Chapter 4 - General Surgery (Part 1) Flashcards
Gastroesophageal reflux may produce vague symptoms, difficult to distinguish from other sources of epigastric distress. When the diagnosis is uncertain, what should be done?
pH monitoring to establish the presence of reflux and its correlation with symptoms
Typical presentation of GER?
Overweight individual, burning retrosternal pain and heartburn brought about by bending over, wearing tight clothes, or lying flat in bed, relieved by antacids or OTC H2 blockers
If there is a long-standing history of GER, what is the primary concern?
The damage that might have been done to the lower esophagus
The possible development of Barret esophagus
In the setting of long-standing GER, what are the indicated tests?
Endoscopy and biopsies
When is surgery for GER indicated?
Appropriate in long-standing symptomatic disease that cannot be controlled by medical means
Necessary in those with complications (ulceration, stenosis)
Imperative if there are severe dysplastic changes
Standard procedure in GER?
Laparoscopic Nissen fundoplication (add radiofrequency ablation if there are dysplastic changes)
Presentation of esophageal motility problems?
Crushing pain with swallowing in uncoordinated massive contraction
Dx motility problems?
Barium swallow is typically done first
Manometry is used for the definitive diagnosis
Achalasis - more common in men or women?
Women
Presentation of achalasia?
Dysphagia that is worse for liquids
Patient learns that sitting up straight and waiting allows the weight of the column of liquid to overcome the sphincter
Occasional regurgitation of undigested food
XR findings in achalasia?
Megaesophagus
Dx achalasia?
Manometry
Rx achalasia?
Balloon dilatation done by endoscopy
Presentation of cancer of the esophagus?
Classic progression of dysphagia starting with meat, then other solids, then soft foods, eventually liquids, and finally (in several months) saliva
Significant weight loss
Classic population affected by squamous cell carcinoma of the esophagus vs. adenocarcinoma?
SqCC - men with a history of smoking and drinking (high incidence in blacks)
Adeno - long-standing GER
Dx esophageal cancer?
Barium swallow BEFORE endoscopy to prevent inadvertent perforation
Biopsies
Role of CT scan in esophageal cancer?
Assesses operability, but most cases can only get palliative (rather than curative) surgery
Dx and Rx Mallory-Weiss tear?
Dx - endoscopy
Rx - photocoagulation (laser)
Presentation of Boerhaave syndrome?
Starts with prolonged, forceful vomiting leading to esophageal perforation
Continuous, severe, wrenching epigastric and low sternal pain of sudden onset, soon followed by fever, leukocytosis, and a very sick-looking patient
Dx and Rx Boerhaave syndrome?
Dx - contrast swallow (gastrografin first, barium if negative)
Rx - emergency surgical repair
Most common cause of esophageal perforation?
Instrumental perforation
Presentation of instrumental perforation of the esophagus?
Symptoms develop shortly after completion of endoscopy
May have emphysema in the lower neck (virtually diagnostic in this setting)
Dx and Rx instrumental perf of the esophagus?
Contrast studies
Prompt repair
Presentation of gastric adenocarcinoma?
More common in the elderly
Anorexia, weight loss, vague epigastric distress or early satiety
Occasional hematemesis
Dx and Rx gastric endocarcinoma?
Dx - endoscopy and biopsies
CT scan - operability
Rx - surgery
Gastric lymphoma is nowadays almost as common as gastric adenocarcinoma. Presentation and diagnosis are similar. Rx?
Rx with chemo or radiotherapy
Surgery if perforation is feared as the tumor melts away
Low-grad lymphomatoid transofmration (maltoma) can be reversed by eradication of H. pylori
Gastrointestinal stromal tumors (GISTs) occur mostly in the ___. Small tumors with few mitoses (for instance, 1 cm and fewer than 5 mitotic figures) are usually benign. Large tumors with many mitotic figures are malignant.
Stomach
Rx GISTs?
