APPENDIX AND KIDNEY TROUBLE
| APPENDICITIS —Kevin M. Klauer, DO, Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd,
and Director, Center for Emergency Medicine Education, Canton, OH
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| Introduction: comprises 4% of claims in emergency department (ED); atypical presentations common (easy to miss); diagnostic
accuracy not improved over last 100 yr; best way to diagnose—history, physical examination, and observation;
one white blood cell (WBC) count neither sensitive nor specific (2 counts taken one day apart helpful); fever may or may
not be present; urinary tract infection (UTI) can cause significant abdominal pain but not tenderness to palpation; should
not rely on negative computed tomography (CT), even if appendix visualized; positive CT result helps; observe patient
for reasonable period, during which patient examined several times to ensure condition not evolving; static or worsening
condition not good sign; need good discharge instructions and follow-up plan if sending patient home; natural history of
appendicitis—worsens until appendix ruptures or removed within 24 hr; indolent appendicitis may last up to 72 hr (can
rupture and be walled off, with minimal pain); if patient has had pain for 24 to 48 hr, perform CT; 5% of all money spent
on malpractice claims from appendicitis; affects all age groups; perforation possible and may result in death, disability, or
sepsis; in women, delayed diagnosis can result in adhesions, leading to infertility
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| Evaluation: history—if early in course of disease, difficult to ascertain; obtain detailed history of pain (time started;
whether pain worsening; aggravating and alleviating factors; positive “car” sign [worsening of pain when car hits bumps]
usually indicative of peritoneal involvement; inability to stand and walk straight [psoas sign]); loss of appetite, nausea,
vomiting, and diarrhea nonspecific symptoms (can lead to misdiagnosis, eg, gastroenteritis); dysuria may be present, depending
on location of inflamed appendix (if under bladder, frequency present; if near ureter, dysuria, leading to WBCs
in urine and misdiagnosis as UTI); documentation—critical in any patient with abdominal pain; inform patient about
possibility of appendicitis and need to watch for pain moving to periumbilical area or right lower quadrant (RLQ) or for
worsening of condition (eg, development of vomiting, fever); document conversation with patient; document reasons for
thinking pain not due to appendicitis (eg, absence of certain findings); some diagnoses not obtainable at time of visit to
ED; document that diagnosis of appendicitis could not be made at time patient in ED, but possibility entertained; physical
examination—note presence or absence of peritoneal signs; rectal examination not necessary in all patients with abdominal
pain (perform only if looking for rectal bleeding or perirectal abscess); reassessment and observation—critical; documentation
should reflect effort to determine cause of abdominal pain; assess vital signs (if abnormal, can be early
finding); note breath sounds and bowel sounds; note location of pain and presence of rebound; in women of childbearing
age, obtain pregnancy test and perform pelvic examination; in men, particularly adolescents and young boys, with lower
abdominal pain, make sure no signs of torsion or inguinal hernia; ancillary testing—complete blood cell count (CBC)
with differential (one not helpful; if second done, 2 points on data curve may help); urinalysis possibly misleading; C-reactive
protein (CRP) no help; plain films helpful if appendical lift seen; ultrasonography (US)—helpful, particularly in
women, when also considering gynecologic pathology; must have expertise to read; if appendical lift present, can go directly
to operating room (OR)
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| Literature review: confirms that no single test, combination of physical findings, or historical features combined with
any other test helps exclude diagnosis of appendicitis; therefore, appendicitis should not be removed from differential diagnosis;
New England Journal of Medicine 2003—CT compared to US; CT better than US for appendicitis, but if also
looking for gynecologic pathology, US may be better test for individual patient; CT provides better chance of identifying
alternative pathology
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| Techniques: not much benefit to performing lengthy protocols to determine abdominal pathology; adding contrast increases
readability of study; exception in pediatrics or in patient without much intra-abdominal fat; rectal contrast CT—
98% sensitive for appendicitis; 94% of normal appendixes visualized; isolates RLQ anatomy and helps distend appendix
better than oral contrast; unenhanced CT—in one study, 30% to 45% of participants had atypical symptoms; 296 adults
