Surgical Block I Flashcards
What is the most frequent acquired nosocomial infection
UTI
Tx prior to any surgery
When should pts stop taking ACEI prior to SRGRY
Advise patients to not take on the day of surgery
—refractory hypotension during general anesthesia
—should be resumed shortly after the operation
Should pts stay on diuretics prior to SRGRY
For operations with potentially significant amounts of fluid losses and resuscitation
commonly withheld on the morning of
When are pre op ABX given
Within 1 hour of incision
-give full dose, parenteral, and DC within 24hours post surgery
(Cephazolin 1g is typically used)
In evaluating a pt pre surgery
What is the risk assessment and reduction approach
ASA cat determination
Prior intubation?
Previous Anesthetic Reactions
Underlying Metabloic Dz
Current Meds and Allergies
ASA I
A NML healthy Pt
ASA II
A pt with mild systemic Dz
ASA III
A pt with severe systemic Dz
ASA IV
A pt with severe systemic dz that is a constant threat to life
ASA V
A Morbund pt who is not expected to survive without the operation
ASA VI
A declared brain dead pt whose organs are being removed for donor purposes
ASA E
Emergency
What is the pt driven tools that mitigate pulmonary complications s/p surgery
Incentive spirometry
What are the 6 independent predictors of cardiac complications for surgery
history of ischemic heart disease,
congestive heart failure
(JVD/ S3 Gallop)
cerebrovascular disease
a high-risk operation
preoperative treatment with insulin
a preoperative serum creatinine greater than 2.0 mg/dL
Any pt with a MACE score greater than 1 should get what reflexive testing?
Stress testing
- Excercise treadmill
- dipyridamole or thallium – increase accuracy
- dobutamine or adenosine echocardiogram – if pt unable to exercise
If a pt is bable to do excercise stress testing
What risk stratifying assessment (CV) should they do prior to surgery
Dobutamine or adenosine echocardiogram
What is the postponement timeline for pts with recent Hx of MI
Postpone 6 months
When should pts stop eating prior to Surgery
before receiving anesthetics or sedatives
avoid eating light meals for at least 6 hours and fatty meals for 8 hours
How do we treat worsening ammonia levels prior to surgery
Lactulose
What is neuropraxia
Typically self resolving condiotn post op
-peripheral nerve injury
Loss of motor function is the most common finding
What is the glucose mgmt goal pre op
The goal is to obtain acceptable blood glucose levels
(< 140 mg/dL fasting and < 180 mg/dL otherwise)
while avoiding hypoglycemia
What is the steroid approach pre op
Give a “stress” dose prior to surgery to avoid addisonian crisis
Albumin less than 3g/dl suggests
Chronic malnutrition
Prealbumin less than 16mg/dl indicates
Acute malnutrition
More sensitive
What is a normal UOP
Approx 1L/24 hours, estimated at 0.5 mL/kg/h in an adult
What serum Cr change is the threshold for AKI
Greater than 2mg/dl
If a pt is NPO for 12 hours what should you give them.,.
A maintenance fluid to prevent hypovolemia
What is the threshold for Blood transfusion
hemoglobin concentration
< 7.0 g/dL
(hematocrit 21%) = transfusion
What is the most reliable sign of moderate shock/?
Oliguria
successful resuscitation is indicated by a return of urine output to 0.5-1 mL/kg/h
If correcting HypoK, what also should you correct
Hypo Mg2+
What is the medical emergency threshold for hyperK+
A serum K+of 6.5 mmol/L or greater is a medical emergency
Initial treatment for Hyperkalemia
IV administration of 50% dextrose in water
10 units of regularinsulin
calcium gluconate
inhaled β-adrenergic agonists like albuterol
What is the preferred IV solution in the trauma bay
Blood>LR>NS
What is the maintence fluid of choice
D5W 1/2NS
What should be added to D51/2NS to prevent Hypokalemia
Add 20mEq of K to prevent hypokalemia
should usually not be added during the first 24 hours after surgery
What is the maintenance fluid rate
Adults: 30ml/Kg/24h
Multiply patient’s weight in kilograms times 30
eg, 1800 mL/24 h in a 60-kg patient
**Bolus 500-1000ml and adjust
UOP to 1ml/Kg/hour
“Maintain with dextrose 5% in 0.45% NaCl + 20 mEq K”
What is a massive transfusion protocol
6 units or more (at least 10) as fast as you can
Most to least perferred blood products
- Cold stored low titer O whole blood
- Pre-screened low titer O fresh whole blood
- Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
- Plasma and RBCs in a 1:1 ratio
- Plasma or RBCs alone
What is the role of DDVAP
Stimulates endothelial cells to release von Willebrand Factor (vWF)
Uremic bleeding as a result of platelet dysfunction
Persistent oozing in the operating room
When using a feeding tube, when can you start feeding post operatively?
2nd post op day
If giving a pt TPN
What is the approach
Get daily electrolytes
(Watch for re-feeding syndrome)
Weekly liver enzymes
What is re-feeding syndrome
Increased Insulin ->
Hypo: K, Mg & P
DRIVEN BY HYPOPHOSPATEMIA!
