ACUTE SURGICAL
CONDITIONS
New Resident Orientation
Michael Hong, MD
June 25, 2013
University of Florida, Department of Surgery
Pancreaticobiliary Service
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Cholecystitis
Cholangitis
Pancreatitis
Cholecystitis
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Low grade fever, RUQ pain, nausea, vomiting
Mild leukocytosis: 10-12
Key points
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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.
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Could indicate gangrenous cholecystitis, perforated
cholecystitis, choledocholithiasis, cholangitis,
pancreatitis.
Cholangitis
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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.
Pancreatitis
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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, medicine stuff, pancreatic
divisum, hypertriglyceridemia.
Treatment depends on the underlying cause,
supportive care, no role for prophylactic antibiotics
Acute Care Surgery
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Appendicitis
Cholecystitis
Small bowel obstruction
Incarcerated hernia
Perforated gastric ulcer
Appendicitis
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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
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CT: enlarged appendix greater than 6 mm, contrast enhancement of the
appendiceal wall, non-filling of appendix lumen with oral contrast, periappendiceal fat stranding.
Management: IV fluids, IV antibiotics (Unasyn or Cipro/Flagyl in adults,
Ceftriaxone in pediatrics), laparoscopic appendectomy in most cases
Additional points: high fever or high leukocytosis often correlates with
perforation.
CT of appendicitis
Small Bowel Obstruction
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History of nausea, vomiting, abdominal distention,
abdominal pain, and no bowel movements for several
days.
Work up includes CT scan with oral contrast
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Most common cause are adhesions and hernias.
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Look for contrast filling, proximal dilatation, distal
decompression, “transition point”
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
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Reducible, incarcerated, strangulated.
Inguinal, umbilical, femoral, obturator, ventral.
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CT scan is helpful
Do not reduce a hernia in someone who is toxic
Maneuvers to increase successful reduction
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Femoral and operator hernias are difficult to diagnose
on physical exam.
Supine position, legs bent, deep constant pressure,
Trendelenburg position, oral sedation
Acutely irreducible hernia is an indication for
surgery.
Inguinal hernia imaging
Perforated Gastric Ulcer
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Acute onset abdominal pain
Peritonitis, rigid abdomen
Free air under the diaphragm on chest x-ray or
KUB
History of using aspirin, NSAIDs, Goody
powder
Treatment: urgent laparoscopy or laparotomy.
Air under the diaphragm
Treatment of Gastric Ulcer
Pediatric Surgery
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Appendicitis
Gastroschisis / Omphalocele
Malrotation / mid-gut volvulus
Intussusception
Pyloric Stenosis
Necrotizing Enterocolitis
Gastroschisis / Omphalocele
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Gastroschisis
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Defect of umbilical membrane near vein
No coverage, to right of umbilicus
Need immediate coverage
Omphalocele
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Incomplete closure of abdominal wall
Associated with other abnormalities (VACTERL)
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Babygram (vertebral)
Echocardiogram
Usually covered by sac, sometimes ruptured
Gastroschisis
Omphalocele
Midgut Volvulus
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Secondary to intestinal malrotation
Bilious emesis
Xray: gastric/duodenal distension
UGI: oral contrast film – corkscrew
appearance in duodenum, extrinsic
compression by Ladd’s bands
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Small bowel on right, colon on left
Duplex US: SMV is normally to right of SMA,
flipped in volvulus
Ladd Procedure
Intussusception
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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
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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
Necrotizing Enterocolitis
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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
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Also for portal venous air, abd erythema, clinical
deteriorization
Pneumatosis intestinalis
Vascular and TCV Surgery
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Acute limb ischemia
DVT/PE
Ruptured AAA
Acute dissection
Acute Limb Ischemia
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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
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Embolectomy
Fasciotomy
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Mild muscle weakness and sensory loss, inaudible arterial
signal with intact venous signal
DVT
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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
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D-dimer is usually elevated postoperatively
Treatment systemic anti-coagulation with
therapeutic dose of heparin or Lovenox
Pulmonary Embolism
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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
Ruptured AAA
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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
Ruptured AAA
Aortic Dissection
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Sudden onset tearing, ripping, 10/10 chest pain
radiating to back
Vitals: hypertension
Work up: CT, Echo
Determine location:
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Stanford A/B: A = asc, B = arch + desc
DeBakey I, II, III
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I asc + desc
II asc + arch
III desc distal to L SCA
Treatment: beta blockers and BP control for Type B
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OR for type A
Aortic dissection
Aortic Dissection
Colorectal Surgery
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Diverticulitis
Diverticulitis
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LLQ pain, hx of diverticulosis
Diagnosis by CT scan
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Uncomplicated – bowel thickening, localized tenderness
Complicated – Hinchey Classification
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Hinchey I: pericolic abscess
Hinchey II: larger mesenteric abscess, extension to pelvis
Hinchey III: free perforation, purulent peritonitis
Hinchey IV: feculent peritonitis
Treatment:
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uncomplicated  clear liquids, oral abx
complicated
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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
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Burns
Necrotizing soft tissue infection
Burn
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Mechanism
Rule out inhalational injury
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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
Necrotizing soft tissue infection
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Risk factors: Diabetes, Immunosuppression
Exam: tachycardia / tachypnea / altered
mental status
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Labs: LRINEC score
Imaging: CT for gas in soft tissue / fascia
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Tenderness / pain away from erythematous area
Crepitus, paralysis, bullae
MRI too sensitive, difficult to obtain quickly
Treatment: wide debridement and IV Abx
NSTI
VA General Surgery
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Anything goes!