with RLQ pain; examination equivocal for appendicitis; unenhanced CTs performed (5-mm sections) looking for absence
of inflammatory changes (not necessary to visualize appendix); found 96% sensitive and 98% specific; negative CT does
not rule out appendicitis; inflammation easily seen without contrast
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| Missed appendicitis: atypical sequence of symptoms; look for change in bowel pattern; the younger the patient, the
more likely to have unusual symptoms (frequently associated with upper respiratory tract symptoms); study found 43%
of patients with missed appendicitis had RLQ pain that physician never acted on; sometimes right information given, but
not acted on appropriately; data show that in 10 of 22 missed appendicitis cases, bowel sounds not documented (inadequate
abdominal examination); no palpation of abdomen performed in 8 of 22 cases; 12 of 22 cases had no comment on
rebound tenderness; poor follow-up arrangements; if appendicitis still in differential diagnosis, discharge instructions
should reflect this; American Journal of Emergency Medicine (1994)—looked at 66 missed appendicitis cases litigated;
reasons for missing diagnosis included patients appearing less ill, absence of RLQ pain, and symptoms masked by narcotic
medications (not shown to be true); usually diagnosed as gastroenteritis
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| Case 1: obese boy, 10 yr of age, presents at 2:00 AM with abdominal pain for 6 hr, nausea, and vomiting; not hungry; afebrile,
with normal vital signs; tenderness in lower abdomen but not localized; CBC performed but of no benefit; CRP normal;
CT performed and read as normal; patient sent home at 7:00 AM ; diagnosed with early gastroenteritis; given
appropriate discharge instructions to return in 24 hr; returns at 3:00 PM with worse pain in bilateral lower quadrants; increased
WBC count; repeat CT performed; diagnosed with appendicitis (evolves quickly)
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| Case 2: boy, 5 yr of age, with generalized abdominal pain for 3 hr (started 1 hr after dinner); vomited twice; afebrile (temperature
99.1°F); slightly tachycardic and tachypneic; positive bowel sounds; mild epigastric tenderness; diagnosed with
gastroenteritis and discharged; sent home with vomiting sheet and flu sheet; advised to follow up with primary care physician
next day; patient seen by primary care physician next day; vital signs not taken; some tests done but not checked;
episodes of vomiting; patient returns to ED that evening; seen by resident first; speaker advises making own clinical
judgment before reading notes from previous visit; patient vomited 3 more times and felt warm; has low-grade fever and
more tachycardic and tachypneic; not in acute distress; some epigastric tenderness; resident noted agreement with previous
diagnosis; patient sent home, but restless and complaining of pain all night; parents call 911, and patient has cardiac
arrest on way to hospital; autopsy showed perforated appendix; blood culture positive for Streptococcus; patient septic;
case settled after depositions prior to trial; problems with care include 3 attempts to obtain correct diagnosis, no adequate
supervision of resident, failure of primary care physician to check test results, inadequate discharge instructions on second
visit, and bad outcome; key points—atypical presentations common; appendicitis difficult to diagnose early in
course of illness; should not be removed from differential diagnosis; urinary tract symptoms and constipation do not rule
out gastroenteritis; significant palpable tenderness not present in true gastroenteritis or viral etiology of abdominal pain
with nausea and vomiting; CT most sensitive diagnostic test; intravenous contrast shown 100% sensitive in some studies;
rectal contrast 98% sensitive, and unenhanced CT 96% sensitive; rectal contrast may be necessary in pediatric patients;
negative CT nondiagnostic, not confirmatory; RLQ pain or tenderness with left shift in WBC count, anorexia, peritoneal
signs, or fever highly suspicious; adequate observation important; if diagnosis unclear at first, have patient return
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| RENAL FAILURE IN THE ED—William K. Mallon, MD, Associate Professor of Emergency Medicine, Keck School of
Medicine at the University of Southern California (USC), Los Angeles, and Director of International Emergency Medicine
at the Los Angeles County/USC Medical Center, Los Angeles
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| Renal dialysis: complications—include hypotension secondary to fluid shifts and fluid unloading; cardiac arrhythmias
related to rapid changes in potassium; bleeding at line or shunt due to heparinization; seizures due to sodium, magnesium,
or calcium shifts; removal of seizure-preventing medication by dialysis; fever; frequent heparinization for dialysis affects
