Surgical Abdomen Flashcards
main reasons for emergent/urgent surgery
Obstruction, necrosis, perforation, and exsanguinating hemorrhage
“when I was riding to the hospital, going over the bumps in the car hurt a lot” sign of..
peritonitis
types of blockage in GI tract
GOO (gastric outlet obstruction), small bowel obstruction, and colonic obstruction
proximal obstruction hallmarks
frequent vomitting, non-feculent, less colicky, late obstipation
distal obstruction hallmark
late vomitting that smells feculent, MORE colicky, early obstipation
what is GOO caused by
pyloric/duodenal pathology- such as foreign body, tumor of antrum/pylorus/duodenum, or pyloric channel ulcer
GOO treatment
EGD with dilation or surgery, resection/bypass around tumor, or removal of FB
most common cause of small bowel obstruction
adhesion (mechanical cause)
most common cause of colonic obstruction
carcinoma (mechanical cause)
workup for SBO includes
AXR, SBFT, CT with oral contrast
tx for small bowel obstruction
IVF, NG tube for decompression, pain control, abx if indicated, and NPO
when is surgery indicated for SBO
if hernia, pain severe, or conservative management failed
preop surgery for SBO
NG tube for decompression, correct electrolytes (IVF), abx within 30 min of decompression, NPO, DVT prophylaxis, consent
types of surgery for SBO
adhesiolysis, small bowel resection, exploratory laparotomy
functional cause of obstruction
SBO- paralytic ileus. LBO- colonic pseudo obstruction or ogilve’s
tx of colonic obstruction
preoperative decompression (stent for stricture or tumor), resection of obstructed segment, or end colostomy/loop ileostomy
right sided vs left sided colon cancer
right sided- presents with anemia and liquid stood. left sided- presents with obstruction and solid stool
what can diverticulitis look exactly like on radiographic study and grossly?
tumor
types of volvulus
sigmoid, cecal, transverse, and cecal bascule
tx of volvulus
decompression colonoscopy or resection
segmental colon resection
diverticulitis, colon cancer, perforation, volvulus
hartman’s procedure
surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy.
subtotal colectomy indications (main)
pseudomembranous colitis with toxic megacolon, UC, ischemia of colon
total colectomy indications
UC
2 finishes of total colectomy
end ileostomy and ileoanal anastomosis with j-pouch plus a temporary diverting ileostomy
LAR indications
high rectal tumor
LAR removes…
sigmoid colon and most of the rectum
abdominoperineal resection
removal of rectum and anus + end colostomy
abdominoperineal resection indication
low rectal tumor
tx of volvulus
decompression with colonoscopy, definitive surgery with sigmoidectomy with end colostomy
“dilated bird beak toward LLQ”
sigmoid volvulus
patient presents with noticeable bulge and severe pain in abdomen. Has N/V. Upon palpation, very tender. Bluish discoloration present on skin. Non-reducible bulge. Dx?
hernia
When is hernia repair emergent?
when there is strangulation of bowel within the hernia sac, otherwise its elective
what type of hernias are at low risk of strangulation?
very large hernias
If patient has hernia that causes strangulation of bowel resulting in death of bowel, what is next course of action?
emergent surgery- necessitates small bowel resection
landmark for differentiating direct vs indirect hernias?
inferior epigastric vessels
borders of hesselbach’s triangle
epigastric vessels, rectus sheath, and inguinal ligament
graham patch used in tx of…
duodenal perforation
graham patch F/U for duodenal perforation
follow up EGD in 6-8 weeks to biopsy
perforated ulcer tx
broad spectrum abs plus antifungal. EMERGENT
gastric perforation tx
excision of the ulcer and repair of gastric wall or gastric resection (antrectomy) and reconnection (Billroth I, II, and Roux-en-Y)
Patient presents with RUQ pain that is severe, diarrhea, fever, Murphy’s sign. LIpase and LFT normal. US shows thickened gallbladder wall. Suspect..
acute cholecystitis
If patient with acute cholecystitis but not good candidate for surgery, what are your other options?
cholecystostomy tube
patient presents with RUQ pain on palpation, jaundice, scleral icterus but no rebound. LFT elevated. suspect
choledocholithiasis
types of tx in choledocholithiasis
MRCP, ERCP, and PTC
what can be done at time of surgery to r/o choledocholithiasis?
intraoperative cholangiogram
patient presents with central abdominal pain that migrates to the RLQ, mild fever, N/V, tenderness at mcburney’s point. suspect
acute appendicitis
most common causes of pancreatitis
alcohol or gallstones (in U.S.)
scorpion bite can cause..
