Table of content
- General Surgery
- 🌯 Esophagus
- 🍤 Stomach (and Duodenum)
- 🦑 Small Intestine
- 🥜Colon
- 💩 Rectum and Anal Canal
- 🎾 Gallbladder and Bile Ducts
- 🧽Pancreas
- 🍑Liver
- 🍠 Spleen
- 🚑Abdominal Emergencies
- 🔪Laparascopic and Bariatric Surgery, Organ Transplantology, Informed consent
Member Resources
Year 4
Year 5
Year 6
General Surgery
Corrosive esophagitis
Grade 0: normal
Grade 1: congestion, hyperemia
Grade 2: A- superficial ulcerations, exudate B- profound, circumferential ulceration
Grade 3: A- small necrotic areas B- extended necrosis
Savary Miller Classification → GERD
Grade 1: non-confluent erosions
Grade 2: multiple, confluent, non-circumferential erosions
Grade 3: confluent, whole circumferential erosions
Grade 4: complications: ulcer, stenpsis. Barrett metaplasia
Johnson Classification → gastric peptic ulcer
Typ 1: single ulcer at gastric angle
Typ 2: associated atric to dudodenal ulcer
Typ 3: single prepyloric ulcer
Typ 4: high located ulcer → at lesser curvature, under the cardia
Typ 5: ulcer by NSAIDs
Forrest Classification → peptic ulcer hemorrhage
1a: arterial bleeding
1b: slow, continuous venous or capillary bleeding
2a: ceased bleeding, vessle stump visible in the crater
2b: ceased bleeding, adherent clot covering the ulcer
2c: ceased bleeding, black crater
3: ulcer without signs of bleeding, buzt with history of hemorrhage
Paris endoscopic Classification → early gastric cancer
1: protrusive, exophytic → may be rough protrusive tumor or small malignant polyp
2: superficial, non-polypoid, non-excavated
2a: slightly elevated
2b: flat, dicoloured mucosa
2c: slightly depressed
3: superficial ulceration
Bormann Classification → advanced gastric cancer
1: protrusive, proliferative
2: ulcerative, elevated uneven margins
3: ulcerative, infiltrating uncertrainly contoured, deep central crater
4: extensive infiltrating, thickened gastric wall
Shah Classification → type of gastric cancer
- intestinal type → at body, antrum
- proximal type → at gatroesophageal juction, cardia
- diffuse type → diffuse infiltration → whole stomach wall thickened → linitis plastica
G grading system
GX - can't be assessed
G1 - well differentiated tumor
G2 - moderately differentiated tumor
G3 - poorly differentiated tumor
G4 - undifferentiated tumor
TNM staging - all
. | Pancreas (adeno)carcinoma | Colon & Rectal cancer | perihilar Cholangiocarcinoma | distal Cholangiocarcinoma | intrahepatic Cholangiocarcinoma | Gallbladder carcinoma |
T O | no | |||||
T is | in situ | |||||
T 1 | <2cm | invades submucosa | limited to bile duct | solitary | invades lamina propria or muscle layer | |
T2 | > 2cm | invades muscularis propira | A: beyond bile duct wall→ fat
B: invades liver | beyond bile duct wall | A: vascular invasion
B: multiple tumors +/- vascular invasion | invades perimuscular connective tissue |
T3 | extension beyond the gland | through muscularis propria into pericolorectal tissue | invades unilateral portal or hepatic artery | invades gallbladder, pancreas, duodenum, adjacent | perforation in visceral peritoneum, invades extrahepatic structure | perforated beyond serosa
may directly invade the liver &/or adjavent organs |
T4 | invasion of sup mesenteric artery or celiac trunk(n.) | A: penetrates to th visceral peritoneum
| main portal vein, both portal & common hepatic artery | invades celiac trunk, sup mesenteric artery | periductal invasion | invades hepatic a., portal vein, 2 or more adjacent organs |
B: direct invades/adherent to other organs | ||||||
N 0 | no | |||||
N1 | regional lymphnodes with metastasis | A: 1 | nodes along cystic duct, common bile duct, hepatic a., protal vein involved | regional lymph nodes metastatsis | regional lymph metastatsis | lymph nodes metastatsis |
B: 2-3 lymph nodes | ||||||
N2 | A: 4-6 | metastasis periaortic, pericaval, sup mesenteric, celiac trunk nodes | ||||
B: >7 lymph nodes | ||||||
M0 | no | |||||
M1 | remote metastasis | A: confined to one organ / site
| distant metastasis | distant metastasis | distant metastasis | distant metastasis |
B: > 1 organ / site, peritoneum |
Dukes Classification → Colon cancer
A: invasion bowl wall
B: invasion through bowl wall, not involve lymph nodes
C: involve lymph nodes
D: widespread metastatsis
Parks Classification → fistula in anno
- intersphincteric
- trans-
- supra-
- extra-
Bismuth Classification → perihilar cholangiocarcinoma / Klatskin tumor
1: common heptaic duct
2: involved the confluence to the right & left hepatic ducts
3a: right hepatic ducts
3b: left hepatic ducts
4: involved both OR multifocal
Todani classification→ Bile duct cyst
1: extrahepatic bile duct cyst (entire, focal segment, CBD)
2: bile duct (true) diverticulum
3: protrusion of cyst of CBD into duodenum
4: multiple intra- & extrahepatic cysts
5: multiple intrahepatic cysts→ caroli disease (congenital)
Balthazar grading scale → acute pancreatitis
A - normal
B - enlargement
C - peripancreatic inflammation
D - single fluid collection
E - multiple fluid collection
Ranson Score → acute pancreatitis
criteria below represent 1 point→ a score > 5 the mortality rises above 50%
at admission:
- age > 55
- WBC > 16 000
- LDH >350
- ASAT > 250
- Glucose > 200
after 48 h:
- Hematocrit decrease with > 10%
- blood urea nitrogen >8
- serum Ca < 8
- arterial oxygen saturation <60 mmHg
- base deficit > 4
- estimalted fluid sequestration > 6000
Cremer Classification → chronic pancreatitis
Stage 1: min damage in small pancreatic ducts
Stage 2: irregular Wirsung duct
Stage 3: cystic dilation of 1/more focal lobular canaliculi
Stage 4: stone in the Wirsung duct (NO upstream dilation)
Stage 5: head pancretitis & long stenosis of Wirsung duct
Stage 6: pancretitis & complete stenosis of Wirsung duct in head of the pancreas
atypia classfication → Pancreatic intraepithelial neoplasia (PanINs)
PanIN-1: minimal atypia
PanIN-2: moderate atypia
PanIN-3: severe atypia
Aldrete Classification → liver trauma
- small laceration + min. bleeding → laparotomy with drainage
- moderate laceration + active, significant bleeding → compression argon beam coagulation, bipolar coagulation, radiofrequency, fibrin glue
- large intraparenchymal hematoma → intraoperativ drainage, hemostasis
- large laceration + transsection intrahepatic vessel (hepatic a., hepatic vein, bile duct) → pringle maneuver + suture
- large laceration + transsection intrahepatic vessel (hepatic a., hepatic vein, bile duct) → resection portion of hepatic parenchyma
- large laceration + injury retrohepatic vein + vena cava → total vascular exclusion & suture the hepatic vein & IVC
Gharbi Classification → hydatid cyst
Typ 1 - pure fluid similar to simple cyst
Typ 2 - fluid collection with hydatid sand & split-wall floating membrane
Typ 3 - fluid collection with septa, daughter cyst = honeycomb image
Typ 4 - heterogenous content
Typ 5 - cyst with reflecting thick wall
🌯 Esophagus
- cervical
- throacic
- abdominal
border betw. squamous + cylindrical epithelium (SCJ) at GE-junction
⇒ barrets esophagus! (b in picture)→ SCJ(Z-line) is above GEJ
From inside to outside:
- Mucosa and Submucosa
- Circular Muscle: Contraction increases luminal pressure.
- Longitudinal Muscle: Contraction causes shortening.
- Adventitia
- Innervation: (1) Meissner/Submucosal Plexus, (2) Auerbach/Myenteric Plexus, (3) Vagus Nerve.
abdominal → serosa instead
motor disorders → shows mobility + supplesness (softness)
hydrosoluble → prevent aspiration!
direct visualization + biopsy (+treatment
- motility disorders (esp after exclusion of structural lesions + when suspicion after barium swallowing)
- Dg achalasia (+treatment monitoring)
- pre-OP before fundoplication
⇒ evaluation peristalsis + sphincter p
- Amplitude
- Duration
- Speed of wave
- Spincter pressure
GE-reflux (GER)
- Penetration esophageal layers + surrounding tissue
- Lymphnode evaluation + biopsy
- dysphagia
- regurgitation
- pain
- Sialorrhea (excess salivation)
only for solids
regurgitation
→ progressive evolution = cancer
in achalasia
first liquids then solids
Corrosive esophagitis
characterized by caustic injury due to the ingestion of chemical agents: acids, bases + salts mainly alkaline substances such as detergents.
effortless involuntary retrograde flow of food in the oral cavity
dilation (above the obstruction)
second. infections → inflammation + ulceraion + pain
advanced stages
stenosis → unable to swallow saliva
Corrosive esophagitis
characterized by caustic injury due to the ingestion of chemical agents: acids, bases + salts mainly alkaline substances such as detergents.
BASES! → liquefying necrosis → transmural necrosis
Acids → coagulation necrosis → no/rare transmural necrosis
acids
→ more base ingestion is possible due to less pain
- acute phase: necrosis + inflammation
- granulation phase
- scarring phase → stenosis (esp. when dmg to entire mucosal thickness)
damage to esophagus: pain, dysphagia
inflammatory signs: fever, laryngeal edema
other damaged structure: recurr. laryngeal n, mediastinitis+peritonitis (when perforation)
later: esophageal stenosis
Endoscopy
0 = normal
1 = congestion + hyperemia
2 = Ulcer
2A = superficial ulcer, exudate
2B = Deep ulcer or circumferential ulcer
3 = Necrosis
3A = small necrotic area
3B = extended necrotic area
4 = perforation (not mentioned in the book)
- Perforation → mediastinitis + peritonitis
- laryngeal edema
- Stenosis
Drugs:
- Analgesics → also leads to ↓shock
- Steroids → in respiratory symptoms, prevention of stenosis, in deep lesions
- ABs + steroids → in deep lesions
Intevention:
- emergency surgery → peritonitis + mediastinitis
- periodic esophagoplasty or dilation → stenosis
- esophagectomy → stenosis (to prevent malignant transformation)
exhalation
<10mmHg
(normal = 16)
90%
- gravity + peristalsis
- bicarbonates (from saliva) = chemical clearance
- ↑intra-abdominal pressure
- obesity
- pregnancy
- coughing
- ascitis
- gastric surgery
- smoking + nutrition (nitrates, alcohol, coffee, chocolate)
Savary-Miller ⇒ 📷
non-confluent breaks → confluent Ø circumferential → circumferential → complication
Elevation of the Z-line 📷
T
- Retrosternal pain = pyrosis (heartburn)→ esp. when lying + postprandially
- regurgitation
- pulmonary symptoms
- Ulcer + ulcer perforation
- Hemorrhage
- Stenosis
- Barretts (+dysplasia)
🚩-symptoms!!
- weight loss
- dysphagia + odynophagia
- anemia
- hemorrhage
- pH-metry → drop of pH<4 for 5min; 3x/ 24h
- Manometry → PES < 10mmHG
- Scintigraphy → Estimate reflux + clearance
- Esophagoscopy → Classification + DD!
alles was es halt dort gibt
- esophagitis
- achalasia
- cancer
- diffuse esophagea spasm (functional)
- diverticuli
endoscopy + biopsy
- Diet
- ↓fat
- ↓coffee, chocolatttta, alcohol, nitrates etc.
- quit 🚬
- Lie down in raised position + dont lie down directly after eating
- drugs that aggrevate:
- beta2-agonist + alpha adrenergics
- Ca-channel blocker
- ... etc.
- PPI
- H2-blocker
- prokinetics
- no response to drug therapy
- persistent esophagitis
- complications
- patient doesnt want long-term treatment
during remission moooofugga
- fundoplication
- reconstruction Hiss-angle (Gubaroff valve)
- Connect cardia → right pillar (crus) of diaphragm 📷
- obtain a 4-5cm esophageal abdominal segment
- hernia reduction
- prevent recurrance
- preserve deflutition, vomiting, eructation
- Nissen 360°
- Dor ant. hemivalve 180°
- Toupet post. hemivalve 270°
→ performed via laparoscopy or combined: laparo- + thoracoscopically
normal size + good contractibility → Nissen
faint peristalsis → Dor or Toupet
- cirrhosis (coagulation defects, portal hypertension and nutritional disorders)
- previous interventions (supra-mesocolic level) (probably bc. adhesion formation?)
male >60y
Cricopharingeal muscle contracts prematurely → pressure zone at pharingo-esophageal junction → progressive weakening of muscular tunica → herniation mucosa + submucosa
dorsal + lat
Hiatal hernia
- dysphagia
- regurgitation
- halitosis (bad breath)
- diverticulitis
- weird noise when liquid is swallowed??
barium swallow + radiography
- perforation
- malignant transformation
- aspiration pneumonia
- hemorrhage
- compression recurr. laryngeal → hoarseness
- intubation
- surgical regsection + reconstruction of the wall (suture in 2 layers)
- cricopharyngeal myotomy (prevention recurrance) [divide cricopharyngeal with laser via endoscopy or open neck ]
men + woman late 40's
After Infection with Koch Bacillus → Mediastinal lymphnode adhering to esophageal wall → retro-scarring retraction
- sharper form
- all layers involved!
