Vascular Surgery

Posted on 8 August، 201913 August، 2019 Tagged SurgeryLeave a comment

Clinical assessment of leg ulcer:

Features	Venous	Arterial	Neurotrophic	Traumatic	Malignant
Site	· Gaiter area:70% · Lateral:20% · Circumferential:5%	· Malleoli · Heel · Metatarsal heads · 5 MT base	· Pressure area	· Site of trauma	· Face · Lips · Tongue
Size/shape	· Large shallow · Vertically oval	· Small deep	· Variable	· Variable	· Variable
Margin	Irregular	Regular	Regular
Edge	Sloping		Punched out	Sloping	Everted/rolled
Floor	Granulation	Slough/necrosis	Slough	Variable	Black mass

· Venous Leg Ulcer:

o Common in elderly

o Result of chronic venous hypertension

o Persistent inflammation

o Hemosiderin deposits

o Lipodermatosclerosis

· Arterial Ulcer:

o Reduced blood supply

o Ischemia, necrosis

o Little exudate

o Atrophic skin

o Common in diabetes

o Pain

· Diabetic Foot Ulcer:

o Common in diabetes

o Hyperglycemia

o Micro/macro-angiopathy

o Neuropathy

o Infection

o Foot deformities

· Pressure Sore:

o Area of tissue necrosis

o Caused by prolonged soft tissue compression

o Local ischemia, moisture

o Multi-morbid and elderly

	Arterial Ulcer
Sx	Pain w/ rest & elevation
PEx	· Sharply demarcated · No discharge or granulation tissue · Distal fingers · Sorrounding skin shows PVD, shiny, and loss of hair
Dx	Clx
Tx	· Wound care w/ debridement if needed · Re-vascularization if needed

Peripheral Vascular Dz

Acute Limb Ischemia

	Acute limb ischemia
Cause	· Cardiac/arterial embolus (e.g., AF, LV thrombus, IE) · Arterial thrombosis (e.g., PVD) · Iatrogenic/blunt trauma
Clx	6Ps of acute limb ischemia · Pain · Pallor · Paresthesias · Pulselessness · Poikilothermia (cool extremity) · Paralysis (late)
Tx	· Anticoagulation (e.g., heparin) · Thrombolysis versus surgery

Acute limb ischemia:

≈ MI of limb

Acute
Cath → cholesterol thrombus

Path:

A Fib → thrombus/embolism

PVD → thrombus

Pt:

6 Ps

Pain
Pallor
Paresthesias
Pulselessness
Poikilothermia (Pared-بارد) (cool extremity)
Paralysis (late)

Dx:

1ْ US Doppler → 2ْ ARTERIOGRAM

Tx:

W/ 6 hours → Embolectomy OR TPA

F/u → Compartment syndrome

Compartment syndrome:

(early pain + paresthesia → S/M Sx)

Common:

Pain out of proportion to injury
Pain ⤴️ on passive stretch
Rapidly increasing and tense swelling
Paresthesia (early)

Uncommon:

⤵️ sensation
Motor weakness (hours)
Paralysis (late)
⤵️ distal pulses (uncommon)

	Extremity Vascular Trauma
Clx	Hard signs: · Observed bleeding · Presence of bruit/thrill over injury · Expanding hematoma · Sign of distal ischemia Soft signs ∆: · Diminished pulses · Bony injury · Neurologic 🆎
Tx	If (hard) signs or HD unstable: · Surgical exploration Otherwise: · CT scan or conventional angiography · Duplex Doppler ultrasound

