardiovascular status.
CLINICAL PEARL
Diphenhydramine is the superior antihistamine in case of anaphylaxis. It is more
effective than the others.
Following an initial assessment, epinephrine should be administered as the first-line
agent. Then, antihistamines (such as diphenhydramine or hydroxyzine), H2 blockers,
and steroids may be added. All patients with an episode of severe anaphylaxis should
be observed for at least 6 to 8 hrs, due to the possibility of a late second reaction.
Beta-blockers are contraindicated in those at risk for anaphylaxis because they can
make it worse. Also, because epinephrine is used as one of the main treatments for
anaphylaxis, beta-blockers will interfere with the ability of the epinephrine to be
effective.
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