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
Splenectomy
- physiology of spleen
- indications for splenectomy
Physiology
- lymphoid organ: plays a role in the immune function of the body: filters the RBCs
- removes old RBCs, bacteria, or other circualting unwanted particles via the macrophages in the spleen
- hypersplenism: too much filtering = leads to cytopenias
- spleen sequesters the platelets!
Indications for splenectomy
- hyperspleneism/splenomegaly
- autoimmune/erythrocyte disorder (TTP, hemophila,etc.)
- trauma or vascualr disease to spleen
- cyst,abcess tumor
- diagnosic need
- iatrogenic/incidental need
Splenectomy
- surgery
- vaccination consideration for splenectomy cases
Surgery
- open: for trauma
- laparoscopic: preferred method
Vaccinations
- elective splenectomy pt. need vaccinations at lease 14 days before surgery
- non-elective splenectomy pts. need to wait at least 14 days post surgery for vaccinations
Vaccines needed (at higher risk of infection)
- Streptococcus penumoniae
- Haemophilus ( H. flu) type B
- Neisseria meningititdis
Hernia
- what is it
- 3 types
Hernias
- abnormal pertrusions of the intra-abdominal contents through a defect in the fascia wall
Reducible: spontaneously reduce or easy manual reduction
Incarcerated: contents cannot be returned to the abdomen; usually the neck is too small to fit it back in: this does NOT mean it is infected/inflammed
Strangulated: blood flow is compromised and ichemia occurs
Indirect inguinal hernia
- anatomy
Indirect Inguinal Hernia
MOST COMMON HERNIA
Anatomy
- when the inguinal canal fails to close during the decent of the tunica vaginalis: the internal inguinal ring remains open & intraabdominal contents can pass through the canal
- considered a congenital hernia
Symptoms and Signs
- buldge in groin when lifting or straining
- direct hernias will not have these symptoms and are less liekly ot be strangualted or incarcerated
- can insert finger into the scrtom at the base of the canal
- contents follow canal into scrotum
Direct Inguinal Hernia
Herniation DIRECTLY through the transversalis fascia
- due to weakness or defect in the fascia
- this hernia will pass medial to the vessels coursing through hesselbach’s triangle
Triangle
- inguinal ligament inferiorly
- inferior epigastric vessels superiorly
- lateral boarder of the rectus muscle
Common in
- older men with weak abd. muscles
Inguinal Hernial Repairs
direct and indirect
Herniorraphy
- goal is to reduce contents back to teh abdomen and repair/close the fascial defect in the inguinal floor
- traditional repair: approximate the native tissue wiht perminate sutures
- mesh plugs (lichtenstein repair) is used to reconstruct the pelvic floor
Indirect Hernia
- should be anatomically isolated & dissected to its origin from the peritoneum and ligated
Femoral Hernia
Etiology
- a hernia passing beneath the iliopubic tract and teh inguinal ligament into the upper thigh
- this follows the vessels as they enter the leg
- common in women
Umbilical Hernia
Epigastric Hernias
Umbilical Hernias
- multiple pregnancies, prlonged labor, obesity and ascites are the highest risk factors
- larger tumors or incisional hernias for surgery are possible
Surgery
- often is emergency as the neck of the hernia is narrow and compromised flow: stragulation and incarceration common
Epigastric Hernias
- protrusion above the umbilicus through the linea alba
Ventral/Incisional Hernias
Causes/risks
Hernias through a previous incisional site
Causes
- poor surgical technique
- postop infection
- age (incr.)
