A 28-year-old woman who is 31 weeks pregnant presents with right lower abdominal pain and vomiting. She has a temperature of 37.8°C, HR 110 and systolic blood pressure of 120. There is tenderness and guarding in the right lower quadrant.
Which ONE of the following statements is TRUE?
Answer: D: Although appendicitis in pregnant patients is the most common abdominal surgical emergency it occurs with equal frequency as it does in the non-pregnant population. Appendiceal rupture, however, occurs more frequently in gravid patients (up to 60% risk in the gravid patient versus up to 20% in the nonpregnant patient) and the risk of perforation is higher in the second and third trimesters. This is most likely due to the enlarging uterus impairing the process of omentum walling off the infection.
The presenting features of appendicitis in a pregnant patient are similar to those of the non-pregnant population with fever, anorexia, nausea, vomiting and right lower quadrant pain. Because nausea and vomiting and leukocytosis can occur with normal pregnancy, diagnosis of appendicitis is frequently delayed.
By a gestation of 20 weeks the appendix starts to become displaced by the expanding uterus. While pain may become less localized, the patient still generally experiences pain in the right lower quadrant. If the patient presents with right flank pain then a retro-caecal appendix, pyelonephritis or renal colic should be suspected.
Laboratory investigations are not helpful in making the diagnosis of appendicitis in a pregnant patient because leukocytosis is frequently seen in normal pregnancies. Radiological imaging can assist in the diagnosis. Ultrasound seems to be as sensitive and specific in the pregnant population and is the investigation of choice. It has 67–100% sensitivity and 83–96% specificity compared with 86% and 96% respectfully in the non-pregnant group. There is no contraindication for MRI; however, it is time consuming and not always readily available.
Pregnancy-specific complications of appendicitis include uterine contractions, miscarriage, premature labour and fetal death. Fetal loss occurs in 1–5% of uncomplicated and up to 30% of complicated cases of appendicitis.
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Which ONE of the following is NOT associated with cholelithiasis?
Answer: D: Gallstones is a common disorder affecting up to 20% of the population. There are two main types of stones: cholesterol stones and pigmented stones.
Cholesterol stones are associated with:
Pigmented stones are associated with:
In haemolytic disorders, such as sickle cell anaemia, β-thalassaemia or hereditary spherocytosis, there is increased unconjugated bilirubin due to the increased breakdown of the red cells. This leads to the formation of calcium biliruninate which can crystallise and form stones. These stones with time develop a black colour and have earned the nickname of black pigment stones.
Biliary infection from any of the organisms mentioned above leads to increased generation of unconjugated bilirubin. This contributes to the formation of the calcium bilirubin salts and stone formation.
A patient who is known to have cholelithiasis presents to the ED.
Which ONE of the following patients does NOT have a complication of gallstones?
Answer: D:
Cholangitis results from extrahepatic bile duct obstruction and bacterial infection. Right upper quadrant pain, fever and jaundice is the classical triad of findings for cholangitis as described by Charcot’s. These features can also be seen in cholecystitis and hepatitis. When signs of hypotension and altered mental state are present it is referred to as Reynold’s pentad. As occurs in cholecystitis, polymorphonuclear leukocytosis is present in patients with cholangitis. However, elevated bilirubin, alkaline phosphatase and transaminases occur more often. A patient with cholangitis generally has a higher fever and appears more unwell than a patient with acute cholecystitis. The presence of jaundice can be used to differentiate between the two as elevated bilirubin is an uncommon feature of acute cholecystits. Ultrasound findings also differ with the presence of dilated common and intrahepatic ducts supporting the diagnosis of cholangitis. The patient should be fluid resuscitated, commenced on broad-spectrum antibiotics and requires prompt surgical consultation.
Patient C has features of SBO secondary to gallstone ileus. This is an uncommon complication and is seen in the elderly population. The gallstone erodes through the gallbladder wall and becomes lodged at the terminal ileum causing obstruction. It is associated with a 15–18% mortality rate.
Patient D has an inferior myocardial infarction until proven otherwise. A patient with an inferior myocardial infarction tends to present with vagal symptoms such as nausea, vomiting, abdominal pain, diaphoresis and bradycardia.
In the investigation and diagnosis of cholecystitis, which ONE of the statements below is the most CORRECT?
Answer: B: Acalculous cholecystitis occurs in approximately 10% of cases. Acalculous cholecystitis is thought to be due to ischaemia. Predisposing factors include:
Acalculous cholecystitis has a more acute course than calculous cholecystitis and has a higher mortality rate.
Ultrasound is the imaging modality of choice. It is highly sensitive, and has a very high negative predictive value for cholecysitits. The positive predictive value for cholecysitis is high when the gallbladder wall is thickened (>3 mm thick) and pericholecystic fluid is seen with the presence of stones in the gallbladder.
CT has 92% sensitivity and 99% specificity so is useful but not as sensitive as ultrasonography for detecting gallbladder stones. It is more useful than ultrasound in detecting stones in the common bile duct.
Laboratory investigations in biliary colic or uncomplicated cholelithiasis are commonly normal; however, in acute cholecystits, polymorphonuclear leukocytosis is seen in two-thirds of patients. Mild elevation of liver transaminases can be seen and occasionally bilirubin and alkaline phosphatase can also be elevated.
Only 10% of stones are visible on plain X-ray.
Recognized complications of pancreatitis include all of the following EXCEPT:
Answer: D: Hypocalcaemia rather than hypercalcaemia is associated with acute pancreatitis. It is one of the Ranson criteria for assessing severity of acute pancreatitis. Hypocalcaemia can result from sequestration of calcium in areas of fat necrosis and also hypoalbuminaemia and hypomagnesaemia which can occur in pancreatitis.
Up to 30% of patients will develop some degree of respiratory complication. ARDS is an uncommon complication of acute pancreatitis but carries a high mortality rate. It is caused by diffuse alveolar damage from inflammatory mediators and results in leaky capillaries. There may also be a reduction in surfactant in patients with pancreatitis. Pleural effusion can occur and is more frequent on the left side.
Other complications of pancreatitis include pseudocyst formation, systemic inflammatory response syndrome (SIRS), shock, coagulopathy, pancreatic oedema or haemorrhage and metabolic complications such as hyperglycaemia, hypocalcaemia and acute tubular necrosis.
Late complications include abscess formation, fistula formation, pseudocyst formation, diabetes and chronic pancreatitis.
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