General Surgery Rotation

EPIGASTRIC PAIN: 

PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss

RUQ PAIN: 

Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis (especially during pregnancy); thoracic causes (e.g., pleurisy/pneumonia), PE, pericarditis, MI (especially inferior MI).

LUQ PAIN: 

PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, thoracic causes, pyelonephritis, nephrolithiasis, hiatal hernia (strangulated paraesophageal hernia), Boerhaave’s syndrome, Mallory-Weiss tear, splenic artery aneurysm, colon disease.

LLQ PAIN:

Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, urinary tract infection, small bowel obstruction, inflammatory bowel disease, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (rare).

RLQ PAIN:

Appendicitis! And same as LLQ; also mesenteric lymphadenitis, cecal diverticulitis, Meckel’s diverticulum, intussusception

Presentation:

• 5 Fs: Female, Fat, Forty, Fertile, Fair
• (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
• RUQ pain after a high-fat meal

Diagnosis:

• Ultrasound is the preferred initial imaging
• Gallbladder wall >3 mm, pericholecystic fluid, gallstones
• HIDA is the best test (Gold Standard)
• porcelain gallbladder = chronic cholecystitis

Treatment: Cholecystectomy

Acute Pancreatitis - epigastric abdominal pain with radiation to the back and elevated lipase

• Etiology: Cholelithiasis or alcohol abuse
• Diagnosis:
  • Clinical + elevated lipase and amylase
  • CT required to differentiate from necrotic pancreatitis
• Signs: Grey Turner's sign (flank bruising), Cullen’s sign (bruising near umbilicus)

Ranson’s criteria for poor prognosis:

Treatment: IV fluids (best), analgesics, bowel rest

Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)

Chronic Pancreatitis - the classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus

• Alcohol abuse
• Treatment: No alcohol, low-fat diet

Anal fissure

• Small split or tear in the anal mucosa There may be blood on the outside of the stool or on the toilet tissue following a bowel movement.
• Anal fissures are extremely common in young infants but may occur at any age. Studies suggest 80% of infants will have had an anal fissure by age one.
• Most fissures heal on their own.
• Vertical fissures= most common
• Horizontal fissures= Crohn’s Dz, HIV

TX: Stool softeners, bulk, Petroleum jelly. These measures generally heal more than 90% of anal fissures.

Anorectal Abscess

• Infection of an anal fissure, STDs, and blocked anal glands are common causes of anorectal abscesses.
• Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis.

Tx: I&D, Warm sitz baths, Pain medication and antibiotics

An anorectal fistula is an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses

•  Fistulae will produce anal discharge and pain when the tract becomes occluded.

• Gastric ulcers: Epigastric pain Vomiting, anorexia, and nausea
• Duodenal ulcers: Epigastric pain—burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain) Bleeding Back pain Nausea, vomiting, and ↓ appetite
• Gastric cancer: “WEAPON”: Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea
• Lower GI bleed: Hematochezia (bright red blood per rectum [BRBPR]), with or without abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock
• Carcinoma of the gallbladder: Biliary colic, weight loss, anorexia; many patients are asymptomatic until late; may present as acute cholecystitis
• Pancreatic carcinoma: Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in the skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes
• Thyroid disease
• Medications: sedatives, digoxin, laxatives, thiazide diuretics, narcotics, antibiotics

• There is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low-grade fever
• As the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium → umbilicus → RLQ
• Right lower quadrant= "McBurney's point." This "rebound tenderness" suggests inflammation has spread to
  the peritoneum

Signs:

• Rovsing – RLQ pain with palpation of LLQ
• Obturator sign – RLQ pain with internal rotation of the hip
• Psoas sign - RLQ pain with hip extension

Clinical diagnosis:

• Imaging if atypical presentation - appy ultrasound or abdominal CT scan
• CBC - neutrophilia supports the diagnosis

TX: surgical appendectomy

• BMI > 40 (basically, 100 pounds above ideal body weight) or
• BMI > 35 with a medical problem related to morbid obesity
• Individuals must have failed other non-surgical weight loss programs.
• They must be psychologically stable and able to follow post-op instructions.
• Obesity is not caused by a medical disease such as endocrine disorders.

