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Surgery - Coggle Diagram
Surgery
Gallbladder
Anatomy
Parts
Fundus
Body
Infundibulum
Neck
Calots Triangle
Boundaries
Apex towards the liver
Right: Cystic duct
Left: Common hepatic duct
Superior: Cystic artery
Yellow : hepatocystic triangle
Purple : Calot's triangle
Conents
Right hepatic artery
Cystic artery
Cystic lymph node of Lund
Connective tissue
Lymphatics
Occasionally accessory hepatic ducts and arteries
Anatomical Anomalies
1/3 of pt have the classic description of the extrahepatic biliary tree and its arteries
Blood Supply
Cystic artery
Function
Bile storage
Bile concentration
Secretion of mucus
Gallstones
Epidemiology
Most common disease of GIT
95% of all GI pathologies
Western worls
1-4% develp symptoms
Definition
Hard solid matter in the gallbladder that are formed when components of bile including cholesterol and bilirubin precipitate out of solution and form crystals
Types
Mixed
Cholesterol
Pigmented :
Black
Brown
Cholesterol GS formation
Impaired gallbladder function
Empyting
Absorption
Secretion
Supersaturated bile
Cholesterol nucleating factors
Mucus
Glycoprotein
Infx
Other
Absorption / entero-hepatic circulation of bile acids
Risk Factors
The 4 Fs
Forty
Female
Fertile
Fat
Diet
Sex /age
Ethnicity
Cholesterol drugs
Oestrogen therapy
Diabetes
Genetisc
Obesity
Complications
Gallbladder
Cholecystitis
Inflammation of gallbladder
Perforation
Empyema
Mucocele
GI
Fistula
Gallstone ileus (obstruction)
Ducts
Jaundice
Pancreatitis
Cholangitis
Inflammation of cystic duct
Biliary colic
Svere abdominal pain
Acute Cholecystitis
Types
Acute calculous
Most common complication of gallstones + emergeny choleystectomy
Acute acalculous
Clinical Features
Progressive RUQ pain or epigastric pain
Mild fever
Anorexia
Tachycardia
Sweating
Nausea
Vomiting
+/- Hyperbilirubinaemia
Mild-moderate leukocytosis
Mild ↑ seum alkaline phosphatase
Definition
Acute cholecystitis is inflammation of the gallbladder that occurs due to occlusion of the cystic duct or impaired emptying of the gallbladder
Aetiology
Impaction of stone at cysic duct
Chemical inflammation
Secondary to bacterial infx
Investigations
FBC
Mild leukocytosis
WBC
Empyema
Perforation
LFTS
Mild elevation of bili, alk phosphatase
US
HIDA
hepatobiliary iminodiacetic acid (HIDA) scan
Positive Findings
Stone
Thicken wall
Perichlecystic fluid
Sonographic murphys sign
Characterisitic US findings
Sludge
Cholelithiasis
Thickened gallbladder wall
Pericholecystic fluid
Sonographic Murphys's sign
Pathophysiology
Impaction of stone at cystic duct / hartmans duct
Chemical inflammation
Secondary bacterial infection
Complications
Hydropes / mucocele
Empysma / emphysema
Gangrene
Perforation
Local / diffuse peritonitis
Cholecystitis
Fistulas
Treatment
Conservative
Floowed by intval / delated cholecystectomy
IV hydration and correction of electrolyte disorders
NO / NGT / maintanence of flui
Analgesic
Antibiotic
Early cholecystectomt
Acute Acalculous Cholecystitis
Risk Factors
Sepsis with hypotension and multiple organ failure
Immunosuppression
Major trauma
Diabetes mellitus
Infections
Pathogenesis
Impaired blood flow to cystic artery
Compromised blood flow leads to ischaemia of galbladder
Inflammation and oedema of gallbladder wall compromises blood flow
Accumulation of microcrytals of cholesterol - biliary sludge
Viscous bile + gallbladder mucous leads to cystic duct obstruction
Clinical Presentation
Abdo pain
Similar to colic but longer duration / severity
Fever
N+V
Physical exam
GA: ill
Vitals : Febrile and tachycardic
RUQ
Murphy's sign
Definition
Acute acalculous cholecystitis is defined as acute inflammation of the gallbladder in the absence of gallstones
Mirizzi Syndrome
