GI

Tough on Stains... and on Bodies

The Case

 Figure 1: :Laundry Detergent Pod  By  Soulbust  - Own work, CC BY-SA 4.0,

Figure 1: :Laundry Detergent Pod

By Soulbust - Own work, CC BY-SA 4.0,

A previously healthy 12-month-old male was brought to the Emergency Department by his parents 20 minutes after ingesting a laundry detergent pod. The patient’s mother reported finding the child with pieces of the lining of an ALL Mighty Pacs detergent pod in his mouth. She removed the pieces and noted the packet was empty of liquid. At that point, the child started gagging and vomiting “almost immediately.” En route to the ED the patient had 2-3 more episodes of clear emesis. On arrival, he continued to have non-bloody, non-bilious emesis and dry heaves. Vitals were within normal limits with oxygen saturations in the mid 90s. On exam, the child was noted to have a hoarse voice and was mildly somnolent but easily arousable. He was drooling and crying in pain with swallowing, but his oropharynx was otherwise clear. Stridor was noted as well as suprasternal, substernal and supraclavicular retractions. The child was given Zofran, a 20cc/kg fluid bolus and decadron. ENT was consulted for increasing stridor and upper airway symptoms. The patient underwent nasopharyngeal scope at beside and was found to have mild vocal cord edema. He was taken emergently to the OR for definitive airway and bronchoscope. GI was also consulted for endoscopy. 

Findings

In the OR the child was intubated and underwent formal bronchoscopy and endoscopy. Significant findings included:

  1. Watery edema of the supraglottic structures
  2. Mild mucosal changes in the proximal esophagus
  3. Somewhat nodular proximal esophagus with patchy edema and mild sloughing of the mucosa (Fig 1. a, b, c)
  4. Mild patchy sloughing and nodularity distally
  5. One small erosion in the stomach
  6. Normal duodenum
  7. Congenital laryngomalacia and elliptical cricoid consistent with congenital subglottic stenosis

Detergent Pods

Laundry detergent “pods” or “packets” are small, often colorful, dissolvable packs containing concentrated laundry detergent. These laundry capsules have been in Europe since 2001, but were introduced to United States markets in 2010. [1] Laundry pods have been identified as a threat to pediatric patients who are often attracted to the candy-like appearance of the pods. The most common route of toxicity is via ingestion in patients younger than 5 years of age.[2] Recently, however, teenagers have become a significant percentage of the patient population via the “Tide Pod Challenge,” a viral, social-media campaign that dares teens to eat the pods. Detergent pods are often packaged in soft linings that consist of a water-soluble polyvinyl alcohol membrane that easily dissolves when exposed to saliva or moist skin.[3] The liquid mixture inside is usually composed of an anionic and a nonionic detergent as well as a cationic surfactant. All contain irritants and some brands also contain alkaline substances.[4] The alkaline nature of detergent pods can cause inflammation and mucosal destruction in the oropharynx, larynx and esophagus.[5]

Ingestion of detergent pods is associated with more severe symptoms than traditional laundry detergent.[6] One explanation for this is the concentrated nature of the detergent pack and the ingredients, which may include propylene glycol and ethoxylated alcohols.[7] Propylene glycol is found in great proportion in detergent packets than in typical detergent formulations.[8] It is not clear exactly how detergent pods cause injury, but there are several explanations.[9] When ingested, propylene glycol is metabolized by the liver to form lactate, acetate and pyruvate. The increased lactate results in a metabolic acidosis. The drug is excreted in the urine, but at higher doses of propylene glycol the renal tubules ability to secrete the drug is impaired. In children, propylene glycol remains in the blood longer than in adults, which results in more toxic effects, such as renal failure and CNS depression. Another important ingredient in laundry pods is ethoxylated alcohols, which can cause sedative effects. Lethargy is a unique feature of pod ingestion that is not seen with less concentrated detergent formulations.[10]

Ingredient Proposed Effect Clinical Manifestation
Alkalinity Inflammation and damage to oral, laryngeal and esophageal mucosa Hoarse Voice, Dysphagia, Drooling, Stridor, Respiratory Distress
Multiple Noxious response Nausea, vomiting, diarrhea
Propylene glycol Conversion to lactic acid and impaired renal clearance CNS Depression, Metabolic acidosis, Renal insufficiency
Phosphates Caustic Rash, Burns

