Surgery EOR Study Guide Newest 2023.

BIO 116 Surgery EOR Study Guide Newest 2023. 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 5) Anorexia a. Screening for Eating Disorders: SCOFF questions i. Do you make yourself Sick because you feel uncomfortably full? ii. Do you worry you have lost Control over how much you eat? iii. Have you recently lost more than One stone (14 lbs or 6.35 kg) in a 3-month period? iv. Do you believe yourself to be Fat when others say you are too thin? v. Would you say that Food dominates your life? vi. “Yes” to 2+ questions = eating disorder b. MC in females age 14-21 y/o (F:M 3:1, median onset = 18 y/o) c. RF: female gender, child sexual abuse, OCD, childhood/parental obesity, substance abuse, rigidi perfectionist, professions that emphasize thinness, athletes, homosexual men d. Basic principle is that starvation induces protein & fat catabolism � loss of cellular volume and atrophy in kidneys, brain, heart, liver, intestines & muscles e. DSM-5 Criteria: i. Persistent restriction of energy intake leading to low body weight in context of age, developmental trajectory & physical health ii. Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain iii. Distorted perception of body weight & shape, undue influence of weight & shape on self-worth or denial of the medical seriousness of the pt’s low body weight f. Types: i. Restricting Type: dieting, fasting or excessive exercise WITHOUT recurrent binge eating or purging ii. Binge-Eating Type: recurrent (1x/week or more) episodes of binge-eating OR purging g. Sx: palpitations, dizziness, weakness, exertional fatigue, cold intolerance, amenorrhea, abdominal pain or bloating, early satiety, constipation, swelling of feet h. Signs: bradycardia (< 60), OH (<90/50), BMI < 17.5, emaciation (body weight < 70% IBW), hypothermia, hypoactive bowel sounds, brittle hair & hair loss, xerosis (dry, scaly skin), lanugo hair growth, abdominal distention, brittle nails, pressure sores, yellow skin (palms), cyanotic/cold hands or feet, ankle or periorbital edema, heart murmur (MVP) i. Dx: clinical i. EKG (if BMI < 14) – increased PRI, 1st degree heart block, ST-T wave abnormalities, QTP ii. CBC – anemia, leukopenia, TCP iii. CMP – hypokalemia, hypomagnesemia, hypophosphatemia, hyponatremia, low Cr, hypoglycemia iv. LFTs – elevated v. Low T3/T4 & low FSH/LH vi. High cholesterol in 50% vii. Also order: Zn, Thiamine, Serum albumin & prealbumin, INR, Vit D, Preg test in females, Testosterone in males viii. Echo/CT – to rule out SMA syndrome ix. If amenorrheic > 9 months consider DEXA 1. MRI if pt has cognitive impairment j. Management: i. Psychotherapy = 1st line 1. CBT, Psychodynamic therapy, motivational interviewing, family therapy, specialist supportive clinical management, cognitive remediation therapy ii. Nutritional Rehabilitation iii. Pharmacotherapy 1. Avoid bupropion – higher incidence of seizures in eating disorders 2. Avoid drugs that impact cardiac fx – antipsychotics & TCAs iv. Health Maintenance: 1. Many comorbid disorders resolve w/ weight restoration 2. Following remission, pt should be reassessed for comorbidities 3. Weigh pt @ each visit w/ as little clothing as appropriate & after voiding 4. For pts who remain ill w/ AN, repeat DEXA q2yrs & repeat EKG only if cardiac sx persist despite weight restoration 5. Follow up w/in 3d after any discharge to check for refeeding syndrome, esp. in first few weeks after weight restoration 6. Initially, weekly to monthly PCP visit to check phosphate, electrolytes & LFTs and monitor weight gain v. Indications for Hospitalization: 1. Unstable vitals: a. HR < 40 w/ hypotension or lightheadedness b. Hypothermia (core temp < 35 C or 95 F) c. Orthostatic increase in pulse (>20 bpm) or decrease in SBP (> 20 mmHg) 2. Cardiac dysrhythmias (QTc > 0.499 ms) or any rhythm other than sinus brady 3. Weight < 70% IBW or BMI < 15, esp. if rapid weight loss 4. Marked dehydration 5. Acute complication of malnourishment: syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, electrolyte disturbance 6. Moderate to severe refeeding syndrome (marked edema, serum Phos <2 mg/dL) 7. Poor response as outpt k. Comorbidities: Depression, Anxiety, OCD (MC personality disorder), body dysmorphic disorder, PTSD, SUDs, disruptive, impulse control or conduct disorders l. Prognosis: 50% fully recover, 34% cross over to bulimia nervosa & 50% of those people will cross back to AN i. ETOH use assoc. with increased mortality ii. RF for developing complications include degree of weight & chronicity m. Complications: i. Medical complications account for 50% of deaths in AN ii. Treatment for each includes nutritional replenishment – most are reversible w/ weight gain iii. Most are managed as inpt or in residential care facilities, though the majority can be effectively handled in the outpt setting if pt’s weight is > 70% IBW or BMI > 15 iv. EKG changes, MVP, Functional hypothalamic amenorrhea, OP, euthyroid sick syndrome, hypercortisolemia, hypoglycemia, constipation/diarrhea, SMA syndrome, hypokalemia, hypomagnesemia, Korsakoff syndrome, Wernicke’s encephalopathy n. Refeeding Syndrome i. Clinical complications that occur as a result of fluid & electrolyte shifts during refeeding too rapidly and/or aggressively for weight restoration in malnourished pts ii. RF: weight <70% of IBW or BMI < 15-16, high amount of weight loss during current episode, rapid weight loss, low baseline PO4/K+/Mg prior to refeeding, little to no intake in previous 5-10d before refeeding 1. Highest risk during first 2 weeks of replenishment iii. S/S: CHF symptoms, SOA, weakness, diarrhea, tremors/paresthesias iv. PE: hyper/hypotension, peripheral edema, delirium, encephalopathy, gait ataxia 1. A normal HR may be indicative of cardiac compromise (>70)!