What are the 3 areas of the abdomen (generally divided)
Divide abdomen into 3 general areas
GI tract: mouth to anus
Biliary: Liver, gall bladder, pancreas
Genito-Urinary: Kidney to urethra
In history taking of an abdominal pain pt always ask what…
ABOUT the recent CSP/EGD!
Colonoscopy
A pt with a tensely distended abdomen with an old surgical scar
Think
Adhesions
Small bowel obstruction
A scaphoid abdomen..
Think
Perforated ulcer
A pt with visible peristalsis
Think
Advanced bowel disease
A pt with an abdomen that feels like soft doughy fullness
Think
early paralytic ileus or mesenteric thrombosis
A pt with a everted umbilicus
Think
IAP
Tympany of the bowel indicates
bowel obstruction
hollow viscus perforation /free air
What is the role of CXR in the review of abdominal pain
More sensitive than abdominal plain films for free intraperitoneal air
What distinguishes the 1st and 2nd portion of the duodenum
Concentric mucosal folds, “Kerckring folds”
If NO air is seen at all in the stomach of the colon
Suspect
If no air seen, rule out gastric outlet obstruction
a giant gastric bubble, with no air in small bowel or colon
Air is not normally seen in the small intestine so if air is seen in the small intestine
Think
rule out ileus or obstruction
What is acute obstination
Inability to pass gas
What is the approach to an Ileus
If abdominal distention, abdominal pain, nausea, or vomiting,
then nasogastric decompression and IV rehydration are indicated
What is Alvimopan used for
a selective mu opioid receptor antagonist,
shown to accelerate GI recovery,
Postoperative
(non-opioid-based) pain management + ERAS protocol may decrease rates of postoperative ileus.
Most common cause of small bowel obstructions
adhesions from previous surgery (50 to 70%),
hernias (25%),
and tumor
Most common causes of Lower Bowel Obstruction
Cancer (65%),
diverticular stricture (20%),
and volvulus (5%)
What is the threshold for risk of ischemia and perforation of the colon
Risk of ischemia and perforation increases with the degree and duration of colon distention
> 12 cm and duration of dilation > 6 days
What is the contrast medium of choice for a suspected bowel perforation
Iodine based- Gastrografin
What is the criteria for strict return post op
Fever, increased N/V, intractable pain
Normally not sent home if narcs are needed
Exception: renal colic
What is ADC-VAN-DISMEL
Admit to floor
Diagnosis
Conditions
Vitals
Activity (lie flat? Fall risk?)
Nursing (always I/Os)
Diet
IVF
Studies
Meds
(Anti ulcer, Anti DVT, Anit N/V, Anti-pain, ABX)
Allergies
Labs
Location of the appendix
~2 cm inferior to the ileocecal valve
Common causes of appendixcitis in adults and children
obstruction due to fecalith in adults
lymphoid hyperplasia in children
What is alvarados score
2- Abd pain that moves to R iliac Fossa
1- N/V
1- Anorexia w/ or W/o ketones
1- Pain on pressure in R iliac fossa
1- Rebound tenderness
1-Fever of 37.3 or more
2- Leukocytosis
1- Neutrophilia
A score of 5-6 compatible with DX
7-8 probable Dx
9-10 very very likely Dx
Gold standard of imaging for appendicitis
CT with IV contrast
looking for inflammation
What are the rule of 2s of Meckels Diverticulum
Rule of 2s
- Gastric or pancreatic tissue
- 2 feet from ilio-cecal junction
- 2% of the pediatric population
What is a postive fotherfgill sign?
Careful palpation will reveal a tender mass within the abdominal wall
DDx for Apendicitis versus Rectus Sheath hematoma
What is the appropriate ABX coverage for Appendicitis
Ciprofloxacin plus Metronidazole (if perforated)
Cephalosporin (nonperforated)
What is the most common cancer assoc with appendicitis
Carcinoid.
What is the most common diverticula observed in GI?
Zenkers
Arises in the killian triangle
Located just superior to the cricopharyngeus muscle
Common Cc is regurgitation of undigested food
Should you do a endoscopic exam zenkers diverticulum ?
No, increased risk of perforation
What is the 1st Dx step of Zenkers Diverticulum
Barium swallow study
What is the treatment approach to Zenkers Diverticulum
Treatment is surgical and must include the division of the cricopharyngeus muscle
“Cricopharyngeal myotomy”
If more than 2 cm in diameter
excised with a linear stapler
What is the gold standard to eval GERD
PH testing
4 criteria to Dx GED
positive pH testing
(Gold standard)
esophageal mucosal breaks on endoscopy in patients with typical symptoms
confirmed Barrett esophagus on biopsy
peptic stricture in the absence of malignancy
MGMT of GERD
Trial of acid suppression with PPI x 8 weeks Daily or BID
SRG: Laproscopic Nissan Fundoplication
What are the three main areas of physical narrowing for esophageal FB
most proximal : cricopharyngeus muscle
followed distally by the level of the aortic arch
the lower esophageal sphincter.
A esophageal perforation greater than 24 hours,.,.
