1. Acute surgical conditions
New Resident Orientation
Michael Hong, MD
June 25, 2013
University of Florida, Department of Surgery

2. Pancreaticobiliary Service
Cholecystitis
Cholangitis
Pancreatitis

3. Cholecystitis Low grade fever, RUQ pain, nausea, vomiting
Mild leukocytosis: 10-12
Key points
RUQ US best test – stones, pericholecystic fluid, gallbladder wall thickening, CBD diameter
Rule 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. Cholangitis
Fever and leukocytosis can depend on early versus late stage of cholangitis.
Rapid progression to sepsis.
Hyperbilirubinemia, dilated common bile duct
Imaging: 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 lipase
Possibly elevated transaminase and alk phos from impacted gallstone
Common causes: alcohol, gallstone, metabolic, malignancy, drugs, medicine stuff, pancreatic divisum, hypertriglyceridemia.
Treatment depends on the underlying cause, supportive care, no role for prophylactic antibiotics
Metabolic: 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 hernia
Perforated 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, Obdurator
Imaging: CT with IV contrast is first line, ultrasound and children and pregnant women, MRI
CT: 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 cases
Additional points: high fever or high leukocytosis often correlates with perforation.
Innervation of the appendix occurs at T10 which can confuse with the umbilicus.

8. CT of appendicitis

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 contrast
Look 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.

10. Dilated promixal / Decompressed Distal

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 helpful
Do not reduce a hernia in someone who is toxic
Maneuvers to increase successful reduction
Supine position, legs bent, deep constant pressure, Trendelenburg position, oral sedation
Acutely irreducible hernia is an indication for surgery.

12. Inguinal hernia imaging

13. Perforated Gastric Ulcer
Acute onset abdominal pain
Peritonitis, rigid abdomen
Free air under the diaphragm on chest x-ray or KUB
History of using aspirin, NSAIDs, Goody powder
Treatment: urgent laparoscopy or laparotomy.

14. Air under the diaphragm

15. Treatment of Gastric Ulcer

16. Pediatric Surgery Appendicitis Gastroschisis / Omphalocele
Malrotation / mid-gut volvulus
Intussusception
Pyloric Stenosis
Necrotizing Enterocolitis

17. Gastroschisis / Omphalocele
Defect of umbilical membrane near vein
No coverage, to right of umbilicus
Need immediate coverage
Omphalocele
Incomplete closure of abdominal wall
Associated with other abnormalities (VACTERL)
Babygram (vertebral)
Echocardiogram
Usually covered by sac, sometimes ruptured

18. Gastroschisis
Omphalocele

19. Midgut Volvulus Secondary to intestinal malrotation Bilious emesis
Xray: gastric/duodenal distension
UGI: oral contrast film – corkscrew appearance in duodenum, extrinsic compression by Ladd’s bands
Small bowel on right, colon on left
Duplex US: SMV is normally to right of SMA, flipped in volvulus

20. Ladd Procedure

21. Intussusception Age 6 months to 2 years Hypertrophied Peyer’s patches
Colicky abdominal pain, currant jelly stool
Tx: air enema by radiology
Operative reduction if enema unsuccessful

22. Intussusception

23. Pyloric Stenosis
Risk factors: first born white male, erythromycin use in pregnancy
Age: 2-6 weeks
History: nonbilious projective vomiting shortly after feeds
Physical: palpable “olive” epigastric area
Labs: hypochloremic hypokalemic metabolic alkalosis
Imaging: abdominal ultrasound
Tx: resuscitation, correct electrolytes
Operation only after medical stabilization

24. Necrotizing Enterocolitis
Abdominal distension, intolerance to feeds, bilious emesis, bloody stools soon after enteral intake in premature infant
Abdominal erythema, crepitus, or discoloration is ominous
Tx: NPO, IV abx, NGT, resuscitation
Operation for pneumoperitoneum
Also for portal venous air, abd erythema, clinical deteriorization

25. Pneumatosis intestinalis

26. Vascular and TCV Surgery
Acute limb ischemia
DVT/PE
Ruptured AAA
Acute dissection

27. Acute Limb Ischemia
6 Ps: pain, pulselessness, paralysis, pallor, paresthesia, poikilothermia
Obtain history about timing, irregular heart rhythm, chest pain suggestive of heart attack, history of aneurysms.
Document good pulse exam
Treatment: immediate anticoagulation with therapeutic dose heparin
Embolectomy
Fasciotomy
Mild muscle weakness and sensory loss, inaudible arterial signal with intact venous signal
Fasciotomy for salvageable limb

28. DVT
History and physical: unilateral, though leg pain increasing with movement. Unilateral leg swelling
Homan’s sign is not useful
Wells criteria
Diagnosis: venous duplex ultrasound
D-dimer is usually elevated postoperatively
Treatment systemic anti-coagulation with therapeutic dose of heparin or Lovenox

29. Pulmonary Embolism Tachypnea, tachycardia, pleuritic chest pain
Assess for DVT
CXR 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 suspicion
V/Q scan, like all nuc med studies, are of limited value
Same tx as DVT
Supplemental O2
EKG to rule out MI, CXR to rule out pneumothorax, pneumonia
V/Q scan always intermediate suspicion
D-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 rupture
Call fellow immediately
If stable, obtain CT scan for possible endovascular repair planning if not already done OR

31. Ruptured AAA

32. Aortic Dissection
Sudden onset tearing, ripping, 10/10 chest pain radiating to back
Vitals: hypertension
Work up: CT, Echo
Determine location:
Stanford A/B: A = asc, B = arch + desc
DeBakey I, II, III
I asc + desc
II asc + arch
III desc distal to L SCA
Treatment: beta blockers and BP control for Type B
OR for type A

33. Aortic dissection

34. Aortic Dissection

35. Colorectal Surgery
Diverticulitis

36. Diverticulitis LLQ pain, hx of diverticulosis Diagnosis by CT scan
Uncomplicated – bowel thickening, localized tenderness
Complicated – Hinchey Classification
Hinchey I: pericolic abscess
Hinchey II: larger mesenteric abscess, extension to pelvis
Hinchey III: free perforation, purulent peritonitis
Hinchey IV: feculent peritonitis
Treatment:
uncomplicated  clear liquids, oral abx
complicated
Hinchey I/II: NPO, IV abx, percutaneous drainage for abscess >5cm
Hinchey III: resection and primary anastomosis vs colostomy
Hinchey IV: diverting colostomy

37. Diverticulitis

38. Burn Surgery
Burns
Necrotizing soft tissue infection

39. Burn Mechanism Rule out inhalational injury
History: enclosed space, smoke
Physical: soot in mouth, singed facial hairs, hoarseness
Labs: methemoglobin on ABG
Bronchoscopy
Resuscitate – Parkland Formula, LR
Evaluate pulses for need for escharotomy / fasciotomy

40. Necrotizing soft tissue infection
Risk factors: Diabetes, Immunosuppression
Exam: tachycardia / tachypnea / altered mental status
Tenderness / pain away from erythematous area
Crepitus, paralysis, bullae
Labs: LRINEC score
Imaging: CT for gas in soft tissue / fascia
MRI too sensitive, difficult to obtain quickly
Treatment: wide debridement and IV Abx

41. NSTI

42. VA General Surgery
Anything goes!

43. I thank you for your attention and am happy to take questions.