Friday, 12 July 2013

Surgery questions

A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms.
Dx: Acute abdomen plus perforated GI tract
(perforated duodenal ulcer in most cases)

Management: Emergency exploratory laparotomy

A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.
Diagnostic test?
If Dx is unclear?
Management? (3 together)
Dx: Acute pancreatitis

Diagnostic test: Serum and Urinary Amylase and Lipase

If unclear: CT scan
(or in a day or two if there is no improvement)

Management: NPO, NG suction, IV fluids.

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Diagnostic test?
Dx: Acute cholecystitis

Diagnostic test: Ultrasound

(If equivocal, an “HIDA” scan: radionuclide excretion scan)

Management: “cool down” the process

Surgery will follow

A 52 year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.
Diagnostic test? (2)
Dx: Ureteral colic

Diagnostic test: Urological evaluation always begins with a Plain Film of the abdomen (a “KUB”)

Ultrasound often is the next step
(but traditionally it has been intravenous pyelogram)

A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.
Diagnostic test?
Dx: Acute diverticulitis

Diagnostic test: CT scan
(Colonoscopy is not safe in acute setting)

Management: Elective Sigmoid resection
(for recurrent attacks, like this case or if she does not respond to medical Tx from initial attack or gets worse)

(Treatment is medical for the acute attack: antibiotics, NPO)

An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot’s beak.
Dx: Volvulus of the sigmoid

Management: Proctosigmoidoscopy should relieve the obstruction

(Rectal tube is another option. Eventually surgery to prevent recurrences could be considered)

A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon.
Tx if mild, moderate or severe?
Dx: Emboli of Mesenteric vessels

(Acute abdomen present in the elderly who has atrial fibrillation, brings to mind embolic occlusi

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