Severe contamination
the esophageal defect usually breaks down if it is surgically closed and is insufficient for treatment
What is the most common cause of esophageal perforations
Instrumental (Dx or Tx)
Most likely to occur in the cervical esophagus
Most common site - Cricopharyngeal area
What imagining should we get for boorhave syndrome
X ray : air in the soft tissues
Esophogram using water soluble contrast- promptly in every pts
(If no leak seen, repeat with barium)
CT Scan of chest
Tx appraoch to Boorhave Syndrome
Broad Spec ABX and Urgen Surgical Referral with 24 hours
What is the general resolution of Mallory-Weiss tears
Expectant managment with spont recovery
MGMT for corrosive esophagitis
Fluid resuscitation and supportive care
Consult GI for possible EGD
Immediate flexible endoscopy is required
Perforation or instability mandates surgical exploration and resection
Do not induce emesis, blindly neutralize chemical or insert NG tube
A pt presents with hoarsness, and dysphagia, wt loss, and pain over bony structures
Think
Carcinoma of the esophagus
What is the most sensitive test for staging of Exophageal cancer
Endoscopic U/S
Determines depth of penetration by the tumor
presence of enlarged periesophageal lymph nodes
invasion of structures next to the esophagus
allows a fine-needle aspiration of lymph nodes
Treatment options for Carcinoma of the Esophaggus
Curative: Neoadjuvant Chemo+rads
Or Esophagectomy
Palliative: cytotoxic (chemo)
Rads, or a stent
5 year survival 25%
What is the Dx imaging for Hiatal Hernias
Upright CXR
Barium Contrast Study
EGD is difficult but necessary to r/o cancer
What is the Gold standard Treatmetn for Hiatal Hernia
Laparoscopic Nissen fundoplication
What are the indications for Bariatric Surgery
BMI greater than or equal to 40 kg/m2
BMI greater than or equal to 35 kg/m2 in patients with high-risk conditions
severe sleep apnea, obesity-related cardiomyopathy, or severe diabetes mellitus
Patient-documented previous failure of nonsurgical weight loss attempts
What is the most commonly performed bariatric procedure
LSG is the most commonly performed bariatric procedure
technically easier to perform
shorter learning curve
effective in sustainable excess weight loss, resolution of comorbidities, and improving survival of morbidly obese patients.
A pt presents with stomach pain that occurs with in 2-3 hours post mean, is relived with food or antacids, and awakens the pt from sleep
Think
Duodenal Ulcer
A pt presents with hyper gastrinemia,. Severe PUD, and non B-islet cell tumors of the pancreas
Think
Zollinger Ellison syndrome
Tumor near pancreas which produces excess gastrin leads to hypersecretion of gastric acid which leads to multiple gastric/duodenal ulcers
How do you Dx Zollinger Ellison Syndrome
Elevated fasting serum gastrin
Be sure to Dc PPIs for 1 week prior to testing
If borderline then get a secretin provocative test
What is the tx for Gastric Ulcers
2 ABX (amox + clarith) And a PPI for a week
Maintenance therapy with PPI can reduce recurrence
If hemodynamic unstable or rebleeding the SRGRY
What is the treatment for refractive gastric ulcers
Antrectomy
What is the tx for performated ulcers
omental (Graham) patch
defect is plugged with omental pedicle
vagotomy is usually not required
What is dumping syndrome and what is the treatment
Shortly after eating : palpitations, sweating, weakness, dyspnea, flushing, nausea, abdominal cramps, belching, vomiting, diarrhea, and, rarely, syncope
Treatment: Diet therapy to reduce jejunal osmolality
low in carbohydrate and high in fat and protein
A pt presents with burning, gnawing epigastric pain, that was not present until an hour post breakfast
Think
Duodenal Ulcer
Get an EGD, and UGI
Gastric analysis and a fasting serum gastrin
Somatostatin receptor scintogrpahy is the pre op study of choice
An ulcer that fails to heal after 12 weeks of med tx
Then
Send for surgery
What is the only curative tx for localized gastric cancer
Surgical resection
What is the most common surgical disorder producing emesis in infancy
With an “olive” pit in the Epigastrum
Hypertrophioc pyloric stenosis
An infant presents with projective, nonbillious emesis 4-6 weeks after birth
Think
hypertrophic pyloris stenosis
What is the most common form of volvulus
Sigmoid
Immediately get sigmoidoscopy
High index of strangulation
What is the dx OC for Intussusception
Barium enema
What is riglers triad
pneumobilia, bowel obstruction, and a gallstone within the bowel
What are the hallmarks of Crohns
Cobblestone, skip lesions, transmural
Normally treated with 5-ASA drugs, steroids, antibiotics
What is the major area of concern for hepato-biliary anatomy
Common bile duct obstruction
What is the cystic duct
joins the common hepatic duct to form the common bile duct
Where and what is the sphincter of oddi
surrounds the common bile duct at the ampulla of Vater
controls the flow of bile into the duodenum
prevents regurgitation
diverts bile into the gallbladder
Where does the common hepatic artery arise from
The common hepatic artery arises from the celiac axis
-The gastroduodenal artery
—marks the point of origin of the proper hepatic artery
—divides into right and left hepatic branches
What is the portal triad
(hepatic artery, portal vein, and biliary duct)
enter the hepatic hilum
Why is hemorrhage control difficult in the Liver
The hepatic veins are typically very short prior to entering the inferior vena cava,
making vascular control of hemorrhage difficult
What makes bilirubin
Conjugated
Liver has processed it and it is now no longer attached to albumin
What vitamins does the liver metabolize
Metabolism of fat-soluble vitamins (A, D, E, K).
