Protrusion, bulge or projection of an organ or part of an organ through the body wall that usually contains it Defect in the fascia of the abdominal wall which allows herniation of the abdominal contents WHERE THE DEFECT IS DETERMINES THE TYPE OF HERNIA Hernias more common overall in men than women

Most common type of groin hernia – approx 96% 4% Femoral hernias Approximately two thirds are indirect, most others are direct Also, uncommonly there is a pantaloon hernia, which has both indirect and direct components SURGICAL REPAIR IS THE SAME GROIN HERNIAS ARE INDIRECT, DIRECT AND FEMORAL 4% FEMORAL MORE COMMON IN WOMEN

DURATION/ONSET SYMPTOMS LOCAL OBSTRUCTIVE PRIOR INCARCERATION - if it begins to incarcerate, there may be discoloration over the area FAMILY HX RELEVANT ONLY RELATED CO-MORBIDITIES CONSTIPATION, CHRONIC COUGH, URINARY STRAIN ASCITES, DM SMOKER? OPERATIVE RISKS

LOCATION SKIN CHANGES TENDER TO PALPATION REDUCIBLE EXTERNAL RING SIZE PALPABLE TESTICLES

Femoral canal is below the inguinal ligament Small bulge in the upper medial thigh May feel the femoral vessel pulsing lateral to bulge More common in women Usually asymptomatic until incarceration occurs MUST BE DISTINQUISHED FROM INGUINAL HERNIA Indication for elective repair greater in femoral hernias, more likely to have complications

The gallbladder is a pear shaped organ that sits in the right liver fossa between the right and left hepatic lobes The bulbous end is the fundus The narrow end is the infundibulum Function of gallbladder Bile ducts, gallbladder and sphincter of Oddi (pancreas) act together to modify, store and regulate the flow of bile – gallbladder contracts releasing bile and Sphincter of Oddi relaxes Gallbladder stores hepatic bile during the fasting state Gallbladder releases bile into duodenum in response to a meal During storage state, absorbs water and electrolytes to dilute the hepatic bile Stores 30-60cc of bile

GI (2) Flashcards by McKenzie Kipe

Definition of hernia

Protrusion, bulge or projection of an organ or part of an organ through the body wall that usually contains it
Defect in the fascia of the abdominal wall which allows herniation of the abdominal contents
WHERE THE DEFECT IS DETERMINES THE TYPE OF HERNIA
Hernias more common overall in men than women

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inguinal hernias

Most common type of groin hernia – approx 96%
4% Femoral hernias
Approximately two thirds are indirect, most others are direct
Also, uncommonly there is a pantaloon hernia, which has both indirect and direct components
SURGICAL REPAIR IS THE SAME
GROIN HERNIAS ARE INDIRECT, DIRECT AND FEMORAL
- 4% FEMORAL
- MORE COMMON IN WOMEN

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indirect vs direct hernias

INDIRECT
- MOST COMMON TYPE
- MOST ARE CONGENITAL
- HERNIA SAC LATERAL TO INFERIOR EPIGASTRIC ARTERY
DIRECT
- ACQUIRED HERNIA
- HERNIA SAC MEDIAL TO INFERIOR EPIGASTRIC VESSELS WITHIN Hesselbach’s triangle
- LESS LIKELY TO INCARCERATE
- WEAKNESS IN FLOOR OF INGUINAL CANAL
- CHRONIC OVERSTRETCHING OR INJURY
- CONNECTIVE TISSUE ABNORMALITY
- DRUG EFFECT
“shutter mechanism” which is believed to close internal ring to a slit may not work properly in patients that have a patent processus vaginalis (communication between the peritoneum and scrotum); then things such as increase in intraabdominal wall pressure can force contents through the widened internal ring resulting in a hernia
Triangle formed by inguinal ligament inferiorly (poupart’s ligament), inferior epigastric vessels laterally and rectus abdominus medially
Aortic aneurysm linked to connective tissue abnormalities associated with groin hernias, chronic steroid use weakens tissue, also age and smoking can be a factor in weakening connective tissue