immune system; emergencies occurring between dialysis appointments—include hypertension, hypotension, infection,
pulmonary edema, bleeding, and access failures; conditions requiring emergency dialysis—best to give nephrologist
clinical reasons rather than laboratory values; hyperkalemia unresponsive to therapy; acidosis; coagulopathy with uncontrollable
bleeding, eg, gastrointestinal (GI) bleeding; acute pulmonary edema with significant hypoxia; acute tubular necrosis;
toxicologic emergencies; uremic encephalopathy; uremic pericarditis and tamponade; protein-bound or fat-soluble
substances and those with large tissue component that leaches out afterward (eg, in chronic aspirin overdose) not cleared
by dialysis; when dealing with toxins that require dialysis, call poison control center rather than nephrologist; “soft” indications
for emergency dialysis—presence of comorbidities (eg, in sickle cell disease, acidosis and hypoxia cause sickling);
sepsis (most patients immunocompromised); fluid overload; hypertensive emergencies; strokes in subarachnoid;
coronary artery disease; coagulopathies
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| Hyperkalemia: succinylcholine increases potassium and could lead to cardiac arrest in patient already hyperkalemic
(use nondepolarizing agent instead, eg, rocuronium); can perform hemodialysis during cardiopulmonary resuscitation
(extracorporeal circulation excellent form of perfusion); cardiac pacemakers affected by hyperkalemia (loss of pacing
activity); reduce potassium level slowly during dialysis; electrocardiography—does not indicate potassium level but
effect potassium having (individual tolerance to hyperkalemia varies); accurate at showing whether patient has conduction
defect due to potassium abnormalities; rate of change more important than actual potassium level; 10-fold increase
results in tall T wave, widened QRS complex, decreased amplitude or loss of P wave, and, ultimately, sine wave
(usually notched); key to recognize that complexes wide and slow (not ventricular tachycardia)
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 | Management: albuterol (lowers potassium), 1 ampule of dextrose injection 50% (D50) and insulin, 1 ampule of sodium
bicarbonate, 1 ampule of calcium chloride, furosemide (Lasix), sodium polystyrene (eg, Kayexalate), and bumetanide
(Bumex) or other diuretics, and ultimately, dialysis; use graduated response (ie, if QRS complex not wide, calcium
chloride not given); beware of iatrogenic hypokalemia; hyperkalemia well tolerated in renal failure, but hypokalemia is
not; low potassium and increased digoxin can cause dysrhythmic death; watch fluid volumes; speaker prefers patient
slightly dehydrated and borderline hypotensive than overloaded with fluids; sodium bicarbonate—each ampule has
300 to 350 mL equivalent of normal saline; causes prompt intravascular fluid shift; pay attention to volume of medications
given; fluid decision-making in these patients challenging; bilevel positive airway pressure (BiPAP)—in acute
pulmonary edema, effective mostly by improving cardiac performance and allowing patient to make urine; therapeutic
bridge in patient with renal failure, but not as effective; in pulmonary edema, effective for patients on wrong side of Starling
curve (increases cardiac output ≈15%); not as effective for patients with renal failure since they cannot make urine;
mnemonic “UNLOADMEBBB”—for acute pulmonary edema; urine out (eg, catheters); nitrates (if hypertensive);
Lasix or other diuretics (including Bumex); oxygen; diuretics and/or dialysis, morphine (for venodilation and often
for panic relief and pain); exsanguination (if unable to resolve pulmonary problems and dialysis not immediately available;
bloodletting of ≈300 mL); patient usually anemic to start with, so might be necessary to give back packed red
blood cells; vitamin B1 (thiamine) if patient alcoholic with renal failure (high-output failure with vitamin deficiency);
B-type natriuretic peptide (BNP) not used in renal failure; renal failure single most important comorbidity in congestive
heart failure (CHF); BiPAP
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| Coagulation states in renal failure: shunts sometimes clot; patients alternate between anticoagulated and procoagulable
states (also seen in patients on clopidogrel [Plavix]); anticardiolipin antibodies and heparin-induced antibodies; renal
failure patients on dialysis most common population to have heparin-induced thrombocytopenia; have elevated
factor VIII and increased fibrinogen; pulmonary embolism underestimated in these patients; if renal failure patient has
chest pain and shortness of breath after dialysis, coronary artery disease not only condition to consider (D-dimer test useless
in this case because patient not low risk); need work-up; dialysis removes contrast; after giving dye load, need prolonged
dialysis (6 hr); superior vena cava syndrome—another prothrombotic complication; in United States, most
