Abdominal Surgery Part I (not including acute abdomen)

Question 1

How does overt vers occult GI bleeding differ in presentation?

Answer 1

Overt GI bleeding is visible in the form of hematemesis, melena, and/or hematochezia, whereas occult GI bleeding typically manifests with nonspecific symptoms due to iron deficiency anemia.

Question 2

Define upper GI bleeding

Answer 2

gastrointestinal bleeding from the esophagus, stomach, or duodenum (proximal to the ligament of Treitz)

Question 3

A degenerative disorder of gastrointestinal blood vessels that consists of abnormal, dilated, and tortuous communications between veins and capillaries. May be asymptomatic or lead to upper or lower gastrointestinal bleeding.

Answer 3

Angiodysplasia

Question 4

Gastric mucosal changes including friability and dilated blood vessels that result from portal hypertension. These changes appear as a mosaic or “snake-skin” pattern on endoscopic evaluation. 10-20% of patients may develop acute or chronic bleeding.

Answer 4

Portal hypertensive gastropathy

Question 5

vomiting blood, which can vary in color from bright red to brown and may resemble coffee grounds, depending on the cause

Answer 5

Hematemesis

Question 6

Hematemesis is often caused by what kind of GI bleed?

Answer 6

Most commonly caused by UGIB

Question 7

black, tarry stool with a strong offensive odor

Answer 7

Melena

Question 8

Melena is often caused by what kind of GI bleed?

Answer 8

Most commonly caused by UGIB

Question 9

passage of blood through the anus with or without stool

Answer 9

Hematochezia

Question 10

Hematochezia is often caused by

Answer 10

Most commonly caused by LGIB

Question 11

Maroon, jellylike traces of blood in stool indicate ___________ bleeding.

Answer 11

colonic

Question 12

Streaks of fresh blood on stool indicate ___________ bleeding.

Answer 12

rectal

Question 13

Perforation of a ______________ ulcer is the most common cause of perforation peritonitis.

Answer 13

duodenal

Question 14

____________ is the preferred imaging modality to confirm the presence of free air within the peritoneal cavity (pneumoperitoneum) and localize the site of the perforated viscus.

Answer 14

CT abdomen with IV contrast

Question 15

_____________________________ is a bacterial infection of ascitic fluid that occurs in the absence of an identifiable intraabdominal source of infection. It is the most common bacterial infection and a leading cause of hospital admission and mortality among patients with cirrhosis.

Answer 15

Spontaneous bacterial peritonitis (SBP)

Question 16

Spontaneous bacterial peritonitis (SBP) is often associated with what pathogens?

Answer 16

Enteric gram-negative bacteria (e.g., E. coli, Klebsiella spp.) have historically been the most common isolates; however, gram-positive, fluoroquinolone-resistant, and multidrug-resistant bacteria are increasingly common.

Summ:
Gram-negative enteric bacteria (e.g., Escherichia coli, Klebsiella spp.)

Gram-positive bacteria (e.g., Streptococcus spp., Staphylococcus spp., Enterococcus spp.)

Question 17

Diagnosis of spontaneous bacterial peritonitis is based on…

Answer 17

Diagnosis is based on the finding of elevated ascitic fluid neutrophil count (≥ 250/mm3) without an intraabdominal surgically-treatable source of infection.

Question 18

Risk factors for Spontaneous bacterial peritonitis

Answer 18

cirrhosis and ascites

Question 19

What abx will we consider for spontaneous bacterial peritonitis in a patient with Community-acquired infection AND no recent exposure to broad-spectrum antibiotics ?

Answer 19

First-line: 3rd-generation cephalosporin IV, preferably cefotaxime [2][11][23]
Alternative: oral ofloxacin

Question 20

What abx will we consider for spontaneous bacterial peritonitis in a patient with Healthcare-associated infection,
suspected resistant pathogen,
AND/OR recent exposure to broad-spectrum antibiotics?

Answer 20

First-line: piperacillin/tazobactam
PLUS one of the following:
Daptomycin if known previous VRE infection or colonization
Vancomycin if known previous MRSA infection or colonization [25]

Alternative for patients with current or recent exposure to piperacillin/tazobactam: meropenem PLUS vancomycin
Consider local resistance patterns and consult infectious diseases for further guidance.

Question 21

Tarry bowel movements and abdominal pain are consistent with upper GI bleeding (UGIB), likely arising as a complication of peptic ulcer disease (PUD) from NSAID use. Hypotension and tachycardia indicate the development of hypovolemic shock. What is the most appropriate next step in management after inital exam?

Answer 21

Esophagogastroduodenoscopy (EGD) is the preferred next step in the management of UGIB as it allows for bleeding source identification and hemostatic interventions (e.g., cauterization, epinephrine injection). In the case of severe hemorrhaging secondary to PUD, intravenous proton pump inhibitors and blood transfusions can be considered.

Question 22

Tarry bowel movements and abdominal pain are consistent with upper GI bleeding (UGIB), likely arising as a complication of peptic ulcer disease (PUD) from NSAID use. Esophagogastroduodenoscopy shows no abnormalities.
Next step?

Answer 22

Because the esophagogastroduodenoscopy did not find a hemorrhage in the upper GI tract, the next step in the management of this patient is a colonoscopy to evaluate the lower GI tract. Should the colonoscopy also be normal, the small bowel needs to be examined (e.g., via push enteroscopy, push-and-pull enteroscopy, capsule endoscopy).

Question 23

What imaging modality/approach do we use to assess melena?

Answer 23

In the context of UGIB, we start with
EGD
nothing on EGD then COlonoscopy
nothing on colonoscopy then enteroscopy

Question 24

Next step?

Answer 24

Ex lap and peritoneal lavage

Question 25

A pt with suspected lower GI bleed continues to bleed and remains hemodynamically unstable even after fluid resuscitation. Urgent intervention is required to reliably localize and stop the hemorrhage. What do we do? He had a normal EGD.

Answer 25

Angiography

Question 26

What is the serum-ascites albumin gradient?

Answer 26

The difference between albumin concentration in ascitic fluid and albumin concentration in the serum. A SAAG >1.1 g/dL indicates that portal hypertension is the likely underlying cause of ascites.

Question 27

What SAAG indicates that portal hypertension is likely the cause of ascites?

Answer 27

The difference between albumin concentration in ascitic fluid and albumin concentration in the serum. A SAAG >1.1 g/dL indicates that portal hypertension is the likely underlying cause of ascites.

Question 28

A patient comes in with a SAAG greater than 1.1, fever, abdominal pain, and a peritoneal leukocyte count of 1900/mm3. What is the likely etiology for his presentation?

Answer 28

Bacterial translocation as in Spontaneous bacterial peritonitis. This condition occurs most commonly in patients with portal hypertension and resulting ascites secondary to advanced liver cirrhosis.

Question 29

In patients with ESRD (end stage renal disease), ∼ 30% of cases of lower GI bleeding are due to __________________-

Answer 29

angiodysplasia.

A degenerative disorder of gastrointestinal blood vessels that consists of abnormal, dilated, and tortuous communications between veins and capillaries. May be asymptomatic or lead to upper or lower gastrointestinal bleeding. ‘arteriovenous malformation’

Question 30

What is retroperitoneal?

Answer 30

Esophagus, adrenals, kidneys, most of the duodenum, pancreas, aorta, ascending and descending colon, IVC, ureters, rectum

Question 31

In the setting of blunt abdominal trauma and damage to the retroperitoneal organs, how can you tell the difference in injury to the duodenum versus the pancreas?

Answer 31

Damage to the duodenum results in AIR in the retroperitoneal space versus FLUID in the space