Only curative treatment is complete surgical resection; care must be taken not to rupture the tumor during surgery to avoid peritoneal contamination
Rx inoperable/metastatic/recurrent GISTs?
Palliation with imatinib (Gleevec)
Mechanical intestinal obstruction is typically caused by what?
Adhesions in those who have had a prior laparotomy
Presentation of mechanical intestinal obstruction?
Colicky abdominal pain
Protracted vomiting
Progressive abdominal distention (if it is a low obstruction)
No passage of gas or feces
Early - high-pitched bowel sounds coincide with colicky pain (after a few days there is silence)
Dx mechanical intestinal obstruction?
XR with distended loops of small bowel and air-fluid levels
Rx mechanical intestinal obstruction?
NPO, NG suction, IV fluids (hoping for spontaneous resolution), watching for early signs of strangulation
Surgery if conservative management is unsuccessful, within 24 hours in case of complete obstruction or a few days in cases of partial obstruction
What is strangulated obstruction?
Compromised blood supply
Presentation of strangulated obstruction?
Presents as mechanical, then progresses to fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis
Rx strangulated obstruction?
Emergency surgery
Mechanical intestinal obstruction caused by an incarcerated hernia has the same clinical picture and potential for strangulation as described, but the physical exam shows what?
Irreducible hernia that used to be reducible
Why do all mechanical intestinal obstructions caused by an incarcerated hernia undergo surgical repair? How does the timing vary?
Because we can effectively eliminate the hernia
Emergently after proper rehydration in those who appear to be strangulated
Electively in those who can be reduced manually and have viable bowel
Rx of abdominal hernias?
All should be electively repaired to avoid the risk of intestinal obstruction and strangulation
Exceptions to the rule that all abdominal hernias should be repaired?
Umbilical hernias in patients younger than 2-5 years old (they may close by themselves)
Esophageal sliding hiatal hernias (not true hernias)
Abdominal hernias that become irreducible need emergency surgery to prevent strangulation. What about those that have been irreducible for years?
Elective repair only
Carcinoid syndrome is seen in patients with a small bowel carcinoid tumor with ___ metastases. How does it present?
Liver; diarrhea, flushing of the face, wheezing, right-sided heart valvular damage (look for prominent JVP)
Dx carcinoid syndrome?
24-hour urine collection for 5-hydroxyindoleacetic acid (offending agent will be at high concentrations in the blood only at the time of the attack - a blood sample taken afterward will be normal)
Classic presentation of acute appendicitis?
Anorexia, followed by vague periumbilical pain that several hours later becomes sharp, severe, constant, and localized to the RLQ
Tenerness, guarding, and rebound are found to the right and below the umbilicus (not elsewhere in the belly).
Modest fever, leukocytosis in the 10-15k range, with neutrophilia and immature forms
Rx acute appendicitis?
Emergent appendectomy
Doubtful presentations that could be acute appendicitis include any that do not have all the classic findings. What is the standard diagnostic modality in these cases?
CT scan
If for any reason a large portion of the small bowel is lost, two factors determine the fat of that patient - what are they?
Age
Status of the pylorus and ileocecal valve
Young child with 2 intact structures has a good chance of survival; an old person lacking them does not
Presentation of cancer of the right colon?
Anemia (hypochromic, iron deficiency) in the elderly for no good reason
Stools 4+ for occult blood
Dx cancer of the right colon?
Colonoscopy and biopsies
Rx cancer of the right colon?
R hemicolectomy
Presentation of cancer of the left colon?
Bloody bowel movements - blood coats the outside of the stool, there may be constipation, stools may have narrow caliber
Dx cancer of the left colon?
Flexible proctosigmoidoscopic exam (45 or 60 cm) and biopsies
Full colonoscopy before surgery to r/o synchronous second primary
CT for operability and extent
Rx cancer of the left colon?
Surgery
Pre-op chemo and radiation if large rectal cancer
Colonic polyps may be premalignant. What is the descending order of probability for malignant generation?