____

Aorta

	AAA	Aortic Dissection
S/S	· Pulstile abdomenal mask, · Smoker · Incidentally found on CT. · >65 male · Atherosclerotic	· HTN · TEARING Chest pn radiating to back · Asymmetric BP in arms · Widened mediastinum
Dx	· US · ~~NOT CT~~ · ~~NOT ARTERIOGRAM~~	BEST? CT ARTERIOGRAM ~~NOT ARTERIOGRAM~~
Tx	Strategy: If small AAA –> I will wait & screen. If big AAA or growing fast, I shall operate. A tender abdominal aortic aneurysm is going to rupture within a day or two, and thus immediate repair is indicated. >3.5 cm –> screen q1 year >4.5 cm –> screen q6 months >5.5 / growin fast (0.5 per 6 m) –> SURGERY	Type A (Ascending): OR –> offer aortic valve replacement Type B (Descending): IV BB

Pre-OP Evaluation

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Baseline	· The overall risk of surgery is low in healthy patients · Screening is not indicated unless there is a clinical indication Baseline tests · complete blood count o > 65 years of age undergoing major surgery o younger patients undergoing surgery expected to have significant blood loss · serum creatinine o > 50 years of age undergoing > intermediate risk surgery o renal disease · pregnancy test o all women in their reproductive age · electrocardiogram (ECG) o coronary artery disease o arrhythmias o peripheral artery disease o cerebrovascular disease o structural heart disease · chest radiograph o underlying cardiac or pulmonary disease o abdominal or thoracic surgery · obesity o increased risk of pulmonary complications
CVS	o If CHF + Fluid overload (EF <35) –> no surgery o If MI –> wait for 6 m · risk w/i 3 m is 40% · if you cant delay, admit to ICE 1 day pre-op o Dx: ECG / Echo o Goldman index: remains useful for listing all the findings that predict trouble. They are (in descending order of importance): · jugular venous distension, · recent myocardial infarction, · premature ventricular contractions or any rhythm other than sinus, · age over 70, · emergency surgery, · aortic valvular stenosis, · poor medical condition, · and surgery within the chest or abdomen.
Lungs	o Ventilation > Oxygenation o Pt: smokers, COPD/Asthma, ILD o Dx: PFT (@ day of surgery: ABG) · obtain older PFT –(if FEV1 is abnormal)–> obtain an ABG o Tx: Give O2 – if pt has underlying condition (Inhalers) o Smoking cessation! (8 weeks before surgery)
Liver	o Check liver synthetic function: Albumin – CFs – T Bili o Sx: Ascites / encephalopathy o Child class, in which class A has 10% mortality, class B 30%, and class C 80%. o Tx: Liver transplant
Renal	if pt needs dialysis –> do it 24h prior to surgery

Post-OP Complications

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Post-op fever

§ SSI¹: due to a group A Streptococcus (GAS) or Clostridium perfringens.

§ SSI²: due to other organisms ( NOT GAS or C perfringens).

§ SSI³: due to indolent organisms.

DVT: deep venous thrombosis; MI: myocardial infarction; PE: pulmonary embolism; SSI: surgical site infection

Causes of postoperative fever (the 5 Ws):

Wind (lungs)	· Pulmonary embolus · Pneumonia · Aspiration
Wound	· Surgical site infection
Water	· Urinary site infection
Walk	· Deep venous thrombosis
Wonder drugs/products	· Drug fever · Blood products · Intravenous lines

· Malignant Hyperthermia

o INTRA-op

o Dx: clx

o Tx: IV Dantrolene, 100% O2, cooling blanket

· Bactremia

o shortly post op

o do cultx 3 times

o start emperic abx

· Mnemonic: Wind – Water – Walking – Wound – Wounder

o Atelectasis is the mcc of post-op fever on the first PO day.

path	· AW obstruction (mucus, foreign body)→Air trapped in the alveoli (then it leaks out)→Lung collapse · Mediastinum shifts TOWARD
Clx	· SOB/Hypoxia · ❌ breath sound/Dullness
Dx	· CXR: opacification of affected lung/ Narrower rib spacing/ Mediastinal shift
Tx	· PPx: incentive spirometry/ chest physiotherapy · Small: Chest physiotherapy · Large: Bronchoscopy (remove mucus plug)

o listen to the lungs, do chest x-ray,

o improve ventilation (deep breathing and coughing, postural drainage, incentive spirometry).

o The ultimate therapy if needed is bronchoscopy.

o Pneumonia

· Chest x-ray will show infiltrates. Do sputum cultures

o UTI: day 3. Work up with urinalysis, urinary cultures. Treat with appropriate antibiotics.

o DVT: D5, Doppler studies of deep leg and pelvic veins is the best diagnostic modality

o Wound infxn: D7, do U/S to r/o abscess, then tx w/ Abx

o Deep abscess: D10-15, ⨁ U/S or CT, tx: drainage (OR)!

