“When to Call A Surgeon”

1. “When to Call A Surgeon” Anneliese Schleyer MD Harborview Medical Center

2. When to Call A Surgeon • Goals: • Review medical management of common abdominal diagnoses • Identify when to call a surgeon • Learn how to communicate concerns effectively

3. Case #1 • 53 y F generally healthy with diffuse abdominal pain and vomiting x 3 days • Small loose nonbloody stools. No flatus, fevers/chills, chest pain, SOB • Surgical history: ventral hernia repair • Medical history: prior IVDU, venous stasis ulcers • Medications: ibuprofen prn

4. Case #1 • Exam: T 36.7, HR 106, BP 103/61 • Awake and alert • Abdomen: distended and quiet except for rare high-pitched sounds • Labs • WBC 6.4, HCT 44. • K 3.1, bicarb 31 creatinine 1.3 • LFTs, amylase normal • What’s the diagnosis?

6. Small Bowel Obstruction • History • Crampy diffuse abdominal pain & distention, nausea/ vomiting. Some still pass flatus. • Risk factors • Prior abdominal surgeries, tumors, hernias, strictures • Exam • Hypoactive or high pitched sounds • Diagnosis made by history and exam

7. Small Bowel Obstruction • Plain films: • Upright CXR to rule out free air • Abdominal series: air-fluid levels, distended bowel. Usually no gas in colon/rectum after 24 hrs. • Abdominal CT: • Different caliber small bowel lumens • Volvulus • Transition point distal to obstruction • Cannot see adhesions

8. Top surgical causes: 1. Adhesions from prior abdominal or pelvic surgery 2. Diffuse carcinoma Extrinsic Volvulus Hernia Intrinsic Tumors Strictures or stenoses Intussusception Intraluminal Stool, gallstones, bezoars Causes of small bowel obstruction

9. Small Bowel Obstruction • Medical Management: • Diagnose and treat underlying cause • Aggressive electrolyte correction • Frequent, serial abdominal exams • No prokinetic agents like metoclopromide • Decompress with NG tube: • Avoid clamping; can cause vomiting/aspiration • Gravity trial when signs of bowel function: • Place canister on ground • If < 200 cc output / 4 hrs, remove tube

10. Case #1 • Hospital course: • Seen and “cleared” by general surgery in ED; admitted to medicine • Symptoms subsided initially with NGT • Patient noted “lymph node” in right inguinal region on hospital day #2 • 2x3 cm mass, mobile, mildly tender • Nausea/vomiting recurred when NGT clamped

13. Case #1 • Hospital course: • HD #3 increased pain, fever and tachycardia; ↓uop; repeat labs K+ 2.6 • CT scan: showed incarcerated hernia • Surgery urgently re-consulted, hernia repaired; patient had an uneventful recovery.

14. Small Bowel Obstruction (SBO) • Pearls: • Diagnose by history and exam • Normalize K+ and other electrolytes • If not improving, check for signs of volvulus or ischemia • Don’t forget to check for hernias

15. Small Bowel Obstruction • Concerning signs/symptoms • Ischemic signs: crampy pain becomes constant, tachycardia, +/- hypotension, fever, ↑WBC, ↑ lactate level, ↓uop • Changing bicarb or increased anion gap • Evidence of volvulus / closed loop • No response to conservative management in 48 hours

16. SBO – Lessons Learned • Seen by surgery in ED does not mean surgical intervention won’t be needed • NGT to gravity rather than clamping when bowel function returns • If no response to conservative management in 48 hours, repeat imaging and consider surgical consult • If any concerning signs or symptoms, consult Surgery immediately

17. Case #2 • 78 yo man 2 weeks s/p colon resection for carcinoma admitted to surgery with colocutaneous fistula/subfascial abscess • PMH: HTN and CAD • Habits: rare EtOH; no IVDU. • Medications: lisinopril, ASA, metoprolol • Allergies: none

18. Case #2 • On HD #2 en route to IR for drain placement, had hematemesis and dark tarry stools in colostomy bag • BP 140/80 HR 88 • HCT: 30  21 • Transferred to ICU

19. Case #2 • Medical management for upper GI bleed: • Two large bore IVs placed; NPO • NG lavage: did not clear • IVF; 2 units PRBCs; coagulopathy reversed • Pantoprazole gtt initiated • Emergent EGD by GI: • diffuse severe esophagitis • large (>50%) adherent clot in duodenal bulb with ‘giant’ duodenal ulcer, no bleeding visualized • Attempt at ulcer injection with epi

20. Case #2 • HD #5, abscess drained successfully • Pt transferred to medicine floor • Pantoprazole gtt continued • SBPs 115-160s • Benign abdominal exam • HCT stable at 30-31 for 48+ hours

21. Case #2 • Called about SBP 80s; resolves without intervention • Repeat Hct 26  29 • Patient has no complaints; ‘looks good’ • Surgery is called: “I’ll follow his labs and decide if I need to see him.”

