Surgery summary 1

• Appendicitis

  • Right lower quadrant pain (McBurney's point)
  • Rebound tenderness
  • Nausea and vomiting
  • Fever
  • Anorexia
  • Rovsing's sign
  • Psoas sign (when retrocecal appendix is inflamed)
  • Obturator sign (when appendix is pelvic)
• Management of Appendicitis

  1. Initial assessment with history and physical examination

  2. Laboratory tests: Complete blood count (CBC), C-reactive protein (CRP), urinalysis

  3. Imaging: Ultrasound, CT scan (especially in atypical presentations or diagnostic uncertainty)

  4. Antibiotics (if surgery is delayed)

  5. Fluid resuscitation and pain management
• Symtoms of Perforation of Digestive Tract

  • Severe abdominal pain
  • Rigidity of the abdomen
  • Fever and chills
  • Nausea and vomiting
  • Tachycardia
  • Hypotension
  • Tachypnea
  • Absence of bowel sounds
• Management of Gastrointestinal Perforation

  1. Resuscitation: Establishing IV access, fluid resuscitation, correction of electrolyte imbalances, and hemodynamic stabilization

  2. Antibiotics: Broad-spectrum antibiotics to cover for gram-negative and anaerobic bacteria

  3. Nasogastric tube: For gastric decompression if there is vomiting or severe nausea

  4. Analgesia: To manage pain

  5. Nil per os (NPO): Patients should not eat or drink to rest the bowel

  6. Monitoring: Close monitoring of vital signs, input and output, and clinical state
• Small Bowel Obstruction (SBO)

  • Abdominal pain: Crampy and intermittent pain that may become constant
  • Vomiting: Can be profuse and is often bilious
  • Distension: Abdominal swelling, particularly in the upper abdomen
  • Constipation: Lack of passing stool or gas
  • Tympanic abdomen: On percussion due to air accumulation in the intestine
  • High-pitched bowel sounds: Initially, which may later diminish or become absent in complete obstruction
  • Dehydration and electrolyte imbalance: Due to vomiting and lack of fluid absorption
• Surgical Treatment for SBO

  1. Indications for Surgery: There is evidence of strangulation or compromised blood supply to the bowel, The obstruction does not resolve with conservative management, There is a complete obstruction, particularly with signs of peritonitis, There is a suspicion of a closed-loop obstruction, The patient develops signs of sepsis or shock

  2. Type of Surgery: Adhesiolysis, Resection, Strictureplasty, Ostomy
• Differential Diagnosis for LBO

  • Colonic stricture: Secondary to inflammatory bowel disease or previous diverticulitis
  • Volvulus: Twisting of the colon on itself, often occurring in the sigmoid or cecum
  • Cancer: Colorectal cancer is a common cause of LBO in adults
  • Fecal impaction: Hardened stool that cannot be expelled
  • Adhesions: Less common in the large bowel than the small bowel
  • Hernia: Particularly if it's incarcerated or strangulated
• Management of LBO

  1. Fluid resuscitation: IV fluids to correct dehydration and electrolyte imbalances

  2. Decompression: Nasogastric tube may be considered, especially if there is vomiting

  3. NPO (nil per os): To prevent further bowel distention and vomiting

  4. Pain management: Appropriate analgesics

  5. Monitoring: Vital signs, abdominal girth, and clinical signs of deterioration

  6. Imaging: Abdominal x-rays, CT scan, and possibly a water-soluble contrast enema to confirm diagnosis and identify the cause
• Incarcerated Hernia

  An incarcerated hernia occurs when the contents of a hernia (which might include fat, bowel, or other tissues) become trapped and cannot be reduced back into the abdominal cavity
• Surgical treatment for upper GI bleeding

  • Variceal bleeding: : Not commonly treated surgically nowadays due to the effectiveness of endoscopic and pharmacological treatments. Transjugular intrahepatic portosystemic shunt (TIPS) might be considered in refractory cases
  • Ulcer disease: Surgery may be required for uncontrolled bleeding or recurrent bleeding despite endoscopic treatment. Procedures may include oversewing of the bleeding vessel, vagotomy, or partial gastrectomy.
• Differentials of lower GI bleeding

  • Diverticulosis
  • Angiodysplasia
  • Colitis
  • Colorectal cancer
  • Hemorrhoids and anal fissures
• Further management of chest trauma

  • Analgesia to relieve pain and facilitate breathing
  • Imaging - chest X-ray, CT scan, or ultrasound (eFAST) to assess internal injuries
  • Observation for signs of worsening condition or complications
• Initial Managementof ischemia of upper and lower extremities

  • Assessment
  • Anticoagulation
  • Pain control
  • Fluid resuscitation
  • Revascularization
  • Monitoring
• Differential Diagnosis for esophageal cancer

  • Gastroesophageal reflux disease GERD
  • Esophageal stricture: Narrowing of the esophagus from inflammation or scar tissue
  • Achalasia: A motility disorder of the esophagus
  • Esophageal ulcers
  • Benign esophageal tumors
• Management of esophageal cancer

  • Endoscopy: For diagnosis, staging, and sometimes as part of treatment (endoscopic mucosal resection)
  • Imaging: CT, PET, and EUS (endoscopic ultrasound) for staging
  • Chemotherapy and radiotherapy: Often used as neoadjuvant (before surgery) to reduce tumor size or as definitive treatment
  • Multidisciplinary approach: Involving oncologists, radiologists, pathologists, and dietitians
• Qualification for surgical treatment

  • Absence of distant metastasis
  • Tumor resectability based on imaging
  • Adequate hepatic reserve and overall patient fitness for surgery
• Postoperative chemotherapy or chemoradiation may be offered depending on the stage and surgical margins
• SBO: type of surgery

  Adhesiolysis: Removal of adhesions that are causing the obstruction.

