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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)

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2
Q

What are the chronic sequellae of pancreatitis?

A

Pancreatic pseudocyst
Splenic vein or portal vein thrombosis
Hemorrhagic pancreatitis

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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

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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)
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5
Q

How will a patient with pancreatitis appear on exam? (General appearance)

A

Ill; may be obtunded or diaphoretic

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6
Q

What vital sign abnormalities will be found in pancreatitis?

A

Tachycardia, fever, tachypnea

Hypotension (or orthostatic)

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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)

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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
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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)

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10
Q

What is the hallmark of pancreatitis?

A

Severe dehydration and intravascular depletion

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11
Q

What is SIRS?

A 
Systemic Inflammatory Response Syndrome: 
two or more of:
- fever or hypothermia
- tachycardia
- tachypnea
- change in blood leukocyte count
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12
Q

What lab finding is most sensitive and specific for pancreatitis?

A

Lipase: often elevated into the thousands

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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

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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

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15
Q

How is pancreatitis treated acutely?

A 
Fluid resuscitation with crystalloid and colloid
Monitor electrolytes
Pain control
NPO
Consider early nutritional support
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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
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17
Q

How is infected pancreatic necrosis diagnosed and treated? What is the mortality?

A

Dx: percutaneous aspiration
Tx: aggressive operative debridement
High mortality.

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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
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19
Q

How long should a patient with pancreatitis be kept NPO?

A

Until pain-free.

Consider NGT if vomiting.

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20
Q

What are immediate post-op concerns with pancreatitis?

A

Bleeding

Ileus, return of bowel function

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21
Q

What are short-term post-op concerns with pancreatitis?

A

Surgical site infection
Anastomotic leak
Intra-abdominal abscess
Pancreatic leak

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22
Q

What are the signs of post-procedure intra-abdominal abscess?

A

Poor appetite

Low-grade fever

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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)

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24
Q

Name three risk factors for developing diverticulitis

A
  • Diverticula
  • Increasing age
  • Western population
    Also possibly low fibre diet, constipation, obesity
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25
Q

What is tenesmus?

A

Continual or recurrent feeling of needing to evacuate bowels (even after having done so)

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26
Q

What are the clinical features of diverticulitis? (Name 2 presenting symptoms, + other SSx)

A

Main:
Steady, deep discomfort in LLQ
Change in bowel habits

Additional:
Urinary symptoms
Tenesmus
GI Bleed
Paralytic ileus
SBO (Small bowel obstruction)
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27
Q

What physical findings are commonly present in diverticulitis?

A
  • Low-grade fever
  • Localized tenderness
  • Left-sided pain on rectal exam
  • Occult blood
  • Rebound and guarding
  • Peritoneal signs (suggest perforation or abscess rupture)
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28
Q

What investigation best confirms a diagnosis of diverticulitis?

A 
CT scan (IV and oral contrast)
Findings: 
- Pericolic fat stranding
- Diverticula
- Thickened bowel wall
- Peridiverticular abscess
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29
Q

What lab finding is present in about 1/3 of patients with diverticulitis?

A

Leukocytosis (present in only 36% of patients)

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30
Q

What is the medical management of diverticulitis?

A
  • Fluids
  • Correct electrolyte abnormalities
  • NPO
  • Abx: For outpatients (non-toxic). Liquid diet x 48 hours, cipro and flagyl
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31
Q

What is the surgical management of diverticulitis?

A

Elective (uncomplicated): primary anastomosis

Emergency (complicated):

  • Primary anastomosis with a proximal diversion, or
  • Hartmann’s (resection with anorectal closure + end colostomy)
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32
Q

Is it necessary to resect all diverticulae?

A

No

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33
Q

Why might there be urinary symptoms in diverticulitis?

A

Spread of inflammation to nearby bladder

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34
Q

What is complicated diverticulitis?

A

Complicated diverticulitis includes perforation, abscess, obstruction, or fistula

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35
Q

What is the pathophysiology of appendicitis?

A

Obstruction of the lumen of the appendix

Continued secretion → impaired venous return & edema → arterial compromise, ischemia → gangrene → perforation

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36
Q

What is a phlegmon?

A

Mass of inflammatory tissue (e.g. can have a phlegmon next to an inflamed appendix)

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37
Q

What systems should be reviewed in suspected appendicitis?

A

GI, GU, Gyne, Resp, MSK, Trauma

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38
Q

What is the classic presentation of appendicitis, and approx what % of pt present this way?

A

1/2 to 2/3 present classically

  • Periumbilical pain
  • Anorexia, nausea, vomiting
  • Pain localizes to RLQ
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39
Q

What % of appendices are retrocecal? in RUQ?

A

26% are retrocecal

4% are in RUQ

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40
Q

Where does a retrocecal appendicitis cause pain?

A

R flank

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41
Q

What symptoms does a suprapubic appendicitis cause?

A

Suprapubic pain

Dysuria

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42
Q

Where might men have pain from appendicitis?

A

Testicles

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43
Q

What signs are present on the physical exam in appendicitis?

A

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)
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44
Q

What labs aid in the diagnosis of appendicitis?