BMI: body weight in kg divided by height in meters squared

Small bowel obstruction - Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery

Large bowel obstruction - Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly

Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds.

KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon

Dilated loops of bowel and air-fluid levels in the abdomen

Treatment: Bowel rest, NG tube placement, surgery as directed by underlying cause

Cholangitis is a complication of gallstones with symptoms secondary to an infected obstruction of the common bile duct (E.coli is the #1 cause)

• Charcot’s triad: RUQ tenderness, jaundice, fever
• Reynold’s pentad: Charcot’s triad + altered mental status and hypotension

ERCP is the optimal procedure both for diagnosis and for treatment

• Apple core lesion on barium enema, adenoma most common type,
• Tumor Marker: CEA
• More likely to be malignant: sessile, > 1 cm, villous
• Less likely to be malignant: Pedunculated, < 1 cm, tubular

Tx: resection and adjuvant chemotherapy

Obstipation is a severe form of constipation, where a person cannot pass stool or gas

Bowel obstruction

• Small bowel obstruction
  • Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery
• Large bowel obstruction
  • Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly

Illeus

• Hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
• Ileus that persists for more than 3 d following surgery is termed postoperative adynamic ileus or paralytic ileus
• Signs: Absent bowel sounds
• CT scan with gastrografin—must exclude mechanical obstruction

Gastroparesis

• A condition that affects the stomach muscles and prevents proper stomach emptying
• MCC: Diabetes

Diarrhea

Pseudomembranous colitis

• Inflammation of the colon caused by the bacteria Clostridium difficile
• Occurs secondary to treatment with antibiotics with broad-spectrum antibiotics - penicillins, cephalosporins, and FQ
• Mild watery foul-smelling diarrhea (> 3 but <20 stools/day)
• IV metronidazole OR PO vancomycin (this is the only use for oral vancomycin)

Inflammation of an abnormal pouch (diverticulum) in the intestinal wall, usually found in the large intestine. The presence of the pouches themselves is called diverticulosis. When they become inflamed, the condition is known as diverticulitis.

• Left-sided Appy
• Most common location: Sigmoid colon
• Fever/chills/Nausea/vomiting/left-sided abdominal pain

DX: Abdominal/Pelvic CT scan revealing Fat stranding and bowel wall thickening

The most common cause of massive lower gastrointestinal bleeding

Treatment = Ciprofloxacin or Augmentin/ + Metronidazole (Flagyl)

• Recurrent attacks or presence of perforation, fistula, or abscess requires surgical removal of the involved portion of the colon.
• Treat by increasing the bulk in the diet with high-fiber foods and bulk additives such as Metamucil

• Squamous cell m/c worldwide and adenocarcinoma common in the US

Adenocarcinoma:

• A complication of Barrett's esophagus (screen Barrett's patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of the esophagus

Squamous cell:

• Associated with smoking and alcohol use
• Affects proximal (upper) 2/3rds of the esophagus
• Progressive dysphagia, weight loss, hoarseness
• Diagnostic studies: Endoscopy + biopsy
• Treatment: Resection

• GERD and Scleroderma
• Ingestion of corrosive substances
• Viral or bacterial infections

Symptoms

• Difficulty and painful swallowing, weight loss, Regurgitation of food

Esophageal achalasia: primary esophageal motility disorder characterized by the absence of lower esophageal peristalsis.

• Difficulty swallowing caused by a failure of the LES to relax and poor peristaltic waves, producing a motor disorder signified by initial complaints of dysphagia for solids and liquids.

