Juan F Alvarez MD University of Florida Department of Surgery New Resident Orientation Pancreaticobiliary Service Acute cholecystitis Acute cholangitis Acute pancreatitis Acute Cholecystitis ID: 914715
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Slide1
Acute surgical conditions
Juan F. Alvarez MD
University of Florida, Department of Surgery
New Resident Orientation
Slide2Pancreaticobiliary ServiceAcute
cholecystitisAcute cholangitisAcute pancreatitis
Slide3Acute Cholecystitis
Low grade fever, RUQ pain, oral intoleranceMild leukocytosis: 10-12Key pointsRUQ US best test – stones, pericholecystic fluid, GB wall thickening >3 mm, CBD >6 mmC
omplicating features: diabetes, peritonitis, high leukocytosis, high-grade fever, jaundice/hyperbilirubinemia.Could indicate gangrenous cholecystitis, perforated cholecystitis, choledocholithiasis, cholangitis, pancreatitis.
Slide4CholangitisFever and leukocytosis Charcot’s Triad/
Reynold’s PentadRapid 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.
Slide5Acute PancreatitisAcute onset epigastric
pain radiating to the backElevated amylase and lipasePossibly elevated transaminase and alk phos from impacted gallstoneCommon causes: alcohol, gallstone, metabolic, malignancy, drugs, hypertriglyceridemia
Treatment depends on the underlying cause, supportive care
Slide6Acute Care Surgery/VA GeneralAppendicitisSmall bowel obstruction
Incarcerated herniaPerforated gastric ulcer
Slide7Acute AppendicitisHistory 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, ObturatorImaging: CT with IV contrast is first line, ultrasound in 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/
Flagyl
in pediatrics)
Laparoscopic appendectomy in most cases
Additional points: high fever or high leukocytosis often correlates with perforation.
Slide8CT of appendicitis
Slide9Small Bowel ObstructionAbsence of flatus, bowel movements
Nausea, vomiting, abdominal distention, abdominal painCT scanLook for proximal dilatation, distal decompression, “transition point”Closed loop, Free fluid, mesenteric swirlingSmall bowel protocol after overnight decompressionMost 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.
Slide10Dilated promixal / Decompressed Distal
Slide11Incarcerated HerniasReducible, 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, sedationAcutely irreducible hernia is an indication for surgery.
Slide12Inguinal hernia imaging
Slide13Perforated Gastric UlcerAcute onset abdominal painPeritonitis, rigid abdomen
Free air under diaphragm on erect CXR or KUBH/o aspirin, NSAIDs, Goody powderTreatment: urgent laparotomy.
Slide14Air under the diaphragm
Slide15Treatment of Gastric Ulcer
Slide16Vascular and TCV SurgeryAcute limb ischemiaDVT/PE
Ruptured AAAAcute dissection
Slide17Acute Limb Ischemia6 Ps: pain,
pulselessness, paralysis, pallor, paraesthesia, poikilothermiaObtain history about timing, irregular heart rhythm, chest pain suggestive of heart attack, history of aneurysms.Document good pulse examTreatment: immediate anticoagulation with heparin infusion
EmbolectomyFasciotomyPossible muscle weakness and sensory loss, inaudible arterial signal with intact venous signal
Slide18DVTUnilateral leg swelling, leg pain, worse with movementHoman’s sign is not useful
Diagnosis: venous duplex ultrasoundD-dimer is usually elevated postoperativelyRx: systemic anti-coagulation with therapeutic heparin GTT or Lovenox SQ
Slide19Pulmonary EmbolismTachypnea, tachycardia,
pleuritic chest painAssess for DVTCXR 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 suspicionV/Q scan, like all
nuc med studies, are of limited valueSame Rx as DVTSupplemental O2
Slide20Ruptured AAASigns of shockPulsatile abdominal mass
Most common presentation is transfer from OSH with CT scan showing AAA ruptureCall fellow on call immediatelyIf stable, obtain CT scan for possible endovascular repair planning if not already doneOperative & Blood Consent, T+C, LabsOR
Slide21Ruptured AAA
Slide22Aortic DissectionSudden onset tearing, ripping, 10/10 chest pain radiating to back
Vitals: hypertensionWork up: CT, EchoTreatment: beta blockers and BP control for Type B OR for type A
Slide23Aortic DissectionStanford A/B:
A = asc, B = arch + descDeBakey I, II, IIII
asc + descII asc + archIII desc distal to L SCA
Determine Location
Classification
Slide24Aortic dissection
Slide25Colorectal SurgeryAcute DiverticulitisPerforated Colon Cancer
Slide26Diverticulitis
LLQ pain, hx of diverticulosis, past episodesDiagnosis by CT scanUncomplicated – bowel thickening, localized tendernessComplicated – Hinchey ClassificationHinchey I: pericolic abscess
Hinchey II: larger mesenteric abscess, extension to pelvisHinchey III: free perforation, purulent peritonitisHinchey IV: feculent peritonitisTreatment: 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
Slide27Diverticulitis
Slide28Burn SurgeryBurnsNecrotizing soft tissue infection
Slide29BurnMechanism
gas on trash, explosion, house fire, electrical, chemicalRule out inhalational injuryHistory: enclosed space, smokePhysical: soot in mouth, singed facial hairs, hoarsenessLabs: methemoglobin on ABG
BronchoscopyResuscitate – Parkland Formula, LR, UOPEvaluate pulses for need for escharotomy / fasciotomy
Slide30Necrotizing soft tissue infectionRisk factors: Diabetes, Immunosuppression
Exam: tachycardia / tachypnea / altered mental statusTenderness / pain away from erythematous areaCrepitus, paralysis, bullaeLabs: LRINEC scoreImaging: CT for gas in soft tissue / fasciaMRI difficult to obtain quickly
Diagnosis is CLINICALTreatment: Urgent wide debridementIV Abx: Vancomycin, Zosyn, Clindamycin
Slide31NSTI
Slide32Pediatric SurgeryAppendicitisGastroschisis
/ OmphaloceleMalrotation / mid-gut volvulusIntussusceptionPyloric StenosisNecrotizing Enterocolitis
Slide33Gastroschisis / Omphalocele
GastroschisisDefect of umbilical membrane near veinNo coverageNeed immediate coverageOmphaloceleIncomplete closure of abdominal wall
Associated with other abnormalities (VACTERL)Babygram (vertebral)EchocardiogramUsually covered by sac, sometimes ruptured
Slide34Gastroschisis
Omphalocele
Slide35Midgut VolvulusSecondary to intestinal
malrotationBilious emesisXray: gastric/duodenal distensionUGI: oral contrast film corkscrew appearance of duodenumextrinsic compression by Ladd’s bands
Small bowel on right, colon on leftDuplex US: SMV is normally to right of SMA, flipped in volvulus
Slide36Ladd Procedure
Slide37IntussusceptionAge 6 months to 2 yearsHypertrophied
Peyer’s patchesColicky abdominal pain, currant jelly stoolTx: air enema by radiologyOperative reduction if enema unsuccessful
Slide38Intussusception
Slide39Pyloric StenosisRisk factors: first born white male, erythromycin use in pregnancy
Age: 2-6 weeksHistory: nonbilious projective vomiting shortly after feedsPhysical: palpable “olive” epigastric areaLabs: hypokalemic hypochloremic
metabolic alkalosisImaging: abdominal ultrasoundTx: resuscitation, correct electrolytesOperation only after medical stabilization
Slide40Necrotizing 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, resuscitationUrgent operation for:
PneumoperitoneumPortal venous gas, abd erythema, clinical deterioration
Slide41Pneumatosis intestinalis
Slide42