General Surgery Notes

GENERAL SURGERY
D r. S . G alli n ge r
G o rd o n B u d u h an an d S am M i n o r, e d i to rs
D an a M
c
K ay, asso ci ate e d i to r
PREOPERATIVE PREPARATION . . . . . . . . . . . . . 2
SURGICAL COMPLICATIONS . . . . . . . . . . . . . . . . . 2
Wo u n d C o m p li cati o n s
U ri n ary an d R e n al
R e sp i rato ry
C ard i ac
P aralyti c I le u s
P o st-O p e rati ve D e li ri u m
P o st-O p e rati ve F e ve r
I n tra-ab d o m i n al Ab sce ss
ACUTE ABDOMEN. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
S p e ci fi c S i gn s o n P h ysi cal E xam i n ati o n
E valu ati o n
ESOPHAGUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
H i atu s H e rn i a
S tru ctu ral L e si o n s
M o ti li ty D i so rd e rs
O th e r D i so rd e rs
E so p h age al P e rfo rati o n
E so p h age al C arci n o m a
STOMACH AND DUODENUM . . . . . . . . . . . . . . . . 12
G astri c U lce rs
D u o d e n al U lce rs
G astri c C arci n o m a
C o m p li cati o n s o f G astri c S u rge ry
BOWEL OBSTRUCTION. . . . . . . . . . . . . . . . . . . . . . 15
S m all B o we l O b stru cti o n
L arge B o we l O b stru cti o n
SMALL INTESTINE . . . . . . . . . . . . . . . . . . . . . . . . . .18
Tu m o u rs o f S m all I n te sti n e
M e cke l s D i ve rti cu lu m
APPENDIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Ap p e n d i ci ti s
Tu m o u rs o f th e Ap p e n d i x
INFLAMMATORY BOWEL DISEASE. . . . . . . . . . .20
C ro h n s D i se ase
U lce rati ve C o li ti s
LARGE INTESTINE . . . . . . . . . . . . . . . . . . . . . . . . . 21
D i ve rti cu lar D i se ase
An gi o d ysp lasi a
Vo lvu lu s
C o lo re ctal P o lyp s
C o lo re ctal C arci n o m a
I le o sto m i e s an d C o lo sto m i e s
ANORECTUM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
H e m o rrh o i d s
An al F i ssu re s
An o re ctal Ab sce ss
P e ri re ctal S u p p u rati o n
F i stu la-i n -an o
P i lo n i d al D i se ase
R e ctal P ro lap se
An al N e o p lasm s
HERNIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s G e n e ral S u rge ry 1
LIVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
L i ve r C ysts
L i ve r Ab sce sse s
N e o p lasm s
P o rtal H yp e rte n si o n
L i ve r Tran sp lan tati o n
BILIARY TRACT. . . . . . . . . . . . . . . . . . . . . . . . . 34
C h o le li th i asi s
B i li ary C o li c
Acu te C h o le cysti ti s
C o m p li cati o n s o f C h o le cyste cto m y
Acalcu lo u s C h o le cysti ti s
G allsto n e P an cre ati ti s
G allsto n e I le u s
D i agn o sti c E valu ati o n o f B i li ary Tre e
C h o le d o ch o li th i asi s
Acu te C h o lan gi ti s
C arci n o m a o f th e B i le D u ct
Jau n d i ce
PANCREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Acu te P an cre ati ti s
C h ro n i c P an cre ati ti s
P an cre ati c C an ce r
SPLEEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
H yp e rsp le n i sm
S p le n e cto m y
FISTULA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
BREAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
F i b ro cysti c D i se ase
F i b ro ad e n o m a
F at N e cro si s
P ap i llo m a
D i ffe re n ti al D i agn o si s o f N i p p le D i sch arge
M asti ti s
B re ast C an ce r
M ale B re ast L u m p s
THYROID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
VASCULAR - ARTERIAL DISEASES . . . . . . . 47
Arte ri al I n su ffi ci e n cy
C h ro n i c I sch e m i a
C ri ti cal I sch e m i a
Acu te L i m b I sch e m i a
Ab d o m i n al Ao rti c An e u rysm
R u p tu re d Ab d o m i n al Ao rti c An e u rysm
Ao rti c D i sse cti o n
VASCULAR - VENOUS DISEASES . . . . . . . . . 51
D e e p Ve i n T h ro m b o si s
Vari co se Ve i n s
S u p e rfi ci al T h ro m b o p h le b i ti s
C h ro n i c D e e p Ve i n I n su ffi ci e n cy
HIV AND GENERAL SURGERY . . . . . . . . . . . 54
S u sce p ti b le O rgan s i n G I Tract
U n u su al M ali gn an ci e s
I n d i cati o n s fo r S u rge ry i n H I V P o si ti ve P ati e n ts
N o so co m i al Tran sm i ssi o n
CANCER GENETICS. . . . . . . . . . . . . . . . . . . . . . 56
G e n e ral S u rge ry 2 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
PREOPERATIVE PREPARATION
J co n se n t
J co n su lts - an e sth e sia, m e d icin e , card io lo gy, e tc...
J co m p o n e n ts - b lo o d co m p o n e n ts: gro u p an d scre e n o r
cro ssm atch d e p e n d in g o n p ro ce d u re
J d ie t - N P O afte r m id n igh t
J AAT, vital sign s ro u tin e
J IV - b alan ce d crystallo id at m ain te n an ce rate 4:2:1 ru le )
- R in ge r's lactate o r n o rm al salin e
J in ve stigatio n s
C B C , U /A, lyte s, B U N , cre ati n i n e
I N R /P T, P T T wi th h i sto ry o f b le e d i n g d i so rd e r
AB G s i f p re d i sp o se d to re sp i rato ry i n su ffi ci e n cy
C XR PA an d late ral) u n le ss < 35 ye ars o ld o r
p re vi o u sly ab n o rm al wi th i n p ast 6 m o n th s
E C G > 35 ye ars o ld o r as i n d i cate d b y p ast card i ac h i sto ry
J d ru gs i n clu d i n g o xyge n )
p ati e n t's re gu lar m e d s i n clu d i n g p re d n i so n e - co n si d e r p re -o p b o o st
p ro p h ylacti c an ti b i o ti cs e .g. ce fazo li n ) i f
cle an /co n tam i n ate d case s i .e . G I /G U /re sp i rato ry tracts are e n te re d )
co n tam i n ate d case s - trau m a
i n se rti o n o f fo re i gn m ate ri al e .g. vascu lar grafts)
h i gh ri sk p ati e n ts e .g. p ro sth e ti c h e art valve s,
rh e u m ati c h e art d i se ase )
b o we l p re p d e cre ase s b acte ri al p o p u lati o n e .g. An ce f, C i p ro , F lagyl)
J d rai n s
n aso gastri c tu b e
i n d i cati o n s: gastri c d e co m p re ssi o n , an alysi s o f gastri c
co n te n ts, i rri gati o n /d i lu ti o n o f gastri c co n te n ts, fe e d i n g
o n ly i f n e ce ssary > d u e to ri sk o f asp i rati o n ,
n aso -je ju n al tu b e p re fe rab le )
co n trai n d i cati o n s: ab so lu te - o b stru cti o n o f n asal
p assage s d u e to trau m a, su sp e cte d b asi lar sku ll
fractu re , re lati ve - m axi llo faci al fractu re s; fo r
th e se m ay u se o ral-gastri c tu b e
F o le y cath e te r
i n d i cati o n s: to accu rate ly m o n i to r u ri n e o u tp u t,
d e co m p re ssi o n o f b lad d e r, re li e ve o b stru cti o n
co n trai n d i cati o n s: su sp e cte d d i sru p ti o n o f th e
u re th ra, d i ffi cu lt i n se rti o n o f cath e te r
SURGICAL COMPLICATIONS
WOUND COMPLICATIONS
Wound Infe ction
J wo u n d s b e co m e i n fe cte d i n th e O R wh i le o p e n
J ri sk o f i n fe cti o n d e p e n d s o n typ e o f p ro ce d u re
cle an e xci si o n al b i o p sy) - 3%
cle an -co n tam i n ate d G I , b i li ary) - 5-1 5%
co n tam i n ate d su rge ry o n u n p re p p e d b o we l, e m e rge n cy
su rge ry fo r G I b le e d s/p e rfo rati o n ) - 1 5-40%
d i rty p e n e trati n g trau m a) - 40%
J m o st co m m o n e ti o lo gi c age n t = S . aureus
J b o we l o p e rati o n s - co n si d e r e n te ri c o rgan i sm s
J p re d i sp o si n g facto rs
p ati e n t ch aracte ri sti cs: age , d i ab e te s, ste ro i d s,
i m m u n o su p p re ssi o n , m aln u tri ti o n , p ati e n t wi th o th e r
i n fe cti o n s, trau m ati c wo u n d , rad i ati o n
o th e r facto rs: p ro lo n ge d p re o p e rati ve h o sp i tali zati o n ,
d u rati o n o f su rge ry, b re ak i n ste ri le te ch n i q u e , u se o f
d rai n s, m u lti p le an ti b i o ti cs
J cli n i cal p re se n tati o n
typ i cally fe ve r P O D 3-4
p ai n , wo u n d e ryth e m a, i n d u rati o n , fran k p u s o r
p u ru lo san gu i n o u s d i sch arge
J tre atm e n t
re -o p e n affe cte d p art o f i n ci si o n , cu ltu re wo u n d , p ack,
h e al b y se co n d ary i n te n ti o n
N o te s
SURGICAL COMPLICATIONS . . . CONT.
an tib io tics ge n e rally n o t in d icate d u n le ss ce llu litis o r
im m u n o d e ficie n cy p re se n t
J p ro p h ylaxis
co n sid e r IV an tib io tics
d e b rid e m e n t o f n e cro tic an d n o n -viab le tissu e
Wound He morrhage /He matoma
J in ad e q u ate su rgical co n tro l o f h e m o stasis
J p atie n ts o n an tico agu lan t th e rap y, m ye lo p ro life rative d iso rd e rs
e .g. p o lycyth e m ia ve ra)
J sym p to m s: p ain , swe llin g, d isco lo ratio n o f wo u n d e d ge s, le akage
Wound De his ce nce
J d e fin itio n - d isru p tio n o f fascial laye r, ab d o m in al co n te n ts co n tain e d
b y skin
J e visce ratio n - d isru p tio n o f all ab d o m in al wall laye rs an d e xtru sio n o f
ab d o m in al co n te n ts m o rtality o f 1 5%)
J in cid e n ce = 0.3-5% o f ab d o m in al in cisio n s
J u su ally P O D 5-8
J m o st co m m o n p re se n tin g sign is se ro -san gu in o u s d rain age fro m wo u n d
J p re d isp o sin g facto rs
lo cal
p o o r clo su re , in cre ase d in tra-ab d o m in al p re ssu re
e .g. C O P D , ile u s, b o we l o b stru ctio n ) , p o o r wo u n d
h e alin g h e m o rrh age , in fe ctio n )
syste m ic
h yp o p ro te in e m ia, ste ro id s, age , d iab e te s,
im m u n o su p p re ssio n , se p sis, jau n d ice
J tre atm e n t - o p e rative clo su re
e visce ratio n is a su rgical e m e rge n cy
m ild d e h isce n ce can b e tre ate d e xp e ctan tly with d e laye d
re p air o f th e re su ltin g h e rn ia
URINARY AND RENAL COMPLICATIONS
Urinary Re te ntion
J m ay o ccu r afte r an y o p e ratio n with G A o r sp in al an e sth e sia
J m o re like ly in o ld e r m ale s with h isto ry o f p ro statism
J tre atm e n t - b lad d e r cath e te rizatio n
Acute Re nal Failure se e N e p h ro lo gy N o te s)
J h igh asso ciate d m o rtality > 50%
J classifie d acco rd in g to p rim ary cau se e .g. p re -re n al, re n al, p o st-re n al
J tre atm e n t - acco rd in g to u n d e rlyin g cau se
J d e cre ase d re n al p e rfu sio n tre ate d with flu id b o lu se s
J co n sid e r C VP lin e o r S wan -G an z cath e te r if p atie n t d o e s n o t re sp o n d to flu id b o lu s
RESPIRATORY COMPLICATIONS
Ate le ctas is
J co m p rise s 90% o f p o st-o p p u lm o n ary co m p licatio n s
J clin ical m an ife statio n s u su ally in first 24 h o u rs p o st-o p
lo w fe ve r, tach ycard ia, crackle s, d e cre ase d b re ath so u n d s,
b ro n ch ial b re ath in g, cyan o sis
J p re -o p e rative p ro p h ylaxis
q u it sm o kin g
d e e p ab d o m in al b re ath in g an d co u gh in g
J p o st-o p e rative p ro p h ylaxis
in ce n tive sp iro m e try
m in im ize u se o f d e p re ssan t d ru gs
go o d p ain co n tro l
fre q u e n t ch an ge s in p o sitio n
d e e p b re ath in g an d co u gh in g
e arly am b u latio n
As piration Pne umonitis
J asp iratio n o f gastric co n te n ts
J can b e le th al
J m ajo r d e te rm in an t o f d e gre e o f in ju ry is gastric p H
J o ccu rs m o st o fte n at tim e o f an e sth e tic in d u ctio n an d at e xtu b atio n
N o te s
J tre atm e n t
im m e d iate re m o val o f d e b ris an d flu id fro m airway
co n sid e r e n d o trach e al in tu b atio n an d fle xib le
b ro n ch o sco p ic asp iratio n
IV an tib io tics to co ve r o ral ae ro b e s an d an ae ro b e s
Pulmonary Ede ma
J o ccu rs d u rin g o r im m e d iate ly afte r o p e ratio n
J re su lts fro m circu lato ry o ve rlo ad
o ve rze alo u s vo lu m e re p lace m e n t
le ft ve n tricu lar failu re
sh ift o f flu id fro m p e rip h e ral to p u lm o n ary vascu lar b e d
n e gative airway p re ssu re
alve o lar in ju ry d u e to to xin s
J tre atm e n t
O 2
re m o ve o b stru ctin g flu id
co rre ct circu lato ry o ve rlo ad
d iu re tics, P E E P in in tu b ate d p atie n t
Re s piratory Failure
J clin ical m an ife statio n s - d ysp n e a, cyan o sis, e vid e n ce o f
o b stru ctive lu n g d ise ase , p u lm o n ary e d e m a, u n e xp lain e d
d e cre ase in P aO 2
J e arlie st m an ife statio n s - tach yp n e a an d h yp o xe m ia
N B : h yp o xe m ia m ay in itially p re se n t with co n fu sio n /d e le riu m
J tre atm e n t
O 2 b y m ask
p u lm o n ary to ile t
b ro n ch o d ilato rs
tre atm e n t o f acu te re sp irato ry in su fficie n cy - m e ch an ical
ve n tilatio n
J if th e se m e asu re s fail to ke e p P aO 2 > 60, co n sid e r AR D S
J co n tro l o f p o st-o p e rative p ain can d e cre ase p u lm o n ary co m p licatio n s
p ro b le m atic with th o racic an d u p p e r ab d o m in al o p e ratio n s
CARDIAC COMPLICATIONS
J ab n o rm al E C G s co m m o n in p o st-o p e rative p e rio d
J co m p are with p re -o p E C G
J co m m o n arrh yth m ia - S VT
Myocardial Infarction
J su rge ry in cre ase s risk o f M I
J m ajo rity o f case s o n o p e rative d ay o r with in first 3 p o sto p e rative d ays
J in cid e n ce
0.5% in p re vio u sly asym p to m atic m e n > 50 ye ars o ld
40-fo ld in cre ase in m e n > 50 ye ars o ld with p re vio u s M I
J risk facto rs
p re -o p e rative h yp e rte n sio n
p re -o p e rative C H F
o p e ratio n s > 3 h o u rs
in tra-o p e rative h yp o te n sio n
an gin a p e cto ris
M I in 6 m o n th s p re ce d in g su rge ry
PARALYTIC ILEUS
J n o rm al b o we l so u n d s d isap p e ar fo llo win g ab d o m in al su rge ry
J also fo llo ws p e rito n itis, ab d o m in al trau m a, an d im m o b ilizatio n
J re tu rn o f G I m o tility fo llo win g ab d o m in al su rge ry varie s
sm all b o we l m o tility re tu rn s b y 24-48 h o u rs
gastric m o tility re tu rn s b y 48 h o u rs
co lo n ic m o tility - u p to 3-5 d ays
J d u e to p aralysis o f m ye n te ric p le xu s
J two fo rm s
in te stin al ile u s
gastric d ilatatio n
J sym p to m s
ab d o m in al d iste n sio n an d vo m itin g
ab se n t o r tin kly b o we l so u n d s
N o te s
J tre atm e n t
N G tu b e an d flu id re su scitatio n
fo r p ro lo n ge d ile u s, co n sid e r T P N
POST-OPERATIVE DELIRIUM
J d istu rb an ce o f sle e p -wake cycle
J d istu rb an ce o f atte n tio n
J flu ctu atin g co u rse th ro u gh o u t d ay
J in cid e n ce : 40% like ly an u n d e re stim ate )
J u n d e r-re co gn ize d 28% m isse d )
J n o co rre latio n with typ e o f an e sth e tic age n t
J risk facto rs
> 50 ye ars o ld
p re -e xistin g co gn itive d ysfu n ctio n
d e p re ssio n
p e ri-o p e rative b io ch e m ical d e ran ge m e n ts
> 5 p re scrib e d m e d icatio n s p o st-o p e rative ly
u se o f an tich o lin e rgic m e d icatio n s p re o p e rative ly
card io p u lm o n ary b yp ass
IC U se ttin g
POST-OPERATIVE FEVER
J fe ve r d o e s n o t n e ce ssarily im p ly in fe ctio n
J tim in g o f fe ve r m ay h e lp id e n tify cau se
J " 6W's" - C L IN C AL P E AR L
Win d p u lm o n ary)
Wate r u rin e -U T I)
Wo u n d
Walk D VT-P E )
Wo n d e r d ru gs d ru g fe ve r
Wan e s rh ym e s with ve in s: IV site s)
J 0-48 h o u rs
u su ally ate le ctasis
co n sid e r e arly wo u n d in fe ctio n e sp e cially Clostridia,
G ro u p A S tre p )
le akage o f b o we l an asto m o sis tach ycard ia, h yp o te n sio n ,
o ligu ria, ab d o m in al p ain )
asp iratio n p n e u m o n ia
J P O D 3
afte r d ay 3 in fe ctio n s m o re like ly
U T I- p atie n t in stru m e n te d ? e .g. fo le y
wo u n d in fe ctio n u su ally P O D 3-5)
IV site - e sp e cially IVs in p lace > 3 d ays
se p tic th ro m b o p h le b itis
in tra-ab d o m in al ab sce ss u su ally P O D 5-1 0)
D VT P O D 7-1 0)
J also co n sid e r - ch o le cystitis, P E , sin u sitis, p ro statitis,
p e ri-re ctal ab sce ss, d ru g fe ve r, U R T I, factitio u s fe ve r
INTRA-ABDOMINAL ABSCESS
J lo calize d in tra-ab d o m in al in fe ctio n
J a co lle ctio n o f p u s walle d -o ff fro m re st o f p e rito n e al cavity b y
in flam m ato ry ad h e sio n s an d visce ra
J n u m b e r o f b acte ria e xce e d h o st's ab ility to te rm in ate in fe ctio n
J d an ge r: m ay p e rfo rate se co n d arily > d iffu se b acte rial p e rito n itis
J u su ally p o lym icro b ial
J clin ical m an ife statio n s
p e rsiste n t, sp ikin g fe ve r, d u ll p ain , we igh t lo ss, le u ko cyto sis
im p aire d fu n ctio n o f ad jace n t o rgan s e .g. ile u s o r
d iarrh e a with re ctal ab sce ss)
co -e xistin g e ffu sio n e .g. p le u ral e ffu sio n with su b p h re n ic ab sce ss
J d iagn o sis
u su ally b y U /S o r C T
d o n 't fo rge t to p e rfo rm D R E b o ggy m ass in p e lvis)
J tre atm e n t
d rain age is e sse n tial
an tib io tics to co ve r ae ro b e s an d an ae ro b e s
N o te s
ACUTE ABDOMEN
M artin , R F, R o ssi, R L . T h e Acu te Ab d o m e n : An O ve rvie w an d Algo rith m s.
Surg Clin North Am. 1 997:77 6) :1 227-43.
SPECIFIC "SIGNS" ON PHYSICAL EXAMINATION
J B lu m b e rg's sign re b o u n d te n d e rn e ss) : co n stan t, h e ld p re ssu re
with su d d e n re le ase cau se s se ve re te n d e rn e ss p e rito n e al irritatio n )
J C o u rvo isie r's sign : p alp ab le , n o n -te n d e r gall b lad d e r with
jau n d ice p an cre atic o r b iliary m align an cy)
J C u lle n 's sign : p u rp le -b lu e d isco lo ratio n aro u n d u m b ilicu s
p e rito n e al h e m o rrh age )
J G re y Tu rn e r's sign : flan k d isco lo ratio n re tro p e rito n e al h e m o rrh age )
J ilio p so as sign : fle xio n o f h ip again st re sistan ce o r p assive
h yp e re xte n sio n o f h ip cau se s p ain re tro ce cal ap p e n d ix)
J M u rp h y's sign : in sp irato ry arre st o n d e e p p alp atio n o f R U Q ch o le cystitis)
J M cB u rn e y's p o in t te n d e rn e ss: 1 /3 fro m an te rio r su p e rio r iliac sp in e
to u m b ilicu s; in d icate s lo cal p e rito n e al irritatio n ap p e n d icitis)
J o b tu rato r sign : fle xio n th e n e xte rn al o r in te rn al ro tatio n ab o u t
th e righ t h ip cau se s p ain p e lvic ap p e n d icitis)
J p e rcu ssio n te n d e rn e ss: o fte n go o d su b stitu te fo r re b o u n d te n d e rn e ss
J R o vsin g's sign : p alp atio n p re ssu re to le ft ab d o m e n cau se s R L Q
M cB u rn e y's p o in t te n d e rn e ss ap p e n d icitis)
J sh ake te n d e rn e ss: p e rito n e al irritatio n b u m p sid e o f b e d in
su sp e cte d m alin ge re rs)
EVALUATION
His tory
J p ain
lo catio n o f p ain
se e Tab le 1
also co n sid e r: ab d o m in al wall d iso rd e rs
e .g. h e m ato m a, h e rp e s zo ste r
re fe rre d p ain
b iliary co lic: righ t sh o u ld e r o r scap u la
re n al co lic: to gro in
ap p e n d icitis: e p igastric to R L Q
p an cre atitis: to b ack
ru p tu re d ao rtic an e u rysm : to b ack o r flan k
p e rfo rate d u lce r: to R L Q righ t p araco lic gu tte r
J asso ciate d sym p to m s
ge n e ral: fe ve rs, ch ills, we igh t lo ss, jau n d ice
gastro in te stin al: an o re xia, n au se a, vo m itin g, d iarrh e a,
co n stip atio n , o b stip atio n , m e le n a, h e m ato ch e zia
u rin ary: d ysu ria, h e m atu ria, u rin ary fre q u e n cy
gyn e co lo gical: 1 st d ay L M P, vagin al d isch arge , p re vio u s S T D , IU D u se
Table 1. Location of Pain
Right Uppe r Quadrant Le ft Uppe r Quadrant
gallb lad d e r/b iliary tract p an cre atitis
h e p atitis, h e p atic ab sce ss sp le n ic ru p tu re , in farct
p e p tic u lce r sp le n ic an e u rysm
p an cre atitis gastritis
M I M I
p n e u m o n ia/p le u risy p n e u m o n ia
e m p ye m a, p e ricard itis e m p ye m a
Right Lowe r Quadrant Le ft Lowe r Quadrant
ap p e n d icitis le akin g an e u rysm
in te stin al o b stru ctio n in te stin al o b stru ctio n
d ive rticu litis d ive rticu litis
u lce r p e rfo ratio n p so as ab sce ss
e cto p ic p re gn an cy e cto p ic p re gn an cy
o varian cyst o r to rsio n o varian cyst o r to rsio n
salp in gitis salp in gitis
u re te ral calcu li u re te ral calcu li
e n d o m e trio sis e n d o m e trio sis
typ h litis
N o te s
ACUTE ABDOMEN . . . CONT.
