Blue Boxes IV Flashcards
guarding
Involuntary contraction of anterior abdominal muscles.
Occurs with cold hands or organ inflammation (acute abdomen) in order to protect viscera from pressure.
Injury to inferior thoracic spinal nerves (T7-T12) and iliohypogastric/ilioinguinal nerves (L1)
Supply motor innervation to rectus abdominis and oblique muscles in their dermatomal distributions.
If damaged during incision, will weaken muscles and predispose patient to inguinal hernias.
Incisions should follow Langer Lines to ensure proper healing.
median incision
longitudinal incision along linea alba from xiphoid process to pubic symphysis.
No neurovascular damage unless well vascularized fat is exposed.
Misalignment of linea alba on closure may lead to necrosis and degeneration.
paramedian incision
muscle retracted laterally to protect neurovasculature above posterior rectus sheath
gridiron incision
oblique incision often used for appendectomy (splits muscle)
McBurney Incision
cuts external oblique aponeurosis in direction of its fibers for retraction to reveal internal oblique/transversus abdominis muscles for splitting/retraction
Iliohypogastric n. must be preserved. If done properly, will damage no musculoaponeurotic fibers
suprapubic incision (pfannenstiel)
horizontal incision above pubic symphysis.
Used for OB operations
transverse incision
Not made through tendinous rectus abdominis intersections to avoid cutaneous nerves and branches of superior epigastric artery
subcostal incision
used on RIGHT to access gallbladder/biliary ducts
used on LEFT to access spleen.
pararectus/inguinal incisions
High risk.
Along lateral border of rectus sheath or inguinal ligament.
May damage nerve supply to rectus abdominis or ilioinguinal nerve.
incisional hernia
omental or visceral herniation thru a surgical incision that has failed to heal
direct inguinal hernias
Protrusion of parietal peritoneum and viscera.
Acquired herniation MEDIAL to inferior epigastric vessels.
Pushes through peritoneum and transversus fascia and into the inguinal canal Exits through the superficial inguinal ring.
Parallel and lateral to spermatic cord.
Distinguished from indirect by palpating an impulse on coughing in the inguinal canal and medial to the epigastric vessels, inguinal ligament, and rectus abdominis muscles.
indirect inguinal hernia
Protrusion of parietal peritoneum and viscera.
Congenital herniation of persistent processus vaginalis.
Passes LATERAL to inferior epigastric vessels.
Pushes thru deep inguinal ring, out to superficial inguinal ring, WITHIN the spermatic cord, and superior to the testes.
cremasteric reflex
Supplied by ilioinguinal nerve (L1).
Seen as a rapid testicular elevation.
Caused by a light stroke on medial, superior aspect of inner thigh.
Hyperactive in children, stimulating undescended testes.
cancer of testis/scrotum
Common lymphogenous metastasis.
Testes descend from posterior abdominal wall to scrotum during development, providing separate lymphatic drainage from scrotum.
testicular cancer
initial metastasis to retroperitoneal lumbar lymph nodes inferior to renal veins.
Then to mediastinal/supraclavicular nodes.
May also exhibit hematogenous spread.
scrotal cancer
initial metastasis to superficial inguinal lymph nodes sitting superior to inguinal ligament along great saphenous vein.
peritonitis
Inflammation of peritoneum.
Due to infection in the peritoneal cavity.
Causes exudation of serum, fibrin, and pus.
Referred pain to overlying skin, and guarding occurs.
If allowed to become generalized, (or spread throughout cavity), it may be lethal due to rapid absorption of material by the viscera.
ascites
General peritonitis may occur with ulceration of stomach or duodenum, spilling acidic chyme into the peritoneal cavity, known as ascitic fluid.
May also be caused by internal bleeding, portal hypertension causing transudation, starvation (decreased plasma proteins causing decreased plasma oncotic pressure and edema, distending the abdomen).
May cause paradoxical abdominothoracic rhythm (abdomen drawn in with inspiration), shallow/rapid breathing, and shifting dullness.
Ascitic fluid or free cancer cells will flow into paracolic gutters at the lateral abdominal edges, spreading intraperitoneal infections into the pelvis, especially when upright.
May also spread up gutters from pelvis to subphrenic recess when supine.
fluid in omental bursa
Perforation of posterior stomach wall or pancreatic inflammation can leak fluid into omental bursa forming a pseudo-cyst
esophageal varices
Inferior esophageal veins drain to both portal and systemic venous systems, forming portosystemic anastamoses.
With portal hypertension, blood flow reverses, from portal vein through submucosal esophageal veins (to azygous v) enlarging them.
Risk of rupture and severe hemorrhage.
hepatopancreatic ampulla blockage
Common bile duct and pancreatic duct join at hepatopancreatic ampulla (of Vater) to enter duodenum via sphincter of Oddi (major duodenal papilla)
May be occluded by descending gallstone causing bile backup in both ducts (or reflex caused by sphincter spasms), causing pancreatitis.
Pancreatic duct has its own pancreatic duct sphincter to prevent reflux, but is easily overwhelmed with blockage.
