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Surgery Clerkship > Acute Care Surgery > Flashcards

Acute Care Surgery Flashcards

1
Q

What is the differential for groin masses?

A 
MINT:
Malformation: hernia, testicular stuff
Infectious/Inflammatory
Neoplastic
Traumatic
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2
Q

What to think: groin mass that protrudes with standing?

A

Hernia

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3
Q

What is a hernia?

A

Protrusion of tissue or organs through a defect, usually in the abdominal wall

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4
Q

What is the difference between a reducible, incarcerated and a strangulated hernia?

A

Reducible: contents in the sac can be pushed back through the defect into the peritoneal cavity
Incarcerated: contents are stuck in hernia sack
Strangulated: Compromised blood flow to the herniated organ

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5
Q

What clues on history and PE point to incarcerated hernia progression to strangulated? Why?

A
  • Fever, tachycardia, elevated WBC, plus redness of overlying skin
  • Due to blood flow compromise, irreversible ischemia and necrosis
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6
Q

What is the pathophys of a direct inguinal hernia?

A

Acquired weakness in the abdominal wall, usually due to chronic straining

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7
Q

What is the pathophys of an indirect inguinal hernia?

A

Congenital: usually due to a patent processes vaginalis

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8
Q

What is the pathophys of a femoral hernia?

A

Multiple pregnancies dilate femoral veins and widen the femoral canal

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9
Q

Which rings do indirect inguinal hernias traverse?

A

deep and superficial

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10
Q

Which rings do direct inguinal hernias traverse?

A

superficial

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11
Q

Why are femoral hernias more prone to incarceration?

A

femoral ring is very rigid and unyielding

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12
Q

What is a Richter’s Hernia?

A
  • Only part of the circumference of the bowel wall is trapped within the hernia sac
  • Herniated segment can become strangulated and result in ischemic changes
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13
Q

What is a sliding hernia?

A

Indirect hernia: retroperitoneal organ typically slides with the sac and essentially makes up the posterior wall of the sac

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14
Q

How to diagnose a hernia?

A

Clinically: history and physical. Patient stands, clinician inserts finger at level of external ring. If patient coughs and a bulge is palpated, a hernia is present.

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15
Q

When do we use imaging to confirm a hernia?

A

CT in an obese patient, or with a Spigelian hernia since they lie between 2 layers of bowel wall and are difficult to palpate

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16
Q

How to treat an asymptomatic hernia?

A
  • Observe! Except: femoral hernias or inguinal hernias in infancy (wait until premie out of ICU)
  • Eventually will become symptomatic and need repair
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17
Q

How to treat indirect hernia?

A

Open the sac anteriorly, reduce any contents and perform a high ligation at the internal ring of the hernia sac

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18
Q

How to treat a direct hernia?

A

Do not open the sac (no patent processus vaginalis) and reinforce floor with mesh

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19
Q

How to treat a femoral hernia?

A
  • Emergently!
  • Medial to the femoral vein and inferior to the inguinal ligament
  • High incarceration risk
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20
Q

What do we do for incarcerated hernia?

A

Attempt reduction, then repair semi-electively

21
Q

What do we do for strangulated hernia?

A

Urgent surgery. Do not try to reduce - necrosis of bowel will cause peritonitis

22
Q

How do we treat an umbilical hernia?

A 
Usually corrects on its own
Repair it if:
- Persists > age 4
- Defect > 2cm
- Progressive enlargement after age 2
23
Q

What are complications of hernia repair?

A
  • Nerve injury due to transection, stretching, cauterization or entrapment of sutures or by scar tissue around the mesh
  • Testicular ischemia: swollen painful testicle after surgery due to venous drainage in spermatic cord being cut
  • Recurrence
24
Q

What is the significance of SBO in the absence of an abdominal scar?

A
  • Removes most common benign etiology of SBO

- less likely to resolve with conservative treatment, may need emergency surgery

25
Q

What is the most common cause of SBO worldwide?

A

Hernias

26
Q

What is the Howship-Romberg sign?

