Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician.
How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.
A paracentesis procedure is often performed in the Emergency Department to rule a patient out for spontaneous bacterial peritonitis (SBP).
- Do you check coagulation studies before performing the procedure?
- How comfortable do you feel that the patient has SBP with an ascites WBC > 500 cells/microliter or ascites PMN > 250 cells/microliter?
Appendicitis is a common presentation in the Emergency Department. Dilemmas arise when deciding whether to image patients with equivocal symptoms and WBC lab results. Given the risk of ionizing radiation with CT scans, we should ideally minimize the number of CT scans ordered in these patients without mistakenly sending patients home with an early appendicitis. A perforated appendix places the patient at risk for bowel obstruction, infertility (in women), and sepsis.
Patients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right) is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.
She presents to your ED.
What do you do?
With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.
- Glucagon IV – relaxes lower esophageal sphincter (LES)
- Nitroglycerin SL – relaxes LES – beware of acute hypotension
- Nifedifine SL – relaxes LES – beware of acute hypotension
- Carbonated beverage PO- gas forming agent to increase intraesophageal pressure
Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.
Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient’s foreign-body symptoms resolved. A simple $1.50 solution.
Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.
These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.