Phys ical Exam and Work-Up
J ste p s in p h ysical e xam
1 ) ge n e ral o b se rvatio n : p atie n t p o sitio n i.e . lyin g still vs.
writh in g)
2) vitals: p o stu ral ch an ge s, fe ve r
3) statu s o f h yd ratio n
4) card io vascu lar/re sp irato ry e xam in atio n
5) ab d o m in al e xam in atio n
o b se rvatio n : d iste n tio n , scars, visib le p e ristalsis
au scu ltatio n : ab se n t, d e cre ase d , n o rm al, in cre ase d b o we l
so u n d s
p e rcu ssio n : h yp e rtym p an ic so u n d s in b o we l o b stru ctio n ,
p e rcu ssio n te n d e rn e ss in d icative o f p e rito n itis
p alp atio n : te n d e rn e ss, ab d o m in al m asse s
6) C VA te n d e rn e ss
7) sp e cific sign s
8) h e rn ias, m ale ge n italia
9) re ctal/p e lvic e xam
J lab s
C B C an d d iffe re n tial
e le ctro lyte s, B U N , cre atin in e
am ylase le ve ls
live r fu n ctio n te sts
u rin alysis
sto o l fo r o ccu lt b lo o d
o th e rs as in d icate d
E C G , -h C G , AB G , se p tic wo rku p , lactate isch e m ic b o we l)
J rad io lo gy
3 vie ws ab d o m e n
C XR
o th e rs as in d icate d
U /S , C T, e n d o sco p y, IVP, p e rito n e al lavage , lap aro sco p y
J in d icatio n s fo r u rge n t o p e ratio n
p h ysical fin d in gs
p e rito n itis
se ve re o r in cre asin g lo calize d te n d e rn e ss
p ro gre ssive d iste n sio n
te n d e r m ass with fe ve r o r h yp o te n sio n ab sce ss)
se p tice m ia an d ab d o m in al fin d in gs
b le e d in g an d ab d o m in al fin d in gs
su sp e cte d b o we l isch e m ia acid o sis, fe ve r, tach ycard ia)
d e te rio ratio n o n co n se rvative tre atm e n t
rad io lo gic
fre e air
m assive b o we l d iste n tio n co lo n > 1 2 cm )
sp ace o ccu p yin g le sio n with fe ve r
e n d o sco p ic
p e rfo ratio n
u n co n tro llab le b le e d in g
p arace n te sis
b lo o d , p u s, b ile , fe ce s, u rin e
Approach to the Critically Ill Surgical Patie nt
ABC, IM FINE
ABC- se e E m e rge n cy M e d icin e N o te s
I - IV: two large b o re IV s with n o rm al salin e , wid e o p e n
M - M o n ito rs: O 2 sat, E K G , B P
F - F o le y cath e te r to m e asu re u rin e o u tp u t
I - In ve stigatio n s: se e ab o ve
N - +/ N G tu b e
E - E x rays
N o te s
ACUTE ABDOMEN . . . CONT.
Figure 1. Abdominal Incis ions Drawingby JackieRobers
Laye rs of the Abdominal Wall
J skin
J su p e rficial fascia
C am p e r's fascia > d arto s m u scle
S carp a's fascia > C o lle s' fascia
J m u scle
e xte rn al o b liq u e > in gu in al ligam e n t, e xte rn al sp e rm atic
fascia, fascia lata
in te rn al o b liq u e > cre m aste ric m u scle
tran sve rsalis ab d o m in u s > p o ste rio r in gu in al wall
J tran sve rsalis fascia > in te rn al sp e rm atic fascia
J p e rito n e u m > tu n ica vagin alis
J at m id lin e
re ctu s ab d o m in u s m u scle : in re ctu s sh e ath , d ivid e d b y lin e a alb a
ab o ve se m icircu lar lin e o f D o u glas m id way b e twe e n sym p h ysis
p u b is an d u m b ilicu s) :
an te rio r re ctu s sh e ath = e xte rn al o b liq u e ap o n e u ro sis
an d an te rio r le af o f in te rn al o b liq u e ap o n e u ro sis
p o ste rio r re ctu s sh e ath = p o ste rio r le af o f in te rn al
o b liq u e ap o n e u ro sis an d tran sve rsu s
b e lo w se m icircu lar lin e o f D o u glas:
an te rio r re ctu s sh e ath = ap o n e u ro sis o f e xte rn al,
in te rn al o b liq u e , tran sve rsu s
J arte rie s: su p e rio r e p igastric b ran ch o f in te rn al th o racic) , in fe rio r
e p igastric b ran ch o f e xte rn al iliac) , b o th arte rie s an asto m o se an d lie
b e h in d th e re ctu s m u scle
N o te s
ESOPHAGUS
HIATUS HERNIA
S lid in g E so p h age al H e rn ia - 90% P arae so p h age al H e rn ia - 1 0%
Figure 2. Type s of Hiatus He rnia
Drawingsby BryceHough
Sliding Hiatus He rnia (Type I)
J u p ward d isp lace m e n t o f gastro e so p h age al ju n ctio n in to ch e st
J 90% o f e so p h age al h e rn ias
J asso ciate d with agin g, we ake n in g o f m u scu lo fascial stru ctu re ,
an d in cre ase d in tra-ab d o m in al p re ssu re e .g. o b e sity, p re gn an cy)
J clin ical p re se n tatio n
h e artb u rn - afte r m e als an d at n igh t
re lie f with sittin g, stan d in g, wate r, an tacid s
re gu rgitatio n o f gastric co n te n ts o fte n acid ic) in to e so p h agu s
co m p licatio n s: e so p h agitis, ch ro n ic o ccu lt G I b lo o d lo ss
with an e m ia, u lce ratio n , d ysp h agia d u e to lo we r
e so p h age al strictu re , B arre tt's e so p h agu s, ad e n o carcin o m a,
p n e u m o n ia asp iratio n )
J d iffe re n tial d iagn o sis: ch o le lith iasis, d ive rticu litis, p e p tic u lce r,
ach alasia, M I, an gin a
J in ve stigatio n
gastro sco p y with b io p sy > d o cu m e n t typ e an d e xte n t
o f tissu e d am age , ru le o u t B arre tt's e so p h agu s an d can ce r
24 h o u r e so p h age al p H m o n ito rin g > o fte n u se d if
atyp ical p re se n tatio n , give s in fo rm atio n ab o u t fre q u e n cy
an d d u ratio n o f acid re flu x, co rre latio n o f sym p to m s with
sign s
e so p h age al m an o m e try > d e te cts d e cre ase d lo we r e so p h age al
sp h in cte r p re ssu re ; m ay d iagn o se m o tility d iso rd e r
u p p e r G I se rie s o r b ariu m swallo w
C XR glo b u lar sh ad o w with air-flu id le ve l o ve r
card iac silh o u e tte , visib le sh ad o w p o ste rio r m e d iastin u m
o n late ral vie w
J tre atm e n t
co n se rvative
sto p sm o kin g
we igh t lo ss
e le vate h e ad o f b e d
n o n o ctu rn al m e als
sm alle r an d m o re fre q u e n t m e als
avo id alco h o l, co ffe e , fat
m e d ical
an tacid s
H 2 an tago n ists e .g. cim e tid in e , ran itid in e )
p ro to n p u m p in h ib ito r e .g. o m e p razo le L o se c)
x 8-1 2 we e ks fo r e so p h agitis
ad ju van t p ro kin e tic age n ts m ay p lay a ro le
e .g. cisap rid e - in cre ase s lo we r e so p h age al p re ssu re ,
e n h an ce s gastric e m p tyin g
su rgical < 1 0%)
N isse n fu n d o p licatio n o r lap aro sco p ic N isse n
wh e re fu n d u s o f sto m ach is wrap p e d aro u n d th e L E S
E so p h agu s
P e rito n e al S ac
D iap h ragm
S to m ach
G e n e ral S u rge ry 1 0 M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s
N o te s
ESOPHAGUS . . . CONT.
90% su cce ss rate
in d icatio n s fo r su rge ry
co m p licatio n s o f slid in g h e rn ia o r
gastro e so p h age al re flu x e sp e cially
strictu re , se ve re u lce ratio n , fib ro sis)
sym p to m s re fracto ry to co n se rvative an d
m e d ical tre atm e n t
co m p le te m e ch an ical failu re o f lo we r
e so p h age al sp h in cte r L E S )
Parae s ophage al Hiatus He rnia (Type II)
J gastro e so p h age al ju n ctio n u n d isp lace d an d sto m ach fu n d u s
h e rn iate s in to ch e st o th e r b o we l lo o p s, sp le e n m ay also h e rn iate with
fu n d u s)
J 1 0% o f e so p h age al h e rn ias
asym p to m atic
h e artb u rn /re flu x u n co m m o n
p re ssu re se n satio n in lo we r ch e st, d ysp h agia
J co m p licatio n s
h e m o rrh age
in carce ratio n , o b stru ctio n , an d stran gu latio n
p alp itatio n s rare ly
J tre atm e n t
su rge ry in alm o st e ve ry case to p re ve n t se ve re
co m p licatio n s
p ro ce d u re : re d u ce h e rn ia, su tu re to p o ste rio r re ctu s
sh e ath gastro p e xy) , clo se d e fe ct in h iatu s
e xce lle n t re su lts
Mixe d Hiatus He rnia (Type III)
J a co m b in atio n o f Typ e s I an d II
STRUCTURAL LESIONS se e G astro e n te ro lo gy N o te s)
MOTILITY DISORDERS se e G astro e n te ro lo gy N o te s)
OTHER DISORDERS
J e so p h age al varice s se e L ive r S e ctio n )
Mallory We is s Te ar se e G astro e n te ro lo gy N o te s)
ESOPHAGEAL PERFORATION
J e tio lo gy: e so p h agu s at risk o f ru p tu re d u e to lack o f se ro sa
in stru m e n tal: e n d o sco p y, d ilatio n , b io p sy, in tu b atio n ,
p lace m e n t o f N G tu b e s
sp o n tan e o u s B o e rh aave 's syn d ro m e ) d u e to fre q u e n t
an d fo rce fu l vo m itin g, co m m o n in alco h o lics an d b u lim ics
trau m a
co rro sive in ju ry
carcin o m a
J clin ical p re se n tatio n : n e ck, ch e st o r u p p e r ab d o m in al p ain ,
d ysp n e a, su b cu tan e o u s e m p h yse m a, p n e u m o th o rax, fe ve r
J d iffe re n tial d iagn o sis: M I, d isse ctin g ao rtic an e u rysm , p u lm o n ary e m b o lu s
J d iagn o sis
C XR sh o ws p n e u m o th o rax, p n e u m o m e d iastin u m , p le u ral
e ffu sio n , su b d iap h ragm atic air
swallo win g stu d y with wate r so lu b le co n trast h yp aq u e )
J tre atm e n t: N P O , flu id re su scitatio n , IV an tib io tics, e arly su rgical re p air
le ss th an 24 h o u rs to p re ve n t in fe ctio n an d su b se q u e n t re p air failu re )
ESOPHAGEAL CARCINOMA
J e p id e m io lo gy
1 % o f all m align an t le sio n s
N o te s
M C C Q E 2000 R e vi e w N o te s an d L e ctu re S e ri e s G e n e ral S u rge ry 1 1
ESOPHAGUS . . . CONT.
m ale :fe m ale = 3:1
50-60 ye ars o f age
in cre ase d in cid e n ce in B lacks, e sp e cially sq u am o u s ce ll carcin o m a
J risk facto rs
p h ysical age n ts: alco h o l, to b acco , n itro sam in e s, lye , rad iatio n
stru ctu ral: d ive rticu la, h iatu s h e rn ia, ach alasia
B arre tt's e p ith e liu m 8-1 0% risk o f ad e n o carcin o m a,
m o n ito r e ve ry 1 -2 ye ars b y e n d o sco p y an d b io p sy)
ch ro n ic iro n d e ficie n cy P lu m m e r-Vin so n syn d ro m e )
J p ath o lo gy
u p p e r 20-33%, m id d le 33%, lo we r 33-50%
sq u am o u s ce ll carcin o m a: 80-85% m id -e so p h agu s)
ad e n o carcin o m a: 5-1 0% b u t in cid e n ce risin g in U .S .
- u p to 40-50% lo we r e so p h agu s) - asso ciate d
with B arre tt's e so p h agu s
fre q u e n tly asym p to m atic - late p re se n tatio n
o fte n d ysp h agia, first fo r so lid s th e n liq u id s
we igh t lo ss, we akn e ss
re gu rgitatio n an d asp iratio n asp iratio n p n e u m o n ia)
h e m ate m e sis, an e m ia
o d yn o p h agia th e n co n stan t p ain
trach e o e so p h age al, b ro n ch o e so p h age al fistu la
vo cal co rd p aralysis
sp re ad d ire ctly o r via b lo o d an d lym p h atics - trach e a
co u gh in g) , re cu rre n t laryn ge al n e rve s h o arse n e ss) ,
ao rta, live r, lu n g, b o n e , ce liac an d m e d iastin al n o d e s
J d iagn o sis an d in ve stigatio n s
b ariu m swallo w first - n arro win g site o f le sio n sh e lf o r
an n u lar le sio n )
e so p h ago sco p y - b io p sy fo r tissu e d iagn o sis an d
e xte n t o f tu m o u r
b ro n ch o sco p y - fo r u p p e r an d m id e so p h age al le sio n s d u e to h igh
in cid e n ce o f sp re ad to trach e o b ro n ch ial tre e
C T scan : fo r stagin g - ad re n al, live r, lu n g, b o n e m e tastase s
J tre atm e n t
su rge ry
lo we r th ird
th o racic e so p h age cto m y, p ylo ro p lasty o r
p ylo ro m yo to m y) an d ce liac lym p h n o d e
re se ctio n
re co n stru ctio n o f G I co n tin u ity with e ith e r
sto m ach o r co lo n
m id d le o r u p p e r th ird
e so p h age cto m y e xte n d s to ce rvical e so p h agu s
an asto m o sis p e rfo rm e d th ro u gh se p arate
n e ck in cisio n
ch e ck m argin s b y fro ze n se ctio n d u rin g su rge ry
co n train d icatio n s: in vasio n o f trach e o b ro n ch ial tre e o r gre at
ve sse ls, le sio n > 1 0 cm
rad iatio n
if u n re se ctab le , p alliatio n re lie f o f d ysp h agia in
2/3 o f p atie n ts, u su ally tran sie n t)
ch e m o th e rap y
alo n e , o r p re an d p o st-o p e rative ly
m u ltim o d al - co m b in e d ch e m o th e rap y, rad iatio n an d su rge ry
p alliative o r cu re , su rvival rate s h igh e r th an su rge ry alo n e
p alliative tre atm e n t
re se ctio n , b yp ass, d ilatio n an d ste n t p lace m e n t, lase r
ab latio n
p ro gn o sis
5-8% o p e rative d e ath rate
1 2% five -ye ar su rvival S tage I) p o st su rge ry
p ro gn o sis sligh tly b e tte r if sq u am o u s ce ll carcin o m a
N o te s
STOMACH AND DUODENUM
GASTRIC ULCERS se e G astro e n te ro lo gy N o te s)
J su rgical m an age m e n t
rare d u e to H . pylori an d m e d ical tre atm e n t
J in d icatio n s fo r su rge ry
u n re sp o n sive to m e d ical tre atm e n t m ay b e m align an t)
d ysp lasia o r carcin o m a
h e m o rrh age - 3x risk o f b le e d in g as co m p are d to d u o d e n al u lce rs
o b stru ctio n , p e rfo ratio n , p e n e tratio n
J p ro ce d u re s
h e m igastre cto m y via B illro th I o r B illro th II se e F igu re 3)
always b io p sy u lce r fo r m align an cy
always o p e rate if fails to h e al co m p le te ly, e ve n if b io p sy
n e gative - co u ld b e p rim ary gastric lym p h o m a
vago to m y an d p ylo ro p lasty o n ly in d icate d in acid
h yp e rse cre tio n rare )
DUODENAL ULCERS se e G astro e n te ro lo gy N o te s)
J m o st with in 2 cm o f p ylo ru s
p e rfo rati o n u su ally i f u lce r o n an te ri o r su rface
su d d e n o n se t o f p ai n an d co llap se
acu te ab d o m e n , ri gi d , b o ard -li ke
n o b o we l so u n d s, i le u s
i n i ti al ch e m i cal p e ri to n i ti s fo llo we d b y b acte ri al p e ri to n i ti s
d i agn o si s: C XR - fre e ai r u n d e r d i ap h ragm
70% o f p ati e n ts)
tre atm e n t: o ve rse w u lce r p li cati o n ) an d o m e n tal p atch
p o ste ri o r p e n e trati o n
i n to p an cre as e le vate d am ylase )
co n stan t m i d -e p i gastri c p ai n b u rro wi n g i n to b ack,
u n re late d to m e als
p o ste ri o r h e m o rrh age
gastro d u o d e n al arte ry i n vo lve m e n t
i n i ti al re su sci tati o n wi th crystallo i d s, b lo o d
tran sfu si o n fo r h yp o te n si o n an d h yp o vo le m i a
d i agn o sti c an d /o r th e rap e u ti c e n d o sco p y
i .e . lase r, cau te ry, i n je cti o n )
su rge ry i f b le e d i n g se ve re o r re cu rre n t
p ro ce d u re : p ylo ro p lasty, tru n cal vago to m y o r vago to m y
wi th an tre cto m y
gastri c o u tle t o b stru cti o n
d u e to e d e m a, sp asm , fi b ro si s o f p ylo ri c ch an n e l
n au se a an d vo m i ti n g u n d i ge ste d fo o d , n o n -b i li o u s) ,
d i late d sto m ach , cram p y ab d o m i n al p ai n
su ccu ssi o n sp lash
su rge ry afte r N G d e co m p re ssi o n an d co rre cti o n
o f h yp o ch lo re m i c, h yp o kale m i c m e tab o li c alkalo si s
p ro ce d u re : vago to m y wi th an tre cto m y o r
vago to m y wi th d rai n age
J su rgi cal m an age m e n t
i n d i cati o n s: p e rsi ste n t b le e d i n g > 8 u n i ts, re b le e d i n h o sp i tal,
rare b lo o d typ e s, Je h o vah s Wi tn e ss, p e rfo rati o n , gastri c o u tle t
o b stru cti o n , i n tractab le p ai n d e sp i te m e d i cal m an age m e n t
J p ro ce d u re s
tru n cal vago to m y an d d rai n age vi a p ylo ro p lasty
b e st co m b i n ati o n o f safe ty an d e ffe cti ve n e ss
5-1 0% re cu rre n ce , b u t lo w co m p li cati o n rate
tru n cal vago to m y an d an tre cto m y wi th B i llro th I o r I I an asto m o si s
lo w re cu rre n ce le ss th an 2% )
h i gh e st m o rb i d i ty d u m p i n g, d i arrh e a) an d m o rtali ty
h i gh ly se le cti ve vago to m y
h i gh re cu rre n ce rate u p to 25% )
J co m p li cati o n s fo llo wi n g su rge ry: re cu rre n t u lce r, re tai n e d an tru m , fi stu la
gastro co li c/gastro je ju n al) , d u m p i n g syn d ro m e , an e m i a, p o stvago to m y
d i arrh e a, affe re n t lo o p syn d ro m e
N o te s
STOMACH AND DUODENUM. . . CONT.
Figure 3. Billroth I and II Gas tre ctomie s
Drawingsby JackieRobers
GASTRIC CARCINOMA
L atif, A. G astric C an ce r U p d ate o n D iagn o sis, S tagin g an d T h e rap y. Postraduate
Medicine. 1 997:1 02 4) :231 -6.
J e p i d e m i o lo gy
m o st co m m o n age gro u p 50-59 ye ars
d e cre ase d b y 2/3 i n p ast 50 ye ars
J ri sk facto rs
sm o ki n g
alco h o l
sm o ke d fo o d , n i tro sam i n e s
H . pylori cau si n g ch ro n i c atro p h i c gastri ti s
p e rn i ci o u s an e m i a asso ci ate d wi th ach lo rh yd ri a an d
ch ro n i c atro p h i c gastri ti s
gastri c ad e n o m ato u s p o lyp s
p re vi o u s p arti al gastre cto m y > 1 0 ye ars p o st-gastre cto m y)
h yp e rtro p h i c gastro p ath y
h e re d i tary n o n p o lyp o si s co lo n can ce r
J p ath o lo gy
h i sto lo gy
92% ad e n o carci n o m a 8% lym p h o m a, le i o m yo sarco m a)
m o rp h o lo gy - B o rrm an classi fi cati o n
p o lyp o i d 25% )
u lce rati ve 25% )
su p e rfi ci al sp re ad i n g 1 5% )
li n i ti s p lasti ca 1 0% ) - d i ffu se ly i n fi ltrati n g
ad van ce d /d i ffu se 35% ) - tu m o u r h as o u tgro wn
ab o ve 4 cate go ri e s
su sp e ct wh e n u lce r fai ls to h e al o r i s o n gre ate r cu rvatu re
o f sto m ach an d card i a
u su ally late o n se t o f sym p to m s
i n si d i o u s o n se t o f: p o stp ran d i al ab d o m i n al fu lln e ss,
we i gh t lo ss, an o re xi a, vagu e ab d o m i n al p ai n , d ysp h agi a,
h e m ate m e si s, e p i gastri c m ass 25% ) , h e p ato m e galy, fe cal
o ccu lt b lo o d , i ro n -d e fi ci e n cy an e m i a, m e le n a
rare ly: Vi rch o w's n o d e le ft su p raclavi cu lar n o d e ) ,
B lu m e r's sh e lf p alp ab le m ass i n p o u ch o f D o u glas
i n p e lvi s) , K ru ke n b e rg tu m o u r m e ts to o vary) ,
S i ste r M ary Jo se p h n o d u le u m b i li cal n o d u le ) ,
m ali gn an t asci te s
sp re ad : li ve r, lu n g, b rai n
J d i agn o si s
E G D an d b i o p sy, u p p e r G I se ri e s wi th ai r co n trast
p o o r se n si ti vi ty i f p re vi o u s gastri c su rge ry)
C T fo r d i stan t m e tastase s
J stagi n g se e Tab le 2)
N o te s
Table 2. Staging of Gas tric Carcinoma
Stage Crite ria Prognos is
(5 ye ar s urvival)
I m u co sa an d su b m u co sa 70%
I I e xte n si o n to m u scu lari s p ro p ri a 30%
I I I e xte n si o n to re gi o n al n o d e s 1 0%
I V d i stan t m e tastase s o r i n vo lve m e n t 0%
o f co n ti n u o u s stru ctu re s
o ve rall 1 0%
TNM CLASSIFICATION
Primary Tumour (T)
J T 1 lim ite d to m u co sa an d su b m u co sa
J T 2 e xte n d s in to , b u t n o t th ro u gh , se ro sa
J T 3 th ro u gh se ro sa, d o e s n o t in vad e o th e r stru ctu re s
J T 4 th ro u gh se ro sa an d in vad e s co n tigu o u s stru ctu re s
Nodal Involve me nt (N)
J N 0 n o lym p h n o d e s in vo lve d
J N 1 in vo lve m e n t o f n o d e s with in 3 cm o f th e p rim ary tu m o u r
J N 2 in vo lve m e n t o f n o d e s m o re th an 3 cm fro m p rim ary tu m o u r
wh ich are re m o vab le at o p e ratio n , in clu d in g th o se alo n g le ft
gastric, sp le n ic, ce liac an d co m m o n h e p atic arte rie s
J N 3 in vo lve m e n t o f in tra-ab d o m in al lym p h n o d e s n o t re m o vab le at
o p e ratio n in clu d in g p ara-ao rtic, h e p ato d u o d e n al, re tro p an cre atic,
an d m e se n te ric
Dis tant Me tas tas is (M)
J M 0 n o kn o wn d istan t m e tastasis
J M 1 d istan t m e tastasis p re se n t
Table 3. Ame rican Joint Committe e on Cance rs
Stage Grouping of Gas tric Cance r
Stage TNM Clas s ification
0 T 1 S N 0 M 0
IA T 1 N 0 M 0
IB T 1 N 1 M 0
T 2 N 0 M 0
II T 1 N 2 M 0
T 2 N 1 M 0
T 3 N 0 M 0
IIIA T 2 N 2 M 0
T 3 N 1 M 0
T 4 N 0 M 0
IIIB T 3 N 2 M 0
T 4 N 1 M 0
IV T 4 N 2 M 0
An y T An y N M 1
J tre atm e n t: su rge ry fo r ad e n o carci n o m a
p ro xi m al le si o n s
to tal gastre cto m y an d e so p h ago je ju n o sto m y R o u x-e n -Y)
i n clu d e lym p h n o d e d rai n age to cle ar ce li ac axi s
m ay re q u i re sp le n e cto m y)
d i stal le si o n s
d i stal rad i cal gastre cto m y wi d e m argi n s, e n b lo c
re m o val o f o m e n tu m an d lym p h n o d e d rai n age )
p alli ati o n
gastri c re se cti o n to d e cre ase b le e d i n g an d to
re li e ve o b stru cti o n th u s e n ab li n g th e p ati e n t to e at
o ve rall 5 ye ar su rvi val - 1 0%
lym p h o m a
ch e m o th e rap y su rge ry rad i ati o n
N o te s
COMPLICATIONS OF GASTRIC SURGERY
J ge n e ral
an e sth e tic re actio n
p o st-o p co m p licatio n s
J sp e cific
alkalin e re flu x gastritis
d u o d e n al co n te n ts re flu x in to sto m ach
co m m o n p o stgastre cto m y 25%)
p o stp ran d ial e p igastric p ain , n au se a, vo m itin g,
we igh t lo ss, an e m ia
d iagn o sis: e n d o sco p y an d b io p sy gastritis, b ile re flu x)
tre atm e n t: co n ve rsio n o f B illro th I o r II to R o u x-e n -Y
an asto m o sis
affe re n t lo o p syn d ro m e - o ccu rs with B illro th II
e arly p o stp ran d ial d iste n tio n , p ain , n au se a, b ilio u s vo m itin g
cau se d b y in te rm itte n t m e ch an ical o b stru ctio n
an d d iste n sio n o f affe re n t lim b
tre ate d b y in cre asin g d rain age o f affe re n t lo o p
b y co n ve rsio n to R o u x-e n -Y
d u m p in g syn d ro m e
se e n in p o stgastre cto m y p atie n ts
e arly - cau se d b y h yp e rto n ic ch ym e re le ase in to sm all b o we l
re su ltin g in flu id accu m u latio n an d je ju n al d iste n tio n
late - d u e to large glu co se lo ad le ad in g to large
in su lin re le ase an d h yp o glyce m ia
p o st-p ran d ial sym p to m s: e p igastric fu lln e ss o r p ain ,
n au se a, p alp itatio n s, d izzin e ss, d iarrh e a, tach ycard ia
tre atm e n t: lo w carb o h yd rate , h igh fat an d p ro te in d ie t, d e lay
gastric e m p tyin g b y in te rp o sitio n o f an tip e ristaltic je ju n al
lo o p b e twe e n sto m ach an d sm all b o we l
tre atm e n t: sm all sn ack 2 h o u rs afte r m e als
p o stvago to m y d iarrh e a u p to 25%)
u su ally im p ro ve s
BOWEL OBSTRUCTION
SMALL BOWEL OBSTRUCTION
J e ti o lo gy
ad h e si o n s 60% ) i n p ati e n t wi th p ri o r
ab d o m i n al o p e rati o n s
h e rn i as 1 5% )
n e o p lasm s 1 5% )
J also asso ci ate d wi th
cysti c fi b ro si s
S M A syn d ro m e
an n u lar p an cre as
vo lvu lu s
i n flam m ato ry le si o n s: C ro h n s, rad i ati o n e n te ri ti s/stri ctu re
i n tralu m i n al o b stru cti o n : gallsto n e i le u s, i n tu ssu sce p ti o n
fo re i gn b o d y b e zo ars, b ari u m , wo rm s)
n o n -stran gu lati n g o b stru cti o n - p ro xi m al, m i d d le , o r d i stal
p ro xi m al o b stru cti o n
p ro fu se e arly vo m i ti n g o fte n b i li o u s) - d e h yd rati o n
co li cky ab d o m i n al p ai n
m i n i m al ab d o m i n al d i ste n si o n
m i d d le le ve l o b stru cti o n
m o d e rate vo m i ti n g afte r o n se t o f p ai n
ab d o m i n al d i ste n si o n
i n te rm i tte n t co li cky p ai n
o b sti p ati o n
d i stal o b stru cti o n
late fe cu le n t vo m i ti n g
m arke d ab d o m i n al d i ste n si o n an d p e ri stalti c ru sh e s
o b sti p ati o n , vari ab le p ai n
N o te s
BOWEL OBSTRUCTION. . . CONT.
