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Small Bowel Surgery (Appendicitis Path: Fecalith :poop: any time you…
Small Bowel Surgery
Appendicitis
Path:
Fecalith
:poop:
any time you block a tube, inflammation occurs behind it
if appendix bursts = bad
take to OR before that happens
Such Presentation!
ahem, such a clear presentation, you dont need diagnostic steps
Pt: Periumbilical px
px goes away &
THEN RETURNS
@
McBurney's point
btw umbilicus & liver in the RLQ
may also see
anorexia
nausea vomiting
:warning:
pt does not have to be peritoneal
Untreated appendicitis (WISE-MD)
abscess
perforation
Dx: Clinical
in real life they will get CT scan :radioactive_sign:
surgeon isn't in the room, surgeon wants a confirmatory CT while theyre coming to the OR
Tx:
Sx
:hocho:
Hernia
Path:
Direct : adults
directly thru the muscle (transversalis) into pelvis
Indirect : baby males
:baby::skin-tone-3:
thru inguinal ring :ring:
intestines in scrotum
Femoral hernias
: females :woman::skin-tone-2:
under the inguinal ligament
generally iatrogentic : postop pt
failure of fascia to close
Pt: abd buldge
use hx and PEx maneuvers to figure out the type
hernias that
can reenter
the peritoneum = reducible
hernias that
can't
= incarcerated/irreducible
hernias that are
ischemic
= strangulated
SBO
Path:
Adhesions
MC in persons
w/ abd sx
:hocho: before
Hernias
most common in
persons w/o abd sx
distal to obstruction is fine: continued flatus, emptying (BM)
everything proximal is stopped
Pt:
Colicky
peristalsis wave comes & passes
creates
Borborgymi sound
: high pitched crescendo after 5 min of auscultation
eventually becomes silent
initially: (+) flatus → later:
obstipation
complete obstruction
gas & fluid proximal to obstruction =
abd distension
Dx:
1st: upright Abd film XR:
KUB
air fluid levels = bowel obstruction
Then: CT scan
:radioactive_sign:
PO contrast
may relieve obstruction
but importantly sees if obstruction is complete or not
incomplete
Contrast reaches rectum
Tx:
conservative- watch & wait
:eyes::timer_clock:
Complete
Tx:
emergent Sx
:hocho::!:
will see poor sx candidates w/ complete SBO
treated conservatively
NG tube decompression & IVF
:ocean:
to correct K+
:battery:(3 days)
then go to sx if no improvement
or
pt becomes
peritoneal
= emergent Sx :hocho:
Reducible
Tx: elective sx :hocho:
Irreducible
or
signs of SBO
Incarcerated
Tx: urgent Sx :hocho:
Peritoneal = Strangulated
Tx: emergent Sx :hocho::!:
Carcinoid :crab:
:crab: Neuroendocrine Tumor
secretes serotonin :smiley:
only if there are mets!
liver & lung break down serotonin
Pt:
flushing
😡
wheezing
💨
Diarrhea
:poop:
R sided
cardiac
fibrosis
:<3:
serotonin :smiley: only affects the R side of the heart
Test loves carcinoid syndrome bc the mets must be in the lung or liver
Dx:
5-HIAA
confirm w/ CT scan :radioactive_sign:
Tx: resect tumor :hocho:
Labs: (WISE-MD)
WBC
infection
H/H : ↓: bleeding/ ↑ :dehydration
platelets (preop eval)
CMP
vomiting : electolytes
BUN/Cr : renal
glucose : infection
LFT
liver pathologies
UA
nephrolithiasis
WBC/bacteria: UTI
ßHcG
pregnancy
Amylase Lipase
pancreatitis r/o
Imaging:
hyperemic targetoid wall
inflammation surrounding
fat stranding
Dx:
CBC
↑ WBC = ischemia/infx/inflammation(nonspec)
Hct/Hgb: dehydration or anemia
platelets: preoperative assessment
CMP
basic electrolytes: hypochloremic hypokalemic met alkalosis (vomiting)
BUN/Cr : renal failure
UA
UTI can lead to ileus
low vol state = concentrated urine
ABG
base deficits (nonspec)
lactate
↑ in dehydration or ischemia (nonspec)
Amylase/Lipase
pancreatitis may mimic BO.
BO may increase amylase, no rise in lipase
imaging
Imaging:
KUB
supine and upright
shows
∆ air fluid level in SBO
ileus can also show ∆ air fluid levels
fluid can mask dilation in supine position
string of beads - air in distended fluid loops : ileus
CT :radioactive_sign:
high sensitivity/specificity
can't see adhesions
can see cancer/ Crohns
oral contrast shows how far the obstruction is
Closed loop obstruction: ↑ risk of strangulation = sx emergency :hocho::!:
Complications of SBO
Portal venous air
branching "crows feet" air in periphery of liver :red_flag: emergency :!:
≠ biliary air (central location : benign
Pneumatosis
Free intraperitoneal air
mesenteric venous air entering mesenteric v.
non-enhancing bowel wall
Operate?
Peritonitis
high fever :fire:
high concern for ischemia
No prior Hx or abd sx
nonoperative management only for adhesive bowel obstructions!
Non-operative
NG tube
decompress
Rescuscitation
IVF :ocean:
ringers lactate or NS (isotonic)
Foley
Reflex to sx if no improvement! (50/50 chance)
diseases of SB & appendicitis
who needs OR & when
peritoneal? = OR :hocho:
no dx tests, straight to OR
peritoneal signs are
not clear
signs are
rebound tenderness, involuntary guarding
assess for these w/ tapping on belly and it
doesn't hurt
; all while referring to an area that does
or shaking bed really hard causes pt to fetal position
peritonitis often accompanied by fever :fire: and leukocytosis (SAS)
but they could have peritonitis w/o systemic s/s