Accessory pancreatic duct (if present) provides a collateral through which the blockage and pressure may release.
liver cirrhosis
Progressive destruction of hepatocytes with fibrous tissue replacement due to toxin exposure.
Alcoholic cirrhosis causes hepatomegaly, portal hypertension, hobnail appearance.
Portosystemic/portocaval shunts from portal venous system to IVC or left renal vein allows reduction of portal hypertension.
cholelithiasis
Gallstones.
Concretion of cholesterol crystals in gallbladder, cystic or bile duct.
More common in females.
Asymptomatic unless stone is large enough to cause injury or obstruct biliary tract. Could lead to jaundice if bile backs up and goes into bloodstream.
cholecystitis
Gall bladder inflammation.
Gallstone lodged in cystic duct.
Sx: biliary colic (intense spasmodic pain)
Pain in posterior thoracic wall or right shoulder due to diaphragm irritation.
May lodge in Hartmann pouch (abnormal sacculation at neck of gallbladder and cystic duct) which can empty stones into duodenum if peptic duodenal ulcer ruptures, forming a false passage between them.
gallbladder impaction
Pain in epigastric region, shifting to R hypochondriac region at junction of 9th costal cartilage and linea semilunaris.
portal hypertension
Produces varicosities at portosystemic anastamoses, which may rupture, causing hemorrhage.
May cause esophageal varices, caput medusa
caput medusa
Recanalization of ligamentum teres to umbilicus with subsequent distention of anterior abdominal veins and paraumbilical veins
pylorospasm
Spasm of pyloric stomach (infants 2-12 weeks).
Causes failure to pass food to duodenum.
Subsequent vomiting.
congenital hypertrophic pyloric stenosis
Hypertrophy of pyloric smooth muscle.
Common in male infants.
Narrowing of pyloric canal causes proximal dilation of stomach due to failure to normally push chyme into duodenum by gastric peristalsis
gastric ulcer
Open lesion of mucosa of stomach.
posterior gastric ulcer
May erode through stomach to pancreas, referring pain to the back (via visceral afferent sympathetic fibers).
Causes erosion to splenic artery.
Severe hemoperitoneum.
peptic (duodenal) ulcer
Lesion of mucosa of pyloric canal or duodenum.
Associated w/ H.pylori, chronic anxiety.
Pepsin digests mucosa.
Usually in posterior wall of superior duodenum near pylorus.
May cause adherence of liver, gallbladder, or pancreas to inflamed duodenum or secondary ulceration.
May cause ulceration of gastroduodenal a w/ hemorrhage and spillage into abdomen (peritonitis).
vagotomy
Parasympathetic vagus n stimulates gastric parietal cells to secrete HCl.
Surgical section of vagal innervation will reduce acid production.
For those w/ chronic ulcers.
May occur w/ resection of ulcerated area.
truncal vagotomy
rare.
Due to damage to downstream gut structures innervated by vagus
selective gastric vagotomy
stomach denervated, but other structures untouched.
selective proximal vagotomy
Denervates only region of stomach with parietal cells to spare gastric motility
visceral referred pain: organ pain
Dull pain.
Poorly localized.
Referred to dermatome level via visceral sympathetic afferent fibers.
visceral referred pain: gastric ulcer
Referred by pain afferents to T7/T8 via greater splanchnic n (synapsed at celiac ganglion).
Seen as pain in epigastric region, supplied by sensory afferents of dermatomal ventral primary rami at T7/T8
visceral referred pain: parietal peritoneum
Somatic pain.
More severe and localizable due to innervation by somatic sensory fibers form thoracic nerves (ventral primary rami).
Visceral peritoneum only has sympathetic innervation.
Stretch sensitive –> rebound tenderness
rebound tenderness
Extreme localized tenderness when fingers are removed after palpation
appendicitis
Acute appendix inflammation.
Worsened by pressure over McBurney point.
Caused by hyperplastic lymphatic follicles occluding the appendix lumen (younger) or obstruction by fecalith that occludes lumen (older).
Appendicular lumen occlusion prevents secretion escape, causing swelling and stretching of visceral peritoneum.
Referred pain to T10 periumbilical region and RLQ.
Guarding due to pain.
May cause thrombosis of appendicular artery and perforation/ischemic necrosis of appendix.
If ruptures, leads to peritonitis.
colonoscopy
Colonoscope inserted thru anus and rectum into colon to observe for tumors in sigmoid colon or rectum.
Often at rectosigmoid junction.
diverticulosis
Multiple false diverticula (external evaginations of colonic mucosa) develop along intestine.
Formed from protrusions of mucous membrane only thru separations in muscle fibers – true diverticula involves entire colonic wall.
Usually occur on mesenteric side of the two nonmesenteric teniae coli at points where nutrient arteries perforate muscular layer to reach submucosa.
May rupture causing diverticulitis
May distort/erode nutrient arteries causing hemorrhage.
Mid-age to elderly.
Reduced occurrence with high fiber diet.
greater splanchnic n (levels, synapse)
T5-T9
celiac ganglion
lesser splanchnic n (levels, synapse)
T10-T11
superior mesenteric ganglion
least splanchnic n (levels, synapse)
T12
aorticorenal ganglion