stran gu lati n g - s urgical e me rge ncy
i m p ai re d b lo o d su p p ly, le ad s to n e cro si s
e arly sh o ck
fe ve r +i n cre ase d WB C co u n t
cram p i n g p ai n tu rn s to co n ti n u o u s ach e
vo m i ti n g gro ss o r o ccu lt b lo o d
ab d o m i n al te n d e rn e ss o r ri gi d i ty
J rad io lo gical (s e e Colour Atlas C1)
C XR , ab d o m in al x-ray 3 vie ws)
d ilate d e d e m ato u s lo o p s o f sm all b o we l lad d e r
p atte rn - p lica circu larae )
air-flu id le ve ls
co lo n o fte n d e vo id o f gas u n le ss o n ly p artial o b stru ctio n
J lab o rato ry
n o rm al e arly
h e m o co n ce n tratio n
le u ko cyto sis m arke d in stran gu latio n )
in cre ase d am ylase
m e tab o lic alkalo sis > p ro xim al S B O
m e tab o lic acid o sis > b o we l in farctio n
J tre atm e n t
1 ) N G tu b e to re lie ve vo m itin g an d ab d o m in al d iste n tio n
2) stab ilize vitals, flu id an d e le ctro lyte re su scitatio n
3) if p artial S B O i.e . if p assage o f sto o l, flatu s) > co n se rvative
m an age m e n t
4) if co m p le te S B O o b stip atio n ) > su rge ry can n o t ru le o u t
stran gu latio n )
5) trial o f m e d ical m an age m e n t m ay b e in d icate d in C ro h n 's,
re cu rre n t sm all b o we l o b stru ctio n , carcin o m ato sis
J p ro gn o sis
m o rtality: n o n -stran gu latin g 2%, stran gu latin g 8% 25% if > 36 h o u rs)
o p e n p e rfo ratio n
se p tice m ia
h yp o vo le m ia
Table 4. Small Bowe l Obs truction vs . Paralytic Ile us
Small bowe l obs truction Paralyt ic ile us
n au se a an d vo m i ti n g + +
ab d o m i n al d i ste n ti o n + +
o b sti p ati o n + +
ab d o m i n al p ai n cram p y m i n i m al o r ab se n t
b o we l so u n d s n o rm al, i n cre ase d ab se n t, d e cre ase d
AXR lad d e r p atte rn , ai r flu i d le ve ls, gas p re se n t th ro u gh o u t
n o gas i n co lo n sm all an d large co lo n
LARGE BOWEL OBSTRUCTION
J e tio lo gy
co lo n carcin o m a 60%
d ive rticu litis 20%
vo lvu lu s 5%
J o th e r cau se s o f large b o we l o b stru ctio n
IB D
b e n ign tu m o u rs
fe cal im p actio n /fo re ign b o d y
ad h e sio n s
h e rn ia e sp e cially slid in g typ e )
in tu ssu sce p tio n ch ild re n )
e n d o m e trio sis
N o te s
BOWEL OBSTRUCTION. . . CONT.
slo we r in o n se t, le ss p ain , late r o n se t o f vo m itin g, le ss flu id /
e le ctro lyte d istu rb an ce th an sm all b o we l o b stru ctio n
cram p y ab d o m in al p ain in h yp o gastriu m
co n tin u o u s, se ve re ab d o m in al p ain in isch e m ia, p e rito n itis
d iste n sio n , co n stip atio n , o b stip atio n , an o re xia
n au se a an d late fe cu le n t vo m itin g
h igh -p itch e d b o rb o rygm i) o r ab se n t b o we l so u n d s
m ay h ave visib le p e ristaltic wave s
o p e n lo o p safe ) :1 0-20%
in co m p e tan t ile o ce cal valve allo ws re lie f o f
co lo n ic p re ssu re as co n te n ts re flu x in to ile u m
clo se d lo o p d an ge ro u s) : 80-90%
ile o ce cal valve co m p e te n t, allo win g b u ild u p o f
co lo n ic p re ssu re s to d an ge ro u s le ve l
co m p ro m ise o f lym p h atic, ve n o u s an d arte rial
circu latio n > in farctio n
ce cu m at gre ate st risk o f p e rfo ratio n d u e to L ap lace s
L aw P re ssu re = wall te n sio n /rad iu s)
h igh risk o f p e rfo ratio n if ce cu m d iam e te r
> 1 2 cm o n AXR
su sp e ct im p e n d in g p e rfo ratio n in th e p re se n ce
o f te n d e rn e ss o ve r th e ce cu m
if o b stru ctio n at ile o ce cal valve > sym p to m s o f S B O
J d iagn o sis
x-ray: " p ictu re fram e " ap p e aran ce
h yp aq u e e n e m a
d o n o t u se co n trast - m ay b e co m e in sp issate d an d co n ve rt
p artial to co m p le te L B O
J tre atm e n t
go al: d e co m p re ssio n to p re ve n t p e rfo ratio n
co rre ct flu id an d e le ctro lyte im b alan ce
su rgical co rre ctio n o f o b stru ctio n u su ally re q u ire s
te m p o rary co lo sto m y)
vo lvu lu s: sigm o id o sco p ic d e co m p re ssio n o r b ariu m
e n e m a fo llo we d b y o p e rative re d u ctio n if u n su cce ssfu l
J p ro gn o sis
d e p e n d e n t u p o n age , ge n e ral m e d ical co n d itio n ,
vascu lar im p airm e n t o f b o we l, p e rfo ratio n , p ro m p tn e ss o f
su rgical m an age m e n t
J m o rtality
o ve rall: 20%
ce cal p e rfo ratio n : 40%
J O gilvie 's syn d ro m e : p se u d o -o b stru ctio n , d iste n tio n o f co lo n
with o u t m e ch an ical o b stru ctio n
asso ciatio n s: lo n g te rm d e b ilitatio n , ch ro n ic d ise ase ,
im m o b ility, n arco tic u se , p o lyp h arm acy, re ce n t
o rth o p e d ic su rge ry, p o st-p artu m
d iagn o sis: ce cal d ilatatio n o n AXR , if d iam e te r > 1 2 cm ,
large ly in cre ase d risk o f p e rfo ratio n
tre atm e n t: d e co m p re ssio n with e n e m a, if u n su cce ssfu l,
d e co m p re ssio n with co lo n o sco p e , n aso gastric tu b e ,
re ctal tu b e ; if p e rfo ratio n o r isch e m ia, su rge ry
N o te s
SMALL INTESTINE
TUMOURS OF SMALL INTESTINE
J ve ry rare 1 -5% o f G I tu m o u rs)
J u su ally p re se n t with b le e d in g an d o b stru ctio n o fte n b e cau se o f in tu ssu sce p tio n
Be nign
J u su ally asym p to m atic
J 1 0 tim e s m o re co m m o n th an m align an t
J m o st co m m o n site s: te rm in al ile u m , p ro xim al je ju n u m
J typ e s
p o lyp s
ad e n o m ato u s, villo u s - rare
fam ilial ad e n o m ato u s p o lyp o sis
m u ltip le in te stin al p o lyp s in asso ciatio n with
d e sm o id tu m o u rs, m an d ib le o r sku ll o ste o m as,
se b ace o u s cysts
m align an t d e ge n e ratio n o f p o lyp s co m m o n
h am arto m ato u s - o ve rgro wth an d ab n o rm al arran ge m e n t
o f n o rm al ce lls
asso ciate d with P e u tz-Je gh e r's syn d ro m e
m u ltip le p o lyp o id h am arto m as an d
m u co cu tan e o u s p igm e n tatio n p e rio ral,
also o n p alm s o f h an d s an d so le s o f fe e t)
rare ly m align an t
au to so m al d o m in an t in h e ritan ce
tre atm e n t: su rgical
ju ve n ile p o lyp s
o th e r e .g. le io m yo m as, lip o m as, ad e n o m as, h e m an gio m as, e tc...)
Malignant
J typ e s
ad e n o carcin o m a 40%
carcin o id 50%
lym p h o m a 20%
o th e r e .g. sarco m a, m e tastase s)
J ad e n o carcin o m a m o st co m m o n p rim ary tu m o u r o f sm all in te stin e )
40-50% in d u o d e n u m , in cid e n ce d e cre ase s d istally
h igh e r risk in C ro h n 's d ise ase
80% m e tastatic at tim e o f o p e ratio n
5 ye ar su rvival 25%
o fte n asym p to m atic, can cau se S B O
d iagn o sis - sm all b o we l fo llo w th ro u gh o r e n te ro clysis
J carcin o id
e n te ro ch ro m affin ce ll o rigin AP U D o m a: am in e p re cu rso r
u p take an d d e carb o xylatio n ) , m ay b e asso ciate d with
M E N I an d II
o fte n slo w-gro win g
site s p ro gn o sis re late d to size )
ap p e n d ix - 46%
d istal ile u m - 28%
re ctu m - 1 7%
lu n g, b re ast
clin ical p re se n tatio n
cram p y ab d o m in al p ain , b le e d in g, o b stru ctio n
carcin o id syn d ro m e < 1 0%) : re q u ire s live r
in vo lve m e n t, +/ m e ts to b ro n ch i, o varie s,
te ste s; se cre te s se ro to n in , kin in s an d vaso active
p e p tid e s d ire ctly to syste m ic circu latio n
n o rm ally in activate d b y th e live r
re su lts in h o t flu sh e s, d iarrh e a, b ro n ch o co n strictio n
wh e e zin g) , h yp o te n sio n vascu lar co llap se ) , an d
tricu sp id an d /o r p u lm o n ic valve in su fficie n cy
co llage n d e p o sitio n )
d iagn o sis: m o st fo u n d at su rge ry fo r o b stru ctio n o r
ap p e n d e cto m y, e le vate d 5-H IAA b re akd o wn p ro d u ct
o f se ro to n in ) in u rin e , o r in cre ase d 5-H T in b lo o d
tre atm e n t: re se ct tu m o u r an d m e ts, +/ ch e m o th e rap y, tre at
carcin o id syn d ro m e ste ro id s, h istam in e , o ctre o tid e )
m e tastatic risk - 2% if size < 1 cm , 90% if > 2 cm
5 ye ar su rvival 70% u n le ss live r m e ts 20%)
N o te s
SMALL INTESTINE. . . CONT.
J lym p h o m a
p ro xim al je ju n u m in p atie n ts with ce liac d ise ase
u su ally d istal ile u m
clin ically: p e rfo ratio n fo llo we d b y o b stru ctio n o r b le e d in g
p re se n ts as fe ve r, m alab so rp tio n , ab d o m in al p ain
tre atm e n t
lo w grad e : ch e m o th e rap y with cyclo p h o sp h am id e
h igh grad e : su rgical re se ctio n , rad iatio n
p alliative : so m ato statin , d o xo ru b icin
p ro gn o sis: 65-80% o ve rall; 95% if lo calize d
su rvival: 40% at 5 ye ars
MECKEL'S DIVERTICULUM
J p e rsiste n t vite llin e d u ct re m n an t o n an tim e se n te ric b o rd e r o f ile u m ;
can co n tain sm all in te stin al, gastric, co lo n ic, p an cre atic m u co sa
J m o st co m m o n d ive rticu lu m o f G I tract
J ru le o f 2's: 2% o f th e p o p u latio n ; sym p to m atic in 2% o f case s;
fo u n d with in 2 fe e t 1 0-90 cm ) o f th e ile o ce cal valve
J clin ical p re se n tatio n : b le e d in g, o b stru ctio n , in flam m atio n
m im ic ap p e n d icitis) , in tu ssu sce p tio n , p e rfo ratio n
p ain le ss b le e d in g d u e to p e p tic u lce ratio n o f h e te ro tro p ic
gastric m u co sa 50% o f p atie n ts < 2 ye ars o ld )
te ch n e tiu m Tc99 can lo calize b le e d in g e cto p ic gastric m u co sa
J tre atm e n t: flu id an d e le ctro lyte re sto ratio n , su rgical re se ctio n if sym p to m atic
APPENDIX
APPENDICITIS
6% o f p o p u lati o n
80% b e twe e n 5-35 ye ars o f age
atyp i cal p re se n tati o n i n ve ry yo u n g an d ve ry o ld
J p ath o ge n e si s
lu m i n al o b stru cti o n o f ap p e n d i x
ch i ld re n to yo u n g ad u lt: h yp e rp lasi a o f su b m u co sal
lym p h o i d fo lli cle s
ad u lt: fe co li th
m o re rare ly: tu m o u r, stri ctu re , fo re i gn b o d y
o b stru cti o n > b acte ri al o ve rgro wth > i n flam m ati o n /swe lli n g
> i sch e m i a> gan gre n e /p e rfo rati o n
o n ly re li ab le fe atu re i s p ro gre ssi o n o f si gn s an d sym p to m s
lo w grad e fe ve r
vagu e m i d ab d o m i n al d i sco m fo rt o r cram p y p ai n
an o re xi a, n au se a an d vo m i ti n g afte r p ai n starts
m i grati o n o f p ai n to R L Q lo cali ze d )
te n d e rn e ss at M cB u rn e y's p o i n t, R L Q o n re ctal e xam
p o si ti ve R o vsi n g's si gn , re b o u n d te n d e rn e ss, p so as si gn , o b tu rato r si gn
J d iagn o sis
m ild le u ko cyto sis with le ft sh ift u n le ss p e rfo ratio n
x-rays: u su ally n o n sp e cific; fre e air if p e rfo rate d , lo o k fo r calcu lu s
co n si d e r C T scan
co n sid e r p e lvic U /S o r lap aro sco p y in fe m ale
J tre atm e n t
su rgical p o ssib le lap aro sco p y)
th e d e cisio n to o p e rate is acce p tab le e ve n if o n ly 70-80%
are fo u n d to h ave tru e ap p e n d icitis
n e e d to b e aggre ssive , e sp e cially in yo u n g fe m ale s sin ce
p e rfo ratio n m ay cau se in fe rtility d u e to tu b al d am age
m o rb id ity/m o rtality 0.6% u n co m p licate d ) , 5% if p e rfo rate d
p e rfo ratio n
25-30%
m o re co m m o n at e xtre m e s o f age
in cre ase in fe ve r an d p ain
N o te s
APPENDIX. . . CONT.
p e rito n itis: lo cal if walle d -o ff b y o m e n tu m ) o r ge n e ralize d
ap p e n d ice al ab sce ss p h le gm o n )
p re se n ts as ap p e n d icitis p lu s R L Q m ass
d iagn o sis b y U /S o r C T
in te rval ap p e n d e cto m y 6 we e ks) as n e e d e d afte r o p tim al
p re p aratio n asp iratio n , an tib io tics)
TUMOURS OF THE APPENDIX (rare )
J b e n ign
m o st co m m o n typ e
u su ally an in cid e n tal fin d in g
J m align an t
carcin o id tu m o u rs
ap p e n d ix is th e m o st co m m o n lo catio n
m ay p ro d u ce carcin o id syn d ro m e with live r
m e tastase s
tre atm e n t: ap p e n d e cto m y if < 2 cm an d n o t
e xte n d in g in to se ro sa; righ t h e m ico le cto m y if
> 2 cm o r o b vio u s n o d al in vo lve m e n t o r b ase o f
ap p e n d ix in vo lve d
ad e n o carcin o m a
50% p re se n t as acu te ap p e n d icitis
sp re ad s rap id ly to lym p h n o d e s, o varie s,
an d p e rito n e al su rface s
tre atm e n t: righ t h e m ico le cto m y
m align an t m u cin o u s cystad e n o carcin o m a
u su ally p re se n t as ab d o m in al d iste n sio n an d p ain
tre atm e n t: ap p e n d e cto m y
p ro gn o sis: lo cal re cu rre n ce is in e vitab le , m o rtality
50% at 5 ye ars
INFLAMMATORY BOWEL DISEASE
CROHN'S DISEASE se e G astro e n te ro lo gy N o te s)
(s e e Colour Atlas C4)
Surgical Manage me nt
J in te rve n tio n re q u ire d in 70-75% o f p atie n ts wh e n co m p licatio n s arise
J go al o f su rge ry is to co n se rve b o we l - re se ct as little as p o ssib le
J in d icatio n s
S B O d u e to strictu re an d in flam m atio n ~ in d icatio n in 50% o f su rgical case s
fistu la: e n te ro co lic, ve sicu lar, vagin al, cu tan e o u s ab sce ss
le ss co m m o n in d icatio n s > p e rfo ratio n , h e m o rrh age ,
in tractab le d ise ase to xic m e gaco lo n ) , failu re to th rive
e sp e cially ch ild re n ) , p e rian al d ise ase
J p ro ce d u re s
p alliative , n o t cu rative
ile o ce cal re se ctio n with in cid e n tal ap p e n d e cto m y u n le ss
b ase o f ap p e n d ix in vo lve d )
strictu re p lasty - wid e n s lu m e n in ch ro n ically scarre d b o we l
e xclu sio n b yp ass - b yp ass u n re se ctab le in flam m ato ry
m ass, b u t late r risk o f can ce r in e xclu d e d se gm e n t
sh o rt gu t syn d ro m e d iarrh e a, ste ato rrh e a, m aln u tritio n )
fistu las
b iliary sto n e s d u e to d e cre ase d b ile salt ab so rp tio n
le ad in g to in cre ase d ch o le ste ro l p re cip itatio n )
kid n e y sto n e s d u e to lo ss o f C a++in d iarrh e a le ad in g to
in cre ase d o xalate ab so rp tio n an d h yp e ro xalu ria > sto n e s)
J p ro gn o sis
re cu rre n ce rate at 1 0 ye ars: ile o co lic 50%) , sm all b o we l
50%) , co lo n ic 40-50%)
80-85% o f p atie n ts wh o n e e d su rge ry le ad n o rm al live s
m o rtality 1 5% at 30 ye ars
re -o p e ratio n at 5 ye ars: p rim ary re se ctio n 20%, b yp ass 50%
N o te s
INFLAMMATORY BOWEL DISEASE. . . CONT.
ULCERATIVE COLITIS se e G astro e n te ro lo gy N o te s)
Surgical Manage me nt
J in d icatio n s
e m e rge n cy
h e m o rrh age
o b stru ctio n
p e rfo ratio n
to xic m e gaco lo n - le ad in g cau se o f d e ath in U C , 40% o f case s fatal
e le ctive
p o o r co n tro l, u n ab le to tap e r ste rio d s
can ce r risk
failu re to th rive in ch ild re n
J p ro ce d u re s
if e m e rge n cy: to tal co le cto m y an d ile o sto m y, re ctal
p re se rvatio n
p ro cto co le cto m y an d ile o an al an asto m o sis o p e ratio n o f
ch o ice )
p ro cto co le cto m y with p e rm an e n t ile o sto m y fo r p atie n ts
n o t can d id ate s fo r ile o an al p ro ce d u re
J p ro gn o sis
m o rtality: 5% o ve r 1 0 ye ars
2% m o rtality with e le ctive su rge ry
8-1 5% m o rtality with e m e rge n cy su rge ry
J to tal p ro cto co le cto m y will co m p le te ly e lim in ate risk o f can ce r
LARGE INTESTINE
DIVERTICULAR DISEASE (s e e Colour Atlas C3)
J te rm i n o lo gy
d i ve rti cu lu m - ab n o rm al sac o r p o u ch p ro tru d i n g fro m th e
wall o f a h o llo w o rgan
d i ve rti cu lo si s - p re se n ce o f d i ve rti cu la
35-50% o f ge n e ral p o p u lati o n M = F )
95% i n vo lve si gm o i d co lo n
m ajo ri ty are asym p to m ati c ap p ro xi m ate ly 80% )
h i gh e r i n ci d e n ce i n We ste rn co u n tri e s, re late d to lo w fi b re co n te n t i n d i e t
re late d to h i gh i n tralu m i n al p re ssu re an d d e fe cts i n th e
co lo n i c wall
fi b re -d e fi ci e n t d i e t - i n cre ase s gu t tran si t ti m e , cau se s
h yp e rtro p h y o f m u scle wall wh i ch o cclu d e s G I lu m e n an d
cau se s i n cre ase d p re ssu re
m u scle wall we akn e ss fro m agi n g an d i lln e ss
d i ve rti cu la o ccu r at gre ate st are a o f we akn e ss, m o st
co m m o n ly at th e si te o f p e n e trati n g ve sse ls, th e re fo re i n cre ase d
ri sk o f h e m o rrh age
le ft si d e d false ) d i ve rti cu la - co n tai n o n ly m u co sal an d
su b m u co sal laye rs acq u i re d )
ri gh t si d e d tru e ) d i ve rti cu la = co n tai n s all laye rs co n ge n i tal)
asym p to m ati c 80% ) , re cu rre n t ab d o m i n al p ai n u su ally L L Q ) ,
co n sti p ati o n , d i arrh e a, o r alte rn ati n g b o we l h ab i ts
b le e d i n g - 2/3 o f all m assi ve lo we r gastro i n te sti n al b le e d s
d i ve rti cu li ti s
J tre atm e n t
m e d i cal: h i gh fi b re d i e t, e d u cati o n , re assu ran ce
su rgi cal: tre at m assi ve h e m o rrh age o r ru le o u t carci n o m a
N o te s
LARGE INTESTINE. . . CONT.