22. Case #2 • Two hours later, SBP 80-90s; sustained despite fluids; HR 105-120s. • HCT 26  29  22  21 • Transferred to ICU; transfused to HCT 30 • SBP and HR improved

23. Case #2 • GI and General Surgery called again • GI repeated EGD: + clot duodenum; no visible bleeding vessel • HCT initally 30, then 21 on repeat • Pt taken emergently to OR where he underwent antrectomy with Billroth II gastrojejunostomy

24. PUD – Lessons Learned • Consult Surgery early if indicated! • Involve Surgery at initial EGD if warranted • Communicate concerning s/s to Surgeon • In PUD consider surgical consultation for: • hemodynamic instability (particularly after initial resuscitation) • recurrent bleeding (unclear bleeding source) • transfusion dependence • any high risk lesion on EGD

25. PUD – Lessons Learned • High Risk Lesions on EGD: • “Giant” (duodenal) ulcer >2 cm • Active bleeding • Visible vessel • Adherent clot • At other hospitals, patients with GI bleeds are often admitted to Surgery

26. PUD – Lessons Learned • Interdisciplinary Guidelines for Management of Gastrointestinal Bleeds at Harborview are under development Stay tuned….

27. Case #3 • Obese 27 yo woman with 5/10 epigastric pain, radiating to back, worse with inspiration and french fries. No h/o alcohol or other medical problems. • Vitals normal; tender in epigastrium/RUQ; diminished BTs • Labs: AST/ALT 226/416, Alk phos 180, T/D Bili 2.6/1.4; WBC 11, HCT 43, Ca 9.5; amylase 1331

28. Case #3 • Ultrasound: • Small gallstones but no wall thickening or ductal dilatation. No sonographic Murphy’s. • Pt received usual medical management • IVF, NPO, pain control • Hospital course: improved quickly, tolerated full diet at 48 hrs, discharged home

29. Case #3 • Pt returned 2 months later with abdominal pain radiating to back, worse with fast food, nausea and vomiting. • Exam: Vitals 38.6; HR 103; o/w normal Tender in RUQ with diminished bowel tones. No rebound or guarding. • Labs: • AST 769, ALT 530, Alk phos 112, T Bili 1.6 • WBC 14.6 + bands, HCT 45, Calcium 9.1 • Pancreatic amylase 4800

30. Case #3 • Ultrasound • Gallbladder wall thickening to 5 mm; CBD grossly normal • Multiple non-mobile gallstones within neck • Liver with diffuse fatty infiltration • No radiographic Murphy’s sign noted

31. Case #3 • Hospital Course • Fever 39.4, ↑abdominal pain, WBC 28,000 • Abdominal CT: enlarged/ edematous pancreas suggesting necrosis • Gallbladder grossly unremarkable • GI consulted; not good candidate for ERCP

33. Case #3 • Surgery: “Why didn’t you call us the last time she was here?” • Patient scheduled for cholecystectomy when clinically improved • Laparascopic cholecystectomy w/ intra-operative cholangiogram on HD #9 • HD #13 discharged home; doing well.

34. Gallstone Pancreatitis: Lessons Learned • When to Call A Surgeon • Cholecystectomy should be performed after recovery in all patients with gallstone pancreatitis prior to discharge • Caveat: if severe/necrotizing pancreatitis, reasonable to wait several weeks until possibility of infection ruled out • Recurrent acute pancreatitis w/ no evidence of gall stones or EtOH may be secondary to microlithiasis; consider elective cholecystectomy

35. Working with Surgery Consultation • Be aware of which patients have potential surgical needs • Bowel obstruction • GI bleed • Gallstone pancreatitis • Any patient with abdominal pain • Don’t assume that “cleared by surgery” means no surgical input will be needed during hospitalization

36. Working with Surgery Consultation • Does this patient need an operation? • Does this patient need a surgeon now? • Patient stable or unstable? • Peritonitis?

37. Working with Surgery Consultation • Perform serial abdominal exams • Note changing history • Loss of flatus • Worsening pain or vomiting • Note changing vitals and exam • New peritoneal signs • Note changing labs • dropping bicarbonate or HCT • rising lactate or anion gap

38. Summary • Many patients admitted to Medicine have potential surgical needs • Careful medical management is important • Call Surgeons early if indicated • Learn to communicate key issues • If additional Surgical assistance is needed, ok to call more Senior Surgeons and/or involve your attending