- Traction diverticuli have a distinct shape and consist of all the layers of the esophagus.
- This type of diverticulum is common.
- Improve writing style to be more confident and academic.
- Retain medical terminology.
- Highlight keywords in bold.
asymptomatic 🤡
- coughing (due to adherence to trachea or bronchi)
- dysphagia (in diverticulitis)
- complication (see below)
- esobronchial fistula
- hemorrhage
- perforation
- pericarditis
- pleuritis
when symptomatic
reconstruction (suture in 2 layers)
interposing of healthy tissue → prevent recurrance
above diaphragm 📷
esophageal dyskinesia (prob. due to ↑pressure)
achalasia
hiatal hernia
- diverticulitis
- perforation
- malignant transformation
- hemorrhage
- dysphagia
- postprandial epigastric pain - relieved after regurgitation
- high epigastric pressure
the typical clinical presentation 🤡
Barium (Radiography + contrast) 📷
when pressure is to ↑↑↑
- compression
- dysphagia
- regurgitation
- perforation 🚑
thoracotomy → resection + suture in double layers 📷
also treat achalasia + hernia
- Failure of LES/cardia relaxation
- Ø well-coordinated persitaltic waves
unknown (infections?, Vit-defic.?, impairment vagal nuclei +trunk?) ⇒ degeneration Auerbach plexus
m+f; 30-50y
- Dysphagia → paradoxical , intermittend+ paroxistic (but over time becomes permanent)
- epigastric pain (in the beginning) → better after esophageal dilation
- Regurgitation → Esp. at night (clinostatism)
- Siallorhea
Stasis esophagitis
- esophagitis
- Ulcer
- Hemorrhage
- Cancer
- Aspiration pneumonia + lung abscess (esp. due to regurgitation)
true
barium swallow
endoscopy
⇒ bird-peak appearance
- terminal narrow portion
- lack of relaxation
- dilation (megaesophagus)
- uncoordinated or missing persitaslsis
iv glucagon → relaxation of cardia (in achalasia)
- DD benign stenosis + cancer → biopsy
- Manometry
- PES > 25mmHg → positive
- uncoordinated contractile wave
clinical presentation → confirmation with radiology and manometry
- Cancer → progressive dysphagia, rapid evolution, general state affected
- Epiphrenic diverticuli → barium (round, regular), normal manometry
- Hiatal hernia → barium (see above), low LES tonus on manometry
- avoid stress
- Ø too hot/cold food
- etc.
2-3 sessions Dilation (mechanic, pneumatic, hydrostatic) 📷
→ Ø result? → Heller esocardiomyotomy = longitudinal incision 6-8cm on esogastric junction + sectioning of muscles up to mucosa 📷
→ Fundoplication to prevent reflux → Nissen in hypermotility forms, Dor in hypo-
If high risk for surgery → Botulinum injection (in LES)
Leiomyoma
(Tumor originating from smooth muscle cells)
- Leiomyoma
- Inflammatory polyps
- granulomas
- papillomas
- congenital cysts
T
bleeding
leiomyoma develops within wall → extrinsic compression → stenosis → ulceration → bleeding
T
contrast xray
F: usually small only rarly large enough to cause obstruction
biopsy
F: may occur at every level + more freq. in the lower esophagus
Barium xray → spherical + regular contour 📷
twist of the polyp → infections, edema + bleeding
small → endoscopic resection
within wall (intraparietal) + malformations → surgery
Cancer of the esophagus is often not detected until it has reached an advanced (incurable) stage.
male 45-65
- alcohol + smokyyyy 🚬
- hot food + liquid
- secondary to pre-existing lesions
- stasis
- caustic esophagitis
- peptic esophagitis
- barrets
- Plummer-Vinson synd
- Pavement Ca → cervical + throacic region
- SCC
- Basal CC
- Adeno Ca → abdominal region
on the lenght under the mucosa
- invasion of wall + neigbouring structures
- lymph + blood dissemination
cervical LN → esp. ant cervical + supraclavicular 📷
- mediastinal
- supraclavicular
- subdiaphragmatic
- celiac LN
- small gastric curvature LN
- airways → fistula
- large vessels
- pleura
- throacic outlet
- reccurent nerves → bitonal voice
hard and enlarged left supraclavicular node (Virchow node) → sign of metastatic abdominal malignancy
- onset
- status
- stage of complication
- dysphagia (slowly progressive)
- burning sensation with warm liquids
→ only for solids
2/3
- dysphagia (becomes permanent first solids → then liquids)
- signs of stenosis/stasis
- regurgitation
- siallorhea
- hallitosis
- pain (due to spasms, not necessarily present)
- hiccup
- aspiration pneumonia (regurgitation+fistula)
- fistula (eso-tracheal+-bronchial)
- mediastinitis (perforation, fistula)
- pain (invasion mediastium, pleura, vertebra)
- B-symptomatic (anoxrexia, weightloss, asthenia)
- hoarsness (voice)
- Barium swallow (double contrast)
- Esophagoscopy
- Endoscopic US (EUS)
- CT
(MRI + PET)
→ incr motility → no effect if cancer
- irregular eccentric stenosis (apple core) 📷
- slight dilation above
- marginal emptiness
- no effect of pharmacodynamic agents
- vizualisation
- type (infiltrative, vegetative, ulcerated)
- site
- biopsy (multiple!!) → confirmation + histology
- EUS
- CT
- Lymphography
- MRI
clinic (male, alcohol, progressive permanent dysphagia, long time Ø pain)
+ radiology barium ( irregular ecccentric stenosis, slight dilation)
+ endoscopy (vizualisation + biopsy → confirms)
+EUS + CT + PET for staging
- Achalasia → paradoxical paroxystic intermittend dysphagia!; normal nutritional state, typical barium, manometry: ↑tonus
- Diverticuli → non-permanent pain+dysphagia; regular, round, lateral on xray
- Benign stenosis → barium: regular contour, marked dilation
- Extrinsic compression (mediastinal adenopathy/tumors; retrosternal gout, osteophytes, aortic aneurysm, hydatic cyst)
- improve general state
- treat respiration infections
- colon prep (for evtl. esophagoplasty)
partial or total
total
→ depends on location, skill, equipment
partial esopagectomy + upper gastric resection, 6-10cm way from tumor
total
thoracic dissection (thoracotomy) 📷
LNs 🍏
anastomasis leaks + fistula
→ mediastinitis + purulent pleurisy
!80% mortality
2x stomach, 2x colon, 3x small intestine
Dan (Geban) gave Rile to (yo)U
- Dan Gavriliu's method (gastric tube esophagoplasty) 📷
- Elevation stomach into chest → vascularization from gastric + right omental a.
- Other parts of intestine: 📷
- EP with transversal colon → vasc. from median colic a.
- EP with terminal colon
- EP with terminal ileum
- EP with Roux-En-Y end-to-side eso-jejunostomy
- self-transplantation of small intestine loop → vasc. from cervical a.
→ gr. stomach curvature → end-to-end to esophagus
→ mainly anastomosis with stomach, colon + jejunum
hilum splenectomy
post. or retrosternal mediastinum
Higher than T2N0M0
Postoperative (adjuvant) Chemotherapy
- spread (local + regional)
- mets
surgery
radiotion
chemo
- palliative esophagoectomy
- stent (transtumoral endoprothesis - esp. in fistula + stenosis)
- laser ablation of stenosis (perforation risk)
- gastrostomy
basal
- after esophagectomy
- unresectable
- recurrance
eso-bronchial fistula
- actinic lung (radiation pneumonitis)
- pericarditis
- tumor necrosis
- fistula (bronchial + aortic)
pre + post operatively
🍤 Stomach (and Duodenum)
break in superficial epithelial cells → penetrations to Muscularis Mucosae
most common location - duodenum
- H.Pylori (↓resistance of mucous coat)
- NSAIDs (↓PG → ↓mucous + ↑acids)
- Gastrinoma (Zollinger-Ellison)
- smoking
- duodeno-gastric reflux
- acid hypersecretion
- HP
- NSAIDS
- motility disorder → rapid gastric content evacuation
- smoking
(1) Epigastric Pain = most common (2) Heartburn = 50% of the time
- Nausea + vomiting
- weight loss
- Bloating + distension
- Fatty food intolerance
- Pain radiation to back
Gastric = worse with meals Duodenum = better with meals
endoscopy + biopsy (lesion + sourrunding)
barium → Haudek niche 📷
radiographic appearance in profile of contrast material filling a gastric ulcer in the wall of the stomach
- check biopsy
- urease breath test
- fecal ag test
- Diameter 1cm
- fine wedged
- diameter >2cm
- fibrous + infiltrated wedged
Type 1: gastric angle, single
Type 2: combined gastric + duodenal ulcer
Type 3: prepyloric, single
Type 4: high on lesser curv, under cardia
Type 5: NSAID-caused
2+3
DRRRRRRRUGS
PPI, H2-Blockers, PGs, HP-treatment, etc.
- complications
- no response to drug treatment
⇒ see below
- hemorrhage (most common)
- perforation
- gastroduodenal outflow obstruction (=chronic complication, due to scarring)
erosion through serosa → digestive content into peritoneum → peritonitis (generalized or localized)
10% of ulcers
ant. wall ulcers
(geht ja auch nach vorne vallah)
- Free perforation → generalized peritonitis (classic form)
- Covered perforation → small perforation diameter → covered from beginning by peritoneal reaction ⇒ localized perionitis (peritoneal abcess)
- Penetration → scleroinflammatory process → adherence of neighboring organs to gastric/duodenal wall → erosion (fistula if cavitary organ is penetrated)
- suddenly worsened ulcer pain or out of the sudden (in asymptomatic ulcer)
- first epigastric → evtl. irradiation towards shoulder (diaphragmatic irritation)
- Then migration into right flank (irritation mesocolon)
- Then generalized
- aggrevated by movement
- antalgic position
- after few hours → gets better → then worsens again
- pain
- evtl. vomiting (esp in late stage when paralytic ileus is present)
- shock (peritoneal irritation → vaso-vagal reflex)
- bradycardia
- hypotension
- pallor + sweating
- late: hypovolemic + toxic shock (due to bacterial peritonitis)
GENERALIZED PERITONITIS:
- "wodden abdomen" w/ intense pain
- pain on rectal/vaginal exam (irritation douglas pouch)
LOCALIZED PERITONITIS:
- epigastric or right illiac fossa guarding (mimic appendicitis)
respiratory impairment + disappearance of hepatic dullness
ileus + bacterial inflammation → abdominal distension
- ↑ Leukos
- ↑ Amylase serum+urinary (due to ↑ peritoneal absorption from spilled content)
- Xray → pneumoperitoneum 📷(semilunar shape under diaphragm when standing or under ant. abdominal wall when laying down)
- CT → Xray not conclusive
CONTRAINDICATED:
- Barium contrast → ↑ peritonitis but: hydrosoluble agents can be used)
- Upper endoscopy → gas insufflation → ↑pneumoperitoneum + could seperate covered perforation (local peritonitis → generalized)
- acute pain
- rigidity (wodden abdomen)
- history of ulcer
cardinal signs (+other signs+symptoms) + pneumoperitoneum
OTHER DISEASES THAT PRODUCE ACUTE UPPER ABDOMINAL PAIN:
- ulcer penetration
- acute pancreatitis + cholecystitis
- renal colic
- intestinal infarction
- acute inf. MI
- basal pneumonitis
surgery
- cover perforation with patch of gr. omentum or suture 📷
- abundant peritoneal wash-out
- bed rest
- naso-gastric tube → aspiration
- i.v. fluids
- PPI (or H2-blocker)
- broad spectrum ABs
- analgesics (short acting)
- transfer to surgery unit
- No signs of peritonitis + 100% perforation is blocked
- Perforation days ago + stable patient
- elderly with surgical risk + no signs or peritonitis
- no surgical units availible (until surgery)
- All the time possibility to evaluate clinico-radiologically
- nothing by mouth
- continous aspiriation
- i.v. fluids
- PPI (4 weeks)
- AB broad spectrum + anti-HP ABs (2 weeks)
resection
- Old ulcer → erosion big vessel outside gastric wall → major hemorrhage → hemostasis required (surgical or endoscopic)
- New acute ulcer → erosion mucosal/submucosal vessels → less severe hemorrhage → mainly spontaneous healing
upper endoscopy → dg. (&forrest-classification) + evtl. treatment
Ia: arterial, spurting
Ib: venous/capillary, slow continous oozing
IIa: ceased-bleeding, visible vessel
IIb: ceased-bleeding, clot adherent
IIc: ceased-bleeding, black crater
III: no signs of bleeding, clean base history of hemorrhage
Ia + IIa
Ib, (Ia - sometimes can be done endoscopically)
IIb, IIc, III
(→ PPI, HP eradication, remove NSAIDs+RF resusscitation etc.)
