General Surgery Flashcards
sutures
absorbable
monocyrl - monofilament
vicryl - polyfilament
catgut - intestine of sheep or cow, polyfilament
chromic gut - monofilament, collagen based (bovine or sheep), wound support for 10-21d, dissolves in 90d
PDS - takes 1 yr to absorb, good for fascia
nonabsorbable
ethibond - nonabsorbable, braided (polyester based)
prolene - skin closure and soft tissue approximation
silk - polyfilament, non-absorbable
trauma triad
coagulopathy
–> lactic acidosis
metabolic acidosis
–> decreased myocardial performance
hypothermia
- -> halts coagulation cascade
- -> coagulopathy
if this occurs intra-op - pack bleeding and temp closure
hernia repair
why would you not put mesh in someone with a bile leak? - bile is not sterile, mesh infection
Lap repairs - TAPP, TEPP
TAPP - trans-abdominal pre-peritoneal repair, robot (easier to suture)
TEPP - totally extra-peritoneal repair
liver disease and cirrhosis
- MELD and Child-Pugh
Effects of liver disease
- encephalopathy - metabolic disturbance (hypoxia, hypovolemia, alkalemia, hypoglycemia, hypoK, hypoNa) can precipitate hepatic encephalopathy
- benzos can exacerbate hepatic encephalopathy (in general these patients are sensitive to sedatives and hypnotics)
- heme - diminished hepatic function has pro- and anticoagulant effects –> rebalanced hemostasis
- coag tests will be prolonged - issue is these tests only reflect changes in procoagulant factors, so are poor in predicting bleeding risk
- prior to surgery - give vitamin K to those suspected to be deficient; consider plts, fibrinogen, and INR
- in terms of operating on a patient with cirrhosis - issue is uncontrolled bleeding (can abort operation in cases of incidental cirrhosis)
- CVD - common in patients with liver disease and a risk for post-op M&M
- patients with cirrhosis have hyperdynamic circulation - low SVR and high CO
- watch IVFs and volume
- pulmonary complications - ascites can affect breathing
- portal HTN –> varices, etc.
- patients with portal HTN can develop portopulmonary HTN - cirrhotic patients undergoing major surgery should be screened per-op with resting echo
- renal dysfunction - retention of Na and free water, renal hypoperfusion, decresaed GFR –> HRS (but this is a diagnosis of exclusion)
- cirrhotic patients are at high risk for more common causes of renal dysfunciton - parenchymal disease, sepsis, nephrotox, hypovolemia
- hyponatremia - develops slowly in patients with cirrhosis, dont correct serum Na unless <120 or neuro symptoms develop (and correct slowly to avoid CPM)
- clearance - impaired lactic acid clearance (cant trust high lactate in cirrhotic, calculate MELD score)
Model for End Stage Liver Disease (MELD)
= 3.78log(serum bili) +11.20logINR + 9.57log(serum Cr) +6.43
components - serum bili, INR, serum Cr
- score ranges from 6-40, < 15 should NOT undergo liver transplantation, scores >15 should NOT undergo elective surgery
- initially created to predict survival of patients undergoing TIPS (transjugular intrahepatic portosystemic shunts), currently used to rank priority of liver transplantation candidates
Child-Pugh (see image)
- assess risk of non-shunt operations in patients with cirrhosis
- encephalopathy, ascites, bilirubin, albumin, PT/INR
- Class A (well compensated cirrhosis)-B (functional compromise)-C (decompensated) - indicates survival at one and two years, also indicates risk of post-op morbidity following abdominal procedure
- if post-op morbidity is unexpectedly high or low, use MELD score in conjunction
Surgery in patients with liver disease
- note - routine screening with LFTs is not recommended in patients with no known liver disease
- contraindications - acute liver failure, acute viral/alcoholic hepatitis
- otherwise, patients iwth mild-moderate chronic liver disease without cirrhosis tolerate surgery well
- cardiac surgery, abdominal surgery, and hepatic resection are all associated with incresaed post-op mortality - presumably due to greater reductions in hepatic blood flow
- anesthesia and the liver - by influencing hepatic blood flow and/or producing hepatotoxic byproducts
- volatile anesthetics (-anes) - don’t use halothane, others decrease hepatic blood flow, newer anesthetics (iso and sevo) are minimally metabolized to toxic byproducts by the liver (so risk of tox is low)
- N2O - decreases blood flow
- IV anesthetics (propofol, etomidate, midazolam aka versed = induction agents) - dont seem to affect liver function
venous insufficiency
venous HTN –> LE edema, loss of fluid, plasma proteins, erythrocytes
- erythrocyte –> hemosiderin deposition –> stasis dermatitis (red-bronze colored legs)
- ultimately - inflammation of venules and capillaries, fibrin deposition, plt aggregation –> microvascular disease and ulcerations
- changes - 1) xerosis (dry chicken skin), 2) lipodermatosclerosis (~panniculitis aka inflammation of subQ fat) and ulcerations LE edema
- venous valvular incompetence is most common (cycle where fluid leaks out of intravascular space so kidneys retain more fluid)
- note lymphatic obstruction is an uncommon cause of edema (due to malignant obstruction, LN resection, trauma, filariasis) - affects dorsa of feet and causes marked thickening and rigidity of skin
ulcers on feet
- diabetic - microvascular disease
- arterial insufficiency - tip of toes, devoid of granulation tissue, start with Doppler (pressure gradient means that surgery may be a treatment option)
- venous stasis - will have granulation tissue
- marjolin ulcer
sphincter of Oddi dysfunction
can develop after any inflammatory process - surgery, pancreatitis
dyskinesia and stenosis of sphincter
- functional biliary disorder - where there is obstruction of flow through the sphincter
- recurrent episodic pain with transaminitis and alk phos elevations
- dilated common bile duct in absence of stones
opioids (morphine) cause contraction of sphincter –> precipitate sxs
manometry is the gold std dx
tx - sphincterotomy
gastritis
gastritis
bile reflux gastritis - due to incompetent pyloric sphincter (following gastric surgery)
- vomiting, heart burn, abd pain
acute erosive gastropathy: hemorrhagic lesions after exposure of gastric mucosa - ASA, cocaine, alcohol (vasoconstriction and direct mucosal injury)
acute adrenal insufficiency
due to - adrenal hemorrhage/infarct
- acute illness/injury/surgery in pt with chronic adrenal insufficiency (PAI, Addisons disease) or long-term glucocorticoid use
- pts on long-term glucocorticoid therapy will eventually develop Cushingoid features (HPA suppression can occur after 3 weeks of prednisone > 20 mg/day)
- side note - pts on <5mg/day of glucocorticoids will not need stress dosing
- for doses 5-20mg/day - get preoperative evaluation with early-morning cortisol level
- px - hypotension/shock, N&V and abd pain, weakness, fever
- hypoglycemia is also common - can cause dizziness and a wide pulse pressure (due to systolic HTN)
- tx - hydrocortisone, dexa, high-flow IVF
pts with PAI will also have mineralocorticoid deficiency - hyponatremia and hyperkalemia
“septic shock” - abx, steroid bolus - if you think someone has septic shock and they “briefly* respond to a steroid bolus –> adrenal infarct
catheters and lines
CVC - used for administration of critical care medications
- IJ, subclavian
- tip in lower superior vena cava (tip placement in smaller veins predisposes to venous perforation) - 2cm above RA
- inappropriately placed catheter can also cause pneumothorax (or myocardial perf or subclavian artery puncture)
- CVC may trigger cardiac arrhythmias if inserted too far into RA
- get confirmatory CXR or portable CXR (imm) - want to see catheter tip at angle between trachea and right mainstem bronchus
pulmonary contusion
presents <24hrs after blunt thoracic trauma - often within a few min
- tachypnea, tachy, hypoxia - rales or decreased breath sounds
- CT/CXR will show patchy infiltrate not restricted by anatomic borders
- tx - pain control, pulm hygiene (neb, chest PT), supplemental O2 and vent. support
ARDS is a common complication of pulm contusion - will present 24-48hrs after trauma
- bilat, patchy infiltrates on CXR
fat embolism
long bone fractures, pancreatitis
- tachypnea (respiratory distress), tachy, hypotension, AMS (confusion, visual field defects), thrombocytopenia, petechiae
- prevention and tx - early immobilization of fracture, supportive care (mechanical vent required fro approx 50% of pts)
rib fractures
rib fractures - pain control!
