Acute Surgical Conditions: New Resident Orientation by Dr. Michael Hong

1. New Resident Orientation Acute surgical conditions Michael Hong, MD June 26, 2012 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. • 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 (Zosyn 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 the diaphragm chest x-ray or KUB • History of using aspirin, NSAIDs, Goody powder • Treatment: urgent 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. 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

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, Immunosupression • 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!