GenSurg Flashcards
Contents: Pancreatitis, Diverticulitis, Appendicitis, Inguinal hernia, Bowel Obstruction, Cholecystitis
1
Q
What are the most common causes of pancreatitis?
A
Chronic EtOH & gallstones.
Less common: hypercholesterolemia, iatrogenic (eg ERCP)
2
Q
What are the chronic sequellae of pancreatitis?
A
Pancreatic pseudocyst
Splenic vein or portal vein thrombosis
Hemorrhagic pancreatitis
3
Q
What are the PQRST symptoms of pancreatitis?
A
Epigastric pain
P: better leaning forward, worse lying down
Q: sharp (though can be dull)
R: radiates straight through to back (not around like chole issues)
S: severe
T: Acute, constant
4
Q
What history is important to elicit in suspected pancreatitis?
A
EtOH Gallstones, biliary disease Hypercholesterolemia Recent procedures like ERCP Medications (eg thiazides can be linked)
5
Q
How will a patient with pancreatitis appear on exam? (General appearance)
A
Ill; may be obtunded or diaphoretic
6
Q
What vital sign abnormalities will be found in pancreatitis?
A
Tachycardia, fever, tachypnea
Hypotension (or orthostatic)
7
Q
What will the HEENT and cardiac exams show in pancreatitis?
A
HEENT: dry mucous membranes, Sx of dehydration, scleral icterus
Chest: Normal (can have atelectasis from shallow breathing)
8
Q
What will be found on abdo exam in pancreatitis?
A
- Soft, non-distended
- Moderate to severe tenderness in epigastrium or upper abdo
- Decreased bowel sounds
- Often, involuntary guarding
9
Q
What other finding may be found on abdo exam in pancreatitis?
A
- if pseudocyst: may have palpable mass
- if hemorrhagic: Grey-Turner’s sign (R flank hematoma) or Cullen’s sign (periumbilical hematoma)
10
Q
What is the hallmark of pancreatitis?
A
Severe dehydration and intravascular depletion
11
Q
What is SIRS?
A
Systemic Inflammatory Response Syndrome: two or more of: - fever or hypothermia - tachycardia - tachypnea - change in blood leukocyte count
12
Q
What lab finding is most sensitive and specific for pancreatitis?
A
Lipase: often elevated into the thousands
13
Q
What imaging is ordered for suspected pancreatitis?
A
Abdo CT with Contrast is diagnostic (sensitive and specific). Can also Dx complications like pseudocyst, hemorrhagic pancreatitis
Consider AXR and CXR to r/o other causes
14
Q
How is pancreatitis prognosis assessed?
A
CT scoring system (Balthazar score) based on degree of necrosis, inflammation, and the presence of fluid collections
15
Q
How is pancreatitis treated acutely?
A
Fluid resuscitation with crystalloid and colloid Monitor electrolytes Pain control NPO Consider early nutritional support
16
Q
What are some acute complications of pancreatitis?
A
Respiratory failure Hemodynamic instability/shock ARDS DIC Sepsis GI Bleed Progression to infected pancreatic necrosis
17
Q
How is infected pancreatic necrosis diagnosed and treated? What is the mortality?
A
Dx: percutaneous aspiration
Tx: aggressive operative debridement
High mortality.
18
Q
What procedures are done for pancreatitis?
A
Depends on presentation.
- pancreatic necrosectomy
- cholecystectomy
- drainage of cysts via cyst gastrotomy (IR, endoscopy, laparoscopic, open)
- splenectomy if splenic vein thrombosis
19
Q
How long should a patient with pancreatitis be kept NPO?
A
Until pain-free.
Consider NGT if vomiting.
20
Q
What are immediate post-op concerns with pancreatitis?
A
Bleeding
Ileus, return of bowel function
21
Q
What are short-term post-op concerns with pancreatitis?
A
Surgical site infection
Anastomotic leak
Intra-abdominal abscess
Pancreatic leak
22
Q
What are the signs of post-procedure intra-abdominal abscess?
A
Poor appetite
Low-grade fever
23
Q
What are diverticula? Where are they found?
A
Small mucosal herniations in the colon.
Often at perforating vasa recta, ie weak points in colon wall.