Chest pain

· MI

o either intra-op, or D2-3 Post-op

o d/t hypotension

o HIGH MORTALITY (50-90%)

o Dx: EKG –> Troponin (most reliable)

o Tx: Cath lab

o NEVER EVER NEVER USE tPA

· PE

o D7

o Pain is pluiritic

o ⤵️ CVP/JVP essentially r/o dx

o Dx: CT Angio

o Tx: Heparin / IVC filter (if you can’t anticoagulate)

o PPx

· Low risk: compression device

· High risk: anticoagulation

· RF: Age >40, prolonged immobilzation, Leg/pelvic fx, femoral venous catheter

Pulmonary complications

· Aspiration

o If full stomach, awake pt

o can be lethal, or cause chemical injurt, or 2˚ pneumonia

o Prevent by NPO + Antacid

o Tx: Bronchoscopy and remove offending agent –> bronchodilators w/ resp support

· Tension pneumothorax

o traumatized lung + positive pressure breathing,

o BP ⤵️ + CVP ⤴️

o Tx: if open abdomen: quick decompression, if not: a needle can be inserted through the anterior chest wall into the pleural space

Postoperative pulmonary complications:

complications	· Atelectasis, infection (e.g., pneumonia) · Bronchospasm, exacerbation of chronic lung disease · Prolonged mechanical ventilation
Risk factors	· Age >50 years · Emergency surgery or surgery duration >3hours · Heat failure, chronic obstructive lung disease · Poor general health (American Society of Anesthesiologists class >2)
Pre-operative strategies (to reduce risk)	· Smoking cessation at least 8 weeks prior to surgery · Symptom control of chronic obstructive lung disease (e.g., preoperative glucocorticoids if not well controlled) · Treatment of any respiratory infections prior to surgery · Patient education for lung expansion maneuvers (e.g., chest physical therapy, coughing, deep breathing exercises, incentive, spirometry)
Post-operative strategies	· Inactive spirometry · Deep breathing exercises · Epidural analgesia instead of parenteral opioids · Continuous positive airway pressure

	Pulmonary contusion
Clx	· Present <24 hours after blunt thoracic trauma · Tachypnea, tachycardia, hypoxia
Dx	· Rales or decreased breath sounds · CT scan (most sensitive) or CXR with patchy, alveolar infiltrate not restricted by anatomical borders
Tx	· Pain control · Pulmonary hygiene (e.g., nebulizer treatment, chest PT) · Supplemental oxygen and ventilatory support

Aspiration syndromes:

	Pneumonia	Pneumonitis
Path	· Lung parenchyma infection · Aspiration of upper airway or stomach microbes (anaerobes)	· Lung parenchyma infection · Aspiration of gastric acid with direct tissue injury
Clx	· Present days after aspiration event · Fever, cough, ↑sputum · CXR infiltrate in dependent lung segment (classically RLL) · Progress to abscess	· Present hours after aspiration event · Range from no symptoms to nonproductive cough, ↓O2, respiratory distress. · CXR infiltrates (one or both lower lobes) resolve without antibiotics
Tx	Antibiotics: Clindamycin or beta-lactam and beta-lactamase inhibitor	Supportive (no antibiotics)

AMS

Abd Distension

· Either: functional vs Mechanical / Severity: partial –> complete

· S/S: Abd distension + pain (obvious). Also they have ø gas / stool (if complete).

· 1˚ Dx step: ALWAYS KUB.

