“When to Call A Surgeon”
Anneliese Schleyer MD
Harborview Medical Center
When to Call A Surgeon
• Goals:
– Review medical management of
common abdominal diagnoses
– Identify when to call a surgeon
– Learn how to communicate concerns
effectively
Case #1
• 53 y F generally healthy with diffuse
abdominal pain and vomiting x 3 days
• Small loose nonbloody stools. No
flatus, fevers/chills, chest pain, SOB
– Surgical history: ventral hernia repair
– Medical history: prior IVDU, venous stasis
ulcers
– Medications: ibuprofen prn
Case #1
• Exam: T 36.7, HR 106, BP 103/61
– Awake and alert
– Abdomen: distended and quiet except for
rare high-pitched sounds
• Labs
– WBC 6.4, HCT 44.
– K 3.1, bicarb 31 creatinine 1.3
– LFTs, amylase normal
• What’s the diagnosis?
Small Bowel Obstruction
• History
– Crampy diffuse abdominal pain & distention,
nausea/ vomiting. Some still pass flatus.
• Risk factors
– Prior abdominal surgeries, tumors, hernias,
strictures
• Exam
– Hypoactive or high pitched sounds
• Diagnosis made by history and exam
Small Bowel Obstruction
• Plain films:
– Upright CXR to rule out free air
– Abdominal series: air-fluid levels, distended bowel.
Usually no gas in colon/rectum after 24 hrs.
• Abdominal CT:
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Different caliber small bowel lumens
Volvulus
Transition point distal to obstruction
Cannot see adhesions
Causes of small bowel obstruction
• Extrinsic
• Top surgical causes:
– Volvulus
– Hernia
• Intrinsic
– Tumors
– Strictures or stenoses
• Intussusception
• Intraluminal
– Stool, gallstones,
bezoars
– 1. Adhesions from prior
abdominal or pelvic
surgery
– 2. Diffuse carcinoma
Small Bowel Obstruction
• Medical Management:
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–
–
–
Diagnose and treat underlying cause
Aggressive electrolyte correction
Frequent, serial abdominal exams
No prokinetic agents like metoclopromide
• Decompress with NG tube:
– Avoid clamping; can cause vomiting/aspiration
– Gravity trial when signs of bowel function:
• Place canister on ground
• If < 200 cc output / 4 hrs, remove tube
Case #1
• Hospital course:
– Seen and “cleared” by general surgery
in ED; admitted to medicine
– Symptoms subsided initially with NGT
– Patient noted “lymph node” in right
inguinal region on hospital day #2
– 2x3 cm mass, mobile, mildly tender
– Nausea/vomiting recurred when NGT
clamped
Case #1
• Hospital course:
– HD #3 increased pain, fever and
tachycardia; ↓uop; repeat labs K+ 2.6
– CT scan: showed incarcerated hernia
– Surgery urgently re-consulted, hernia
repaired; patient had an uneventful
recovery.
Small Bowel Obstruction (SBO)
• Pearls:
– Diagnose by history and exam
– Normalize K+ and other electrolytes
– If not improving, check for signs of volvulus
or ischemia
– Don’t forget to check for hernias
Small Bowel Obstruction
• Concerning signs/symptoms
– Ischemic signs: crampy pain becomes
constant, tachycardia, +/- hypotension,
fever, ↑WBC, ↑ lactate level, ↓uop
– Changing bicarb or increased anion gap
– Evidence of volvulus / closed loop
– No response to conservative
management in 48 hours
SBO – Lessons Learned
• Seen by surgery in ED does not mean
surgical intervention won’t be needed
• NGT to gravity rather than clamping when
bowel function returns
• If no response to conservative management
in 48 hours, repeat imaging and consider
surgical consult
• If any concerning signs or symptoms,
consult Surgery immediately
Case #2
• 78 yo man 2 weeks s/p colon resection for
carcinoma admitted to surgery with
colocutaneous fistula/subfascial abscess
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•
•
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PMH: HTN and CAD
Habits: rare EtOH; no IVDU.
Medications: lisinopril, ASA, metoprolol
Allergies: none
Case #2
• On HD #2 en route to IR for drain placement,
had hematemesis and dark tarry stools in
colostomy bag
• BP 140/80 HR 88
• HCT: 30  21
• Transferred to ICU
Case #2
• Medical management for upper GI bleed:
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–
–
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Two large bore IVs placed; NPO
NG lavage: did not clear
IVF; 2 units PRBCs; coagulopathy reversed
Pantoprazole gtt initiated
• Emergent EGD by GI:
– diffuse severe esophagitis
– large (>50%) adherent clot in duodenal bulb with
‘giant’ duodenal ulcer, no bleeding visualized
– Attempt at ulcer injection with epi
Case #2
• HD #5, abscess drained successfully
• Pt transferred to medicine floor
• Pantoprazole gtt continued
• SBPs 115-160s
• Benign abdominal exam
• HCT stable at 30-31 for 48+ hours
Case #2
• Called about SBP 80s; resolves without
intervention
• Repeat Hct 26  29
• Patient has no complaints; ‘looks good’
• Surgery is called:
“I’ll follow his labs and decide if I need to see him.”