Figure 4. Cros s -Se ction of Dive rticulum
Drawingby Myra Rudakewich
Dive rticulitis
J i n flam m ati o n se co n d ary to p e rfo rati o n o r i n fe cti o n o f d i ve rti cu la
J o fte n i n vo lve s si gm o i d co lo n
le ft lo we r q u ad ran t L L Q ) p ai n an d te n d e rn e ss, p alp ab le
m ass i f p h le gm o n o r ab sce ss
co n sti p ati o n o r fre q u e n t d e fe cati o n co m m o n
o ccu lt o r gro ss b lo o d i n sto o l le ss co m m o n
lo w-grad e fe ve r, le u ko cyto si s
li ke a le ft-si d e d ap p e n d i ci ti s
d ysu ri a i f i n flam m ati o n ad jace n t to b lad d e r
p n e u m atu ri a, fe calu ri a i f co lo ve si cal fi stu la
J i n ve sti gati o n s
p lai n fi lm x-ray
lo cali ze d d i ve rti cu li ti s: i le u s, th i cke n e d wall, sm all
b o we l o b stru cti o n , p arti al co lo n i c o b stru cti o n
fre e ai r m ay b e se e n i n 30% wi th p e rfo rati o n an d
ge n e rali ze d p e ri to n i ti s
b ari u m e n e m a - co n trai n d i cate d d u ri n g an acu te attack
ri sk ch e m i cal p e ri to n i ti s
m ay i n te rfe re wi th su b se q u e n t i n ve sti gati o n s
co lo n sco p y) an d tre atm e n t an asto m o si s)
can u se h yp aq u e - wate r so lu b le
saw-to o th p atte rn co lo n i c sp asm )
tri ckle o f co n trast o u t o f co lo n
ab sce ss cavi ti e s o r si n u s tracts
si gm o i d o sco p y/co lo n o sco p y
n o t d u ri n g an acu te attack
m u co sal e d e m a, e ryth e m a > can n o t ad van ce sco p e
b i o p sy
C T scan
J tre atm e n t
co n se rvati ve an d m e d i cal 50% re so lve )
lo cali ze d o m e n tu m h as walle d -o ff are a)
N P O , I V, N G tu b e , an d an ti b i o ti cs cli n d am yci n , m e tro n i d azo le )
an alge si a
o b se rve e ve ry 2-4 h o u rs
su rgi cal i n d i cati o n s fo r d i ve rti cu li ti s
co m p li cati o n s - se p si s se co n d ary to p e rfo rati o n , ab sce ss) ,
h e m o rrh age , fi stu la ve si cal, vagi n al, cu tan e o u s) ,
o b stru cti o n e xtra-lu m i n al ab sce ss, ch ro n i c fi b ro si s)
re cu rre n t i n flam m ati o n , p e rsi ste n t p ai n o r m ass,
ri gh t si d e d d i ve rti cu li ti s, age < 40, cli n i cal d e te ri o rati o n
wi th i n 48 h o u rs, ru le o u t can ce r
su rgi cal p ro ce d u re s
re se cti o n wi th co lo sto m y an d clo su re o f d i stal re ctal
stu m p H artm an n p ro ce d u re ) , re -an asto m o si s 3 m o n th s late r
si gm o i d e cto m y an d p ri m ary co lo re ctal an asto m o si s
i s an alte rn ati ve p ro ce d u re
N o te s
Figure 5. Hartmann Proce dure
Drawings by Myra Rudakewich
ANGIODYSPLASIA
J in tram u ral m u scu lar h yp e rtro p h y > su b m u co sal ve n o u s o b stru ctio n
> fo cal su b m u co sal ve n o u s d ilatatio n an d to rtu o sity
J m o st fre q u e n tly in righ t co lo n o f p atie n ts > 60 ye ars o ld
J b le e d in g typ ically in te rm itte n t m e le n a, an e m ia, gu aiac p o sitive sto o ls)
J d iagn o sis: co lo n o sco p y ch e rry re d sp o ts o n m u co sa) , an gio grap h y
slo w fillin g/e arly e m p tyin g m e se n te ric ve in , vascu lar tu ft) , re d ce ll
te ch n e tiu m scan
J b ariu m e n e m a is co n train d icate d o b scu re s o th e r x-rays, i.e . an gio gram )
J tre atm e n t if sym p to m atic
e le ctro cau te ry th ro u gh co lo n o sco p e o r righ t h e m ico le cto m y with
ile o sto m y if b le e d in g p e rsists o r re cu rs)
e n d o sco p ic e m b o lizatio n
te m p o rary, risk o f co lo n ic n e cro sis o r p e rfo ratio n )
VOLVULUS
J ro tatio n o f se gm e n t o f b o we l ab o u t its m e se n te ry
J 50% o f p atie n ts > 70 ye ars o ld an d o fte n b e d rid d e n
J sym p to m s d u e to b o we l o b stru ctio n o r b o we l isch e m ia
sigm o id 65%)
in te rm itte n t cram p y p ain s, o b stip atio n an d d iste n sio n
ce cal 30%) - co n ge n ital an o m o ly - ce cu m o n m e se n te ry rath e r
th an re tro p e rito n e al
like d istal S B O p re se n tatio n : co licky p ain , vo m itin g, o b stip atio n +/ d iste n sio n
p lain x-ray
" co ffe e -b e an " sh ap e o f d ilate d b o we l lo o p
co n cavity o f b e an " p o in ts righ t fo r ce cal vo lvu lu s, le ft fo r sigm o id
b ariu m e n e m a
" ace o f sp ad e s" ap p e aran ce d u e to co n trast-fille d
lu m e n tap e rin g o f u p p e r e n d o f lo we r se gm e n t
J tre atm e n t
ce cu m
co rre ct flu id an d e le ctro lyte im b alan ce
always o p e rate - ce co p e xy su tu re b o we l to p arie tal p e rito n e u m )
o r righ t co le cto m y with ile o tran sve rse co lo n ic an asto m o sis
sigm o id
o p e rate H artm an n p ro ce d u re ) if an y e vid e n ce
stran gu latio n o r p e rfo ratio n
o th e rwise - n o n su rgical d e co m p re ssio n d e to rt
b y fle xib le sigm o id o sco p e o r b ariu m e n e m a an d
in se rt re ctal tu b e p ast o b stru ctio n )
e le ctive su rge ry re co m m e n d e d re cu rre n ce = 50-70%)
COLORECTAL POLYPS
m o st asym p to m atic
re ctal b le e d in g, ch an ge in b o we l h ab its
J p re vale n ce : 30% at age 50, 40% at age 60, 50% at age 70
J p ath o lo gy
b e n ign lym p h o id p o lyp s
h am arto m atas
ju ve n ile p o lyp s
P e u tz-Je gh e r's p o lyp o sis
N o te s
h yp e rp lastic
asym p to m atic
in cid e n tal fin d in g o n e n d o sco p y
b e n ign
n e o p lastic
all p re m align an t
o fte n carcin o m a-in -situ
so m e h ave fran k in vasio n in to m u scu laris
ad e n o m as
Table 5. Clas s ification of Ade nomatous Polyps
Tubular Tubulovillous Villous
% o f ad e n o m as 65% 25% 1 0%
m o rp h o lo gy p e d u n cu late d p e d u n cu late d se ssile
% carcin o m a-in -situ o r in vasive can ce r 1 5% 1 9% 25%
J in cre ase d risk o f m align an cy
all n e o p lastic p o lyp s
size > 1 cm
villo u s 35%) vs. tu b u lar 5%)
m align an t p o lyp syn d ro m e s: fam ilial p o lyp o sis
J d iagn o sis
60% with in re ach o f fle xib le sigm o id o sco p e , o r
co lo n o sco p y an d b io p sy
J tre atm e n t
in d icatio n s: sym p to m s, m align an cy, o r risk o f m align an cy
e n d o sco p ic re m o val o f e n tire gro wth
su rgical re se ctio n fo r th o se in vad in g in to m u scu laris an d
th o se to o large to re m o ve e n d o sco p ically
fo llo w-u p e n d o sco p y 1 ye ar late r, th e n e ve ry 3-5 ye ars
FAP - su b to tal co le cto m y an d ile o re ctal an asto m o sis o r
p ro cto co le cto m y +/ ile al p o u ch o r ile o sto m y if m an y
re ctal p o lyp s
H N P C C - su b to tal co le cto m y an d ile o re ctal an asto m o sis
COLORECTAL CARCINOMA
Yo u n e s Z ., Jo h n so n D A. M o le cu lar an d G e n e tic Ad van ce s in G astro in te stin al
C an ce r: S tate o f th e Art. DigestiveDiseases. 1 997:1 5 4-5) :275-301
th i rd m o st co m m o n carci n o m a afte r ski n an d lu n g)
m e an age = 70 ye ars
4% o f co lo re ctal carci n o m a h ave syn ch ro n o u s le si o n s,
th e re fo re , i n ve sti gate th e wh o le co lo n
J ri sk facto rs
fam i li al p o lyp o si s co li
ad e n o m ato u s p o lyp s
p re vi o u s co lo re ctal can ce r
I B D
fam i ly h i sto ry o f co lo n can ce r
age > 50
d i e t i n cre ase d fat, d e cre ase d fi b e r
p ri m ary: ?, d i e t lo w fi b re , h i gh fat) , ge n e ti c
se co n d ary: I B D ri sk o f can ce r 1 -2% /ye ar i f U C > 1 0 ye ars, le ss ri sk i f C ro h n 's)
J cli n i cal p re se n tati o n : se e Tab le 6
N o te s
Table 6. Clinical Pre s e ntation of Colore ctal Carcinoma
Right Colon Le ft Colon Re ctum
Fre que ncy 25% o f case s 35% o f case s 30% o f case s
Pat hology large p o lyp o i d le si o n s th at an n u lar le si o n ap p le co re ) u lce rati n g le si o n
te n d to b le e d o ccu ltly > o b stru cti o n
Sympt oms we i gh t lo ss, we akn e ss, co n sti p ati o n +/ o ve rflo w, o b stru cti o n , te n e sm u s
R si d e d ab d o m i n al p ai n , ab d o m i n al p ai n ,
o b stru cti o n rare d i arrh e a, p e n ci l sto o ls
Signs p alp ab le R L Q m ass 1 0% ) , gro ss b le e d i n g p alp ab le m ass o n re ctal e xam ,
i ro n d e fi ci e n cy an e m i a b ri gh t re d re ctal b le e d i n g
J sp re ad
d i re ct e xte n si o n
re gi o n al n o d e s m o st co m m o n )
h e m ato ge n o u s: li ve r, lu n gs
tran sp e ri to n e al sp re ad : o vary
i n tralu m i n al
J d i agn o si s
si gm o i d o sco p y: 50% wi th i n re ach
co lo n o sco p y/ai r co n trast b ari u m e n e m a (s e e Colour At las C6, C10)
m e tastati c wo rk-u p i f n o o b vi o u s m e tastase s
lab s: C B C , u ri n alysi s, li ve r fu n cti o n te sts, C E A, C XR
h e m o ccu lt
d i gi tal re ctal e xam 1 0% are p alp ab le )
J stagi n g se e Tab le 7)
Table 7. Duke -As tle r-Colle r Staging of Colore ctal Carcinoma
Stage Crite ria 5 Ye ar Survival
A li m i te d to m u co sa > 90%
B 1 i n to m u scu lari s p ro p ri a 70-85%
B 2 th ro u gh m u scu lari s p ro p ri a 55-65%
C 1 i n to m u scu lari s p ro p ri a wi th + n o d e s 45-55%
C 2 th ro u gh m u scu lari s p ro p ri a wi th + n o d e s 20-30%
D d i stan t m e tastase s < 1 %
J tre atm e n t
su rge ry
fo r all case s
cu rati ve : wi d e re se cti o n o f le si o n wi th n o d e s an d m e se n te ry
p alli ati ve : i f d i stan t sp re ad , th e n lo cal co n tro l fo r h e m o rrh age o r o b stru cti o n
80% o f re cu rre n ce s o ccu r wi th i n 2 ye ars o f re se cti o n
i m p ro ve d su rvi val i f m e tastasi s co n si sts o f so li tary h e p ati c m ass th at i s re se cte d
rad i o th e rap y an d ch e m o th e rap y
d e cre ase re cu rre n ce s o n ly i n re ctal D u ke 's B /C ) , n o t co lo n carci n o m a
ch e m o th e rap y
5-F U an d le vam i so l o r le u co vo ri n fo li n i c aci d ) i m p ro ve su rvi val i n D u ke s C
J scre e n i n g
C E A: n o t go o d fo r scre e n i n g b u t ap p ro p ri ate to m o n i to r fo r re cu rre n ce
i n cre ase s b e fo re cli n i cal fi n d i n gs) ; th e re fo re , o b tai n p re an d p o st-o p e rati ve le ve ls
an n u al d i gi tal re ctal e xam
si gm o i d o sco p y e ve ry 3-5 ye ars i n p ati e n ts > 40 ye ars
ILEOSTOMIES AND COLOSTOMIES
J i le o sto m i e s
B ro o ke : i n co n ti n e n t, co n ti n u o u s d rai n age
K o ch : co n ti n e n t n o co n ti n u o u s d rai n age ) , i n cre ase d co m p li cati o n s
J co lo sto m i e s
lo o p co lo sto m y: an o p e n i n g i s cre ate d i n a lo o p o f
b o we l wh i ch i s b ro u gh t to th e ski n su rface
e n d te rm i n al) co lo sto m y th e co lo n i s d i vi d e d an d
o n e e n d i s b ro u gh t o u t to th e ski n su rface
J co m p li cati o n s 20% )
o b stru cti o n : h e rn i ati o n , ste n o si s ski n an d ab d o m i n al wall)
p e ri -i le o sto m y ab sce ss an d fi stu la
ski n i rri tati o n
p ro lap se o r re tracti o n
N o te s
ANORECTUM
HEMORRHOIDS
Etiology
J an al cu sh io n s, vascu lar an d co n n e ctive tissu e co m p le xe s, b e co m e
e n go rge d fo rm in g h e m o rrh o id s
J p ro p o se d cau sal facto rs
in cre ase d in tra-ab d o m in al p re ssu re
ch ro n ic co n stip atio n
p re gn an cy
o b e sity
Clas s ification and Manage me nt
J in te rn al h e m o rrh o id s
p le xu s o f su p e rio r h e m o rrh o id ve in s > p o rtal circu latio n
e n go rge d vascu lar cu sh io n s ab o ve d e n tate lin e u su ally se e n at
3, 7, 1 1 o clo ck p o sitio n s > wh e n p atie n t in lith o to m y p o sitio n
p ain le ss re ctal b le e d in g, an e m ia, p ro lap se , m u cu s d isch arge ,
p ru ritis, b u rn in g p ain
1 st d e gre e : b le e d b u t d o n o t p ro lap se th ro u gh th e an u s
h igh fib re /b u lk d ie t, sitz b ath s, ste ro id cre am , ru b b e r
b an d ligatio n , scle ro th e rap y, p h o to co agu latio n
2n d d e gre e : b le e d b u t p ro lap se with strain in g, sp o n tan e o u s re d u ctio n
ru b b e r b an d ligatio n , p h o to co agu latio n
3rd d e gre e : b le e d an d p ro lap se re q u irin g m an u al re d u ctio n
sam e as 2n d d e gre e , m ay re q u ire clo se d h e m o rro id e cto m y
4th d e gre e : p e rm an e n tly p ro lap se d , can n o t b e m an u ally re d u ce d , b le e d in g
clo se d h e m o rro id e cto m y
J e xte rn al h e m o rrh o id s
p le xu s o f in fe rio r h e m o rrh o id ve in s > syste m ic circu latio n
d ilate d ve n u le s b e lo w d e n tate lin e o r p e rian al skin tags u su ally
asym p to m atic u n le ss th ro m b o se d , in wh ich case th e y are ve ry p ain fu l
u su ally p re se n t with p ain afte r b o we l m o ve m e n t
m e d ical th e rap y: d ie tary fib e r, sto o l so fte n e rs, avo id p ro lo n ge d strain in g
th ro m b o se d h e m o rrh o id s re so lve with in 2 we e ks
h e m o rrh o id e cto m y wh e n p atie n t p re se n ts with in th e first
48 h o u rs o f th ro m b o sis, o th e rwise tre at co n se rvative ly
ANAL FISSURES
J te ar o f an al can al se n sitive sq u am o u s e p ith e liu m b e lo w d e n tate lin e
J 90% p o ste rio r m id lin e , 1 0% an te rio r m id lin e
J if o ff m id lin e : IB D , S T D s, T B , le u ke m ia o r an al carcin o m a
J e tio lo gy
large , h ard sto o ls an d irritan t d iarrh e al sto o ls
tigh te n in g o f an al can al se co n d ary to n e rvo u sn e ss/p ain
o th e rs: h ab itu al u se o f carth artics, ch ild b irth
Acute Fis s ure
J ve ry p ain fu l b righ t re d b le e d in g e sp e cially afte r b o we l m o ve m e n t
J tre atm e n t is co n se rvative : sto o l so fte n e rs, sitz b ath s
Chronic Fis s ure
J triad : fissu re , se n tin e l skin tags, h yp e rtro p h ie d p ap illae
J tre atm e n t = su rge ry
o b je ctive is to re lie ve sp h in cte r sp asm > in cre ase s b lo o d flo w
an d p ro m o te s h e alin g
late ral su b cu tan e o u s in te rn al sp h in cte ro to m y at 3 o clo ck p o sitio n
ANORECTAL ABSCESS
J b acte rial in fe ctio n o f in te rsp h in cte ric sp ace startin g fro m an al glan d s
th at e m p ty in to an al cryp ts
J E. Coli, Proteus, Streptococci, Staphylococci, Bacteriodes, an ae ro b e s
J ab sce ss can sp re ad ve rtically d o wn ward p e rian al) , ve rtically u p ward
su p rale vato r o r h o rizo n tally isch io re ctal)
J tre atm e n t: in cisio n an d d rain age are cu rative in 50% o f case s,
50% d e ve lo p an o re ctal fistu las
Pe rianal Abs ce s s
J u n re m m itin g p ain , in d u rate d swe llin g
Is chiore ctal Abs ce s s
J ab sce ss in fatty fo ssa, can sp re ad re ad ily: n e cro tizin g fasciitis, F o u rn ie r's gan gre n e
J p ain , fe ve r an d le u ko cyto sis p rio r to re d , flu ctu an t m ass
N o te s
ANORECTUM. . . CONT.
Suprale vator Abs ce s s
J d ifficu lt to d iagn o se , re ctal m ass an d swe llin g d e te ctab le with e xam u n d e r an e sth e sia
FISTULA IN ANO
J u su ally asso ciate d with an o re ctal ab sce ss; co u ld in d icate IB D
J an in flam m ato ry tract with in te rn al o s at d e n tate lin e , e xte rn al o s o n
skin acco rd in g to G o o d sall's ru le
J in te rm itte n t o r co n stan t p u ru le n t d isch arge fro m p ara-an al o p e n in g, p ain
J p alp ab le co rd -like tract
J tre atm e n t
id e n tify in te rn al o p e n in g
fistu lo u s tract id e n tificatio n p ro b in g o r fistu lo grap h y) u n d e r an e sth e sia
u n ro o f tract fro m e xte rn al to in te rn al o p e n in g, allo w d rain age
se to n th ick su tu re ) can b e p lace d th ro u gh tract
1 ) p ro m o te s d rain age
2) p ro m o te s fib ro sis an d d e cre ase s in cid e n ce o f in co n tin e n ce
3) d e lin ate s an ato m y
p o st-o p : sitz b ath s, irrigatio n an d p ackin g to e n su re h e alin g p ro ce e d s fro m in sid e to o u tsid e
re cu rre n ce , fe cal in co n tin e n ce
Figure 6. Goods alls Rule Drawingby M. Gail Rudakewich
PILONIDAL DISEASE
J acu te ab sce ss o r ch ro n ic d rain in g sin u s in sacro co ccyge al are a
u su ally asym p to m atic u n til acu te ly in fe cte d
J d e ve lo p s se co n d ary to o b stru ctio n o f th e h air fo llicle s in th is are a >
le ad s to fo rm atio n o f cysts, sin u se s o r ab sce sse s
J tre atm e n t
acu te ab sce ss - in cisio n an d d rain age
ch ro n ic d ise ase - p ilo n id al cysto to m y o r e xcisio n o f sin u s
tract an d cyst +/ m arsu p ializatio n
RECTAL PROLAPSE
J p ro tru sio n o f fu ll th ickn e ss o f re ctu m th ro u gh an u s th at in itially
re d u ce s sp o n tan e o u sly u n til co n tin u o u sly p ro lap se d . M u st b e
d iffe re n tiate d fro m h e m o rrh o id al p ro lap se
J in cre ase d in cid e n ce in gyn e co lo gical su rge rie s, ch ro n ic n e u ro lo gic/
p sych iatric d iso rd e rs affe ctin g m o tility
J fe cal an d flatu s in co n tin e n ce se co n d ary to d ilate d an d we ake n e d sp h in cte r
J o ccu rs in e xtre m e s o f age
< 5 ye ars o ld sp o n tan e o u sly re so lve with co n se rvative tre atm e n t sto o l so fte n e rs)
> 40 ye ars o ld u su ally re q u ire su rgical tre atm e n t: an ch o rin g re ctu m
to sacru m e .g. R ip ste in p ro ce d u re ) , e xcisio n o f re d u n d an t
re ctu m fo llo we d b y co lo n an astam o sis to lo we r re ctu m
ANAL NEOPLASMS
J e p id e rm o id carcin o m a o f an al can al ab o ve d e n tate lin e )
m o st co m m o n tu m o u r o f an al can al 75%)
sq u am o u s ce ll o r tran sitio n al ce ll
p re se n ts with re ctal p ain , b le e d in g, m ass
tre atm e n t o f ch o ice is ch e m o th e rap y, rad iatio n +/ su rge ry with 80% 5 ye ar su rvival
J m align an t m e lan o m a o f an al m argin
3rd m o st co m m o n site afte r skin , e ye s
aggre ssive , d istan t m e tastase s are co m m o n at tim e o f d iagn o sis
e arly rad ical su rge ry is tre atm e n t o f ch o ice
< 1 5% 5 ye ar su rvival
An te rio r
S e co n d ary o p e n in g
P o ste rio r
P rim ary o p e n in g
in cryp t Tran sve rse
an al lin e
N o te s
HERNIA
J p ro tru sio n o f a viscu s in to an are a in wh ich it is n o t n o rm ally
co n tain e d
J in cid e n ce
life tim e risk o f d e ve lo p in g h e rn ia
m ale s 5%
fe m ale s 1 %
m o st co m m o n su rgical d ise ase o f m ale s
J ge n e ral typ e s
in te rn al h e rn ia - sac is with in ab d o m in al cavity
e xte rn al h e rn ia - sac p ro tru d e s co m p le te ly th ro u gh
ab d o m in al wall
stran gu late d h e rn ia - vascu lar su p p ly o f p ro tru d e d viscu s
is co m p ro m ise d
in carce rate d h e rn ia - irre d u cib le h e rn ia, n o t n e ce ssarily
stran gu late d
R ich te r's h e rn ia - co n te n ts o f th e sac co n sist o f o n ly o n e
sid e o f in te stin al wall u su ally an tim e se n te ric)
slid in g h e rn ia - p art o f wall o f h e rn ia fo rm e d b y
p ro tru d in g viscu s u su ally ce cu m o r sigm o id co lo n )
Locations and Anatomy
J b o rd e rs o f H asse lb ach 's trian gle - late ral e d ge o f re ctu s sh e ath ,
in gu in al ligam e n t, in fe rio r e p igastric ve sse ls
J in gu in al
te n d s to affe ct m ale s > fe m ale s, b u t re m ain s m o st co m m o n
h e rn ia in wo m e n
in d ire ct
e tio lo gy
p e rsiste n t p ro ce ssu s in 20% o f ad u lts
an ato m y
o rigin ate s in d e e p in gu in al rin g
late ral to in fe rio r e p igastric arte ry
o fte n d e sce n d s in to scro tal sac
co m p licatio n s
in carce ratio n , stran gu latio n
d ire ct
e tio lo gy
aq u ire d we akn e ss in flo o r o f H e sse lb ach 's
trian gle tran sve rsalis fascia)
d u e to we ar/te ar, co m b in e d with in cre ase d
in tra-ab d o m in al p re ssu re
an ato m y
th ro u gh H asse lb ach 's trian gle
m e d ial to in fe rio r e p igastric arte ry
o fte n d o n o t d e sce n d in to scro tal sac
co m p licatio n s
in carce ratio n rare
p an talo o n
co m b in e d d ire ct an d in d ire ct h e rn ias
p e rito n e u m d rap e d o ve r in fe rio r e p igastric ve sse ls
J fe m o ral
e p id e m io lo gy
affe cts m o stly fe m ale s
an ato m y
in to fe m o ral can al, b e lo w in gu in al ligam e n t b u t
m ay o ve rrid e it
lo cate d m e d ial to fe m o ral ve in
co m p licatio n s
te n d e n cy to stran gu late sin ce it h as a n arro w n e ck
J o th e r
in cisio n al: ve n tral h e rn ias - h e rn ia at site o f wo u n d clo su re
u m b ilical: u su ally co n ge n ital, p asse s th ro u gh u m b ilical rin g
e p igastric: d e fe ct in lin e a alb a ab o ve u m b ilicu s
o b tu rato r: th ro u gh o b tu rato r fo ram e n
sp ige lian : ve n tral h e rn ia th ro u gh d e fe ct in lin e a se m ilu n aris
lu m b ar: d e fe ct in p o ste rio r ab d o m in al wall;
su p e rio r - G ryn fe ltt's, in fe rio r - P e tit's
N o te s
HERNIA. . . CONT.
