In the above figure, we see valvulae conniventes,which are folds of the
small bowel that cross the entire width of the bowel. (e)Neither the clini-
cal scenario nor the plain film is consistent with inflammatory bowel dis-
ease. Most patients with inflammatory bowel disease are younger.
107.The answer is a.(Rosen, pp 1293-1295.)The test is the Obturator
sign,in which the patient is supine with the right thigh flexed; passive
internal or external rotation of the hip eliciting pain is a positive test for
appendicitis.The pain is attributed to an inflamed appendix that is irri-
tated by stretching the obturator internus muscle.
(b)The psoas sign for appendicitis is tested by having the patient lie
on his or her left side; pain caused by passive right hip extension is a posi-
tive result. (c)Rovsing sign refers to pain in the RLQ elicited by palpation
in the LLQ. (d)McBurney point is the classic location of maximum ten-
derness to palpation in the RLQ, one-third the distance from the anterior
superior iliac crest to the umbilicus. It is common in patients with an ante-
rior appendix. (e)Murphy sign refers to pain causing cessation of respira-
tion during palpation of the RUQ and is seen in acute cholecystitis.
108.The answer is b.(Tintinalli, pp 584-585.)Although there are no stud-
ies stating how long it takes for a tract to mature, tracts that are 7 to 10 days
old probably will remain open long enough to allow replacement. Insertion
of a new tube should be performed with water-soluble lubricant. If resistance
is met, the attempt should be aborted. After replacing the tube, 20- to 30-mL
bolus of water soluble contrastmaterial should be instilled into the tube,
and a supine abdominal radiographshould demonstrate rugae of the stom-
ach. If there is any question of improper placement, immediate consultation
should be obtained.
(a)Aspiration of gastric contents does not confirm proper placement
of a G-tube. The intragastric location of a replaced tube should be con-
firmed by a contrast study before feedings. Many patients have received
intraperitoneal feedings in the absence of such a confirmatory test. (c)If
the tract is open, a tube should be replaced; otherwise observation would
be appropriate until a new tube could be arranged. (d)A CT scan may be
helpful to determine if the tube is out, but once it is, clinical signs would
be sufficient to evaluate for intraperitoneal soilage. (e)Surgical G-tubes
generally involve anchoring the stomach to the anterior abdominal wall.
Contamination is unlikely and the tube tract will be patent for a short time.
There is no immediate indication for surgery.
120 Emergency Medicine