Gallbladder Disease, Diverticular Disease and Hernias - Ritesma Flashcards
Strangulated Hernia
not reducible
vascular supply compromised
surgical emergency
Hernia Causes
- congenital defect
- obesity
- pregnancy
- chronic cough
- constipation
- heavy lifting
- family history
Reynolds Pentad
- Pain
- Fever/chills
- Jaundice
- Altered Mental Status
- Hypotension
Ventral and Umbilical Hernia
frontal wall of abdomen
secondary to tears or seperation of muscle
- pregnancy
- surgical incisions
- congential weakness
TX:
- attempt to reduce & assess for danger signs
- surgical referral
- hernia belt or binder
Diverticulitis
microperforation of the diverticula: inflammation & infection
SYMPTOMS:
- lower abdominal pain
- constipation or loose stools are common
- nausea and vomiting
- can be mild (microperforation) to severe (macroperforation - abscess)
PHYSICAL EXAM
- low grade fever
- LLQ tenderness and palpable mass
- rectal exam - + occult blood
- Lekocytosis
- perforation would have more dramatic peritonal signs (Obturator, Psoas, Markle)
IMAGING TREATMENT
- Abdominal CT - more severe symptoms or not responsive to antibiotics
TREATMENT
- MILD: liquid diet & oral antibiotics
- MODERATE: admit to hospital, NPO, IV fluids, IV ABX
- SEVERE: surgery
COMPLICATIONS
- fistula formation
- bowel obstruction
- abscess
- perforation
Hernia
protrusion of intra-abdominal contents through a weakness or abnormal fascia opening in abdominal wall
Diverticulosis
presence of diverticula (pockets/puches) of intestinal mucosa and submucosa
PATHOPHYSIOLOGY:
- sigmoid and descending colon
- lack of fiber in the diet
- patients with connective tissue disorders are predisposed
PHYSICAL EXAM:
- often an incidental finding
- LLQ discomfort on exam, thickened palpable sigmoid and descending colon
IMAGING: None
TREATMENT: high fiber diet
Epididymitis
STD: men
UTI and Prostatitis: older men; gram negative rods
pain in FLANK or ABDOMEN
urinary retention, urgency
nausea/vomiting, fever
EXAM: tender and swollen epididymis, scrotum inflamed, warm, and red
Cholecystitis
INFLAMMATION & DISTENSION of the GALLBLADDER
CAUSES:
- obstruction
- acalculus cholecystitis - due to biliary stasis from fasting, TPN, trauma
- infection: CMV, cryptosporidosis, vsculitis
PATHOGENESIS
- gallbladder inflammed, lysolecithin is released due to trauma to gallbladder wall
SYMPTOMS
- RUQ pain may radiate to back or R shoulder
- pain is constant and severe
- nausea
- vomiting
- anorexia
- fever
PHYSICAL
- RUQ + guarding
- Murphy’s sign
- fever
- tachycardia
LABS
- complete blood count
- metabolic panel
- amylase (may be elevated), lipase
DIAGNOSTIC
- ultrasound - can detect stones, thinckened wall and sonographic murphy’s sign
TREATMENT
- GI rest - NPO
- IV pain medications, anti-emetics, hydration,
- surgery?
- IV antibiotics - 2nd or 3 rd generation
Reducible Hernia
can be manually of spontaneously repositioned into abdominal cavity
Charcot Triad
- Pain
- Fever/chills
- Jaundice
Testicular Torsion
MEDICAL EMERGENCY
acute, severe unilateral testicular pain
pain on palpation
most common 12-18 yo; left
Indirect Hernia
passes THROUGH inguinal ring
LATERAL TO EPIGASTRIC A.
occurs in younger males and females
Testicular Tumor
painless enlargment of testis
negative urinalysis
Cholelithiasis
GALLSTONES
classified according to chemical composition
RUQ episodic pain due to stones moving, no infection, inflammation or blockage; often eating fatty or fried foods
no fever, no elevated WBC/liver enzymes
EXAM
- RUQ tneder to palpation
- Murphy’s sign
LAB
- CBC, LFT, chemisty, amylase, lipase - usually normal
IMAGING
- ULTRASOUND gold standard
- HIDA scan
TREATMENT
- Pain medication
- IV hydration
- Elective laprascopic cholecystectomy
Direct Hernia
passes through abdominal wall
MEDIAL TO EPIGASTRIC A.
more common in older men; uncommon in females
Gallbladder Disease Prevalence
- 9x greater prevalence in Native American women
- 5.5% in men
- 8.6% in women
Special Populations
- family hx of gallbladder
- cystic fibrosis patients
- pancreatic disease
- patients on TPN
- male/female > 60
Risk for Gallbladder Disease (5 F’s)
- Female
- Fat
- Fair
- Fertile
- Forty
other risks:
- estrogen/progesterone replacement tx
- rapid weight loss
- dyslipidemia
- DM2/glucose intolerance/insulin resistance
- medications
Incarcerated Hernia
cannot be reduced
can lead to bowel obstruction but no vascular compromise
Choledocholithiasis
Bile Duct Stones
Features:
- hx of recurrent RUQ pain
- chills and fever w/ pain episode
- jaundice w/ pain episode
Charcot Triad
- Pain
- Fever/Chills
- Juandice
Reynolds Pentad - acute cholangitis - EMERGENCY
- Pain
- Fever/Chills
- Jaundice
- Altered Mental Status
- Hypotension
EXAM
- hepatomegaly
- tenderness of RUQ or epigastrium
- charcot triad or tirad + lab evidence of inflamation, elevated liver enzymes or biliary dilation on imaging
TREATMENT:
- surgery
Hydrocele
painless accumulation of fluid in the tunica vaginalis or along spermatic cord (bag of worms)
tx: aspiration (temporary), surgery
Murphy’s Sign
when palpating at the edge of the gallbladder fossa just beneath the liver edge, ask patient to inspire deeply
+ patient stops inspiration or has increased pain