co n trib u tin g facto rs
o b e sity, ch ro n ic co u gh , p re gn an cy, co n stip atio n ,
strain in g o n u rin atio n , ascite s, activitie s wh ich in cre ase
in tra-ab d o m in al p re ssu re
p re vio u s h e rn ia re p air
gro in m ass o f variab le size
d e ve lo p s in sid io u sly in m o st case s
o ccasio n ally p re cip itate d b y sin gle fo rce fu l
m u scu lar e ve n t
asso ciate d d isco m fo rt
wo rse at e n d o f d ay
re lie ve d at n igh t wh e n p atie n t re clin e s an d h e rn ia
re d u ce s
re lie ve d with m an u al re d u ctio n
+/ o b stru ctio n
+/ lo cal te n d e rn e ss
m u st e xam in e p atie n t in b o th su p in e an d stan d in g p o sitio n s
h e rn ial sac an d co n te n ts e n large an d tran sm it p alp ab le
im p u lse wh e n p atie n t co u gh s o r strain s
m ay au scu ltate b o we l so u n d s
u n ab le to ge t ab o ve gro in m ass with p alp atio n
m ass d o e s n o t tran sillu m in ate
stran gu latio n re su lts in
in te n se p ain fo llo we d b y te n d e rn e ss
in te stin al o b stru ctio n
gan gre n o u s b o we l
se p sis
a su rgical e m e rge n cy
sm all, n e w h e rn ias m o re like ly to stran gu late
d o n o t atte m p t to m an u ally re d u ce h e rn ia if se p sis p re se n t
o r co n te n ts o f h e rn ial sac th o u gh t to b e gan gre n o u s
J tre atm e n t
su rgical: go als are to p re ve n t stran gu latio n , e visce ratio n s
an d fo r co sm e tics
in d ire ct h e rn ias - p rin cip le o f re p air is h igh ligatio n o f sac
an d tigh te n in g o f th e in te rn al rin g
d ire ct h e rn ias - p rin cip le o f re p air is to re b u ild
H e sse lb ach 's trian gle : n e e d go o d fascia o r a p ro sth e sis
fe m o ral h e rn ias - p rin cip le o f re p air is to re m o ve sac o f
fat an d clo se th e fe m o ral can al with su tu re s
J p o sto p e rative co m p licatio n s
scro tal h e m ato m a
d e e p b le e d in g - m ay e n te r re tro p e rito n e al sp ace an d n o t
b e in itially ap p are n t
d ifficu lty vo id in g
p ain fu l scro tal swe llin g fro m co m p ro m ise d ve n o u s re tu rn
o f te ste s
n e u ro m a/n e u ritis
ste n o sis/o cclu sio n o f fe m o ral ve in wh e n tre atin g fe m o ral
h e rn ias cau sin g acu te le g swe llin g
J p ro gn o sis in gu in al h e rn ia re p air
in d ire ct: < 1 % risk o f re cu rre n ce
d ire ct: 3-4% risk o f re cu rre n ce
N o te s
LIVER
LIVER CYSTS
J n o rm ally asym p to m atic
J if large > u p p e r ab d o m in al d isco m fo rt/m ass
Paras itic Live r Cys ts
J h yd atid d ise ase tap e wo rm )
in fe ctio n with p arasite Echinococcus granulosus
e n d e m ic S o u th e rn E u ro p e , M id d le E ast,
Au stralia, S o u th Am e rica
Echinococcus granulosusp asse d b y fe cal/o ral ro u te in
co ws, sh e e p , m o o se , carib o u o r h u m an s
se co n d ary in fe ctio n with te n d e r h e p ato m e galy, fe ve r, ch ills
asym p to m atic m ass m o st o fte n ) o r ch ro n ic p ain , h e p ato m e galy
ru p tu re in to b iliary tre e > b iliary co lic, jau n d ice o r an ap h ylaxis
d iagn o sis
C aso n i skin te st risk an ap h ylaxis)
co m p le m e n t fixatio n - b e st
p re se n ce o f m ass, o fte n calcifie d , o n U /S o r C T
tre atm e n t
m e d ical - alb e n d azo le
su rgical - re m o ve cyst sp illage o f an tige n ic co n te n ts
in to p e rito n e al cavity can cau se an ap h ylaxis) an d
o m e n to p lasty
Non-Paras itic Live r Cys ts
J sim p le cyst
J m u lticystic 50% h ave p o lycystic kid n e y; 33% o f p atie n ts with
au to so m al d o m in an t p o lycystic kid n e y d ise ase h ave live r cysts)
J ch o le d o ch al cyst
co n ge n ital m alfo rm atio n s o f p an cre atico b iliary tre e
4 typ e s with th e e xtre m e fo rm calle d C aro li's d ise ase
m u ltip le cystic d ilatio n s in in trah e p atic d u cts)
sign s an d sym p to m s in clu d e re cu rre n t ab d o m in al p ain ,
in te rm itte n t jau n d ice , R U Q m ass
30% p ain , jau n d ice , ab d o m in al m ass
d iagn o sis - U /S , tran sh e p atic ch o lan gio grap h y, L F Ts
tre atm e n t is su rgical e xte n t o f re se ctio n d e p e n d s o n
typ e o f cyst) - live r tran sp lan t in d icate d if cyst
in vo lve m e n t o f in trah e p atic b ile d u cts C aro li's d ise ase )
co m p licatio n s o f ch ro n ic d ise ase are b iliary cirrh o sis, p o rtal
h yp e rte n sio n , b ile d u ct carcin o m a
J n e o p lastic
cystad e n o m a; p re m align an t, u su ally re q u ire re se ctio n
cystad e n o carcin o m a
LIVER ABSCESSES
Bacte rial Live r Abs ce s s
J m o st co m m o n h e p atic ab sce ss in We ste rn wo rld
J u su ally se co n d ary to su p p u rative p ro ce ss in ab d o m e n
ch o lan gitis, ap p e n d icitis, d ive rticu litis,
ge n e ralize d se p sis, also se e d in g fro m e n d o card itis
J o rgan ism re late d to p rim ary so u rce
ab d o m in al - G ram ve ro d s E . coli , an ae ro b e s
Bacteroides, Enterococcus
e xtra-ab d o m in al - G ram +ve o rgan ism s e .g. fro m b acte rial
e n d o card itis, p n e u m o n itis)
J 25% h ave n o an te ce d e n t in fe ctio n = cryp to ge n ic in fe ctio n
J u su ally p re se n t with fe ve r, m alaise , ch ills, an o re xia, we igh t lo ss,
ab d o m in al p ain o r n au se a with righ t u p p e r q u ad ran t R U Q )
te n d e rn e ss, h e p ato m e galy, jau n d ice , an d p le u ral d u lln e ss to
p e rcu ssio n
J lab - le u ko cyto sis, an e m ia, e le vate d L F Ts
J d iagn o sis
U /S , C XR R b asilar ate le ctasis/e ffu sio n ) , C T, se ru m
an tib o d y titre , p e rcu tan e o u s asp iratio n an d d rain age
m o re co m m o n in righ t lo b e
N o te s
LIVER. . . CONT.
J tre atm e n t
tre at u n d e rlyin g cau se
su rgical d rain age an d IV an tib io tics
J o ve rall m o rtality 1 5% - h igh e r rate if d e lay in d iagn o sis,
m u ltip le ab sce sse s, m aln u tritio n
Amoe bic Abs ce s s
J fo llo ws in te stin al m an ife statio n b y Entamoeba histolyticavia
co n tam in ate d d rin kin g wate r, fo o d , p e rso n -to -p e rso n
J asso ciate d with fe ve r, le u ko cyto sis, d iarrh e a, R U Q p ain , h e p ato m e galy
J o fte n a sin gle large cavity in th e righ t lo b e 90%)
J tre atm e n t: p are n te ral an tib io tics m e tro n id azo le ) , asp iratio n o f
ab sce ss if large ; su rgical d rain age in d icate d if co m p licatio n s arise ru p tu re )
NEOPLASMS
Be nign Live r Ne oplas ms
J h e m an gio m a cave rn o u s)
m o st co m m o n b e n ign h e p atic tu m o u r; re su lts fro m
m alfo rrn atio n o f an gio b lastic fe tal tissu e
fe m ale :m ale = 6:1 asso ciate d with O C P u se
u su ally n o tre atm e n t, u n le ss tu m o u r b le e d s o r is sym p to m atic
e xcisio n b y lo b e cto m y o r e n u cle atio n )
can cau se ab d o m in al p ain co m p re ssio n o f n e arb y
stru ctu re s, e xp an sio n ) o r fo rm p alp ab le m ass if > 4 cm
arte rio grap h y is d iagn o stic, b u t re d b lo o d ce ll scan as u se fu l an d ch e ap e r
d o n o t b io p sy > m assive h e m o rrh age
J ad e n o m a
b e n ign glan d u lar e p ith e lial tu m o u r
yo u n g wo m e n o n b irth co n tro l p ill B C P ) fo r m an y ye ars
25% p re se n t with R U Q p ain o r m ass
u p to 30% p re se n t with h e m o rrh age in to p e rito n e al cavity
m align an t p o te n tial
d iagn o sis: m ass o n U /S o r C T
tre atm e n t
sto p B C P o r an ab o lic ste ro id s
e xcise e sp e cially if large d u e to in cre ase d risk o f
m align an cy an d sp o n tan e o u s ru p tu re /h e m o rrh age
J fo cal n o d u lar h yp e rp lasia F N H , h am arto m a, b e n ign )
fe m ale :m ale = 2:1 in age 40 o n ave rage )
rare ly gro w o r b le e d
" ce n tral ste llate scar" o n C T scan
tre atm e n t: re se ct o n ly if sym p to m atic
Malignant Live r Ne oplas ms
J p rim ary
u su ally h e p ato ce llu lar ad e n o carcin o m a h e p ato m a)
u n co m m o n in N o rth Am e rica, b u t 20-25% o f all carcin o m as in th e O rie n t an d Africa
risk facto rs
ch ro n ic h e p atitis B an d C in fe ctio n s
cirrh o sis e sp e cially m acro n o d u lar
B C P s - 3x in cre ase d risk
ste ro id s
sm o kin g, alco h o l
ch e m ical carcin o ge n s aflato xin , vin yl ch lo rid e - asso ciate d with an gio sarco m a)
p arasite in fe ctio n Clonorchis sinensisasso ciate d with ch o lan gio carcin o m a)
h e m o ch ro m ato sis, -1 -an titryp sin d e ficie n cy
p ath o ge n e sis o f h e p ato ce llu lar carcin o m a with h e p atitis B p re su m ab ly
in vo lve s in te grate d H B V-D N A th at acts as a can ce r p ro m o te r
sign s an d sym p to m s
R U Q d isco m fo rt, righ t sh o u ld e r p ain
jau n d ice in 1 /3, we akn e ss, we igh t lo ss, fe ve r
h e p ato m e galy, b ru it, ru b
1 0-1 5% ascite s with b lo o d su d d e n in tra-ab d o m in al h e m o rrh age )
p aran e o p lastic C u sh in g's syn d ro m e
d iagn o sis
e le vate d alkalin e p h o sp h atase , b iliru b in , an d
-fe to -p ro te in 80% o f p atie n ts)
N o te s
LIVER. . . CONT.
im agin g: U /S b e st) , live r scan , C T, M R I, an gio grap h y
b io p sy
tre atm e n t
cirrh o sis re lative co n train d icatio n to tu m o u r
re se ctio n d u e to d e cre ase d h e p atic re se rve
su rge ry - 1 0% o f p atie n ts h ave re se ctab le tu m o u rs
live r tran sp lan t n o t if H e p B )
p e rcu tan e o u s e th an o l in je ctio n
cryo th e rap y
ch e m o th e rap y - syste m ic o r h e p atic arte rial in fu sio n
p ro gn o sis
70% h ave m e ts to n o d e s an d lu n g
5 ye ar su rvival o f all p atie n ts - 5%
3 m o n th su rvival if n o tre atm e n t
5 ye ar su rvival o f p atie n ts u n d e rgo in g co m p le te re se ctio n - 1 1 -40%
o th e r typ e s: ch o lan gio carcin o m a 7%) ,
an gio sarco m a, h e p ato b lasto m a ch ild re n )
J se co n d ary 20 x m o re co m m o n th an p rim ary)
m e tastase s to th e live r
25-50% o f p e o p le with can ce r at au to p sy h ave live r m e tastase s
b ro n ch o ge n ic m o st co m m o n ) , G I, p an cre as, b re ast,
o vary, u te ru s, kid n e y
tre atm e n t
h e p atic re se ctio n if co n tro l o f p rim ary is p o ssib le ,
n o e xtrah e p atic m e ts an d < 4 le sio n s
cryo th e rap y
p o ssib ly ch e m o th e rap y
5 ye ar o ve rall su rvival 20-50% with re se ctio n o f co lo re ctal m e ts
o ve rall su rvival with co lo re ctal m e stastase s to live r
ap p ro xim ate ly 6-7 m o n th s)
PORTAL HYPERTENSION se e G astro e n te ro lo gy N o te s)
Table 8. Child's Clas s ification for De te rmining Ope rative Ris k for
Shunting Proce dure in Portal Hype rte ns ion
A B C
S e ru m b i li ru b i n m g/d L ) < 2 2-3 > 3
S e ru m alb u m i n g/d L ) > 3.5 3-3.5 < 3
P re se n ce o f asci te s ab se n t co n tro llab le re fracto ry
E n ce p h alo p ath y ab se n t m i n i m al se ve re
M aln u tri ti o n ab se n t m i ld se ve re
O p e rati ve m o rtali ty 2% 1 0% 50%
Surgical Manage me nt of Ble e ding Varice s in Portal Hype rte ns ion
J in d icatio n s
b le e d in g co n tin u e s d e sp ite tran sfu sio n o f b lo o d 5 u n its) with in 24 h o u rs
J scle ro th e rap y - u su ally tre atm e n t o f ch o ice 90% e ffe ctive ) ;
+/ vaso p re ssin , N T G , so m ato statin , p ro p ran o lo l with 20-30% m o rtality
J b allo o n tam p o n ad e B lake m o re tu b e )
1 2-24 h o u rs: 75% e ffe ctive in itially 20-50% re b le e d rate )
risk o f asp iratio n , u lce ratio n , asp h yxiatio n , o r ru p tu re ;
th e re fo re o ro /n aso trach e al in tu b atio n in d icate d
J tran sju gu lar in trah e p atic p o rto -syste m ic sh u n t T IP S S )
Shunting Proce dure s to De cre as e Portal Ve nous Pre s s ure
J p o rtal d e co m p re ssio n
o p e rative m o rtality: C h ild 's A 0-5%, B 5-1 5%, C 20-50%
n o n se le ctive sh u n ts: d ire ct all p o rtal b lo o d flo w away fro m live r
p o rto caval e n d -to -sid e an d sid e -to -sid e an asto m o se s)
d ire ct an asto m o sis b e twe e n IVC an d p o rtal ve in
u se d in acu te b le e d in g/ascite s
ve ry e ffe ctive > 90%) , lo w re -b le e d
risk o f h e p atic e n ce p h alo p ath y h igh 1 1 -38%) ; h e p atic failu re
1 3-1 8%) d u e to lo w p o rtal flo w fro m sh u n t
d istal sp le n o -re n al Warre n )
an asto m o sis o f sp le n ic ve in to le ft re n al ve in
N o te s
LIVER. . . CONT.
p ro ce d u re o f ch o ice fo r e le ctive sh u n t su rge ry
n o t u se d in p atie n ts with ascite s
d e cre ase d rate o f h e p atic e n ce p h alo p ath y an d
failu re as p o rtal flo w an d live r d e to xificatio n
p artially in tact
tran sju gu lar in travascu lar p o rtasyste m ic sh u n t T IP S S )
n e w te ch n iq u e p e rfo rm e d b y rad io lo gists
cre ate s a sh u n t b e twe e n p o rtal an d h e p atic ve in
via a cath e te r p lace d in th e live r
can b e u se d to sto p acu te b le e d in g o r p re ve n t re b le e d in g
sh u n t u su ally re m ain s o p e n u p to o n e ye ar
live r tran sp lan t
70% 5 ye ar su rvival in n o n -alco h o lic cirrh o tic
As cite s
J m an age m e n t
p o rto caval sh u n t sid e to sid e )
p e rito n e o ve n o u s sh u n t: d rain age o f in trap e rito n e al flu id
to vascu lar co m p artm e n t i.e . L e ve e n sh u n t)
in d icatio n s: failu re o f m e d ical tre atm e n t, e n ce p h alo p ath y, azo te m ia
Hype rs ple nis m
J tre ate d co n se rvative ly
J sp le n e cto m y o r Warre n sh u n t if se ve re o r d e ve lo p m e n t o f
sp le n ic ve in th ro m b o sis
LIVER TRANSPLANTATION
J in d icatio n s: e n d -stage co m p licatio n s re fracto ry ascite s,
e n ce p h alo p ath y an d b le e d in g varice s)
Candidacy for Trans plantation
J p are n ch ym al d ise ase
p o st-n e cro tic cirrh o sis ch ro n ic active h e p atitis)
alco h o lic cirrh o sis
acu te live r failu re
B u d d -C h iari syn d ro m e
co n ge n ital h e p atic fib ro sis
cystic fib ro sis
J ch o le static d ise ase
b iliary atre sia
p rim ary b iliary cirrh o sis
scle ro sin g ch o lan gitis
J in b o rn e rro rs o f m e tab o lism
-1 -an ti-tryp sin d e ficie n cy
Wilso n 's d ise ase
J tu m o u rs
p rim ary m align an t
b e n ign
Proce dure
J d u ratio n 6-1 0 h o u rs
J in vo lve s e xte rn al ve n o ve n o u s b yp ass, ve n o u s an asto m o se s,
re p e rfu sio n o f n e w live r, h e m o stasis an d re co n stru ctio n o f
b iliary tract R o u x-e n -Y) o r e n d -to -e n d an asto m o sis
Pos t-op Complications
J su rgical - h e p atic arte ry th ro m b o sis, asso ciate d with an asto m o sis
b e twe e n d o n o r an d re cip ie n t
J acu te an d ch ro n ic re je ctio n
J p o st-tran sp lan t d e ath M O S F )
J re cu rre n ce o f h e p atitis B
Survival
J p e d iatric 78% 1 ye ar, 74% 5 ye ars
J ad u lt 76% 1 ye ar, 63% 5 ye ars
N o te s
BILIARY TRACT
CHOLELITHIASIS
Pathoge ne s is
J im b alan ce o f ch o le ste ro l an d its so lu b ilizin g age n ts, b ile salts
an d le cith in co n ce n tratio n s
J if h e p atic ch o le ste ro l se cre tio n is e xce ssive th e n b ile salts an d
le cith in are o ve rlo ad e d , su p e rsatu rate d ch o le ste ro l p re cip itate s
an d can fo rm gallsto n e s
Type s of Stone s
J ch o le ste ro l 80%) = m ixe d > 70% ch o le ste ro l b y we igh t)
risk facto rs
fe m ale , fat, fe rtile , fo rtie s
N o rth Am e rican In d ian s h igh e st in cid e n ce
p ro lo n ge d fastin g +to tal p are n te ral n u tritio n
T P N ; u su ally re su lts in acu te acalcu lo u s ch o le cystitis)
rap id we igh t lo ss
te rm in al ile al re se ctio n o r d ise ase e .g. in flam m ato ry
b o we l d ise ase )
J p igm e n t sto n e s 20%)
sm o o th gre e n /b lack to b ro wn : co m p o se d o f
u n co n ju gate d b iliru b in , calciu m , b ile acid s
b lack p igm e n t sto n e s
asso ciate d with cirrh o sis, ch ro n ic h e m o lytic state s
calciu m b iliru b in ate sto n e s
asso ciate d with b ile stasis, b iliary strictu re s,
d ilatatio n an d b iliary in fe ctio n Clonorchis sinensis)
Natural His tory
J 80% are asym p to m atic
J 1 8% d e ve lo p sym p to m s o ve r 1 5 ye ars
Clinical Pre s e ntation (in s e ve rity of incre as ing orde r)
J asym p to m atic sto n e s
m o st asym p to m atic gallsto n e s d o N O T re q u ire tre atm e n t
co n sid e r o p e ratin g if calcifie d " p o rce lain " gallb lad d e r
1 5-20% asso ciate d can ce r , d iab e te s, h isto ry o f b iliary
p an cre atitis
J b iliary co lic
J ch o le cystitis - acu te an d ch ro n ic
J co m p licatio n s o f ch o le cystitis
J ch o le d o ch o lith iasis C B D sto n e s)
BILIARY COLIC (or CHRONIC CHOLECYSTITIS)
J m an y p atie n ts with acu te ch o le cystitis h ave a h isto ry o f
e p iso d ic b iliary co lic
J m e ch an ism : gallsto n e te m p o rarily im p acte d in cystic d u ct, n o in fe ctio n
J sign s an d sym p to m s
ste ad y p ain n o t co lic) in e p igastriu m o r R U Q fo r m in u te s to h o u rs
fre q u e n tly o ccu rs at n igh t o r afte r fatty m e al
can rad iate to righ t sh o u ld e r o r scap u la
asso ciate d n au se a/vo m itin g
n o p e rito n e al fin d in gs
n o syste m ic sign s
J d iffe re n tial d iagn o sis - p an cre atitis, P U D , h iatu s h e rn ia with
re flu x, gastritis
J d iagn o stic in ve stigatio n
n o rm al b lo o d wo rk
U /S sh o ws gallsto n e s
J tre atm e n t
e le ctive ch o le cyste cto m y 95% su cce ss)
ACUTE CHOLECYSTITIS
J m e ch an ism
in flam m atio n o f gallb lad d e r re su ltin g fro m o b stru ctio n o f
cystic d u ct b y gallsto n e 80%)
n o ch o le lith iasis in 20% acalcu lo u s - se e b e lo w)
N o te s
BILIARY TRACT. . . CONT.