—absorbed in the intestine
—Vitamin K-dependent clotting factors, II, VII, IX, and X.
What is the most commonly injured solid organ in trauma
Liver
What is the most common sequelae of hepatic trauma
Biliary fistulae - most common sequelae of hepatic trauma
Central injury patterns warrant close surveillance for biliary leaks- Billoma
A rupture into the bile duct leads to…
Arterial pseudoaneurysms - potential for rupture
Rupture into a bile duct results in hemobilia
-intermittent episodes of right upper quadrant pain, upper gastrointestinal hemorrhage, and jaundice
Best managed with hepatic arteriography and embolization
Air in the biliary tree
Think
Pneumobilia - air in biliary tree
Rare with trauma
May occur if infected with gas producing bacteria
- Ischemic bowel
- Necrotic gall bladder
Major Liver leaks are treated with
ERCP (Tx and Dx)
And sphincerotomy
(Sphinter of oddi)
Minor leaks can resolve with conservative MGMT
What are the two malignant liver diseases
Primary- Hepatocellular Carcinoma (HCC)
Metastatic
LOOK for colon cancer any time you have metz to the liver
A smooth, contoured anechoic lesion with a well-defined interface between tissue and fluid in the liver think
Simple Hepatic Cyst
Usually AS/s
Requires no treatment
What is the tx approach for a Echinococcosis Cyst of the liver
This is a parasitic infection
DO NOT ASPIRATE!
Should be resected
On U/S of the liver you see Complex, internal septae, irregular lining, papillary projections
Think
Cystadenoma
-premalignant
Should be resected
Define Polycystic Liver Dz
Occurs in patients with
-autosomal dominant polycystic kidney disease
- Gene mutation
- a progressive condition
- cystic replacement of virtually the entire liver
Most patients asymptomatic
rarely result in hepatic insufficiency
What is the treatment approach for Polycystic liver with less than 10 cysts that are lager than 10cm
What is the approach
Cyst fenestration (Type I PLD)
What is the tx threshold for Polycystic Liver Dz Type III
Liver transplant
What is the most common liver tumor
Hepatic Hemangioma
(PANCE!!)
Congenital Vascular Malformations
On MRI - sensitivity & specificity of 98%
-hypointense lesion on T1-weighted imaging
and
-a hyperintense lesion on T2-weighted sequences
How does hepatic hemangioma appear of a T1 and T2 MRI
On MRI - sensitivity & specificity of 98%
hypointense lesion on T1-weighted imaging and a hyperintense lesion on T2-weighted sequences
What is the tx for a Hemangioma of the liver
Observation
Indications for operation include
severe pain, compressive symptoms, hemorrhage, or uncertain diagnosis with a suspicion of malignancy
What is risk to the liver with OCPs and Androgen steroid use
Hepatocellular Adenmo
How will a Hepatic Adenoma appear on a Nuclear Medicine Scan
COLD!
DDx for Heptocellualar carcinoma
What is the tx appraoch to hepatic ADENOMA
Complete surgical resection with negative margins indicated for:
-Hepatocellular adenomas >5 cm in diameter, those demonstrating rapid growth, or tumors suspicious for malignant transformation
How will Focal nodular Hyperplasia appear on Nucelar scans
Will be “hot” on nuclear medicine scan
- Diagnostic uncertainty
- core-needle biopsy; open or laparoscopic resection
DDx for HCC: The fibrous septations appear grossly as a central scar in FNH
is Focal nodular Hyperplasia malignant?
NO
What are the major risk factors for HCC in chronic liver dz
chronic hepatitis B virus (HBV) or C virus (HCV) infections!!!
~ alcohol abuse, nonalcoholic steatohepatitis, aflatoxin B1 exposure, a1-antitrypsin deficiency, hemachromatosis, and primary biliary cirrhosis
What is the workup for HCC
For high-risk patients - -ultrasonography with or without serum α-fetoprotein (AFP) testing every 6 months
To properly diagnose - either a high-resolution CT or MRI
What are the palative options for HCC
transarterial chemoembolization (TACE),
transarterial radioembolization (TARE),
stereotactic body radiation therapy (SBRT),
and SORAFENIB!!
