1. Acute surgical conditions
New Resident Orientation
Daniel J. Farrugia, MD PhD
June 24, 2014
University of Florida, Department of Surgery

2. Pancreaticobiliary Service
Acute cholecystitis
Acute cholangitis
Acute pancreatitis

3. Acute Cholecystitis Low grade fever, RUQ pain, oral intolerance
Mild leukocytosis: 10-12
Key points
RUQ US best test – stones, pericholecystic fluid, GB wall thickening >3 mm, CBD >6 mm
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 Charcot’s Triad/Reynold’s Pentad
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.
RUQ pain, fever, jaundice; + AMS, +shock

5. Acute 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, hypertriglyceridemia
Treatment depends on the underlying cause, supportive care
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/VA General
Appendicitis
Small bowel obstruction
Incarcerated hernia
Perforated gastric ulcer

7. Acute 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, Obturator
Imaging: CT with IV contrast is first line, ultrasound in 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/Flagyl 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.
Rovsing: palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant
Psoas: irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocaecal. passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip
Obturator:

8. CT of appendicitis

9. Small Bowel Obstruction
Absence of flatus, bowel movements
Nausea, vomiting, abdominal distention, abdominal pain
CT scan
Look for proximal dilatation, distal decompression, “transition point”
Closed loop, Free fluid, mesenteric swirling
Small bowel protocol after overnight decompression
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, 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 diaphragm on erect CXR or KUB
H/o aspirin, NSAIDs, Goody powder
Treatment: urgent laparotomy.

14. Air under the diaphragm

15. Treatment of Gastric Ulcer

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

17. Acute Limb Ischemia
6 Ps: pain, pulselessness, paralysis, pallor, paraesthesia, 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 heparin infusion
Embolectomy
Fasciotomy
Possible muscle weakness and sensory loss, inaudible arterial signal with intact venous signal
Fasciotomy for salvageable limb

18. DVT Unilateral leg swelling, leg pain, worse with movement
Homan’s sign is not useful
Wells criteria
Diagnosis: venous duplex ultrasound
D-dimer is usually elevated postoperatively
Rx: systemic anti-coagulation with therapeutic heparin GTT or Lovenox SQ

19. Pulmonary Embolism Tachypnea, tachycardia, pleuritic chest pain
Assess for DVT
CXR and EKG nonspecific (rule out other stuff)
ABG: decreased CO2 (tachypnea)
Radiology:
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 Rx 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

20. Ruptured AAA Signs of shock Pulsatile abdominal mass
Most common presentation is transfer from OSH with CT scan showing AAA rupture
Call fellow on call immediately
If stable, obtain CT scan for possible endovascular repair planning if not already done
Operative & Blood Consent, T+C, Labs OR

21. Ruptured AAA

22. Aortic Dissection
Sudden onset tearing, ripping, 10/10 chest pain radiating to back
Vitals: hypertension
Work up: CT, Echo
Treatment:
beta blockers and BP control for Type B
OR for type A

23. Aortic Dissection Stanford A/B: DeBakey I, II, III A = asc,
Determine Location
Classification
Stanford A/B:
A = asc,
B = arch + desc
DeBakey I, II, III
I asc + desc
II asc + arch
III desc distal to L SCA

24. Aortic dissection

25. Colorectal Surgery
Acute Diverticulitis
Perforated Colon Cancer

26. Diverticulitis LLQ pain, hx of diverticulosis, past episodes
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, ?outpatient management
complicated
Hinchey I/II: NPO, IV abx, percutaneous drainage for abscess >5cm
Hinchey III: resection and primary anastomosis vs colostomy
Hinchey IV: diverting colostomy

27. Diverticulitis

28. Burn Surgery
Burns
Necrotizing soft tissue infection

29. Burn Mechanism Rule out inhalational injury
gas on trash, explosion, house fire, electrical, chemical
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, UOP
Evaluate pulses for need for escharotomy / fasciotomy

30. 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 difficult to obtain quickly
Diagnosis is CLINICAL
Treatment: Urgent wide debridement
IV Abx: Vancomycin, Zosyn, Clindamycin

31. NSTI

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

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

34. Gastroschisis
Omphalocele

35. Midgut Volvulus Secondary to intestinal malrotation Bilious emesis
Xray: gastric/duodenal distension
UGI: oral contrast film
corkscrew appearance of 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

36. Ladd Procedure

37. 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

38. Intussusception

39. 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: hypokalemic hypochloremic metabolic alkalosis
Imaging: abdominal ultrasound
Tx: resuscitation, correct electrolytes
Operation only after medical stabilization

40. 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
Urgent operation for:
Pneumoperitoneum
Portal venous gas, abd erythema, clinical deterioration

41. Pneumatosis intestinalis

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