pancreatitis
“sword through stomach” sensation - severe upper abdominal pain that radiates through to the back, N/V, dehydration, tachycardia. Decreased or absent bowel sounds, non-peritoneal tenderness. suspect
acute pancreatitis
lab findings in acute pancreatitis
lipase and amylase
criteria for acute pancreatitis
ranson’s criteria
tx for acute pancreatitis
if cause is gallstones, allow pancreatitis to resolve then cholecystectomy. if no cause found, gallbladder removed
in which cases would you operate on pancreas itself?
pseudocyst, necrosis with infection, chronic pancreatitis, and pancreatic cancer
potential complication of pancreatic pseudocyst
chronic pancraticocutaneous fistula
management of large pancreatic pseudocyst
wait until “rind” forms, then do a cystgastrostomy, cystduodenostomy, or cystjejunostomy
if pancreatic pseudocyst becomes infected…
IR catheter drainage preferred over internal drainage
treatmetn of pancreatic necrosis
broad spectrum antibiotics. if signs of infection, necrosectomy is indicated
unrelenting pain in chronic pancreatitis. tx
surgical therapy- drainage procedures or pancreatectomy
drainage procedure vs. pancreatectomy in tx of chronic pancreatitis
drainage procedure best when duct is dilated (chain of lakes), puestow procedure. pancreatecomy best when duct looks normal
whipple procedure
pancreaticoduodenectomy
total pancreatectomy leads to
brittle DM
pancreatic cancer is treated surgically ONLY if
there is a chance of surgical cure
upper abdominal pain, jaundice, high transaminase. Normal gallbladder. NO fever.
hepatitis
patient presents with acute onset lower abdominal pain, well localized, change in bowel habits, fever
diverticulitis
what diagnostic test MUST you do if suspect diverticulitis
CT
3 categories of inpatient diverticulitis
unperforated, microperforated/abscess, freely perforated
tx of diverticulitis
po antibiotics
unperforated diverticulitis tx
IV abs, NPO, re-CT if worsening
microperforated diverticulitis
IV abs, NPO, IR drainage of abscess, interval CT’s
freely perforated diverticulitis
IV abs, sugical management
to prevent recurrence of diverticulitis
high fiber diet and fiber supplements
surgical tx considered for GERD if
young patients on maximal medical therapy, patients with poor control of their symptoms, and patients with severe esophagitis
does surgical tx cure baretts esophagus?
NO, though regresion may occur. these patients still need surveillance every 2 years
gold standard for diagnosing GERD
ph monitoring using pH probe (obtain deMeester score)
GERD surgeries if indicated
nissen fudoplication, toupet, belsey mark IV, collis, endoscopic (TIF)
distinguish US and HIDA in acute vs. chronic cholecystitis
acute- US shows thickened gallbladder wall and pericholecystic fluid. HIDA shows non-filling of gallbladder. chronic- US shows no fluid or GB wall thickening, stones. HIDA- slow filling, low EF
what organ most commonly affected in nissen fundoplication in GERD tx?
spleen
chronic cholecystitis and biliary dyskinesia tx
laparoscopic cholecystecomy, intraoperative cholangiogram, possible open
if patient with biliary dyskinesia indicated for surgery, what do you warn them/
that 10% chance pain will not change after surgery
bacterial infection of bile ducts
bacterial cholangitis
bacterial cholangitis always signifies…
obstruction
causes of bacterial cholangitis
choledocholithiasis (most common), biliary stricture, and neoplasm
charcot’s triad
biliary colic (RUQ abdominal pain), jaundice, fever/chills in bacterial cholangitis
severe form of bacterial cholangitis
suppurative cholangitis
diagnostic pentad of suppurative cholangitis
biliary colic, jaundice, fever, confusion/lethargy, and shock
patient presents with painless jaundice
pancreatic head cancer
tx bacterial cholangitis
IV abx, then decompression of the duct
common organisms in bacterial cholangitis
e. coli, klebsiella, pseudomonas, enterococcus
patient presents with anal pain, esp after bowel movment, BRBPR
anal fissure
patient with anal fissure treated medically with fiber suppleemtns, miralax, hydrocortisone suppositories and cream, sitz baths. no relief. what surgery do you consider/
lateral internal sphincterotomy - open, closed, or lateral position
types of surgeries in liver
wedge resection, hepatic segmentectomy, partial hepatectomy, RFA, needle biopsy, TIPS
RFA for liver surgery should not be used near…
large vessels (heat sink)
patient with cirrhosis with hypervascular mass larger than 2 cm, serum AFP larger than 400 ng/mL diagnostic of
hepatocellular carcinoma
TIPS =
transjugular intrahepatic portosystemic shunt - liver disease