Definition
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct
Investigations
USG
Dilation of the biliary system above the level of the GB neck
Stone impacted in the GB neck
Abrupt change to normal width of the common duct below the stone level
ERCP
Checks for:
Obstruction of the CHD
Impacted stone in the GB neck or cystic duct
Stone size
Bilio-biliary fistulas from proximal dilated biliary channels into gallbladder
Duodenal , pancreatic or ampullary pathology
Features of malignancy
CT + MRCP
Only helpful in ascertaining malignancy
Csendes Classification
External compression of the common heaptic duct due to a stone impacted at the neck of the gallbladder or at the cystic duct
Fistula involves less than one-third of the corcumference of the common bile duct
Involvement of 1/3-2/3 of the circumference of the common bile duct
Destruction of the entire wall of the common bile duct
Cholecystoenteric fistula together with any other type of Mirizzi syndrome
Management
Partial or total open cholecystectomy
CBD exploration not required
Cholecytectomy + closure of fistula
Suture repair, T tube placement through fistula or choledochoplasty
Cholecystectomy + choledochoplasty or bilioenteric anastomosis
Bilioenteric anastomosis - typically choledochojejunostomy as whole wall of CBD has been destroyed
Bilioenteric anastomissi
Check entire GI tract and remove escaped stones
Gallstone Ileus
Definition
Complication of cholelithiasis and is defined as a mechanical intestinal obstruction due to impaction of one or more gallstones within the gastrointestinal tract.
Epidemiology
Elderly pt with significant co-morbidities
Complicates <0.5% of gallstones
Complications
Biliary enteric fistula:
Cholecysto-duodenal
Cholecysto-colonic
Choledochocysto-enteric
Cholecysto-gastric - Bouveret syndrome
Tumbling obstruction
Transient gallstone impaction causing abdominal pain and vomiting
Subside as stone disimpacted only to recur as stone lodges more distaly
Vague and intermittent symptoms may be presen for some days prior
Common sites of impaction
Ileum
Narrowest diameter of GIT
Jejunum
Stomach
Colon
Investigations
AXR
Signs of intestinal obstruction
Aerobilia
Change in position of a previously located stone
Two adjacent small bowel air-flui levels in the RUQ
Diagnosis frequently made on the table
Management
Resus
Empirical antibiotic
Analgesics
Surgery
One stage
Enterotomy proximal to impaction site + cholecystectomy
Fistula division +/- CBD exploration
Two Stage
Enterotomy prox to impaction site or bowel resection
Definitive biliary procesure later once pt recovered
Choledocholithiasis
Definition
Presence of stone within main biliary outflow tract
Types
Primary
Secondary
Clinical Features
Abdominal pain
Fever
Jaundice
Anorexia
N+V
Clay stools
Complications
Ascending cholangitis
Gallstone pancreas
Liver abcess
Ectatic CBD
Investigations
Biochemistry
LFTS
↑ DB
↑ GGT
↑ ALP
UFEMA
↑ Urobilinogen
US
Dilated biliary treee
Cholelithiasis
Distal CBD obscured by bowel gas
Complications:
Liver abcess
Ectatis CBD
Endoscopic ultrasonography
Microlithiasis
Distal CBD stones
ERCP
Diagnostic and therpuetic
Invasive and radiation
Intervention
Ascending Cholangitis
Definition
Acute inflammation of the wal of bile ducts due to bacterial infection
Aetiology
Any lesion obstruction the bile flow
Choledocholithiasis
Surgery involving the biliary tree
Tumours
Indwelling stents / catheters
Acute pancreatitis
Benign strictures
Charcot's Cholangitis Triad
Fever
Jaundice
Abdominal RUQ pain
Pathophysiology
Elevated intra-ductal pressure du to biliary obstruction
Bacterial translocation into bile duct and forward into lymphatic + venous systems
Clinical Features
Charcots Triad
Fever
Jaundice
RUQ pain
Reynaud's pentad