Familial polyposis (and variants such as Gardner) > familial multiple inflammatory polyps > villous adenoma > adenomatous polyp
Non-pre-malignant polyp?
Juvenile
Peutz-Jeghers
Isolated inflammatory
Hyperplastic
Presentation of Crohn’s disease and chronic UC?
Severe diarrhea with blood and mucus
When is Crohn’s disease treated surgically?
Only when there are complications such as bleeding, stricture, or fistulization (cannot be cured surgically because it happens in multiple locations)
Chronic UC can be surgically cured - why are surgeons reluctant to do it?
Requires removal of the rectal mucosa, leaving the patient with either a stoma or an ileoanal anastomosis
Clear indications for surgical treatment of chronic UC?
Active disease for more than 20 years (malignant degeneration)
Severe nutritional depletion
Multiple hospitalizations
Need for high-dose steroids or immunosuppressants
Development of toxic megacolon
___ is caused by overgrowth of C. difficile in patients who have been on antibiotics. Any antibiotic can do it. ___ was the first one described, and currently, ___ are the most common cause.
Pseudomembranous enterocolitis; clindamycin; cephalosporins
Presentation of pseudomembranous enterocolitis?
Profuse watery diarrhea, crampy abdominal pain, fever, leukocyotosis
Dx pseudomembranous enterocolitis?
Toxin the stool (culture takes too long, pseudomembranes are not always seen on endoscopy)
Manage pseudomembranous enterocolitis?
D/C antibiotic
Do NOT use antidiarrheals
Rx of choice: metronidazole (alternative - vanc)
When should an emergency colectomy be performed in a patient with pseudomembranous enterocolitis?
Virulent form of disease that is unresponsive to treatment, WBC >50,000, serum lactate > 5
___ has recently been reported as a very effective cure for the overgrowth of C. difficile.
Fecal enema
In all anorectal disease, ___ should be ruled out by proper physical exam (including proctosigmoidoscopic exam), even though the clinical presentation may suggest a specific benign process.
Cancer
Hemorrhoids typically bleed when they are ___ (can be treated with ___), or hurt when they are ___ (may need ___ if conservative treatment fails).
Internal; rubber band ligation; external; surgery
Presentation of anal fissure?
Young women
Exquisite pain with defecation and blood streaks covering the stools
Fear of pain is so intense that they avoid bowel movements (and get constipation) and sometimes refuse proper physical exam of the area (may be done under anesthesia)
Where are anal fissures typically located?
Posterior, in the midline
What is believed to cause and perpetuate anal fissure?
Tight anal sphincter
Manage anal fissure?
Stool softeners, topical nitroglycerin, local injection of botulinum toxin, forceful dilatation, or lateral internal sphincterotomy
CCBs such as diltiazem ointment 2% TID topically for 6 weeks have had an 80-90% success rate (only 50% with botulinum toxin)
Crohn’s disease often affects the anal area. It starts with a fissure, fistula, or small ulceration, but the diagnosis should be suspected when what happens?
The area fails to heal and gets worse after surgical intervention (anal area typically heals very well because it has excellent blood supply - failure to do so indicates Crohn’s)
Manage Crohn’s disease of the anus?
Do NOT do surgery
A fistula, if present, could be drained with setons while medical therapy is underway. Remicade helps healing
Presentation of ischiorectal (perirectal) abscess?
Very common
Febrile, exquisite perirectal pain that does not let the patient sit down or have bowel movements
Exam shows the classic findings of an abscess lateral to the anus, between the rectum and ischial tuberosity
Rx ischiorectal abscess?
Incision and drainage
R/o cancer by proper exam during the procedure
If severely diabetic, monitor closely, as horrible necrotizing soft issue infection may follow
___ develops in some patients who have had an ischiorectal abscess drained. How does this develop?
Fistula-in-ano; epithelial migration from the anal crypts (where the abscess originated) and from the perineal skin (where the drainge was done) form a permanent tract.