Management

In the case of any suspected ingestion local poison control should be contacted for advice. Management efforts should initially focus on stabilizing airway, breathing and circulation. If eyes are involved, copious irrigation should begin as soon as possible, as delayed irrigation may be associated with increased morbidity, including burns.[11] Any contaminated clothing should be removed. Activated charcoal, whole bowel irrigation, or gastric lavage is not indicated in the treatment of alkaline ingestions such as detergents.[12] Charcoal and whole bowel irrigation has not been shown to have an effect. Gastric lavage is contraindicated due to risk of perforation and aspiration.[13]

The most important aspects of management are supportive care and symptom control. It is necessary to monitor for respiratory failure and depressed mental status, which may lead to the need for mechanical ventilation. Steroids have been used to mitigate airway edema, but studies have not confirmed their utility.[14] Zofran and other anti-emetics are useful for nausea and vomiting. Fluids should be administered for metabolic derangements or losses secondary to emesis. Endoscopy is important for injury staging and can help to risk stratify patients, however, many complications are delayed. Esophageal stricture is a rare, but possible, long-term sequela.[15]

Case Conclusion

The patient was admitted to the pediatric ICU for further care and management. On hospital day 1 frothy secretions were noted to be draining from his endotracheal tube. He was treated with Lasix for pulmonary edema and had improvement. Decadron was continued for a total of 4 doses of 0.5mg/kg. Feeds were given via NG tube. On hospital day 2 the child underwent repeat endoscopy to monitor for possible progression of mucosal damage. On hospital day 3 he was successfully extubated. Prior to discharge the patient was tolerating a regular pediatric diet with instructions to avoid acidic foods and juices. On hospital day 4 the child was discharged with ENT and GI follow-up. He was instructed to take omeprazole daily for 4-6 weeks

Faculty Reviewer: Dr. Jane Preotle

References

[1] Celentano A, Sesana F, Settimi L, Milanesi G, Assisi F, Bissoli M, Borghini R, Della Puppa T, Dimasi V. Accidental exposures to liquid detergent capsules. SKIN. 2012 May 25;5:0-9.

[2] Stromberg PE, Burt MH, Rose SR, Cumpston KL, Emswiler MP, Wills BK. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. The American journal of emergency medicine. 2015 Mar 1;33(3):349-51.

[3] Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian family physician. 2013 Dec 1;59(12):1295-6.

[4] Fraser L, Wynne D, Clement WA, Davidson M, Kubba H. Liquid detergent capsule ingestion in children: an increasing trend. Archives of disease in childhood. 2012 Aug 1:archdischild-2012.

[5] Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. American Journal of Gastroenterology. 1992 Mar 1;87(3).

[6] Valdez AL, Casavant MJ, Spiller HA, Chounthirath T, Xiang H, Smith GA. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Nov 10:peds-2014.

[7] Beuhler MC, Gala PK, Wolfe HA, Meaney PA, Henretig FM. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatric emergency care. 2013 Jun 1;29(6):743-7.

[8] Shah LW. Ingestion of Laundry Detergent Packets in Children. Critical care nurse. 2016 Aug 1;36(4):70-5.

[9] Huntington S, Heppner J, Vohra R, Mallios R, Geller RJ. Serious adverse effects from single-use detergent sacs: Report from a US statewide poison control system. Clinical toxicology. 2014 Mar 1;52(3):220-5.

[10] Shah LW. Ingestion of Laundry Detergent Packets in Children. Critical care nurse. 2016 Aug 1;36(4):70-5.

[11] Haring RS, Sheffield ID, Frattaroli S. Detergent Pod–Related Eye Injuries Among Preschool-Aged Children. JAMA ophthalmology. 2017 Mar 1;135(3):283-4.

[12] Riordan M, Rylance G, Berry K. Poisoning in children 4: household products, plants, and mushrooms. Archives of disease in childhood. 2002 Nov 1;87(5):403-6.

[13] McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. American family physician. 2009 Mar 1;79(5).

[14] Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. New England Journal of Medicine. 1990 Sep 6;323(10):637-40.

[15] Smith E, Liebelt E, Nogueira J. Laundry detergent pod ingestions: is there a need for endoscopy?. Journal of medical toxicology. 2014 Sep 1;10(3):286-91.

Ultrasound Case of the Month

Case: Submitted by Dr. Sam Goldman

This is an 83-year old woman with a history of prior abdominal surgeries presenting to the ED as a transfer from her SNF with increasing abdominal distention. Patient has not had a bowel movement in four days although endorses passing occasional flatus. She denies emesis though endorses nausea, hiccupping, and burping. She denies any abdominal pain, fevers, chills, dysuria or urinary frequency. 

Diagnosis:

Small Bowel Obstruction

Image was acquired with the curvilinear probe, but any high penetration probe (eg curvilinear of phased array probe) can also be used.  Multiple regions of the abdomen should be interrogated when evaluating for SBO.