- >60y
- long history of ulcer
- freq. relapse
- continued melena/hematemesis
- >4U blood transfusion required during resucitation
- continued bleeding or relapse after endoscopic treatment
- intense bleeding→lesion cant be identified
- Bleeding from different origin
- Conditions with ↑bleeding risk
→ esophageal varices, mucosal erosions, tumors, mallory-weiss synd
→ thrombocytopenia, anticoagulant tx, haemophilia
=chronic complication
untreated/relapsing ulcer → fibrotic scarring → retraction → stenosis
prepyloric + duodenal ulcers
hourglass stomach 📷
- morning gastric resting juice is > 200ml
- pediatric endoscope can't pass
- stenic phase: compensation by dilation + hypertrophy of the muscularis layer → not really symptomatic (maybe a seldome vomiting)
- atonic phase: failure of compensation → dilation → profuse vomiting → weightloss, dehydration, constipation, weakness
- contains gastric juice
- food ingested previous days
- free from bile
Darrow syndrome = metabolic alkalosis + paradoxical aciduria
- vomiting → loss of H+, K+, Cl-, Na+ ⇒ Dehydration + "the 3 hypo" (↓K, ↓Na, ↓Cl)
- beginning: alkaline urine → kidney compensation → acidic urine
- dehydration can also lead to shock
- Kussmaul signs (peristaltic waves seen through skin in skinny+dehydrated patients)
- Clapotage sign (succussion splash)
- #1Endoscopy:
- dilated stomach
- chronic ulcer
- stenosis (usually prepyloric)
- passing not possible with pediatric endoscope
- Barium meal
- stenic phase: antrum hyperkinesia + weak duodenal passage
- atonic phase: dilated stomach appears dropped in pelvic area: "plate bottom" or "in sink" 📷
rehydration + rebalance of acid-base-status + other abnormalities
- nasogastric tube + aspiration
- Saline solution + ion supplements → check BGA to control!
- Protein solution if hypoproteinemia
- Anemia correction
CARDIAC ARREST!
(unbalanced ions + anastomosis fistula [due to ↓proteins])
- Gastric Resection 📷
- + Gastro-duodenal anastomosis (Bilroth I or Pean- termino-terminal)
- + Gastro-jejunal anastomosis (Bilroth II or Hofmeister-Finsterer - termino-lat.)
- Gastro-enterostomy 📷 = side-to-side anastomosis (less risky OP: in elderly + comorbidities)
- Balloon dilation by endoscopy (if ↑↑ operation risk)
chronic inflamed mucosa → intestinal metaplasia → dysplasia (light ,moderate or severe) → severe dysplasia is considered eq. to "Ca in situ" → invasive carcinoma
- HP
- Chronic athropic gastritis
- intestinal metaplasia
- partial gastrectomy (20-30y ago)
- smoking
- nitrates + preserved food
- ↓ fruit + vegetables
- family history → HNPCC = Lynch syndrome II
- Mentrier's disease = Giant hypertrophic gastropathy
- Adenomatous polyp
- visible + palpable on surgical exploraion
- firm + infiltrated
local adenoCa limited to mucosa or submucosa
active mass screening (japan, south-korea)
>90%
0-I : exophytic
0-II: non-polypoid
0-IIa: elevated (only slightly, up to 5mm)
0-IIb: flat, discolored mucosa
0-IIc: slightly depressed
0-III: superficial ulceration
infiltration beyond submucosa
Bormann-classification: 📷
I : protrusive
II : ulcerative + elevated margins
III : Ulcerative-infiltrating
IV : extensive infiltration + thickening of wall (linitis plastica)
- #1 adenocarcinoma
- lymphoma
- GIST
- Neuroendocrine tumor (i.e. gastrinoma)
Shah's clas sificiation
- Intestinal type (located at body or antrum) → associated with HP, smoking, salt, alcohol
- Proximal type (GE-junction + cardia) → HP protective!, worse prognosis + ↓resectability rate
- Diffuse type (linitis plastica) → due to E-cadherin mutation → diffuse infiltration of gastric wall, thickening of entire stomach, becomes rigid tube; esp in young patient, worst prognosis, no precursor lesion identified
none
nonspecific: epigastric pain, postprandial meteorism, early satiety
- signs of upper GI-bleeding
- occult (low grade)
- melena, hematemesis [fresh or coffee ground](intermediate)
- rare: acute massive bleeding (invasion artery i.e. splenic)
- Anemia (iron def) → hemocult test for every patient with signs of anemia
- B-symptomatic
- Weight loss
- anorexia-cachexia syndrome (anorexia specific for meat + bread) → serum albumin reflects nutritional status
- fatigue
- Dysphagia
- palpable tumor
= GERD symptomatic with dysphagia
Dysphagia, reflux, heartburn, regurgitation (if prox at esogastric junction)
= stenotic tumor ⇒ gastric outlet obstruction (malignant pyloric stenosis)
LATE STAGE (disseminated): = irresectability
- Jaundice (liver mets → intrahepatic; CBD compression or invasion → extrahepatic)
- irregular, large liver → large mets
- Ascitis → peritoneal carcinomatosis
- Virchow node (large left supraclavicular node)
- Sister mary joseph node (umbilical metastasis nodule)
- Blumers Shelf (large peritoneal/intestinal mets into douglas pouch → rectal exam)
- Krunkenberg tumor (ovarian mets → vaginal exam)
- pain radiating back → invasion pancreas + celiac plexus
gastroscopy → direct visualization + biopsy possible
- dyspepsia + alarm signs
- positive family history
F → never
if grossly suspected lesion but neg biopsy → close follow-up: repeat gastroscopy + biopsy
gentle brushing of lesion during endoscopy, if normal biopsy failed to confirm malignancy
T stage → infiltration + invasion of neighboring organs
TNM
- N + M stage
- CEUS → in suspected hepatic lesions
detection small+very distant mets
also only selectively used
- segmental rigidity (of gastric wall)
- lacunar image = filling defect 📷
TNM, → selectively used (cost+similiar infos but more accurately than CT))
lesions suspected but not detected with 100% by imaging
→ detects very small peritoneal (carcinomatosis)+ hepatic mets
esp in T3 or T4
they only increase in advanced stages thats why they are only useful:
- to evaluate accuracy of surgical resection (drop back to normal in R0 [radical resection])
- to suspect mets or locat reccurance (during post-OP follow-up)
→ CEA, CA19-9, CA 72-4, CA50
specific stage → specific therapeutic protocol
- dissemination + mets
- like peptic ulcer:
- hemorrhage,
- stenosis,
- perforation,
- invasion of neighboring organs
R0 (radical complete) resection
- intestinal type (Ødiffuse!)
- only mucosa + submucosa (Tis, T1a+T1b)
- N0
Erradication HP
(to prevent metachronous gastric carcinoma)
- only mucosa
- well-diff.
- elevated + <20mm
- depressed, no ulcer + <10mm
- mucosa + submucosa
- well diff
- mucosa: >20mm+Øulcer OR <30mm w/ ulcer
- submucosa: <30mm
- non-total resection (cancer in margins, unprecise degree of wall infiltration)
- difficult location: curvature + fundus
resecting all layers
fix gastric wall defect → endoscopic clips
T2 or higher → neoadjuvant chemoT
(evtl. also adjuvant after resection)
5-6cm
- Wedge resection
- Subtotal gastrectomy
- Total gastrectomy
- Wedge - early submucosal Ca + GIST
- Subtotal gastrectomy - distal
- Total gastrectomy - proximal (corpus + fundus) + diffuse
- distal 3/4 Stomach
- pylorus
- Duodenum 3cm
- greater + lesser omentum (omentectomy) [LN group 4]
- same distal limit as subtotal (with 3cm duodenum)
- esophagus 3-5cm
- greater+lesser omentum
D2 lymphadenectomy = perigastric + regional lymphnode stations
send the specimen to pathologist → only after confirmation: proceed with reconstruction
- Billroth 1 - gastro-duodenostomy (t-t)
- Billroth 2 - gastro-jejunostomy (t-l) with first jejunal loop
- Roux-En-Y - gastro-jejunostomy (t-l)
Roux-En-Y → eso-jejunostomy (t-l) 📷
Billroth II + Braun📷 anastomosis
(eso-jejunostomy + jejuno-jejunal-anastomosis)
stump is closed → but distal part gets connected to jejunum
- in T3 or T4 → laparoscopic abdominal check: peritoneal carcinomatosis?? (could be there is radiological understaging with M0 but microscopic mets already spread to peritoneum ⇒ irresectable) → see staging laparoscopy
- GIST
- gastric Ca (similiar radicality + also complete lymphadenectomy as surgery)
- After endoscopic resection of early gastric cancer but suspicion of LN involvement
20%
90%
antro-pyloric + e-g-j ⇒ earlier signs (see clinical features)
antro-pyloric = best resectability rates + prognosis
🦑 Small Intestine
- Developmental → Agenesia, Atresia, Stenosis, Duplication, Persistence
- Position, Rotation, Joining
- By Extrinsic compression (i.e. ring pancreas📷)
- Histological (nerve+epithelial abnormality)
occlusion
persistence omphalo-mesenteric canal (aka vitelline duct) 📷
The omphalomesenteric (vitelline) duct is a normal component of fetal development. It connects the fetal intestine to the yolk sac
1-12cm
last 60cm
( Tee (1) im Diverticulum in Tonnenform (12) befindet sich in der letzten Scheisse (60) vom ileum)
fibrous cord → connecting post. umbilicus + diverticulum 📷
contains all layers of small intestine
ectopic tissue → most often gastric mucosa + parietal cells
when complications occur
rarely (4%) symptomatic → children<10y + adults <30y
- Bleeding
- Occlusion (due to volvulus, invagination or adhesion)
- Ac. diverticulitis → Perforation
- Ulcer (on ectopic gastric mucosa)
Bleeding → for DD with bleeding from other source
appendicitis
last 80-100cm of ileum
(note: to be sure, <60cm is the most common distance
symptomatic diverticulum
- peritonitis
- occulusion
- profuse bleeding
delay surgery → do barium enema to further investigate bleeding source
PPI or H2-blocker
ulcer bleeding from ectopic mucosa
after 60y
only mucosa + submucosa
herniate through vascular penetration orifices → into wall → penetration mesenteric sheets → Bleeding + Perforation
malabsorption syndrome
segmental resection 📷
- abdominal pain
- diarrhea
- extraintestinal manifestation
- fistulas
- abcesses (intra-abdominal + ani-perineal)
- occlusion
terminal ileum
but can appear anywhere
granulomas
Trrrrue, often positive family history (anamnesis!)
F: 18-20y → 5-7x ↑risk
- masked symptoms
- stenosed ileum → impossible endoscopic access
- multiple transversal ulcer → cobblestone appearance
- fibrosis of the lesions → stenosis
- thickend wall + mesentery (also enlarged lymphnodes)
- involvement of all layers (in longitudinal section)
- fixed adhesion betw. intestinal loops ⇒ developtment of fistulas within them → abcesses + duodeno-/jejuno-colic shunts (→ malabsorption)
- alternation with normal segment = skip lesions
- Granulomas (non-caseous)
- Apthous ulceration (above these lymphoid follicles)
- Pain
- Diarrhea
- Weight loss (+evtl. fever)
- Iron deficiency anemia → due to occult bleeding
Para-umbilical or right iliac fossa
food ingestion produces pain + distension, nausea + vomiting → patients give up eating
- Incomplete reabsorption of bile salts (impaired ileum , can’t absorb bile) → colon → electroly + water influx→ diarrhea ⇒ cholesthyramine
- Bacterial infection ⇒ AB tetracyclin or metronidazole
- Fistulas → duodeno-/jejuno- colic → shunting of absorption → undigested bolus into colon → diarrhea ⇒ surgery
- Extensive colon involvement → colon mucosa damage (structural) → ↓water+electrolyte reabsorption → osmotic diarrhea ⇒ 5-ASA + steroids
- ↓Albumin (due to malnutrition + inflammation)
- Anemia (iron def)
- ↑ESR
secondary occulusion
Østeroids!!
→ nasogastric tube aspiration
- fibrous organic stenosis → appears after 8y→ surgery needed
- reversible stenosis → in active phase: steroids solve this
growth retardation (+weight loss)
- Joint disorders (i.e. ankylosing spondylitis)
- Skin:
- Erythema nodosum
- pyoderma gangrenosum
- (Red) Eye: Uveitis + Keratoconjunctivitis
- Fistulas + Abcesses
- Bile- + kidney-lithiasis
- Ureteral stenosis
Ulcer perforation → usually Øfree into peritoneal cavitiy BUT inside blocks of adhesions → Abcesses → Fistulas: entero-peritoneal, entero-vesical, recto-vaginal, ano-perineal and more(see later)
- entero-cutaneous
- level of anastomosis/post-operative scar
terminoileitis or resection of ileum → ↓bile salt reabsorption → ↑cholesterol (relative) + ↓bilesalts in bile → lithogenic bile
terminoileitis or removal of illeum → ↓FFA reabsorption → FFA bind Ca2+ → ↓free Ca2+ to bind oxalate → ↑Natrium-oxalate (soluble) → absorbed by colon → hyperoxalemia → oxalic lithiasis
right ureter
sclerotic-inflammatory progress in terminal ileum + ceco-asc. colon
hydronephrosis
anti-inflammatory therapy → associated with active phase
- Abdominal pain (slow onset, most often right illiac fossa)
- ↓Body weight
- Diarrhea
- fever
- underdeveloped child
- positive family history
Physical exam:
- Pallor? (anemia)
- Weightloss?
- Inflammatory tumor (painful) in right iliac fossa
- fistulas/abcesses peri-anorectal
- extraintestinal manifestations (skin, joint, eye, bile+kidney stones, hydronephrosis)
Check Lab
- Iron def. anemia?
- ↓Albumin?
- ↑ESR?
- UC (location, bloody diarrhea, +paraclinical investigations)
- Intestinal TBC (history(bacillus), pulmonary signs)
- Lymphoma
- ilio-cecal tumors
Paraclinical
- Irigography with Barium enema
→ Reflux into ileum?