Presentation of fistula-in-ano?
Fecal soiling and occasional perineal discomfort
Exam shows opening(s) lateral to the anus, a cordlike tract may be felt, and discharge may be expressed
Manage fistula-in-ano?
R/o necrotic and draining tumor
Rx with fistulotomy
Squamous cell carcinoma of the anus is more common in what patient populations?
HIV+
People with receptive sexual practices
Presentation of squamous cell carcinoma of the anus?
Fungating mass grows out of the anus, metastatic inguinal nodes are often felt
Dx and Rx squamous cell carcinoma of the anus?
Dx with biopsy
Rx with Nigro chemo-radiation protocol, followed by surgery if there is residual tumor
Currently the 5 week chemo-radiation protocol has a 90% success rate, so surgery rarely is required.
75% of cases of GI bleeding originate in the ___ GI tract.
Upper (above the ligament of Treitz)
DDx - GI bleeding from the colon?
Angiodysplasia, polyps, diverticulosis, cancer (all diseases of older people)
True or false - vomiting blood always denotes a source within the upper GI tract.
True (same is true when blood is recovered by NG tube in a patient who shows up with bleeding per rectum)
Next best diagnostic test in a patient vomiting blood?
Upper GI endoscopy; be sure to look at the mouth and nose first
Melena (black, tarry stools) always indicates what?
Digested blood (suggests it must originate high enough to undergo digestion)
Work-up of melena?
Start with upper GI endoscopy
First diagnostic maneuver in a patient actively bleeding BRBPR?
Pass an NG tube and aspirate gastric contents. If blood is retrieved, this establishes an upper source -> upper endoscopy. If no blood is retrieved and the fluid is white (no bile), the territory from the tip of the nose to the pylorus has been excluded, but the duodenum is still a possible source. Upper endoscopy should follow. If no blood is recovered and the fluid is green (bile), the entire upper GI tract has been excluded and there is no need for upper GI endoscopy.
Work-up of active bleeding per rectum when upper GI has been excluded?
Bleeding hemorrhoids should always be excluded first (anoscopy), but colonoscopy is not helpful during active bleeding (oncoming blood obscures the field).
Some practitioners proceed according to the estimated rate of bleeding - if >2 mL/min (1 unit of blood every 4 hours), they do an angiogram, which has a very good chance of finding the source and may allow for angiographic embolization. If <0.5 mL/min, wait until the bleeding stops and do a colonoscopy. In between -> tagged red-cell study. If it puddles somewhere, an angiogram may be productive. However, this is often useless because it is a slow test and the bleeding often stops, making the angiogram useless. If tagged red cells do not show up, a subsequent colonoscopy is planned.
Some always begin with the tagged red-cell study regardless of rate of bleeding.
Work-up for patients with a recent history of BRBPR but not actively bleeding at presentation?
Start with upper GI endoscopy if they are young (overwhelming odds); if old, need both an upper and lower GI endoscope (at the same session)
Work-up for blood per rectum in a child?
Likely from Meckel diverticulum; start work-up with technetium scan, looking for ectopic gastric mucosa
Massive upper GI bleeding in the stressed, multiple trauma, or complicated post-op patient is probably from ___.
Stress ulcers
Dx and Rx massive upper Gi bleeding from ulcers?
Endoscopy will confirm.
Angiographic embolization is the best therapeutic option.
Avoid these by maintaining the gastric pH above 4.
Acute abdominal pain can be caused by what 3 general processes?
Perforation
Obstruction
Inflammatory or ischemic processes
Presentation of acute abdominal pain caused by perforation?
Sudden onset, constant, generalized, and very severe
Patient is reluctant to move, very protective of his abdomen
Impressive generalized signs of peritoneal irritation are found (tenderness, muscle guarding, rebound, silent abdomen) -> exceptions in very old or very sick
Confirm dx of perforation? Rx?