- in general - surgery is rarely indicated (indications include flail chest with failure to wean from vent, refractory, deformity)
Flail chest
- when 3+ consecutive ribs are fractured in 2 places flail segment moves in during inspiration, balloons out during expiration
- requires large amount of trauma - so make sure that there is no traumatic transection of aorta
- px - chest pain, tachypnea, rapid shallow breaths (splinting)
- rib fractures +/- contusion/hemothorax
- tx - pain control, supplemental O2
- pain control - tylenol, nsaid, pain catheter, rib block, epidural, paraspinous catheter (locoregional block)
- PPV (+/- chest tube) for respiratory failure (due to the pulmonary contusions)
GCS
GCS - for prognosis of medical conditions
eye opening
- spont - 4
- verbal command - 3
- pain - 2
- none - 1
verbal
- oriented - 5
- disoriented - 4
- inappropriate words - 3
- incomprehensible sounds - 2
- none - 1
motor
- obeys - 6
- localizes - 5
- withdraws - 4
- flexure posturing (decorticate, hold on) - 3
- extensor posturing (decerebrate, let me go) - 2
- none - 1
how to dx coma - brainstem activity, decorticate/decerebrate, impaired consciousness
nasopharyngeal carcinoma
associated with EBV - tumor expresses EBV DNA and EBV assays are often used to monitor treatment
- endemic to souther china (and Africa, middle east) - risk is higher here due to diet
- salt-cured food and genetic predisposition
tumors obstruct the nasopharynx and invade adjacent tissues –> nasal congestion, epistaxis, headache, CN palsies, otitis media
- early metastatic spread to cervical lymph nodes = non-tender neck mass
vs nasal polyposis - nasal congestion and rhinorrhea - due to recurrent bacterial sinusitis nasal polyps
- asthma, allergic rhinitis
BAT
factors increasing the likelihood of intra-abd injury - seat-belt sign, rebound, abd distention/guarding, concomitant femur fracture
work-up of BAT (almost always get a FAST)
- pos fast, hemodynamically unstable –> ex lap
- pos fast and hemodynamically stable –> CT scan of abdomen to determine need for laparotomy (will distinguish blood from urine or ascites, site of injury)
- negative fast –> serial abd exams +/- CT
- note DPL can be used if FAST is inconclusive
- r/o BAT labs
duodenal hematomas - most commonly occur following BAT, more commonly seen in kids (due to anatomic differences)
- occurs when BAT compresses the duodenum against the vertebral column
- blood collects between submucosal and muscular layers –> obstruction –> gastric distention 24-36hrs after injury
- dx confirmed with CT manage with NG decompression and TPN
- surgery or perc drainage if non-op management fails
spillage of blood, bowel contents, bile, pancreatic secretions into peritoneum –> acute chemical peritonitis, diffuse abd pain and guarding
- rupture of DOME of bladder will cause urine spillage into the peritoneum - because this the only part of the bladder that is intraperitoneal (also the weakest part of the bladder)
BAT –> damage to mesenteric blood supply –> delayed perf - most commonly of jejunum
small bowel perf
fever, hemodynamic instability, diminished bowel sounds
pain with impending bowel perf (small and large) = periumbilical
- ex - acute appy, mesenteric ischemia (get mesenteric angiography)
- note - visceral pain is poorly localized
nec fasc
micro - Strep pyogenes, S aureus, clostridium perfringens, polymicrobial
pathogenesis - bacteria spread through subQ tissue + deep fascia - most commonly involves extremities and perianal region
clinical - hx of trauma, erythema of skin, swelling and edema, POOP, fever and hypotension
- can also result from significant peripheral vascular disease - diabetes
- LRINEC score - inflammatory markers (CRP, WBC, fibrinogen levels), clinical signs of infection (pain, fever, tachy), other (RBC count, Hgb, Cr, clinical signs of acute renal injury)
tx - surgical debridement and BS abx
- if untreated - progresses to rapid discoloration of skin, purulent discharge, bullae, and necrosis
- zosyn+vanc
- clinda (covers strep antitoxin)
- side note - vanc+zosyn has been associated with increased risk of AKI, can try flagyl+cefepime+vanc
thrombophlebitis
erythema, tenderness, swelling, cord-like vein
aortic injury
consider in MVC or falls >10ft - also in rapid deceleration
- traumatic rupture of aorta - also consider if first rib, scapula, or sternum are broken (because these are very hard to break)
blunt chest trauma sxs - variable but anxiety, tachy, and hypertension are common
- get CXR! - will see mediastinal widening
- can also have tracheal deviation to R or depression of L mainstem bronchus
- CXR –> get chest CT and angiography (possibly transesophageal echo) in stable patients
other injuries in trauma
- myocardial contusion - tachy, rib fractures or sternal fracture, new bundle branch blocks or arrhythmia
- pulm contusion - opacities caused by hemorrhage in lung segments
hemoptysis
pulmonary Tb - on CXR - patchy or nodular opacity, multiple nodules, cavity in apical-posterior segments of upper lobes of lungs
- place pt in respiratory isolation
hemoptysis - rule out oropharyngeal and GI causes
- pulmonary cause
- mild/moderate - CXR, CBC, coag studies, RFTs, UA, rheum work up –> CT scan and possibly bronch
- in pts with hemoptysis and hemodynamic instability or poor gas exchange, severe dyspnea, or massive hemoptysis - FIRST intubate
- massive hemoptysis = >600 mL/day or 100 mL/hr –> bronchoscopy –> pulm arteriography if that fails –> urgent thoracotomy
- give FFP to patients with coagulopathy as the cause of hemoptysis (INR > 1.5)
pancreatic adenocarcinoma
pancreatic cancer is the 4th leading cause of cancer deaths in the US
- more common in men and AA
RF - *smoking*, hereditary pancreatitis (relatives, BRCA, PJ syndrome), chronic pancreatitis, obesity and lack of physical activity most common
sxs - B symptoms (>85%), *abdominal pain/back pain* (80%), jaundice
- others include recent onset DM, unexplained migratory superficial thrombophlebitis (Trousseau sign, most likely because the tumor releases mucins that react with plts to form thrombi)
- hepatomegaly and ascites with mets
- L supraclavicular adenopathy (Virchows node) in pts with metastatic disease
labs/imaging
- cholestasis - increased alkP and direct bili
- CAA 19-9 - will tell about tumor response to chemo
- get abd US if jaundiced or CT scan if not jaundiced (ERCP /MRCP if first two fail)
- ERCP can be used in pts with cholestasis - stenting
- cancer - “explodes” from head - does not have regular borders
- vs a pseudocyst - which will have regular borders
most tumors are at the head of the pancreas - will present with jaundice, steatorrhea
- as these tumors expand –> compress pancreatic duct and common bile duct –> double duct sign
- Courvoisier sign - distended, non-tender gallbladder
jaundice can appear late if tumor is in tail or body ampullary cancer
- will present with obstructive jaundice + anemia and blood in stool
- start with scopes
volvulus
insidious sx onset in adults - ascending colon and sigmoid colon
- transition point usu in cecum or sigmoid
tx - proctosigmoid exam, leave rectal tube in
management of gallstones
RUQ pain –> US
- cholesterol gallstones - with increased estrogen or with decreased enterohepatic recycling (cholesterol saturates)
- asymptomatic - no treatment (only 20% of pts with asx gallstones will develop sxs within 15yrs)
- gallstones with biliary colic (pain is due to gallstone pressing against opening of cystic duct) - elective lap chole, possible usodeoxycholic acid in poor surgical candidates
- complicated gallstone disease (acute chole, choledocho, gallstone pancreatitis) - cholecystectomy within 72hrs
- acute chole - obstruction of cystic duct by gallstone
- note: sxs often subside in a few days with volume resuscitation, abx, and pain meds. However, early cholecystectomy has better outcomes than delayed cholecystectomy (after 7d)
- fenofibrate can contribute to gallstone formation
choledocholithiasis - stone in CBD (CBD dilation, concerned when diameter > 6mm)
- RUQ pain, jaundice (due to biliary obstruction), elevated direct bili, transaminitis
- ERCP + sphincterotomy
- if you have pos IOC:
- 1) glucagon will dilate sphincter of Oddi - give glucagon, wait 5 min
- 2) CDB exploration
gallstone ileus - due to biliary-enteric fistula, sxs intermittent over several days, pneumobilia (air in biliary tree) and dilated loops of bowel
- sxs are intermittent because - stone causes tumbling obstruction –> eventually lodges in ileum
- will have hyperactive bowel sounds
- confirm dx by abd CT
- tx is removal of stone and chole (at some point)
cholecystitis
acute cholecystitis - RUQ pain, fever, leukocytosis (other signs include wall thickening, hydropic GB, dilated CBD)
- etiology - cystic duct obstruction, inflammation, and ischemia? (cystic artery is an end-artery)
- complications - …abscess, chronic cholecystitis
- tx - NPO, IV abx, analgesia
- lap chole shortly after hospitalization
- perform immediately in cases of perforation or gangrene emphysematous cholecystitis
- risk factors - gallstone, DM, vascular compromise (of cystic artery), immunosuppression
- px - …crepitus in abd wall adjacent to gallbladder
- dx - air-fluid levels in GB, cultures with gas-forming bac (Clostridium, E coli), unconjugated hyperbili (because of Clostridium-induced hemolysis)
- tx - emergent chole, BSAbx with clostridium coverage (ampicillin-sulbactam)
chronic cholecystitis - porcelain gallbladder –> increased for gallbladder carcinoma (also, presence of single, asymptomatic gallstone portends increased risk for cancer)
- cholecystectomy is considered
acalculous cholecystitis - ischemic process, biliary stasis leads to infection
acute cholangitis
cause is biliary stasis - bile duct obstruction from gallstones, malignancy, stenosis
Charcot: 1) RUQ pain, 2) jaundice, 3) fever
Reynolds: + hypotension, AMS
significantly elevated alk phos and conjugated bili bile duct dilation on US or CT
tx - abx coverage of enteric bacteria, biliary drainage by ERCP within 24-48hrs
pilonidal disease
age 15-30, M, obese, sedentary lifestyles
issue is an infected hair follicle in the intergluteal region –> abscess, sinus tract –> recurrent abscesses
C diff colitis
sx - tachy, leukocytosis, diarrhea
abx implicated - clinda, FQs, penicillins, and cephalosporins
- PPIs change colonic microbiome - increases risk of C diff proliferation (note the spores are acid resistant)
- C diff carriage is 8-15% and extensive proliferation is required to reach exotoxin levels that are pathogenic
get stool studies (PCR for toxin) - pt with negative studies may require sigmoidoscopy or colonoscopy with bx
- bacterial toxins –> apoptosis of colonic cells, loss of tight junctions
tx with oral metro or vanc
- mild-mod = WBC < 15K, Cr < 1.5x baseline - metro
- severe = WBC > 15K, Cr > 1.5x baseline, serum albumin <3 g/dl - oral vanc
- if pt has an ileus –> add IV metro and switch to rectal vanc
- if pt develops WBC > 20K, lactate >2.2, toxic megacolon, or severe ileus –> subtotal colectomy or diverting loop ileostomy with colonic lavage
- fidaxomicin can also be used
- note: IV vanc is not excreted into the colon (that is why it is not used)
cyclic vomiting syndrome
no symptoms in between vomiting episodes, no underlying condition
often fhx of migraines (CVS is thought to be related to abd migraine) for kids
- 2/3 will outgrow sxs in 5-10yrs
- can give sumatriptan for kids with fhx of migraines
cancer syndromes
Lynch, AD: CRC, endometrial cancer, ovarian cancer
- defect in mismatch repair gene
- early screening via colonoscopy and embx
- ppx hysterectomy and BSO at age 40
FAP: CRC, desmoids, osteomas, brain tumors
- side note - rectum is usually spared
VHL, AD: hemangioblastomas, RCC, pheo
MEN1, AD (adenomas): parathyroid adenomas, pituitary adenomas, pancreatic adenomas
MEN2, AD: medullary thyroid cancer, pheo, parathyroid hyperplasia
biliary cysts
type 1 cysts are most common - extrahepatic single cystic dilatation of the bile duct
px - triad of pain, jaundice (obstructive cholestasis), and palpable mass
- majority present at < 10 yrs, infants can present with jaundice and acholic stools
- adults present with vague epigastric pain/RUQ pain/cholangitis
dx - US, ERCP if obstruction is suspected
tx - surgical resection to relieve obstruction and prevent malignant transformation
nonalcoholic fatty liver disease
hepatic steatosis - occurs due to increased transport of FFA from adipose to liver, decreased oxidation of FF in liver, and decreased clearance of FFA from liver (decreased VLDL production)
- cause = peripheral insulin resistance –> increased peripheral lipolysis and hepatic uptake of Fas
- normally insulin decreases lipolysis in adipose cells
px - mostly asx, metabolic syndrome, AST:ALT < 1, hyperechoic texture on US
tx - diet, exercise, and bariatric surgery if BMI > 35
- safe to continue statin therapy in these patients
note on AST and ALT
- AST is in liver, heart, kidney, and skeletal muscule
- ALT is in reduced quantities in other tissues but is predominantly in liver - more specific for hepatocyte injury (and usually more elevated in liver disease, except for alcoholic liver disease)
hepatic encephalopathy
precipitating factors - drugs (sedatives, narcotics), hypovolemia, hypokalemia or metabolic alkalosis (acid-base problems), increased N load (GI bleeding), infection, TIPS
- note - UGIB will present with elevated BUN and nl Cr
tx - correct precipitating cause and decrease blood ammonia concentration (lactulose, rifaximin)
- lactulose –> metabolized to short-chain fatty acids by colonic bacteria –> acidifies colon –> ammonia becomes charged and trapped in stool
acute pancreatitis
acute pancreatitis
alcohol or gallstones
- rarely drug-induced - valproate, diuretics, ACEi, IBD drugs, immunosuppressants, HIV meds, abx like metro and tet
- drug-induced pancreatitis is usually mild
- hypertriglyceridemia >1000 mg/dL (xanthomas on exam)
- infections - CMV, legionella, aspergillus
- iatrogenic - post-ERCP, ischemic/atheroembolic
dx - 2/below
- acute epigastric pain radiating to back
- (get first) amylase or lipase >3 ULN
- amylase rises 6-12hrs (remains elevated for 3-5d), lipase rises 4-8 hrs (remains elevated for 8-14d)
- (next) abnormalities in imaging
- (CA-19-9 can be elevated)
Imaging
- CT NOT required to dx pancreatitis, but it will show - swelling of pancreas, peri-pancreatic fluid, and fat-stranding
- or RUQ US if you suspect biliary pancreatitis - ALT>150 suggests biliary pancreatitis (also look at BMI, alk phos)
Treatment - SUPPORTIVE (attacks are usu self-limited, resolve in 4-7d), IVFs, NPO, trend lipase (some people like to do this)
- for gallstone pancreatitis - early lap chole
- ERCP only if pt has cholangitis, visible CBD obstruction, or increasing LFTs
- ppx abx are not used (unless there is a necrotizing infection)
severe disease = pancreatitis with failure of 1 organ
- pancreatic enzymes enter vascular system, SIRS –> increased vascular permeability
- fever, tachy, hypotension
- dyspnea, tachypnea, basilar crackles
- abd tenderness or distention
- Cullens (periumbilical), Grey-Turner
- associated with: age >75, obesity, alcoholism, CRP >150 at 48hrs, rising BUN/Cr in first 48hrs, CXR with pulm infiltrates or pleural effusion, CT with necrosis and extrapancreatic inflammation
- complications - pseudocyst, peripancreatic fluid collection, necrotizing pancreatitis, ARDS, ARF, GI bleed acute hemorrhagic pancreatitis
- daily CTs to monitor for abscess development (this is a common pathway to death)
pancreatic pseudocyst
- complications - spont infection, duodenal/biliary obstruction, pseudoaneurysm (due to digestion of adjacent vessels), pancreatic ascites, pleural effusion
- no sxs - symptomatic therapy, NPO
- sig sxs, size > 6cm, older (> 6wk), infection, pseudocyst, pseudoaneurysm - endoscopic drainage
- cystgastrostomy
- then pt starts vomiting –> has aspirated pancreatic secretions –> ARDS
others - pancreatic abscess/necrosis, pleural effusion, ileus, ARDS
gastrinoma/ZE syndrome
80% sporadic, 20% MEN1 (check PTH, ionized ca, prolactin)
- located in duodenum or pancreas uncontrolled gastrin secretion –> parietal cell hyperplasia –> excessive production of gastric acid
px - chronic diarrhea (inactivation of pancreatic enzymes and injury to mucosal brush border) and weight loss when do you suspect a gastrinoma?
