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Appendix and Small Bowel

Appendix and Small Bowel. Lucas Henn. Pre op. 300,000 performed every year Diagnosis challenging Classic Appy story? Most common cause in kids? Adults? McBurney’s Sign, Psoas Sign, Rovsig’s Sign, Obturator Sign.

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Appendix and Small Bowel

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  1. Appendix and Small Bowel Lucas Henn

  2. Pre op • 300,000 performed every year • Diagnosis challenging • Classic Appy story? • Most common cause in kids? • Adults? • McBurney’s Sign, Psoas Sign, Rovsig’s Sign, Obturator Sign

  3. Appy story: periumbilical pain for 24 hours, localized RLQ, anorexia, low grade fever, minimal elevated WBC, small shift, positive signs • Most common kids: Lymph hyperplasia • Most common adults: fecalith

  4. Uncomplicated Appy • Laparoscopic vs. Open • Similar morbidity and mortality- less post operative pain, earlier return to work • Incision types, port placement

  5. Complicated Appy • Difference in clinical picture? • Midpoint of antimesenteric border most likely to perf • Intervention options • Perc drain • Open drainage • Laparoscopic drainage

  6. More sick, high WBC, high fever, generalize peritonitis, hypotension

  7. Carcinoid • Size (2cms) • Location (Base or tip) • Treatment of Carcinoid syndrome?

  8. If less than 2 cm and at tip- appy • If greater than 2 cm or at base- RHC • Treat with Octreotide

  9. Small Bowel • Vascular supply: Duodenum- superior pancreaticoduodenal off Gastroduodenal and inferior pancreaticoduodenal off SMA • Jejunum and Ileum from SMA

  10. Fistulas • F (foreign body) R (radiation) I (IBD) E (epithelialization) N (neoplasm) D distal obstruction) S (sepsis/infection) • High output more likely proximal- less likely to close with conservative management • Colonic more likely to close than small bowel • Most common cause iatrogenic

  11. Small Bowel Obstruction • Prior abdominal surgery • Adhesions • Hernia • Cancer Without proir surgery • Hernia • IBD • Cancer

  12. SBO Treatment • NPO, IVF, NGT decom, serial Xrays, Correctly electrolyte imbalence- cures 80% of partial, 20-40% complete • Surgical indications: progressing pain, peritoneal signs, fever, increasing WBC • OR- run entire small bowel if able- if lysing adhesions- lyse all adhesions

  13. Crohns • Surgery for complications: fistula, perf, obstruction, hemorrhage- but surgery is not curative • Try to conserve bowel- stricturoplasty (H-M, Finney) as much as possible- probably not good for patient’s first operation (leaves disease behind)

  14. H-M and Finney

  15. Side to side

  16. Small Bowel Tumors • Carcinoid: Treat with resections and lymphadenectomy- Chemo for unresectable or syndrome • Adenocarcinoma: rare- if in duodenum- Whipple • Lymphoma: resection if obstructing- otherwise chemo • Leiomyosarcoma: hard to diff from Leiomyoma (done on Path)- resect, no lymph nodes

  17. Bit stuff • Gallstone ileus: Gallstone in the TI, can see air in biliary tree with SBO- fistula between GB and duodenum- Treat depends on clinical status (stable vs. unstable) • Meckel’s: rule of 2’s (2 feet from IC valve, 2%, first 2 years of life, 2 types of mucosa- Pancreatic most common, gastric most symp), failure of closure of omphalomesenteric duct- primary presentation is LGIB in a child (obstruction in adults)… incidental finding?, scan to diagnose?

  18. GI: Stable: enterotomy and remove stone, cholecystectomy and close duodenum with patch • Unstable: Remove stone, close • Meckel’s: Incidental- if feels thick (gastric) or thin neck- resect- can get Meckel’s Scan if trouble localizing • If diverticulum is greater than 1/3 the diameter of the bowel- segmental resection

  19. Small Bowel Stomas • Loop ileostomy: 1-2 % obstruction rate • Diversion colitis- due to decrease in short chain fatty acids- enemas • Ischemia most common cause of stoma stenosis- can dilate if mild • Increased incidence of gallstones and uric acid kidney stones with ileostomy- also electolyte abnormalities • Crohns most common cause of peristomal fistula

  20. SMA insufficiency Diagnosis and Treatment of • Thombosis • Embolus • Low Flow State

  21. Thombosis • Usually secondary to athlerosclerosis- sudden onset of pain after history of food fear, post parandial pain- need rapid diagnosis and then A-gram- stent vs. bypass

  22. Embolus • Sudden onset of pain- just like embolus to leg, arm or brain- from left atrium or paradoxyl- prompt diagnosis and embolectomy with patch angioplasty- if bowel dead- resect

  23. Low Flow State • From sepsis or cardiogenic shock- need to correct the inciting event (MI, infection, hypovolemia)- treatment is via volume resusitation, inatropes, antibiotics- resection for acute abdomen and dead bowel

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