ACUTE SURGICAL CONDITIONS

Daniel J. Farrugia, MD PhD

University of Florida, Department of SurgeryJune 24, 2014

New Resident Orientation

Pancreaticobiliary Service

• Acute cholecystitis• Acute cholangitis• Acute pancreatitis

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.

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.

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

Acute Care Surgery/VA General

• Appendicitis• Small bowel obstruction• Incarcerated hernia• Perforated gastric ulcer

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.

CT of appendicitis

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.

Dilated promixal / Decompressed Distal

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.

Inguinal hernia imaging

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.

Air under the diaphragm

Treatment of Gastric Ulcer

Vascular and TCV Surgery

• Acute limb ischemia• DVT/PE• Ruptured AAA• Acute dissection

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

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

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

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

Ruptured AAA

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

Aortic Dissection

• Stanford A/B: • A = asc, • B = arch + desc

• DeBakey I, II, III• I asc + desc• II asc + arch• III desc distal to L

SCA

Determine Location Classification

Aortic dissection

Colorectal Surgery

• Acute Diverticulitis• Perforated Colon Cancer

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

Diverticulitis

Burn Surgery

• Burns• Necrotizing soft tissue infection

Burn

• Mechanism • 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

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

NSTI

Pediatric Surgery

• Appendicitis• Gastroschisis / Omphalocele• Malrotation / mid-gut volvulus• Intussusception• Pyloric Stenosis• Necrotizing Enterocolitis

Gastroschisis / Omphalocele

• Gastroschisis• 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

Gastroschisis Omphalocele

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

Ladd Procedure

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

Intussusception

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

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

Pneumatosis intestinalis