How do you find Colorectal/ Liver Metz
Most patients with CRLMs are asymptomatic
-identified through preoperative staging or intraoperative examination
CRLMs can be identified by CT, MRI, or PET/CT
-PET/CT - when there is a high clinical suspicion for metastatic disease but equivocal imaging
A pt presents with jaundice, encephalopathy, and coag d/o
Think
Acute liver failure
ALF - no evidence of chronic liver disease and in which liver disease develops within 8 wks after the initial onset
DefineL Fluminant Hepatic Failure
Fulminant hepatic failure (FHF)
- ALF complicated by encephalopathy within 2 weeks!! of the onset of jaundice
—portends a more severe course
What is the threshold for Acute Liver Failure
Onset within 8 weeks on insult
What is the threshold of Fulminant Hepatic Failure
Encephalopathy within 2 weeks of Jaundice onset
What is the primary cause of Acute liver failure in the USA
Acetaminophen
Accounts for 40-60% of cases
A pt presents with massive liver necrosis, jaundice, profound coagulopathy, cerebral edema, brain damage, coma, and death
2 weeks after onset of jaundice
Think
Fulminant Liver failure
What is the initial lab eval for ALF
CBC, a platelet count, liver function tests, a coagulation profile, and assessment of renal function
What is the most commonly used system to classify Acute liver failure
The Child-Pugh classification remains the most commonly used system -class C designation is normally a contraindication to hepatic resection
The MELD score - more than 11 reliably predicting POHF
Treatment appraoch to chronic liver Disease
Admission and resusc
Shunts for the transcutaneous intrahepatic portosystemic shunt
(Short term and stabilizing)
B.Blockers can prevent first bleed in the 1st year
Abstinence of alcohol
And Lactulose to bind free NH3
Define Budd-Chiari Syndrome
An unusual cause of ALF is the Budd-Chiari syndrome
acute hepatic vein thrombosis - -Hepatic outflow obstruction
-Mostly women in hypercoagulable state
The typical patient is a young woman who presents with
right upper quadrant pain of acute onset, hepatomegaly, and ascites
W/u: US or CT
Tx: Anti-coagulation initially
TIPS or other portosystemic shunt
-Portal decompression if done before massive hepatic necrosis
occurs
Otherwise Liver transplant is the only option
Chole vs Cholecyst
Chole- bile or gall
Cholecyst- gall bladder
What is the imaging modality of choice for Chole D/o
U/S
hyperechoic, mobile structures with acoustic shadowing= stone
Differentiate between symptomatic cholelithiasis and acute cholecystitis -gallbladder wall thickening (> 3 mm) -pericholecystic fluid -sonographic Murphy sign
How do you DDx cholelithiasis vs cholecystitis
gallbladder wall thickening (> 3 mm), pericholecystic fluid, and sonographic Murphy sign
= Choilecytitis
What is the risk associated with ERCP
Complication includes pancreatitis
What is the role of ECRP
Tx and Dx for the biliary treat d/o and can remove stones
What is the role or MRCP
Noninvasive way of visualizing the biliary tract -compared with abdominal US (AU) better sensitivity (93%) and specificity (94 to 100%)
-equivalent to ERCP and cholangiogram
Avoids a contrast load or invasive instrumentation
-a screening tool
IS NOT THERAPEUTIC!!
cannot be used in certain patients with implants,
has a poor detection of small stones less than 6 mm,
What is the role of a HIDA scan
The most sensitive & specific study to diagnose acute cholecystitis is cholescintigraphy
aka HIDA; Radionuclide Scan
-Injecting a radioisotope tracer taken up by the liver, excreted into biliary system, passes through duodenum,
Provides both anatomic and functional information about the liver, gallbladder, and biliary system
What is the threshold for obstruction of the cystic duct on HIDA scan
a lack of visualization of the gallbladder, but filling of the CBD and duodenum 1 hour after injection of the tracer
When is HIDA used over U/S for biliary D./o
Cholescintigraphy is generally used when ultrasonography is equivocal or limited due to a patient’s body habitus (HEB+)
What are the major risk factors of cholelithiasis
Female, obese , pregnant
Mexican or Native Americans
(think mom)
Why does pregnancy increase gall stones
Pregnancy (Estrogen-> increases cholesterol secretion ; Progesterone decreases bile acid secretion)
What type of stones in the gall bladder are seen in Sickle cell, Thalessema, and Spherocytosis
Pigment gallstones occur in the setting of hemolysis
The amount of unconjugated bilirubin is increased in bile, precipitates out as calcium bilirubinate
A pt presents with Transient colicky right upper quadrant pain,
often occurring after meals (especially high-fat meals)
Nausea and vomiting may accompany the pain,
which can last anywhere from 30 minutes to several hours
episodes increase in both frequency and intensity over time
NON-FEBRILE!