What are we looking for with abdominal US for SBO?

When evaluating for an SBO, we are looking for fluid filled small bowel loops >2.5-3cm in width. You maybe more likely to see an increase in intestinal contents (fluid and echogenic materials) and you may see to-and-fro or whirling of the intestinal contents. In more severe cases, you may see bowel wall thickening (greater than 3mm) and free fluid which is extraluminal. pSBO may be more difficult to evaluate with the US machine.   

What do we see in this video?

  • Dilated loops of bowel > 2.5cm measured outer wall to outer wall (most sensitive and specific finding). 
  • Bidirectional flow of bowel contents (to and fro or whirling)
  • Visualization of plicae circularis (“keyboard sign”)

How good is U/S for Detecting SBO?

Ultrasound is superior to abdominal plain films and approaches the sensitivity and specificity of CT scan in many cases. 

Sensitvity Specificity
Abdominal Films 66-77% 50-57%
CT 92% 93%
Ultrasound 88% 96%

Faculty Reviewer: Dr. Kristin Dwyer

References

(Mallo RD, et al. Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review. Journal Gastrointestinal Surgery. 2005. May-Jun;9(5):690-4.)

(Ogtata M, et al. Prospective Evaluation of Abdominal Sonography for the Diagnosis of Small Bowel Obstruction. Annals of Surgery. 1996. 23(3):237-241.) 

Additional resources:

Podcast on US of SBO from www.ultrasoundpodcast.com: Episode 36 - Small Bowel Obstruction - Ultrasound Podcast

Great view of Plicae Circularis (“Keyboard Sign”) from Emory University

POCUS for Appendicitis

Case:

A previously healthy 8 year-old male presents to the ED with two days of abdominal pain, nausea, vomiting and fever. Pain was initially located in the periumbilical area, but has now migrated to the right lower quadrant. On exam, the patient has tenderness to palpation over the right lower quadrant and suprapubic areas. Lab work is notable for a leukocytosis.

Background:

We have all heard this story before. After all, the overall lifetime risk for appendicitis is 6.7 % for females and 8.6 % for males in the USA.[i] Before we start pushing the stretcher towards the operating room, we need some proof though. Despite how common it is, diagnosing appendicitis can be difficult. Symptoms are frequently non-specific and overlap with several other disease processes. However, it is a no-miss diagnosis as complications, including perforation, abscess formation, and peritonitis, can be life threatening. In the ED, our goal is to get patients with appendicitis treated before any complications arise, while trying to avoid sending a patient with a healthy appendix to the OR for removal.

Is this patient is going home or to the OR?

Before sending the patient to radiology, there is another imaging modality to consider, that being the bedside ultrasound.  It is becoming increasingly popular and can be an extremely useful tool in the ER. There are many advantages to using ultrasound to make your diagnosis. For one, ultrasound has no ionizing radiation, making it an optimal choice in young or pregnant patients. Also, ultrasound is more cost-effective and has broader availability than CT or MRI. And remember, there are other structures in the abdomen that you can visualize with ultrasound too. In a patient with abdominal pain of unclear etiology, consider scanning the renal and biliary systems, and consider a pelvic US for females with right lower quadrant pain.

How good is ultrasound for diagnosing acute appendicitis?

In a literature review, there was extremely variable diagnostic accuracy of US with sensitivities ranging from 44 % to 100 % and specificities ranging from 47 % to 99 %.[ii] This gap is due to variation in operator skill, body habitus, bowel gas, and differences in anatomy.  The 2011 Appropriateness Criteria for suspected appendicitis state that in pediatric patients the sensitivity and specificity of graded-compression US can approach that of CT, without the use of ionizing radiation.[iii] Don’t feel bad if you cannot find the appendix at first. In the literature, there is a large range of frequency cited for appendix visualization, and you will get better with experience!

How to find it: 

Set yourself up with the patient supine, pain controlled, relaxed, and have a good view of the ultrasound screen. Start with a high frequency linear transducer. Place the probe in the transverse position in the right upper quadrant and apply deep, graded compression to displace bowel gas.  You should see liver, and large bowel in this location. Large bowel can be identified as a non-peristalsing structure with haustra and the presence of stool, gas or fluid.[iv]

 Figure 1: Normal colon. Photo source:  http://bowel-ultrasound.org/images.html

Figure 1: Normal colon. Photo source:  http://bowel-ultrasound.org/images.html

Trace the large bowel down to the cecum and identify the psoas muscle and the iliac vessels. The appendix can often be seen arising from the cecum, or draped above the iliac vessels just medial to the psoas muscle.