se ve re co n stan t e p igastric o r R U Q p ain
syste m ic sign s - fe ve r, tach ycard ia
fo cal p e rito n e al fin d in gs - M u rp h y's sign su d d e n
ce ssatio n o f in sp iratio n with d e e p R U Q p alp atio n )
p alp ab le gallb lad d e r in o n e th ird o f p atie n ts
J d iffe re n tial d iagn o sis
p e rfo rate d o r p e n e tratin g p e p tic u lce r
m yo card ial in farctio n
p an cre atitis
h iatu s h e rn ia
righ t lo we r lo b e p n e u m o n ia
ap p e n d icitis
h e p atitis
h e rp e s zo ste r
e le vate d WB C , le ft sh ift
m ild ly e le vate d b iliru b in , AL P
so m e tim e s sligh t e le vatio n AS T, ALT
U /S sh o ws d iste n d e d , e d e m ato u s gallb lad d e r,
p e rich o le cystic flu id , large sto n e stu ck in gallb lad d e r
n e ck, so n o grap h ic M u rp h y's sign
h yd ro p s: m u cu s accu m u latio n in gallb lad d e r d u e to
cystic d u ct o b stru ctio n ; m ay le ad to n e cro sis
gan gre n e an d p e rfo ratio n : m ay cau se lo calize d ab sce ss
o r ge n e ralize d p e rito n itis can o ccu r 3 d ays afte r o n se t)
e m p ye m a o f gallb lad d e r su p p u rative ch o lan gitis)
ch o le cysto e n te ric fistu la fro m re p e ate d attacks o f ch o le cystitis
gallsto n e ile u s se e b e lo w)
ch o le d o ch o lith iasis - 1 5% o f p atie n ts with gallsto n e s
J m o rtality 5%
J tre atm e n t
ad m it, h yd rate , N G tu b e , an tib io tics if h igh risk e ld e rly,
im m u n o su p p re sse d )
lack o f im p ro ve m e n t with co n se rvative tre atm e n t >
o p e rate with in 24-48 h o u rs ch o le cyste cto m y)
e arlie r O .R . if h igh risk D M , ste ro id s) o r se ve re d ise ase
ch o le cysto sto m y tu b e if ge n e ral an e sth e tic co n train d icate d
COMPLICATIONS OF CHOLECYSTECTOMY
J ge n e ral
an e sth e tic risk
p o st-o p co m p licatio n s se e S u rgical C o m p licatio n s S e ctio n )
J sp e cific
b ile d u ct in ju ry 0.2-1 %)
co rre ct with R o u x-e n -Y ch o le d o ch o je ju n o sto m y
Figure 7. Roux-e n-Y Chole dochoje junos tomy
Drawingsby Myra Rudakewich
N o te s
ACALCULOUS CHOLECYSTITIS
J acu te o r ch ro n ic ch o le cystitis in th e ab se n ce o f sto n e s
J u su ally d iab e tic, im m u n o su p p re sse d o r p o st-o p
J e tio lo gy
d e h yd ratio n
syste m ic d ise ase e .g. M O S F )
ge n e ralize d se p sis
kin kin g o r fib ro sis o f th e gallb lad d e r
th ro m b o sis o f th e cystic arte ry
sp h in cte r sp asm with o b stru ctio n o f th e b iliary an d
p an cre atic d u cts
p ro lo n ge d fastin g
co llage n vascu lar d ise ase
J tre atm e n t
ch o le cyste cto m y o r ch o le cysto sto m y
GALLSTONE PANCREATITIS
J m e ch an ism : gallsto n e im p acte d in co m m o n p an cre atic d u ct
e p igastric, b ack p ain
h igh am ylase , lip ase
h igh live r e n zym e s
m o st case s m ild R an so n 's crite ria
U /S m ay sh o w m u ltip le sto n e s m ay h ave p asse d
sp o n tan e o u sly) , e d e m ato u s p an cre as
C T if se ve re to e valu ate fo r co m p licatio n s
J tre atm e n t
su p p o rtive
ch o le cyste cto m y d u rin g sam e ad m issio n afte r acu te
attack su b sid e d
GALLSTONE ILEUS
J m e ch an ism - ch o le cysto e n te ric fistu la u su ally d u o d e n al)
with large gallsto n e im p actin g m o st co m m o n ly at th e
ile o ce cal valve
J n o t an ile u s, b u t a tru e p artial o r co m p le te sm all b o we l
o b stru ctio n
cram p y ab d o m in al p ain , n au se a, vo m itin g
3 vie ws ab d o m e n sh o ws d ilate d sm all in te stin e ,
gallsto n e in R L Q an d air in b iliary tre e 1 5%)
u p p e r G I if u n cle ar
J tre atm e n t
h yd rate , o p e rate to re m o ve sto n e ; e n te ro to m y) u su ally
d o n 't h ave to re m o ve gallb lad d e r 30% ch o le cyste cto m y)
o n ly if ch ro n ic sym p to m s
fistu la u su ally clo se s sp o n tan e o u sly
J m o rtality 1 0-1 5%
DIAGNOSTIC EVALUATION OF BILIARY TREE
J U /S is d iagn o stic p ro ce d u re o f ch o ice
J o ral ch o le cysto grap h y
o p aq u e d ru g take n n igh t b e fo re , lo o k fo r fillin g d e fe ct sto n e s)
failu re o f gallb lad d e r to o p acify in d icative o f co m p le te
o b stru ctio n b y sto n e o r u n ab le to co n ce n trate b e cau se
o f in flam m atio n
J H ID A scan
rad io iso to p e te ch n e tiu m e xcre te d in h igh co n ce n tratio n s in b ile
h igh ly su gge stive o f acu te ch o le cystitis wh e n gallb lad d e r
n o t visu alize d d u e to cystic d u ct o b stru ctio n 4 h o u rs afte r in je ctio n
re liab le wh e n b iliru b in > 20
J P T C
in je ctio n o f co n trast via n e e d le p asse d th ro u gh h e p atic p are n ch ym a
u se fu l fo r p ro xim al b ile d u ct le sio n s o r wh e n E R C P fails
an tib io tic p re m e d icatio n always, co n train d icate d with ch o lan gitis
N o te s
J E R C P
o p acificatio n o f b ile an d p an cre atic d u cts p o ssib le
p re fe rre d m e th o d to d e m o n strate C B D sto n e s an d
p e riam p u llary re gio n
CHOLEDOCHOLITHIASIS
J sto n e s in co m m o n b ile d u ct
50% asym p to m atic
te n d e rn e ss in R U Q o r e p igastriu m
b iliary p ain with in te rm itte n t ch ills, fe ve r o r flu ctu atin g jau n d ice
e p iso d ic ch o lan gitis
sp e ctru m fro m h e alth y to icte ru s, to xicity, h igh fe ve r an d ch ills
J d iagn o stic in ve stigatio n s
in cre ase d b iliru b in < 1 0) , AL P
le u ko cyto sis o fte n > 20 x 1 0
9
/L
U /S - d u ct d ilatatio n , d o e s n o t d e te ct C B D sto n e s
E R C P if n o p re vio u s ch o le cyste cto m y) o th e rwise P T C ap p ro p riate
J tre atm e n t
an tib io tics, N G tu b e , IV h yd ratio n
if n o im p ro ve m e n t in 2-4 d ays th e n E R C P /P T C +sp h in cte ro to m y o r
su rge ry with C B D e xp lo ratio n an d lap aro sco p ic ch o le cyste cto m y
ACUTE CHOLANGITIS
J m e ch an ism : o b stru ctio n o f co m m o n b ile d u ct le ad in g
to b iliary stasis, b acte rial o ve rgro wth , su p p u ratio n , an d
b iliary se p sis - life th re ate n in g
J e tio lo gy
ch o le d o ch o lith iasis 60%)
p o st-o p e rative strictu re
p an cre atic o r b iliary n e o p lasm s
J o rgan ism s: E . coli, Klebsiella, Pseudomonas, Enterococci, B. fragilis, Proteus
C h arco t's triad : fe ve r, jau n d ice , R U Q p ain
R e yn o ld 's p e n tad : C h arco t's triad +m e n tal co n fu sio n ,
h yp o te n sio n le ad in g to re n al failu re
J d iagn o stic in ve stigatio n s
e le vate d WB C
e le vate d live r fu n ctio n te sts an d co n ju gate d b iliru b in
U /S sh o ws gallsto n e s in gallb lad d e r +/ sto n e s se e n
in b ile d u cts ap p ro xim ate ly 1 0-1 5%) +/ d ilate d
e xtrah e p atic o r in trah e p atic b ile d u cts
J tre atm e n t
an tib io tics, h yd ratio n
u rge n t E R C P - d iagn o stic an d th e rap e u tic with
p ap illo to m y to re m o ve sto n e s
if E R C P u n availab le o r u n su cce ssfu l, th e n P T C
if E R C P, P T C u n availab le , su rge ry to d e co m p re ss C B D > T-tu b e
if e ld e rly, u su ally) d o n t h ave to re m o ve gallb lad d e r
if ad e q u ate E R C P +p ap illo to m y
CARCINOMA OF THE BILE DUCT
J m ajo rity ad e n o carcin o m a
J 2% o f can ce r d e ath s 1 /8 as co m m o n as p an cre atic can ce r
J asso ciatio n s
age 50-70 ye ars
age 20-40 if ch ro n ic u lce rative co litis, C lo n o rch is sin e n sis
in fe statio n , scle ro sin g ch o lan gitis, ch o le d o ch al cysts
fe m ale :m ale = 2:1
lo cal: R U Q p ain , p alp ab le m ass if tu m o u r in C B D )
syste m ic: u n re m ittin g jau n d ice , p ru ritu s, we igh t lo ss, an o re xia
K latskin tu m o u r at co m m o n h e p atic d u ct b ifu rcatio n )
cau se s in cre ase d AL P, b iliru b in , b u t n o rm al AS T
J d iagn o sis: U /S an d C T d ilate d b ile d u cts) , E R C P an d P T C d e p ict tu m o u r
J tre atm e n t
+/ ste n ts fo r p alliatio n
rad iatio n o r Wh ip p le 's if tu m o u r at lo w e n d o f C B D
N o te s
J p ro gn o sis
sp re ad : gro wth in to p o rtal ve in o r h e p atic arte ry, live r, h ilar n o d e s
1 0-1 5% 5 ye ar su rvival
d e ath re su lts fro m p ro gre ssive b iliary cirrh o sis, p e rsiste n t
in trah e p atic in fe ctio n an d ab sce ss fo rm atio n , o r se p sis
JAUNDICE
Figure 8. Surgical Jaundice
p rim ary b iliary cirrh o sis
to xic d ru g jau n d ice e .g. B C P )
ch o le static jau n d ice o f p re gn an cy
p o st-o p ch o le static jau n d ice
m e d ical
se e G astro e n te ro lo gy N o te s)
N o te s
PANCREAS
ACUTE PANCREATITIS se e G astro e n te ro lo gy N o te s)
J u su ally n o su rgical m an age m e n t in u n co m p licate d acu te p an cre atitis
J su rgical in d icatio n s in acu te p an cre atitis
se co n d ary p an cre atic in fe ctio n s - ab sce ss, in fe cte d p se u d o cysts/n e cro sis
gallsto n e -asso ciate d p an cre atitis
u n ce rtain ty o f clin ical d iagn o sis
wo rse n in g clin ical co n d itio n d e sp ite o p tim al su p p o rtive care
p se u d o cyst 2-1 0%)
co lle ctio n o f p an cre atic se cre tio n s in a cyst lackin g tru e e p ith e liu m
risk o f ru p tu re , h e m o rrh age an d in fe ctio n rare )
2-3 we e ks p o st-attack: p e rsiste n t p ain , fe ve r, ile u s, m ass,
n au se a/vo m itin g, e arly satie ty, p e rsiste n t e le vatio n o f am ylase
40% re so lve sp o n tan e o u sly with in 6-1 2 we e ks ke e p N P O an d o n T P N )
d iagn o sis: clin ical, U /S , C T
tre atm e n t: in te rn al p re fe re d ) o r e xte rn al d rain age latte r if
in fe cte d o r sick p atie n t) o n ce p se u d o cyst m atu re s
b io p sy to ru le o u t m align an cy
re cu rre n ce rate 1 0%
ab sce ss 5%)
1 -4 we e ks p o st-attack: fe ve r, to xic, ab d o m in al p ain , d iste n tio n
d iagn o sis: in cre ase d am ylase , in cre ase d AS T / ALT 50%) ,
e le vate d WB C , C T flu id an d gas)
h igh m o rtality - re q u ire s e xte n sive su rgical d e b rid e m e n t
an d b ro ad -sp e ctru m an tib io tics
ascite s
se co n d ary to p se u d o cyst d isru p tio n co m m o n ) o r
d ire ct p an cre atic d u ct d isru p tio n
d iagn o se b y p arace n te sis: h igh am ylase , h igh p ro te in
tre atm e n t: N P O , T P N 2-3 we e ks, so m ato statin
E R C P if n o t re so lve d to d e te rm in e an ato m y; R o u -e n -Y
je ju n o sto m y to site o f le ak
n e cro sis
d iagn o sis b y C T
tre atm e n t: d e b rid e m e n t
h e m o rrh age
e ro sio n o f arte rial p se u d o an e u rysm se co n d ary to
p se u d o cyst, ab sce ss, o r n e cro tizin g p an cre atitis
clin ical p re se n tatio n : in cre ase d ab d o m in al m ass,
ab d o m in al p ain , h yp o te n sio n
d iagn o sis: an gio grap h y
tre atm e n t: im m e d iate su rge ry
se p sis
M O S F
J p ro gn o sis o f all co m p licatio n s
80% im p ro ve rap id ly
20% h ave at le ast o n e co m p licatio n fro m wh ich 1 /3 d ie
CHRONIC PANCREATITIS se e G astro e n te ro lo gy N o te s)
J su rgical tre atm e n t
in d icatio n s fo r su rgical tre atm e n t: d e b ilitatin g ab d o m in al p ain , C B D
o b stru ctio n , d u o d e n al o b stru ctio n , p e rsiste n t p se u d o cyst
E R C P fo r p lan n in g su rgical m an age m e n t - d ilate d d u cts
with are as o f strictu re ch ain o f lake s)
d rain age p ro ce d u re if d u cts > 8 m m
P u e sto w lo n gitu d in al p an cre atico -je ju n o sto m y)
80-90% h ave p ain re lie f, b u t 5 ye ars p o st-o p o n ly 50-60% re m ain p ain -fre e
Wh ip p le p an cre atico d u o d e n e cto m y) 80% h ave p ain re lie f
p an cre ate cto m y
u se wh e n n o d ilate d d u cts
am o u n t o f re se ctio n d e p e n d s o n d ise ase fo cu s
i.e . lim ite d vs. su b to tal vs. to tal p an cre ate cto m y)
d o n o t p e rcu tan e o u sly acce ss a p se u d o cyst u n le ss im m e d iate d rain age
o f in fe ctio n re q u ire d . G o al is to allo w wall o f p se u d o cyst to m atu re
3-4 we e ks) fo llo we d b y in te rn al d rain age th ro u gh sto m ach
N o te s
PANCREAS . . . CONT.
PANCREATIC CANCER
J e p id e m io lo gy
fifth m o st co m m o n cau se o f can ce r d e ath
African d e sce n t at in cre ase d risk
m ale :fe m ale = 1 .7:1
age ave rage 50-70)
J risk facto rs
in cre ase d age
sm o kin g - 2-5x in cre ase d risk
h igh fat/lo w fib re d ie ts
ch ro n ic p an cre atitis
d iab e te s
h e avy alco h o l u se
ch e m ical: b e tan ap h th ylam in e , b e n zid in e
J clin ical p re se n tatio n is re late d to lo catio n o f tu m o u r
h e ad o f th e p an cre as 70%)
we igh t lo ss, p ain le ss o b stru ctive jau n d ice
p alp ab le tu m o u r m ass = in cu rab le
C o u rvo isie rs sign = p alp ab le n o n -te n d e r gall
b lad d e r in jau n d ice d p atie n t su gge stin g m align an t
co m m o n b ile d u ct o b stru ctio n
C o u rvo isie r's L aw = a p alp ab ly d iste n d e d , n o n
te n d e r gallb lad d e r is u n like ly to b e d u e to ch o le lith iasis
carcin o m a o f b o d y o r tail o f p an cre as 30%)
te n d s to p re se n t late r an d u su ally in o p e rab le
< 1 0% jau n d ice d
we igh t lo ss, vagu e m id e p igastric p ain
su d d e n o n se t d iab e te s m e llitu s
J su rgical d ictu m : vagu e ab d o m in al p ain with we igh t lo ss
+/ jau n d ice in a p atie n t > 50 ye ars o ld is p an cre atic can ce r
u n til p ro ve n o th e rwise
J d iagn o sis
se ru m ch e m istry n o n -sp e cific: e le vate d AL P an d b iliru b in > 1 8)
e vid e n ce o f o b stru ctio n : U /S , E R C P b e st) , P T C , C T
b e ware o f T B , lym p h o m a
th e se are n o t tre ate d su rgically
J p ath o lo gy
d u ctal ad e n o carcin o m a - m o st co m m o n typ e 75-80%)
gian t ce ll carcin o m a 4%)
ad e n o sq u am o u s carcin o m a 3%)
o th e r: m u cin o u s, cystad e n o carcin o m a, acin ar ce ll carcin o m a
J sp re ad
e arly to lo cal lym p h n o d e s an d live r
J tre atm e n t
o p e rab le i.e . n o m e tastase s o u tsid e ab d o m e n , live r, o r
p e rito n e al stru ctu re s, an d n o in vo lve m e n t o f p o rta h e p atis,
su p e rio r m e se n te ric arte ry, p o rtal ve in at b o d y o f p an cre as)
20% o f h e ad o f p an cre as can ce rs can b e re se cte d
Wh ip p le 's p ro ce d u re p an cre ato d u o d e n e cto m y)
fo r cu re - 5% m o rtality
d istal p an cre ate cto m y +/ sp le n e cto m y,
lym p h ad e n e cto m y if carcin o m a o f m id b o d y an d tail o f p an cre as
in o p e rab le i.e . in vo lve s live r, vascu latu re o r re gio n al n o d e s)
m o st b o d y an d tail can ce rs n o t re se ctab le
re lie ve b iliary/d u o d e n al o b stru ctio n with
e n d o sco p ic ste n tin g o r d o u b le b yp ass p ro ce d u re :
ch o le d o ch o e n te ro sto m y, gastro e n te ro sto m y
p alliative p ain co n tro l
co m b in atio n ch e m o th e rap y/rad io th e rap y fo r
p alliatio n , in cre ase d m e d ical su rvival p o st-su rge ry
J p ro gn o sis
ave rage su rvival - 7 m o n th s
5 ye ar su rvival is 1 0%
fo llo win g Wh ip p le 's p ro ce d u re , m e an su rvival - 1 8 m o n th s
if re se ctio n m argin s cle ar an d n o tu m o u r sp re ad , th e n 5 ye ar
su rvival fo r am p u llary carcin o m a 30%, p an cre atic carcin o m a 20%
m o st im p o rtan t p ro gn o stic in d icato r is lym p h n o d e statu s
N o te s
PANCREAS . . . CONT.
Figure 9. Whipple Proce dure
Drawingsby Myra Rudakewich
SPLEEN
HYPERSPLENISM se e H e m ato lo gy N o te s)
J e xagge ratio n o f n o rm al sp le n ic fu n ctio n s su ch as re m o val an d
d e stru ctio n o f age d /d e fe ctive R B C , se q u e stratio n o f n o rm al
ce lls an d p ro d u ctio n o f im m u n o glo b u lin s
J e tio lo gy
p rim ary h yp e rsp le n ism
rare
d iagn o sis o f e xclu sio n
se co n d ary h yp e rsp le n ism
co n ge stio n m o st co m m o n ) se co n d ary to p o rtal h yp e rte n sio n
n e o p lasia- lym p h o m a, le u ke m ia, m ye lo id m e tap lasia
in fe ctio n s - E B V, T B
in flam m ato ry d ise ase s - sarco id , rh e u m ato id arth ritis
h e m ato lo gic - sp h e ro cyto sis, G 6P D d e ficie n cy
sto rage d ise ase s - G au ch e r's d ise ase , am ylo id
+/ L U Q fu lln e ss, d isco m fo rt, sp o n tan e o u s ru p tu re
an e m ia, le u ko p e n ia, th ro m b o cyto p e n ia
J d iagn o sis
C B C , d iffe re n tial an d sm e ar, H b e le ctro p h o re sis
b o n e m arro w b io p sy
sp le n ic fu n ctio n te sts: rad io lab e le d R B C /p late le ts
m e asu re rate o f d isap p e aran ce )
J tre atm e n t
sp le n e cto m y
re d u ce s n u m b e r o f tran sfu sio n s, n u m b e r o f
in fe ctio n s, p re ve n ts h e m o rrh age , an d d e cre ase s p ain
SPLENECTOMY
J in d icatio n s
always
p rim ary sp le n ic tu m o u r rare )
h e re d itary sp h e ro cyto sis
u su ally
p rim ary h yp e rsp le n ism
ch ro n ic im m u n e th ro m b o cyto p e n ia p u rp u ra
sp le n ic ve in th ro m b o sis cau sin g e so p h age al varice s
sp le n ic ab sce ss
N o te s
SPLEEN. . . CONT.
so m e tim e s
sp le n ic in ju ry m o st co m m o n re aso n fo r sp le n e cto m y)
sh o rt te rm
ate le ctasis o f th e le ft lo we r lu n g
in ju ry to su rro u n d in g stru ctu re s e .g. gastric wall, tail o f p an cre as
p o st-o p h e m o rrh age
p o st-o p th ro m b o cyto sis, le u ko cyto sis
su b p h re n ic ab sce ss
lo n g te rm
p o st-sp le n e cto m y se p sis e n cap su late d o rgan ism s)
4% o f sp le n e cto m ize d p atie n ts
50% fatality
J p ro p h ylaxis
vaccin atio n s: p n e u m o co ccal, Haemophilus influenzae
p e n icillin fo r ch ild re n < 1 8 ye ars o ld
FISTULA
J ab n o rm al co m m u n i cati o n b e twe e n two e p i th e li ali ze d su rface s
J e ti o lo gy
fo re i gn o b je ct e ro si o n e .g. gallsto n e , graft)
i n fe cti o n
I B D e sp e ci ally C ro h n 's d i se ase )
co n ge n i tal
trau m a
i atro ge n i c
J wh y fistu las stay o p e n F R IE N D O )
Fo re ign b o d y
Rad iatio n
In fe ctio n
Ep ith e lializatio n
Ne o p lasm
Distal o b stru ctio n m o st co m m o n )
Oth e rs: in cre ase d flo w; ste ro id s m ay in h ib it clo su re , b u t u su ally
will n o t m ain tain fistu la)
J b o we l fistu la m an age m e n t
re lie ve o b stru ctio n
flu id an d e le ctro lyte b alan ce
n u tritio n - e le m e n tal/lo w re sid u e
d e cre ase flo w - N P O , T P N
d e cre ase se cre tio n - o ctre o tid e /so m ato statin
skin care e n te ro cu tan e o u s fistu la - p ro te o lytic e n ze ym e s)
id e n tify an ato m y - fistu lo gram
su rgical in te rve n tio n d e p e n d e n t u p o n e tio lo gy, o r
u n ce rtain ty o f d iagn o sis
BREAST
FIBROCYSTIC DISEASE
J b e n ign b re ast co n d itio n co n sistin g o f fib ro u s an d
cystic ch an ge s in b re ast
J age 30-50 ye ars
J p ain with m u ltip le b ilate ral lu m p s
J flu ctu ate in size an d te n d e rn e ss with m e n stru al cycle
J if n o d o m in an t m ass, o b se rve to e n su re n o m ass d o m in ate s
J fo r a d o m in an t m ass, F in e N e e d le Asp iratio n se e b e lo w)
J if > 40 ye ars, m am m o grap h y e ve ry 3 ye ars
FIBROADENOMA
J m o st co m m o n b e n ign b re ast tu m o u r in wo m e n
J n o m align an t p o te n tial
J u su ally age < 30 ye ars
J sm o o th , ru b b e ry, d iscre te n o d u le , n o n -te n d e r, m o b ile
J u su ally e xcise d to co n firm d iagn o sis
N o te s
BREAST. . . CONT.
