General Surgery Flashcards
Notes on Hx. and PE of general surgical complaints
- get a good history and impression of the pt.
- when getting the PE f the abd. always inspect, ausculate, percuss then palpate last
- ensure you palpate the area of pain last!!!
Visceral Abd. Pain
- character
- where
- from what
Visceral Pain
- pain which originates from the organ: specifically the hollow organs of the abd.
- this pain is dull, diffuse and poorly localized
- this is because of the visceral nerve fibers: autonomic fibers which are responding to contraction and distention
- forgut (stomach, duodenum, liver and pancrease) = upper abd. pain
- midgut (small bowel, prox. colon and appendix) = periumbilical pain
- hindgut (dostal colon and GU) = lower abd. pain
Somatic/Parietal Pain
- character
- from where
- what
Somatic/Parietal Pain
- pain which is originating in the parietal peritoneum (the wall, tissue strcutres)
- these are somatic nerve fibers which respond to irritation from infection, chemical cahnges or other inflammation
- this is sharp, well localied pain
Referred Pain
- character
- why
- what
Referred Pain
- pain felt away from the original location: occuring in a distant sight because the nerve fibers of multiple locations converge at the spinal cord– and the brain cannot dictate which incoming signal was the pain signal
- scapula = biliary colic pain
- LLQ from RLQ appendix
- shoulder pain when diaphragm is irritated or heart
- groin pain from renal colic
define the “acute abdomen”
information to obtain
top ddx.
labs and imaging
- sudden
- severe and spontaneous
- abd pain with unclear origins that began less than 24 hours ago
-
surgery can be warrented here
_____________________________________________
get infor about
- location, quality, mode of onset and progression of pain
ddx. to watch
- abcess
- etopic preg.
- perforated bowel
- rupture of anyuresum
Labs
- the classic workup
- blood culutres and gases
- lipase/amylase
- lactate: will behigh in ischemia, hypoxia, sepsis, etc.
Imaging
- CXR: for free air in the abd.
- US: gallstones
- CT; is the most widely used
any pt. with > 6 hours of acute abd. pain should nt go home; they are probably a surgical canidate & well-localized pain = better idea of surgery (remember appendicitis in kids!!)
Peritoneum & Peritonitis
Peritoneum
- a thin layer of mesothelial lining: for the abd. cavity and the visera within (parietal peritoneum lines the abd. wall and the viseral peritoneum lines the organs)
- normally a sterile area
- the omentum sits below the peritoneum: the vascualr cover to aid in immunity
- sits just below the transversalis fascia
Peritonitis
- inflammation of the peritoneal cavity
- MCC is a perforation in the GI tract causes immediate chemical irritation of the lining & infection
- can also result from extreme inflammation due to appendicitis, pancreatitis, diverticulitis or any other inflammation within the cavity
Severity of Peritonitis
- depends on the locaion of the inflammation/infection source & type of bug & pt. specifics
- bacteria of the distal gut or infected biliary will quickly get bad fast (anaerobes)
- prox. GI bugs are more sterile
Intraabdominal Abcess
Etiology
- a collection of infected fluid within the cavity
can be due to
- perforations
- post-op complications
- penitrating trauma
- GU infection
Formation via
- adjacent diseased viscus organ forms it
- or due to external contaminiation
Treatment
- prompt and urgent draingage of the abcess & control of cause
- antibiotics
- IR percut. drainage is preferred
- smaller abcesses may be left
- open draingage if they cannot be done by IR or if need to source control
Appendicitis
Etiology
Symptoms
PE/Labs/Imaging
Etiology
- acute inflammation of the appendix with distention or obstruction
- can be a result of fecaliths: hard fecal masses, stones, lymphoid, infection or tumors which cauase the inflammation/obstruction
- common in teens/early 20s
Symptoms
- poorly localized (starting as this because its visceral pain) periubilically which localizes to the RLQ at McBurney’s point
- steady, sharp and crampy pain aggrivated with movement and coughing
PE
- tender RLQ palpation & rebound tenderness
- Rosuvig’s signs
- Obturator Sign
- Psoas Sign
Labs
- +/- elevated WBC
- imaging: CT or US if pregnant/child
Appendicitis
imaging findings
open v laproscopic technique
Imaging: CT
- enlarge appendix ( > 6mm) with occluded lumen
- wall thickening & fat-stranding
Surgery
- most are laproscopic (converted to open if needed) for reduced infection risk and pain
Open Appendectomy
- RLQ incision 1/3 from ASIS and umbilicus
- Rocky Davis Incision = horizontal
- McBurney = steep perpendicualr incision
Laproscopoic Appendectomy
- 3 ports: 1 at umbilicus for camera & 2 for instruments
- appendix freed from adhesions, window made, stapled and specimen removed via endocatch bag
for some, perforated appendix or those unfit for surgery abx. course prior to surgery can be done
Complication s
- bleeding
- infection: superfiscial wound or abcess
- illeus (lack fo muscle contraction in the bowel)
- damange to other organs
- scar/adhesions
the Post-Op Fever Ruleof W’s
Wind (atelectasis) = first 24-48 hours
Water (UTI) = 48-72 hours
Wound (infection) = after 72 hours
Walking (DVT) = after 72 hours
WOnder Drug (drug induced fever) = after 1 week
GB physiology
Gallstones
GB review
- liver = makes bile
- bile = stored in GB
- when bile needed to digest = CCK from duodeum released
- triggers GB to squeeze and release bile
Gallstones
- majority of pt. stones are made of cholesterol (others are pigmented stones)
- when the liver is oversatureated with cholesterol, makes crystals of cholesterol within the GB
- fourty, fertile, fat and female
Biliay Cholic & Chronic Cholyecystitis
Etiology
- repeated minor eipsodes of obstructions in the cystic duct as a result of the gallstone blocking the exit = intermittenet nature usually when fatty food eaten, the pain comes on and goes away
- leading overtime to inflammation and scarring ofthe GB and the cystic duct
Symptoms
- RUQ crampy abd pain minutes to hours
- radiates to epigastric region or scapula
- post-prandial with fatty foods
- +/- N/V
Work-Up
US is the most sensitive test for stones
- thickend GB, stones, sludge, etc.
- HIDA can be done if US negative or thick acalculous cholycystits
- CT can show it
- ERCP: GI to direct visualize the duct and remove stone
Cholycystitis Treatment (nonacute)
Treatment
Cholycystectomy is indicated in most pt. who have symptoms
- elective procedure
- advise for low fat diet
Surgery
- can be done open (long diagonal incision) or laproscopicly
Acute Cholecystitis
etiology
symptoms
Etiology
- this is also a stone in the cystic duct (most of the time) which causes inflammation within the GB
- most of these pt. will have had episodes of biliar colic before
Symptoms
- leading to acute URQ pain, tenderness
- + sonograic murphys sign
- palpabale GB sometimes
- fever and leukocytosis indicated these pt. are sick and there is an inflammatory process happening
- can have a mild inc. in serum bilirubin
Treatment
- majority of the time pt. will respond well to IV abx supportive measures d/c and then a planned choleycysectomy
- the preferred tx. is to do surgery on all pt. unless specific contraindcations (age, comorbidities)
Acute Cholycystitis: complications
Complications
Empyema: GB with pus
gangrene: dead GB
perforamation +/- abcess
these pt. will be toxic/septic appearing
choledocolithiasis: a gallstone in the common bile duct
ascending cholyangitis: infection from duodenum to the common bile duct (stone there too)
Charcot’s triad: jaundice, fever and biliar colic