Case #2
• Two hours later, SBP 80-90s; sustained despite
fluids; HR 105-120s.
• HCT 26  29  22  21
• Transferred to ICU; transfused to HCT 30
• SBP and HR improved
Case #2
• GI and General Surgery called again
• GI repeated EGD: + clot duodenum; no visible
bleeding vessel
• HCT initally 30, then 21 on repeat
• Pt taken emergently to OR where he underwent
antrectomy with Billroth II gastrojejunostomy
PUD – Lessons Learned
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Consult Surgery early if indicated!
Involve Surgery at initial EGD if warranted
Communicate concerning s/s to Surgeon
In PUD consider surgical consultation for:
– hemodynamic instability (particularly after
initial resuscitation)
– recurrent bleeding (unclear bleeding source)
– transfusion dependence
– any high risk lesion on EGD
PUD – Lessons Learned
• High Risk Lesions on EGD:
• “Giant” (duodenal) ulcer >2 cm
• Active bleeding
• Visible vessel
• Adherent clot
• At other hospitals, patients with GI bleeds
are often admitted to Surgery
PUD – Lessons Learned
• Interdisciplinary Guidelines for
Management of Gastrointestinal Bleeds
at Harborview are under development
Stay tuned….
Case #3
• Obese 27 yo woman with 5/10 epigastric pain,
radiating to back, worse with inspiration and
french fries. No h/o alcohol or other medical
problems.
• Vitals normal; tender in epigastrium/RUQ;
diminished BTs
• Labs: AST/ALT 226/416, Alk phos 180, T/D Bili
2.6/1.4; WBC 11, HCT 43, Ca 9.5; amylase 1331
Case #3
• Ultrasound:
– Small gallstones but no wall thickening or
ductal dilatation. No sonographic Murphy’s.
– Pt received usual medical management
– IVF, NPO, pain control
• Hospital course: improved quickly, tolerated
full diet at 48 hrs, discharged home
Case #3
• Pt returned 2 months later with abdominal pain
radiating to back, worse with fast food, nausea
and vomiting.
• Exam: Vitals 38.6; HR 103; o/w normal
Tender in RUQ with diminished bowel tones. No
rebound or guarding.
• Labs:
– AST 769, ALT 530, Alk phos 112, T Bili 1.6
– WBC 14.6 + bands, HCT 45, Calcium 9.1
– Pancreatic amylase 4800
Case #3
• Ultrasound
– Gallbladder wall thickening to 5 mm; CBD
grossly normal
– Multiple non-mobile gallstones within neck
– Liver with diffuse fatty infiltration
– No radiographic Murphy’s sign noted
Case #3
• Hospital Course
– Fever 39.4, ↑abdominal pain, WBC 28,000
• Abdominal CT: enlarged/ edematous
pancreas suggesting necrosis
– Gallbladder grossly unremarkable
• GI consulted; not good candidate for
ERCP
Case #3
• Surgery: “Why didn’t you call us the last
time she was here?”
– Patient scheduled for cholecystectomy when
clinically improved
• Laparascopic cholecystectomy w/ intraoperative cholangiogram on HD #9
• HD #13 discharged home; doing well.
Gallstone Pancreatitis: Lessons Learned
• When to Call A Surgeon
– Cholecystectomy should be performed after
recovery in all patients with gallstone
pancreatitis prior to discharge
• Caveat: if severe/necrotizing pancreatitis, reasonable
to wait several weeks until possibility of infection ruled
out
– Recurrent acute pancreatitis w/ no evidence of
gall stones or EtOH may be secondary to
microlithiasis; consider elective cholecystectomy
Working with Surgery Consultation
• Be aware of which patients have potential
surgical needs
– Bowel obstruction
– GI bleed
– Gallstone pancreatitis
– Any patient with abdominal pain
• Don’t assume that “cleared by surgery”
means no surgical input will be needed
during hospitalization
Working with Surgery Consultation
• Does this patient need an operation?
• Does this patient need a surgeon now?
• Patient stable or unstable?
• Peritonitis?
Working with Surgery Consultation
• Perform serial abdominal exams
• Note changing history
– Loss of flatus
– Worsening pain or vomiting
• Note changing vitals and exam
– New peritoneal signs
• Note changing labs
– dropping bicarbonate or HCT
– rising lactate or anion gap
Summary
• Many patients admitted to Medicine have
potential surgical needs
• Careful medical management is important
• Call Surgeons early if indicated
• Learn to communicate key issues
• If additional Surgical assistance is needed,
ok to call more Senior Surgeons and/or
involve your attending