common cause indwelling catheter (previously bronchogenic carcinoma); cor pulmonale—if patient has upper extremity
shunt, vascular volume returning to heart increased, increasing pressure; central circulation responds with balancing pressure
(pulmonary hypertension); compression of upper extremity shunt for 1 min decreases pulmonary artery pressure by
25%; several shunts available; vascular access—problem in renal failure patients; responsible for 50% of hospitalization
dollars for end-stage renal disease and 20% of total cost for hemodialysis; in Europe, 90% of vascular access established
by nephrologists; infectious complications of shunts significant; fever of unknown origin and sepsis common in these patients;
continuous ambulatory peritoneal dialysis—problems include cuff erosion, hernia, masked bleeding, and GI dysfunction;
spontaneous bacterial peritonitis—of great concern; use urine dipstick on fluid from peritoneal catheter
(problem if positive for leukocytes); common; 80% gram-positive, mostly Staphylococcus; vancomycin first-line therapy;
culture indicated; culture negative in some patients; unusual organisms not uncommon
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| Long-term complications of dialysis: hyperparathyroidism; worsening of diabetes; anemia; CHF; neuropathy; social
and financial pressures (individual who requires dialysis automatically eligible for MediCal and Medicare); depression
and suicide; GI bleeding
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| Renal transplantation: patients usually on powerful immunosuppressant drugs and antilymphocyte antibody therapy;
sepsis most important problem; involve infectious disease specialist
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Suggested Reading
Antevil JL et al: Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation.
J Am Coll Surg 203:849, 2006; Badruddoja M: Delayed appendectomy for acute appendicitis. Arch Surg 142:99;
author reply 100, 2007; Chou JS et al: Pain in the right lower quadrant. Am Fam Physician 75:1541, 2007; De Waele
JJ et al: Antibiotic use and delayed source control in acute appendicitis. Arch Surg 142:99, 2007; Ditillo MF et al: Is
it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 244:656, 2006; Ekeh AP et al: Laparoscopy in
the contemporary management of acute appendicitis. Am J Surg 193:310, 2007; Kizilisik AT et al: Improvements in dialysis
access survival with increasing use of arteriovenous fistulas in a Veterans Administration medical center. Am J Surg
188:614, 2004; Moteki T et al: New CT criterion for acute appendicitis: maximum depth of intraluminal appendiceal
fluid. AJR Am J Roentgenol 188:1313, 2007; Needham E: Management of acute renal failure. Am Fam Physician
72:1739, 2005; Pluijmen MJ et al: Images in cardiovascular medicine. Sine-wave pattern arrhythmia and sudden paralysis
that result from severe hyperkalemia. Circulation 116:e2, 2007; Richardson E et al: Clinical inquiries. History,
exam, and labs: is one enough to diagnose acute adult appendicitis? J Fam Pract 56:474, 2007; Rosner MH: Hemodialysis
for the non-nephrologist. South Med J 98:785, 2005; Sheen V et al: The use of B-type natriuretic peptide to assess
volume status in patients with end-stage renal disease. Am Heart J 153:244, 2007; e1-5.Van Deusen SK et al: Treatment
of hyperkalemia in a patient with unrecognized digitalis toxicity. J Toxicol Clin Toxicol41:373, 2003; Yigla M et
al: Pulmonary hypertension in patients with end-stage renal disease. Chest 123:1577, 2003
Educational Objectives
| The goal of this program is to improve the management of appendicitis and renal failure in the emergency department.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Recognize the importance of obtaining a good history and physical examination, and of observation in the diagnosis
of appendicitis.
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| 2. Recommend appropriate tests to aid in the diagnosis of appendicitis.
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| 3. Identify the indications for emergency hemodialysis.
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| 4. Recognize (through electrocardiographic changes) and manage hyperkalemia.
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| 5. Discuss coagulapathies and other complications seen in patients on dialysis for renal failure.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Klauer was recorded at the 18th Annual High Risk Emergency Medicine, held April 16-17, 2007, in Las Vegas,
NV, and sponsored by the Center for Emergency Medicine Education. Dr. Mallon was recorded at the 2007 CAL/
ACEP Scientific Assembly, held May 31 to -June 2, 2007, in Newport Beach, CA, and sponsored by the American
College of Emergency Physicians, State Chapter of California, Inc. The Audio-Digest Foundation thanks the speakers
and the sponsors for their cooperation in the production of this program.
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