- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
Chapter 48 / Colon and Rectum 319
What is Cronkhite-Canada Diffuse GI hamartoma polyps (i.e., no syndrome? cancer potential) associated with
malabsorption/weight loss, diarrhea, and loss of electrolytes/protein; signs include alopecia, nail atrophy, skin pigmentation
What is Turcot’s syndrome? Colon polyps with malignant CNS tumors (glioblastoma multiforme)
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is diverticulosis? Condition in which diverticula can be found within the colon, especially the sigmoid; diverticula are actually false diverticula in that only mucosa and submucosa herniate through the bowel musculature; true diverticula involve all layers of the bowel wall and are rare in the colon
Diverticula
Blood vessel
Describe the pathophysiology. Weakness in the bowel wall develops at points where nutrient blood vessels enter between antimesenteric and mesenteric taeniae; increased intraluminal pressures then cause herniation through these areas
What is the incidence? 50% to 60% in the United States by age 60, with only 10% to 20% becoming symptomatic
What is the most common site?
95% of people with diverticulosis have sigmoid colon involvement
320 Section II / General Surgery
Who is at risk?
What are the symptoms/ complications?
What is the diagnostic approach:
Bleeding?
Pain and signs of inflammation?
What is the treatment of diverticulosis?
What are the indications for operation with diverticulosis?
People with low-fiber diets, chronic constipation, and a positive family history; incidence increases with age
Bleeding: may be massive
Diverticulitis, asymptomatic (80% of cases)
Without signs of inflammation: colonoscopy
Abdominal/pelvic CT scan
High-fiber diet is recommended
Complications of diverticulitis (e.g., fistula, obstruction, stricture); recurrent episodes; hemorrhage; suspected carcinoma; prolonged symptoms; abscess not drainable by percutaneous approach
When is it safe to get a colonoscopy or barium enema/sigmoidoscopy?
DIVERTICULITIS
Due to risk of perforation, this is performed 6 weeks after inflammation resolves to rule out colon cancer
What is it?
What is the pathophysiology?
What are the signs/ symptoms?
What are the associated lab findings?
What are the associated radiographic findings?
Infection or perforation of a diverticulum
Obstruction of diverticulum by a fecalith leading to inflammation and microperforation
LLQ pain (cramping or steady), change in bowel habits (diarrhea), fever, chills, anorexia, LLQ mass, nausea/vomiting, dysuria
Increased WBCs
On x-ray: ileus, partially obstructed colon, air-fluid levels, free air if perforated
On abdominal/pelvic CT scan: swollen, edematous bowel wall; particularly helpful in diagnosing an abscess
|
Chapter 48 / Colon and Rectum 321 |
What are the associated |
Barium enema should be avoided in |
barium enema findings? |
acute cases |
Is colonoscopy safe in an |
No, there is increased risk of perforation |
acute setting? |
|
What are the possible |
Abscess, diffuse peritonitis, fistula, |
complications? |
obstruction, perforation, stricture |
What is the most common |
Colovesical fistula (to bladder) |
fistula with diverticulitis? |
|
What is the best test for |
CT scan |
diverticulitis? |
|
What is the initial therapy? |
IV fluids, NPO, broad-spectrum |
|
antibiotics with anaerobic coverage, |
|
NG suction (as needed for emesis/ileus) |
When is surgery warranted?
What is the lifelong risk of recurrence after:
First episode?
Second episode?
Obstruction, fistula, free perforation, abscess not amenable to percutaneous drainage, sepsis, deterioration with initial conservative treatment
33%
50%
What are the indications for elective resection?
What surgery is usually performed ELECTIVELY for recurrent bouts?
What type of surgery is usually performed for an acute case of diverticulitis with a complication (e.g., perforation, obstruction)?
