Paucis Verbis: Upper GI bleeding

Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention.

Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I’m breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you risk stratify for an upper GI bleed requiring urgent intervention using the Blanchard score.

Let’s say you have a patient with a Blanchard score of 0, as in the case of the JAMA example. Starting with a general 30% pretest probability that your upper GI bleed patient has a severe GI bleed, your post-test probability becomes <1% for a severe GI bleed.

PV Card: Upper GI Bleed

Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

References

Kumar R, Mills A. Gastrointestinal bleeding. Emerg Med Clin North Am. 2011;29(2):239-52, viii. [PubMed]
Srygley F, Gerardo C, Tran T, Fisher D. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072-1079. [PubMed]

By Michelle Lin, MD|2021-10-10T18:50:55-07:00May 18, 2012|ALiEM Cards, Gastrointestinal|

Paucis Verbis: Blunt Abdominal Injury, Likelihood Ratios

This month’s issue of JAMA addresses the question “Does this patient have a blunt intra-abdominal injury?” as part of the always-popular Rational Clinical Examination series.

The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability.

The most predictive positive LR include: Abdominal rebound tenderness, a “seat belt sign”, ED hypotension, hematocrit < 30%, AST or ALT > 130, urine with > 25 RBCs, base deficit < -6 mEq/L, and a positive FAST ultrasound.

The trouble is that the absence of these findings aren’t as helpful in ruling-out injury, with negative LR’s very close to 1.0. The two exceptions are base deficit and FAST ultrasound with a negative LR of 0.12 and 0.26, respectively.

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

I find it interesting that there are studies on hepatic transaminase levels. Anyone else getting these in their trauma patients? I traditionally don’t. Many of our patients have a history of hepatitis C and underlying alcoholic hepatitis. If suspicious for blunt abdominal trauma, we just get the CT.

Reference

Nishijima D, Simel D, Wisner D, Holmes J. Does this adult patient have a blunt intra-abdominal injury? JAMA. 2012;307(14):1517-1527. [PubMed]

By Michelle Lin, MD|2021-10-10T19:02:16-07:00Apr 20, 2012|ALiEM Cards, Gastrointestinal, Trauma|

Paucis Verbis: Diagnostic testing tips for acute abdominal pain

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.

My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.

Reference

Panebianco N, Jahnes K, Mills A. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am. 2011;29(2):175-93, vii. [PubMed]

By Michelle Lin, MD|2021-10-12T16:23:35-07:00Jul 22, 2011|ALiEM Cards, Gastrointestinal, Radiology|

Paucis Verbis: NSAIDS and upper GI bleeds

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.

PV Card: NSAIDs and Upper GI Bleed

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Massó G, Patrignani P, Tacconelli S, García R. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592-1601. [PubMed]

By Michelle Lin, MD|2021-10-12T16:27:37-07:00Jul 15, 2011|ALiEM Cards, Gastrointestinal, Tox & Medications|

Paucis Verbis: Clostridium Difficile

I just finished taking the 2011 LLSA exam to remain eligible for recertification. The only good thing about this test is that it gives me interesting topics for my Paucis Verbis cards.

Here’s a card on a disease process that is becoming increasingly prevalent — Clostridium difficile. This is a summary based on the 2010 guidelines by Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).

Because healthcare workers are often the culprit for transmitting C. difficile to other patients, be sure you wash your hands with soap and water really well. Wear gloves. Be aware that alcohol-based hand rubs (eg. hand sanitizers) are ineffective in killing C. difficile spores.

PV Card: Clostridium Difficile Infection

Reference

Cohen S, Gerding D, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455. [PubMed]

By Michelle Lin, MD|2021-10-13T08:41:07-07:00Jun 24, 2011|ALiEM Cards, Gastrointestinal, Infectious Disease|

Paucis Verbis: Outpatient treatment for diverticulitis

The classic prior teaching for the treatment of diverticulitis includes:

Hospital admission
Bowel rest (NPO)
IV fluids
Broad spectrum IV antibiotics

Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.

This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.

PV Card: Diverticulitis

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Word of caution

This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.

Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.

Reference

Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011;57(6):600-602. doi: 10.1016/j.annemergmed.2010.11.008

By Michelle Lin, MD|2021-10-13T08:49:38-07:00May 27, 2011|ALiEM Cards, Gastrointestinal|

Paucis Verbis: Strength of diagnostic tests for cholecystitis

You have a 40 year-old man who presents to the ED for persistent right upper quadrant abdominal pain for 12 hours after eating a fatty meal. He has no fevers, nausea, flank pain, or dysuria. His physical exam shows no fever and only moderate tenderness in the RUQ without guarding. He has a Murphy’s sign which is improved after a total of 8 mg of IV morphine. His laboratory results, which include a WBC, liver function tests, lipase, and urinalysis, are normal.

Can you safely say that the patient doesn’t have cholecystitis? Can you discharge him for outpatient ultrasonography to assess for symptomatic cholelithiasis?

As bedside ultrasonography becomes more of a staple in Emergency Departments, it is easy to just perform the ultrasound yourself if such a patient presents. If you do not have an ED ultrasound available, however, you need to send this patient for a formal ultrasound because he is still very much at risk for cholecystitis despite having unremarkable lab tests and no fever.

JAMA published a meta-analysis of 17 studies on the test characteristics for cholecystitis. I found it odd that they defined a fever as temperature >35 Celsius. The best performing characteristic was a Murphy’s sign, although the positive likelihood ratio (LR) slightly crossed 1.0 (0.8-8.6).

PV Card: Diagnostic Testing for Cholecystitis

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Trowbridge RL, Rutkowski NK, Shojania KG. Does This Patient Have Acute Cholecystitis? JAMA. 2003;289(1). doi: 10.1001/jama.289.1.80

By Michelle Lin, MD|2021-10-16T19:25:53-07:00Mar 18, 2011|ALiEM Cards, Gastrointestinal|

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