Acute surgical conditions

1. New Resident Orientation Acute surgical conditions Daniel J. Farrugia, MD PhD June 24, 2014 University of Florida, Department of Surgery

2. Pancreaticobiliary Service Acute cholecystitis Acute cholangitis Acute pancreatitis

3. 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.

4. 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.

5. Acute 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, hypertriglyceridemia Treatment depends on the underlying cause, supportive care

6. Acute Care Surgery/VA General Appendicitis Small bowel obstruction Incarcerated hernia Perforated gastric ulcer

7. 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.

8. CT of appendicitis

9. 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.

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, 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 diaphragm on erect CXR or KUB H/o aspirin, NSAIDs, Goody powder Treatment: urgent laparotomy.

14. Air under the diaphragm

15. Treatment of Gastric Ulcer

16. Vascular and TCV Surgery Acute limb ischemia DVT/PE Ruptured AAA Acute dissection

17. 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

18. 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

19. 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

20. 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

21. Ruptured AAA

22. 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

23. Aortic Dissection Determine Location Classification • Stanford A/B: • A = asc, • B = arch + desc • DeBakey I, II, III • I asc + desc • II asc + arch • III desc distal to L SCA

24. Aortic dissection

25. Colorectal Surgery Acute Diverticulitis Perforated Colon Cancer

26. 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

27. Diverticulitis

28. Burn Surgery Burns Necrotizing soft tissue infection

29. 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

30. 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

31. NSTI

32. Pediatric Surgery Appendicitis Gastroschisis / Omphalocele Malrotation / mid-gut volvulus Intussusception Pyloric Stenosis Necrotizing Enterocolitis

33. 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

34. Gastroschisis Omphalocele

35. 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

36. Ladd Procedure

37. 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

38. Intussusception

39. 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

40. 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

41. Pneumatosisintestinalis