→ segmental stenosis ileum
→ cobble stone appearance (healthy + damaged segments)
→ entero-enteral + -colic fistula
- Colonoscopy
- CT
- Upper Endoscopy → only if uncertain
→ Normal lower colon + rectum
→ Cobblestone-appearance 📷 : Extensive longitudinal + transversal ulcers delimiting edematous mucosa
→ BIOPSY❗→ granuloma
💡 might be not possible to perform because severe stenosis
→ stenosis, abcesses, wall thickening
→ Radiological DD with lymphoma + tumor
histological confirmation → granuloma
5-ASA + Steroids
active phases
- Steroids failed
- long term treatment required (+5-ASA is not enough)
- Loperamide
- If due to removal of ileum → Cholestyramine
- If due to bacterial infection → Tetracyclin
- iron (+B12+ folic acid) replacement
- caloric supplements or parenteral nutrition
steroids + NSAIDs
- emergency (i.e. toxic megacolon+fulminant colitis, massive hemorrhage, peritonitis, acute stenosis, abcesses)
- elective surgery (stenosis, fistula, abcesses)
- Stenosis
- Perforation
- fistula + abcess
- right hemicolectomy → anastomosis ileal stump + transv. colon 📷
- ileo-colic or ceco-ileal resection → anast. ileal stump +cecum/asc. colon 📷
- long term occlusion + bad patient condition → ileo-transverostomy 📷 or ileostomy📷
- good condition but previous multiple jejuno-ileal resection → interal bypass (connect segment above + below stenosis) or strictureplasty📷
- ileo-cecal or ileo-ileal
- ileo-sigmoid
- ileo-vesical
- recto-vaginal
- colo-vaginal
- colo-vesical
- colo-jejunal
- colo-gastric/-duodenal
- ileo-cecal or ileo-ileal
- ileo-sigmoid
- ileo-vesical
- recto-vaginal
- colo-vaginal
- colo-vesical
- colo-jejunal
- colo-gastric/-duodenal
→ only surgery indicated when w/ abcesses → ileo-cecal/-colic resection
→ ileo-cecal/-colic + sigmoid resection → 2 anastomosis OR only ileocolic resection + suture of sigmoid wall
→ ileal segment resection + suture bladder wall → catheter for 1 week
→ fistula, ulcer + fibrous resection + suture vaginal+rectal defect → protective colostomy
→ segmental, subtotal or total colectomy
→ colic segment resection +/- protective colostomy
→ both segments resected
→ colon segment resection + suture gastric wall/jejunal patch on duodenum
malabsorption → severe weight loss
level of anastomotic sutures
- Drainage of perifistular abcess
- ext. derivation of fistula
- Resection of fistula trajectory
- excision of affected segment
- suture + protective colostomy
- OR Hartmann resection 📷 (if recto-sigmoid location)
- washing + drainage of peritoneum
- US guided puncture + drainage
- OR surgery with treatment of entero-colic lesion
- surgical excision of segment
- evtl. intra-operative enteroscopy/colonoscopy or opening of segment to correctly identify source of bleeding
- Steroids
- AB
- decompression with long tubes
- → subtotal colectomy + ileostomy
- radioloy: "empty abdomen" + dilation 📷
- signs of inflammation: altered state, fever, ↑Leukos, tachycardia
nope freq. recurrance after resection
- history: Afib?? (causes 80% of EMI)
- shock + tendency to collapse
- cold extremities
- pale, sweaty, restless
- occlusive picture:
- distended abdomen
- Øtransit of feces+gas
- nausea + vomiting
- Diarrhea + enterorrhagia
Physical exam
- distension
- Auscultation: ØPeristalsis
- Signs of peritonitis (i.e. wodden abdomen)
- painful to palpation (max at affected loop → might feel a „soft sausage“)
- Rectal exam: Douglas p. round + tender, bloody stool
- Percussion: Tympanism
other abdominal disorders with intese pain + shock
- acute pancreatitis
- intestinal occulusion
- diffusse acute peritonitis due to perforation (i.e. ulcer)
- Posterior MI
- ruptured extrauterine pregnancy
aprupt + persistent supression of blood flow in SMA, IMA, SMV, IMV or in capillaries → hemorrhagic necrosis of intestinal segment involved
- EMI of arterial trunk
- Embolic → thrombi from heart
- Thrombotic → thrombi from arterial plaque
- Other → aortic dissection, abdominal trauma+rupture of mesenteric vessels
- EMI of venous trunk
- EMI of microcirculation (capillaries)
- Apoplexy:
- Infarction proper:
- Gangrenous stage:
→ spasm of microcirculation → dilation → plasma exudate
⇒ cyanotic, edema, red loop
→ capillary rupture → blood into lumen +wall → intraparietal hematoma
⇒ purple-black loop
→ Stercoral peritonitis
⇒ greenish-gray loop with multiple perforation
- triangle
- clear deliniation from healthy area
- #1 Afib
- mitral valve disease
- MI
- endocarditis
hypotension + blood stasis
→ i.e. in MI or heart failure
reflex arterial spasm (above + below + in microcirculation) → fix embolus even more in vessel → pain
→ secondary extensive postembolic thrombosis → further damages intestinal wall
F:
90% - SMA
10% - IMA
→ SMA has sharper angle + no supplement blood supply (IMA gets blood from middle hemorrhoidal a. (from left iliac)
pelvic or IVC phlebitis
- hypercoagulability → polycythemia, hemoconc, post-splenectomy thromcytosis
- stasis → portal HT, tumoral compression of PV
- suppuration → diverticulitis, peritonitis
- abdominal trauma + surgery
- irradiation
- endo-toxic shock → ↑bacteria in ischemic area → toxins into general circulation
- Hypovolemic shock → massive accumulation of plasma + blood cells in wall+lumen
T 80-93%
Lab:
- ↑Leukos
- ↓Hb+Htc (bleeding)
- Metabolic acidosis (defective reabsorption + loss in peritoneal space)
- ↓K+
- hyperazotemia (renal failure due to ↓Volume)
- hyperamylasemia (↑peritoneal absorption, spilled content)
Xray → selective arteriography/angiography of SMA 📷⇒ Answers where the obstacle is located
US:
- thickend ischemic loops
- dilation loops above
- Ø peristalsis
- peritoneal fluid
Doppler US:
- location of obstacle
- DD thrombosis vs embolus
puncture abdominal fluid → ↑Leukos
- Volume correction
- volume+ acid-base correction
- blood transfusion
- parlytic Ileus correction
- nasogastric aspiration
- AB + Analgesics
- antibiotics
- peridural anesthesia → pain + improvement of microcirculation (dont give in collapse (↓BP))
6-8h
- anticoagulants + antiplatelets
- streptokinase
- vasodilations
second look laparotomy
- mesenteric artery catheter 📷
- enterectomy of necrotic loops
- washing + drainage of peritoneal cavity
T
- direct portal thrombectomy (if injury is reversible)
- Øintestinal resection! (contraindicated)
- Heparin
- Dextran
- AB
- beta-analoges
- alpha-blocker
- vasodilations (papaverin)
- streptokinase
primary tumors in other locations
F → only 10%
T → 75%
- bleeding
- occlusion
→ benign + malignant (mainly)
💡[open for questions]
T
F - solitary
bleeding + occlusion
T
Peutz-Jegers syndrome → polyposis of Gi-trakt + hyperpigmentation of mucosa📷
F → low
symptomatic cases → polyps >1cm removed
- familial polyposis colon (premalignant) + small intestine
- osteomas
- fibromas
- subcutaneous cysts
- colon cancer (>40y)
- duodenal periampullar cancer
F → may eliminate spontaneously (self-amputation)
acute abdomen
prox jejunum
segmental + adjacent mesentery resection
F → usually asymptomatic → 80% have mets when dg.
T - 25% only
..ileum .. submucosa .. rigid..
malabsorption syndrome + refractory fever
- splenectomy
- liver + retroperitoneal ganglia biopsy
malignant melanoma
good general condition
endocrine cells (in intestine)
neoplasm other enterochromaffin tissue:
- thyroid medullary cancer
- pheochromacytoma
T - 25-45y
1.appendix
2.ileum
biopsy + special stains
The diagnosis of carcinoid tumor is initially based on histology with confirmation by positive immunohistochemical staining, defined as positive staining for one or more neuroendocrine marker.
The size of the tumor
<1cm - 25%
>2cm - 80%
none 🤡
- pain
- carcinoid syndrome
- bleeding
- occlusion
- episodic flushing
- diarrhea
- right heart valve disorders → bronchial constriction
unusually inactivated by the liver → if liver mets → direct spill into systemic circulation
- serotonin
- ACTH
- calcitonin
- catecholamins
- ...
F - even metastazised indicated
true → strptozocin
selective embolization
- Phenothiazin - blocks D2-R
- Coticosteroids - esp. to treat flushing
- H1+H2 blockers - for flushing
- Somatostatin - diarrhea
🥜Colon
- proctitis (rectum)
- (proctosigmoiditis)
- left colitis
- pancolitis
E1 → ≤15cm above anal verge📷
E2 → ≤ 25-30cm above anal verge
F - ↑risk for non-smokers + patients who quit
smoking = protective factor 😎 💨
⇒ recommend to your patient to never quit smoking 🤡
only mucosa + submucosa
more severe + extended lesions (the more colon involvement + the more severe lesions ⇒ the more symptoms
- diarrhea (procitis, proctosigmoiditis, pancolitis)
- rectorrhagia (proctitis, proctosigmoiditis, pancolitis [↑severity])
- tenesmus (esp. proctitis)
- abdominal pain LLQ (in proctosigmoiditis and more extended)
- fever (in proctosigmoiditis and more extended)
- weight loss (in proctosigmoiditis and more extended)
⇒severe anemia + dehydration (in pancolitis due to ↑↑diarrhea+bleeding)
- Skin lesion (erythema nodusum + pyoderma gangrenosum)
- Uveitis + keratoconjunctivitis
- Arthritis - evtl. ankylosing spondylitis
- primary sclerosing cholangitis
- Crohns D → perianal fistula + abcesses, transmural, thickening of rectal wall
- infectious proctitis → homosexual, culture + serologic test
- ischemic proctitis
- post-radiotherapy proctitis → pelvic radiation (rectal+pelvic malignancy)
- secondary to colostomy proctitis → 2-3month after!
only rare extension upstream → most often Øsurgery needed!
multiple biopsies!!!
microscopic extension might be more than macroscopic!
periodic → periods of remission
10% → continous + Øresponse to medical treatment → colectomy!
- Acute:
- Diarrhea + rectorrhagia ≥6x/days
- Hb < 11
- fever + tachycardia
- ESR > 30
- Mild:
- ≤4x stools/day
- Hb > 11
- Øfever + Øtachycardia
- ESR < 30
- Moderate:
- inbetween
Ulcer >[5]mm in diameter OR more then [10] ulcers over [10]cm colon lenghts are associated with [spontaneous hemorrhage], and therefore criteria for the severe form.
rarely severe bleeding
10-13%! → every 10. UC patients
F
much higher with perforation
septic shock
- tachycardia
- fever
- hypotension
- abdominal distension
- signs of perioneal irritation (perforation/abcess)
⇒ early detection of free air in peritoneal cavity (=perforation)
- Xray
- US
- CT
- Leukos
- dilation of transv. colon >6cm
- loss of haustrations
1. ↑body T (by 3 tens of degree - under steroid therapy)
2. colic pneumatosis 📷
local smooth muscle hypertrophy
(Øsclero-fibrotic)
2-3cm
≥5cm → more likely malignant (esp. when long evolution)
Colonoscopy
- Erythema
- Granular mucosa (sandpaper like) → later nodular + friable
- pseudoinflammatory polyps
- hemorrhagic, ulcerated, stenosis ≤3cm in severe
- skip lesions
- Øpseudo-polyps
- cobblestone
- distorted Crypt + abcesses
- inflammatory cells in muscularis mucosa
- lesions limited to mucosa or submucosa
barium enema might be useful → not really used anymore
- Lead pipe appearance 📷 → loss haustrations, edema, colon wall thickening, continous lesions
- Dg of toxic megacolon
- Pancolitis
- ≥3 y evolution
- early onset → childhood, adolescence
5asa+steroids in den po
- 5-ASA suppository
- Hydrocortison/ACTH enemas
switch to oral 5-ASA
- Try Sulfasalazine first (orally)
- Then Steroids if doesnt bring remission (orally)
- If Corticosteoid resistance → Immunosuppressiva (Azathioprine, 6-MP, Cyclosporin, MTX)
Sulfasalazin → remains remission for 1y or longer
- i.v. fluids
- transfusions
- steroids
- 2nd line (steroids fail): Infliximab or Cyclosporine
- Surgery See later (If complications + 2nd line fail)
- treat distension
- nasogastric suction
- long intestinal tubes (placed endoscopically)
- narcotics
- antidiarrheals
- anitcholinergics
→ precipitate it
T 👍🏾
- before-mentioned medical treatment fails
- pre-pubertal children (↑stature + ↓retardation)
- Malignancy or dysplasia
- Extra-intestinal manifestation
↓OPEN FOR FURTHER QUESTIONS↓
nope.