Usually L colon (R in Asian pop)
24
Q
Name three risk factors for developing diverticulitis
A
- Diverticula
- Increasing age
- Western population
Also possibly low fibre diet, constipation, obesity
25
What is tenesmus?
Continual or recurrent feeling of needing to evacuate bowels (even after having done so)
26
What are the clinical features of diverticulitis? (Name 2 presenting symptoms, + other SSx)
Main:
Steady, deep discomfort in LLQ
Change in bowel habits
```
Additional:
Urinary symptoms
Tenesmus
GI Bleed
Paralytic ileus
SBO (Small bowel obstruction)
```
27
What physical findings are commonly present in diverticulitis?
- Low-grade fever
- Localized tenderness
- Left-sided pain on rectal exam
- Occult blood
- Rebound and guarding
- Peritoneal signs (suggest perforation or abscess rupture)
28
What investigation best confirms a diagnosis of diverticulitis?
```
CT scan (IV and oral contrast)
Findings:
- Pericolic fat stranding
- Diverticula
- Thickened bowel wall
- Peridiverticular abscess
```
29
What lab finding is present in about 1/3 of patients with diverticulitis?
Leukocytosis (present in only 36% of patients)
30
What is the medical management of diverticulitis?
- Fluids
- Correct electrolyte abnormalities
- NPO
- Abx: For outpatients (non-toxic). Liquid diet x 48 hours, cipro and flagyl
31
What is the surgical management of diverticulitis?
Elective (uncomplicated): primary anastomosis
Emergency (complicated):
- Primary anastomosis with a proximal diversion, or
- Hartmann's (resection with anorectal closure + end colostomy)
32
Is it necessary to resect all diverticulae?
No
33
Why might there be urinary symptoms in diverticulitis?
Spread of inflammation to nearby bladder
34
What is complicated diverticulitis?
Complicated diverticulitis includes perforation, abscess, obstruction, or fistula
35
What is the pathophysiology of appendicitis?
Obstruction of the lumen of the appendix
Continued secretion → impaired venous return & edema → arterial compromise, ischemia → gangrene → perforation
36
What is a phlegmon?
Mass of inflammatory tissue (e.g. can have a phlegmon next to an inflamed appendix)
37
What systems should be reviewed in suspected appendicitis?
GI, GU, Gyne, Resp, MSK, Trauma
38
What is the classic presentation of appendicitis, and approx what % of pt present this way?
1/2 to 2/3 present classically
- Periumbilical pain
- Anorexia, nausea, vomiting
- Pain localizes to RLQ
39
What % of appendices are retrocecal? in RUQ?
26% are retrocecal
| 4% are in RUQ
40
Where does a retrocecal appendicitis cause pain?
R flank
41
What symptoms does a suprapubic appendicitis cause?
Suprapubic pain
| Dysuria
42
Where might men have pain from appendicitis?
Testicles
43
What signs are present on the physical exam in appendicitis?
**Depends on duration of Sx**
- RLQ tenderness (or ROsving sign: LLQ)
- Rebound tenderness, voluntary guarding, rigidity, tenderness on rectal exam
- Psoas or Obdurator sign
- Fever is a late finding (indicates rupture)
44
What labs aid in the diagnosis of appendicitis?
WBC usually mildly elevated (eg 12 x10^9/L; normal is 4-10 x10^9/L)
CBC is not sensitive or specific
45
What imaging is best used to diagnose appendicitis? What are the findings?
CT (with contrast). Appendix enlarged, inflamed.
May also see:
Pericecal inflammation, abscess, periappendiceal phlegmon, fluid collection, localized fat stranding
46
What other imaging may also be helpful in diagnosing appendicitis (not most useful)?
Abdo XR
| May see: Appendiceal fecalith or gas, localized ileus, blurred right psoas muscle, free air
47
If you're quite certain your patient has appendicitis (eg in ED), what should you do?
Call your surgeon
48
What is the pre-op treatment for appendicitis?
NPO
| IV fluids
49
What should you document in your note for your pt with appendicitis, for bonus points/if you want to impress your staff?
Alvarado score: predicts likelihood of appendicitis
1-4 Discharge
5-6 Observe/Admit
7-10 Surgery
50
Your patient has had a temperature of 37.8C for 2d post-op. Is this concerning?