Figure 2: Appendix arising from the cecum. Photo source: http://ultrasoundconnection.com/word-of-the-day-appendicitis/

 Figure 3: Inflamed appendix (arrow) draped over the psoas muscle. Photo source: http://posterng.netkey.at/esr/viewing/index.php? module=viewing_poster&task=viewsection&pi=126056&ti=418256&searchkey=

Figure 3: Inflamed appendix (arrow) draped over the psoas muscle. Photo source: http://posterng.netkey.at/esr/viewing/index.php? module=viewing_poster&task=viewsection&pi=126056&ti=418256&searchkey=

 Figure 4: Photo source: https://www.researchgate.net/profile/Samuel_Stafrace2/publication/256332872/figure/fig3/AS:202764446638091@1425354219309/A-normal-appendix-is-seen-draped-over-the-iliac-vessels-in-a-10-year-old-girl-This-is.png

Figure 4: Photo source: https://www.researchgate.net/profile/Samuel_Stafrace2/publication/256332872/figure/fig3/AS:202764446638091@1425354219309/A-normal-appendix-is-seen-draped-over-the-iliac-vessels-in-a-10-year-old-girl-This-is.png

 Figure 5: Appendix draping over the iliac vessels. Iliac vessels shown using color Doppler 

Figure 5: Appendix draping over the iliac vessels. Iliac vessels shown using color Doppler 

The Normal Appendix:

The appendix can be identified as a tubular, blind ending structure arising from the cecum.  The normal appendix should be empty or filled with gas and fecal material. It should be compressible. Remember, a normal appendix is 8-10 cm in length, but some people can have a 20 cm long appendix! [v]

It is important to visualize the appendix arising from the cecum, as there are many other structures in the right lower quadrant that can mimic the appendix.  Lymph nodes and small bowel are two such examples.  Follow the appendix along its whole length.  This is critical as appendicitis may only affect the tip.  Your exam is not complete until you find that blind end.

 Figure 6: Normal appendix tip. Photo source: http://www.ultrasoundpaedia.com/normal-appendix/

Figure 6: Normal appendix tip. Photo source: http://www.ultrasoundpaedia.com/normal-appendix/

Remember, while the base of the appendix is usually found 2 cm below the ileocecal valve, the tip of the appendix can be located in variable locations.  

 Figure 7: Photo source: http://cephalicvein.com/wp-content/uploads/2016/08/appendix-location-dr-herry-setya-yudhautama-spb-finacs-mhkes-ics-digestive.jpg

Figure 7: Photo source: http://cephalicvein.com/wp-content/uploads/2016/08/appendix-location-dr-herry-setya-yudhautama-spb-finacs-mhkes-ics-digestive.jpg

If you clinically suspect appendicitis and the patient has a normal appendix, comprehensive imaging should follow. Repeating the exam after a few hours increases the sensitivity, so consider sending the patient home with instructions to return tomorrow if he or she is still symptomatic or admitting the patient for observation. Other options are an MRI when radiation protection is a priority (pediatric and pregnant patients) or a CT scan. [vi]

Tips and Tricks: [vii]

  • A technique that can improve visualization of the appendix is the posterior manual compression technique. Use your left hand to press on the posterior aspect of the colon (and use your hand behind the patient to push anteriorly)
  • Try scanning the patient with the right or left side down to move loops of bowel out of the way.
  • If you are having trouble, try again after the patient has an empty bladder.

Abnormal Appendix:

If you suspect appendicitis, you can try having the patient put the probe on the most tender region on his or her abdomen. This will often give away the location of the appendix and is the fastest technique. Perform some graded compression in that region. If you see appendicitis and visualize the entire appendix, you are done! If not, start from the right upper quadrant using the method described above.

Findings supportive of the diagnosis of appendicitis include:

  • A non-compressible appendix
  • An appendix with an outer diameter measuring > 6 mm. Remember, that there are many normal appendixes that are >6 mm, and there are also abnormal appendixes <7 mm
  • Wall thickness of 3 mm or greater
  • Echogenic, inflammatory periappendiceal fat
  • An appendicolith - an echogenic focus with a posterior acoustic shadow
  • Localized tenderness with graded compression
  • Secondary, supporting signs: Free fluid in the RLQ, periappendiceal fluid collection, increased echogenicity of the adjacent fat, or large mesenteric lymph nodes.

Of note, ultrasound has a lower sensitivity for a perforated appendix as the targetoid shape may not be maintained (you may not see the classic tubular structure).  