errector nerves → rectum is mobilized
perineal resection
mild/Ø rectal involvement
↑Risk for:
- Reappearance of UC proctitis in rectum
- Malignization
- Soft stools → contraindicated in ↓sphincter tonus
- excision of rectal mucosa → less risk for recurrance + malignancy
5-6cm above dentate line
complication
- Fulminant colitis resistant to drugs
- Toxic megacolon (Absolute indications for surgery: perforation, massive hemorrhage, incr transfusion requirements, progressive dilation, worsening signs of toxicity, 2nd line fail)
- Perforations + Abcesses
- Hemorrhage (↑↑)
- Stenosis
- chronic overpressure (chronic constipation)
- collagen defect
- others that disturbe colonic parietal structures (with normal pressure)
mucosa penetrates circular muscle at vasa recta fenestrations (minimum resistance area)
- between mesenteric + antimesenteric taenia 📷
- sigmoid + desc. colon
- asymptomatic for a long time
- cramping pain - left illiac fossa (for hours-days)
- reliefed after defecation+farting 🍑 💨
- Bowel habit alteration (change in rhythm+nature of defecation)
- diverticulitis +complications
- Penetration:
- abcesses (blocked perforation) → fever pain, guarding, palpable mass, ↑leukos
- peritonitis (free perforation)
- partial or complete obstructions (stenosis due to repeted inflammatory episodes)
- Fistula
- vaginal
- bladder
- small intestine
- skin
- Hemorrhage (erosion of blood vessel)
- Malignancy
- US → thick wall, intra-abdominal collections, fistula
- Irrigography + barium → opaque diverticula + fistula
- CT → thick wall, strictures, abcesses
- Bleeding investigation:
- Colonoscopy → mucosal change, source of hemorrhage, detection of benign+malignant tumors (!!risk of perforation)
- Angiography + RBC labeled with Tc → source of bleeding
fiber-rich diet + glucagon
- water diet
- broad spectrum AB = Amoxi 10days→ severe cases gentamycin + tobramycin
- nasogastric suction (in distension in severe cases)
- ≥2x diverticultis episodes
- immunosupressed
- long-term steroid treatment
- first diverticulitis <40y
- subocclusive syndrome (partial obstruction)
- Øpossible to exclude cancer
- fistulas
- Generalized peritonitis (due to free perforation or abcess)
- severe bleeding
- complete occlusion
- located at sigmoid colon → segmental sigma resection
- located at desc. colon → left hemicolectomy
- prepared colon → colorectal anastomosis
- unprepared colon or peritonitis or abcess(emergency) → temporary colostomy + closure of distal stump (Hartmanns)→ restoration after 6-8w
mainly you dont 🤡 → 80% stop spontaneously
20% → IMA catheterization + continous ADH perfusion → clinical delay
→ surgery after re-equilibration of patient (bc. bleeding recur sooner or later)
- anastomosis leak
- peritonitis
- infection
- obstruction
- bleeding
- urinary tract injury
- lymphatic
- invasion neigbouring structures
- peritoneal dissemination
- blood → portal v.
- malignant syndrome (weight loss, anemia, fatigue etc
- right colon location (anemia, palpable, diarrhea, fever)
- left colon location (rectosigmoidian synd., obstruction, abnormal transit)
- COMPLICATIONS (see below)
- Metastases: Liver,lung
- Left colon → perforation → supratumoral or diastatic caecum perf. ⇒ fecal peritonitis
- Right colon → anemia, obstruction (ileo-cecal valve)
- Peritoneal carcinomatosis (→ascitis)
- obstruction
- Right:
- Appendicitis + apendix-tumor
- Crohns+UC
- Ileo-cecal TBC
- other intra-abdominal tumors
- Left
- diverticulosis
- other intra-abdominal tumors
- granulomatous colitis
- TNM
- Dukes classification
Dukes A → only wall
Dukes B → through wall, ØLN involvement
Dukes C → LN involv.
Dukes D → mets
- radical (surgery)
- palliative
- symptomatic
- endoscopic
- oncologic
- Mechanism bowel prep → Fortrans
- AB prophylaxis
↑risk for anastomotic fistula → ↑risk for peritonitis
most often multiagent chemo (i.e. FOLFIRI or FOLFOX)
neoadjuvant treatment might downgrade tumor → ↑survival
yesss → downstaging → ↑survival in stage IV
💩 Rectum and Anal Canal
abnormal dilation (varix) of ano-rectal veins
low fiber diet, reading on toilet, etc → Anorectal stasis → dilation of veins→ mucosa easily traumatized → bleeding (bright red)
- internal (above dentate line📷) → simple columar epithelium, no somatic sensory innervation → painless
- external (below dentate line) → stratified sq. epithelium, somatic sensory innervation → pain
anitis (inflammation anal mucosa) → spreads to vein → hemorrhoidal phlebitis → veins dilates + get hyperthropic → reflex contracture of sphincter → irreducable hemorrhoid → thrombosis
DD
Longo - Stapler:
Radial tear of anal epithelium
- constipation
- foreign body
- trauma
- iatrogenic
- diarrhea (inflammed+fragile epithelium)
persistent ulcerous lesion → granulation-tissue covered base + fibrotic margins 📷
- 90% post. midline (post. commisure most poorly perfused)
- rarely ant. midline
!consider STD
- pain
- spasm
- small bleedings (on t-paper or surface of stools)
- Crohns
- TBC
- syphilis
- carcinoma
you dont, heal spontaneously🤡
(just hygiene + avoid constipation)
- anestetic gel
- nitroglycerin ointment in anal canal (↑bloodflow)
- warm local bath before+after defecation
- botox injection (recurrance risk after 3mo)
- Electrocautery → remove fibrous tissue
- Partial lateral internal sphincterotomy (closed mainly used) ⇒ reliefs spasm + lesion
- closed: mainly used - leaves mucosa unharmed → thin scalpal betw. sphincters📷 →cutting internal component 📷
- open: incision betw. sphincters → internal sphincter resection 📷
- Recurrancy → Flaps (plastic surgery)📷
obstruction mucus secreting anal gland (drain into crypts) → cryptitis
- submucous (+subcutaneous)
- ischiorectal
- Supralevator (pelvirectal, pelvisubperitoneal)
- intersphincteric
- Inflammatory (Celsian) signs: swelling, tenderness, red, ↑Temp of skin
- perianal pruritus +discomfort
- Rectal exam → protrusion of rectal wall
- If really aggressive bacteria strains → Fournier gangrene (perianal ST necrosis)
..urinary.. spread to reptroperitoneal space
- US - Endorectal or vaginal
- CT (in deep)
- Spinal anesthesia
- punction + drainage → drainage left for 1-3d
- Local antiseptics
- broad-spectrum AB (before surgery)
A perianal fistula
hollow tract lined with granulation tissue →usually from dentate line to perianal skin
mainly after spontaneous drainage of perianal abcesses (see above)
≥1 distal opening
- Crohns
- Diverticulitis
- local radiotherapy
- steroid therapy
- HIV
- Extrasphincteric
- Suprasphincteric
- Transsphincteric
- Intersphincteric
cutaneous opening ant. to frontal plane → fistula will have straight course to dentate line
if post → curved course with internal opening on post. midline
- Hydradenitis
- Pilonidal sinus (see later)
- TBC
- Rectovaginal fistula
- Urethral-cutaneous fistula
- history of peranal abcess
- orrifice with discharge (small volume, might also be slightly hemorrhagic)
- Rectal exam → evtl. fibrotic tract palpation
- recurrent cases → fistulography
- Endorectal US + CT (any cavities that dont heal??)
- Fistulectomy
- or Fistulotomy → partial fistulectomy (cutaneous part) → ligatures (or just rubber bands) put into remaining part → 1st knot in surgery → others at 3 day interval → cuts through the tissue ⇒ used in recurrences, complex fistula (i.e. Crohns), elderly people 📷
- Collagen into fistula → colonization with fibroblast + inner orifice sutured
granulation tissue formation around hair → trans-cutaneous migration
- excision + Øclosure (second. healing)
- Evtl. secondary suture after healthy granulation tissue occurs → faster healing
→ dye to localize + capsule+fibrotic tissue removed
90%=50y → ↑with age
- Environmental factors: smoking, alc, obesity, diet (low fiber, high meat)
- Acromegaly
- Cholecystectomy
- Ureterosigmoidostomy
- pelvic radiation
- Familiar: lynch synd + FAP
- history of polyps (adenoma + sessile serrated=
yes → 3rd often cancer in men, 2nd in woman
sup, middle, inf rectum
adenoCa
others: signet ring, SCC, carcinoid, GIST, etc
- ulcerative(most freq.) → invade all layer
- polypoid → into lumen, Øinvasion
- annular → obstruction (circumferential evolution)
- infiltrating (worse prognosis)
FFFFFFFFFFFFFFFFFF
differentiation (G1-4) → 4 has worst prognosis
- depth of invasion
- LN mets
- direct invasion (wall)
- transperitoneal
- on pre-existing lesion (hemorrhoids, fistula)
- venous
- lymphatic
- bleeding (lower GI)
- pain
- bowel habit alteration
- B-symptomatic → weight loss + anorexia
- Obstruction → pencil-stool, tenesmus, sensation of incomplete evacuation
- Signs of advanced: back pain, jaundice (liver mets) + inguinal LN, vaginal + urinary invasion
- acute abdomen (in tumor perforation or bowel obstruction) → resection or ostomy!!
DRE → hard mass (if inf rectum); blood on gloves (if sup/middle)
- hemorrhoids
- benign polyps
- UC + CD
- ischemic colitis
- invasion from other location (prostate cancer)
- radiation proctitis
- Lab: Anemia, LFT, ↑Leukos, CEA (for treatment monitoring)
- Colonoscopy → macroscopic, biopsy + check for other neoplasias
- Rigid sigmoidoscopy 📷→ distance inf. tumor margin + anal verge → for resection-choice (ant. vs. abdominoperineal resection)
- EUS → depth + LN involvement
- MRI → invasion ST: fascia propria, levator ani + sphincter 📷→ circumferatial resection magin is predictor of reccurance → evtl. neoadjucant chemo needed
- PET-CT → local + distant spread (esp. CT) + detection of recurrent rectal Ca (esp. PET)
- X-ray → lungs mets
TNM
pTNM - pathologic
rTNM - recurrent
yTNM - neoadjuvant
- bowel prep (optional)
- AB prophylaxis (metronidazole)
Operability → stages(mets?) + patient condition
Resectability → can be taken out (no invasion of artery etc)
Hartmanns → stabilization → surgery to restore continouity after 6month
non-invasive: Stent or lasertherapy
- good blood supply
- tension-free
- do air test (post-OP air insufflation) when stapler is used, Ønot hand sewn
you could (but Øsignif. ↓ in anastomosis leakage)
remove the tissue + free margins
F → may still benefit from curative resection
- excision
- hepatic artery infusional chemotherapy
- Radiofreq. ablation
- microwave ablation
- Cryotherapy
take mets put (metastatectomy)
- Resect primary tumor
- chemotherapy
→ longer period of disease control
- ovaries
- bones
- brain
→ shortens post-op ileus time
- early oral nutrition
- early ambulation
- post-op ↓dosage of opioids
- thrombosis prophylaxis
- pre-sacral plexus hemorrhage 📷
- urinary bladder injury
- Spleen injury
- hemorrhage (first 24h)
- anastomosis leak (5-7d esp. when low + ultralow anastomosis in ant. resection )
- anastomotic stenosis
- urinary retention
- post-op ileus
- wound infection
- fecal incontinence
- evisceration 📷
- anemia
- male >65y
- comorbidities (CV + pulmo)
- ↓Prot + ↓Albumin
colonoscopy >50y → every 10years
and/or stool testing → repeated after 1y
- First 2y: physical exam(DRE) + CEA (if≥T2) → every 3-6month
- after 1y → colonoscopy (evtl. repeated after 1y)
- every year CT (chest, abdomen, pelvis)
→ then every 6month for 5y
🎾 Gallbladder and Bile Ducts
intrahepatic duct → le + ri hepatic duct → CBD (at hepatic junction) → along portal vein + proper hepatic artery →cross post. 1st part of duodenum → cross post pancreas head → join Wirsung duct (in pancreas parenchyma) → duodenum
V
above duodenum or sometimes retroduodenal part
Calot triangle 📷→ formed by cystic duct, right side of CBD+ inf. face of liver
⇒ contains CYSTIC ARTERY
Calot triangle is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct must be identified before ligation and division to avoid intra-operative injury.
low p → stasis
phospholipid + bile salt binding cholesterol
→ ↓salts + phosphoL OR ↑cholesterol
→ unbound cholesterol → crystallize(lithogenic bile)
→ stone formation
due absence/defect of ileum (i.e. resected) → Øre-absorption of salts
- fat malabsorption
- Vit ADEK def.