Charcots Triad +
Altered mental state (septic shock
Hypotension
Pathogens
E.coli
Klebsiella
Enterococci
Clostridium
Bacteroides
Parasitic
Diagnosis
Signs of inflammation
Fever
Chills
Rigor
Elevated CRP or TWC
Signs of Cholestasis
Jaundice
Abnormal LFTS
Imaging signs
Biliary tree dilation
Evidence of aetiology
Stones
Stricture
Stent
Assign severity
Mild
Severe
Management
Resus
Empirical broad spectrum antibiotics
Analgesis
Biliary drainage
Endoscopic
ERCP
Least invasive
Sphincterotomy
Stent
Nasobiliary tube
Percutaneous
PTBD
Indications
Inaccessible papilla
Altered GI anatomy
No skilled endoscopist available
Failure of endoscopic
Surgical
Reserved for advanced malignant cases requiring concurrent biliary enteric bypass
Carcinoma of Gallbladder
Epidemiology
Uncommon
Women 70s
Mexico + Chile
Aetiology
Recurrent trauma
Chronic inflammation
Gallstones present in 60-90% of cases
Parasitic disease of biliary tree
Risk Factors
Cholithiasis
Porcelain gallbladder
Primary sclerosing cholangitis
Chledochal cyst
Association with gallstones
Pathology
Adenocarcinoma 90%
Scirrhous
Papillary
Mucoid
Spread
Haemato
Lymphatic
Direct
Clinical Features
Insidious onset
Similar to cholelithiasis
Abdo pain
Jaundice
Anorexia
N+V
Incidental finding during cholecystectomy for symptomatic gallstone
Management
Surgical resection including adjacent liver
+/- chemotherapy
Diagnostic Work up
Abdomin US
CT scan
MRI/MRC
ERCP
Sepsis
Findings
Leukocytosis or leukopenia
Normal WBC count with greater than 10% immature forms
Hypoglycaemia in abscence of diabetes
CRP elevated
Altered hypoxeia
Acute oliguria
Creatinine >0.5 mg/dL
INR > 1.5
aPTT >60 sec
PLT <100,000
Hyperbilirubinemia
Lactate >2 mmol/L - organ hypoperfusion
Lactate >4 mmol/L - shock
Elevated procalcitonin
Risk Factors
ICU admission
Bacteriemia
Advanced age >65
Immunosuppresion
Diabetes and obesity
Cancer
CAP
Previous hospitilisation
Genetic factor
Evaluation and Management
Oxygen
Target 90-906%
Nasa canula / face mask → Non-invasive ventilation →High flow oxygen→Intubation and mechanical ventilation
Venous Access ASAP
Fluid resucitation
Crytalloyds 30ml/kg withing first 3hr
Bloods for labs
FBC, LFT, Coag, Creatinine, D-dimer
Serum Lactate
Blood culture
Empiric antibiotics
Target at suspected source of infx
Closed space infection should be properly drained
Within 45 min
Laboratories: FBC; LFT; Coag; Crea; D-Dimer
Serum Lactate
Peripheral Blood Culture (2 set) + Urinalysis + Microbial culture form suspected source
ABG: Metabolic assessment; Hypoxemia or hypercapnia
Imaging
Procalcitonin
Sepsis 6
Take 3
Blood culture
Blood tests
Urine output
Give 3
O2
IV fluids
IV antimicrobials
Presentation
Fever - hypothermia
Leukocytosis / leucocytopenia
Tachypnea
Tachycardia
Causative Agents
E. coli
Staph aureus
Klebsiella pneumoniae
Strep pneumoniae
Pathogenesis
Release of pro-inflammatory mediators in response to infx exeed the boundaries of the local environment leading to a more generalised response
Progression
Infection
Sepsis
Confirmed or suspected infx
+
Aberrant or dysregulated host response leading to organ dysfunction
Septic Shock
Sepsis
+
Persisting hypotension requiring vassopressors to maintain MAP
+
Serum lactate >2 mmol/L
MODS
Septic shock
+
Multiple organ dysfunction syndrome (MODS)
Screening Tools
qSOFA
Quick sequential organ failure assessment
NEWS
National early warning score
Septic Shock
Patients who fulfil the criteria for sepsis who despite adequate therapy require vasopressor to maintain a Mean Arteria Pressure (MAP) > 65 and have Lactate >2 mml/L (MORTALITY > 40%)
Presentation
Hypotension
Tachycardia
Fever
Leukocytosis
Definition
A life-threatening organ dysfunction caused by a dysregulated host response to infection.