A

WBC usually mildly elevated (eg 12 x10^9/L; normal is 4-10 x10^9/L)

CBC is not sensitive or specific

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45
Q

What imaging is best used to diagnose appendicitis? What are the findings?

A

CT (with contrast). Appendix enlarged, inflamed.

May also see:
Pericecal inflammation, abscess, periappendiceal phlegmon, fluid collection, localized fat stranding

46
Q

What other imaging may also be helpful in diagnosing appendicitis (not most useful)?

A

Abdo XR

May see: Appendiceal fecalith or gas, localized ileus, blurred right psoas muscle, free air

47
Q

If you’re quite certain your patient has appendicitis (eg in ED), what should you do?

A

Call your surgeon

48
Q

What is the pre-op treatment for appendicitis?

A

NPO

IV fluids

49
Q

What should you document in your note for your pt with appendicitis, for bonus points/if you want to impress your staff?

A

Alvarado score: predicts likelihood of appendicitis

1-4 Discharge
5-6 Observe/Admit
7-10 Surgery

50
Q

Your patient has had a temperature of 37.8C for 2d post-op. Is this concerning?

A

No: low-grade fever is normal for a day or two after surgery (<38C)

51
Q

What are normal findings a week after operation?

A

Incision pain and tenderness (should be slowly improving)

Pruritis at incision site

52
Q

What are abnormal findings a week after appendectomy? (name 6)

A
  • wound erythema
  • incisional drainage
  • intermittent fevers
  • persistent nausea
  • obstipation
  • urinary urgency or frequency
53
Q

What is obstipation?

A

Severe or complete constipation; intractable constipation characterized by an inability to evacuate the mass of dry, hard feces

54
Q

What is an inguinal hernia?

A

Protrusion of peritoneum into inguinal canal

55
Q

What is Hasselbach’s triangle?

A

Floor of the inguinal canal
Formed by transversalis fascia
Delineated by the ilioinguinal ligament, rectus border, and epigastric blood vessels

56
Q

What is the difference between a direct and an indirect hernia?

A

Direct: herniates directly through transversalis muscle

Indirect: herniates through the deep ring into the inguinal canal, following along with the spermatic cord

57
Q

What is the presentation of an early inguinal hernia?

A

Painless reducible bulge, groin pain on exertion

58
Q

Describe progression of an inguinal hernia

A

Can progress to irreducible or incarcerated hernia; can further progress to strangulated hernia

59
Q

What are the risks of a strangulated inguinal hernia?

A

Compromised blood supply –> ischemia, eventual necrosis

60
Q

Are inguinal hernias more common in men or women?

A

Men

61
Q

What % of groin hernias are indirect?

A

75%

62
Q

What is the incidence of groin hernias?

A

In men in US: 5% overall

63
Q

Is family history relevant for inguinal hernias?

A

Yes: common to have FHx of hernia or weak abdominal wall

64
Q

What are the risk factors for inguinal hernias?

A

Increased abdo pressure

obesity, pregnancy, heavy lifting, straining, chronic cough, etc

65
Q

Should all inguinal hernias be treatment?

A

Truly asymptomatic hernias don’t need treatment.

66
Q

What is SSx point to incarcerated inguinal hernia?

A

Severe pain over site of hernia

SSx of bowel obstruction (N/V, obstipation)

67
Q

What physical exam manoeuvres are important in assessing inguinal hernias?

A

Coughing or valsalva

Palpation of superficial inguinal ring

Examination of scrotum/testes (mass can mimic hernia)

68
Q

What are the management options for inguinal hernias?

A

Watch & wait
Compression device (eg truss)
Surgery (open or laparoscopic)

69
Q

What is the rate of post-op recurrence of inguinal hernia?

A

10%

70
Q

What imaging is required for diagnosis of inguinal hernia?

A

None: it is a clinical diagnosis

71
Q

What are the two most common causes of bowel obstruction?

A 
#1 - Adhesions from previous surgery
#2 - Groin hernia incarceration
72
Q

Name the two categories of bowel obstruction

A

Mechanical and non-mechanical (Ileus)

73
Q

What are the common causes of ileus?

A

Opiates
Electrolyte abnormalities
Intra-abdominal infections

74
Q

What is an ileus?

A

Impaired bowel motility with no mechanical explanation

75
Q

What are the 4 most common causes of small bowel obstruction?

A

Adhesions (from prior surgery)
Incarcerated hernias
Inflammatory bowel disease
Cancers

76
Q

What are the e most common causes of large bowel obstruction?

A

Volvulus
Diverticulitis/ischemic strictures
Colorectal cancer

77
Q

What historiecal features are typical of bowel obstructions?

A
  • Crampy, intermittent pain (Periumbilical or diffuse)
  • Inability to have BM or flatus
  • N/V
  • Abdominal bloating
  • Sensation of fullness, anorexia
78
Q

What are the commonest physical finding in bowel obstruction?

A

Distention
Tympany
Absent, high pitched or tinkling bowel sound or “rushes”
Abdominal tenderness

79
Q

What are the 3 causes of distention?

