Surgical Abdomen- Beloy Flashcards
Who will you be treating?
-Lots of cancer patients
-Trauma patients
-People with other comorbidities:
–Cirrhosis (ETOH, fatty liver)
–Chronic constipation, IBS, –Chron’s disease
Infectious diseases
RLQ?
appendicitis
LLQ pain?
diverticulitis
PE: (what do you need?)
- Vitals
- Cardiac/Pulmonary brief exam
- Abdomen:
- -Inspection
- -Auscultation of all 4 quadrants
- –Bowel sounds, bruits
- -Palpation of all 4 quadrants and major organs (liver, spleen)
- -Percussion
- Skin, sclera, mucous membrane (check for jaundice or yellow tint to mucosal membranes)
- **Rectal exam if indicated
Peritonitis=
inflammation of the lining of the stomach
Important General Questions:
-Where is the pain?
-Appetite, when was the last time you ate?
-Nausea, Vomiting (what color?)
Constipation, Diarrhea (what color?) (note: c diff will smell horrible)
Are you passing gas?
Any irregular bleeding/easily bruising? (**thinking of liver function and clotting factors)
Genral GI pre-operative work up
- EKG (ordered cuz can the Pt tolerate surgery)
- Chest x-ray (ordered cuz can the Pt tolerate surgery)
- UA (pregnancy test if indicated)
- CBC, **CMP (includes liver enzymes), INR/PTT, Type and Screen (order when you want to know the Pt’s blood type). Crossmatch– reserves the blood for you, when you anticipate a large blood loss with future surgery)
- Appropriate radiology imaging
- Bowel preps (helps flush the system out)
- Surgical consent discussion (sit down with the Pt and educate them with the risks/benefits of the procedure)
Gastric ulcers:
______ have significantly reduced surgical intervention
antacids
Gastric ulcers:
-which ones require surgery
Bleeding, obstruction, perforation or non-healing sometimes require surgery
34 yo female with acute onset abdominal pain:
- can you point to where the pain is?
- last cycle was 20 days ago
- describe the pain? stabbing
- When did it start? 24 hrs ago
- does it radiate? no
- when’s the last time you ate? dinner yesterday, no appetitie
- pain came on suddenly
- no diarhea, but slight nausea
hx: esophageal spasms 10 yrs ago and she had to undergo an endoscopy
- she’s had 3 c-sections
Labs: order a chest X ray
- V/S
- EKG
- pregnancy test
- CMP
- all tests were normal
- Pt still has pinpoint pain in epigastric pain
- order a GI cocktail : malox and zofran
- Get a CAT scan–> it came back normal
Next day: she had severe abdominal pain and went back to ER
2nd CT scan: showed an acute gastric perforation (possibly from a non symptomatic ulcer), there was NO air, so the Pt did not need surgery
-she recieved an NG tube and slowly introduced foods back into her diet and gfollowed up with a GI specialist
Duodenal ulcers are strongly associated with _____
H. pylori,
Other pathology ex’s associated with the abdomen
- Zollinger-Ellison syndrome. (outlier, a genetic disorder that calls hypersecretion of acid)
- Obesity
- Gastric Cancer: –Adenocarcinoma (high risk factor is smoking), –Gastrointestinal Stromal Tumors (GIST)
Ulcer is considered non-healing after failure of ____ weeks of medical therapy (but most providers tx much longer).
> 12
Gastointestinal tumors (GIST)=
space occupying lesions within the GI tract .