 Figure 8:&nbsp;Longitudinal and transverse, cross-sectional views of a distended, noncompressible appendix surrounded by hyperechoic/inflamed fat (arrows).&nbsp;Photo source: &nbsp;http://www.radiologyassistant.nl/data/bin/w440/a5097976c13458_inflamed-app.jpg

Figure 8: Longitudinal and transverse, cross-sectional views of a distended, noncompressible appendix surrounded by hyperechoic/inflamed fat (arrows). Photo source:  http://www.radiologyassistant.nl/data/bin/w440/a5097976c13458_inflamed-app.jpg

Figure 9: Ultrasound demonstrating a thickened appendix containing an echogenic, shadowing appendicolith. Photo source: https://images.radiopaedia.org/images/23961/de2254ff0c7343f84778b0451b1924_gallery.jpg

Fake Outs: [viii]

There are a few things that can be misinterpreted as appendicitis on US:

  • Measuring small bowel instead of the appendix!  Once you visualize what you think is the appendix, gently release pressure on the probe and make sure the appendix stays at approximately the same size on the ultrasound screen. If it expands significantly as pressure is released, you are likely getting fooled by small bowel.
  • Mesenteric Adenitis.  Patients with mesenteric adenitis may present with pyrexia and right lower quadrant pain. You will usually see multiple enlarged lymph nodes and a normal appendix in this diagnosis.
  • Ovarian pathology in girls, such as torsion or a hemorrhagic cyst.
  • Hydroureter from renal stones, which can appear tubular in shape and noncompressible.
  • Meckel’s diverticulum. The leftover omphalomesenteric duct can appear as a non-compressible, blind ending structure. This can be confusing, but luckily it is not very common.
  • Terminal ileitis from Crohn’s disease or infections (like Salmonella and Yersinia). On ultrasound, you would see bowel wall thickness <3 mm and you may see other features, such as perienteric fluid or fistulas.

Take Home Points:

  • This is a difficult ultrasound to master. We see appendicitis often. Next time you have a patient with appendicitis, grab the probe and practice. Next time you have a thin patient without appendicitis, grab the probe and practice looking at a normal appendix. Practice makes perfect!
  • Some studies are difficult, especially if the patient is obese. If it takes you more than 5 minutes to identify the appendix, consider thinking about alternative imaging.
  • Remember, there are other structures in the abdomen that you can visualize with ultrasound that may mimic appendicitis. Consider scanning the renal and biliary systems. Consider a pelvic US for females with right lower quadrant pain.
  • Remember, MRI is a great option in kids or pregnant patients!
  • Visual learner? Dr. Adam Sivitz does an awesome how-to video. https://vimeo.com/152378669. Prefer podcasts? Check out www.ultrasoundpodcast.com.

Always try ultrasonography first! Remember, you can always get additional imaging studies to complement your amazing scans, if needed.

Resident Reviewer: Dr. TJ Ye

Faculty Reviewer: Dr. Erika Constantine

References:

[i] Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990 Nov;132(5):910-25.

[ii] Pinto F, Pinto A, Russo A, et al. Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature. Crit Ultrasound J. 2013;5(Suppl 1):S2. doi: 10.1186/2036-7902-5-S1-S2. 

[iii] Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL, Grant TH, Greene FL, Jones B, Katz DS, Lalani T, Miller FH, Small WC, Spottswood S, Sudakoff GS, Tulchinsky M, Warshauer DM, Yee J, Coley BD. ACR Appropriateness Criteria® rightlower quadrant pain--suspected appendicitis. J Am Coll Radiol. 2011 Nov;8(11):749-55. doi: 10.1016/j.jacr.2011.07.010.

[iv] Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in paediatric patients: methodology and pictorial overview of findings seen.Insights into Imaging. 2013;4(6):741-751. doi:10.1007/s13244-013-0275-3.

[v] Park NH, Oh HE, Park HJ, Park JY. Ultrasonography of normal and abnormal appendix in children. World Journal of Radiology. 2011;3(4):85-91. doi:10.4329/wjr.v3.i4.85.

[vi] Mostbeck G, Adam EJ, Nielsen MB, et al. How to diagnose acute appendicitis: ultrasound first. Insights into Imaging. 2016;7(2):255-263. doi:10.1007/s13244-016-0469-6.

[vii] Lee JH, Jeong YK, Park KB, Park JK, Jeong AK, Hwang JC. Operator-dependent techniques for graded compression sonography to detect the appendix and diagnoseacute appendicitis. AJR Am J Roentgenol. 2005 Jan;184(1):91-7.

[viii] Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in paediatric patients: methodology and pictorial overview of findings seen.Insights into Imaging. 2013;4(6):741-751. doi:10.1007/s13244-013-0275-3.