Surgery EOR Study Guide Newest 2023 Graded A+.

Surgery EOR Study Guide Newest 2023 Graded A+. Surgery EOR Study Guide GI/Nutritional (50%) 1) Abdominal Pain RUQ Epigastric LUQ Periumbilical RLQ Suprapubic LLQ Colonic Colitis, Diverticulitis Early appendicitis Appendicitis, colitis, diverticulitis, IBD, IBS Appendicitis, colitis, diverticulitis, IBD, IBS Colitis, diverticulitis, IBD, IBS Biliary Cholecystitis, cholelithiasis, cholangitis Cholecystitis, cholelithiasis, cholangitis Hepatic Abscess, hepatitis, mass Pulm PNA, embolus Cardiac MI, pericarditis Angina, MI, pericarditis Vascular Aortic dissection, mesenteric ischemia Aortic dissection, mesenteric ischemia Aortic dissection, mesenteric ischemia Pancreat ic Mass, pancreatitis Mass, pancreatitis Renal Nephrolithiasis, pyelonephritis Nephrolithias is, pyelonephriti s Nephrolithiasi s, pyelonephriti s Nephrolithiasi s, pyelnoephriti s, cystitis Nephrolithias is, pyelonephriti s Gastric Esophagitis, gastritis, PUD Esophagitis, gastritis, PUD Esophagitis, gastritis, PUD, small bowel mass, obstruction GYN Ectopic, fibroids, ovarian mass, torsion, PID, endometriosi s Ectopic, fibroids, ovarian mass, torsion, PID, endometriosi s Ectopic, fibroids, ovarian mass, torsion, PID, endometriosi s Primary test of choice US CT CT w/ contrast US CT w/ oral and IV contrast 2) Acute/Chronic Cholecystitis a. Acute Cholecystitis i. Inflammation and infection of the gallbladder d/t obstruction of the cystic duct by gallstones ii. E. coli MC, Klebsiella & other gram (-) enteric organisms iii. S/S: continuous RUQ or epigastric pain, may be precipitated by fatty foods or large meals, may be assoc. with nausea, guarding & anorexia iv. PE: fever (often low grade), enlarged, palpable GB 1. (+) Murphy’s sign – RUQ pain or inspiratory arrest w/ palpation of the GB 2. (+) Boas sign – referred pain to the right shoulder or subscapular area (phrenic N. irritation) v. Diagnosis: US = initial test of choice 1. Shows thickened or distended GB, pericholecystic fluid, sonographic Murphy’s sign 2. CT – alternative to US and can detect complications 3. Labs – increased WBC (leukocytosis w/ left shift), increased bilirubin, increased ALP, increased LFTs 4. HIDA scan = most accurate test – cholecystitis is present if no visualization of GB vi. Management: 1. NPO, IV fluids, antibiotics (s/a Ceftriaxone + Metronidazole) followed by cholecystectomy (usually w/in 72h) a. Laparoscopy preferred whenever possible 2. Cholecystectostomy (percutaneous drainage of GB) if pt is nonoperative b. Acute Acalculous Cholecystitis i. Acute necroinflammatory disease of the GB not due to gallstones ii. Accounts for 10% of acute cholecystitis iii. Pathophys: Gallbladder stasis & ischemia � local inflammatory reaction in the GB wall � concentration of bile salts, GB distention, secondary infection, perforation or necrosis of GB tissue iv. RF: current hospitalization, critically ill pts v. S/S: fever, leukocytosis, jaundice, sepsis, vague abdominal discomfort vi. Diagnosis: based on clinical sx in the setting of supportive imaging & exclusion of alternative dx 1. US = initial test of choice – distended GB w/ thickened walls and pericholecystic fluid WITHOUT calcifications 2. CT abdomen w/contrast if diagnosis remains uncertain after US 3. HIDA scan performed if dx remains uncertain after CT scan vii. Management: supportive – IV fluids, bowel rest, pain control, correction of electrolytes, broad-spectrum ABX c. Chronic Cholecystitis i. Fibrosis & thickening of the GB d/t chronic inflammatory cell infiltration of the GB evident on histopathology ii. The presence of chronic cholecystitis does not correlate with symptoms iii. Almost always assoc. with gallstones 3) Acute/Chronic Pancreatitis a. Acute Pancreatitis i. Acinar cell injury � intracellular activation of pancreatic enzymes � autodigestion of pancreas ii. Etiologies: 1. Gallstones (40%) & ETOH abuse (35%) = 2 MC causes 2. Meds: Thiazides, Protease inhibitors, Estrogens, Didanosine, Exenatide, Valproic acid 3. Others: iatrogenic (ERCP), malignancy, scorpion sting, idiopathic, trauma, CF, hypertriglyceridemia, hypercalcemia, infection, abdominal trauma/mumps in children iii. S/S: 1. Epigastric pain – constant, boring, often radiates to back or other quadrants, exacerbated if supine or eating & relieved w/ leaning forward, sitting or fetal position 2. N/V & fever common, shock in severe case 3. Necrotizing or Hemorrhagic: (+) Cullen’s sign (periumbilical ecchymosis) and (+) Grey Turner sign (flank ecchymosis) iv. PE: epigastric tenderness, tachycardia, decreased BS may be seen secondary to adynamic ileus, dehydration or shock if severe v. Diagnostic Criteria: 2 of the following 3 1. Acute onset of persistent, severe epigastric pain often radiating to the back 2. Elevation in serum lipase or amylase 3+x UNL 3. Characteristic