Think
Chronic Cholecystitis
biliary colic
If a pt presents with chronic cholecystitis and transient episodes of hyperbilirubinemia
What should you do
suggests transient episodes of choledocholithiasis
should be further investigated
-Review previous LFTs determine if cholangiography is warranted
Is US is equivocal for cholecystisis
What is the next step
HIDA scan
US - most practical and cost-effective
sensitivity of approximately 80%
-sonographic Murphy sign
-thickened gallbladder wall, -pericholecystic fluid, gallbladder distention, and a hyperemic gallbladder wall
But if it doesnt show that get a HIDA scan (more sensitive and specific)
Role of MRCP in Acute cholecystisis
Pt is jaundiced and you think there is choledoclithiasis
What are the perferred ABX for abdominal surgeries
Ciprofloxacin and metronidazole
What is the definitive tx for Acute Cholecystitis
Definitive management - Laparoscopic cholecystectomy
Optimum timing - within 72 hrs of symptom onset
Pts that are not good surgical candidates for gall bladder surgery
Can get what intervention
Percutaneous cholecystostomy (PCT) -Candidates not suitable for operation
-clinical improvement within 48 hours
-If patients recover sufficiently
elective cholecystectomy at a later date
What is the most common complication of Acalculous Cholesytitis
Gangrene is most common;
Perforation & gallbladder empyema
What is the risk of biliary stasis in critically ill pts
Acalculous cholecystitis
What is the treatment for Acalculous cholecystitis
Treatment - Mortality = 30%
early laparoscopic cholecystectomy
poor surgical candidates -> cholecystostomy tube
Slide 41-45 internet failure
High risk pts for suspected choledocholithiasis
High risk: age >55 years, bilirubin >1.7mg/dL CBD >6 mm, and visible stone on US
What is Charcots triad
Charcot’s Triad: RUQ pain, Fever, Jaundice
What ist Reynolds Pentad
Charcot’s Triad: RUQ pain, Fever, Jaundice
+ HOTN and AMS
A pt presents wtih abdominal pain that radiates to the back, jaundice, nausea, and stools and dark urine
Think what biliary D/o
Choledocholithiasis
MAy have Charcots triadL:
RUQ Pain, Fever, and Jaundice
What is the best individual lab result for Choledocholithiasis
A rise in serum bilirubin -best individual lab result
usually remains under 10 mg/dL
most in the range of 2-4 mg/dL
Can MRCP detect stones less than 6 cm
Not as good
What is the treatment approach to Choledocholithiasis
Systemic antibiotics & other measures as above
-usually controls the attack within 24-48 hours
If worsens - endoscopic sphincterotomy or surgery
Typical pt: Laparoscopic cholecystectomy
What are the predominant organisms in the bile
E coli, Klebsiella, Pseudomonas, Enterococci, and Proteus
What is the approach to Cholangitis
Cholangiography is dangerous during active cholangitis
Further workup (THC, ERCP, etc) can proceed later after the acute manifestations are brought under control
Resuc and Do not delay ABX
(Cipro and Metro)
Decompress the biliary duct
- emergency ERCP
- if unsuccessful then laparotomy
Where is the cut made for open cholecystectomy
Kockers Point incision
What is an IOC
Intra-Operative Cholangiogram (IOC)
-Cystic duct stump cannulated
-Contrast introduced and fills CBD channels
-Used to identify CBD injury
(extravasation of contrast) or CBD obstruction
(CBD: Common bile duct)
What is the worst complication of A Cholecystectomy
Damage to the CBD- evaluated with IOC
Post cholesctectomy
What are the major complications to look out for
Stricture ( months to weeks s/p)
2/2 cautery
Intrahepatic abcess
CBD damage
Poor surgical candidate for surgery with cholecyst d/o
If surgery is a poor option, a cholecystostomy tube can be placed to decompress the gallbladder
Done at bedside under US guidance
Should show improvement post procedure within 24 to 48 hours!
Should remain in place till fully recovered
(T-Tubes)
Biliary pancreatitis should be suspected if
gallstones are identified on a sonogram or CT scan
or if the liver function tests are abnormal
What are the lead metabolic and mechanical etiologies of acute pancreatitis
Metabolic
-alcohol!!, hyperlipidemia, hypercalcemia, drugs, genetic, scorpion venom
Mechanical
cholelithiasis!!, postoperative, pancreas divisum, posttraumatic, ERCP, pancreatic duct obstruction, pancreatic ductal bleeding, duodenal obstruction
What are the infx causes of Acute panc.
mumps, coxsackie B, cytomegalovirus,Cryptococcus
What is the clinical presentation of Acute Panc.
severe in intensity,
boring and constant in character,
and upper abdominal
(supra umbilical) in location.
N/V are prominent
+Fever
(underlying inflammation/ infx)
Dry sunken membranes
+scleral icterus (biliary cause)
+Grey/Turner Sign (rare)
+/-Plueral effusions
+/- Ileus
(abdominal distention, tympani, and hypoactive bowel sounds)
Maybe a peritinic abd
What is the most accurate single test for Acute Panc.
Lipase > 3x normal
most accurate single test
Gold standard is Lipase and Amylase
CRP can be used but it used to TRACK the disease process
(Necrotizing)
What does Acute Panc. Look like on plain film
calcifications or sentinel loop
What is the single most accurate imaging test for Acute Panc.
Contrast-enhanced CT
- quantifying the inflammatory process
- staging the severity of the disease process
What is the Dx criteria for Acute Panc.
The diagnosis of acute pancreatitis requires two of three features:
(1) abdominal pain suspicious for pancreatic origin,
(2) serum amylase and/or lipase activity
- usually at least three!! times greater than the upper limit of normal, or
(3) characteristic findings on either CT or MRI
What are 2 prognostics for morbidity and mortality for Acute Panc.
Ranson criteria , BISAP score
Are good scoring systems but not very useful in treatment approach
What is the most useful serum test for Acute Panc.
CRP to Trend and Lipase to Dx
Tx approach to Acute Panc.
3-6 L of LR over 24hrs to a UOP of 30/ml hr
Close Glucose Control (less than 180 or 140 fasting)
NaRCs NARCS NARCS (IV)
+/- NG tube (ileus or distention)
PPI and anticoagulant is mandatory in all pts
What is the Tx approach to Mild Biliary Panc.
-elective laparoscopic -cholecystectomy and IOC
-after acute pancreatic inflammation has subsided
but prior to their hospital discharge
Tx approach to severe acute panc. With evidence of cholangitis
ERCP +/- endoscopic sphincterotomy (ES) for stone extraction
Look at treatment slide 17 in lecture 7
If acute panc fails to recover within a week of treatment
Think
Pseudo cyst
Commonly occur in patients with duct abnormality – Complicates surgery
The majority should not be treated by cyst drainage alone
Also pancreatic duct drainage, ~parenchymal resection
On cross-sectional imaging
You see density increase in the fluid w/in the panc.