DX: Barium swallow shows there is acute tapering at the lower esophageal sphincter and narrowing at the gastroesophageal junction, producing a "Bird’s beak" or "rat's tail" appearance - distal 2/3 most common

• Esophageal manometry is the best test to diagnosis shows the absence of esophageal peristalsis

TX: EGD dilation of the esophagus or myotomy is the preferred treatment

Esophageal web: thin membranes in the mid-upper esophagus. May be congenital or acquired

Plummer-Vinson: esophageal webs + dysphagia + iron deficiency anemia

A Schatzki ring is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur

• Adenocarcinoma
• The incidence is extremely high in Japan, Chile, and Iceland.
• Risk factors for gastric cancer:
  • a family history of gastric cancer
  • gastric ulcers
  • Helicobacter pylori
  • pernicious anemia
• SX:
  • a loss of appetite
  • difficulty swallowing, particularly difficulty that increases over time
  • vague abdominal fullness
  • nausea and vomiting weight loss
  • abdominal fullness prematurely after meals
• DX: EGD (esophagogastroduodenoscopy) and biopsy showing gastric cancer
  • a CBC showing microcytic/hypochromic anemia
  • positive guaiac
• Radiation therapy and chemotherapy can be beneficial but the prognosis is poor

Three causes:

1. Autoimmune or hypersensitivity reaction (e.g. pernicious anemia)

• Location: Body of the fundus
• Pernicious anemia: + schilling test + ↓ intrinsic factor and parietal cell antibodies

2. Infection - H. pylori (most common)

• Location: Antrum and body
• Studies: Urea breath test or fecal antigen.
• Treatment: PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole

3. Inflammation of the stomach lining (NSAIDS and Alcohol)

• NSAIDs: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum.
• Alcohol: a leading cause of gastritis

Peptic ulcer disease

Etiology: H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) - gastrin-secreting tumor

• Duodenal ulcer- pain improves with food*
• Gastric ulcer- pain worsens with food

Diagnosis: Endoscopy with biopsy is the gold standard for diagnosis

Treatment:

• H. pylori infection: Triple therapy PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole
• NSAIDs use: discontinue use
• Zollinger-Ellison syndrome: PPI and resect the tumor

• Peptic ulcer disease: hematemesis, abdominal discomfort, dull pain
• Esophageal varices: hematemesis, bleeding, difficulty swallowing
• Alcohol abuse: physical dependence, craving, vomiting
• Mallory-Weiss syndrome: a tear in the lining of the stomach just above the esophagus caused by violent retching or vomiting
• Coagulation disorders: characterized by a decreased ability to form a clot
• Esophageal cancer: progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis
• Gastrointestinal System Neoplasms: Abdominal pain and unexplained weight loss are most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool

Very common especially during pregnancy and after childbirth.

• Constipation, prolonged sitting during bowel movements
• Bright red blood in the stool
• Anal itching

Tx: Stool softeners Corticosteroid Sitz baths. Internal hemorrhoids=rubber band ligation

Etiology: Cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, Aflatoxin from Aspergillus

• Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging

Treatment: Resection, Transplant - Poor prognosis

• Indirect (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
• Direct: Passage of intestine through the external inguinal ring at Hesselbach's triangle, rarely enters the scrotum.

Ventral: Often from previous abdominal surgery, obesity.  Abdominal mass noted at the site of previous incision.

Umbilical hernia: Very common, generally is congenital and appears at birth.  Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life.

Strangulated: Hernia becomes strangulated when the blood supply of its contents is seriously impaired.

Obstructed: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel. 

Incarcerated: Hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

• It can cause symptoms of GERD

Tx: acid reduction may suffice, although surgical repair can be used for more serious cases.