findings of acute pancreatitis on imaging (CT, MRI, US) a. No imaging required if pt meets the first 2 criteria vi. Diagnostic Labs: 1. Increased amylase & lipase – best initial tests a. Lipase more specific than amylase; levels don’t equal severity (not specific) b. ALT 3-fold increase is highly suggestive of gallstone pancreatitis c. Hypocalcemia – necrotic fat binds to Ca++, lowering serum levels (saponification) d. Leukocytosis, elevated glucose, bilirubin & triglycerides vii. Diagnostic Imaging: 1. Abdominal CT = imaging test of choice – also recommended in pts who fail to improve or worsen after 48h to assess extent of necrosis a. MRI is an alternative 2. Transabdominal US – recommended to assess for gallstones & bile duct dilation 3. Abdominal XR – “sentinel loop” (localized ileus of a segment of small bowel in the LUQ), Colon cutoff sign (abrupt collapse of the colon near the pancreas) a. Pancreatic calcification is suggestive of chronic pancreatitis 4. MRCP useful to detect stones, stricture or tumor 5. Chest XR – left sided, exudative pleural effusion in moderate to severe cases viii. Management: 1. 90% recover w/o complications in 3-7 days & require supportive measures only – “rest the pancreas” 2. Supportive – NPO, high-volume IV fluid resuscitation, Analgesia a. LR preferred – assoc. with decreased systemic inflammatory response compared to NS b. Analgesia – s/a Meperidine (Demerol) 3. Antibiotics – not routinely used; broad-spectrum abx (s/a Imipenem) used if severe infected pancreatic necrosis seen (>30% necrosis on CT or MRI) 4. Ranson Criteria – used to determine prognosis (can also use APACHE score) a. If score >/= 3, severe pancreatitis is likely. If < 3, severe pancreatitis is unlikely. b. Score 0-2 = 2% mortality, score 3-4 = 15% mortality, score 5-6 = 40% mortality, score 7-8 = 100% mortality Admission W/in 48h Glucose >200 mg/dL Calcium <8.0 mg/dL Age >55 years Hematocrit fall >10% LDH >350 IU/L Oxygen PO2 <60 mmHg AST >250 IU/dL BUN >5 mg/DL p IV fluids WBC >16,000/mcL Base deficit >4 mEq/L Sequestration of fluid >6L b. Chronic Pancreatitis i. Progressive inflammatory changes to the pancreas that lead to loss of pancreatic endocrine & exocrine function ii. Etiologies: ETOH abuse (MC), idiopathic, hypocalcemia, hyperlipidemia, islet cell tumors, familial, trauma, iatrogenic 1. Gallstones not as significant as in acute iii. S/S: triad of calcifications, steatorrhea & DM = hallmark but seen in only 1/3 of pts 1. Weight loss, epigastric and/or back pain may be atypical or completely absent iv. Dx: 1. Amylase & lipase usually normal or mildly elevated 2. CT: calcification of the pancreas, often done in pts with acute pain to r/o other causes of abdominal pain 3. Abdominal radiographs: calcified pancreas 4. Endoscopic US or MRCP 5. Pancreatic function testing: fecal elastase most sensitive & specific, pancreatic stimulation w/ secretin & CCK usually not done v. Management: 1. ETOH abstinence, pain control, low fat diet, vitamin supplementation 2. PO pancreatic enzyme replacement 3. Pancreatectomy only if retractable pain despite medical therapy 4) Anal Disease (Fissures, Abscess, Fistula) a. Anal Fissure i. Painful linear tear/crack in the distal anal canal ii. Etiologies: low-fiber diets, passage of large hard stools, constipation or other anal trauma iii. S/S: severe painful rectal pain & bowel movements causing the pt to refrain from defecating, bright red blood per rectum iv. PE: longitudinal tear in the anoderm that usually extends no more proximally than the dentate line 1. MC at the posterior midline (99% men, 90% women), skin tags seen in chronic v. Management: Supportive = 1st line management – warm water Sitz baths, analgesics, high fiber diet, ↑ water intake, stool softeners, laxatives & mineral oil 1. >80% resolve spontaneously 2. 2 nd line tx: topical vasodilators – NTG (ADR HA & dizziness), Nifedipine ointment 3. Botox injections to reduce spasm of internal sphincter (may be more effective than topical dilators) 4. Surgery – s/a lateral internal sphincterectomy (reserved for refractory cases) b. Anorectal Abscess & Fistula i. Abscess: often results from bacterial infection of anal ducts or glands 1. Pathogens: Staph aureus (MC), E. coli, Bacteroides, Proteus, Streptococcus 2. Post. rectal wall = MC site ii. Fistula = open tract b/w two epithelium lined-areas, seen esp. with deeper abscesses iii. S/S: 1. Abscess: anorectal swelling, rectal pain that is worse w/ sitting/coughing/defecation, +/- fever; focal edema, induration & fluctuance on exam. a. Deeper abscesses may only be palpated on DRE or seen on imaging studies 2. Fistula: may cause anal discharge & pain iv. Management: 1. I&D = mainstay of tx 2. Followed by WASH – Warm-water cleansing, Analgesics, Sitz baths, High-fiber diet 3. Abx not usually required in simple case.