- microbial flora disturbance
- impairment intestinal wall trophicity
lithogenic bile + functional/anatomical abnormality of gallbladder
- Cholesterol
- pigment (heme) → ↑in haemolytic anemia
- mixed (chol + pig) #most common (75%)
- pregnancy
- contraceptive
- family history
- obesity
- low fiber diet
🤡none 80%
gallbladder contracting against obstacle ⇒ stone impacted in narrow part: infundibulum (hartmanns pouch📷), cystic duct or sphincter of oddi
T - if small enough or if fistula
smaller stone → migrates
Bigger stone → does Ø migrate → but might cause neoplasia + cholecysto-duodenal fistula
acute severe pain:
- renal colic
- peptic ulcer
- appendicular colic
- subhepatic block = inflammatory adhesions to gr. omentum, duodenum, colon
- Obstructive jaundice → Mirizzi syndrome type I: swollen gallbladder →compression CBD 📷
→ perforation into subhepatic block → subhepatic abcess (infect. synd)
- Hydrocholecyst →distended, palpable gallbladder w/ clear content
- perforated peptic ulcer
- acute pancreatitis
- acute appendicitis
- acute hepatitis
- right basal pneumonia
- inf. MI
thick hyperthrophied → sclerohypertrophic cholecystitis
thin, moulded → scleroatrophic
T: might present with attacks of acute cholecystitis
acute → fever+started with fatty meal but stays long as hell+murphy,
chronic → no fever, pain intermittend with fatty meal
- chronic dyspepsia
- hiatal hernia
- coronary insufficiency
Charcot triad (major choledocal synd)
→ pain, fever, jaundice (obstructive) with dark urine
50% of cases missing jaundice
→ minor coledocal syndrome → pain, chills, dark urine
→ intermittent hepatic fever of charcot→ fever + toxemia
→ dyspepsia
- hepatic jaundice
- posthepatic by other conditis
pain
→peptic ulcer
→ acute pancreatitis (but can also be caused by stone)
→ intest. obstruction
→ angina pectoris
→renal colic
stones are Ø removed → chronic bile-back-pressure → repeated episodes of cholangitis → liver fibrosis + inflammation (second. biliary cirrhoiss)
const. ↑pressure → wall ischemia → focal necrosis → adhesion neighboring elements of biliary tree → adhesion become progress. tighter → fistula
!biliary symptoms 8-20years prior to fistula
choledocholithiasis: gallbladder-CBD-fistula →migration of stones
esp in obstructive jaundice (indirect)
but also just above normal limit in severe ac. cholecystitis
- cholecystectomy → 24-72h after onset of cholecystitis (also allows dissection of subhepatic block)
- Prior:
- Hydration
- AB
- Antispastics
- Analgesics
Cholecystectomy + Roux-En-Y with Hepaticojejunostomy 📷
complete mapping of biliary tree before surgery
cholecystotomy
Not used in dg. anymore because MRCP (magnetic resonance cholangiopancreatography) has Ø complications
→ complications ERCP:
ac. pancreatitis, peritonitis, beeding, perforation of ducts, allergy to contrast
Used to remove stones + insert stents (before sphinctereotomy) in CBD (THERAPEUTIC PURPOSE ONLY) → see "Main bile duct lithiasis"
↑Risk of complications:
- young + large stones
- hemolytic stones
- tranplant recipients
ri + le hepatic duct → converge: CHD → continous as CBD at junction with cystic duct
portal triad:
portal v + proper hepatic artery
epicholedochal arterial plexus formed by:
- right + proper hepatic
- cystic
- retroduodenal
F only 4%
Bile stasis → Bact. superinfection → bacteria deconjugate the conjugated bili → unconjugated bili precipitates → pigmented stones
- PSC (Primary sclerosing cholangitis)
- Parasites (Asia) → epithelial damage → fibrosis → segmental biliary stenosis
- Sclerosing odditis (benign stenosis of oddi)
- Sclerosing papilla
- post-traumatic (iatrogenic) CBD stenosis
- Caroli disease
- Mirizzi synd I
T → "95% with choledocolithiasis also have gallbladder lithiasis"
- Øpigmented
- high cholesterol content (primary have low)
- blackberry-like
Bergman's triad:
- Migration (into CBD)
- Cholestasis
- Cholangitis (superinfection)
- Small stones (3-7mm)
- contractile gallbladder (triggered by fatty meal)
- Cholecysto-choledochal fistula → migration of large stones (Mirrizi II-IV)
- long evolution of cholecystolithiasis
- During cholecystectomy → turning bladder upside down
- residual cystic duct stones after cholecystectomy → reccur. choledocholithiasis (double-barrel shotgun sign 📷)
- large cystic duct → migration large stones
large stone impacted in infundibulum/Hartmanns pouch → pressure on cystic duct → destruction → in time: becomessqueezed, shorted + dilated → transformed into fistula → continous compression enlarge fistula → migration of large stone into CBD
Mirizzi II → 1/3 CBD caliber eroded
Mirizzi III → 2/3 CBD
Mirizzi IV → complete CBD caliber destruction
sphincter of oddi → reflex spasm → stasis + ↑upstream pressure ⇒ colic pain → over time: superinfection ⇒ chills + fever
T → ↑↑upstream p → papilla opens → clinical features disappear
fistula or ↑cystic duct diameter
→ sphincter of oddi spasm → edema + inflammation → dilation extrahepatic duct → upstream regurgitation into general circulation → jaundice
relaxation of oddi spasm → stone "fall back" into CBD → temporary disobstruction → alternation clinical symptoms with episodes of Øsymtoms
→ chronic inflammation → permanent fibrosis → benign stenosis of papilla + chronic pediculitis (thickend CBD wall + adhesion to portal v+hepatic a.)
accumulation many stones → but Øjaundice (paradoxical) because bile flows like "river water through rocks" 📷
large stones irreversible impacted in papilla → acute papillary obstruction with pain + jaundice → progressive increasing + stays constant (icterus melas)
- hepatocytolysis (satellite hepatitis)
- Ac. biliary pancreatitis (due do const. regurgitation into Wirsung d.) → repeated episdes of ac. pancreatitis → chronic biliary pancreatitis → distal choledocal stenosis + pancreatic insuff (exo+endocr.)
(double click!)
(double click)
2 + 3 mg/dl
- Bili → esp ↑in direct (rarly over 15, except neoplastic-like form)
- ALP + GGT
- AST + ALT (↑ in prolonged cholestasis)
- PT/INR (Vit K def)
- Amylase (second. acute pancreatitis)
- Very high probability: clinical ac. cholangitis, total bili>4, confirmation by US
- High probability: total bili>1.7; bile duct dilation by US
- Moderate prob: clinical: biliary pancreatitis, age>55y; altered hepatic test (Øbili)
- Low Prob: Øjaundice; Ødilation
Generally US + MRCP is enough
If not positive consider → CT, EUS, intraductal US
- Ac. pancreatitis
- Ac. cholangitis
- Ac. cholecystitis
- Duodenal perforation → peritonitis
- cardiac or pulmonary failure
- severe coagulation disorder (Øcorrectable)
- stenosis (eso, gasto, duod) → cant pass
- refusal (#ZeugenJehovas)
- Cholangiography (fluroscopy) → procedure of choice → contrast injected through gallbladder or cystic duct
- Intraoperative US → in open + laparoscopic approach
- Choledochoscopy → transcystic or through site of choledocotomy
ERCP +/- endoscopic sphincterectomy
- electrosection → papillary sphincterctomy
- guidewire + catheter
- basket or ballon inserted upstream of the lesion → close of basket/inflation of balloon
stones >15mm
→ Lithotripsy → break into smaller fragments
- mechanical lithotripsy
- electrohydraulic l.t.
- laser l.t.
- extracorporal l.t.
biliary strictures
- cholangitis
- ac. pancreatitis
- hemorrhage + duct lesions
pneumatic dilation of papillary sphincter (with balloons) → but less effective + ↑post-surgical risk)
endoprosthesis + ursodeoxycholic acid → litholysis → improved general stage → endoscopic stone extraction OR permant endoprosthesis
- acute pancreatitis (3-5%) → dyskinetic sphincter of oddi
- Hemorrhage (2-5%) → ↑risk in patient with coagulopathy or re-sphincterctomy
- Cholangitis (1-2%) → insufficient post-OP bile drainage
- Perforation (<1%)
- Impaction of catheter in papilla ry orifice (when extracting big stone) → might req. duodenotomy, enlargment of sphincterectomy + sphincterplasty
- Papillary stenosis → too short sphincterectomy → fibrous scarring ⇒ re-sphincterectomy needed
transcystic laparocopic approach (see below)
cholecystectomy + choledocholithiasis-resolution (through cystic duct)
- transcystic
- choledocotomy
- #1 line after ERCP (fails)
- Stones ≤8mm
- Contraindication of choledochotomy
above junction CD-CBD, big stone or cystic duct problem
- Stones >8mm
- intrahepatic lithiasis (cant pass upwards)
- cystic duct diameter <4mm (stones cant pass)
- cystic duct with post. insertion or distal insertion (double shotgun)
- stones prox. to cystic d.-CBD junction
- Stones >8mm
- impossibility/Failure transcystic approach
- Contraindication transcystic approach
- multiple stones (large number)
- Portal hypertension ("pericholedochal varices")
- CBD diameter <5-6mm (high risk late stenosis at suture site)
- Impossibility for CBD suture
- Sclerosing Pediculitis + Peripediculitis (pedicle of the gallbladder; sclero-inflammatory changes → cant dissect + identify CBD)
- cholangiography - exploratory
- transcystic acess to CBD
- lavage (saline + glucagon) under pressure → might push out stones <4mm)
- →Dormia or Foley → extract stones ≤8mm
- →electrohydraulic lithotripsy → for larger stones
- re-check by choleangiography or choledocoscopy
- Section cystic duct + cholecystectomy
- leaving transcystic-duct drainage catheter in place for 15-18days
- choleangiography
- guiding treads → traction on ant. supraduodenal CBD
- →choledochotomy
- lavage
- foley or dormia
- larger stones → lithotripsy
- check with choledochoscopy or choleangiography
- #1 Primary Choledochorrhaphy → primary suture + Ø drainage; preffered over 2.
- T-Tube external drainage → suture around tube → percutaneous orifice → removed after 10-14days (dont forget choleangiography after placement + before removal)
Transcystic → cheaper, ↓morbidity, ↓hospitalization, ↑comfort)
T-Tube → biliary decompression (when residual stones or papillary edema); Post-OP T-tube choleangiography is possible; extraction of residual stones without need for endoscopic sphincterotomy
- Failure / Contraindication of ERCP + laparoscopic approach
- Large stones
- CBD dilation >20mm
- benign stenosis
- primary stones
- Impacted stones in papilla
- Detection of CBD stones during cholecystectomy
- After gastric resection (Billroth or Roux-En-Y) or gastroenteroanastomosis→ you cant get in endoscopically lel
- rock paving
like laparoscopy just open
choledochotomy + intraoperative cholangiography → lavage + extraction + lithitripsy → choledochorraphy or T-Tube
- Portal HT (peridoledochal varices → ↑bleeding risk)
- CBD diameter <6mm (high risk late stenosis at suture site)
- Sclerosing pedicultis (sclero-inflammatory changes → cant dissect + identify CBD)
- Acute cholenagitis + septic shock → emergency endoscopic billiary decompression needed!
- #1 cholecysto-duodenal 📷
- cholecysto-colic
- cholecysto-gastric
- choledoco-duodenal
- #1 stones (80-90%)
- Crohns
- cholecystectomy + sphincterectomy (iatrogenic)
- Chronic duodenal ulcer → most common cause of choledocho-duodenal fistula
- Cancer:
- distal CBD
- Ampulla of Vater
- Head of pancreas
- duodenal
- gallbladder
- colon
large stone → obstruction in cystic duct → recurrent cholecytitis (acute+chronic) → pericholecystitis → adhesion blocks → decubitus lesions trough gallbladder + digestive wall
invasion + erosion of the tumor
- often asymptomatic (slowly progressive) → detected incidentially during imaging/surgery
- epigastric / RUQ pain
- intermittent cramps
- nausea + vomiting
- weight loss + diarrhea (esp in cholecysto-colic f.)
bilio-digestive reflux (asc. regurgitation)
→ air bubbles into biliary duct (aerobilia)
fistula erosion of visceral wall
- large stone (3-4cm)
- stuck in terminal ileum
obstructive ileus
- sudden onset
- vomiting → 1.bilous 2.fecaloid (12-24h later)
- abdominal distension
- Øbowel movements
- altered general state
stones >3cm → obstruction in duodenal bulb or inf. duodenal flexure
→ prox. to ampulla of vater (duodenal bulb) → prox acute bowel obstruction (alimentary + gastric acid vomiting)
→ dist. to ampulla (inf. duodenal flexure) → biliary vomitus + water-electrolyte imbalance + alteration general state
- US → aerobilia?; sclero-atrophic gallbladder?; residual gallstone?
- Xray → Ileus????
- CT → stones, fistula, ileus
- MRCP → esp. for fistula
- ERCP → for choledoco-duodenal + bilio-biliary f.
- Gastroduodenoscopy → Bouveret (when searching for obstructive cause)
→ Ringler Triad (air-fluid-levelaerobilia, large mass in ileum)
→ Balthazar-Schechter sign (air in gallbladder)
nope (only when intra-operatively discovered incidentially)
- cholecstectomy
- suture of duodenal/colic fistula orifice
→or stapler when laparoscopic
- primary colic tumor (right flex/right third of transv. colon)
- primary gallbladder tumor
→ right hemicolectomy + "en block" cholecystectomy
→ resection rarly possible
- Stent (palliative)
- pancreatico-duodenectomy 📷
- transv colon
- first 2 portions of duodenum
Mascagni LN next to the cystic artery
chronic inflammation of biliary tract:
- PSC
- stones
- IBD
- choledocal cyst
- anatomical variants of bile + pancreatic duct
- obesity, alcohol, smoking
- TP53 tumor suppressor gene mutation
F - 95% malignant
adenoCa
the bileduct walls → lumen stenosis
- Intrahepatic CAC (10%)
- Perihilar CAC (65%) #1
- Distal CAC (25%)
HCC
Klatskin tumor
BISMUTH CLASSIFICIATION 📷
I - common hepatic duct; below confluence
II - confluence
IIIa - confluence + ri. hepatic duct
IIIb - confluence + le. hepatic duct
IV - ri + le hepatic duct OR multifocal
those of pancreatic head tumor
- early - asymptomatic
- Symptoms → due to obstruction:
- upper abdominal pain
- malignant jaundice (obstructive) with acholic (white) stool, choluria📷
- B-symptomatic: weight loss, fatigue
- nausea + vomiting
- distal → acute pancreatitis
- perihilar → evtl cholangitis
Malignant → slow progression, Øpain, Øfever, Curvoisier-Terrier Sign; Tumor markers; masses,lymphadenopathy, ascitis on imaging
Benign → sudden onset, pain, fever, Charcot, inflammatory markers; stones in gallbladder/ducts on imaging
TNM
but different for each location (intrahep, perihilar, distal)
F - only a small proportion is resectable
- multiple tumors (intrahepatic)
- periportal adenopathy
- distant mets
- segmental hepatic resection
- OR hepatectomy,
also removal biliary confluence+ caudate lobe → esp when involving both hepatic ducts
Biliary tract + liver resection
often also parts of gallbladder, LN, intestine + pancreas resected
⇒ biliary-intestinal anastomosis
Whipples 📷 : resection CBD, gallbladder, duodenum, antrum of stomach, head of pancreas →gastro-jejunal + hepatico-jejunal anastomosis
or
Transverso-Longmire: like whipple but preservation of pylorus
- bleeding
- anastomosis fistula
- liver damage
- anastomotic stenosis (long-term compl.)