- thickened gastric folds, multiple peptic ulcers, refractory ulcers, ulcers in the jejunum (gastric acid cant be fully neutralized in the duodenum)
suspected gastrinoma
1) check serum gastrin level off PPI therapy for 1 week
- level >1000 pg/mL is diagnostic
- check gastric pH to make sure that achlorhydria (failure of gastric acid secretion is not the cause of elevated gastrin)
- <110 rules it out
- for 110-1000 pg/mL, get secretin stimulation test
- normal G cells are inhibited by secretin (but secretin will stimulate gastrinoma cells)
- last ditch effort - calcium infusion study, calcium can lead to increased serum gastrin levels in gastrinoma pts
2) EGD (ulcers and thickened gastric folds)
3) CT/MRI and somatostatin receptor scintigraphy for tumor localization
resection is the treatment of choice for primary pancreatic neuroendocrine tumors (insulinoma, glucagonoma, VIPoma)
- insulinoma - reactive hypoglycemia (after meals)…
- glucagonoma - by serum glucagon levels
- VIPoma - VIP levels, somatostatin scintigraphy to localize
- for these tumors - get CT to locate tumor
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any perforated ulcer - strict NPO, NGT 5d –> look for a leak
TIPS
performed when a pt has ascites that does not respond to medical therapyORhas active/recurrent variceal bleeding even after appropriate treatment with upper endoscopy
Zenkers
cause - upper esophageal sphincter dysfunction and esophageal dysmotility
dx - barium esophagram, esophageal manometry
- side note - oral contrast in a pt with a hx of aspiration is associated with a risk of pneumonitis, but do this regardless because benefits > risks
management - open/endoscopic surgery, cricopharygneal myotomy
complications - tracheal compression, ulceration with bleeding, regurgitation, and pulm aspiration
shingles
may have RUQ pain - pain may precede onset of vesicular rash
- consider shingles in pts with recent cancer (and chemo)
post-chole changes
bile is stored in upper small bowel during fasting
for the first few wks-mo - diarrhea because of insufficient bile acid absorption by terminal ileum
SBO vs ileus
SBO - hx of surgery, distention and INCreased bowel sounds (but will progress to absent bowel sounds, esp if bowel is ischemic), small bowel dilation (with no large bowel dilation)
- will have return of bowel functional temporarily post-op
- proximal v.s. mid/distal
- proximal obstructions - early vomiting, abd discomfort, abnormal contrast filling on XR
- distal - colicky abd pain, delayed vomiting, abd distention, constipation-obstipation
- simple (luminal obstruction) v.s. strangulated (loss of blood supply)
- partial v.s complete
- partial - air in colon
- complete - transition point, no air in colon
- transition point
- complications - ischemia/necrosis, bowel perf
- tx - bowel rest, NG suction, IVFs
- surgical exploration when you are concerned about risk of ischemia, strangulation, and necrosis (signs are fever, hemodynamic instability, metabolic acidosis)
ileus - recent surgery - hrs-d
- hypoK –> what causes hypoK - GI losses, loops/excess aldosterone, correction of DKA (K rapidly moves into cells)
- med induced - morphine
(- pancreatitis)
- possible distension, REDuced bowel sounds - small and large bowel dilation with no transition point
- some degree of ileus occurs following most abdominal procedures, due to increased splanchnic nerve tone (peritoneal irritation) and inflammatory mediator release
- however ileus of >3-5d post-op is prolonged post-op ileus
- techniques to prevent post-op ileus - epidural anesthesia, MIS, judicious peri-op use of IVFs (minimize GI edema)
Ogilvie = paralytic ileus of the colon - massively dilated colon in elderly, sedentary post-op pts
1) fluid and electrolyte correction
2) colonoscopy to suck out air and place a long rectal tube
clinically - 1) rectal enema for decompression, 2) neostigmine to promote evacuation (AchE inhibitor, admit to ICU because it can cause arrhythmias)
Return of bowel function? gas/stool up, NG output down –> resume feeding
solid liver masses
focal nodular hyperplasia (benign) - anomalous arteries
- arterial flow and central scar on imaging
hepatic adenoma - benign epithelial tumor
- long-term OCPs, anabolic androgen use, pregnancy
- possible hemorrhage (so needle bx is not recommended) or malignant transformation
hepatic angiosarcoma - rare
- older men who have been exposed to toxins (vinyl chloride gas, arsenic compounds, thorium dioxide)
regenerative nodules - acute or chronic liver injury
HCC - B symptoms, chronic hepatitis or cirrhosis, elevated AFP
- mass often with satellite lesions
liver mets - multiple (or can be solitary, look at hx)
- most commonly secondary to GI malignancies (portal system) = colon cancer
- often silent until pressure on liver capsule or obstruction of biliary tree causes sxs
- LFTs may be normal
hydatid cysts - Echinococcus tapeworm infections
- southwest - exposure to sheep and dogs
entamoeba - tx with metro
causes of steatorrhea
pancreatic insufficiency - ..CF
bile-salt related
- Crohns, bacterial overgrowth (due to surgical blind loop or motility disorders like scleroderma), PBC, PSC, surgical resection of ileum (at least 60-100 cm)
impaired intestinal surface epithelium
- celiac disease, AIDs enteropathy, giardia
other - Whipple disease, ZES, meds
GOO
mechanical obstruction - post-prandial pain, vomiting, early satiety
- causes - malignancy, PUD, Crohns, strictures (pyloric stenosis)
- physical exam will elicit abdominal succussion splash (auscultation maneuver)
initial management - NG suction, IVFs, endoscopy for definitive dx
esophageal perf
endoscopy is the most common cause
- with severe vomiting - occurs when pt is resisting vomiting reflex
px - … Hammans sign (crunching sound on chest auscultation)
dx - CXR or CT scan will show wide mediastinum, pneumomediastinum, pneumothorax, pleural effusion (late)
- can see esophageal wall thickening, mediastinal air-fluid level on CT
- gastrin esophagram
tx - NPO, abx, IV PPI
- surgical repair (for significant leak with SIRS)
Mallory-Weiss tear associated with alcohol use and hiatal hernia
- bleeding stops spontaneously in 90% of pts
- for ongoing bleeding - endoscopic electrocoagulation or local epi injection
dysphagia
work-up
- orophargyneal dysphagia (difficulty initiating swallowing + cough, choking, nasal regurg)
- videofluoroscopic modified barium swallow (swallow study)
- stroke, dementia, oropharyngeal malignancy, NM disorder (myasthenia)
- px with aspiration pneumonia
- esophageal dysphagia
- solids + liquids –> motility disorder - 1) barium swallow, 2) manometry
- solids then progressing to liquids –> mechanical obstruction
- hx of prior radiation, caustic injury, stricture, or surgery for esophageal/larygneal cancer
- if yes barium swallow then egd
- if no –> EGD
- in general - alarm sxs –> proceed straight to EGD
achalasia - dysphagia to solids and liquids
- mild weight loss - chest pain and heartburn (many pts are initially diagnosed with GERD)
- dx by *manometry* - loss of peristalsis in the distal esophagus with lack of LES relaxation; barium esophagram
- tx - EGD to exclude malignancy, lap myotomy, pneumatic balloon dilation (other options include botox, nitrates, CCBs)
pseudoachalasia - due to esophageal cancer
- sxs are usu more rapid onset and associated with weight loss
- risk factors for squamous cell (anywhere) - tobacco, alcohol
- risk factors for adeno (distal) - Barrett’s, GERD , smoking, obesity
- classically presents with dysphagia to solids (bread, meat), chest pain, weight loss
- CXR will show narrowing of distal esophagus
- barium swallow prior to EGD for cancers - to prevent inadvertent perf
- get EGD and CT for staging
- differentiate by EGD (with bx)
- achalasia - normal mucosa, easy to pass endoscope through LES (unlike in malignancy)
globus sensation - no abnormalities on barium swallow
polymyositis - affects upper third of esophagus (striated muscle)
- also other sxs of weakness (difficulty climbing stairs)
IBD
Crohns - more women, smoking risk factor
- non-bloody diarrhea (if diarrhea is bloody, it is colitis), oral ulcers, arthritis, uveitis, scleritis, erythema nodosum, *lung disease*
- mouth to anus - rectum spared, skip lesions, perianal disease (skin tags, fistulas)
- transmural inflammation, linear mucosal ulcerations, cobblestoning, creeping fat, noncaseating granulomas
- intestinal complications - fistulas, strictures (bowel obstructions), abscesses
- perianal crohns - treat with medical management (fistula tract will appear as a nodule/mound of granulation tissue)
- treat with - 5-ASA, corticosteroids, biologics
- things on differentials - TB enteritis
UC - males, A. Jews, bimodal distribution
- mucosal and submucosal inflammation, erythema and friable mucosa
- pseudopolyps
- crypt abscesses
- other manifestations - arthritis, uveitis, episcleritis, erythema nodosum
- complications - toxic megacolon, primary sclerosing cholangitis, erythema nodosum, pyoderma gangrenosum (looks like necrotic skin infection), spondyloarthritis
- start screening for CRC 8-10 after disease dx
toxic megacolon
- inflammation limited to colonic mucosa in UC - however subset of pts have inflammation that extends to smooth muscle layers –> muscle paralysis –> colonic dilation
- usu occurs early in the disease