SOFA score
Sequential Organ Failure Assessment score
Bowel Obstruction
Cardinal Features
Vomiting
Nausea and anorexia
Colic
Constipation - may be absoloute
Abdominal distention
Causes
Small Bowel
Adhesions
Hernias
Large Bowel
Colon carcinoma
Constipation
Diverticular stricutre
Volvulus
Sigmoid volvulus
Caecal volvulus
Rarer
Crohn's stricture
Gallstone ileus
Intussusception
TB
Foreign body
DDx
Gastroenteritis
Bowel ischaemia
Acute pancreatitis
Bowel perforation
Acute appendicitis
Investigations
Bedside
Vital Signs
Pregnancy test - female
Labs
Full blood count:
raised white cell count
Urea & electrolytes:
vomiting may cause deranged renal function and electrolyte disturbance
CRP & lactate:
suggestive of bowel ischaemia
Group & save:
pre-operative
Imaging
PFA
CT abdo pelvis with IV contrast
Appendix
Appendicitis
Anatomy
Identification
Convergence of the taeniae at the tip of the cecum
Position
Post ileal
Pre-ileal
Pelvic
Retrocecal
Blood Supply
Ileocolic artery from the SMA
Pathophysiology
Risk Factors
Fecal Stasis / fecaltih
Lymphoid hyperplasia
neoplasm
Fruit and Vegetable material
Barium
Parasites (ascaridis)
Clinical Presentation
Tenderness maximal at McBurney's point
Low grade fever
Constipation or diarrhoea
N+V
Rebound tenderness
Rovsing's signs
Psoas sign
Obturator signs
DDx
Children
Acute Gastroenteritis
Meckel's diveticulitis
Intussusception
Mesenteric adenitis
IBD
Testicular torsion
Female of Child Bearing Age
Ruptured ovarian cysts
Mittleshmerz
Endometriosis
Ovarian torsion
Ectopic pregnancy
Pelvic Inflammatory Disease
Elderly
Diverticulitis
Malignant disease
Neutropenic Pt
Typhilitis
Investigations
Imaging
Plain Radiograph
CT
US
Management
Appendiceal Mass
Ddx
Crohn's
Carcinoma of caecum
Progression
Resolution
Gangrenous perforation
Walled off by omentum and small bowel
Presentation
Longer hx of RLQ pain
Tender palpable mass in the RIF
Treatment
Non operartive
Decreased complication rate
Percutaneous drainage for fluid collection
Appendix Tumours
Types
Carcinoid
Adenocarcinoma
Mucinous tumours :
Ulcers
Management of Perforation
Washout
Ometal patch repair
Grahms Patch
Biopsy gastric ulcers for malignancy
Sepsis 6
Managemetn
Triple therapy
PPI
Amoxacillin
Wound Healing