A

Air, fluid, mass
Air: bowel obstruction
Fluid: Ascites
Mass: e.g. CA

80
Q

What is the classic clinical picture of SBO?

A
  • abdominal pain: begins as crampy, may progress to constant
  • nausea and vomiting
  • abdominal distension
  • altered pattern of flatus or bowel movements
81
Q

What is the character of pain in bowel obstruction?

A

Often severe from outset, coming in bouts/spams (peristalsis)
Periodicity 8-10min in LBO, 2-3min in SBO

82
Q

What about referred pain can be diagnostic?

A

Pain is referred to the dermatome distribution correlating with the spinal nerve that innervates the involved bowel segment

83
Q

What tests are indicated in suspected bowel obstruction?

A
  • CBC & lytes
  • Abdo XR
  • CT
84
Q

What electrolyte findings are expected in bowel obstruction?

A

Electrolyte abnormalities (causing ileus, or from N/V)

85
Q

What CBC findings are worrisome in bowel obstruction?

A

WBC >20 000 suggests necrosis, abscess, or peritonitis

86
Q

What abdo XR findings are expected for bowel obstruction? What can be ruled out with abdo XR?

A

Air-fluid levels, dilated loops of bowel
Lack of gas in distal bowel and rectum
Rule out perforation

87
Q

Why do a CT scan in bowel obstruction?

A

CT scan can diagnose cause of obstruction

88
Q

When can a patient with bowel obstruction be managed non-operatively?

A

Functional ileus

Adhesion-cause obstruction

89
Q

What must be present in bowel obstruction due to adhesions?

A

Surgical history
Scars
Other MHx –> adhesions (e.g. IBD)

If there is no reason to think the patient has adhesion, needs operation

90
Q

What is the non-operative or pre-operative management of bowel obstruction?

A
  • IV Fluids
  • NGT
  • Analgesia
  • Observation
91
Q

What is the prognosis for untreated small bowel obstruction, and what is the pathophysiology?

A

Sepsis, Death

Ischemia –> perforation –> bacteria from bowel contents travel to liver –> sepsis –> death

92
Q

What are the indications for emergent surgery for bowel obstruction?

A 
Peritonitis
High fever
Elevated white count
Incarcerated hernia
Primary SBO (tumour)
Other reason for high concern of ischemia
93
Q

What is the overview of the surgical approach to bowel obstruction?

A

Midline incision or laparoscopic
Run the bowel
Adhesive band is cut

94
Q

Why should you run the whole bowel (in bowel obstruction)?

A

There can be more than one obstruction

95
Q

Why start distally, in running the bowel for bowel obstruction?

A

Reduce handling of distended bowel

96
Q

What is the classic presentation of cholecystitis?

A

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
Q

What are the physical exam findings in cholecystitis?

A

Epigastric or RUQ pain

Murphy’s sign

98
Q

If there is no Murphy’s sign, does that rule out cholecystitis?

A

Yes: very sensitive.

Not specific – could be something other than cholecysitis

99
Q

What SSx suggest cholangitis?

A

Charcot’s triad:

  • jaundice
  • fever (usually with rigors)
  • RUQ pain

Reynold’s pentad: Triad +

  • shock (low BP, high HR)
  • altered mental status
100
Q

What is Charcot’s other triad?

A

Charcot’s neurologic triad:

  • nystagmus
  • intention tremor
  • scanning/staccato speech

Associated with MS

101
Q

What should be asked about on history to differentiate cholecystitis from choledocolithiasis?

A
  • Hx of similar episodes

- Hx of jaundice: sclera, skin, acholic (pale) stools

102
Q

What diagnostic tests should be done for acute cholecystitis?

A

CBC, LFTs, lipase, total bilirubin
RUQ US
Consider HIDA scan: more sensitive and specific than US

103
Q

What lab findings will/may be present in acute cholecystitis?

A

Elevated alk phos, GGT
Elevated total bilirubin

If lipase elevated, suggests pancreatitis

104
Q

What findings will present on RUQ US?

A

Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic Murphy’s sign

105
Q

What is the overall difference between cholecystitis, choledocolithiasis, and cholangitis?

A

Cholecystitis: WBC moderately elevated

Choledocolithiasis: LFTs elevated, alk phos most sensitive

Cholangitis:
LFTS elevated, and WBC very elevated (>20)

106
Q

What is the treatment plan for cholecystitis?

A
  • Surgical consult
  • IV Fluids
  • Correct electrolyte abnormalities
  • Analgesia
  • Abx
107
Q

What is the antibiotic regimen for cholecystitis?

A

Ceftriaxone 1 gram IV

If septic, add Flagyl

108
Q

What complications are important to consider for cholecystitis?

A

Acute: Bleeding
Infectious: Wound infection, intra-abdominal abscess
Biliary tract: bile leak, CBD injury

109
Q

What is the most sensitive lab test for choledocolithiasis?

A

Alkaline phosphatase

110
Q

What is Courvoisier’s sign?

A

Enlarged, non-tender galbladder on exam, in pt with mild jaundice

Usually related to pancreatic CA

Surgery (11 decks)

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