Think
Pseudo cyst or Psuedoaneurysms
The two primary options of intraoperative for Panc trauma treatment are
Drainage vs resection
What does chronic alcoholism do to the panc
characterized by glandular fibrosis leading to pancreatic endocrine (diabetes mellitus) and exocrine (steatorrhea) insufficiency
Distinguishing features of acute vs/ chronic panc
What is the clinical triad of Chronic Panc.
Abdominal pain
Weight loss
Diabetes
Steatorrhea
How do you Gauge both the overall functional (renal, hepatic) and nutritional status of the patient with chronic panc
Assessment of both the endocrine (hemoglobin A1C) and the exocrine (fecal elastase) function
What is the imaging approach to Chronic Panc.
Both ductal and parenchymal information is required to accurately classify patients
pancreatic duct: MRCP/ERCP
pancreatic morphology: CT/MRI
What is the srg op for large duct pancreatitis (chronic)
The Puestow or Frey
What is the the srg op for small duct chronic panc
the Whipple, Beger, or Frey procedure
What is the tx option for panc. Cancer
Operative management of all four is identical (pancreaticoduodenectomy)
A pt presents with painless jaundice.. think
Panc. Cancer
+acholic stools, dark urine, pruritus, and cutaneous jaundice
anorexia and weight loss
+Courvoisier sign
Palpable, nontender gallbladder in presence of clinical jaundice
+bilirubin level in the 18s
Draw serum lipase
What is the imaging for all panc cancer pts
CT SCAN !
If no mass is found on CT for panc cancer
What is the next step
ERCP
A pt presents with bizarre behavior, memory lapse, or unconsciousness
palpitations, sweating, and tremulousness
Think
Insulinoma
2/2 glucose deprivation
What is the WHipple Triad
(1) hypoglycemic symptoms produced by fasting,
(2) blood glucose below 50 mg/dL during symptomatic episodes, and
(3) relief of symptoms by intravenous administration of glucose
Dx for Insulinoma
Tx approach to Insulinoma
If Whipples triad is pos.
Surgery should be done promptly
A pt presents with abdominal pain and diarrhea
in the presence of refractory peptic ulcer disease
Think
Gastrinoma
Assoc with MEN1
(screen all pts with MEN1)
Gastrin Level greater than 1000
If not met then secretin provocative test
Primary Tx: Surgical Resection
What is the spleen treatment for idiopathic Thrombocytopenic purpura
60 mg of prednisone daily until the platelet count returns to normal
Splenectomy indicated for patients who do not respond to corticosteroids
What is the most common reason for splenectomy
symptomatic relief of splenomegaly
hypersplenism secondary to chronic illnesses
What is the criteria for a Explore. Lap
In spleen truama
blunt abdominal trauma + diffuse peritonitis or hemodynamically unstable (+/- Kehr sign)
What is the immunization appraoch to post op complications of splenectomy
2 weeks prior to elective splenectomy
2 weeks after emergent splenectomy
or
on day of discharge if <2 weeks; 3 months after chemo/radiation
Then give vaccines for Strep Pneumo and H. Flu, and Meningococcus
Expect to see VTE - platelet counts >600,000 - 800,000/μL
incidence of about 5%
Not an indication for anticoagulants
Can use Aspirin
How many layers does the colon have
5 layers: mucosa (innermost layer), submucosa, circular muscle, longitudinal muscle, and serosa (outermost layer)
What are the two areas of the colon not covered by taenia
the appendix and the rectum
helps identify transection lines during surgery
Define Small outpouchings of colon mucosa and submucosa
Occur at sites of vascular penetration within colon wall
Diverticula
What is the difference between psuedo and true diverticula
Occur between the mesenteric tenia and the two nonmesenteric teniae
Termed diverticulosis
-Majority are pseudodiverticula
missing the muscular layer
-Minority are true diverticula
predominantly in the right colon
What is the most common cause of LGI bleeding
Diverticulosis
What is the vulnerable site of bleeding in diverticulosis
Thinning of the colonic wall at the outpouching
-superficial vasa recta - vulnerable to bleeding
When should SRGRY be considered for for pts with diverticulosis
70-80% will stop on its own without therapy
Consider surgery for:
multiple episodes of confirmed bleeding from a specific location
How do you investigate the source of LGI bleed/ UPGi bleed
Upper: Nasogastric (NG) lavage
To rule out upper GI source of bleeding
If blood= upper endoscopy
Lower: Colonoscopy
the optimal imaging modality
Allows for diagnosis and therapy
What is the approach to a slow LGI bleed
Colonoscopy
What is the approach to brick bleeding in the LGI
CT angiogram
If source not identified, colonoscopy
A pt with an ongoing bleed but a negative colonoscopy
What is the approach
Tagged RBC scans - used before angiography
-help target vessels accurately during angiography
CT angiography
- to localize extravasation of blood into the GI lumen
- Can be diagnostic and therapeutic
Indications for SRGRY in ongoing bleeding treatment
persistent massive hemorrhage, transfusion requirement or more than six units in 24 hours, and recurrent diverticular bleeding
segmental colonic resection vs. total abdominal colectomy