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risk factors for inguinal hernias

Increased intra-abdominal pressure
Abdominal wall injury
Strain from heavy lifting
Loss of skin turgor with advancing age weakens fascia
History of hernia or prior hernia repair
Male
Caucasian
Including a chronic cough or constipation
Men 8 times more likely to develop hernia and 20 times more likely to need a repair
Obesity actually a negative risk factor for developing groin hernia although may be more difficult to assess due to body habitus

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clinical presentation and assessment of hernias

Discomfort of heaviness in the inguinal region
Bulge may be present
Discomfort may radiate to scrotum
Worse with extended activity or standing, improves with rest
IMPORTANT QUESTIONS: Symptoms of bowel obstruction
- Nausea, Vomiting, abdominal distention, abdominal pain
CAN BE VAGUE PELVIC DISCOMFORT IN WOMEN
MOD-SEVERE PAIN IS UNUSUAL AND SHOULD MAKE YOU CONCERNCED ABOUT INCARCERATION OR STRANGULATION
Pain with standing or stretching of ilioinguinal nerve pt’s may call “twinge”

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pertinent hx

DURATION/ONSET
SYMPTOMS
- LOCAL
- OBSTRUCTIVE
PRIOR INCARCERATION - if it begins to incarcerate, there may be discoloration over the area
FAMILY HX
- RELEVANT ONLY
RELATED CO-MORBIDITIES
- CONSTIPATION, CHRONIC COUGH, URINARY STRAIN
- ASCITES, DM
- SMOKER?
- OPERATIVE RISKS

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pertinent exam

LOCATION
SKIN CHANGES
TENDER TO PALPATION
REDUCIBLE
EXTERNAL RING SIZE
PALPABLE TESTICLES

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physical exam for inguinal hernia

VISUALLY AND MANUALLY EXAMINE WHILE PATIENT IS SUPINE AND STANDING
FOR MEN, PLACE FINGERTIP INTO INGUINAL CANAL BY INVAGINATING SCROTUM
FOR WOMEN, EXAM CAN BE CHALLENGING; DIRECT PALPATION OVER GROIN AREA; CAN SOMETIMES DESCEND TO LABIA MAJORA;
PERFORM EXAM WITH AND WITHOUT PT PERFORMING VALSALVA MANEUVER (COUGHING OR BEARING DOWN)
BULGE MOVING LATERAL TO MEDIAL IS INDIRECT – TIP OF FINGERTIPS
BULGE FROM DEEP TO SUPERFICAL IS DIRECT – DORSUM OF FINGER
Women may have to have ultrasound to detect the hernia
For any patient if there is difficulty assessing hernia due then ultrasound is best initial diagnostic modality to begin with

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incarcerated and strangulated hernias

Incarceration refers to trapping of hernia contents within hernia sac reducing not possible
Leads to swelling of incarcerated tissue
Eventually blood flow to contents of hernia sac is compromised
Strangulation occurs which is ischemia and necrosis of the hernia sac contents
Risk factors for incarceration or strangulation:
- Advancing age
- Femoral hernia
- Recurrent hernia
Tissue can be bowel, omentum bladder or ovary
Risk of this is low between 0.3 and 3% per year
Less than 2 people for every thousand people will strangulation occur in pts that chose watchful waiting
Pts will ask if they have to have surgery and important to know that it is unlikely for their inguinal hernia to progress to strangulation

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incarcerated and strangulated hernias physical exam

PAIN WITH PALPATION
FEVER
ERYTHEMA OR CHANGES IN SKIN COLOR OVERLYING BULGE
NAUSEA/VOMITING
ABDOMINAL PAIN OR BLOATING
TREATMENT IS URGENT SURGICAL REPAIR FOR STRANGULATED OR

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surgical treatment of hernias