FAT NECROSIS
J d u e to trau m a alth o u gh p o sitive h isto ry in o n ly 50%)
J firm , ill-d e fin e d m ass with skin o r n ip p le re tractio n
J +/ te n d e rn e ss
J will re gre ss o n o wn b u t co m p le te e xcisio n al b io p sy th e safe st
ap p ro ach to ru le o u t carcin o m a
PAPILLOMA
J so litary in trad u ctal b e n ign p o lyp
J m o st co m m o n cau se o f b lo o d y n ip p le d isch arge
DIFFERENTIAL DIAGNOSIS OF NIPPLE DISCHARGE
J b lo o d y - p ap illo m a, p ap illary/in trad u ctal carcin o m a, P age t s, fib ro cystic ch an ge
J se ro u s - d u ct h yp e rp lasia, p re gn an cy, B C P, m e n se s, can ce r
J gre e n /b ro wn - m am Illary d u ct e ctasia, fib ro cystic ch an ge
J p u ru le n t - ab sce ss
J m ilky - p o stlactatio n , B C P, p ro lactin o m a
MASTITIS
J n u rsin g m o th e rs; sp o rad ic o r e p id e m ic
J e tio lo gic age n t: S . aureus
J u n ilate ral lo calize d p ain , te n d e rn e ss an d e ryth e m a
J sp o rad ic: acin ar an d d u ct syste m s u n in vo lve d , th e re fo re , in fan t
sh o u ld co n tin u e b e in g n u rse d
J re cu rre n t: d u e to re gu rgitatio n o f m ilk b ack in to d u cts,
th e re fo re , d isco n tin u e n u rsin g an d su p p re ss lactatio n
J an tib io tic th e rap y: if start d e laye d > 24 h o u rs, in cre ase d risk o f
ab sce ss re q u irin g in cisio n an d d rain age
BREAST CANCER
m o st co m m o n can ce r i n wo m e n e xclu d i n g ski n )
se co n d le ad i n g cau se o f can ce r m o rtali ty i n wo m e n
m o st co m m o n cau se o f d e ath i n 5th d e cad e
li fe ti m e ri sk o f l/9
J e ti o lo gy
m u lti facto ri al
ge n e ti cs p lay ke y ro le i n 1 5% o f case s
J ri sk facto rs
age - 80% > 40
se x - 99% fe m ale
1 st d e gre e re lati ve wi th b re ast can ce r
ri sk i n cre ase d fu rth e r i f re lati ve was p re m e n o p au sal
ge o grap h i c - h i gh e st n ati o n al m o rtali ty i n E n glan d an d
Wale s, lo we st i n Jap an
n u lli p ari ty
late age at fi rst p re gn an cy
m e n arch e < 1 2; m e n o p au se > 55
o b e si ty
e xce ssi ve alco h o l i n take
so m e fo rm s o f m am m ary d ysp lasi a
p ri o r h i sto ry o f b re ast can ce r
h i sto ry o f lo w-d o se i rrad i ati o n
p ri o r b re ast b i o p sy re gard le ss o f p ath o lo gy
B C P /e stro ge n re p lace m e n t m ay i n cre ase ri sk
J d iagn o stic wo rku p o f b re ast m ass
h isto ry
h o w lo n g th e lu m p h as b e e n n o te d
an y ch an ge s th at h ave b e e n o b se rve d
h isto ry o f b io p sy o r b re ast can ce r
b re ast C A risk facto rs sh o u ld b e n o te d , b u t th e ir p re se n ce o r ab se n ce
d o n o t in flu e n ce d e cisio n to fu rth e r in ve stigate b re ast lu m p
p h ysical
to id e n tify th o se fe atu re s th at d istin gu ish m align an t
fro m b e n ign lu m p
b e n ign : sm o o th , we ll-d e m arcate d , m o b ile
m align an t: irre gu lar, p o o rly d e fin e d , le ss m o b ile
o th e r sign s o f m align an cy
skin ch an ge s: e d e m a, d im p lin g, re tractio n , re d n e ss, u lce ratio n
n ip p le : b lo o d y d isch arge , cru stin g, u lce ratio n , in ve rsio n
p ro m in e n t ve in s, p alp ab le axillary/su p raclavicu lar lym p h n o d e s, arm e d e m a
N o te s
BREAST. . . CONT.
m am m o gram
ste llate ap p e aran ce an d sp icu late d b o rd e r -
p ath o gn o m o n ic o f b re ast can ce r
m icro calcificatio n s
ill-d e fin e d le sio n b o rd e r
lo b u latio n
arch ite ctu ral d isto rtio n
in cre ase d vascu larity
in te rval m am m o grap h ic ch an ge s
N O R M AL M AM M O G R AM D O E S N O T R U L E O U T S U S P IC IO N O F
C AN C E R B AS E D O N C L IN IC AL F IN D IN G S )
F in e N e e d le Asp iratio n
if n o n -b lo o d y flu id an d m ass co m p le te ly d isap p e ars,
d iagn o sis is sim p le cyst - n o n e e d fo r cyto lo gy
if b lo o d y/n o flu id o r m ass d o e s n o t fu lly d isap p e ar -
se n d ce lls fo r cyto lo gy
b io p sy
wh e n e ve r re aso n ab le d o u b t re m ain s as to wh e th e r a
lu m p is b e n ign o r m align an t
co re b io p sy - re m o val o f co re o f in tact tissu e th ro u gh 1 4-gau ge n e e d le
e xcisio n al b io p sy - su rgical re m o val o f e n tire le sio n with
cu ff o f n o rm al tissu e
J stagin g
clin ical vs. p ath o lo gical
clin ical: asse ss tu m o u r size , n o d al in vo lve m e n t, an d m e tastasis
tu m o u r size b y p alp atio n , m am m o gram
n o d al in vo lve m e n t b y p alp atio n
m e tastasis b y p h ysical e xam , C XR , L F Ts
p ath o lo gical
h isto lo gy
axillary d isse ctio n sh o u ld b e p e rfo rm e d fo r accu rate
stagin g an d to re d u ce risk o f axillary re cu rre n ce
e stro ge n /p ro ge ste ro n e re ce p to r te stin g
Table 7. Staging of Bre as t Cance r (Ame rican Joint Committe e )
Stage Tumour Node s (re gional) Me tas tas is
0 i n si tu n o n e n o n e
I < 2 cm n o n e n o n e
I I < 2 cm m o vab le i p si late ral n o n e
o r 2-5 cm n o n e o r m o vab le i p si late ral n o n e
o r > 5 cm n o n e n o n e
I I I an y si ze fi xe d i p si late ral o r i n te rn al m am m ary n o n e
o r ski n /ch e st an y n o n e
wall i n vasi o n
I V an y tu m o u r an y d i stan t
J p ath o lo gy
n o n -in vasive
d u ctal carcin o m a in situ
risk o f d e ve lo p m e n t o f in filtratin g d u ctal carcin o m a in sam e b re ast
e xcisio n with cle ar m argin s +/ rad iatio n
lo b u lar carcin o m a in situ
risk m arke r fo r fu tu re in filtratin g d u ctal carcin o m a
in e ith e r b re ast 20 to 30 % twe n ty ye ar risk)
clo se fo llo w-u p co n sid e r b ilate ral
m aste cto m y fo r h igh -risk p atie n t)
i n vasi ve
i n fi ltrati n g d u ctal carci n o m a m o st co m m o n - 80% )
ch aracte ri sti cs - h ard , sci rrh o u s, i n fi ltrati n g
te n tacle s, gri tty o n cro ss-se cti o n
i n vasi ve lo b u lar carci n o m a 8-1 0% )
m o re ap t to b e b i late ral, b e tte r p ro gn o si s
P age t s d i se ase 1 -3% )
d u ctal carci n o m a th at i n vad e s n i p p le wi th scali n g, e cze m ato i d le si o n
i n flam m ato ry carci n o m a 1 -4% )
d u ctal carci n o m a th at i n vo lve s d e rm al lym p h ati cs
m o st aggre ssi ve fo rm o f b re ast can ce r
p e au d o ran ge i n d i cate s ad van ce d d i se ase I I I b -I V)
also p ap i llary, m e d u llary, co llo i d , tu b u lar can ce rs
N o te s
BREAST. . . CONT.
sarco m as o f b re ast rare )
m o st co m m o n = gi an t b e n i gn vari an t o f
fi b ro ad e n o m a cysto sarco m a p h yllo d e s) -
1 i n 1 0 m ali gn an t
Primary Tre atme nt of Bre as t Cance r
J stage s I, II - su rge ry fo r cu re
B re ast C o n se rvin g S u rge ry lu m p e cto m y)
re m o val o f tu m o u r alo n g with cu ff o f n o rm al tissu e , p re se rvin g
co sm e tic ap p e aran ce o f b re ast
ad ju van t rad iatio n to b re ast d e cre ase s lo cal re cu rre n ce
n o ch an ge in su rvival)
re su lts ge n e rally e q u al to m aste cto m y
m aste cto m y
re m o val o f e n tire b re ast in clu d in g n ip p le an d fascia o ve rlyin g
p e cto ralis m u scle s, wh ile sp arin g u n d e rlyin g m u scle s an d in n e rvatio n
in d icatio n s
facto rs th at in cre ase risk o f lo cal re cu rran ce : e xte n sive
calcificatio n o n m am m o gram , m u ltip le tu m o u rs, o r failu re
to o b tain tu m o u r-fre e m argin
co n train d icatio n s to rad iatio n th e rap y: p re gn an cy, p re vio u s irrad iatio n ,
co llage n vascu lar d ise ase , p h ysical d isab ility p re clu d in g tre atm e n t
large tu m o u r size re lative to b re ast
p atie n t p re fe re n ce n o n e e d fo r rad iatio n )
se e figu re 1 0
J stage s III, IV - o p e rate fo r lo cal co n tro l
J in d u ctio n ch e m o th e rap y
tu m o u rs > 5 cm
in flam m ato ry carcin o m as
ch e st wall o r skin e xte n sio n
S tage I o r II
M aste cto m y M R M ) /axillary n o d e d isse ctio n
o r
S e gm e n tal M aste cto m y lu m p e cto m y)
+axillary n o d e d isse ctio n
+rad iatio n th e rap y
P re m e n o p au sal P o stm e n o p au sal
E R +ve E R ve E R +ve E R ve
N o d e s N o d e s N o d e s N o d e s
ve +ve ve +ve ve +ve ve +ve
?)
C o n sid e r C o m b in atio n Tam o xife n C o n sid e r
Tam o xife n C h e m o th e rap y C o m b in atio n
C h e m o th e rap y
N B co n tro ve rsy re late d to ad ju van t ch e m o th e rap y fo r p re m e n o p au sal n o d e ve
Figure 10. NIH Re comme ndations
Adjuvant The rapy - Che mothe rapy
J i n d i cati o n s
su b -gro u p s o f stage I at h i gh ri sk o f re cu rre n ce
lym p h ati c i n vasi o n
h i gh -grad e tu m o u rs
h i gh S -p h ase fracti o n
an e u p lo i d D N A
J p re -m e n o p au sal p ati e n ts te n d to h ave b e tte r re sp o n se to cyto to xi c
ch e m o th e rap y b e cau se o f te n d e n cy fo r m o re aggre ssi ve tu m o u rs
N o te s
BREAST. . . CONT.
J tre atm e n t
p o stm e n o p au sal p ati e n ts wi th p o si ti ve lym p h n o d e s,
n e gati ve e stro ge n re ce p to rs
C M F x 6 m o n th s
Adjuvant The rapy - Hormonal
J e stro ge n an d p ro ge ste ro n e re ce p to rs
h e lp s p re d i ct li ke li h o o d o f re gre ssi o n wh e n tre ate d
wi th h o rm o n al th e rap y
p ro gn o sti c si gn i fi can ce
J m o st co m m o n ad ju van t th e rap y = Tam o xi fe n an ti -e stro ge n )
J se co n d ary tre atm e n ts
p re vi o u s cli n i cal re sp o n se to o n e h o rm o n al tre atm e n t p re d i cts
re sp o n se to an o th e r, th u s se co n d ary h o rm o n al th e rap i e s
th e rap i e s are i n sti tu te d
p ro ge sti n s - m e ge stro l ace tate M e gace )
aro m atase i n h i b i to rs - i n d u ce m e d i cal ad re n ale cto m y
e .g. am i n o -glu te th am i d e +h yd ro co rti so n e
e stro ge n s - d i e th ylsti lb e stro l
an d ro ge n s - flu o xym e ste ro n e
o o p h o re cto m y - p re m e n o p au sal p ati e n ts wi th m e tastati c
d i se ase n o b e n e fi t o ve r tam o xi fe n
Adjuvant The rapy - Radiation
with b re ast-co n se rvin g su rge ry
th o se with h igh -risk o f lo cal re cu rre n ce
ad ju van t rad iatio n to b re ast d e cre ase s lo cal re cu rre n ce , in cre ase s
d ise ase fre e su rvival n o ch an ge in o ve rall su rvival)
Pos t-Surgical Bre as t Cance r
J fo llo w-u p o f p o st-m aste cto m y p ati e n t
h i sto ry an d p h ysi cal e ve ry 4-6 m o n th s
ye arly m am m o gram o f re m ai n i n g b re ast
J fo llo w-u p o f se gm e n tal m aste cto m y p ati e n t
h i sto ry an d p h ysi cal e ve ry 4-6 m o n th s
m am m o gram s e ve ry 6 m o n th s x 2 ye ars,
th e n ye arly th e re afte r
J wh e n cli n i cally i n d i cate d
ch e st x-ray
b o n e scan
L F Ts
C T o f ab d o m e n
C T o f b rai n
Local-Re gional Re curre nce
J re cu rre n ce i n tre ate d b re ast o r i p si late ral axi lla; 1 0% d e ve lo p
co n tralate ral m ali gn an cy
J 50% h ave m e tastati c d i se ase - n e e d m e tastati c wo rku p ; o ccu rs
m o st fre q u e n tly i n fi rst 3 ye ars
J co m p le te su rgi cal e xci si o n o r rad i ati o n th e rap y o r b o th
J tre atm e n t i s p alli ati ve fo r th i s gro u p
Me tas tatic Dis e as e
J lu n g 65%
J b o n e 56%
J li ve r 56%
Scre e ning
J i m p o rtan ce o f e arly d e te cti o n
J b re ast se lf e xam , start age 20
J m am m o grap h y > 50 ye ars e ve ry 1 -2 ye ars o r e ve ry ye ar i f h i gh ri sk
Prognos is
J all p atie n ts: 63% 5 ye ar su rvival, 46% 1 0 ye ar su rvival
J m o st re liab ly d e te rm in e d b y stage
J if d ise ase lo calize d to b re ast: 75-90% clin ical cu re rate
J if lo calize d an d re ce p to r-p o sitive : 90% 5-ye ar su rvival
J if p o sitive axillary n o d e s: 40-50% 5-ye ar su rvival, 25% 1 0-ye ar su rvival
N o te s
BREAST. . . CONT.
MALE BREAST LUMPS
J gyn e co m asti a
J b re ast carci n o m a
u su ally > 50 ye ars
h ard , p ai n le ss lu m p +/ n i p p le re tracti o n , d i sch arge ,
u lce rati o n
o fte n m e tastati c at ti m e o f d i agn o si s, th e re fo re , p o o r
p ro gn o si s
THYROID
se e O to laryn go lo gy/E n d o crin o lo gy N o te s)
VASCULAR - ARTERIAL DISEASES
ARTERIAL INSUFFICIENCY
J ge n e ral o ve rvi e w
m ajo r ri sk facto rs
sm o ki n g
h yp e rte n si o n
h yp e rch o le ste ro le m i a
m i n o r ri sk facto rs: d i ab e te s, h yp e rtri glyce ri d e m i a, o b e si ty,
se d e n tary li fe style , fam i ly h i sto ry
p re d o m i n an tly lo we r e xtre m i ti e s
fe m o ro p o p li te al syste m m o re co m m o n th an ao rto i li ac
tan d e m le si o n s o fte n p re se n t
CHRONIC ISCHEMIA
J p re d o m i n an tly d u e to ath e ro scle ro si s
J 80% i m p ro ve o r re m ai n u n ch an ge d wi th co n se rvati ve
tre atm e n t, 5% d e ve lo p gan gre n e
J si gn s an d sym p to m s
clau d i cati o n : 3 co m p o n e n ts
1 ) d i sco m fo rt wi th e xe rti o n - u su ally i n calve s
2) re li e ve d b y re st - 5 to 1 0 m i n u te re st
3) re p ro d u ci b le - clau d i cati o n d i stan ce
p u lse s: m ay b e ab se n t at so m e lo cati o n s d o cu m e n t all p u lse s)
si gn s o f p o o r p e rfu si o n : h ai r lo ss, d e fo rm e d n ai ls, atro p h i c
ski n , u lce rati o n s an d i n fe cti o n s
o th e r m an i fe stati o n s o f ath e ro scle ro si s; C VD , C AD
J d i ffe re n ti al d i agn o si s
sp i n al ste n o si s
d i sc d i se ase
arth ri ti s
ve n o u s d i se ase
h an d -h e ld D o p p le r to co n fi rm , asse ss an d q u an ti fy p re ssu re s
an kle -b rach i al i n d e x: AB I = an kle systo li c p re ssu re
d i vi d e d b y th e arm systo li c p re ssu re
AB I > 1 n o rm al; AB I < 0.5 re st p ai n ;
AB I < 0.3 i n ju ri e s u su ally can n o t h e al
an gi o gram = go ld stan d ard
J tre atm e n t
co n se rvati ve
90% o f clau d i can ts tre ate d co n se rvati ve ly i m p ro ve
d e cre ase ri sk facto rs: sto p sm o ki n g, m an age d i ab e te s
an d h yp e rte n si o n , lo se we i gh t, lo we r fat i n take
e xe rci se p ro gram to trai n m u scle s an d d e ve lo p
co llate ral ci rcu lati o n
fo o t care e sp e ci ally i n d i ab e te s)
cle an se b e twe e n to e s, cu t n ai ls care fu lly, tre at
so re /i n fe cti o n p ro m p tly
N o te s
VASCULAR - ARTERIAL DISEASES . . . CONT.
