American Family Physician Review-October 1

1. Susana A. Alfonso, MD, MHCM January 20,2011 American Family Physician Review-October 1

2. Differential Diagnosis • Guided by the age and presentation of the pt • V-vascular (ischemic colitis, pelvic vein congestion • I-Infectious-cystitis, pyelo, salpingitis, diverticulitis • N-neoplastic-ovarian, colon ca. teratoma, ovarian cysts • D-drug induced-laxatives • I-inflammatory-ulcerative colitis, vasculities • C-cardiovascular-aortic aneurysm • Atopic/allergic- • T-Traumatic/toxic-envenomination • E-Endocrine-carcinoid

3. Imaging in Left Lower Quadrant Pain • Diverticulosis occurs in 5-10% adults age 45 • 80% of adults aged 80 • Diverticulitis is the most common complication • “itis” occurs in 10-20% • 25% of these are recurrent

4. Clinical Presentation • Older patients • Often with known diverticulosis • Triad of Left lower quadrant pain, fever, and leukocytosis • Imaging useful in LLQ pain of unclear etiology

5. ACR Recommendations • “The ACR Appropriateness Criteria specifies CT as the most appropriate imaging test for patients with acute, severe left lower-quadrant pain with or without fever; for patients with chronic, intermittent, or low-grade left lower-quadrant pain; and for patients who are obese with left lower-quadrant pain.”

6. American College of Radiology Appropriateness Criteria for Left Lower-Quadrant Pain in Older Patients with Suspected Diverticulitis Procedure Rating • Abdominal and pelvic computed tomography, with contrast 8 • Abdominal and pelvic computed tomography, without contrast 6 • Radiography with contrast enema 5 • Abdominal and pelvic magnetic resonance imaging, with or without contrast 4 • Abdominal and pelvic radiography 4 • Abdominal ultrasonography with transabdominal compression 4 • Transrectal or transvaginalultrasonography 4 • *—American College of Radiology rating scale: 1, 2, 3 = usually not appropriate; 4, 5, 6 = may be • appropriate; 7, 8, 9 = usually appropriate. • Adapted with permission from American College of Radiology. ACR Appropriateness Criteria: left lower quadrant pain. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/LeftLowerQuadrantPainDoc8.aspx. Accessed February 24, 2010.

7. CT with contrast • Highly sensitive and specific approaches 100% • Widely available and reproducible • Helps determine extent and severity of disease • Optimized by use of contrast-rectal is faster but less practical

8. Most common findings • Pericolonic fat stranding • Bowel wall thickening • Diverticula

9. Pericolonic fat stranding

10. Pericolonic Rim Enhancing lesion consistent with an abscess

11. Ultrasonography • Evidence suggests not superior over CT • Difficult to perform with graded compression in a pt with abdominal pain • More variation in interpretation • CT better identifies other cause of abdominal pain • PREFERRED in women of childbearing age

12. Rocky Mountain Spotted Fever • Most common rickettsial disease • Mortality of 5-10% • Seasonal- 90% of cases during April-September • South Atlantic and Central States • Transmitted by Rickettsia ricketsii • Natural host is Ixodidae ticks (wood tick in Western US and dog tick in the Eastern US)

13. Natural history of RMSF • Transmission of organism occurs through the tick bite • Causes a vasculitis with increase vascular permeability of all organs especially skin and adrenals • Decreased osmotic pressure, hypoalbuminemia, hyponatremia, hypotension

14. TRIAD RMSF: Fever, HA, Rash

15. Rash of RMSF • Appears AFTER the onset of fever in 80-90% of pts • Begins at wrists and ankles and spreads to palms and soles (40% of pts present classically) • Eventually spreads to extremities and trunk • Usually spares the face

16. RMSF-rash

17. Treatment • Doxycycline is first line • Treatment later than 5 days increases mortality by 3X • Report to Health Department • Hospitalize G6PD

18. Infectious Rashes on Palms and Soles • Syphilis • Enteroviruses (coxsackie and echovirus) • Rocky Mountain Spotted Fever • Scabies (atypical)

19. Necrotizing Fasciitis • Rapidly progressive infection of deep fascia with necrosis of subQ • Mortality of 25-70% (if sepsis) • Risk factors: DM, ETOH, injection drug users, NSAIDS, severe PVD, trauma • Type I: polymicrobial, preceeded by trauma/surgery, strep (not A), bacteroides etc • Type II: single organism, strep (GAS), staph aureus • Most common site: Low. ext. abdomen, perineum

20. Clinical Findings • h/o wound or trauma • Fever and chills • Warmth, erythema, and pain out of proportion to findings • Erythematous skin develops vessicle and bullae • Violaceous bullae, anesthesia, crepitus (35%)

21. Necrotizing Fasciitis

22. Necrotizing Fasciitis

23. Necrotizing Fascitis

24. Treatment • Radiologic studies suggest pyomyositis or gas within soft tissue • Surgical debridement • Broad spectrum antibiotics against gram positive and negative aerobes and aneorobes • Fluids • Hyperbaric oxygen and IV Immunoglobulin controversial

25. Stevens-Johnson/Toxic Epidermal Necrolysis • Acute hypersensitivity reactions • Stevens-Johnson affects <10% BSA • Toxic Epidermal Necrolysis >30% • Winter/early Spring • Ages 20-40 • Male:female 2:1 • Mortality 5-30%