· If pt is stable –> you can go for CT w/ contrast

· If pt is allergic to contrast or u are in ER –> U/S can work

· If you are suspecting perforation? Use CT w/ gastrofringen contrast as it’s water-solube

ileus

Obstruction

· Path: Functional (pt got surgery, things take a while to move)

· Post-OP day 1-2

· Pt has ø Gas ø Stool

· Absent bowel sounds

· Dx: KUB

· Findings: Everything is affected & dilated w/ air

· Tx: Make pt move, IVF + K+

· Path: obstruction

· Types: SMO vs. LBO

· SBO: Vomits early, constipate later.

· LBO: Vomits late, constipate early

· Post-op day 5

· Pt has ø Gas ø Stool

· High-pitched bowel sounds

· Dx: KUB

· Findings: only 1 area affected (distal to it: ø / Proximal: dilated + filled w/ gas)

· Tx:

· Conservative:

§ If pt is stable & not detriorating

§ NPO + NG Tube

§ for 3 days. if no improvement ⤵️

· Surgical:

§ If pt deteriorates (ischemia/necrosis, hypotensive, persistant obstruction 3-5 days)

§ If pt is peritoneal

§ Surgical decompression.

Acute Urinary Retention

The major risk factors for development of AUR include:

· 👨🏻 (rarely occurs in women)

· Advanced age (~33% of men age will develop AUR)

· History of neurologic disease (eg, mild cognitive impairment)

· Surgery (especially abdominal surgery, pelvic surgery, and joint arthroplasty)

Dx: bladder ultrasound demonstrating 2300 mL of urine.

Tx: insertion of a Foley catheter, + UA to rule out UTI.

Foley catheter insertion can be both diagnostic and therapeutic.

Penis & Balls Diseases

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Fast dx:

Firm mass + does not transluminate + nontender	cancer
fluid that transluminates	Hydrocele
Bag of worms	Varicocele
connection w/ inguinal canal	inguinal hernia
ACUTE + pain in balls	either torsion or epidydimitis

	Acute Epididymitis
#	· Age <35: STD (chlamydia, gonorrhea) · Age >35: Bladder outlet obstruction (coliform bacteria)
S/S	· ⓤ , posterior testicular pain, gradual onset · Epididymal edema · Pain improved with testicular elevation · ⓝ Reflex · Dysuria, frequency (with coliform infection)
Dx	· NAAT for chlamydia and gonorrhea · Urinalysis/culture

	Testicular Torsion
#	· Most common in adolescents
Clx	· Testicular, inguinal, abdominal pain · N/V · Horizontal testicular lie with elevated testicle لما ترفع الخصية تصير أفقية · ABSENT Cremasteric reflex ⊖. (torsion tore’s reflex) · Swollen, erythematous scrotum
Dx	· Dx is made Clx · US w/doppler: NO blood flow on scrotal
Tx	· Surgical detorsion and fixation with exploration of the contralateral side · Manual detorsion (if immediate surgery is not available)

Hernias

Posted on 8 August، 201914 June، 2024 Tagged SurgeryLeave a comment

Hernias

Protrusion of an organ through a body wall

Path

· Indirect inguinal

· hernia protrudes via the internal inguinal ring and lateral to the inferior epigastric vessels

· Direct inguinal

· hernia protrudes via the Hesselbach’s triangle and medial to the inferior epigastric vessels

· Hesselbach’s triangle consists of the

o inferior – inguinal ligament

o lateral – inferior epigastric artery

o medial – conjoint tendon

· Femoral

· hernia protrudes through the femoral ring which is inferior to the inguinal ligament

· the femoral ring is medial to the femoral vein and lateral to the lacunar ligament

· Aging

· Male sex 🤵🏻

· increased intra-abdominal pressure secondary to

· heavy lifting

· chronic coughing

· COPD

· Family history

· smoking

· prior history of hernia

· prior history of hernia repair

S/S

· Asx

· localized pain

· heavy sensation in the groin

· hernia may worsen with activities that increase intra-abdominal pressure

Clx (if uncertain → US)

Reducible	Irreducible	Strangulated (peritoneal)
OR ELECTIVELY	OR URGENTLY	OR NOW EMERGENTLY 🚨

Esophagus-Stomach-Small Intestine

Posted on 8 August، 2019 Tagged Surgery1 Comment

Esophagus

GERD

· How to Dx? Hx + Trial of PPI –> Releives Sx.