- will see systemic toxicity
- dx - abd xray and 3/following: temp >39, pulse >120, WBC > 10.5, anemia
- abd xray - will see dilated colon (haustra markings that dont cross the entire lumen), right colon > 6cm
- note - small bowel will look like stacked coins
- medical EMERGENCY –> colonic perf
- tx - IVFs, BS abx, bowel rest, corticosteroids, surgery if unresponsive to medical management
- DONT give opioids - because they have antimotility effects and can promote colonic perforation
PSC - frequently asx or present with chronic fatigue and pruritis
- inflammation of intra and extrahepatic bile ducts - onion skin connective tissue pattern and lymphocytic infiltration on liver bx (but this is not necessary for dx)
- pos pANCA
- ERCP/MRCP will confirm diagnosis
- complications - biliary stricture, cholangitis and cholelithiasis, cholangiocarcinoma, cholestasis (ADEK deficiency, osteoporosis), colon cancer
alcoholic hepatitis
anorexia, *liver pain*, jaundice, leukocytosis (predominantly neutrophils), decreased albumin if malnourished… LFTs elevated, AST:ALT 2, <300 IU/L
- GGT elevated
- ferritin - acute phase reactant, elevated
- leukocytosis
abd imaging may show fatty liver
for these pts - have them discontinue alcohol (and drug use) and repeat LFTs in 6 mo
- if transaminitis persists - then pt has chronic alcoholic liver disease
- test for hemochromatosis, viral hep, and fatty liver
for treatment of acute AH - quit drinking, supportive therapy
- prednisolone used to treat severe cases - fever, abd pain, jaundice, N&V
blood per rectum
angiodysplasia - painless GI bleeding (maroon stools), venous and low volume
- pts with anemia/gross or occult bleeding can be treated with cautery during endoscopy
- increased incidence after age 60, most common in the R colon
- more frequent in pts with advanced renal dz and vW disease (maybe because of tendency to bleed in these diseases)
- may also be more common in pts with AS - possibly due to acquired vW deficiency (turbulent valve space)
- angiodysplasia can be missed on colonoscopy - due to poor bowel prep
colon cancer - microcytic anemia
diverticulOSIS - arterial bleeding –> BRBPR, painless
- most common cause of lower GI bleeding in adults
- deformation in the colonic wall can cause weakness in associated arterial supply –> bleed
- diverticulosis is more common in sigmoid, bleeding more common in R colon
- confirmed with colonoscopy
- most cases will resolve spontaneously
- strongly associated with chronic constipation –> acute diverticular complications are lower in inds with high fiber intake
- seeds and nut = myth
ischemic colitis - abd pain –> rectal bleeding/bloody diarrhea in 24hrs
hemorrhoids - rarely cause massive bleeding
active bleeding per rectum - first exclude upper GI bleed
1) bleeding hemorrhoids - anoscopy
2) >2 mL/hr - angiogram (may allow for angiographic embolization)
3) <0.5 mL/min - wait for bleeding to stop –> colonoscopy
4) 0.5-2 - tagged red cell study
for past blood per rectum
- young - get EGD
- old - EGD and colonscopy
liver cirrhosis (alcoholic)
definitive dx? cirrhosis by liver bx
jaundice, hyperestrinism (spider angiomata, gynecomastia, loss of sexual hair, testicular atrophy, palmar erythema), ecchymosis and edema (hepatic synthetic dysfunction), portal HTN (esophageal varices, splenomegalcy, ascites, caput medusa, anorectal varices)
- cirrhosis can cause direct gonadal injury, HPA dysfunction, and increased estradiol
- liver also synthesizes thyroid-binding proteins - total T3 and T4 will be reduced (but free levels are unchanged)
- can have parotid gland enlargement - due to fatty infiltration
compensated cirrhosis - asx or non-specific sxs
- uncompensated - jaundice, prurits, upper GU bleeding, ascites, hepatic encephalopathy
if you dx someone with alcoholic liver disease - check for potential complications
- varices (EGD), HCC (screening US every 6 mo)
complications
- variceal hemorrhage - non-selective b-blockers and annual EGD
- ascites - dietary Na restriction, diuretics, paracentesis, quit drinking
- hepatic encephalopathy - id cause, lactulose
- chronic PVT presents as variceal bleeding
- acute PVT - sudden-onset abdominal pain
pts with small varices + risk factors for bleeding, or medium-large varices
- primary ppx - non-selective b-blocker = propranolol or nadalol (reduces portal blood flow and portal pressure) (or endoscopic variceal ligation in patients with contraindications)
TIPS in pts with refractory ascites or varices
acute bacterial parotitis
dehydrated post-op patients and elderly are most prone S. aureus
adequate fluid hydration and oral hygiene pre- and post-op will prevent this complication
b-blockers peri-op
peri-op b-blockers in pts with CAD decreases likelihood of myocardial ischemia peri-op
MI is due to hypotension - will usu not present with chest pain
peri-op abx
give routine for pts undergoing abdominal surgery
aortic aneurysm
thoracic aneurysm - definitive dx by *MR angio*/CT angio
- ascending - repair with surgery
- descending - repair with HTN control (ICU)
abd aneurysm is >3cm - involves all aortal layers and does not create and intimal flap or false lumen (unlike thoracic aortic aneurysms)
AAA rupture - blood can collect into adventitial layer, rupture can occur into peritoneum or retroperitonuem
- sxs - abd pain/back pain and hypotension (syncope)
- CT only in stable pts, OR for unstable pts
- AAA can rupture into retroperitoneum and create and aortocaval fistual –> venous congestion in bladder –> gross hematuria
complications following repair
- for thoracic aortic aneurysm - anterior spinal cord syndrome
- because anterior spinal artery is dependent on thoracic aorta blood, px will be *bilateral* flaccid paralysis and impaired pain/temp sensation
- late complication from AAA repair is aortoenteric fistula - duodenum..
post-op fever
definition - T> 38.6
immediate
- prior trauma/infection
- blood products
- mal hyperthermia (…metabolic acidosis, hypercalcemia, muscle rigidity)
- bacteremia - 30-45min classically
- normal post-op physiologic response - will be less than 38.5
5Ws - atelectasis (doesnt cause fever), pneumonia, UTI, DVT, wound infection, deep abscess POD1d-1wk
- nosocomial infections - S epi will be from central line, enteric orgs will be associated with foley
- VAP - after 48hrs of being on ventilator
- surgical site infection due to group A strep (beta hemolytic strep classically causes high fevers early in the post-op period) or clostridium
- non-infectious - MI, PE, DVT (doppler)
- many institutions dont recommend removing dressing until 24hrs post-op
POD1wk-1mo
- surgical site infection due to other orgs - C diff, E coli and MRSA (d5-7)
- drug fever - DOE, occurs 1-2 wks after mediation administration, often accompanied by rash and peripheral eosinophilia (drugs implicated are anticonvulsants, abx, allopurinol)
- PE/DVT
POD1mo and more
- viral infections (from blood products)
- infective endocarditis
- surgical site infection due to indolent orgs
- note on necrotizing SSI - DM, polymicrobial - pain, edema, or erythema spreading beyond the surgical site
- systemic signs (SIRS)
- paresthesia or anesthesia at edges of the wound
- dishwater drainage
- subQ crepitus –> EARLY surgical exploration (to prevent nec fasc)
reactions to blood products
- febrile nonhemolytic transfusion reaction - small amounts pf cytokines in PRBC bag (due to plasma or leukocyte debris) –> transient fevers, chills, malaise within 1-6hrs after transfusion
- acute hemolytic reaction
- TRALI
Fever in the SICU >38.5
- fever at 38 in - patients on CVVH (dialysis), immunosuppressed/transplant
- fever in ICU - 50% of febrile ICU patients have no source of infection
other notes
- temps are greater in the evenings compared to mornings
- temp below 35 or above 40 indicates severe disturbance of body’s autoregulatory system
- at T > 40, cellular damage will begin - important to control temp
compartment syndrome
common features - POOP, pain on passive stretch, rapidly increasing and tense swelling, parasthesia
- uncommon - decreased sensation, motor weakness, paralysis (late), decreased distal pulses
- when will you see this? - ischemia-reperfusion syndrome
- also with lower extremity embolectomy
- circumferential eschar - constricts venous and lymphatic drainage…
- dx by compartment pressure > 30 mm HG
- if compartment pressures are improving - pts may be observed
- pts with elevated pressures and no signs of improvement –> fasciotomy
v.s an embolism - absent pulses, pallor of affected limb, lack of local swelling
v.s. DVT - vague aching pain (rather than this exquisite pain)
traumatic diaphragm injury
more common on L
some pts (esp kids) will have no sxs initially
- will px mo-yrs later with vague chest pain (due to expansion of diaphragmatic defect and herniation of abdominal organs)
CXR - abdominal contents in thorax, shifting of mediastinum
- may see NG tube in thorax
- but CT is more sensitive so get CT if CXR is unrevealing
hemothorax
each hemithorax is capable of holding up to 50% of circulating blood volume
- massive hemothorax is >1.5L or 600 mL/6hrs
- most common cause of massive hemothorax are traumatic lac to lung parenchyma, damage to intercostal or internal mammary artery
atelectasis
lobar or segmental collapse –> decreased lung volume
- decreased FRC?