A
  • Pain in the medial thigh with abduction, extension or hip internal rotation
  • Due to compression of obturator nerve by obturator hernia
27
Q

What is the significance of severe abdominal pain and localized tenderness in association with an SBO?

A
  • Suggests strangulated SBO - vascular perfusion is impaired leading to intestinal ischemia and necrosis
  • Surgical intervention needed
28
Q

What are the 4 cardinal signs of strangulated bowel?

A

Fever
Tachycardia
Leukocytosis
Localized abdominal tenderness

29
Q

What is a closed loop obstruction?

A
  • Segment of intestine obstructed proximally and distally
  • Gas and fluid accumulate in segment and cannot escape
  • Causes rapid strangulation with ischemia and perforation
30
Q

What are the most common causes of an SBO

A
  • Intra abdominal adhesions due to prior abdominal surgery
  • Hernia
  • Gallstone ileus: gallstone at ileocecal valve
  • Crohn’s
  • Intususception
  • Neoplasm
  • Volvulus
31
Q

What are the common causes of adhesions leading to SBO?

A
  1. Surgery: appendectomy, colorectal resection, gyn procedures
  2. Inflammatory: appendicitis, diverticulitis
32
Q

What are the mechanisms of fluid loss in SBO?

A
  • Repeated emesis
  • Refusal of oral intake
  • Transudative loss into peritoneal cavity
  • THIRD SPACING: Stasis in lumen: bacterial overgrowth –> increased hydrostatic pressure –> fluid accumulates in bowel wall and starling forces change: net filtration of fluid, electrolytes and protein into bowel wall and lumen
33
Q

What labs to get when working up SBO? Why do they matter?

A

CBC
Chemistry panel
Serum lactate
Need to assess dehydration, possibility of bowel ischemia or compromise

34
Q

What imaging is recommended for SBO?

A
  1. Abdominal series

2. CT abdomen and pelvis with oral and IV contrast

35
Q

How to tell small bowel vs. large bowel on X-ray?

A

Small: plica circulates all the way through the bowel
Large: hausfrau only halfway through the bowel

36
Q

What do we see on abdominal series for SBO?

A
  1. Dilated loops of small intestine
  2. Air-fluid levels
  3. Bowel stacking
37
Q

How is complete SBO different than partial SBO?

A

Complete: intestinal lumen entirely occluded: no passage of gas or fluid
Partial: gas and fluid are able to pass

38
Q

How are symptoms of complete and partial SBO different?

A

Complete: colicky ab pain, N/V/obstipation
Partial: similar symptoms but develop more slowly, and continue to pass gas and stool beyond 12 hours after symptom onset

39
Q

Why is it important to distinguish between complete and partial SBO?

A

Partial: low risk of strangulation. Can manage non-op
Complete: substantial risk of strangulation, may require surgical intervention

40
Q

How to distinguish between small and large bowel obstruction?

A

Depends on etiology and location. Proximal colon more likely to be mistaken since luminal contents similar to SB.
LBO: gradually increasing abdominal pain, progressive dissension, constipation and occasional feculent vomiting. Longer intervals between pain and pain in suprapubic area

41
Q

What are common causes of LBO?

A

Colon cancer: apple core
diverticulitis
volvulus: bird beak to LLQ

42
Q

How to distinguish between postoperative ileus and SBO?

A

CT

43
Q

What are complications/sequelae of SBO?

A

Emesis and third spacing: dehydration, pre renal azotemia and hypochloremic hypokalemic metabolic acidosis

44
Q

What are initial management steps of an SO?

A
  1. Aggressive fluid resuscitation
  2. Place NG tube to evacuate air and fluid
  3. Electrolyte repletion
45
Q

How do we treat complete SBO?

A
  • Manage conservatively for 12-24 hours

- If no clinical improvement: surgical intervention

46
Q

When is it appropriate to proceed to OR with SBO?

A

Signs or symptoms of peritonitis or bowel ischemia

47
Q

What to do if you suspect nonviable bowel during laparotomy for SBO?

A

Bowel resection

48
Q

What is the management of early postoperative SBO?

A

Avoid re-operation on early post-op SBO unless clear evidence of peritonitis or bowel compromise

Surgery Clerkship (16 decks)

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