· When the diagnosis is uncertain, pH monitoring (gold standard) is best to establish the presence of reflux and its correlation with the symptoms

· Barrett esophagus: Endoscopy and Bx are the indicated tests.

· When to do surgery?

o Chronic sx uncontrolled medically,

o If pt has complications (ulceration, stenosis);

o Severe dysplastic changes.

Motility dz

· S/S:

o Obstructive: Solid –> Liquid

o Functional: Solid = Liquid

o Achalasia: Liquid –> Solid

· Dx: Barium –> Manometry

· Barium swallow is typically done first.

· Manometry studies are used for the definitive diagnosis.

Achalasia

· More common in females

· S/S: Pt learns that sitting up straight helps swallowing / regurgitation of food

· WORSE W/? Liquids

· Dx: 1˚ X-ray (essentially dxic) –> 2˚ Manometry (confirm)

· Tx: Ballon dilation done by endoscopy

Cancer:

· Solid > Liquid

SqCC	Adenocarcinoma
in men with a history of smoking and drinking	GERD
Dx: · Barium –> Endo + Bx	Dx: · Barium –> Endo + Bx
Tx: SURGERY	Tx: SURGERY

Post-vomiting hematemesis:

Mallor-wies	Boerhaave syn
prolonged, forceful vomiting. Eventually, bright red blood comes up. Endoscopy establishes diagnosis and allows photocoagulation (laser).	· straining (can be by vomiting) –> esophageal perforation. · Triad: Chest pn + hematemesis + sc emphysema · VERY SICK Pt, EMERGENCY · Contrast swallow (Gastrografin first, barium if negative) is diagnostic, · emergency surgical repair should follow

· Instrumental perforation of the esophagus is by far the most common reason for esophageal perforation.

Stomach

Gastric adenocarcinoma

· is more common in the elderly.

· There is anorexia, weight loss, and vague epigastric distress or early satiety. Occasionally hematemesis.

· Dx: Endo + Bx

· CT scan helps assess operability.

· Surgery is the best therapy.

Gastric lymphoma

· is now very common,

· has similar presention as gastric adenocarcinoma,

· Dx: Bx

· Tx: CHEMOTHERAPY (not surgery)

· When to operate? in case of perforation. or in case you are afraid of perforation

Obesity:

Indications for surgery:

· Motivated patient

· BMI >40

· BMI > 35 with serious comorbidities (life-threatening cardiovascular problems, such as severe sleep apnea, Pickwickian syndrome, and cardiomyopathy, or severe diabetes)

· Reasonable surgical risk

· Failure of previous weight-loos regimens

Small Intestine

Obstruction:

· Caused by? MCC is Adhesion, Hernia can also cause mechanical obstruction

· Sx? colicky abdominal pain and protracted vomiting, progressive abdominal distention (if it is a low obstruction), and no passage of gas or feces.

· Dx? X-ray w/ Air-fluid level (dilated loops of intestine)

· Tx? NPO + NG Tube + IV Fluid –(if no spontaneous resolution w/i 24h in case of complete obstruction)–> Surgery

· If any signs of strangulation develops? Immediate surgery

o the patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis. Emergency surgery is required.

Ogilvie syndrome

· non-mechanical colon pseudo-obstruction

· happens in elderly

· Immobilized / Electrolytes disturbance

· Tx: Correct electrolytes + decompression

Endocrine Surger

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Thyroid Nodule

Gastrinoma (ZES)

Dx:

1. Gastrin level –(very very high ⤴️⤴️⤴️⤴️)–> Gastrinome –> CT / SRS to localize the tumor.

2. Gastrin level –(not that high ⤴️)–> Secretin test –(fails to ⤵️ gastrin)–> gastrinoma –> CT / SRS to localize the tumor.