- high reccurence risk
- advanced stage
T
F → only 1 out of 5
Chronic inflammation of gallbladder wall
- stones (most important risk factor!!)
- Porcelain-gallbladder (wall calcifications)
- Bile duct abnormalities
- polyps of the gallbladder
- choledocal cyst
- IBDs
- obesity + female
F → adenoCa (90%); SCC only 5-10%
T
cholecystitis + jaundice + b-symptoms
- symptoms mimicking biliary colic or chonic cholecystitis → Dg in 50% of cases after cholecystectomy!! lel
- RUQ pain
- jaundice obstructive (poor prognosis)
- palpable tumor
- B-symptomatic: weight loss, fatigue
- nausea+vomiting
- Lab: (like CAC)
- conj. bili
- ALP + GGT
- PT + INR
- AST+ALT
- Tumor markers (Ca19-9 + CEA, etc)
- US
- CT → obstruction + extension
- MRI → same as CT + staging
- PET-CT → local adenopathies
- Choleangiography w/ ERCP → in jaundice → assess hepatic+biliary invasion (but MRI prefered)
TNM
if T1a → no intervention
if >T1a → new intervention → extended resection
open → when discovered pre-operatively
laparoscopic → when post.OP dg. for new intervention
chemo: pre- + post-OP
radio: post-OP if ≥T2
palliative care + chemo
- biliary drainage (relief obstruction)
- Chemo (drainage before!!!)
- palliative procedures
🧽Pancreas
- vagal n.
- CCK (cholecytokinin)
- VIP (vasoactive intestinal peptide)
- Secretin
- GRP (gastrin releasing peptide)
minimal organ dysfunction + recovery w/o sequele
pancreatic necrosis + complication + organ dysfunction
aggression → lysosomes enaled → activate trypsinogen intracellulary → in extracell. space → attracts Np + Mp → further aggravation of inflammation → gets systemic
elastase → damage vascular wall → hemorrhage + necrosis
respiratory + renal complications!!
alcohol + gallstones
- Idiopathic
- Gallstones → irritate Oddi (1/3 of AP)
- Ethanol (Alcohol) (1/3)
- Trauma → blunt trauma: crush pancreas against spine
- Steroids
- Mumps + Malignancy(obstructive tumor/mets)
- Autoimmune + ascaris
- Scorpion sting
- HyperCa + HyperTG
- ERCP → ↑intra-ductal p due to contrast → enzyme activ., Choleangiography + Manometry
- Drugs: AZA, 6-MP, 5-ASA, Octreotide, Tetracyclin, VitD, furosemide + Divisum 📷
- upper abdominal pain → radiating in back
- ↑ in intensity
- stays several days if untreated
- Fever → moderate first (inflammation), high after at least 2weeks (infection of necrotic areas)
- shock ↓BP + ↑HR
- ØBowel sounds (reflex bowel paralysis) + Øpassing of stool+gas → abdominal distension
- nausea + vomiting
- mimic peptic ulcer peritonitis → pain, tenderness, guarding, Blumberg sign → but negative rectal exam (Douglas pouch not irritated)
- Grey Turner + Cullen sign 📷
- Jaundice (in biliary obstrution or liver failure in severe)
- Dyspnea → subphrenic collection → irritation diaphragm → pleural effusion or ARDS (acute resp. distress syd) in severe
- Ascitis (severe)
- Erythematous nodule 📷 → due to subcutaneous fat necrosis
- ischemic injuries on funduscopy
- Damage to sphingomyeline in NS → by phosphlipase A
- pseudocyst
- Pancreatic abcess + infected necrosis
- Pancreatic duct disruption (↑↑↑Amylase)
- Haemorrhage (rare)
- other causes for acute abdomen
- From biliary system
- biliary lithiasis (might be cause of AP)
- cholecystitis
- cholangitis
- perforated ulcer
- colon obstruction
- mesenteric infarct
- ectopic pregnancy
- false acute abdomen
- MI
- Bacterial pneumonia
- Renal colic
check pancreatic damage, complications + causes
- Amylase + Lipase(more specific)
- ALP, GGT, AST, ALT → biliary obstruction
- ↓Ca → due to soaps formed with FFA
- Glucose↑
- Tripsin + Trypsinogen
- TG+ Cholesterol (Hyperlipidemia I + V)
- WBC → inflamm + infection
- Hematocrit↑ → edema + ascitis (but can ↓ in necrotic-hemorrhagic lesions)
- CRP → prognostic factor for organ damage
- Electrolytes, BUN, Crea → renal
- arterial blood gas → pulmo
>3
F - no help in differentiating betw. mild + severe + also not in prognosis
total pancreatitc necrosis (no tissue left to produce enzymes)
CT → Balthazar grading scale
A: Normal
B: Enlarged
C: Peripancreatic inflammation
D: Single fluid collection
E: Multiple fluid collect.
[A+B→normal mortality+infection, C-E→incr. mortality+infection]
- Biliary AP
- US → gallbladder lithiasis (Øgucci for choledocholithiasis)
- MRCP → also for choledocholithiasis
- ERCP but only carefully in the first 3 days! (later: ↑aggravation risk)
- Paralytic ileus (Sentineal loop📷 + colon cut off sign📷) + Pneumoperitoneum + Pancreatic Calcifications
- CT/US guided needle aspiration from necrotic tissue → antibiogram
- EUS → biopsy
→ Xray
edema of peripancreatic tissue (retroperitoneal) = fat stranding 📷
retroperitoneal fat necrosis = cytosteatonecrosis (mesentery + toldt fascia)
First 48h:
- >55y
- WBC >16k
- LDH > 350
- AST > 250
- Gluc >200
After 48h:
- Htc ↓ by >10%
- BUN ↑ more the 8 mg/dl
- Ca < 8
- arterial SpO2 <60
- Base deficit >4
- Estimated fluid sequestration >6 liter
⇒ score >5 ⇒ mortality rises at 50%
- fluid resuscitation → 2-4l bolus, then 500ml/h; !!not to much→pulmonary edema
- bladder catheter + gastric aspiration → fluid balance
- Analgesia (ØMorphine → spastic effect on oddi)
- No oral intake → continous when gastric plegia subsides
- Nasojejunal feeding tube OR surgical jejunostomy
- AB prophylaxis (in high risk patient + if complications)
- Antifungal prophylaxis
- Protease inhibitors - Continous reginal arterial infusion → ↓vasospasm → ↓ischemia
- Ocreotide (↓ pancreatic exocrine secretion)
- Hemodiafiltration → eliminating cytokines
→Selective digestive contamination (SDD) = AB (only for selected)
- Øsurgery in first 2 weeks
- sterile necrosis → conservative treatment → only consider surgery if extension or fulminant AP
- infection of necrosis (pancreatic or peripancreatic) → SURGERY
- SPARE AS MUCH HEALTHY TISSUE AS POSSIBLE
- Cholecystectomy if gallstone or idipathic induced
Necrosectomy📷 + closed continous lavage OR laparostomy (if extended)
→ closed continous lavage: tubes in+around omental pouch → some irrigating liters of saline → other tubes evacuate it ⇒ wash away necrotic debris (only possible for 48h - blocked by adhesions)
→ laparostomy(if extensive necrosis) → suture opened gastrocolic ligament to parietal peritoneum+aponeurosis ⇒ alls easier excess + repeated necrosectomy
⇒special type Vac-pac in SAP with abdominal HT + compartment synd) → protective layer over viscera + second over invsion → aspiration tube inbetween → delayed aponeurotic suture after 5 days 📷
- pseudocyst
- Pancreatic abcess + infected necrosis
- Pancreatic duct disruption
- Haemorrhage
→ pseudocysto-jejunostomy📷/gastrostomy;
→ transpapillary drainage 📷(in commincating pseudocysts + Persistent external fistula) stent is left in place;
→ percutaneous aspiration(temporary only)
→ laparoscopy after 3-4weeks (for better discrimiation healthy/necrotic tissue) → removal of pus + necrotic tissue
→ transpapillary stent
→ ultraselective angiography → embolization
- pseudocyst
- diabetes
TIGAR-O" 🐯 → 📷
- Toxic+metabolic factors → alcohol #1+ smoking + ↑Ca
- Idiopathic (early(20y) + late (56y) onset → late has pain + calcifications
- Genetic
- Autoimmune (isolated or w/ other AI-diseases [Sjogren, scleroderma, PSC)
- Reccurent severe acute pancreatitis (after necrosis)
- Obstructive (stones, benign/malign. stenosis of oddi, divisum, etc)
Cremer classification
Stage | Description |
1 | Minimal damage in small pancreatic ducts |
2 | Wirsung duct slightly irregular |
3 | Cystic dilatation of 1 or more focal lobular canaliculi |
4 | Stone (single or multiple) in the duct of Wirsung, without upstream dilation |
5 | Cephalic pancreatitis with a long stenosis of Wirsung duct at same level |
6 | Pancreatitis with complete stenosis of Wirsung duct in cephalic pancreas |
- intense pain upper abdomen → lumbar radiation
- exocrine insuff(when 90% acinar destroyed) → steatorrhea, VitADEK def, weightloss+muscle dysfunct.
- endocrine insuff (later) → Diabetes (but high risk for hypoglycemia, due do altered glucagon → insulin surveillance!!)
→ persistent or recurr.
→ “Mohammedan prayer” sign (antalgic position)
→ exacerbates by alcohol + fatty food
Due to direct damage
- Pseudocysts (due to ductal rupture)
- obstruction/Infarction/bleeding/rupture of adjacent tissue (stomach, CBD, duodenum) due to compression
- Pseudoaneurysm
- due to autodigestion of arterial wall or erosion by pseudocyst
- Splenic vein thrombosis → gastric variceal bleeding
Stenosis complications:
- CBD obstruction →second. to pancreatic fibrosis → jaundice, pain
- Duodenal obstruction(due to compression or second. to pancreatic fibrosis)
Later complication:
- Fistula → might produce pancreatic ascitis, pleural effusion or pericarditis
- Pancreatic cancer
- pancreatic tumor
- gallstones
- acute pancreatitis
- ulcer
- gastric cancer
- IBS
- malabsorption synd.
- Crohns
T → can not be used to exclude!
(DDx acute pancreatitis: typically very high lipase and amylase)
- ↓Na+↓K
- Gluc (↑ in endocrine dysf)
- Bili + AST+ALT → compression CBD
- Proteins ↓ → malabsorption
- exocrine: Secretin-CCK administration → measures HCO3+trypsin+amylase
2. endocrine: OGTT, glucosuria, Gluc
- US → hypertrophy or atrophy; calcifications; pseudocysts; guided biopsy on pseudotumoral pancreatitis
- CT contrast+ → Hyper-/atrophy of pancreas, wirsung dilation, pseudocysts, diameter CBD
- MRCP→ pancreatic + biliary ductal system vizualisation
- EUS → biopsy + DD with pseudotumoral pancr. + cancer
- XRay → calcifications + pancreatic duct stones
- ERCP → not really used for diagnotic purpose!! could vizualise stenosis, dilation of Wirsung, communications of pseudocysts, bile duct stenosis
- Analgesics: NSAID → Tramadol → opiods
- Lipase + trypsin administration (exoc insuf)
- insulin administration (endoc insuf)
- diet (Øgood stuff (alcohol, tobacco, coffee, fat))
- drainage surgery
- excision surgery
- denervation
- complication (pseudocyst, jaundice, duodenal stenosis)
wirsung duct >7mm
pancreatico-jejunal anastomosis on Roux-En-Y 📷
#1 Whipple (pancreaticoduodenectomy) 📷→ exision of antrum, duodenum, pancreatic head, first jejunal loop, bileduct + gallbladder → pancreatico-jejunal, hepaticojejunal + gastroenteroanastomis
alternative procedures:
- Transverso-Longmire 📷→ preserved pylorus
- Beger 📷→ preserved duodenum
- Frey 📷→ local resection pancreatic head
⇒ pancreatico-jejunal anastomosis on Roux-En-Y
Distal pancreatectomy
→ +/- splenectomy
→ Wirsung <5mm
→ pancreatic stump suture or end-toside-pancreatico-jejunal-anastomosis
- peristent pain
- partial resection →Ø effect
- total exocrine + endocrine insufficiency
bilateral thoracoscopic splanchnicectomy
- percutaneous drainage (US or CT guided)
- endoscopic transpapillary drainage 📷 (when communication cyst - main pancreatic duct)
- or transmural drainage (when cyst is close to digestive organ) 📷
Picture Description:
“Illustration of transpapillary drainage of a pancreatic pseudocyst. A, Pancreatogram shows a leak off a side branch of the main pancreatic duct (arrows). B, A pancreatic duct stent is in place across the leak”
stent or biliary-digestive bypass
- gastro-entero anastomsis
- pseudocyst drainage (if compresses duodenum)
F → most common detected incidentally
- Adenoma
- Cystadenoma
- Cystic papillary tumor
- Intraductal papilloma
→ well vascularized
pulsatile mass
angiography
- Serous (microcyst) → Øbecome malignant
- Mucinous → border-line tumors (↑↑malignant potential)
young woman → easily removed bc encapsulated
obstruction → recurr ac. pancreatitis → obstructiv. chron. pancreatitis
- US + biopsy
- EUS + biopsy
- symptomatic
- big as fuck
- mucinous cystadenoma(organ+LN !!)