su rgi cal
co n si d e r i f su b je cti ve d i sab i li ty i s se ve re ,
i .e . walk < 1 b lo ck
se e b e lo w fo r su rgi cal o p ti o n s
CRITICAL ISCHEMIA
J arte ri al co m p ro m i se e ve n tu ally le ad i n g to n e cro si s
re st p ai n , n i gh t p ai n i n le gs re li e ve d b y h an gi n g fe e t
o ve r si d e o f b e d
u lce rati o n s, gan gre n e o f to e s
p allo r o n e le vati o n , d e p e n d e n t ru b o r, slo w cap i llary re fi ll
d e cre ase d o r ab se n t p u lse s
si gn i fi can t b ru i ts m ay b e h e ard at 50% o cclu si o n ) - i f
ste n o si s se ve re , n o b ru i t wi ll b e h e ard
AB I < 0.5
as ab o ve
J tre atm e n t
n e e d s i m m e d i ate su rge ry d u e to ri sk o f li m b lo ss
i n i ti al p ro ce d u re s: tran slu m i n al an gi o p lasty, lase r,
ath e re cto m y an d ste n ts
o p e rati o n s i n clu d e
i n flo w p ro ce d u re s fo r ao rto i li ac d i se ase
e n d arte re cto m y
re co n stru cti ve p ro ce d u re s fo r su p e rfi ci al fe m o ral
arte ry o cclu si o n
p ro fu n d o p lasty
fe m o ro p o p li te al b yp ass
ao rto i li ac o r ao rto fe m o ral b yp ass
axi llo fe m o ral b yp ass u n co m m o n )
ACUTE LIMB ISCHEMIA
J ti m e i s o f th e e sse n ce : afte r 6 h o u rs, i sch e m i a an d m yo n e cro si s
i rre ve rsi b le
J e m b o li
e ti o lo gy
card i ac so u rce - m o st co m m o n ; m u ral th ro m b u s
fro m p re vi o u s M I , atri al fi b ri llati o n , rh e u m ati c
h e art d i se ase , m i tral ste n o si s, card i o m yo p ath y,
e n d o card i ti s, atri al m yxo m a
arte ri al so u rce - p ro xi m al arte ri al so u rce su ch as
an e u rysm , ath e ro e m b o li sm
p arad o xi cal e m b o li sm - ve n o u s e m b o lu s p assi n g
th ro u gh i n tracard i ac sh u n t
p re se n tati o n
su d d e n o n se t
n o p ast h i sto ry o f clau d i cati o n
p u lse s o fte n p re se n t i n co n tralate ral li m b
m ay h ave e m b o li to o th e r lo cati o n s i .e . h e ad ,
arm , ki d n e y
J arte ri al th ro m b o si s
e ti o lo gy
ath e ro scle ro si s, co n ge n i tal an o m aly, i n fe cti o n ,
h e m ato lo gi c d i so rd e rs, lo w flo w state s e .g. C H F
p re se n tati o n
d e ve lo p s o ve r a fe w d ays wi th grad u al
p ro gre ssi o n o f sym p to m s
p ast h i sto ry o f clau d i cati o n
atro p h i c ch an ge s o b vi o u s
n o co n tralate ral p u lse s u su ally n o te d
J o th e rs
arte ri al trau m a, d ru g-i n d u ce d vaso sp asm i lli ci t d ru g
u se ) , ao rti c d i sse cti o n , se ve re ve n o u s th ro m b o p h le b i ti s,
p ro lo n ge d i m m o b i li zati o n , i d i o p ath i c
J p h ysi cal e xam i n ati o n an d i n ve sti gati o n s
card i ac e xam i n clu d i n g co m p le te b i late ral p u lse e xam i n ati o n
6 " P 's" o f acu te arte ri al i n su ffi ci e n cy
p ai n , p allo r, p u lse le ss, p are sth e si a, p aralysi s, p o lar co ld )
N o te s
atro p h i c ski n an d n ai l ch an ge s - lo n gstan d i n g arte ri al i n su ffi ci e n cy
C XR , E C G , arte ri o grap h y
J m an age m e n t
i m m e d i ate h e p ari n i zati o n i n all case s
th ro m b u s
p lan b yp ass wi th an gi o gram , b yp ass o cclu si o n
e m b o lu s: e m b o le cto m y
su rgi cal
F o garty cath e te r
re p e at an gi o grap h y
i d e n ti fy an d tre at u n d e rlyi n g cau se
co n ti n u e h e p ari n p o st-o p , start warfari n p o st-o p d ay 3
re p e rfu si o n p h e n o m e n o n
to xi c m e tab o li te s fro m i sch e m i c m u scle > re n al
fai lu re an d m u lti o rgan syste m fai lu re
b e ware co m p artm e n t syn d ro m e wi th p ro lo n ge d i sch e m i a;
re q u i re s fasci o to m y
tre atm e n t o f i rre ve rsi b le i sch e m i a i s am p u tati o n
ABDOMINAL AORTIC ANEURYSM
J an e u rysm = a p e rm an e n t in cre ase in arte rial d iam e te r > 50% o f
n o rm al arte ry
J AAAs m o st co m m o n ly in frare n al
J in cid e n ce = 1 .8-6.6%
J fre q u e n tly asso ciate d with o th e r p e rip h e ral an e u rysm s
Etiology
J > 95% d u e to ath e ro scle ro si s
J o th e rs - trau m a, i n fe cti o n , co n n e cti ve ti ssu e d i se ase
J h i gh ri sk gro u p s
> 65 ye ars o ld
m ale :fe m ale = 3.8:1
p e ri p h e ral vascu lar d i se ase , C AD , C VD
fam i ly h i sto ry AAA
Clinical Pre s e ntation
J 75% asym p to m ati c o fte n d i sco ve re d i n ci d e n tally)
J sym p to m s d u e to acu te e xp an si o n o r d i sru p ti o n o f wall
syn co p e , p ai n ab d o m i n al, flan k, b ack)
J p arti al b o we l o b stru cti o n
J d u o d e n al m u co sal h e m o rrh age > G I b le e d
J e ro si o n o f ao rti c an d d u o d e n al walls> ao rto d u o d e n al fi stu la
J e ro si o n i n to I VC > ao rto caval fi stu la
J d i stal e m b o li zati o n
J si gn s
h yp o te n si o n
p alp ab le m ass fe lt at/ab o ve u m b i li cu s
b o u n d i n g fe m o ral p u lse s
d i stal p u lse s m ay b e i n tact
U /S co n fi rm AAA wi th i n i ti ally)
C T accu rate vi su ali zati o n )
Tre atme nt and Prognos is
J i n d i cati o n fo r o p e rati o n i s to p re ve n t ru p tu re
J ri sk o f ru p tu re d e p e n d s o n
si ze
4-5 cm - 5%
5-6 cm - 20%
> 6 cm -50%
rate o f gro wth > 0.4 cm /yr
p re se n ce o f sym p to m s, h yp e rte n si o n , C O P D
J o p e rate at 5-6 cm si n ce ri sk o f ru p tu re > ri sk o f su rge ry
m o rtali ty o f e le cti ve re p ai r = 3-5% m o stly d u e to M I )
J co n si d e r re vascu lari zati o n fo r p ati e n ts wi th C AD b e fo re
e le cti ve re p ai r
N o te s
RUPTURED ABDOMINAL AORTIC ANEURYSM
J 1 00% m o rtali ty i f u n tre ate d
J d i agn o si s m u st b e m ad e b y h i sto ry an d p h ysi cal
classi c tri ad - ab d o m i n al p ai n , p u lsati le ab d o m i n al m ass,
syn co p e
n e arly p ath o gn o m o n i c fo r R AAA
su d d e n co llap se
sh o ck, p e ri p h e ral vaso co n stri cti o n , h yp o te n si o n , an u ri a
re tro p e ri to n e al R AAA m ay n o t cau se h yp o te n si o n o r tri ad
E C G co n fu si n g
m ay sh o w card i ac i sch e m i a
J i f p ati e n t stab le wi th o u t classi c tri ad > co n si d e r C T
J d o n o t waste ti m e i n rad i o lo gy i f R AAA stro n gly su sp e cte d
J tre atm e n t
i n i ti al re su sci tati o n i n clu d i n g vascu lar acce ss, n o ti fy O R ,
e n su re avai lab i li ty o f b lo o d p ro d u cts, i n vasi ve m o n i to ri n g
J p ro gn o si s
45% su rvi val fo r p ati e n ts wh o m ake i t to O R
AORTIC DISSECTION
J u su ally i n th o raci c ao rta
starts wi th i n ti m al te ar> e n try o f b lo o d se p arate s
m e d i a > false lu m e n cre ate d > d i sse cti o n o fte n
co n ti n u e s to ao rti c b i fu rcati o n
J m ale :fe m ale = 3-4:1
J p re d o m i n an tly o ld e r p ati e n ts
J e ti o lo gi c facto rs
h yp e rte n si o n
cysti c m e d i al n e cro si s n o t ath e ro scle ro si s)
J asso ci ate d facto rs
M arfan 's S yn d ro m e
co arctati o n o f ao rta
co n ge n i tal b i cu sp i d ao rti c valve
J cli n i cal m an i fe stati o n s
su d d e n se ari n g ch e st p ai n th at rad i ate s to b ack
b ran ch ve sse l sh e are d o ff" le ad i n g to vari o u s i sch e m i c
syn d ro m e s
M I wi th p ro xi m al e xte n si o n to co ro n ary arte ri e s
" u n se ati n g" o f ao rti c valve cu sp s
n e w d i asto li c m u rm u r i n 20-30%
asym m e tri c B P s an d p u lse s b e twe e n arm s
n e u ro lo gi c i n ju ry - stro ke 1 0% ) an d sp i n al co rd
p arap le gi a 3-5% )
re n al i n su ffi ci e n cy
lo we r li m b i sch e m i a
card i ac tam p o n ad e wi th ru p tu re o f false lu m e n i n to
p e ri card i u m
75-85% o f p ati e n ts h yp e rte n si ve
J d i agn o si s an d i n ve sti gati o n s
C XR
p le u ral cap
wi d e n e d m e d i asti n u m
le ft p le u ral e ffu si o n wi th e xtravasati o n o f b lo o d
E C G
m o st co m m o n ab n o rm ali ty i s LVH 90% )
tran se so p h age al e ch o card i o grap h y
C T
ao rto grap h y
J tre atm e n t
i m m e d i ate d ru g th e rap y to lo we r B P an d d e cre ase
card i ac co n tracti li ty
u su ally so d i u m n i tro p ru ssi d e an d -b lo cke r
asce n d i n g ao rti c d i sse cti o n s o p e rate d o n e m e rge n tly
d e sce n d i n g ao rti c d i sse cti o n s i n i ti ally m an age d m e d i cally
1 0-20% re q u i re u rge n t o p e rati o n fo r co m p li cati o n s
N o te s
VASCULAR-VENOUS DISEASES
DEEP VEIN THROMBOSIS
Vi rch o w's Tri ad - stasi s, h yp e rco agu lab i li ty, e n d o th e li al d am age
J ri sk facto rs
stasi s
su rge ry
trau m a an d su b se q u e n t i m m o b i li zati o n
i m m o b i li zati o n d u e to : acu te M I , stro ke , C H F
h yp e rco agu lab i li ty
p re gn an cy
e stro ge n u se
n e o p lasm s: d i agn o se d , o ccu lt, u n d e rgo i n g
ch e m o th e rap y
ti ssu e trau m a: acti vati o n o f co agu lati o n
n e p h ro ti c syn d ro m e
d e fi ci e n cy o f an ti -th ro m b i n I I I , p ro te i n C o r S
e n d o th e li al d am age : ve n u li ti s, trau m a
m o st fre q u e n t si te o f th ro m b u s fo rm ati o n i s calf
i so late d calf th ro m b i o fte n asym p to m ati c
30-50% are asym p to m ati c o r m i n i m al sym p to m s
20-30% e xte n d p ro xi m ally an d acco u n t fo r m o st
cli n i cally si gn i fi can t e m b o li
classi c p re se n tati o n < 1 /3
calf o r th i gh d i sco m fo rt
e d e m a
ve n o u s d i ste n si o n
J co m p li cati o n s
vari co se ve i n s
ch ro n i c ve n o u s i n su ffi ci e n cy
p u lm o n ary e m b o lu s
ve n o u s gan gre n e
p h le gm asi a ce ru le a d o le n s P C D ) - m assi ve D VT wi th
clo t e xte n si o n to i li o fe m o ral syste m an d m assi ve ve n o u s
o b stru cti o n re su lti n g i n a cyan o ti c, i m m e n se ly swo lle n ,
e xtre m e ly p ai n fu l an d cri ti cally i sch e m i c le g
ri sk ve n o u s gan gre n e
p h le gm asi a alb a d o le n s PAD ) - as ab o ve wi th ad d i ti o n al
re fle x arte ri al sp asm re su lti n g i n le ss swe lli n g th an P C D
co o l le g an d d e cre ase d p u lse s
J d i agn o si s re fe r to P I O P E D stu d y fo r d e tai ls)
h i sto ry an d p h ysi cal
calf te n d e rn e ss i f e li ci te d o n an kle
d o rsi fle xi o n = H o m an s si gn )
wi d e r ci rcu m fe re n ce o f affe cte d le g
fe ve r P O D 7-1 0
cli n i cal asse ssm e n t i n co rre ct 50% ti m e , th e re fo re
m u st co n fi rm b y o b je cti ve m e th o d
n o n -i n vasi ve te sts
d u p le x d o p p le r U /S
93% se n si ti ve an d 98% sp e ci fi c fo r
sym p to m ati c p ati e n ts, d e cre ase d fo r
asym p to m ati c p ati e n ts
d e te cts p ro xi m al th ro m b i
i n i ti al n e gati ve e xam sh o u ld b e re p e ate d
6-7 d ays late r to d e te ct p ro xi m al e xte n si o n
i n vasi ve te sti n g
asce n d i n g p h le b o grap h y ve n o gram )
th e go ld stan d ard b u t co stly
d e te cts d i stal an d p ro xi m al th ro m b i
co m p li cate d b y co n trast-i n d u ce d th ro m b o si s
o f p e ri p h e ral ve i n s 2-3% )
J tre atm e n t
go als o f tre atm e n t
p re ve n t fo rm ati o n o f ad d i ti o n al th ro m b i
i n h i b i t p ro p agati o n o f e xi sti n g th ro m b i
m i n i m i ze d am age to ve n o u s valve s
p re ve n t p u lm o n ary e m b o li
25% d e ve lo p P E i f u n tre ate d ; 5% i f tre ate d
N o te s
VASCULAR-VENOUS DISEASES . . . CONT.
co n se rvati ve
b e d re st wi th li m b e le vati o n fo r 1 -3 d ays
m e d i cal
I V h e p ari n , 5000 U b o lu s +1 000 U /h r to ke e p
aP T T 2-2.5x co n tro l
co n ve rt to warfari n 3-7 d ays afte r fu ll
h e p ari n i zati o n
3-6 m o n th s o f p ro p h ylacti c warfari n agai n st
re cu rre n ce
ri sks o f th e rap y - b le e d i n g, h e p ari n -i n d u ce d
th ro m b o cyto p e n i a, warfari n i s te rato ge n i c
su rgi cal
ve n o u s th ro m b e cto m y - i f arte ri al i n su ffi ci e n cy
wi th e xte n si ve i li o fe m o ral th ro m b o si s,
+/ ve n o u s gan gre n e
I VC G re e n fi e ld ) fi lte r- i n se rte d p e rcu tan e o u sly
i n d i cati o n s
re cu rre n t P E d e sp i te an ti co agu lati o n
co n trai n d i cati o n to an ti co agu lati o n
e .g. i n tra-cran i al trau m a
ce rtai n o p e rati o n s fo r can ce r, p u lm o n ary
e m b o le cto m y
se p ti c e m b o li re fracto ry to co m b i n ati o n
an ti b i o ti c an d an ti co agu lati o n
" fre e -flo ati n g" th ro m b u s lo o se ly ad h e re n t to
wall o f I VC o r p e lvi c ve i n s
I VC li gati o n , su rgi cal cli p s - i n cre ase s ri sk o f
ve n o u s i n su ffi ci e n cy; rare ly u se d
J D VT p ro p h ylaxi s
co n se rvati ve
m i n i m i ze ri sk facto rs
e arly am b u lati o n , p assi ve ran ge o f m o ti o n
an ti -e m b o li sm sto cki n gs
p n e u m ati c se q u e n ti al co m p re ssi o n d e vi ce s
e le vati o n o f li m b
m e d i cal p ro p h ylaxi s
o p ti m i ze h yd rati o n
E C AS A, d e xtran , warfari n , m i n i d o se h e p ari n
5,000 U S C q 8-1 2h ) i n h i gh ri sk si tu ati o n s
VARICOSE VEINS
J saccu lar d i latati o n s an d e lo n gati o n o f su p e rfi ci al ve i n s o f le g
J can also o ccu r i n
e so p h agu s - e so p h age al vari ce s
an o re ctu m - h e m o rrh o i d s
scro tu m - vari co ce le
J e ti o lo gy
p ri m ary
m o st co m m o n fo rm o f ve n o u s d i so rd e r o f lo we r
e xtre m i ty
affe cts 1 0-20% o f p o p u lati o n
i n h e ri te d stru ctu ral we akn e ss o f ve i n wall i s
m ai n facto r
co n tri b u ti n g facto rs
age
fe m ale
B C P u se
o ccu p ati o n s re q u i ri n g lo n g h o u rs o f stan d i n g
p re gn an cy
o b e si ty
se co n d ary
re su lt o f i n cre ase d ve n o u s p re ssu re fro m
d e e p -ve n o u s valvu lar i n su ffi ci e n cy an d
i n co m p e te n t p e rfo rati n g ve i n s
m ali gn an t p e lvi c tu m o u rs wi th ve n o u s
co m p re ssi o n
co n ge n i tal an o m ali e s
aq u i re d /co n ge n i tal arte ri o ve n o u s fi stu lae
N o te s
gre ate r sap h e n o u s ve i n i s m o st fre q u e n tly i n vo lve d wi th
d i late d tri b u tari e s
d i ffu se ach i n g, fu lln e ss o r ti gh tn e ss, o ccasi o n al n o ctu rn al
cram p i n g
aggravate d b y p ro lo n ge d stan d i n g, e n d o f d ay, p ri o r to
m e n se s
re li e ve d b y e le vati o n o f le g, e lasti c sto cki n gs
J co m p li cati o n s
re cu rre n t su p e rfi ci al th ro m b o p h le b i ti s
h e m o rrh age - e xte rn ally o r i n to su b cu tan e o u s ti ssu e s
u lce rati o n , e cze m a, li p o d e rm ato scle ro si s, h yp e rp i gm e n tati o n
J p h ysi cal e xam
p ati e n t stan d i n g: lo n g, d i late d an d to rtu o u s su p e rfi ci al
ve i n s alo n g th i gh an d le g
i f u lce rati o n , h yp e rp i gm e n tati o n , i n d u rate d ap p e aran ce
th i n k se co n d ary vari co se ve i n s
B ro d i e -Tre n d e le n b e rg te st valvu lar co m p e te n ce te st)
wh i le p ati e n t i s su p i n e , rai se le g an d co m p re ss
sap h e n o u s ve i n at th i gh ; h ave p ati e n t stan d ; i f
ve i n s fi ll q u i ckly fro m to p d o wn th e n
i n co m p e te n t valve s; n o rm ally grad u al fi ll fro m
b o tto m u p ; d o te st wi th m u lti p le to u rn i q u e ts to
lo cali ze i n co m p e te n t co m m u n i cati n g ve i n s
J tre atm e n t
p ri m ary i n d i cati o n i s u su ally co sm e ti c
su rge ry fo r fai lu re o f co n se rvati ve m an age m e n t o r co m p li cati o n s
n o n -o p e rati ve
le g e le vati o n
grad u ate d co m p re ssi o n sto cki n gs
o p e rati ve
h i gh li gati o n o f sap h e n o fe m o ral ju n cti o n an d
stri p p i n g o f gre ate r sap h e n o u s ve i n
scle ro th e rap y-n o t favo re d
J p ro gn o si s
n atu ral h i sto ry b e n i gn , slo w wi th u n p re d i ctab le co m p li cati o n s
alm o st 1 00% sym p to m ati c re li e f i f vari co si ti e s are p ri m ary
ge n e rally go o d co sm e ti c re su lts
1 0% p o st-o p e rati ve re cu rre n ce
SUPERFICIAL THROMBOPHLEBITIS
J a co m b i n ati o n o f th ro m b o si s an d p h le b i ti s o ccu ri n g i n an y
su p e rfi ci al ve i n i n th e b o d y
p ai n an d co rd -li ke swe lli n g alo n g co u rse o f i n vo lve d ve i n ;
m o st co m m o n ly i n vo lve s lo n g sap h e n o u s ve i n
n o n -i n vasi ve te sts e .g. d u p le x d o p p le r U /S to e xclu d e
p re se n ce o f asso ci ate d D VT 5-1 0% )
J e ti o lo gy
trau m a
asso ci ati o n wi th vari co se ve i n s
m i grato ry su p e rfi ci al th ro m b o p h le b i ti s
B u e rge r's d i se ase
S L E
p o lycyth e m i a
th ro m b o cyto si s
o ccu lt m ali gn an cy e sp e ci ally p an cre as)
i d i o p ath i c
J tre atm e n t
co n se rvati ve
m o i st h e at, co m p re ssi o n b an d age s, m i ld
an alge si cs e .g. AS A) , am b u lati o n
su rgi cal - fo r fai lu re o f co n se rvati ve m e asu re s; e xci se
i n vo lve d ve i n
i f su p p u rati ve th ro m b o p h le b i ti s - I V an ti b i o ti cs
an d e xci se i n vo lve d ve i n
N o te s
CHRONIC DEEP VEIN INSUFFICIENCY
J p o st-p h le b i ti c syn d ro m e
J late co m p li cati o n o f D VT
J re can ali zati o n o f th ro m b o se d ve i n s wi th re su lti n g d am age d
i n co m p e te n t valve s
J i m p ai rm e n t o f calf m u scle p u m p
J su stai n e d ve n o u s h yp e rte n si o n
J o n se t i s we e ks to ye ars afte r i n i ti al th ro m b o si s
m o st co m m o n sym p to m i s p ai n ; re li e ve d o n re cu m b e n cy
an d fo o t e le vati o n
ach i n g fu lln e ss o f le g, e d e m a
p i gm e n tati o n - h e m o si d e ri n d e p o si ts
vari co se ve i n s
ve n o u s d e rm ati ti s
u lce rs ab o ve m e d i al m alle o lu s
p o si ti ve B ro d i e -Tre n d e le n b e rg
J d i agn o sti c te sts
go ld stan d ard i s am b u lato ry ve n o u s p re ssu re m e asu re m e n t
rare ly d o n e
d o p p le r U /S
p h o to p le th ysm o grap h y
J tre atm e n t
n o n -o p e rati ve
e lasti c co m p re ssi o n sto cki n gs, le g e le vati o n ,
avo i d p ro lo n ge d si tti n g/stan d i n g
u lce rs tre ate d wi th zi n c-o xi d e wrap s u n n a b o o t) ,
sp li t-th i ckn e ss ski n grafts, an ti b i o ti cs, d e b ri d e m e n t
o p e rati ve
co n si d e r afte r fai lu re o f co n se rvati ve m e asu re s,
re cu rre n t o r ve ry large u lce rati o n s
su rgi cal li gati o n o f p e rfo rato rs i n re gi o n o f u lce r,
stri p gre ate r sap h e n o u s ve i n
HIV AND GENERAL SURGERY
GI Manife s tations
J co m m o n p ath o ge n s
C yto m e galo vi ru s
Mycobacteriumaviumintracellulare M AI )
Cryptosporidium
Microsporidia
Isospora belli
SUSCEPTIBLE ORGANS IN GI TRACT
J o ro p h aryn x
K ap o si 's sarco m a cau si n g d ysp h agi a, o b stru cti o n , b le e d i n g
J e so p h agu s
e so p h agi ti s +/ d ysp h agi a se co n d ary to C. albicans, C M V o r H e rp e s
su rge ry o n ly i f p e rfo rati o n o ccu rs
J sto m ach an d sm all b o we l
ab d o m i n al p ai n
an tral o b stru cti o n
p ai n
d u o d e n i ti s wi th u lce rati o n +/ p e rfo rati o n an d b le e d i n g
J li ve r an d b i li ary tract
h e p ati ti s se co n d ary to C M V, M AI o r P. carinii
scle ro si n g ch o lan gi ti s-li ke syn d ro m e se co n d ary to C M V an d Cryptosporidium
ch o lan gi ti s/ch o le cysti ti s se co n d ary to o b stru cti o n b y K ap o si 's o r lym p h o m a
acalcu lo u s ch o le cysti ti s
J p an cre as
rare ly i n vo lve d
p an cre ati ti s se co n d ary to H I V th e rap i e s e .g.d i d e o xyn u cle o si d e s)
J ap p e n d i x
can p re se n t wi th ve ry co n fu si n g p i ctu re - o fte n n o t
d i agn o se d u n ti l p e rfo rate d
N o te s
HIV AND GENERAL SURGERY. . . CONT.
can n o t re ly o n i n cre ase d WB C s
m o rb i d i ty o f n e gati ve ap p e n d e cto m y h i gh
J co lo n
co li ti s i n tractab le d i arrh e a, we i gh t lo ss, fe ve r, m e le n a,
h e m ato ch e zi a) se co n d ary to C M V
p e rfo rati o n an d m assi ve b le e d i n g can o ccu r re q u i ri n g
se gm e n tal re se cti o n wi th co lo sto m y
wate ry d i arrh e a, d e h yd rati o n , m alab so rp ti o n , p ai n se co n d ary
to M AI - m ay cau se p e rfo rati o n , o b stru cti o n , fi stu la
J an o re ctu m
co n d ylo m a acu m i n ata se co n d ary to H P V) - m ali gn an t
tran sfo rm ati o n to sq u am o u s carci n o m a h as b e e n re p o rte d
fi stu la
an o re ctal u lce rs
n o n -H o d gki n 's lym p h o m a
K ap o si 's sarco m a
J re m e m b e r th at ju st b e cau se a p ati e n t h as H I V d o e s n o t m e an
th e y can 't h ave G I p ath o lo gy u n re late d to H I V
UNUSUAL MALIGNANCIES
Kapos i's Sarcoma of GI Tract
d ysp h agi a, p ro te i n lo si n g e n te ro p ath y, ab d o m i n al p ai n ,
d i arrh e a, te n e sm u s, o b stru cti o n , b le e d i n g, p e rfo rati o n
m ay b e asym p to m ati c
J d i agn o si s
e n d o sco p y an d d e e p b i o p si e s
J su rgi cal tre atm e n t
i n d i cate d fo r li fe -th re ate n i n g si tu ati o n s, o r fo r se ve re co m p lai n ts
n e ve r cu rati ve
Lymphoma
J te n d to b e aggre ssi ve
J rare ly su rgi cal
J go o d re sp o n se to ch e m o th e rap y
J h i gh re cu rre n ce rate
INDICATIONS FOR SURGERY IN HIV+ PATIENTS
J d i agn o sti c p ro ce d u re s
C D 4+< 200/m m
3
d i agn o sti c o f AI D S
fe we r p ro ce d u re s re q u i re d to d i agn o se o p p o rtu n i sti c
i n fe cti o n s an d tu m o u rs K ap o si 's)
lym p h ad e n o p ath y m ay re q u i re d i agn o sti c p ro ce d u re s su ch as b i o p sy
b i o p sy re co m m e n d e d o n p ati e n ts wi th si n gle n o d e o r
gro u p o f n o d e s th at are e n large d o u t o f p ro p o rti o n to
o th e r n o d e s, e sp e ci ally wh e n syste m i c sym p to m s fe ve r,
we i gh t lo ss) are also p re se n t
J su p p o rti ve su rgi cal m e asu re s
trach e o sto m i e s an d lo n g te rm I V acce ss d e vi ce s
n o stu d i e s o n m o rb i d i ty an d m o rtali ty rate s o n th e se i n d i cati o n s
J e m e rge n cy su rge ry
acu te ab d o m e n m ay b e se co n d ary to AI D S o r i n d e p e n d e n t o f d i se ase
i n fe cti o u s d i agn o si s rare ly asso ci ate d wi th p e ri to n e al fi n d i n gs
b o we l o b stru cti o n i n H I V+o r AI D S p ati e n t m o st o fte n
se co n d ary to H I V-asso ci ate d p ro b le m s i n te sti n al lym p h o m a, K ap o si 's)
G I p e rfo rati o n se co n d ary to C M V le ad i n g to e m e rge n cy su rge ry h as 30 d ay
m o rtali ty rate o f 50-70% ; h i gh rate s u su ally se co n d ary to u n d e rlyi n g i lln e ss;
i f su rvi ve , m o rb i d i ty h i gh ; 31 % wo u n d d e h i sce n ce rate i n all
i n tra-ab d o m i n al se p si s case s
p o o r o u tco m e fro m e m e rge n cy su rge ry i s co m b i n ati o n o f
h yp o alb u m i n e m i a an d kn o wn o p p o rtu n i sti c i n fe cti o n
NOSOCOMIAL TRANSMISSION
J 0.3% tran sm i ssi o n rate o f H I V fro m p ati e n t to h e alth care wo rke r
J F lo ri d a d e n ti st case re m ai n s o n ly i n stan ce i n wh i ch tran sm i ssi o n fro m
i n fe cte d h e alth care wo rke r to p ati e n t h as b e e n d o cu m e n te d
J p re ve n ti o n th ro u gh : H I V te sti n g o f p ati e n ts +/ d o cto rs b u t
co sts h i gh ) , n o n o p e rati ve m an age m e n t an d u n i ve rsal p re cau ti o n s
N o te s
CANCER GENETICS
J rap id ly e vo lvin g
J e th ical, le gal, so cial issu e s im p o rtan t
J ge n e tic co u n se lin g m an d ato ry
J m o st D N A te stin g still with in re se arch p ro to co ls
Table 10. Cance r Ge ne s in Clinical/Re s e arch Te s ting
Ge ne Syndrome
AP C F am i li al ad e n o m ato u s p o lyp o si s FAP )
M S H 2, M L H I , P M S I , P M S 2 H e re d i tary n o n -p o lyp o si s co lo re ctal can ce r H N P C C )
B R C A1 H e re d i tary b re ast/o vari an can ce r
B R C A2 H e re d i tary b re ast can ce r/m ale b re ast can ce r
p 53 L i -F rau m e n i syn d ro m e
AT M Ataxi a-te lan gi e ctasi a i n cre ase d b re ast can ce r ri sk)
O P C 4 Ju ve n i le P o lyp o si s

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