- malnutrtion/poor healing
- obesity
- chronic coughing
- drain placements
- lots of blood loss
- failure to close the fascia in the laproscopic trocar sites > 10 mm
Laproscopic Herniorraphy
repairs utalzie mesh to cover repair
IPOM: transabd. intraperitoneal layer of mesh
TAPP: transabd. preperitoneal layer
TEP: total extraperitoneal mesh layer
Small Bowel Obstruction
Etiology
- MCC: adhesions
- others: hernias, volvus, intusceeption, FB, strictures (Chrons) or gallstone ileus
Symptoms
- vomiting
- abd. pain (rises and falls)
- distension
- tympany
- hyperactive BS before the obstruction, lack of BS after
- transition point = location of obstruction
can be see on xray or CT
SBO
treatment and surgery
Treatment
- conservative: bowel rest, NG decompression
- serial abd. exams can be done to monitor to see if return to normal
- those who do not improve within several days will be considered for the OR or clincial declining pt. (elevated WBC or lactate)
Surgery
- laproscopic lysis of adhesions
- ex. lap with lysis
- small bowel resection with anastamosis for areas of nonviable bowel
Types of Colectomy’s
colectomy
- colon cancer
- diverticu
- IBD UC/Chrons
- LBO
Colecomty types
- right colecetomy
- left coleectomy
- sigmoid colectomy
- LAR: lower anterior resection: mesorectal excision for rectal cancer with a lower rectoanal anastamosis this if for cancer which does NOT impact the anal sphncter
- APR: abdominperitoneal resection: removes rectum, anus and creates end colsotomy to remover rectal cancer that is invovled in teh anal sphincter
Complications
- Most serious is an anastomotic leak
- ensure good blood supply to help anstamosis
- test with air leak test
- when in doubt divert with loop ileostomy to let it heal
Diverticulosis and diverticulitis
Diverticulosis
- the outpuches exisit in the serosal layer of mucosa and submucosa
- most stay asymptomatic = refer to a high fiber diet
Diverticulitis
- perforation thought the diverticulum due to high pressure = Sigmoid colon MC
- mild paint to peritonitis possible
- perforation (not transmural) leads to local inflamamtion and can lead to fistual, abcess or phelgmon
Symptoms
- LLQ pain and tender and dsitention
- fever
- n/v
Labs
- leukcocytosis
- CT to confirm
Maangement of Diverticulitis
mild (uncomplicated)
- manage outpt. with oral abx (cipro/levo + metronidazole)
severe episodes (with or without abcess)
- manage with bowel resection and IV abx. + fluids
- large abcess = IR to drain
some pt. need NPO or PICC TPN
get interval colonospcy 6-8 weeks after to r/o cancer
Emergent Surgical Treament
- for those with peritonitis or large perforation or unstable
- for those who faield conservative
- ex lap with washout infection = Hartmanns procedure
- remove infected, stable stump & end descending colostomy
Preferred Management
- to wait until uninfected: then elective surgery (for complicated or uncomplicated)
- primary resection of the sigmoid with anastamosis
Large Bowel Obstruction
Etiology
- MC = tumor
- diverticuliis, volvus, impaction of FB are rarer causes
Necessary for Dx.
- determine constipation or obstipation (severe constipation)
- abd. tenderness + pain
- N/V
- xray findings
Chrons Disease
can affect mouth to anus anywhere in patchy spots with transmural impact
- most have small and large bowel involvement
- surgery = palliative resection not curable
- meds (immunosup.) can help
Findings
- terminal illeum fiberosis/stenosis, abcess and enteroenteric fistuals
- ileocecetomy done and try to preserve as much bowl as possible
- perianal severe abcesses and fistulas
Hemorrhoids
etiology
- some cushion is important to help and protect anoderm
- but can be from constipation and straining
Internal = PAINLESS
- bright red and full
- graded 1-4
- grade 1 = do not prolapse
- 2 prolapse but retunr spotan.
- 3 prolapse but manual return
- 4 prolapase and dont return
External = PAINFUL
- sudden and severe pain
- grape size mass
- creates skin tag
Managment
Lifestyle mod. first
- fiber supp. + stool softeneds
- increase liqud
- sitz bath 2-3 a day
- laxitives
if no improvement
- surgery
- if lots of bleeding: exam under anesthesia cna be done to find underlying
