NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Case Variation 8.14.6. Tenderness of adnexa on the right side ◆ ◆ This finding tends to confirm pelvic inflammatory disease, possibly with a tubo-ovarian abscess and should also prompt gynecologic consultation. Case Variation 8.14.7. Cervical discharge This finding tends to confirm pelvic inflammatory disease. It is necessary to stain for gonococcus and obtain gynecologic consultation. Case Variation 8.14.8. Other family members at home with gastroenteritis ◆ ◆ It is probable that this patient has been in contact with family members who have gastro- enteritis. Although the patient could still have appendicitis, gastroenteritis is much more likely, and the patient should receive treatment for this latter condition. Case Variation 8.14.9. Voiding symptoms in a 65-year-old man ◆ ◆ This patient may have bladder outlet obstruction and a large, distended bladder. With care- ful physical examination, percussion of the distended bladder may be possible. Treatment involves insertion of a Foley catheter, and reexamination. Case Variation 8.14.10. Family history of inflammatory bowel disease (IBD) ◆ ◆ The presentation of IBD, which is sometimes familial, may be similar to appendicitis. With suspected IBD, further studies may be appropriate before exploration takes place. CT may show a thickened loop of bowel or enlarged nodes in the terminal ileum. With certain IBD, exploration is not necessary. It is appropriate to establish the diagnosis with colonoscopy. Initial treatment involves antiinflammatory medication and immunomodulation. It is pru- dent to remember that appendicitis may develop even in patients with established IBD. The addition of steroids to a missed appendicitis will surely create complications and delay or obscure the correct diagnosis of appendicitis. ◆ ◆ Exploration of a patient with suspected appendicitis may reveal a normal appendix and establish the diagnosis of IBD (terminal ileitis). Gross findings such as an inflamed ileum, fat wrapping of the intestine, a thickened wall, and enlarged nodes are the basis of diagnosis of IBD. Because of the risk of anastomotic breakdown and GI fistula, most surgeons would not biopsy the bowel. It is possible to biopsy a local node, and if granulomas are present, make the diagnosis, but this is not necessary. Most surgeons remove the appendix if it is not involved with the inflammatory process but leave it in place if the cecum is inflamed; removal eliminates the possibility of a future diagnosis of appendicitis. Case Variation 8.14.11. Two-month history of crampy pain and diarrhea ◆ ◆ It is necessary to consider a cause other than appendicitis to account for this problem. IBD, constipation, and carcinoma are all possible diagnoses. A more complete workup with im- aging and colonoscopy should be considered. ◆ ◆ When an appendix is retrocecal or deeper in the pelvis, it may not cause localized pain in the anterior abdominal wall because it is not in contact with the parietal peritoneum. Tenderness on rectal examination may be the best clue to localize this problem; US or CT can diagnosis appendicitis, in which case the patient should go to the operating room. SAMPLE Case Variation 8.14.12. Marked tenderness in the right pelvis on rectal examination