SYMPTOMATIC
- PAIN WITH EXERTION
- DAILY ACTIVITIES COMPROMISED
- CHRONIC INCARCERATION
ASYMPTOMATIC
- WATCHFUL WAITING
- TRUSS
- STRICT PRECAUTIONS FOR MEDICAL ATTENTION IF SX OF INCARCERATION DEVELOP
OPEN V LAPARASCOPIC
MESH V NO MESH
INCLUDING EXERCISE
IN GENERAL, LAP REPAIR ASSOC WITH LESS POST OP PAIN AND QUICKER RECOVERY BUT LONGER OPERATIVE TIME AND HIGHER RECURRENCE
OPEN MINIMIZES RISK OF BOWEL INJURY OPEN ALSO USED FOR LARGE SCROTAL HERNIAS MORE DIFFICULT TO REDUCE WHEN LARGE
IF PT CANNOT TOLERATE ANESTHESIA CANNOT USE LAP REPAIR
MESH NOT USED IF BOWEL PERFORATION HAS OCCURRED
DEPENDS ON WHERE YOU GO, AGAIN STUDY THE SURGICAL PROCEDURE PRIOR TO THE OR DATE

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femoral hernia

Femoral canal is below the inguinal ligament
Small bulge in the upper medial thigh
May feel the femoral vessel pulsing lateral to bulge
More common in women
Usually asymptomatic until incarceration occurs
MUST BE DISTINQUISHED FROM INGUINAL HERNIA
Indication for elective repair greater in femoral hernias, more likely to have complications

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umbilical hernia and risk factors

MORE COMMON IN WOMAN
MULTIPLE PREGNANCIES
OBESITY
PRIOR SURGERY NEAR UMBILICUS
RISK OF INCARCERATION IF NOT REPAIRED

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post operative hernia

What is expected
- Pain improving
- Mild/Moderate scrotal swelling
- Induration at incision site
- Numbness/tingling along scrotum, inner thigh
What is concerning
- Pain worsening
- Systemic changes
- Incision with overlying skin changes, discharge or pain with palpation
- Bulge at incision site concerning for recurrence
Always want to ask about eating, bowel movements, passing gas

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gallbladder

The gallbladder is a pear shaped organ that sits in the right liver fossa between the right and left hepatic lobes
The bulbous end is the fundus
The narrow end is the infundibulum
- Function of gallbladder
  - Bile ducts, gallbladder and sphincter of Oddi (pancreas) act together to modify, store and regulate the flow of bile – gallbladder contracts releasing bile and Sphincter of Oddi relaxes
  - Gallbladder stores hepatic bile during the fasting state
  - Gallbladder releases bile into duodenum in response to a meal
  - During storage state, absorbs water and electrolytes to dilute the hepatic bile
  - Stores 30-60cc of bile

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cholelithiasis (gallstones)

Prevalence in the US
- 10-15% of general population but approx 15-20% of those patients become symptomatic
Risk factors
- North American Indians
- Rapid Weight Loss or Gain
- TPN
- Cirrhosis
- Anemia
- Hyperlipidemia
- Relative with gallstones
- Pregnancy (estrogen exposure)
- Obesity
- Female
- 40’s

classifications of gallstones

Cholesterol – most common
Pigment
- Black – hemolytic blood dyscrasias
- Brown - Bacterial or parasitic infection of biliary tree

what happens with gallstones

Most people with stones are asymptomatic and do NOT require removal of their gallbladder
- Risk of observation when asymptomatic is less than or equal to risk of surgery
Special populations that are exception to the rule:
- Patients with an increased risk of GB cancer
- Pts with congenital hemolytic disorders
- Pts undergoing bariatric surgery
Biliary Colic (symptomatic cholelithiasis)
Complications
- Acute cholecystitis
- Choledocolithiasis
- Acute Cholangitis
- Gallstone pancreatitis
- Rare: gallbladder ca, gallstone ileus, Mirizzi syndrome
Porcelain GB; gallstones larger than 3cm; gb adenomas or polyps
Sickle cell, hereditary spherocytosis (pigment gallstones)
Higher incidence of developing gallstones (30%)
Impaction of a gallstone in cystic duct, causing compression of common bile or hepatic duct