-throughout the entire alimentary canal. MC symptom GI bleedingRecurrence rate is high 20-50%
GI procedures: (list examples)
- vagotomy
- Antrectomy
- Roux-en Y Gastric Bypass vs Laparoscopic Adjustable banding (Lap Band) vs Gastric Sleeve
- Gastrectomy
Roux-en Y Gastric Bypass also eliminates _____
the fundus of the stomach where some hormones for hunger are produced
Gastric bypass has 2 functions:
- restrictive
- and malabsorptive
Gastrectomy=
Removal of all or part of the stomach
Antrectomy=
Gastrin (the hormone that stimulates gastric acid secretion is in the antrum of the stomach)
Vagotomy- is used for?
peptic ulcer disease, not common
–Resection of a branch of the Vagus nerve
Gastric sleeve is a _______ surgery
restrictive surgery
–staple across the stomach
Lap band surgery–>
put a lap band around antrum of stomach and you can control how small or large the band is
Gastric bypass: formal roux and Y
BOTH malabsorptive and restrictive
Gastric sleeve, Lab band surgery, and gastric bypass is considered in Pts with ..
BMI >40 or BMI >35 +weight related health problem
Post-op care/complications: describe dumping syndrome
-(esp. with gastric bypass surgery)
Sx: Post prandial tachycardia, diaphoresis, abdominal pain, & diarrhea
–Watch for after a vagotomy or any stomach resection
Post-op care/complications: others?
Nausea, vomiting, diarrhea
-Gastroparesis
Describe the Post gastrectomy diet
Eat small frequent meals, high fiber, avoid simple sugars, do not drink fluids with meals, wait 30-60 mins after meals
Gastroparesis- sx?
(stomach is not emptying in the way it should)
Sx: Nausea/vomiting
Gastroparesis: tx?
NPO status
- IV fluids
- May include TPN (Total Parental Nutrition)
- **Reglan, Erythromycin (these are GI motility drugs, Reglan s/e is tardive dyskinesia)
- NG tube verse Dobhoff (do a dobhoff if you want to feed the Pt)
- -Used for stomach decompression
- -Can use for medications/nutrition
- -Confirm placement with CXR prior to use
Dobhoff=
can be a feeding tube (for ppl with dysphagia)
-do an NG tube if you’re not trying to feed them and you just want to decompress the stomach
Each segment of the liver has a biliary system, portal vein leaves liver
-IF portal vein gets damaged!!!! ??
BIG problems
Liver: work-up
- Exam
- Hepatic ultrasound, CT scan
- -Future Liver remnant, how much function will the remaining liver have?
- -Child-Pugh classification (<7)
- -3D CT volume to asses vascular inflow/outflow biliary drainage
- Bilirubin levels (is it more then twice the upper limit of normal?)
- Comprehensive metabolic panel, Coags, Ammonia levels
-CBC (Heme-8)
Just know!! for child pugh score
<7 , dont need to memorize criteria
Most important # on CBC involving the liver?
**platelet count
pathology associated with the liver?
- Tumors (Metastatic or primary; Hepatic adenoma; Hepatocellular carcinoma, Intrahepatic Cholangiocarcinoma)
- Liver cysts
- Liver abscess
- Hepatic hemangioma (benign vascular malformation)
Do you need to do anything about hemangioma inside the liver?
most of the time it’s fine. but have them return in 3 months to get CT scan and evaluate growth
Any mass that has “rim enhancing” is indicative of______
( KNOW!!!)
INFECTION!!! this is infectious until proven otherwise, get biopsy and WBC count send bx to microbiology
Portal vein embolization=
- Typically preformed as pre-operative radiology procedure
- Done several weeks prior to liver resection can help to redirect blood flow
Other procedures:
- Liver resections
- liver transplants
Describe liver transplants (what criteria is needed?)** KNOW
- End-stage liver disease from cirrhosis
- Model for End Stage Liver disease (MELD) score: Assess the severity of liver and kidney disease to prioritize patients for transplantation
POST op care issues: often have ________ drain
jackson-pratt
Post op: labs to monitor?
-Watch Coags, LFTs, bilirubin
- What could go wrong?
- -Ileus verse small bowel obstruction?
- -Nausea/vomiting
- -Wound infection
- -Post op hernia?
If INR goes up?
-give them vitamin k
or FFP
56 yo male with RU quadrant pain and a fever?