- will hear decreased breath sounds in that section
post-op atelectasis - accumulation of pharyngeal secretions, tongue prolapsing into pharynx, airway tissue edema, residual anesthetic effects, splinting
- low pO2 (small-airway mucus plugging) and low pCO2 (fast shallow breathing)
- loss of lung volume
- side note - in this regard, intercostal nerve blocks have shown success in reducing post-op pulm complications
ABG - pt will be hypoxemia due to lung collapse and V/Q mismatch
- low PaO2 - pt will hyperventilate due to hypoxemia
- low PaCO2
post-op pulm complications
atelectasis, bronchospasm or exacerbation of chronic lung disease, prolonged mechanical ventilation
risk factors - age >50, emergency surgery or surgery longer than 3hrs, HF, COPD, poor general health (ASA >2)
pre-op strategies
- smoking cessation 8wks pre-op
- note on smoking - issue with ventilation = high PCO2, low FEV1 - no issue with oxygenation
- sx control of COPD (pre-op glucocorticoids)
- tx of respiratory infections prior to surgery
- pt education of pulm toilet post-op strategies - pulm toilet, epidural instead of opioids, PEEP
suspected variceal hemorrhage
1) place 2 large bore IVs - volume resus, IV octreotide (leads to splanchnic vasoconstriction and decreased portal flow), abx (ppx abx for pts with cirrhosis, to prevent SBP)
urgent endoscopic therapy with band ligation or sclerotherapy
- if no further bleeding - start b-blocker and endoscopic band ligation 1-2 wks later
- if continued bleeding - balloon tamponade (eponymed tubes) temporarily –> TIPS/shunt
- if early rebleeding - repeat endoscopic therapy –> recurrent hemorrhage –> TIPS/shunt
in approx 50% of variceal bleeding - hemorrhage ceases on its own
- in other UGIB - this rate is 90% side note - current guidelines suggest keeping hgb >9 in variceal hemorrhage
AKI
oliguria <500 mL/24hrs
Pre-renal
- decreased renal perfusion - true volume depletion, decreased EABV (heart failure, cirrhosis), displacement of intravascular fluid (sepsis, pancreatitis), renal artery stenosis (afferent arteriole vasoconstriction), NSAIDs
- features - increase in serum Cr (50% from baseline), decreased UOP
- BUN/Cr >20:1
- BUN increases because it is passively reabsorbed during the active reabsorption of Na and water
- FeNa <1%
- treat by restoring renal perfusion - give bolus of saline
b-lactam abx - cause acute interstitial nephritis
- will see WBC on UA and a skin rash
- if blood flow drops too much –> acute tubular necrosis
Evaluation
suspect AKI - get urine lytes, AKI increases mortality risk
- if pt has been on diuretics in the last 3d, FeNa is unreliable - get FeUrea
Other
ACE/ARB in SICU pt - dont restart post-operatively –> causes vasodilation and AKI???
varicocle
soft scrotal mass (bag of worms) - more common on L side
- left spermatic vein drains into left renal vein (passes in between the SMA and aorta)
- can be compressed beneath SMA
- v.s. the R spermatic vein - drains directly into IVC
- R-sided varicoceles are rare and can be a sign of malignant compression or thrombosis
- can cause elevated scrotal temps –> subfertility, testicular atrophy
- US - retrograde venous flow, tortuous, anechoic tubules adjacent to testis
- dilation of pampiniform plexus veins
- tx - gonadal vein ligation - boys and young men with testicular atrophy
- scrotal support and NSAIDs - for men who dont desire children
other testicular masses
- spermatocele - painless mass at superior pole of testis
- testicular cancer- painless mass, almost always malignant
- tx by radical orchiectomy, metastatic dz responsive to radiation or platinum-based chemo
- hydrocele
burns
at home - IRRIGATION
airway - supraglottic airway is very susceptible to direct thermal injury –> edema and blistering
- subglottic airway is protected from injury by reflexive closure of vocal cords upon exposure to extremely hot air
- all burn pts should be given high-flow O2 - maintain a low threshold for intubation
increased metabolic rate - due to release of inflammatory mediators - increased basal temp, tachycardia and tachypnea, hyperglycemia
steroids are contraindicated in burn pts - steroids are diabetogenic and immunosuppresive and burn pts are already prone to metabolic derrangements and immunosuppression
infections - immediately after a severe burn - gram pos organisms dominate
- after 5d - gram negative or fungi dominate (pseudomonas, candida) - burn wound sepsis
- partial-thickness injury turns into full-thickness injury, temp changes, tachycardia, tachypnea, refractory hypotension, oliguria, unexplained hyperglycemia, TCP, and AMS
- quantitative wound culture and bx for histopathology
- treat with BS iv abx (pip/tazo, carbapenem), MRSA (vanc), MDR pseudomonal coverage (AG)
- local wound care and debridement
other things
- tetanus
- silver sulfadiazine = standard
- if thick eschar, cartilage - mafenide acetate
- triple abx near eye
(acute) colonic/mesenteric ischemia
pathophys - non-occlusive, occurs in watershed areas - splenic flexure (SMA and IMA) and rectosigmoid (between sigmoid and superior rectal)
- underlying atherosclerotic disease/thrombus (…recent MI, infective endocarditis emboli) = small bowel ischemia
- low blood flow - post-AAA repair
- adverse effect can be minimize by checking sigmoid colon perfusion following placement of aortic graft
px - mod abd pain and tenderness, urge to defecate, hematochezia, diarrhea, leukocytosis, lactic acidosis (low bicarb)
- elevated amylase and phosphate
dx - CT will show colonic wall thickening and fat stranding
- mesenteric angio if dx unclear - EGD will was edematous and friable mucosa
management - IVFs and bowel rest, abx, anticoag to limit clot expansion (if pt is not actively bleeding)
- immediate operative eval if evidence of bowel infarct
- embolectomy w/ bypass or endovascular thrombolysis
- colonic resection if necrosis develops
v.s. chronic mesenteric ischemia - epigastric pain shortly after eating (blood is shunted away from intestines to feed the stomach)
- atherosclerosis - smoking, dyslipidemia
- food aversion, abdominal bruit in 50% of pts
- get CT angio
- tx - risk reduction, nutritional support, and endovascular or open surgical revascularization
splenic injury
one of the most common intra-abdominal complications of BAT signs - hypotension, pleuritic CP, left abd wall bruising or tenderness, abd guarding
pts who are hemodynamically stable
- FAST –> if negative FAST –> CT for pts with high risk features
- pts with AMS - proceed directly to CT
if operative intervention is required - every effort is made to SAVE the spleen
note - if someone has mono (fever, sore throat, spleen will be enlarged), there is a greater risk of splenic injury
encapsulated bacteria - S. pneumoniae, Hib, N. meningitidis, E. Coli, Salmonella, Klebsiella, Group B streptococci
abscess
any old abscess
- if you leave a penrose drain in place - you dont need packing
- wound will drain and heal by secondary intention
abdominal abscess
- not amenable to drainage - start IV abx, trend WBC, CT scan in 5d (will not see any appreciable change if you scan earlier)
psoas abscess - fever, abd/flank pain that radiates to the groin
- abdominal pain with hip extension (psoas sign)
- risk factors - HIV, IVDA, DM, crohns disease
- can be direct (even from diverticulitis) or hematologic seeding
- get CT abd/pelvis and BC and abscess cultures
- tx - drainage, broad spectrum abx
- note psoas abscess is on the differential for fever of unknown origin
chronic radiation proctopathy
often causes bloody stools - usu presents for the first time within the first of treatment
GSW
because of diaphragm movement during inspiration and expiration
- any penetrating injury below the nipple line has the potential to involve the abdomen
- infact it is thought to involve the thorax and abdomen until proven otherwise
- for a hemodynamically unstable pt –> ex lap (even if there is no peritoneal fluid on fast exam)