complications of gallstones

Acute cholecystitis
- Pain lasting > 8hrs
- Positive Murphy’s sign
- Thickened gallbladder wall
Choledocolithiasis
- +/- jaundice
- CBD dilated
- LFTs elevated
Acute Cholangitis
- Chariot’s triad (fever, RUQ pain, jaundice)
- Reynold’s pentad (Chariot’s triad plus altered mental status and shock)
- CBD stones
Gallstone pancreatitis
- Epigastric tender to deep palpation
- CBD dilation
- Elevated white count and serum amylase
Rare: gallbladder ca, gallstone ileus,

imaging for gallbladder

Abdominal U/S
- Initial imaging
- Not great study for choledocholithiasis
MRCP
- MRI study for billiard ducts and pancreatic ducts
- Cannot be used for extraction of CBD stones of visualized
ERCP
- Flexible endoscope
- Can be performed for duct clearance
HIDA SCAN
- Also known as cholescintigraphy and hepatobiliary scintigraphy
- Good study for cholecystitis but also for cystic duct leaks or gallbaldder dyskinesia

symptomatic cholelithiasis

Gallstones become symptomatic when they obstruct gallbladder outlet or cystic duct
Increase in pressure is what leads to pain
Usually constant, not colicky
RUQ but could be epigastrium, or even substernal
Radiating to back (or shoulder blade)
Associated with diaphoresis, nausea and/or vomiting
30 min – 1 hr, usually less than 6hrs
ONCE PT HAS FIRST EPISODE OF BILIARY COLIC APPROX 30% WILL HAVE A RECURRENCE
Increase in intra-gallbladder pressure; gb relaxes then stone falls back
Usually post-prandial although not universal
A lot of patients report pain at night
Typically not daily sx but patients usually have characteristic pattern they can relay in their hx

uncomplicated symptomatic cholelithiasis

Biliary colic
- Typical sx
- Atypical sx
  - Chest pain
  - Epigastric pain or burning
  - Nonspecific abdominal pain
  - gas, bloating, dypepsia, early satiety
Normal physical exam
Normal labs
- CBC, LFTs, serum amylase
Imaging
- US
- CT
may lead to search for other causes
Not “ill appearing”, no fever or tachycardia
Benign (ish) abdominal exam (biliary colic is visceral pain gb not inflamed but pt may be gaurding)
Labs: should be nl (no elevated white count or abnormal LFTs)
Us showing gallstones but shouldn’t be increase in CBD (<5mm) or murphys sign

pertinent hx and PE for gallbladder

DURATION/ONSET
SYMPTOMS
- location
- Radiation
- Timing
PRIOR INCIDENTS
- ED visits?
- ROS
- Constitutional including weight loss
- Jaundice
- Bowel changes
FAMILY HX
- RELEVANT ONLY
RELATED CO-MORBIDITIES
- Hepatitis? Pancreatitis?
- GERD/PUD
- OPERATIVE RISKS/SURGICAL CANDIDATE?
ABDOMINAL EXAM
- RUQ, rule out Murphy’s

surgical treatment for gallbladder

Options for surgery
- Lap vs Open
Laparoscopic cholecystectomy
- Pros
  - Less post operative pain
  - Better cosmetic
  - Shorter hospital stay
  - Less time off work
- Cons
  - Increased risk of common bile duct injury
  - May require conversion to open
Open cholecystectomy
- Absolute indications
  - Patients unable to tolerate pneumoperitoneum
  - Refractory coagulopathy
  - Suspect gallbladder cancer
  - Additional abdominal pathology needing gb removed as part of procedure

complications of gallbladder surgery

* Bleeding * Bowel or bile duct injury * Infection * Diarrhea/loose stool * Retained common bile duct stone * Postcholecystectomy syndrome