Appendicitis

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	Acute appendicitis
Clx	· N/V, anorexia Diffuse → Localize (RLQ) · Initially: diffuse abdominal pain (visceral pain) · Later: Localized RLQ pain (somatic pain) · Mild leukocytosis
PEx	· McBurney point tenderness · Psoas sign: pain with right hip extension · Obturator sign: pain with right hip internal rotation · Revising sign: RLQ pain with LLQ palpation
Dx	· Clinical · CT or US
Tx	· Appendectomy

· diarrhea only with retrocecal appendicitis

· Blumbergsign: rebound tenderness at McBurney’s point

· Psoas/Obturator sign: raise the patient’s right leg with the knee flexed –> rotate the leg internally at the hip –> increased abdominal pain indicates a positive obturator sign

· Rovsing’ssign: pressure over the LEFT colon causes pain in the RLQ

· if u are not sure ––> CT.

Examination signs in appendicitis:

Sign	Findings	Significance
Peritoneal signs · Rebound tenderness · Involuntary guarding · Abdominal rigidity	· Acute increase in pain after removing the hand from applying pressure · Tensing of abdominal wall muscles during palpation of abdomen · Persistent tension of abdominal wall muscles	Peritoneal irritation (rupture or impending rupture)
Psoas sign	RLQ pain with extension of right thigh	Abscess adjacent to psoas or retrocecal appendix
Obturator sign	RLQ pain with internal rotation of right thigh	Pelvic appendix or abscess
Rovsing’s sign	RLQ pain with LLQ palpation and retropulsion of colonic contents	Acute appendicitis
Rectal tenderness	· Right pelvic pain during rectal examination, especially with pressure on right rectal wall	Pelvic appendix or abscess

	Psoas Abscess
RF	· IVDU · HIV · DM · Crohn’s
Path	Spread from another infxn
S/S	· Fever · Lower abd pain → groin · Psoas sign: abdominal pain w/ hip extension
Dx	· Leukocytosis · CT is needed for dx
Tx	Abx + Drainage

Anorectal

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ALWAYS:

R/O cancer by PEx (Proctosigmoidoscopy).

Hemorrhoids:

· If they bleed: internal (tx w/ rubber band ligation)

· If they hurt: External

Initial management of hemorrhoids:

Dietary	· Increased fluid intake · Increased fiber intake (foods, fiber supplements) · Reduced fat intake · Moderation of alcohol intake
Behavioral	· Limit time sitting on toilet (e.g., 3 minutes) · Limit defecation to once daily · Avoid straining during defection
Topical Agents	· Analgesics (e.g., benzocaine) · Astringents (e.g., witch hazel) · Hydrocortisone

Fissure:

· Females

· Pain w/ defecation + blood coat stool

· Pt avoid defecation –> constipation

· PEx hurt –> you may need to do it w/ Anesthesia –> you will fine Posterior midline fissure.

· Tx: Soften the sphincter + Stool

o Stool softener

o CCB

o Sphinctrotomy

Abscess:

· Fever + Severe pain (pt can’t sit)

· On PEx: Lateral – Red, hot, painful mass w/ pus.

· Tx: I/D + Abx

Complication of Abscess → Fistula:

· A canal b/w Skin (site of I/D) and anal crypt (site of abscess).

· PEx: Lateral opening w/ Discharge

· Tx: fistulotomy

SqCC

· HIV+

· Fungating mass + inguinal LN

· Dx: Bx

· Tx: Nigro chemoradiation –> surgery.

Chron’s:

· When to suspect? pt fail to improve/deteriorates after surgery!

· Tx: SURGERY

· Colo-vesical fistulas may occur in inflammatory processes (e.g., diverticulitis, Chron disease), iatrogenic injury, foreign body, or malignancy.