-chronic cramping for months
- denies vomiting
-not eating helps
-sometimes radiates to left shoulder
-denies weight changes
-he still has his gallbladder
-Alcohol- 1x a week
-
Order:?
- CMP and CBC
- start with RUQ ultrasound
56 yo male with RU quadrant pain and a fever?
-chronic cramping for months
- denies vomiting
-not eating helps
-sometimes radiates to left shoulder
-denies weight changes
-he still has his gallbladder
-Alcohol- 1x a week
-
Order:?
- CMP and CBC
- start with RUQ ultrasound
- or order a
DDX:
- cholecystitis
- chollithiasis= irritation within gallbladder
Tx: usually laparoscopic resectomy (in this surgery you CUT the ______ DUCT!!!!) know!!!
CYSTIC
Murphy’s sign=
pathopneumonic for gallbladder issues ***
HIDA scan=
Hepatobiliary Iminodiacetic acid scan, inject Pt with CCK and look at the EF of the gallbladder. If you have low EF–> you may have choleli
MRCP=
Magnetic resonance cholangiopancreatography (gives you a picture)
ERCP=
better, Endoscopic retrograde cholangiopancreatography (you can do something during this imaging procedure)
Non-operative treatment methods tried:
Diet adjustment
Weight loss
Smoking sensation
During an ERCP:
- tube goes in and you can take pictures and also
- requires sedation during an ERCP
Cholelithiasis=
Choledagon..??
Gallstones
-stones within a duct!!
Cholecystitis=
Inflammation of the gallbladder
Ascending cholangitis=
- MC organisms?
- Sx?
- Tx?
- Infection of the bile duct (MC gram neg bacilli Escherichia coli, Klebsiella, Enterobacter)
- Sx: Jaundice, abdominal pain, fever
- Tx: IV fluid and antibiotics
Cholecystectomy
Open verse laparoscopic
Endoscopic retrograde cholangiopancreatography (ERCP)= allows for..
Allows for sphincterotomy, lithotripsy, stent placement
Percutaneous Transhepatic Cholangiography= is used when..
obstruction is too great you can use ultrasound and percutaneous approach (often done by radiology)
Cholecystectomy: during this procedure you cut the ____
cystic duct
What will you find in the gallbladder?
- stones
- cancer-RARE
describe gallstones
- Cholesterol vs mixed (cholesterol, calcium bilirubinate)
- In the US 80% of all gallstones contain cholesterol
- Can see calcium bilirubinate in patient with high hemoglobin breakdown, remember bilirubin is a bi-product of hemoglobin breakdown
Porcelain gallbladder=
=CANCER=calcification of the gallbladder) leads to higher risk
-Can also include lymph node and partial liver resections
-Tx: Chemo/radiation as adjunct (poor prognosis if late stage– high mortality)
Post op care/complication: after laparoscopic cholecystectomy
-Laparoscopic cholecystectomy usually done as outpatient (ie pt sent home same day)
- Bile leak
- Damage to surrounding blood vessels, tissues, nerves
- Incisional hernias
- Ileus
- Diet adjustment
- –Cut back on dairy and fatty/cholesterol rich foods
-Diarrhea
52 yo diabetic female presents with nausea, vomiting, and abdominal pain. She has noticed greasy/pale white stools the past 2 days?
Questions to ask: -pain? center of abdomen -they're a diabetic -+ for weight changes and sweats -
- U/S
- CMP
- CBC
- *CT scan!!! and admit the Pt
Pancreas: important to note that it shares a blood supply with the ____ at the distal end
spleen
Work-up for pancreatic issues:
- Complete metabolic panel
- Physical exam
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Pancreas protocol CT
Pancreatic adenocarcinoma=
5%, 5-year survival rate without other intervention
Pancreatic cysts can cause..
pancreatitis
Intraductal Papillary Mucinous Neoplasms= can progress to..