  
  

  Resection: Removal of a diseased or necrotic section of the intestine with anastomosis of the remaining ends.

  
  

  Strictureplasty: Widening of a narrowed segment without resection.

  
  

  Ostomy: In cases where a large resection is needed or the bowel is not healthy for an anastomosis, a temporary or permanent ostomy may be created.
• Type of surgery depends on location and type of perforation, may include:

  Primary repair: The perforation is directly sutured closed.

  Resection: Part of the digestive tract is removed, and an anastomosis is created.

  Ostomy: Creation of an external opening in the body for the discharge of body wastes, particularly when large resections are done or the tissue is not healthy enough for a primary repair.

  Lavage and drainage: Washing out the abdominal cavity and placing drains to remove infectious material or fluids
• Resection: Removal of the obstructed section of the colon, which may be followed by primary anastomosis or the creation of an ostomy.

  Hartmann's procedure: Resection of the rectosigmoid colon with the creation of an end colostomy and closure of the rectal stump, typically performed in emergency settings.

  Colostomy or ileostomy: To divert the fecal stream in cases where immediate anastomosis is not safe.
• Herniorrhaphy, Hernioplasty, Bowel resection types of surgery for hernia


  Herniorrhaphy: Surgical repair that may involve pushing the herniated tissue back into the abdomen and repairing the hernia defect with sutures.

  Hernioplasty: Repairing the defect with the placement of a synthetic mesh to reinforce the abdominal wall.

  Bowel resection: If a section of the bowel is found to be non-viable due to strangulation, that portion may be removed.
• Differential Diagnosis of GI bleeding

  Peptic ulcers: Gastric or duodenal ulcers can erode into blood vessels.

  Esophageal varices: Dilated submucosal veins that can rupture, often associated with liver cirrhosis.

  Mallory-Weiss tear: A tear in the mucous membrane at the gastroesophageal junction.

  Gastritis or esophagitis: Inflammation of the stomach or esophagus.

  Gastric erosions: Superficial erosions that can bleed. Gastrointestinal malignancies.
• Management of digestive tract bleeding.

  Resuscitation: IV fluids and blood transfusions if needed.

  Proton pump inhibitors (PPIs): High-dose IV PPIs to reduce gastric acid production and stabilize blood clots.

  Endoscopy: For diagnosis and therapeutic intervention, such as banding varices, injecting epinephrine into ulcers, or coagulating bleeding vessels.

  Medications: For variceal bleeding, drugs like octreotide may be used to reduce portal blood pressure
• Why do you do endoscopy for Upper GI bleeding?

  Diagnosis + therapeutic. Banding vericies, inj. epi to ulcer, coagulating bleeding vessel.
• Vasoactive drugs


  Medications that constrict blood vessels in the digestive tract to reduce pressure in the portal vein and decrease the risk of further bleeding. Examples include octreotide and terlipressin.
• Diverticulosis


  A condition where small pouches or sacs form in the wall of the colon, which can become inflamed or infected and cause bleeding.
• Angiodysplasia


  A condition where the blood vessels in the gastrointestinal tract become abnormal, leading to bleeding. It is more common in older adults.
• Colitis


  An inflammation of the colon, which can be caused by a variety of factors such as infections, inflammatory bowel disease, or lack of blood flow. Colitis can cause abdominal pain, diarrhea, and bleeding.
• Colorectal cancer


  A type of cancer that occurs in the colon or rectum. It is the third leading cause of cancer-related deaths in the United States. Colorectal cancer can cause bleeding, among other symptoms.
• Hemorrhoids and anal fissures

  Hemorrhoids are swollen veins in the rectum or anus that can cause bleeding, especially during bowel movements. Anal fissures are small tears in the lining of the anus that can also cause bleeding.
• Gallstones


  Small, hard deposits that form in the gallbladder, often made of cholesterol, bile salts, or calcium. Gallstones can cause pain, inflammation, and infection in the gallbladder, leading to a condition called cholecystitis.
• Cholecystitis


  An inflammation of the gallbladder, often caused by gallstones. Symptoms can include severe abdominal pain, fever, nausea, and vomiting. Cholecystitis can lead to serious complications if left untreated.
• Primary sclerosing cholangitis (PSC)


  A chronic, progressive disease that affects the bile ducts, causing inflammation and scarring. PSC can increase the risk of liver cirrhosis, liver failure, and bile duct cancer.
• Hepatitis


  An inflammation of the liver, often caused by a viral infection. Symptoms can include jaundice, fatigue, abdominal pain, and nausea.
• Liver cirrhosis


  A chronic liver disease characterized by the replacement of healthy liver tissue with scar tissue. Cirrhosis can lead to a variety of complications, including liver failure, bleeding, and an increased risk of liver cancer.
• Pancreatic cancer


  A type of cancer that forms in the tissues of the pancreas. Symptoms can include abdominal pain, jaundice, weight loss, and fatigue. Treatment options may include surgery, radiation therapy, and chemotherapy.