26. Causes • Stevens-Johnson-50% caused by medications • Toxic Epidermal Necrolysis-80% by medications • Sulfa drugs, antiepilepsy, antibiotics • Vaccinations, sunlight exposure, radiation, pregnancy, connective tissue disease, neoplasm

27. Clinical Findings • One-three weeks after exposure • Prodrome-fever, HA, cough conjunctivits • Skin lesions 1-3 days later • Erythematousmacules with dark purpuric centers and bullae • Lesions begin on face and trunk • Almost always involve MUCOSA • Most common sequelae are ocular scarring and blindness

28. Clinical Findings • Bullae coalesce forming flaccid blisters • Full thickness epidermal necrosis • Large areas of sloughing • Painful palms and soles with edema and erythema

29. Stevens-Johnson syndrome

30. Stevens-Johnson syndrome

31. Toxic Epidermal Necrolysis

32. Toxic Epidermal Necrolysis

33. Treatment • Intensive Care or Burn Unit • Supportive Care • Discontinue medication • Antibiotics if infection • IVIG? • Optho consult

34. Hereditary Hemorrhagic Telangiectasia • AKA Osler-Weber-Rendu • 1 in 5000-8000 people • Autosomal dominant with variable penetrance and expressivity • Abnormal blood vessel development manifested as telangiectasias • Telangiectasias and AVM are both direct connections b/n arteries and veins without bridging capillaries

35. Clinical manifestations • Telangiectasis occur on mucocutaneous surfaces (GI tract, nose, skin) • AVM in larger organs-lungs ,liver, brain • Associated with juvenile polyposis and primary pulmonary hypertension • Most common symtoms is epistaxis 90% of pts with range in severity

36. Clinical Manifestations • Suspect in recurrent/unprovoked nosebleeds, skin or mucosal telangiectasias, family hx., • Telangiectasias increase with age-face, chest, hands • Generally develop by age 30 • Blanch with pressure • GI telangiectasias contribute to 30% of pt with HHT have iron deficiency anemia

37. Telangiectasias

38. Clinical Manifestations-AVM • 15-30% of pts with HHT • 70% of pts with AVM have HHT • Creates a right-left shunt which can cause hypoxemia and emboli • Diagnosed with bubble Echocardiography • Confirmed with CT angiography • Important to dx and tx in pregnancy b/c of risk of postpartum hemorrhage

39. Pulmonary AVM

40. Hepatic AVM • 30% of pts with HHT • May lead to portal HTN, high output cardiac failure, biliary disease, hepatic bruit, elevated LFTs • Diagnosed with MRI, CT, or Doppler Ultrasound • Only 5% are symptomatic • No Biopsy

41. Cerebral AVM • 10% of pts with HHT • Headache, seizures, catastrophic bleeding • Diagnosis with MRI

42. Curacao Criteria • Spontaneous, recurrent epistaxis • First degree relative with HHT • Telangiectasias in characteristic sites • Visceral lesions Definite if >3 criteria, possible if 2 and unlikely if <2 criteria are met

43. Screening • Not all genetic mutations are known • If a mutation is found in a family member and other family members tested do not have the mutation then they are considered negative • Children of a parent with HHT who do not meet criteria are considered to have it for screening purposes unless excluded by genetic testing

44. Screening • Transthoracic contrast Echo-repeat 3-5 yrs • Pulse oximetry in young children • MRI with and without contrast in adults and without in children (first 6 months of life) • Cerebral AVMs are thought to be congenital so don’t need repeat testing (maybe once in adulthood) • GI and liver involvement only if symptoms

45. Treatment • Iron replacement • Local measure for epistaxis • Coagulation, dermis grafting, nasal closure if extreme • Pulmonary AVMs treated with coil embolization-PROPHYLAXIS WITH ABX • GI AVMs –endoscopic laser • Hepatic may require transplant

46. Counseling Pts about HRT • EVERYONE used to be on Hormones • Bone health, mental health, cardiac health, vaginal health • 2002 WHI- 16,000 women • Combined HRT (premarin and provera) increased risk of cardiac diseases, CVA, VTE, and breast cancer….YIKES!!! • Decreased risk of colorectal cancer, fractures

47. BUT…the rest of the story • Average age of women 61 YOA • Average age of menopause is 51 • 2004 estrogen only arm results were published • Subsequent post-hoc re-analysis • WHAT SHOULD WE RECOMMEND???

48. Strength of Recommendation Taxonomy (SORT) • A = consistent, good-quality patient-oriented evidence; • B = inconsistent or limited-quality patient-oriented evidence; • C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series

49. Heart Disease • Hormone therapy is not recommended for cardiac protection in women of any age and does not treat existing heart disease. A • Early hormone therapy (at the initiation of menopause) is reasonable for relief of menopausal symptoms in women at low risk of cardiovascular disease. B • Beginning hormone therapy in a woman’s 60s or 70s increases the risk of coronary heart disease; this should be reserved for symptomatic women who cannot tolerate nonhormone medications and who have had a thorough discussion of the risks and benefits with their physician. A

50. Stroke • Combined estrogen and progestogen therapy and estrogen therapy alone increase the risk of ischemic stroke, particularly during the first one to two years after initiation of therapy. A • There does not appear to be an increased risk of stroke in women who begin hormone therapy between 50 and 59 years of age, although information is inconsistent. B