into invasive pancreatic cancer
Other pancreatic pathology:
- Traumatic pancreatic duct disruption (ie skateboard to the abdomen)
- Formation of Pseduocyst
Pancreatic procedures
- Distal Pancreatectomy +/- splenectomy–> Open verse laparoscopic
- Transgastric pseudocyst gastrostomy= Draining of pseudocyst through stomach
- Pancreaticoduodenectomy “Whipple”
Describe Pancreaticoduodenectomy “Whipple”
-Open verse laparoscopic
(done for tumors on the head of the pancreas)
-Resection of the head of the pancreas, gallbladder (including part of the common bile duct), a portion of the duodenum, sometimes the pyloric sphincter
-Can increase 5-year survival rate to 20%
Pancreaticoduodenectomy
high risk for leaking, so they put lots of tubes around there to help catch leaks
Post op care/complication: post pancreatic surgery
-Several JP drains
Have to watch out for amylase; the pancreas is like a sponge and can leak
- NG tube
- Diabetes (you took away their insulin maker)
- Ileus/constipation
- Gastroparesis
80 yo female presents to ED from an outside facility after a fall to a night stand. she has LUQ pain. Systolic BP is 75/50 after 2L of IV fluids
-do FAST exam
-emergent splenectomy
OR
-spleen has splenic artery and splenic vein
Workup for spleen issues:
Complete metabolic panel CBC Complete immunization history Physical exam CT scan -Ultrasound (sometimes a FAST exam in the ED)
Pathology of the spleen:
-Illnesses that increase the size of the spleen: Idiopathic thrombocytopenic purpura: antibodies target and destroy RBC OR Hereditary spherocytosis
OR Blood cancers: leukemia, lymphoma
- Splenic artery aneurysm vs splenic infarction
- Splenic cyst/Abscess
- Spleen trauma
During a splenic artery embolization–> spleen fx is
-can be partially preserved! this is debated– if splenic fx be preserved
“rim enhancing”
infectious abscess
Pre op plan for young Pt with ITP getting a laproscopy:
-REquires immunizations!!!!
for encapsulated organisms!! KNOW
Immunization prior to discharge if not given pre-operatively (need to give 3 weeks pre-op)
Pneumococcal, H. influenza and meningococcal
-+/- antibiotics prophylaxis
Post op care for Exploratory laparotomy with Splenectomy
Ileus/constipation
Reactive thrombocytosis and leukocytosis– Aspirin therapy?
Nausea/vomiting
Work-up for Small intestine issues:
Complete metabolic panel
CBC
KUB or abdominal erect and lateral decubitus views
Physical exam
CT scan
Ultrasound (sometimes a FAST exam in the ED)
Pathology of the small intestine
- Trauma
- Ischemic colitis, Mesenteric ischemia, Cancer, Obstruction
- Enterocutaneous, Enterovaginal Fistuals
- Cancer: Carcinoid, Lymphoma, Adenocarcinoma, GIST tumors, metastatic disease
- Intussusception
- Meckel’s Diverticula: MC cause of lower GI bleeding in pediatrics
Pathopneumonic Sx for intussusception is
**Jelly current stool
KNOW
Procedures assoc. with the small intestine
- Small bowel perforation repair
- Small bowel resection
- Fistula repair
-Manual reduction of intussusception verse resection (+/- appendectomy)
Post op small intestine complications:
-Ileus= a painful obstruction of the ileum or other part of the intestine.
- Bowel leakage
- Small bowel obstruction
- Adhesions!
- Malabsorption issues
constipation= tx
VERY common!
tx:
Senna, Colace, Miralax (stimulant), Go-Lightly Suppository, Enema, De-impaction
Ileus (common):
- suspect with a Pt with which sx?
- dx?
prolonged constipation, Abdomen Distension
-KUB (or Abd supine and erect) to diagnosis–>**dilated bowel loops
SBO=
=small bowel obstruction
Sx: Distension, Diminished bowel sounds
-NOT passing gas
-NPO, NG tube, Surgical resection
abdominal cramping and RLQ pan?
