M&M - Dr. Bronner

Case 1 -    Post-Operative Pneumoperitoneum and Perforated Marginal Ulcer After Roux-en-Y

1. Pneumoperitoneum, or "Free air"
   
1. 90% of the time this is perforated viscous until proven otherwise!
   
2. CT far more sensitive in detecting than plain films.
   
3. ONLY CONSIDER NON-SURGICAL IF:
   
1. No fever
   
2. No Abdominal Pain
   
3. No Leukocytosis
   
4. No Peritonitis
   
   
4. For the other 10%:
   
1. MOST COMMON cause is Post-Surgical Pneumoperitoneum (PP)
   
1. Will be present in 44% of post-op patients in 3 days
   
2. 30% on days 4-18
   
3. Should be resolved in all patients in 18 days
   
4. Drains increase PP rate more than double (52% vs 21%)
   
2. Other causes:
   
1. Pseudopneumoperitoneum - Radiographic Artifact
   
2. Thoracic sources - CPR, PTX, Mechanical Ventilation
   
3. Gyn sources - Procedures, Vaginal Insufflation
   
4. Misc - Cocaine, SCUBA, Idiopathic
   
   
2. Complications of Bariatric Surgery  (i.e. CALL BLUE SURGERY EARLY!!!)
   
1. Understand major types and their complications
   
1. Review Articles worth your time:
   
1. Campanile FC, Boru CE, Rizzello M, Puzziello A, Copaescu C, Cavallaro G, Silecchia G. Acute complications after laparoscopic bariatric procedures: an update for the general surgeon.
   
2. Langenbecks Arch Surg. 2013;398:669-686.Edwards ED, Jacob BP, Gagner M, Pomp A. Presentation and Management of Common Post-Weight Loss Surgery Problems in the Emergency Department. Ann Emerg Med. 2006;47:160-166.
   
2. Can be found here! (click link!)
   
3. Gibbs Bonus factoid! -- Gastric banding on xray -
   
1. 45 degree rectangle = normal
   
2. Horizontal = band migration and needs deflation
   
   

Case 2 - Complications of Chronic Suppurative Otitis Media (CSOM)

1. Ruptured TM from Otitis - Quinolone drops are initial therapy, no aminoglycocides (ototoxic)
   
2. TM rupture over 6 weeks = ENT Consult!
   
3. CSOM with mastoid tenderness - CT brain +/- temporal bone
   
1. Also be VERY CONCERNED if fever, AMS, N/V, focal neuro deficits
   
4. Intratemporal and Intracranial Infections need IV Ab
   
1. Cover for Staph (incl MRSA), Pseudomonas, Hemophilus PLUS Enteric bugs via eustachian tubes
   
2. FIRST LINE OPTION:  Cefepime, Flagyl, Vanc, +/- otic quinolone
   
5. Great review of the badness transmitted through the temporal bones found here!
   
1. Smith JA, Danner CJ. Complications of Chronic Otitis Media and Cholesteatoma. Otolaryngol Clin N Am. 2006;39:1237-1255.
   
6. ADDITIONAL DISCUSSION POINTS:
   
1. LP without CT is safe (NEJM 2001, 345: 1727-33)
   
1. No Papilledema
   
2. Age < 60
   
3. No immmunocompromised
   
4. No hx of CNS disease
   
5. No seizure within 1 week
   
6. Physical Exam - normal, non focal with normal mental status
   
2. When not to do LP on CT findings
   
1. Midline shift
   
2. Obstructive hydrocephalus
   
3. Basilar cistern compression
   
4. Posterior fossa mass (displacement or compression of 4th ventricle)
   
3. Gibbs factoid - Herniation after LP is likely Urban Legend
   

Case 3 - Acetabular Protrusio

Important Radiographic Signs to Identify on AP Pelvis/Hip

        Ilioischial Line (Kohler's Line)

1. Straight Line along medial border of Ilium through Ischium (Inf Pubic Ramus)
2. If femoral head bulges inside of this line = acetabular disruption        

        Center Edge Angle of Wiberg

1. Find center of femoral head
   
2. Draw vertical line from this point
   
3. Draw second line from this point to roof of acetabulum
   
1. 20-40 degrees = Normal
   
2. <20 degrees = Suspect Developmental Hip Dysplasia
   
3. >40 degrees = Acetabular Protrusion