Diseases of the Small Intestine (PEARLS) - Appendicitis, Intussusception, Small bowel obstruction (Smarty PANCE)

What is a positive Rovsing sign?

A positive Rovsing sign is indicative of acute appendicitis, and occurs when a patient experiences severe lower right quadrant abdominal pain upon palpation of the lower left quadrant of the abdomen.

What constitutes a positive obturator sign?

A positive obturator sign, pain on passive flexion and internal rotation of either hip, is indicative of acute appendicitis.

How does a ruptured appendix present?

A ruptured appendix results in peritonitis that presents with guarding and rebound tenderness.

What may be felt on physical examination in intussusception?

A sausage-like mass may be felt on abdominal exam

What additional imaging studies should be ordered?

Abdominal CT scan with contrast in order to identify the potential cause of obstruction. Abdominal ultrasonography may be useful for individuals with contraindications to CT scanning, like those with contrast allergies and pregnant females.

How does acute appendicitis classically present?

Acute appendicitis classically presents with nausea/vomiting, fever, and diffuse periumbilical pain migrating to the McBurney point.

What is the most common cause of acute abdomen?

Acute appendicitis is the most common cause of acute abdomen.

What is the treatment of adults with intussusception?

Adults generally require surgery

What will be seen on abdominal x-ray in intussusception?

An abdominal x-ray will reveal a "Crescent sign" or a "Bull's eye/target sign/coiled spring lesion" representing layers of the intestine within the abdomen

What are complications of SBO?

Complications include dehydration, electrolyte abnormalities, bowel perforation and peritonitis

What type of stool is pathognomonic for intussusception?

Currant jelly stool

What will the bowel sounds be early on in a small bowel obstruction? What will they be later on?

Early they are hyperactive and high pitched. Late they are absent.

What should you suspect if you see free air under the diaphragm?

Free air under the diaphragm means there's perforation, so emergency surgery is needed

What is the initial imaging study performed in those with suspected SBO?

Imaging studies are important, starting with an upright abdominal X ray (KUB)

In addition to clinical signs what imaging study can help make the diagnosis of appendicitis?

In addition to clinical signs a CT scan or ultrasound can help make the diagnosis of appendicitis.

What is used for both the diagnosis and treatment of intussusception in children?

In children, barium or air enema may be both diagnostic and therapeutic. In adults, barium enema should not be used. For adults, barium enema should not be used, and abdominal plain-film radiography shows nonspecific obstruction. CT is the best means of establishing the diagnosis, but many cases are diagnosed only at surgery.

What will be seen on abdominal US in intussusception?

Intussusception has a bull's-eye appearance on ultrasound.

What is intussusception of the bowel?

Intussusception is the invagination of a proximal segment of the bowel into the portion just distal to it.

What is the most common cause of SBO in children?

Intussusception is the most common cause in children

Is intussusception more common in children or adults?

It occurs most commonly in children (95% of cases), generally following a viral infection

What is seen on KUB in small bowel obstruction?

KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon.

What are the late symptoms of intussusception?

Later, as intestinal ischemia develops, pain becomes steady, the child becomes more lethargic, and mucosal hemorrhage causes heme-positive stool on rectal examination and sometimes the spontaneous passage of a currant jelly stool.

What is the treatment of small bowel obstruction?

Most bowel obstructions resolve on their own, so treatment typically focuses on relieving the symptoms. This involves administering intravenous fluids, or nasogastric suction to remove the fluid and gases that have built up. If symptoms don't improve or there's complications such as perforation; then surgery might be needed.

What are mechanical causes of small bowel obstruction (SBO)?

Most small bowel obstructions are caused by adhesions or hernias; other causes include neoplasm, intussusception, foreign body, inflammatory bowel disease, and volvulus

Pain on active hip flexion constitutes what?

Pain on active hip flexion constitutes a positive psoas sign, which is indicative of acute appendicitis.

Pain referral in early appendicitis usually involves what dermatome?

Pain referral in early appendicitis usually involves the T10 dermatome at the level of the umbilicus

What are the functional causes of small bowel obstruction?

Postoperative ileus (transient paralysis of smooth muscle), infection or inflammation, hypothyroidism, electrolyte abnormalities (hypokalemia and hypercalcemia), and medications (i.e. opioids)

How does small bowel obstruction present?

Small bowel obstruction presents with abdominal pain (periumbilical), distention, vomiting of partially digested food, and obstipation. The pain is often described as cramping, and intermittent, with bouts that last for a few minutes at a time.

What is McBurney's point?

The McBurney point is an anatomical landmark located one-third of the distance from the right anterior superior iliac spine to the umbilicus.

What is the best treatment for appendicitis?

The curative treatment of appendicitis is appendectomy.

What are the initial symptoms of intussusception?

The initial symptoms are sudden onset of significant, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. Paroxysmal abdominal pain is the main symptom. The child appears relatively well between episodes or may appear lethargic.

What is the most common cause of intussusception in adults?

The most common cause of intussusception in adults is a tumor

What is the most common cause of small bowel obstruction in adults?

The most common cause of small bowel obstruction in adults is adhesions from previous surgery.

What is the most common known cause of intussusception in children?

The most common known cause of intussusception in children is lymphoid hyperplasia

Where is the most common location for an intussusception?

The most common location for intussusception is at the ileocecal junction

When there's progression from cramping and vague pains to more focal and constant pain what should you expect?

When there's progression from cramping and vague pains to more focal and constant pain it can indicate peritoneal irritation due to a perforation of the intestine.