Much Thanks to Elise Lovell, MD who was the guest author of this weeks notes!
1. Trale asked about cecal vs. sigmoid volvulus. The "coffee bean" sign on abdominal Xray is useful for diagnosis in both, but in sigmoid volvulus, the bowel loop usually points to the RUQ, whereas in cecal volvulus, the bowel loop points to the LUQ. See images (look at discussion for hyperlink to additional visuals of cecal):
Attached is a review article on cecal volvulus. Sigmoid volvulus is usually seen in the elderly, especially those with chronic constipation or immobility, and those with neuropsych conditions. Cecal volvulus is less common, and can be seen in younger patients. Cecal volvulus is associated with inadequate right colon fixation during embryogenesis, leading to a mobile cecum. Prior abdominal surgery is an associated cecal volvulus risk factor. Both types of volvulus can be seen in pregnancy. Case reports have associated cecal volvulus with marathon running. Cecal volvulus clinical presentation is highly variable, whereas sigmoid volvulus patients usually present with abdominal pain, nausea, distension, constipation. Management for cecal volvulus = surgical. Management for sigmoid volvulus = reduction using sigmoidoscopy.
2. Beware of new/different headache in the pregnant/post-partum patient. They bleed, they stroke, they get hypertensive and seize. Attached is a nice article on post partum headache. There's a differential diagnosis table, as well as a table with a history driven approach to post-partum headache along with appropriate workup recommendations.
3. Finally, with regards to stab wounds to the anterior abdomen, we've reviewed some of the work of Inaba and Demetriades at USC before. Abstract from most recent big study is below. They advocate selective non-operative management of abdominal GSW as well as abdominal stabs. CT abdomen is recommended for all potentially observable GSW abdomen patients, whereas in abdominal stabs, plain Xrays and serial exams are enough if the patient is stable, no evisceration, no retained implement, no bleeding from other orifice, and no peritonitis. Like Dr. Salzman discussed today, need a low threshold for laparoscopy of left sided thoraco-abdominal penetrating trauma even in stable patients due to concern of left diaphragm injuries.
J Trauma. 2011 Feb;70(2):408-13; discussion 413-4. doi: 10.1097/TA.0b013e31820b5eb7.
Selective nonoperative management of anterior abdominal stab wounds: 1992-2008.
Source
Abstract
BACKGROUND:
The use of selective nonoperative management for anterior abdominal stab wounds has evolved into a readily accepted practice. Multiple reports have shown this strategy to be both safe and effective. However, there is a paucity of long-term studies.
METHODS:
A retrospective review was performed of all trauma patients presenting for anterior abdominal stab wounds at a Level I trauma center during a 17-year time period. Primary outcomes were the percentage of patients undergoing an exploratory laparotomy and the negative laparotomy rate.
RESULTS:
A total of 7,033 patients sustained a stab wound with 1,961 involving the anterior abdomen. The percentage of patients undergoing exploratory laparotomy decreased during the study period from 64.8% to 37.6% (overall 45.8%). The negative laparotomy rate decreased from 21.3% to 8.6% (overall 18.7%). The negative laparotomy rate of patients who underwent exploratory laparotomy immediately did not change over time (13.8%), whereas the negative laparotomy rate of those patients who underwent exploratory laparotomy in a delayed fashion decreased from 25.0% to 6.25%. The overall mortality was 1.9%, with 6.2% mortality for patients undergoing an immediate laparotomy, 0.7% for patients undergoing a delayed laparotomy, and 0.0% for patients managed nonoperatively (p<0.04). The mean length of hospital stay was 6.6 days±0.5 days, with a mean of 9.4 days±0.9 days in patients undergoing an immediate laparotomy, 8.1 days±0.5 days in patients undergo a delayed laparotomy, and 3.8 days±0.2 days in patients managed nonoperatively (p<0.001).
CONCLUSIONS:
Selective nonoperative management for stab wounds to the anterior abdomen is associated with a decreased operative rate and decreased negative laparotomy rate over time. Selective nonoperative management is both safe and effective for anterior abdominal stab wounds.