Crohn’s Disease Vs Ulcerative Colitis

Crohn’s Disease: any part of the GI tract from the mouth to the anus

• “skip areas” with transmural (full-thickness)
  • young adults (20-40) 2 to 3 times more common in Jews
  • Pathology: antibodies against intestinal epithelial cells.
  • Appearance leading to the typical “cobblestone”
• SXS: cramping, tenderness, flatulence, N/V/D, F/C, mild bleeding or may be massive, diarrhea (4 to 6 times/day) RLQ pain, steatorrhea, marked weight loss.
• Obstruction, fistulas, abscesses, and perforation. Malabsorption of B12, megaloblastic anemia. ??Arthritis and uveitis??

DX: barium “string sign” (segments of stricture separated by normal bowel) BX

TX: Maintenance meds: sulfasalazine (Azulfidine®)

• Mesalamine (Pentasa®, Asacol ®) DMAR/NSAIDs
• Prednisone during flare-up
• Restrict fiber in the diet

Ulcerative Colitis

• Acute inflammation of the large bowel rectosigmoid area.
• Increase risk of colorectal CA
• Pathology: cause is unknown, antibodies that cross-react with intestinal epithelial cells and certain serotypes of E. Coli, food allergy to proteins
• Mucosal surface shows superficial ulcerations area is greatly thickened and rigid “lead pipe”
• Backwash ileitis can be seen in UC versus Ileitis which is seen in Crohn’s

SXS: bloody diarrhea containing pus and mucus

• N/V, abdominal pain, spastic rectum, and anus
• anemia (Fe++ deficiency)
• coagulation defects due to Vit K deficiency,
• erythema nodosum, uveitis, Toxic Megacolon

DX: sigmoidoscopy and BX

TX: Maintenance meds: sulfasalazine (Azulfidine®)

• Mesalamine (Pentasa ® Asacol ®,) NSAIDs
• Prednisone during flare-up
• Antispasmodics only used for patients with frequent and troublesome diarrhea may precipitate Toxic Megacolon

Causes of postoperative jaundice: 

Prehepatic: Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, post cardiopulmonary bypass, blood transfusions (decreased RBC compliance leading to cell rupture)

Hepatic: Drugs, hypotension, hypoxia, sepsis, hepatitis, “sympathetic” hepatic inflammation from adjacent right lower lobe infarction of the lung or pneumonia, preexisting cirrhosis, right-sided heart failure, hepatic abscess, pylephlebitis (thrombosis of portal vein), Gilbert syndrome, Crigler-Najjar syndrome, Dubin-Johnson syndrome, fatty infiltrate from TPN

Posthepatic: Choledocholithiasis, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors (e.g., cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g., ceftriaxone [Rocephin®])

• Gastric cancer, duodenal ulcers, right-sided colon cancer, portal hypertension with esophageal varices, severe erosive esophagitis, Mallory-Weiss syndrome.

Hematochezia: bright red blood per rectum (BRBPR) - lower GI bleed

• Hemorrhoids, anal fissures, polyps, proctitis, rectal ulcers, and colorectal cancer. Diverticulosis is generally an incidental finding, since diverticular bleeding is usually of greater volume.

• Vomiting or retching can result in wound dehiscence, esophageal rupture, aspiration, dehydration, increased intracranial pressure, and pneumothorax.

Nausea can have causes that aren't due to underlying disease. Examples include motion such as from a car and plane, taking pills on an empty stomach, eating too much or too little, or drinking too much alcohol

• Gastroenteritis: nausea, vomiting, diarrhea, stomach cramps
• Common cold: nausea, vomiting, runny nose
• Migraine headache: nausea, vomiting, headache
• Food poisoning: nausea, vomiting, malaise
• Influenza virus: nausea, vomiting, cough with phlegm
• Pyloric Stenosis: Infant with projectile vomiting
• Peptic ulcer disease: upper abdominal pain, may have nausea or vomiting
• Hiatal hernia: symptoms of GERD

Painless jaundice is pathognomonic

• The 4th leading cause of death from cancer in the U.S.
• The disease is slightly more common in men than in women and risk increases with age.
• The cause is unknown, but the incidence is greater in smokers.
• Almost one-third of cases of pancreatic carcinoma can be attributed to cigarette smoking and ETOH abuse.
• Most commonly ductal adenocarcinoma located at the pancreatic head

