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Clin Med III > surgical abdomen > Flashcards

surgical abdomen Flashcards

1
Q

acute abdomen

A
  • abrupt onset
  • usually assoc with pain d/t inflammation, perf, obstruction, infarction, or rupture of organs
  • usu requires emergency intervention
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2
Q

what age group is appendicitis very common in

A
  • 10-19 years old
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3
Q

what is the most common surgical emergency

A
  • appendicitis
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4
Q

what causes appendicitis

A
  • usually obstruction
  • fecalith, stricture, FB
  • bacterial proliferation
  • tumor, lymphoid hyperplasia
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5
Q

common organisms assoc with appendicitis

A
  • e coli
  • peptostrepto
  • bacteroides fragilis
  • pseudomonas
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6
Q

clinical presentation of appendicitis

A
  • periumbilical pain -> R iliac fossa pain*
  • colicky pain -> dull constant pain*
  • n/v/d, anorexia
  • low grade fever, malaise
  • appendix may be in dif place on dif people
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7
Q

work up/ dx of appendicitis

A
  • good hx
  • PE: rebound tenderness, mcburney’s point tenderness, rosving sign, obturator sign, psoas sign
  • bowel sounds prsent
  • WBW usualy elevated
  • US*- > 6 mm diameter, wall thickness > 2 mm
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8
Q

treatment of appendicitis

A
  • NPO, IVF
  • peri-op IV abx: 3rd gen ceph or gent + flagyl
  • most go to surgery
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9
Q

possible exceptions for surgery for appendicitis

A
  • pain is very focal
  • treated with IVF, IV abx, bowel rest
  • often have palpable mass- abscess
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10
Q

complications of appendicitis

A
  • perforation
  • surgical site infection
  • bleeding/ bowel injury
  • fistula
  • DVT
  • hernia
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11
Q

elderly and appendicitis

A
  • diminished inflammatory response
  • fewer PE findings
  • increased rate of perforation at presentation
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12
Q

kids and appendicitis

A
  • if classic presentation get surgical consult before imaging
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13
Q

pregnancy and appendicitis

A
  • may present “nonclassically”
  • heart burn, bowel irregularity, diarrhea, malaise
  • elevated WBC is normal in pregnancy
  • only use US for imaging
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14
Q

what does the SMA supply

A
  • midgut
  • duodenum
  • jejunum
  • ileum
  • cecum
  • ascending colon
  • proximal 2/3 of transverse colon
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15
Q

small bowel obstruction (SBO)

A
  • occurs when normal BF is interrupted
  • 80% due to a mechanical obstruction
  • most often related to adhesions
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16
Q

causes of SBO

A
  • adhesions**
  • hernias- most common in developing world
  • malignant tumors
  • intussusception, volvulus
  • crohns disease
  • gallstones
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17
Q

types of SBO

A
  • intraluminal
  • intramural (intrinsic)
  • extramural (extrinsic)
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18
Q

intraluminal causes of SBO

A
  • FB
  • bezoars
  • gallstones
  • parasites
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19
Q

intramural causes of SBO

A
  • stricture
  • crohns
  • intussusception, volvulus
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20
Q

extramural causes of SBO

A
  • adhesions

- hernia

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21
Q

simple SBO

A
  • above obstruction peristalsis increases -> intestine dilates -> reduction in peristalsis strength -> flaccidity and paralysis
  • below obstruction -> empty and immobile bowel
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22
Q

strangulated SBO

A
  • leads to impaired venous return -> increased congestion -> impaired arterial BF -> free peritoneal fluid -> ischemia and gangrene
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23
Q

RF for SBO

A
  • prior abdominal or pelvic surgery
  • abdominal wall or groin hernia
  • intestinal inflammation
  • prior irradiation
  • hx of FB ingestion
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24
Q

clinical presentation of SBO

A
  • abrupt onset abd pain and cramping
  • n/v, possible hypovolemia
  • obstipation
  • abd distension
  • hx of prior abd surgery or SBO
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25
Q

chronic SBO

A
  • may have chronic partial obstruction
  • dev superimposed si/sx of acute SBO
  • intermittent episodes, usually resolve and recur again
  • medically managed
26
Q

imaging for SBO

A
  • abd CT- find transition point between dilated and non-dilated bowel
  • xrays- string of pearls, multiple loops of bowel and air fluid levels
27
Q

PE findings for SBO

A
  • dehydration*- hallmark
  • tachycardia, orthostasis, decreased urine output
  • +/- fever
  • high pitched “tinkling” on auscultation*
  • abd distension, tympanic on percussion
  • +/- scars
28
Q

work up for SBO

A
  • CBC with diff
  • BMP
  • blood gas and lactate markers- mesenteric ischemia
  • blood cultures
29
Q

treatment for SBO

A
  • NPO- bowel rest
  • IVF resuscitation *
  • NGT
  • no data to support abx
  • surgery - laparoscopic preferred, may need to be converted to laparotomy
30
Q

need for urgent surgical exploration in SBO

A
  • evidence of strangulation
  • perforation
  • irreducible hernia
  • mesenteric ischemia
  • intussusception
31
Q

complications of SBO

A
  • ischemia -> necrosis -> perforation

- pts will look very ill with systemic sx

32
Q

ileus

A
  • small intestines not moving
  • post op paralytic ileus common- normal response and is benign, usu resolves in 24 hours
  • from non-mechanical insult
33
Q

