Presentation on theme: "Acute surgical conditions"— Presentation transcript:
1 Acute surgical conditions New Resident OrientationMichael Hong, MDJune 25, 2013University of Florida, Department of Surgery
2 Pancreaticobiliary Service CholecystitisCholangitisPancreatitis
3 Cholecystitis Low grade fever, RUQ pain, nausea, vomiting Mild leukocytosis: 10-12Key pointsRUQ US best test – stones, pericholecystic fluid, gallbladder wall thickening, CBD diameterRule out complicating features: diabetes, peritonitis, high leukocytosis, high-grade fever, jaundice/hyperbilirubinemia.Could indicate gangrenous cholecystitis, perforated cholecystitis, choledocholithiasis, cholangitis, pancreatitis.GB wall 3mm
4 CholangitisFever and leukocytosis can depend on early versus late stage of cholangitis.Rapid progression to sepsis.Hyperbilirubinemia, dilated common bile ductImaging: only indicated if diagnosis is not certain. No role for MRCP in clear-cut cholangitis.Treatment: emergent ERCP for stone extraction and sphincterotomy.
5 Pancreatitis Acute onset epigastric pain radiating to the back Elevated amylase and lipasePossibly elevated transaminase and alk phos from impacted gallstoneCommon causes: alcohol, gallstone, metabolic, malignancy, drugs, medicine stuff, pancreatic divisum, hypertriglyceridemia.Treatment depends on the underlying cause, supportive care, no role for prophylactic antibioticsMetabolic: hereditary, hypercalcemia, hyperlipidemia, malnutrition.Drugs: sulfa, steroids, Lasix, hydrochlorothiazide.Medicine stuff: infection such as mumps, Coxsackie, mycoplasma pneumonia, Ascaris, Clonorchis
6 Acute Care Surgery Appendicitis Cholecystitis Small bowel obstruction Incarcerated herniaPerforated gastric ulcer
7 Appendicitis History and physical are the most important Acute onset peri-umbilical pain migrating to the right lower quadrant.Nausea and vomiting, subjective fevers, chills.Pain at McBurney’s point, peritonitis.Signs: Rovsing, Psoas, ObduratorImaging: CT with IV contrast is first line, ultrasound and children and pregnant women, MRICT: enlarged appendix greater than 6 mm, contrast enhancement of the appendiceal wall, non-filling of appendix lumen with oral contrast, peri- appendiceal fat stranding.Management: IV fluids, IV antibiotics (Unasyn or Cipro/Flagyl in adults, Ceftriaxone in pediatrics), laparoscopic appendectomy in most casesAdditional points: high fever or high leukocytosis often correlates with perforation.Innervation of the appendix occurs at T10 which can confuse with the umbilicus.
9 Small Bowel Obstruction History of nausea, vomiting, abdominal distention, abdominal pain, and no bowel movements for several days.Work up includes CT scan with oral contrastLook for contrast filling, proximal dilatation, distal decompression, “transition point”Most common cause are adhesions and hernias.History must include documentation of prior abdominal or pelvic surgeries.Must rule out incarcerated hernias, volvulus.Treatment for small bowel obstruction caused by adhesions is initial conservative management with NPO, NG tube, IV fluids.
11 Incarcerated Hernias Reducible, incarcerated, strangulated. Inguinal, umbilical, femoral, obturator, ventral.Femoral and operator hernias are difficult to diagnose on physical exam.CT scan is helpfulDo not reduce a hernia in someone who is toxicManeuvers to increase successful reductionSupine position, legs bent, deep constant pressure, Trendelenburg position, oral sedationAcutely irreducible hernia is an indication for surgery.
13 Perforated Gastric Ulcer Acute onset abdominal painPeritonitis, rigid abdomenFree air under the diaphragm on chest x-ray or KUBHistory of using aspirin, NSAIDs, Goody powderTreatment: urgent laparoscopy or laparotomy.
17 Gastroschisis / Omphalocele Defect of umbilical membrane near veinNo coverage, to right of umbilicusNeed immediate coverageOmphaloceleIncomplete closure of abdominal wallAssociated with other abnormalities (VACTERL)Babygram (vertebral)EchocardiogramUsually covered by sac, sometimes ruptured
19 Midgut Volvulus Secondary to intestinal malrotation Bilious emesis Xray: gastric/duodenal distensionUGI: oral contrast film – corkscrew appearance in duodenum, extrinsic compression by Ladd’s bandsSmall bowel on right, colon on leftDuplex US: SMV is normally to right of SMA, flipped in volvulus
23 Pyloric StenosisRisk factors: first born white male, erythromycin use in pregnancyAge: 2-6 weeksHistory: nonbilious projective vomiting shortly after feedsPhysical: palpable “olive” epigastric areaLabs: hypochloremic hypokalemic metabolic alkalosisImaging: abdominal ultrasoundTx: resuscitation, correct electrolytesOperation only after medical stabilization
24 Necrotizing Enterocolitis Abdominal distension, intolerance to feeds, bilious emesis, bloody stools soon after enteral intake in premature infantAbdominal erythema, crepitus, or discoloration is ominousTx: NPO, IV abx, NGT, resuscitationOperation for pneumoperitoneumAlso for portal venous air, abd erythema, clinical deteriorization
26 Vascular and TCV Surgery Acute limb ischemiaDVT/PERuptured AAAAcute dissection
27 Acute Limb Ischemia6 Ps: pain, pulselessness, paralysis, pallor, paresthesia, poikilothermiaObtain history about timing, irregular heart rhythm, chest pain suggestive of heart attack, history of aneurysms.Document good pulse examTreatment: immediate anticoagulation with therapeutic dose heparinEmbolectomyFasciotomyMild muscle weakness and sensory loss, inaudible arterial signal with intact venous signalFasciotomy for salvageable limb
28 DVTHistory and physical: unilateral, though leg pain increasing with movement. Unilateral leg swellingHoman’s sign is not usefulWells criteriaDiagnosis: venous duplex ultrasoundD-dimer is usually elevated postoperativelyTreatment systemic anti-coagulation with therapeutic dose of heparin or Lovenox
29 Pulmonary Embolism Tachypnea, tachycardia, pleuritic chest pain Assess for DVTCXR and EKG nonspecific (rule out other stuff)ABG: decreased CO2 (tachypnea)PE protocol CT is expensive, requires heavy dye load, and is not appropriate for low suspicionV/Q scan, like all nuc med studies, are of limited valueSame tx as DVTSupplemental O2EKG to rule out MI, CXR to rule out pneumothorax, pneumoniaV/Q scan always intermediate suspicionD-dimer can rule out, but low sensitivity
30 Ruptured AAA Signs of shock Pulsatile abdominal mass Most common presentation is transfer from OSH with CT scan showing AAA ruptureCall fellow immediatelyIf stable, obtain CT scan for possible endovascular repair planning if not already doneOR
32 Aortic DissectionSudden onset tearing, ripping, 10/10 chest pain radiating to backVitals: hypertensionWork up: CT, EchoDetermine location:Stanford A/B: A = asc, B = arch + descDeBakey I, II, IIII asc + descII asc + archIII desc distal to L SCATreatment: beta blockers and BP control for Type BOR for type A