Presentation:

• weight loss/epigastric abdominal pain, clay-colored stools
• Jaundice + palpable non-tender gallbladder (Courvoisier’s sign)
• Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer

DX:

• ERCP
• abdominal CT scan:  75% show tumor at the head of the pancreas, 25% at the tail
• pancreatic Bx
• abdominal MRI
• elevated serum bilirubin
• abnormal liver function tests
• CA 19-9 is present in about 80% of patients who have pancreatic cancer

TX:

• At the time of diagnosis, only about 20% of pancreatic tumors can be removed by the standard procedure is called a pancreaticoduodenectomy (Whipple procedure).
• When the tumor is confined to the pancreas but cannot be removed, a combination of radiation therapy and chemotherapy may be recommended

• Cystic collection of tissue, fluid, and necrotic debris surrounding the pancreas
• Classically occur 2-3 weeks after acute pancreatitis
• Presents with abdominal pain and a palpable epigastric mass
• CT scan is the study of choice

Treatment - if pseudocyst persists for 4 to 6 weeks or continues to enlarge

• Surgical decompression (pancreaticogastrostomy)
• Percutaneous drainage
• Can become infected and lead to peritonitis

Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food)

• Duodenal ulcers are more than twice as common as gastric ulcers
• Duodenal ulcers are most commonly caused by H. pylori (95%)
• Pts typically present with epigastric pain that is better postprandial

Gastric ulcer (food classically causes pain)

• Gastric ulcers are most commonly caused by H. pylori. Can also be caused by NSAIDs, acid reflux, smoking
• Pain is described as gnawing or burning and usually radiates to the back
• Pts typically present with epigastric pain that is worse postprandial

Bleeding — Acute upper gastrointestinal hemorrhage is the most common complication of peptic ulcer disease

DX: Upper endoscopy is the most accurate diagnostic test for peptic ulcer disease

• Biopsy for H. pylori should be obtained in all patients undergoing upper endoscopy for PUD unless contraindicated
• Ulcer biopsy of benign-appearing duodenal ulcers is not recommended
  • All ulcers with malignant features should be biopsied

TX: All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (eg, omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks

• Patients with evidence of H. pylori on biopsy should receive eradication therapy
  • Treatment for H.Pylori ⇒ think Baseball "CAP" = clarithromycin + amoxicillin + PPI
  • In patients with active bleeding, a negative biopsy result does not exclude H. pylori, and a breath test or a stool antigen test for H. pylori should be performed to confirm a negative result
  • In patients who receive treatment for H. pylori, eradication should be confirmed four or more weeks after the completion of therapy
• Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs)
• Patients with duodenal ulcers who have been treated do not need further endoscopy unless symptoms persist at four weeks or recur

• palpable epigastric olive-shaped mass (is pathognomonic for the disorder)
• On ultrasound, you will see a “double-track”
• Barium studies will reveal a “string sign” or “shoulder sign”

Treatment is by pyloromyotomy- known as the Ramstedt procedure

• Adenocarcinomas represent from 25 to 40 percent of small bowel cancers - highest in the duodenum
• Crohn's disease predisposes to adenocarcinoma within the involved area of the small intestine
• Diagnosis includes radiographic (computed tomography [CT] scan, small bowel series, enteroclysis) or endoscopic (wireless capsule endoscopy, push enteroscopy, double-balloon endoscopy)

Treatment is surgery — Localized adenocarcinomas of the small bowel are best managed with wide segmental surgical resection

• Adjuvant chemotherapy to patients with lymph node-positive

• Toxic patient: sepsis, febrile, abdominal pain
• Megacolon: acutely and massively distended colon
• Can occur with IBD (UC > Crohn's)

Decompression of the colon is required

• In some cases, colostomy or even complete colonic resection may be required