No: low-grade fever is normal for a day or two after surgery (<38C)
51
What are normal findings a week after operation?
Incision pain and tenderness (should be slowly improving)
| Pruritis at incision site
52
What are abnormal findings a week after appendectomy? (name 6)
- wound erythema
- incisional drainage
- intermittent fevers
- persistent nausea
- obstipation
- urinary urgency or frequency
53
What is obstipation?
Severe or complete constipation; intractable constipation characterized by an inability to evacuate the mass of dry, hard feces
54
What is an inguinal hernia?
Protrusion of peritoneum into inguinal canal
55
What is Hasselbach's triangle?
Floor of the inguinal canal
Formed by transversalis fascia
Delineated by the ilioinguinal ligament, rectus border, and epigastric blood vessels
56
What is the difference between a direct and an indirect hernia?
Direct: herniates directly through transversalis muscle
Indirect: herniates through the deep ring into the inguinal canal, following along with the spermatic cord
57
What is the presentation of an early inguinal hernia?
Painless reducible bulge, groin pain on exertion
58
Describe progression of an inguinal hernia
Can progress to irreducible or incarcerated hernia; can further progress to strangulated hernia
59
What are the risks of a strangulated inguinal hernia?
Compromised blood supply --> ischemia, eventual necrosis
60
Are inguinal hernias more common in men or women?
Men
61
What % of groin hernias are indirect?
75%
62
What is the incidence of groin hernias?
In men in US: 5% overall
63
Is family history relevant for inguinal hernias?
Yes: common to have FHx of hernia or weak abdominal wall
64
What are the risk factors for inguinal hernias?
Increased abdo pressure
| obesity, pregnancy, heavy lifting, straining, chronic cough, etc
65
Should all inguinal hernias be treatment?
Truly asymptomatic hernias don't need treatment.
66
What is SSx point to incarcerated inguinal hernia?
Severe pain over site of hernia
| SSx of bowel obstruction (N/V, obstipation)
67
What physical exam manoeuvres are important in assessing inguinal hernias?
Coughing or valsalva
Palpation of superficial inguinal ring
Examination of scrotum/testes (mass can mimic hernia)
68
What are the management options for inguinal hernias?
Watch & wait
Compression device (eg truss)
Surgery (open or laparoscopic)
69
What is the rate of post-op recurrence of inguinal hernia?
10%
70
What imaging is required for diagnosis of inguinal hernia?
None: it is a clinical diagnosis
71
What are the two most common causes of bowel obstruction?
```
#1 - Adhesions from previous surgery
#2 - Groin hernia incarceration
```
72
Name the two categories of bowel obstruction
Mechanical and non-mechanical (Ileus)
73
What are the common causes of ileus?
Opiates
Electrolyte abnormalities
Intra-abdominal infections
74
What is an ileus?
Impaired bowel motility with no mechanical explanation
75
What are the 4 most common causes of small bowel obstruction?
Adhesions (from prior surgery)
Incarcerated hernias
Inflammatory bowel disease
Cancers
76
What are the e most common causes of large bowel obstruction?
Volvulus
Diverticulitis/ischemic strictures
Colorectal cancer
77
What historiecal features are typical of bowel obstructions?
- Crampy, intermittent pain (Periumbilical or diffuse)
- Inability to have BM or flatus
- N/V
- Abdominal bloating
- Sensation of fullness, anorexia
78
What are the commonest physical finding in bowel obstruction?
Distention
Tympany
Absent, high pitched or tinkling bowel sound or “rushes”
Abdominal tenderness
79
What are the 3 causes of distention?
Air, fluid, mass
Air: bowel obstruction
Fluid: Ascites
Mass: e.g. CA
80
What is the classic clinical picture of SBO?
- abdominal pain: begins as crampy, may progress to constant
- nausea and vomiting
- abdominal distension
- altered pattern of flatus or bowel movements
81
What is the character of pain in bowel obstruction?
Often severe from outset, coming in bouts/spams (peristalsis)
Periodicity 8-10min in LBO, 2-3min in SBO
82
What about referred pain can be diagnostic?
Pain is referred to the dermatome distribution correlating with the spinal nerve that innervates the involved bowel segment
83
What tests are indicated in suspected bowel obstruction?