- ED thoracotomy for refractory shock, SBP < 60
- for a stable pt and fast negative - get CT
GSW to abdomen
- can involve chest cavity - consider if you perform and ex lap and find no blood in the abdomen
- can vent chest (pericardial window) through the diaphragm
pts with suspected spinal cord injury
place urinary cath - to assess for urinary RT and prevent possible bladder injury (from acute distention)
traumatic amputation
place limb/digit in sterile, saline moistened gauze and in a plastic bag –> place the bag on ice
appendicitis
Rovsing sign - RLQ pain with deep palpation of LLQ
for pts with classical presentation –> lap appy
- for pts where dx is unclear - CT or US to confirm dx
- pts with appendicitis who have had sxs for >5d usu have phlegmon with abscess (phlegmon = localized area of acute inflammation of the soft tissues)
- IV abx, bowel rest, and delayed appendectomy (6-8wks later, because presently the appendix will be inflamed, infection, friable)
- these pts will present without peritoneal signs, instead they may have pos psoas sign
mesenteric adenitis - RLQ pain, guarding, tenderness
- can be mistaken for appendicitis - get CT
C-spine trauma
scenario - fall
pre-hospital - spinal immobilization, careful helmet removal, airway oxygenation
ED - orotracheal intubaion - RSI if pt is unconscious pts who are breathing but need ventilatory support
- cervical stabilization unless it interferes with intubation
- CT Cspine - monitor for neurogenic shock
when would you get CT c-spine - basilar skull fracture, blunt neck trauma, facial fracture, CHI
airways
securing an airway
1) jaw thrust, head tilt-chin lift
2) bag mask (6-8 breaths/min)
3) RSI - 7Ps (prep, pre-oxygenate, pretreatment, paralysis w sedation [sux], protection and positiioning, placement with proof, post-intubation management)
- ET tube - 2 cm from carina
- LEMON - look externally, eval 332 fingerbreadths (mouth opening, hyoid, thyroid cartilage), mallampati, obstruction/obesity, neck mobility
unable to intubate (mulitple attempts) - surgical airway (cric)
nasotracheal intubation - blind procedure
- contraindicated in apneic/hypopneic pts
- also contraindicated in basillar skull fracture as these fractures may have cribiform plate disruption (tube could enter brain)
subQ emphysema - fiberoptic bronchoscope
cric is FAST
- needle cric - not ideal in pts with head injury (these pts may require hyperventilation to treat intracranial HTN)
- cric has risk of CO2 retention
- surgical crich - prolonged use of cric has a high incidence of tracheal stenosis
surgical tracheostomy, formal tracheostomy
- dreaded complication - tracheoinominate fistula
Gilbert syndrome
more common in males, most common inherited disorder of bilirubin glucuronidation AR or AD
- decreased UDP-glucuronosyltransferase activity –> increased UCB
px - intermittent mild jaundice provoked by stress
only lab abnormality will be unconjugated hyperbilirubinemia - Hgb will be normal
- NO evidence of hemolysis
tx - reassurance and supportive care
acalculous cholecystitis
critically ill hospitalized pts - severe trauma or recent surgery, prolonged fasting/TPN, critical illness (mechanical vent)
- likely due to cholestasis and gallbladder ischemia –> secondary infection
unexplained fever, leukocytosis, elevated LFTs and bili (but normal results dont exclude the dx), RUQ pain
- jaundice and RUQ pain are less common
dx
- US - will see thickened gallbladder wall with distention, pericholecystic fluid
- get HIDA or CT if needed
tx - perc cholecystostomy and chole after pt’s medical condition improves
- enteric abx coverage
complications - sepsis, death, gangrene, perf, emphysematous cholecystitis (cholecystitis with clostridium)
blunt GU trauma
get UA for hemodynamically stable pts –> contrast CT to id and stage renal trauma
unstable pts –> IV pyelogram –> surgery
- note - most renal injuries can be managed non-operatively
bleeding considerations
O2 delivery doesnt become deficient until Hgb < 7g/dL
DDAVP increases factor 8 levels (indirectly) - give pre-op to patients with hemophilia A
plts >50K will provide adequate hemostasis for most procedures
hypocalcemia
- signs
- why?
tetany, seizures, LONG QT
- Chvostek sign, Trousseau sign (carpopedal spasm upon inflation of blood pressure cuff)
primary
- post-surgical - most common cause, takes a modest decrease to cause sxs
- automimmune primary hypoparathyroidism
- congenital absence of parathyroid glands (DiGeorge syndrome)
- defective Ca-sensing receptor on parathyroid glands
- non-autoimmune destruction of parathyroid gland due to infiltrative diseases (hemochromatosis, Wilson disease, neck irradiation)
secondary: insufficient Ca intake –> secondary hyperparathyroidism –> increased PTH and hyperplasia of parathyroids –> increased Ca and increased renal phosphate loss (hypophosphatemia)
tertiary: due to chronic renal disease (very increased PTH –> increased Ca)
other reasons - CYP450 inducers (phenytoin, carbamazepine, rifampin) cause vitamin D deficiency by degrading vitamin D into inactive metabolites
- kidneys convert 25-OH-D to 1,25-OH-D
- note - serum phosphorous is low in vitamin D deficiency
- precipitation of Ca with phosphate - renal failure, rhabdo, phosphate administration
PTH actions
- bone - long-term indirect action on osteoclasts –> increased Ca and phosphate
- kidney - increased Ca reabsorption and phosphate excretion
vitamin D
- increased Ca and phosphate absorption from gut and kidney
persistent hypothyroidism
can be seen post-thyroidectomy - can also see hyponatremia
complications of cardiac cath
local vascular complications at the cath site are the most common complications - bleeding
- hematoma - localized or with retroperitoneal extension (back pain)
- arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula
cholesterol emboli - s/p cardiac cath
- pts who have risk factors for aortic atherosclerosis
- signs and sxs - livedo reticularis, blue toe syndrome, AKI, pancreatitis, mesenteric ischemia
anterior mediastinal mass
4Ts: thymomas, teratoma, thyroid neoplasm, terrible lymphoma teratoma - Ca deposition (tooth), fat
- note - for seminoma, only bhCG will be elevated
melena
UPPER gi bleed- PUD, gastritis, esophagitis, Mallory-Weiss teargive anti-secretory medication (PPI)
deep neck space
retropharyngeal compartment - infection in this compartment drains to superior mediastinum
- spread to the carotid sheath –> thrombosis of IJ and deficits of CN 9-12
- extension through danger space (two fascias) –> posterior mediastinum and diaphgram
- acute necrotizing mediastinitis - fever, chest pain, dyspnea, odynophagia, requires urgent surgical intervention
paranasal sinus infection –> bone –> subdural empyema
infected molar –> Ludwig angina - bilateral cellulitis of submandibular and sublingual spaces
- AIRWAY
- infection in central face area –> cavernous sinus thrombosis - occurs due to valveless facial venous system
nasal furunculosis is potentially life threatening as it can spread to cavernous sinus
- px = diplopia, facial pain, fever
- EMERGENCY - dx with MRI, tx with early IV abx, and drain affected paranasal sinuses
acute mediastinitis
complication of cardiac surgery - due to intra-op wound contamination
px - within 14d post-op, fever, tachy, chest pain, leukocytosis, sternal wound drainage (or purulence)
- widened mediastinum
tx - surgical debridement with immediate closure and prolonged abx therapy
other things post-cardiac surgery
- afib is common - self-limited, rate control with b-blockers or amiodarone is best
- anticoagulation and/or cardioversion reserved for patients with atrial fib >24hrs post
- pericardiotomy syndrome - fever, leukocytosis, tachy, and chest pain
- autoimmune, occurs few wks following procedure where incision was made into pericardium - NSAIDs to treat (any) pericardial inflammation)
PUD
majority of duodenal ulcers are cause by H pylori infection and NSAIDs