What is the treatmetn for a colovesical fistula
pneumaturia, abdominal pain, fecaluria, recurrent urinary tract infections, hematuria, and urinary frequency
Treatment - elective surgical resection
What is the treatment for a colovaginal fistula
passage of gas or stool through the vagina or presence of persistent foul smelling discharge
Speculum examination may reveal a site of drainage
A pt with a free wall perforation
What is the tx
Emergent surgery
What is the current standard of cancer for the Dx and triage
CT is the current standard of care for diagnosis and triage
IV contrast is routinely used
Oral/rectal contrast can help visualize, but can add delays
The most frequent CT findings are
- bowel wall thickening
- pericolonic inflammation
- and diverticula
Complications of diverticulitis : colovesical fistula
Tx approach to UNCOMP diverticulitis
Bowel rest with ABX
(Metro/ Cipro)
Colonoscopy in 6-8 weeks for cancer screen (very important)
Modifiable risk factors for colorectal cancer
Meat consumption, smoking, and alcohol
What is the common colorectal cancer type
Adenomas - common
indicates an increased risk for CRC, may harbor malignancy
Haggit Classification for colorectal cancer
Polyps greater than 1 cm =
Complete excision with a 2 mm margin
Tier 1 colorectal screening
Q10yrs starting at age 45
Tier 2 screening for colorectal cancer
CT colonography q 5 years or a FIT DNA q 3 years
Or flex sigmoid q5
(If not desiring a colonoscopy)
A pt with a 1st degree FAMHx of colorectal cancer should be screened when
Colonoscopy q5yrs starting at age 40 or 10- years prior to FAMHx onset age
What is the most common cause of colon obstruction in adults
Colorectal cancer
Left sided colorecatal cancer
Hematochezia
Obstruction
Change in bowel habits ->stool thinner
R sided CR cancer
Acute blood loss anemia
Occult blood > Melena > Hematochezia
Palpable right sided abdominal mass
Rectal Cancer
Hematochezia
Tenesmus
DRE - drop metastases in the Pouch of Douglas (Blumer shelf)
Any pt with Iron Def. Anemia has colorectal cancer until proven otherwise
What is the approach to clinical staging of colorectal cancer if a colonoscopy cannot be performed
CT colonography or air-contrast barium enema
What are the main sites of Metx for colorectal cancer
Liver and lungs
What is the approach to pts with familial polyposis
Prophylactic colectomy
Obstipation =
Obstruction
Where is the most likely place for a volvulus
Colonic volvulus – 5% of all cases of LBO in the US
- Twisting of cecal or sigmoid colon
- Sigmoid more common in elderly
- Colonoscopy to remove trapped air and f/u surgery to prevent recurrence
Pain with defecation
Think
Ulcerative colitis
What is the treatment for inflammatory bowel
Admission and resuscitation
- mIVF and NPO with NGT suctioning
- Abx’s if necrotic bowel or perforation suspected
Upright abdominal film
-Air fluid levels suggestive of obstruction
Barium enema – largely replaced by CT
- May be both diagnostic and therapeutic
- Apple core lesion highly suggestive of colon cancer
CT abdomen/pelvis with rectal contrast
-Most useful single test
Colonoscopy – stable pts for diagnostic biopsy of mass
Grading of a hemmrhoid
I- Bleeding, no tissue prolapse out of anus
II- prolapse with Valsalva and spontaneously reduces
III- prolapse with Valsalva and requires manual reduction
IV- incarcerated (always prolapsed)
Hemorrhoid Tx
Stool softener (colasce)
Sitz bath
Lidocaine jelly
Nitroglycerin ointment
Or CCB ointments
Sclerotherapy
Band Ligation
Treatment for post banding sepsis in the hemorrhoid pt
early antibiotic treatment coupled with aggressive surgical drainage
Everted edges of the rectum with a central ulceration
Think
SCC of the rectum/ anus
When to do abdomino-perineal resection for anal cancer
recurrent disease, residual disease after radiation, or bulky tumors
MC endocrine tumors of the GI system
Carcinoid
S/S hot flashes, bronchospasms, and arrhythmias
carcinoid syndrome
liver is not able to metabolize the active substances
Anal fissures that are lateral or in multiple locations think
Indicators of other disease :
Crohn disease, syphilis, tuberculosis and even squamous cell carcinomas
What is the majority of tx for anal fissures
Two thirds successfully treated with conservative measures
-Topical nitroglycerin (0.2% NTG) and nifedipine (2%)
Symptoms that do not resolve may improve with injection of botulinum toxin
Cryptoglandual infections of the anal canal
Perirectal abcess
PRIMARY CARE MANTRA: “NEVER LET THE SUN GO DOWN ON A PERIRECTAL ABSCESS”
What is the post op Care for perianal abcess
Antibiotics are not necessary except in patients with significant cellulitis
Use a pad as necessary, drainage & pain should decrease in several days
Pain medication, stool softeners, and laxatives
i
nstructed to shower or take warm tub soaks for perianal hygiene.
What is the threshold for SRGRY for pilonidal dz
Persistent drainage x 2-3 months are surgical candidates
If the abscess is greater than 5 cm or recurrent, it may include loculated segments separated by subcutaneous septae
these patients are best operated on
Bascom is the mc surgry
