Paucis Verbis card: Dysphagia

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 read the figure?

Determine first if patient has oropharyngeal vs esophageal dysphagia.
Determine if mechanical (problem is solid foods only) vs neuromuscular (problem with liquids and solids)is more likely.

Tip:

Medications can cause dysphagia from esophageal mucosal injury or reduced lower esophageal sphincter tone.
CVA is most common cause of oropharyngeal dysphagia

Workup:

Endoscopy
Barium swallow
Consider esophageal pH probe, manometry

PV Card: Dysphagia

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

Reference

Spieker M. Evaluating dysphagia. Am Fam Physician. 2000;61(12):3639-3648. [PubMed]

By Michelle Lin, MD|2021-10-17T09:20:02-07:00Dec 3, 2010|ALiEM Cards, Gastrointestinal|

Trick of the Trade: "Pour some sugar on me" | Reducing a rectal prolapse

Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.

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.

Trick of the Trade: Pour some sugar on it.

Def Leppard may have been right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The prolapse often reduces spontaneously or with gentle manual pressure.

References

Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum. Dec 1992;35(12):1154-6.
Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9.

By Michelle Lin, MD|2021-03-01T09:25:47-08:00Sep 1, 2010|Gastrointestinal, Tricks of the Trade|

Paucis Verbis card: Ascites assessment with paracentesis

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?

This installment of the Paucis Verbis (In a Few Words) e-card series provides an evidence-based review of the literature on topics related to the paracentesis procedure. Especially helpful is the pooled data of likelihood ratios. Like most everything in medicine, a lab test should be used in conjunction with your pretest probability in clinical decision making, and LR’s help with with this.

PV Card: Ascites and Paracentesis

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

Reference

Wilkerson RG, Sinert R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Annals of Emergency Medicine. 2009;54(3):465-468. doi: 10.1016/j.annemergmed.2008.09.005

By Michelle Lin, MD|2021-10-18T10:26:22-07:00Jun 25, 2010|ALiEM Cards, Gastrointestinal|

Paucis Verbis card: Appendicitis – ACEP Clinical Policy

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.

Where does the American College of Emergency Physicians (ACEP) stand on the critical issues surrounding the evaluation of appendicitis?

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the ACEP Clinical Policy on Appendicitis. In the end, the policy conjures up more questions than answers, but a comprehensive presentation of the literature to date and helpful risk-stratification data are provided.

PV Card: ACEP Clinical Policy on Appendicitis

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

Reference

Howell J, Eddy O, Lukens T, et al. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. 2010;55(1):71-116. [PubMed]

By Michelle Lin, MD|2021-10-18T10:28:05-07:00Jun 18, 2010|ALiEM Cards, Gastrointestinal|

Tricks of the Trade: Low tech solutions to esophageal foreign bodies

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.

Trick of the Trade: What did we do?

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.

Teaching point

Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.

Caveat

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.

By Michelle Lin, MD|2016-11-11T19:01:54-08:00Oct 21, 2009|Gastrointestinal, Tricks of the Trade|

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