- if H pylori is likely - start eradication triple therapy (PPI, amox, clarithro)
dx - EGD
tx - NG suction, IVFs, broad spectrum abx, **IV PPI**
- for stable pts with Hgb < 7 - give PRBC
- transfuse at Hgb <9 for pts with ACS
- for pts with active bleeding and hypovolemia - transfuse at higher Hgb levels
pericardial tamponade
acute - only takes 100-200mL to compromise hemodynamics, cardiac silhouette may appear normal
chronic processes (malignancy, renal failure) cause slow accumulation of pericardial fluid - 1-L before intrapericardial reaches a critical point
- globular cardiac silhoutte
dumping syndrome
sxs - abd pain, diarrhea, nausea
- hypotension, tachycardia
- dizziness/confusion, fatigue, diaphoresis - 12-30 min after meals
common postgastrectomy - 50% of pts
- due to loss of normal action of the pyloric sphincter due to injury or surgical bypass - *rapid emptying* of hypertonic gastric contents
- causes fluid shifts from intravascular space to SI = hypotension, stimulation of autonomic reflexes, release of intestinal vasoactive polypeptides
initial management - small frequent meals
- replace simple sugars with complex carbs
- incorporate high fiber and protein-rich foods
- drink fluids in between meals (not during meals)
diverticulitis
acute diverticulitis - inflammation due to microperforation of diverticulum LLQ abd pain, fever, N&V, ileus (peritoneal irritation)
- can have urinary signs from an inflamed sigmoid colon
- dx - abd CT (oral and IV contrast)
uncomplicated (75%)
- can be managed outpatient with bowel rest, oral abx, observation
- hospitalization recommended if pt is elderly, immunosuppressed, severe comorbidities, or high fever/WBCs
complicated (25%) - abscess, perf, obstruction, or fistula formation
- fluid collection <3cm - tx with IV abx and obs
- fluid collection >3cm - CT-guided perc drainage –> surgical drainage and debridement recommended if sxs dont improve by 5d
on your differential - epiploic appendigitis
hip fracture
intracapsular - femoral neck and head
- higher risk of avascular necrosis
extracapsular - intertrochanteric, subtrochanteric
- greater need for implant devices
- requires immobilization - high risk of DVT and PE, recommend post-op anticoagulation
in general - operate asap
- may delay surgery up to *72hrs* if need to address an unstable medical comorbidity (do skeletal traction in the meantime) - need medical stability prior to operating
nutrition in alcoholics
nutritional deficiencies - banana bag useless, give high dose IV thiamine
scurvy - signs arise w/i 3 mo of deficiency
- follicular hemorrhage, bleeding gums, arthralgias, weakness, impaired wound healing
- vasomotor instability if severe/prolonged
- dx by serum ascorbic acid level
- tx - oral/injectable vitamin C (sxs resolve w/i days), watch for tox (abd pain, diarrhea, nausea)
sepsis treatment
1) give crystalloid (it is cheaper than albumin) - 500-1000mL boluses to achieve SBP >90
2) vasopressors - dopamine
3) IV hydrocortisone
other randoms
- hemodialysis if: uremia, fluid overload, major electrolyte abnormalities (AEIOU)
- bicarb if severe acute acidosis (pH <7.2)
hematuria
initial hematuria (urethra issue) - urethritis, trauma (cath)
total hematuria (kidney) - renal mass, glomerulonephritis, urolithiasis, PKD, pyelo, urothelial cancer, trauma
- renal cell carcinoma - tx is surgery
terminal hematuria (bladder issue) - urothelial cancer, cystitis, urolithiasis, BPH, prostate cancer
- clots suggest bleeding in bladder or ureters (get cystoscopy)
- cancer of bladder - SMOKING
most cases of hematuria are benign - 1) CT scan, 2) cystoscopy
signs of peritonitis
guarding, rigidity, reduced bowel sounds, rebound tenderness = perforated viscus
complications - subphrenic abscess (rare)
general anesthesia
impairs to laryngeal defenses –> aspiration of gastric contents, hypoventilation
sux (rapid on/off)- depolarizing NM blocker, binds to postsynaptic AchR –> influx of Na and efflux of K –> temp paralysis
- contraindicated in crush injury - pt can be at risk for life-threatening cardiac arrhythmia due to severe hyperkalemia (use roc instead)
- side note - post-syn AchR upregulated in skeletal muscle injury (burn, disuse muscle atrophy, and denervation also have this)
etomidate - inhibits 11b-hydroxylase –> adrenal insuffiency
- elderly and critically ill are most susceptible
NO - inactivates B12, problems for pts with pre-existing B12 def
propofol - severe hypotension (due to myocardial depression)
air embolism
following major thoracic trauma acute circulatory failure (hypotension, SOB) and neuro signs (stroke type signs)
immediate management - cardiac massage
PAT
indications for urgent ex lap
- hemodynamic instability
- peritonitis
- evisceration
- blood from NG tube or on DRE
no indications for urgent ex lap –> locally explore wound and get eFAST (to asses for pneumo- and hemothorax)
penetrating neck trauma - surgical exploration IF expanding hematoma, deteriorating vital signs, or signs of esophageal/tracheal injury
- upper zone - arteriography
- base of neck - arteriography, esophagram, esophagoscopy, bronchoscopy
penetrating urologic injury is surgically explored
extremity vascular trauma
hard signs –> surgical exploration
- observed pulsatile bleeding
- bruit/thrill over the injury
- expanding hematoma
- signs of distal ischemia (absent pulses, cool extremity)
soft signs - hx of hemorrhage, diminished pulses, bony injury, neuro abnormality –> injured extremity index (<0.9 is ABnormal) –> CT/CT angio, doppler
shock
hypovolemic
- hypovolemic shock drop in blood pressure occurs when 25-30% of blood volume has been lost
- low CO
- if you mechanically ventilate someone in hypovolemic shock –> increase intrathoracic pressure –> collapse of venous system, loss of RV preload
obstructive - PE, cardiac tamponade
hiatal hernia
type 1 (sliding, 90%) - GE junction migrates above diaphragm
- widening of muscular hiatal tunnel, circumferential laxity of phrenoesophageal ligament
type 2 (rolling) - GE junction normal, fundus herniates through diaphgram
- localized defect in phrenoesophageal ligament
type 3 (mixed) - type 1 + type 2
- progressive enlargement of hernia through hiatus causes phrenoesophageal ligament to stretch
type 4 - something other than stomach herniates (omentum, colon, small bowel)
phrenoesophageal ligament - extenion of inferior diaphragmatic fascia, upper and lower limbs (which attach to superior and inferior surfaces of the diaphragm)
vagus nerve CN10
- along the esophagus - anterior (from primarily L vagus) and posterior (R vagus) trunks
- function
- PSNS to all orans from neck to second segment of transverse colon (acid secretion)
- controls skeletal muscles of neck, palate, pharynx, larynx
- fibers that innervate the pharynx - gag reflex
- 5-HT3 receptor mediated vagus stimulation in gut –> vomiting
- role in satiety
- SNS (via peripheral chemoreceptors, activated due to hypoxemia) - vasoconstriction and increased BP
- PSNS - heart, SA node
paraesophageal hernia - heartburn, dysphagia
- pre-op eval - barium esophagram, upper EGD, sometimes 24hr esophageal pH study/manomatery (but are omitted if it is difficult to instrument the esophagus)
- steps: 1) divide gastroheaptic ligament, 2) divide gastrosplenic ligament (now both crus are visualized), 3) Nissen (360)
- if the esophagus below the diaphgram is too short –> Collis gastroplasty - staple down left side of esophagus into stomach creating a neoesophagus (can now sufficiently wrap fundus around esophagus)
- complications of Nissen - gas bloat syndrome, dysphagia, dumping syndrome, vagus nerve injury, achalasia (rare)
- post-op - remove NGT on POD1, barium swallow on POD1 to evaluate for a leak, start CLD if there is no leak
- discharge on POD2
- f/u in 1 mo with another barium swallow
Mirizzi syndrome
gallstone impacted at gallbladder neck –> chronic inflammation and fibrosis –> obstruction and erosion of CBD wall