sx of ileus

A
  • obstipation
  • intolerance to PO intake
  • quiet or absent bowel sounds
  • mild and diffuse pain
  • no fever or tachycardia
34
Q

ischemic bowel disease types

A
  • mesenteric ischmia

- ischemic colitis

35
Q

mesenteric ischemia

A
  • ischemia of small bowel

- secondary to acute cause with SMA and SMV involvement

36
Q

ischemic colitis

A
  • ischemia of colon

- rarely known precipitating cause

37
Q

causes of mesenteric ischemia

A
  • 70% of the time the SMA is inolved
  • embolism- MI, afib, endocarditis, valve disease
  • thrombosis- atherosclerotic plaque ruptures
  • may also be non-occlusive: hypoperfusion+ vasoconstriction
  • watershed areas -> limited collateral circulation
  • venous thrombosis
38
Q

what are the most common watershed areas in mesenteric ischemic bowel

A
  • splenic flexure

- rectosigmoid junction

39
Q

presentation of mesentaric ischemic bowel disease

A
  • rapid onset severe and unrelenting periumbilical pain
  • pain out of proportion to PE (usually normal)
  • n/v
  • forceful/ urgent bowel evacuation
    • RF for ischemia
40
Q

lab markers for ischemic bowel disease

A
  • marked leukocytosis
  • elevated hematocrit
  • metabolic acidosis
  • 50% have elevated amylase
  • if D dimer negative then r/o ischemia
41
Q

imaging for ischemic bowel disease

A
  • xrays: thumb printing from distended bowel loops, thick walls, free air
  • mesenteric angiography test of choice*
  • CT in stable pts
42
Q

ischemic colitits risk factors

A
  • embolic states- a fib
  • post MI
  • post AAA reconstruction
  • mesenteric vein thrombosis- factor V leiden
43
Q

where does ischemic colitis usually happen in elderly

A
  • left colon
44
Q

what is the most frequent form of intestinal ischemia

A
  • ischemic colitis
45
Q

100% predictive of colonic ischemia if 4 or more of following RF present

A
  • 60 y/o
  • hemodialysis
  • HTN
  • hypoalbuminemia
  • DM
  • constipation inducing medications
46
Q

early PE for ischemic colitis

A
  • abd may be normal, possible mild distention
  • no peritoneal inflammation, no rebound or guarding
  • +/- occult blood in stool
47
Q

later PE findings for ischemic colitis

A
  • transmural bowel infarction
  • gross abd distension
  • absent bowel sounds
  • peritoneal signs
  • feculent breath
  • possible signs of dehydration or shock
48
Q

general clinical presentation of ischemic colitis

A
  • rapid onset mild cramping and tenderness
  • urgent desire to deficate
  • NOT as severe as menesteric ischemia
  • felt laterally
  • mild- mod rectal bleeding or bloody diarrhea within 24 hours of abd pain
  • 15% of pts have abd pain without bleeding
49
Q

dx of ischemic colitis

A
  • xray, CT
  • colonoscopy*
  • CBC, CMP, coag studies
  • stool culture, O&P, c diff
50
Q

treatment for mild ischemic colitis

A
  • supportive care

- most colonic ischemia will resolve with supportive care

51
Q

treatment for mod ischemic colitis

A
  • empiric broad spectrum abx
52
Q

treatment for severe ischemic colitis

A
  • surgical exploration: laparotomy for systemic inspection, restoration of BF, resection of infarcted bowel
  • usually need 2nd inspection in 12-24 hours
  • ICU for hemodynamic support
53
Q

toxic megacolon

A
  • possibly lethal
  • total segmental non-obstructive colonic dilation and systemic toxicity
  • walls become thin
  • deep ulcers
  • colon becomes paralyzed from inflammation
54
Q

causes of toxic megacolon

A
  • complication of IBD
  • infections- c diff
  • ischemic colitis
  • volvulus
  • diverticulitis
  • obstruction- cancer
55
Q

presentation of toxic megacolon

A
  • abd distention
  • acute or chronic diarrhea
  • 3 of the following: fever, HR > 120, WBC > 10,500, anemia
  • at least one of following: dehydration, altered sensorium, electrolyte disturbances, hypotension
56
Q

work up for toxic megacolon

A
  • CMP, CBC
  • stool cultures
  • xray- marked dilation
  • CT- thinned walls
57
Q

treatment of toxic megacolon

A
  • non-operative first line*
  • NPO, fluid resuscitation
  • correct lab abnormalitites
  • abx and IV steroids for IBD
  • bowel decompression with NGT
58
Q

surgical options for toxic megacolon

A
  • subtotal colectomy with end ileostomy

- high mortality rates

59
Q

what type of cancer is most pancreatic cancer

A
  • ductal adenocarcinoma

- majority are exocrine

60
Q

presentation of pancreatic cancer

A
  • insidious onset epigastric pain
  • jaundice- may be painful or painless
  • weight loss
  • most have METs at time of dx
61
Q

work up for pancreatic cancer

A
  • AST/ ALT, bilirubin, alk phos, serum lipase
  • CA 19-9*- tumor biomarker
  • US- highly sensitive for masses > 3 cm and preferred first study
  • CT
  • requires biopsy
62
Q

treatment for pancreatic cancer

A
  • surgical resection in 15-20% of pts
  • whipple- for tumors in head of pancreas
  • poor prognosis even after resection
  • chemo may improve pt survival

Clin Med III (26 decks)

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