Upright x-rays with free air under the diaphragm
Emergency surgery
Most common cause of acute abdominal pain 2/2 perforation?
Perforated peptic ulcer
Presentation of acute abdominal pain caused by obstruction of a narrow duct (ureter, cystic, or common)?
Sudden onset of very severe colicky pain, with typical location and radiation according to source. Patient moves constantly, seeking a position of comfort. Few physical findings, limited to focal area where the process is
Presentation of acute abdominal pain caused by inflammatory process?
Gradual onset and slow build-up (at the very least a couple of hours, more commonly 6 or 10 or 12 hours)
Constant, starts as ill-defined
Eventually locates to the area where the problem is
Often has typical radiation patterns
Physical findings of peritoneal irritation in the affected area, and (except for pancreatitis), systemic signs such as fever and leukocytosis
___ affecting the bowel are the only ones that combine severe abdominal pain with blood in the lumen of the gut.
Ischemic processes
___ should be suspected in the child with nephrosis and ascites, or the adult with ascites who has a “mild” generalized acute abdomen with equivocal physical findings, and perhaps some fever and leukocytosis.
Primary peritonitis
Dx and Rx primary peritonitis?
Cultures of the ascitic fluid with yield a single organism
Rx with ABX, NOT surgery
Rx for a generalized acute abdomen?
Ex-lap, with no need to have a specific diagnosis as to the nature of the process
What needs to be ruled out prior to doing an ex-lap for generalized acute abdomen?
MI (EKG, troponins), lower lobe pneumonia (CXR), PE (immobilized patient), pancreatitis (amylase or lipase), urinary stones (CT abdomen)
Presentation of acute pancreatitis?
Alcohol use with "upper" acute abdomen Rapid onset (couple hours) Constant epigastric pain radiating straight through to the back with N/V, retching
Exam findings are relatively modest, found in the upper abdomen
Dx and Rx acute pancreatitis?
Dx - serum or urinary amylase or lipase (serum from 12-48 hours, urinary from 3rd-6th day). CT if dx not clear
Rx - NPO, NG suction, IV fluids
___ should be suspected in a fat woman in her 40s with many children and who develops RUQ abdominal pain.
Biliary tract disease
Presentation of ureteral stones?
Sudden onset of colicky flank pain radiating to inner thigh and scrotum (or labia), sometimes with other urinary symptoms like urgency and frequency, and with microhematuria in the UA.
Dx ureteral stones?
CT scan
Presentation of acute diverticulitis?
LLQ
Middle-age or older
Fever, leukocytosis, physical findings of peritonea irritation in the LLQ, sometimes palpable tender mass
Dx and Rx acute diverticulitis?
CT
Rx with NPO, IV fluids, ABX; most will cool down. About 90% of those who do not have an abscess that can be drained percutaneously by IR. The few that cannot will need emergency surgery
Indication for elective surgical removal of area affected by acute diverticulitis?
2+ episodes of acute diverticulitis
Presentation of volvulus of the sigmoid?
Old people
Signs of obstruction and severe abdominal distension
Dx volvulus of the sigmoid?
XR, show air-fluid levels in the small bowel, very distended colon, and a huge air-filled loop in the RUQ that tapers down toward the LLQ with the shape of a “parrot’s beak”
Rx volvulus of the sigmoid?
Proctosigmoidoscopic exam with the old rigid instrument resolves the acute problem. Rectal tube is left in. Recurrent cases need elective sigmoid resection.
Presesntation of mesenteric ischemia?
Predominantly in the elderly
Key - development of acute abdomen in someone with AF or a recent MI (source of the clot that breaks off and lodges in the SMA)
Acidosis and sepsis often develop because the diagnosis is made late
What is the only condition that mixes acute pain with GI bleeding?
Mesenteric ischemia
Dx and Rx mesenteric ischemia?
Arteriogram and embolectomy
