Acute surgical conditions

1. New Resident Orientation Acute surgical conditions 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.

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 alkphos 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

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.

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 • Gastroschisis • 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. Pneumatosisintestinalis

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

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

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!