- CBC & lytes
- Abdo XR
- CT
84
What electrolyte findings are expected in bowel obstruction?
Electrolyte abnormalities (causing ileus, or from N/V)
85
What CBC findings are worrisome in bowel obstruction?
WBC >20 000 suggests necrosis, abscess, or peritonitis
86
What abdo XR findings are expected for bowel obstruction? What can be ruled out with abdo XR?
Air-fluid levels, dilated loops of bowel
Lack of gas in distal bowel and rectum
Rule out perforation
87
Why do a CT scan in bowel obstruction?
CT scan can diagnose cause of obstruction
88
When can a patient with bowel obstruction be managed non-operatively?
Functional ileus
| Adhesion-cause obstruction
89
What must be present in bowel obstruction due to adhesions?
Surgical history
Scars
Other MHx --> adhesions (e.g. IBD)
If there is no reason to think the patient has adhesion, needs operation
90
What is the non-operative or pre-operative management of bowel obstruction?
- IV Fluids
- NGT
- Analgesia
- Observation
91
What is the prognosis for untreated small bowel obstruction, and what is the pathophysiology?
Sepsis, Death
Ischemia --> perforation --> bacteria from bowel contents travel to liver --> sepsis --> death
92
What are the indications for emergent surgery for bowel obstruction?
```
Peritonitis
High fever
Elevated white count
Incarcerated hernia
Primary SBO (tumour)
Other reason for high concern of ischemia
```
93
What is the overview of the surgical approach to bowel obstruction?
Midline incision or laparoscopic
Run the bowel
Adhesive band is cut
94
Why should you run the whole bowel (in bowel obstruction)?
There can be more than one obstruction
95
Why start distally, in running the bowel for bowel obstruction?
Reduce handling of distended bowel
96
What is the classic presentation of cholecystitis?
RUQ or epigastric pain
- Radiation to the back or shoulders
- Dull and achy → sharp and localized
- Pain lasting longer than 6 hours
N/V/anorexia
Fever, chills
97
What are the physical exam findings in cholecystitis?
Epigastric or RUQ pain
| Murphy’s sign
98
If there is no Murphy's sign, does that rule out cholecystitis?
Yes: very sensitive.
Not specific -- could be something other than cholecysitis
99
What SSx suggest cholangitis?
Charcot's triad:
- jaundice
- fever (usually with rigors)
- RUQ pain
Reynold's pentad: Triad +
- shock (low BP, high HR)
- altered mental status
100
What is Charcot's other triad?
Charcot's neurologic triad:
- nystagmus
- intention tremor
- scanning/staccato speech
Associated with MS
101
What should be asked about on history to differentiate cholecystitis from choledocolithiasis?
- Hx of similar episodes
| - Hx of jaundice: sclera, skin, acholic (pale) stools
102
What diagnostic tests should be done for acute cholecystitis?
CBC, LFTs, lipase, total bilirubin
RUQ US
Consider HIDA scan: more sensitive and specific than US
103
What lab findings will/may be present in acute cholecystitis?
Elevated alk phos, GGT
Elevated total bilirubin
If lipase elevated, suggests pancreatitis
104
What findings will present on RUQ US?
Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic Murphy's sign
105
What is the overall difference between cholecystitis, choledocolithiasis, and cholangitis?
Cholecystitis: WBC moderately elevated
Choledocolithiasis: LFTs elevated, alk phos most sensitive
Cholangitis:
LFTS elevated, and WBC *very* elevated (>20)
106
What is the treatment plan for cholecystitis?
- Surgical consult
- IV Fluids
- Correct electrolyte abnormalities
- Analgesia
- Abx
107
What is the antibiotic regimen for cholecystitis?
Ceftriaxone 1 gram IV
| If septic, add Flagyl
108
What complications are important to consider for cholecystitis?
Acute: Bleeding
Infectious: Wound infection, intra-abdominal abscess
Biliary tract: bile leak, CBD injury
109
What is the most sensitive lab test for choledocolithiasis?
Alkaline phosphatase
110
What is Courvoisier's sign?
Enlarged, non-tender galbladder on exam, in pt with mild jaundice
Usually related to pancreatic CA
