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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
chronic SBO
- may have chronic partial obstruction - dev superimposed si/sx of acute SBO - intermittent episodes, usually resolve and recur again - medically managed
26
imaging for SBO
- abd CT- find transition point between dilated and non-dilated bowel - xrays- string of pearls, multiple loops of bowel and air fluid levels
27
PE findings for SBO
- dehydration*- hallmark - tachycardia, orthostasis, decreased urine output - +/- fever - high pitched "tinkling" on auscultation* - abd distension, tympanic on percussion - +/- scars
28
work up for SBO
- CBC with diff - BMP - blood gas and lactate markers- mesenteric ischemia - blood cultures
29
treatment for SBO
- NPO- bowel rest - IVF resuscitation * - NGT - no data to support abx - surgery - laparoscopic preferred, may need to be converted to laparotomy
30
need for urgent surgical exploration in SBO
- evidence of strangulation - perforation - irreducible hernia - mesenteric ischemia - intussusception
31
complications of SBO
- ischemia -> necrosis -> perforation | - pts will look very ill with systemic sx
32
ileus
- small intestines not moving - post op paralytic ileus common- normal response and is benign, usu resolves in 24 hours - from non-mechanical insult
33
sx of ileus
- obstipation - intolerance to PO intake - quiet or absent bowel sounds - mild and diffuse pain - no fever or tachycardia
34
ischemic bowel disease types
- mesenteric ischmia | - ischemic colitis
35
mesenteric ischemia
- ischemia of small bowel | - secondary to acute cause with SMA and SMV involvement
36
ischemic colitis
- ischemia of colon | - rarely known precipitating cause
37
causes of mesenteric ischemia
- 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
what are the most common watershed areas in mesenteric ischemic bowel
- splenic flexure | - rectosigmoid junction
39
presentation of mesentaric ischemic bowel disease
- 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
lab markers for ischemic bowel disease
- marked leukocytosis - elevated hematocrit - metabolic acidosis - 50% have elevated amylase - if D dimer negative then r/o ischemia
41
imaging for ischemic bowel disease
- xrays: thumb printing from distended bowel loops, thick walls, free air - mesenteric angiography test of choice* - CT in stable pts
42
ischemic colitits risk factors
- embolic states- a fib - post MI - post AAA reconstruction - mesenteric vein thrombosis- factor V leiden
43
where does ischemic colitis usually happen in elderly
- left colon
44
what is the most frequent form of intestinal ischemia
- ischemic colitis
45
100% predictive of colonic ischemia if 4 or more of following RF present
- 60 y/o - hemodialysis - HTN - hypoalbuminemia - DM - constipation inducing medications
46
early PE for ischemic colitis
- abd may be normal, possible mild distention - no peritoneal inflammation, no rebound or guarding - +/- occult blood in stool
47
later PE findings for ischemic colitis
- transmural bowel infarction - gross abd distension - absent bowel sounds - peritoneal signs - feculent breath - possible signs of dehydration or shock
48
general clinical presentation of ischemic colitis
- 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
dx of ischemic colitis
- xray, CT - colonoscopy* - CBC, CMP, coag studies - stool culture, O&P, c diff
50
treatment for mild ischemic colitis
- supportive care | - most colonic ischemia will resolve with supportive care
51
treatment for mod ischemic colitis
- empiric broad spectrum abx
52
treatment for severe ischemic colitis
- 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
toxic megacolon
- possibly lethal - total segmental non-obstructive colonic dilation and systemic toxicity - walls become thin - deep ulcers - colon becomes paralyzed from inflammation
54
causes of toxic megacolon
- complication of IBD - infections- c diff - ischemic colitis - volvulus - diverticulitis - obstruction- cancer
55
presentation of toxic megacolon
- 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
work up for toxic megacolon
- CMP, CBC - stool cultures - xray- marked dilation - CT- thinned walls
57
treatment of toxic megacolon
- non-operative first line* - NPO, fluid resuscitation - correct lab abnormalitites - abx and IV steroids for IBD - bowel decompression with NGT
58
surgical options for toxic megacolon
- subtotal colectomy with end ileostomy | - high mortality rates
59
what type of cancer is most pancreatic cancer
- ductal adenocarcinoma | - majority are exocrine
60
presentation of pancreatic cancer
- insidious onset epigastric pain - jaundice- may be painful or painless - weight loss - most have METs at time of dx
61
work up for pancreatic cancer
- 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
treatment for pancreatic cancer
- 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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