-appendix!! she had an abscess in her appendix
Appendicitis=MC surgical _____
emergency of the abdomen
-Approximately 250,000 appendectomies performed annually
Sx: Appendicitis (KNOW)
**Usually cramping, periumbilical pain migrating to RLQ +/- fever
- McBurney’s point
- Rovsing’s, obturator, and Iliopsoas “psoas” sign
appendicitis: imaging?
- in peds order U/S, for adults CT cuz its more sensitive
- On CT looking for a thick wall >2mm, increased size >7mm, phlegmon or abscess, free fluid
Rovsing’s=
palpation of LLQ ellicts pain in the RLQ
Obturator and iliopsoas
Obturator: pain with internal rotation of the hip
Iliopsoas: pain with extension of the right hip
Mcburneys point=
McBurney’s point: 2/3 distance from the umbilicus to the ASIS
Tx: appendicitis
Antibiotics
Becoming more favorable, but the patient needs to be reliable and have close follow up
- Laparoscopic verse open Appendectomy
- -If Appendicolith is noted on CT, surgery is indicated
Laparoscopic vs Open
appendectomy
- Hospital stay usually overnight, unless perforated
- If perforated consider antibiotic 3-7day, may required longer hospital stay
Post op care:
Tolerated well, N/V, diarrhea, decreased appetite
Abscess
Hernia
Large intestine Workup:
-Complete metabolic panel
CBC
-KUB or abdominal erect and lateral decubitus views
- Physical exam, *including rectal!
- CT scan
- Ultrasound (sometimes a FAST exam in the ED)
Large intestine: assoc. pathology
- Cancer: Colon cancer, Colorectal cancer
- **Diverticulosis/Diverticulitis
- Colitis -> perforation/toxic megacolon/bleeding. Can be Ulcerative, Chron’s, Ischemic, C-diff
- Obstruction
- Rectal prolapse
Ogilvie’s syndrome
=Also known as colonic pseudo-obstruction.
-When the cecum is >10cm in diameter
- Dysregulation within the autonomic nervous system
- Tx= decompression (NG tube or colonoscopy, Neostigmine(S/E: is arrythmia) or surgical resection
Colectomy is typically
partial
Colostomy=
=bringing up a section of the colon and connecting it to another part
-Done when you can’t reconnect the colon
Is reversible in some cases
Other surgical procedures involving the colon:
- Ileostomy (divert the entire colon and bring a loop of the ilium to the surface– now drain waste through )
- Hemorrhoidectomy
- Sphinecterotomy–>Not common, can be done for chronic anal fissure
Hemorrhoids=
=Engorgement of normal fibrovascular cushions
-Classified into internal (above dentate line) or external (below)
Problem with ileostomy?
- dehydration (since colon cant absorb h20 anymore)
- monitor their creatine levels!!
Tx options for hemorrhoids
- Always try OTC medical management first! ie Witch Hazel, Phenylephrine supp, Hydrocortisone crm, Sitz Baths
- Sclerotherpathy (can be done in the office)
- Hemorrhoidectomy–> Always indicated for incarcerated or gangrenous hemorrhoids
- Suture ligation
Abdominal hernia tx:
sew a mesh over the abdominal wall
Trauma:
- ATLS (Advance Trauma Life Support)
- CT scan verse Focused Assessment with Sonography for Trauma
- FAST exam: US to look at Pericardial, Perihepatic, Perisplenic and Pelvic region (Can also be used to evaluate pleural spaces)
- Open laparotomy
- Abdominal packing if all else fails
Kidney injuries
- Kidney laceration
- Kidney hematoma: **Blood in the urine is always a problem
- Always rule out Foley trauma
- Call urology!
Take home:
- Need a complete history physical and exam
- Abdominal surgery can have a lot of complications–> When in doubt make the patient NPO
- Never be afraid to order imaging (if indicated!)
