From the Guidelines
For a patient with suspected appendicitis, the most concerning issue is appendiceal perforation, which can lead to increased morbidity, mortality, and length of stay. The primary concern in appendicitis is the risk of perforation, which can be identified through CT scans by looking for signs such as extraluminal gas, intraluminal fecalith, and wall thickness >3 mm 1.
Diagnostic Approach for Suspected Appendicitis
- Physical examination focusing on right lower quadrant tenderness, rebound pain, and Rovsing's sign
- Laboratory tests including complete blood count to check for leukocytosis and C-reactive protein to assess inflammation
- Imaging studies such as ultrasound or CT scan of the abdomen to confirm appendicitis
Diagnostic Approach for Gastrointestinal Bleeding
- Assess hemodynamic stability immediately
- Establish IV access using two large-bore catheters (18-gauge or larger)
- Laboratory tests including hemoglobin levels, coagulation studies, and type and cross-match for potential blood transfusion
- Upper endoscopy or colonoscopy based on suspected bleeding location
Diagnostic Approach for Esophageal Dysfunction
- Barium swallow studies
- Esophageal manometry to assess motility
- Possibly pH monitoring if reflux is suspected
Diagnostic Approach for Pancreatic Cyst
- Characterization through abdominal imaging such as contrast-enhanced CT or MRI/MRCP to determine size, location, and features suggesting malignancy
- Endoscopic ultrasound with fine-needle aspiration for fluid analysis and cytology, as the presence of high glycogen levels in the cyst fluid may indicate a mucinous cyst 1
The diagnostic approach must be prioritized based on clinical presentation, with appendicitis and active bleeding addressed as potential emergencies before the more chronic conditions of esophageal dysfunction and pancreatic cyst are fully evaluated. In the case of a pancreatic cyst with low amylase and high glycogen levels, the most likely type of cyst is a mucinous cyst.
From the Research
Appendicular Abscess by CT
- The most concern for appendicular abscess by CT is appendiceal perforation, as it can lead to peritonitis and other complications 2, 3, 4.
- Appendiceal perforation is a potential complication of acute appendicitis, and its diagnosis can be challenging due to varying presentations 2.
- CT findings such as appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with a higher risk of treatment failure with an antibiotics-first approach 3.
Diagnostic Steps for Gastrointestinal Bleeding
- For a middle-aged female with a history of severe abdominal pain relieved with morphine and hematemesis, diagnostic steps may include:
- Laboratory tests such as complete blood count (CBC) and bleeding profile to assess for anemia and coagulopathy 3.
- Imaging studies such as abdominal radiograph or CT scan to evaluate for potential sources of bleeding.
- Endoscopy to visualize the upper gastrointestinal tract and identify potential sources of bleeding.
Esophageal Dysfunction
- For a 76-year-old man with chronic dysphagia and retrosternal chest pain, diagnostic steps may include:
- Endoscopy with biopsy to evaluate for esophageal cancer or other mucosal abnormalities 3.
- Esophageal manometry to assess esophageal motility and function.
- 24-hour esophageal acid monitoring to evaluate for gastroesophageal reflux disease (GERD).
Pancreatic Cyst
- For a patient with a pancreatic cyst and aspiration showing fluid low in amylase with high glycogen level, the type of cyst is likely to be:
- Mucinous cyst, as they are known to have high glycogen levels and low amylase levels 3.
- Further diagnostic steps may include:
- Imaging studies such as CT or MRI to evaluate the size and characteristics of the cyst.
- Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) to obtain a cytological diagnosis.