GI (2) Flashcards
1
Q
Definition of hernia
A
- 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
2
Q
inguinal hernias
A
- 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
3
Q
indirect vs direct hernias
A
-
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
4
Q
risk factors for inguinal hernias
A
- 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
5
Q
clinical presentation and assessment of hernias
A
- 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”
6
Q
pertinent hx
A
- 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
7
Q
pertinent exam
A
- LOCATION
- SKIN CHANGES
- TENDER TO PALPATION
- REDUCIBLE
- EXTERNAL RING SIZE
- PALPABLE TESTICLES
8
Q
physical exam for inguinal hernia
A
- 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
9
Q
incarcerated and strangulated hernias
A
- 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
10
Q
incarcerated and strangulated hernias physical exam
A
- 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
11
Q
surgical treatment of hernias
A
- 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
12
Q
femoral hernia
A
- 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
13
Q
umbilical hernia and risk factors
A
- MORE COMMON IN WOMAN
- MULTIPLE PREGNANCIES
- OBESITY
- PRIOR SURGERY NEAR UMBILICUS
- RISK OF INCARCERATION IF NOT REPAIRED
14
Q
post operative hernia
A
- 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
15
Q
gallbladder
A
- 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
- Function of gallbladder