· Pneumaturia is pathognomonic.

· CT scan of the abdomen and pelvis with contrast is the best imaging modality to start the workup.

· Management begins with NPO and intravenous antibiotic, and ultimately surgical exploration with colonic resection.

Acute Abdomen

Posted on 8 August، 201913 August، 2019 Tagged SurgeryLeave a comment

A surgical emergency characterized by

· sudden onset of severe abdominal pain

· tenderness and muscular rigidity.

· Tx: explatory Laporotomy

Peptic Ulcer Perforation

Features

· PMHx of peptic ulcer disease

· Long-term use of NSIADs

· A case of acute abdomen

S/S

· Sudden severe abdominal pain

· Pt has peritoneal signs (generalized rigidity, guarding, exacerbated by movement)

· Clx

· Abdominal X-ray: Air under diaghragm (sign of perforation)

· 1˚: broad spectrum antibitoics, PPI,

· THEN GO TO SURGERY EMERGENTLY 🚨

	Esophageal perforation
?	· Instrumentation (Endoscopy) · Trauma · Boerhaave syndrome/ Esophagitis
Clx	· Chest/back and/or epigastric pain · Systemic signs (e.g., fever) · Crepitus, Hamman sign (crunching sound on auscultation) · Pleural effusion with atypical (e.g., green) fluid
Dx	· CXR/CT: widened mediastinum, pneumomediastinum, PTX · CT: esophageal wall thickening, mediastinal fluid collection · Esophagography with water-soluble contrast: leak from perforation
Tx	· NPO, IV Abx and PPI · Emergency surgical consultation

	Small Bowel Obstruction
Clx	· Colicky abdominal pain, vomiting · Inability to pass flatus or stool if complete · Hyperactive → Absent bowel sounds · Distended and tympanitic abdomen
Dx	· Dilated loops of bowel with air-fluid levels on plain film or CT scan · Partial: Air in colon ⊕ · Complete: transition point (abrupt cutoff), NO air in colon ⊖
🚨	· Ischemia/necrosis (strangulation) · Bowel perforation
Tx	· Bowel rest · NGT suction · IVF · If complicated (fever, ⤴️WBC’s, unstable) → Surgical exploration for signs of complications

	Small bowel obstruction	Ileus
Etiology	· Prior surgery (weeks to years)	· Recent surgery (hours to days) · Metabolic (e.g., hypokalemia) · Medication induced
Abdominal examination	· Distension · Increased bowel sounds	· Possible distension · Reduced/absent bowel sounds
Small bowel dilation	Present	Present
Large bowel dilation	Absent	Present

	Colonic ischemia
Path	· No occlusion · Hypovolemia → “watershed” ischemia · U/C atherosclerosis
Clx	· Abdominal pain and tenderness · Hematochezia · Leukocytosis, lactic acidosis
Dx	· CT scan: Colonic wall thickening, fat stranding · Endoscopy; Edematous and friable mucosa · Hemorrhagic ulceration · Clear cut from normal to abnormal
Tx	· IVF · Bowel rest (NPO) · Abx with enteric coverage · Colonic resection if necrosis develops

	Acute Mesenteric Ischemia
Sx	· ACUTE periumbilical pain (often severe) · Pain out of proportion to PEx · Hematochezia (late complication)
RF	· Atherosclerosis (acute on chronic) · Embolic source (thrombus, vegetations) · Hypercoagulable disorders
🏥	· ⤴️WBC · ⤴️Amylase and phosphate levels · Metabolic acidosis (elevated lactate)
Dx	· CT (preferred) or MR angiography · Mesenteric angiography , if diagnosis unclear

Fast HY Review

Tag: Surgery

Vascular Surgery

Pre-OP Evaluation

Post-OP Complications

Penis & Balls Diseases

Hernias

Esophagus-Stomach-Small Intestine

Endocrine Surger

Appendicitis

Anorectal

Acute Abdomen