postoperative cholecystectomy

* The patient presents to clinic with her first post operative appointment since her laparoscopic cholecystectomy 2 weeks ago. She denies fever/chills, n/v. She is reporting some diarrhea and but has been much improved in past several days. Her pain is what she is worried about. * What else do you want to know? * What is expected * Pain usually improving * Lap v Open * Numbness near incision sites, especially with open procedure * Loose stool * What is concerning * Pain that is worsening * Fever/chills, tachycardia (systemic signs) * Incision sites with erythema * It is not unusual for patients to have pain may last for several months. Associated symptoms with worsening pain is what we would be concerned about

appendix anatomy and physiology

* Worm-like appendage at the base of the cecum where the three tenae coli come together * Location of base at cecum is always the same but the tail can be rotated from it’s “normal” retrocecal to retroperitoneal or pelvic position * Average length is 9 cm * Lymphoid tissue * Secretes immunoglobulins as part of the colonic system ## Footnote **Appendectomy does not alter immune function**

appendicitis

* Most common acute surgical disease in North America * RISK FACTORS * 10-30 year old * Males * Dependent on amount of lymphoid tissue in appendix * SPECIAL POPULATIONS * WOMEN OF REPRODUCTIVE AGE * ELDERLY AND SICK * Incidence is highest 10-19yo * WOMEN: GYN PATHOLOGY PID, OVARIAN TORSION * PRESENT WITH NONCLASSICAL SX (IMMUNOCOMPROMISED MAY NOT HAVE A WHITE COUNT)

etiology of appendicitis

* Obstruction of appendix lumen/orifice followed by inflammation * Fecalith * Lymphoid hyperplasia * Foreign body * Tumor * Localized ischemia, bacterial overgrowth and eventually necrosis * Unless removed à Perforation * Contained abscess, phlegmon or peritonitis

patient presentation of appendicitis

* Mild periumbilical discomfort progressing over next 24-48h to more specific right- sided pain * Pain exacerbated with moving, walking and coughing * Anorexia * Nausea and vomiting * Constipation or diarrhea

physical exam and diagnostic studies

* May be subtle in beginning * Slight tachycardia * Low grade fever * Rebound tenderness with one finger palpation * Slight guarding * Negative rectal and pelvic exam * Labs * WBC, serum CRP and pregnancy test * Imaging * CT * U/S * Preferred in children and pregnant women * Can be performed at bedside * RECTAL EXAM NO * Labs: wbc, serum Crp, serum pregnancy test * Us operator dependent

additional physical exam findings for appendicitis

* PSOAS SIGN * PAIN ON PASSIVE EXTENSION OF RIGHT THIGH * Associated with retrocecal appendix * OBTURATOR TEST * Flexing patients right hip and knee with internal rotation of right hip causes RLQ pain * Associated with pelvic appendix * ROVSINGS SIGN * PAIN IN RLQ WITH PALP OF LLQ * DUNPHY’S SIGN * INCREASED PAIN WITH COUGHING * MARKLE SIGN * Pain elicited in abdomen when patient drops from standing on toes to heels * BLUMBERG SIGN * Rebound tenderness

alvarado score (modified)

* Migratory RLQ pain (1 pt) * Anorexia (1 pt) * Nausea or vomiting (1 pt) * Tenderness in RLQ (2 pts) * Rebound tenderness in RLQ (1 pt) * Fever \>37.5°C (99.5°F) (1 pt) * WBC \> 10,000 (2 pts) * SCORING * \< 4 - Safe to observe * \> 4 - Imaging and surgical evaluation

surgical treatment of appendicitis

* LAPARASCOPIC APPENDECTOMY * Lower rate of infection * Less pain * Shorter duration of hospital stay * Pts with uncertain dx, obese patients, or older patients * OPEN APPENDECTOMY * Lower rate of intra-abdominal abscesses * Shorter operative time * Open may convert to Lap

postoperative appendectomy

* Pt returns to clinic approx 2 weeks post lap appy and reports that he is feeling much better * What questions do you have for him? * What is expected * Pain usually much improved * Lap v Open * Numbness near incision sites, especially with open procedure * What is concerning * Pain that is worsening * Severe constipation or not passing gas * Fever/chills, tachycardia (systemic signs) * Incision sites with erythema, drainage