Two episodes of diverticulitis; should be considered after the first episode in a young, diabetic, or immunosuppressed patient
One-stage operation: resection of involved segment and primary anastomosis (with preoperative bowel prep)
Hartmann’s procedure: resection of involved segment with an end colostomy and stapled rectal stump (will need subsequent reanastomosis of colon usually after 2–3 postoperative months)
322 Section II / General Surgery |
|
What is the treatment of |
Percutaneous drainage; if abscess is not |
diverticular abscess? |
amenable to percutaneous drainage, then |
|
surgical approach for drainage is necessary |
How common is massive |
Very rare! Massive lower GI bleeding is |
lower GI bleeding with |
seen with diverticulosis, not diverticulitis |
diverticulitis? |
|
What are the most common |
Diverticulosis (especially right sided), |
causes of massive lower GI |
vascular ectasia |
bleeding in adults? |
|
What must you rule out in |
Colon cancer |
any patient with diverticulitis/ |
|
diverticulosis? |
|
COLONIC VOLVULUS |
|
|
|
What is it? |
Twisting of colon on itself about its |
|
mesentery, resulting in obstruction and, if |
|
complete, vascular compromise with |
|
potential necrosis, perforation, or both |
What is the most common |
Sigmoid volvulus (makes sense because the |
type of colonic volvulus? |
sigmoid is a redundant/“floppy” structure!) |
SIGMOID VOLVULUS |
|
|
|
What is it? |
Volvulus or “twist” in the sigmoid colon |
|
Chapter 48 / Colon and Rectum 323 |
What is the incidence? |
75% of colonic volvulus cases (Think: |
|
Sigmoid Superior) |
What are the etiologic |
High-residue diet resulting in bulky stools |
factors? |
and tortuous, elongated colon; chronic |
|
constipation; laxative abuse; pregnancy; |
|
seen most commonly in bedridden elderly |
|
or institutionalized patients, many of |
|
whom have history of prior abdominal |
|
surgery or distal colonic obstruction |
What are the signs/ |
Acute abdominal pain, progressive |
symptoms? |
abdominal distention, anorexia, |
|
obstipation, cramps, nausea/vomiting |
What findings are evident |
Distended loop of sigmoid colon, often in |
on abdominal plain film? |
the classic “bent inner tube” or “omega” |
|
sign with the loop aiming toward the RUQ |
What are the signs of necrotic |
Free air, pneumatosis (air in bowel wall) |
bowel in colonic volvulus? |
|
How is the diagnosis made? |
Sigmoidoscopy or radiographic exam with |
|
gastrografin enema |
Under what conditions is |
If sigmoidoscopy and plain films fail to |
gastrografin enema useful? |
confirm the diagnosis; “bird’s beak” is |
|
pathognomonic seen on enema contrast |
|
study as the contrast comes to a sharp end |
What are the signs of strangulation?
Discolored or hemorrhagic mucosa on sigmoidoscopy, bloody fluid in the rectum, frank ulceration or necrosis at the point of the twist, peritoneal signs, fever, hypotension, c WBCs
What is the initial treatment?
What is the percentage of recurrence after nonoperative reduction of a sigmoid volvulus?
Nonoperative: If there is no strangulation, sigmoidoscopic reduction is successful
in 85% of cases; enema study will occasionally reduce (5%)
40%!
324 Section II / General Surgery
What are the indications for Emergently if strangulation is suspected surgery? or nonoperative reduction unsuccessful
(Hartmann’s procedure); most patients should undergo resection during same hospitalization of redundant sigmoid after successful nonoperative reduction because of high recurrence rate (40%)
CECAL VOLVULUS
What is it?
What is a cecal “bascule” volvulus?
What is the incidence?
What is the etiology?
Twisting of the cecum upon itself and the mesentery
Instead of the more common axial
twist, the cecum folds upward (lies on the ascending colon)
25% of colonic volvulus (i.e., much less common than sigmoid volvulus)
Idiopathic, poor fixation of the right colon, many patients have history of abdominal surgery
What are the signs/ |
Acute onset of abdominal or colicky pain |
symptoms? |
beginning in the RLQ and progressing to |
|
a constant pain, vomiting, obstipation, |
|
abdominal distention, and SBO; many |
|
patients will have had previous similar |
|
episodes |
How is the diagnosis made? |
Abdominal plain film; dilated, ovoid |
|
colon with large air/fluid level in the |
|
RLQ often forming the classic “coffee |
|
bean” sign with the apex aiming toward |
|
the epigastrium or LUQ (must rule out |
|
gastric dilation with NG aspiration) |
What diagnostic studies |
Water-soluble contrast study (gastrografin), |
should be performed? |
if diagnosis cannot be made by AXR |
What is the treatment? |
Emergent surgery, right colectomy with |
|
primary anastomosis or ileostomy and |
|
mucous fistula (primary anastomosis may |
|
be performed in stable patients) |