- men
- age 60-80y
- family history
- smoking + alcohol + coffee
- diet → red meat + fats
- high risk disease: chr. pancreatitis, diabetes, cirrhosis, peutz-jeghers synd
- Genetic
- activated oncogenes: KRAS
- or deactivated suppressor genes: CDKN2A, Tp53, SMAD4
= pancreatic intra-epithelial neoplasia
PanIN-1 (minimal atypia) → Ø invasion
PanIN-2 (moderate atypia) → Ø invasion
PanIN-3 (severe atypia) → can give rise to infiltrating ductal adenocarcinoma
ductal adenocarcinoma!!
head 70%
(body 15%, tail 10%)
local invasion (but also lymph, blood, perineural)
head → liver, lung, pleura
corpus+tail → also peritoneum
TNM + staging of pancreatic cancer
1A: <2cm (T1N0M0)
1B: >2cm (T2N0M0)
2A: beyond gland extension (T3N0M0)
2B: (AnyT except T4)+N1 (T1;2;3N1M0)
3: Invasion SMA/celiac axis (T4anyNM0)
4: (AnyTanyN)M1 (anyT,AnyN,M1)
- Tis: Carcinoma in situ
- T1: Tumor diameter ≤ 2cm, no extension beyond the pancreas
- T2: Tumor limited to the pancreatic gland, > 2cm in diameter
- T3: Extension of tumor beyond the gland, not invading superior mesenteric artery or celiac trunk
- T4: Primary tumor invading celiac axis or superior mesenteric artery (unresectable)
F → often jaundice is the cause for the first presentation, but its a late clinical signs → too late for curative treatment (in 80%)
- jaundice
- weight loss
- pain
- special DM ⇒ non-obese, 60y, smokers, ØFH of DM (but mainly assoc. with body+tail)
- repetetive attacks of ac. pancreatitis
- intermittend epigastric/left hypochondrium
- progressively radiation to back
- exacerbated when lying down
- B-symtoms: weight loss, Øappetite, fatigue
- jaundice
- Trousseau sign of malignancy 📷
- nausea
- constipation/diarrhea
- malignant biliary obstruction
- slow progression
- painless
- no fever
- no remission
- choluric urine
- acholic stool
- Courvoisier-Terrier signs (palpable + non-tender gallbladder)
- pruritus preceeds jaundice! (DD→ in lithiasis after!)
invasion celiac plexus → excruciating pain → opipods or splanchnicectomy needed
- severe+rapid weightloss → patient "shrinks down" each day
- pain (constant or intermittend)
- Mental disturbance
- Duodenal invasion → stenosis: anorexia, adynamic, vomiting
- Trousseau sign of malignancy
- Upper GI bleeding (splenic v. dilation → Portal HT → varices)
- DM
- Ascitis
→ more severe when lying down
→ radiating back
jaundice
- Continous pain
- constipation
- DM
- Dyspeptic syndrome
- Portal hypertension
advanced:
6. jaundice (if advanced) + weightloss
7. DM
8. invasion/compression duodenum, stomach, colon
9. Ascitis
10. Virchow nodule
- US
- EUS
- MRI/CT+contrast
- Staging laparoscopy
- CEUS
- Angio-MRI
- Choleangio-MRI
- ERCP + Transparietohepatic choleangiography → only for therapeutic procedures (palliative: Stent (ERCP) or external decompression (TPC))
→ volume changes, hypo-echoic tumoral mass
→ UPSTREAM-DILATION: dilated CBD, main pancreatic duct, intrahepatic ducts, distended gallbladder
→ Liver mets + LN
→ double-duct sign (main bile + pancreatic duct)
→ biopsy (percutaneous)
→ tumors >1.5-2cm cna be detected
→ detect tumors <1cm + T-stage
→ biopsy
→ TNM
→ in every body + tail
→ in every "radiologically resectable" pancreatic head
→ might detect peritoneal or liver mets → M0 vs. M1
→ liver mets (M-stage)
→ invasion adjacent vessels (PV, SMA, SMV)
→ detection billiary intraductal obstuctions
Radical (R0) resection
T1-3
N1
correct malnutrition + hypoalb
Whipple (pancreatico-duodenectomy)
→ gallbladder, CBD, antrum, entire duodenum, head of pancreas (or even more, when needed), 10-20cm from jejunum
OR Transverso-Longmire - Pylorus-preserving pancreatico-duodenectomy
anastomotic fistula
→ Regional pancreatectomy
BUT ONLY PORTAL V. RESECTION IS JUSTIFIED → mesentero-portal anastomosis 📷
ARTERIAL RESECTION IS NOT JUSTIFIED (high mortality)
BILIARY DECOMPRESSION
→ ERCP → Stent #1
→ OR transparietohepatic choleangiography (ext. drainage)
octreotide
distal spleno-pancreatectomy 📷
chemoradiation improves survival in advanced cases (not much information in the book)
but only recently started → not muchos informatione
- M0
- locally advanced
- unresectable
- chemical splanchnicectomy → neurolytic substance in celiac plexus
- OR thoracoscopic splanchnicectomy
F → 10% are malignant
- head or tail
- ectopic (duodenum, stomach, spleen,retroperitoneum.)
HYPOGLYCEMIA SYMPTOMS → neuropsychiatric
- diplopia, convulsions, coma
- flushing, hunger, sweating, vomiting
- restlessness
→ REGULAR INTERVALS OF PERIODICAL HYPOGLYCEMIA (after exercise or fasting) → subside after eating
⇒ WHIPPLE TRIAD:
- Hypoglycemia after exercise or fasting
- Gluc<50 during hypoglycemic episodes
- subside after gluc administration
- Gluc
- Insulin + proinsulin radioimmunoassay
- insulin/gluc ratio
- secretin stimulation test
- US → hypoechoic, clear margins
- EUS, Intra-OP US + Laparoscopic US → better accurary
- CT + MRI
- Selective celiac angiography #highest accuracy
→ smaller lesions not detected previously??
⇒ do aparoscopic or intraoperative US
measure insulin before + after excision
histologic...
....metastases
embolization of hepatic artery 📷
- Diazoxid → insulin antagonist
- Somatostatin → ↓pancreatic secretion (esp. when freq+severe attacks)
inoperable malginant insulinoma
woman
- body + tail (60%)
- pan-pancreatic (30%)
- head (10%)
F high malignant potential → when dg. most often already malignant + voluminous
- migratory necrotising erythema → perineum, extremities, chest
- Glossitis + mouth corner sores
- vulvovaginitis
- DM-symptomatic (polyuria, polydipsia etc)
- Anemia (due to anorexia + ↓Aminoacids)
- Weight loss (anorexia + anti-anabolic glucagon effect)
- DVT
Glucagon radioimmune essay → >500 pg/ml
(anemia markers, gluc, D-dimers, proteins)
- US (percutaneous, endoscopic, intra-OP, laparoscopic)
- CT
⇒ guided biopsy
hyperglycemia challange test → exogenous glucagon
- primary DM
- Other disease that ↑glucagon: (never >500)
- cushings
- chronic pancreatitis
- cirrhosis
Curative:
- surgical resection
Palliative:
- Tumor ablation + chemo (if mets are present)
- Palliative debulking excision
- Repeated multiple re-excision for recurrences (local + mets)
- Hepatic transplant (if liver mets)
Zollinger-Ellison
eutopic → areas normally containing G-cells (antrum, duodenum)
ectopic → normally Ø g-cells (i.e. pancreas)
often multiple (80%) and malignant (66%) [but low degree of malignancy]
Type 1: solitary or multiple, eutopic, malignancy (60-90%)
Type 2: multiple, pancreas, mostly benign
- peptic ulcers
- refractory to treatment
- complications of ulcers
- diarrhea + steatorrhea (due to ↑gastric acid secretion)
- Test for acid hypersection, also noctural acid secretion + basal gastrinemia 10x normal
- Barium xray + fibroscopy of stomach → ulcer + ↑acid secretion
- US, CT + selective angiography → localization
→ also intraoperative US → to detect small tumors
T
- PPI or H2-blocker
- Ocreotide
- gastrectomy
- vagotomy
- pancreas
- head → enucleation
- body tail → corporo-caudal pancreatectomy
corpus + tail of pancreas
↑↑secretion of Cl + HCO3 → exeeds colon absorption capacity → watery diarrhea (pancreatic colera) → hypovolemia + hypoK + hypoCl + metabolic acidosis (hco3 lost)
→ also inhibit acid gastric secretion (hypochlorhydria)
- Diarrhea
- dehydration (lost water)
- metabolic acidosis (lost HCO3)
- hypokalemic nephropathy → uremia, fatigue, itching
- heart disturbances (low K)
- ↓K
- ↓Mg
- ↓Cl
- ↓HCO3
- radioimmune assay VIP >500pmol/l
- US + CT → location
- selective angiography (well vascularized tumor)
- Surgical removal
- corpo-caudal pancreatomy (corpus+tail location)
- hypo-electrolytic rebalance
- octreotide (↓secretion of HCO3+Cl)
head of pancreas
T
INHIBITION OF
- GH
- TSH
- Insulin
- Glucagon
- Gastrin
- CCK
- mild diabetes (insulin inhibition)
- biliary lithiasis (↓lipid absorption + gallbladder atonia (CCK))
- Diarrhea with steatorhea (bile + gastrin is not released)
- Nausea, vomiting, bloating
- weight loss
US + CT → pre-operative biopsy!
- Whipples (cephalic duodeno-pancreatectomy)
- Corporo-caudal pancreatectomy (if body+tail)
chemo has poorer results than in the other endocrine tumors
head
inhibitory effect on gallbladder contaction + bile secretion
→ diarrhea +/- steatorrhea → weight loss
→ hypochlorhydria
- Radiummunoassay PP > 1k pg/ml
- CT + US (pre- + intra-OP) → location
- like pancr. adenocarcinoma (see above)
- streptozocin + somatostatin
chromaffin
Due to ↑Serotonin + Pre-cursers of serotonin
- flushing
- HT
- Eye edema
- Hypersecretion saliva+tears
- Diarrhea + pain
⇒ paroxistic appearance
F - high like snoop doggy dog 📷
Whipples
🍑Liver
the ligaments
progressive dilation of microhamartromas
T
simple aspiration (if not symptomatic)
- usually asymptomatic
- evtl. compression
- hemorrhage
US
symptomatic = hemorrhage or compression
- aspiration + inspection of liquid → DDx → Ca19.9? hydatic cyst?
- Resection superficial cyst wall = unroofing
→ Secretion is absorbed by peritoneum
cytology pls
IV → extrahepatic + intrahepatic bile duct cysts
V → =Caroli's disease → multiple intrahepatic (left surgical lobe)
- cholangitis + lithiasis
- malignant transformation
- resection +/- hepatectomy (if intrahepatic) → bilio-jejunostomy on Y-loop
- transplantation (if diffuse advanced)
cystadenoma → cystadenocarcinoma
- irregular spheroidal
- septa with projections
- thickened calcified wall
- aspiration → mucus, CA19-9, cytology
- hemorrhagic or mucos = suspicious
- frozen sections
Cystadenoma → cystectomy
cystadenocarcinoma → cystectomy + safety margins
blunt abdominal trauma
lacking epithelium → just intraparenchymal fluid accumulation
if symptomatic or complicated (infection or bleeding)
→ interventional angiography (embolisation of affected artery)
→ ERCP
cirrhosis due do alcohol or hepB+C
esophageal, umbilicus, hemorrhoids etc
- Encephalopathy (esp if to big diameter)
- Thrombosis (esp if too small)
- asc. cholangitis due to:
- lithiasis
- malignant obstruction
- Carli's disease
- bilio-enteric anasthomosis
- portal vein → infectious territy drained by portal vein
- hepatic arteria in septicemia
- trauma → necrosis → abscess
- cryptogenic → microinfarction → infection via artery
right
→ right portal branch runs almost straigt
- fluctuant to palpable (if superficial)
- fever
- RUQ pain
- tenderness
- malaise
- jaundice (from pre-existing biliary disease or liver failure)
- respiratory problems (pleural collection)
- second. peritonitis (rare)
- ↑Leukos
- AST+ALT
- ↓Albumin+Anemia if chronic
US → detect >90%
CT 📷
- amoebic abcess
- echnococcal Garbia IV cyst
⇒ due serological test
- Broad-spectrum AB
- Punction
- Drainage (percutaneous)
- Culture
⇒ if not successful or contraindication ⇒ laparoscopic removal
contaminated water, food humans → Entamoeba histolytica
right (like pyogenic abcess)
necrosis → bacterial superinfection
- like pyogenic abcess
- diarrhea
- recent travel to endemic area
Metronidazole
#1 Hemangioma (H)
#2 Focal nodular hyperplasia (FNH)
#3 Liver cell adenoma (LCA)
- Detection typically by ultrasound
- If suspect mass, dynamic CT scan
- If lesion with homogeneous enhancement with contrast on CT scan without features of hemangiomas, viral hepatitis markers, and tumor markers (AFP, CEA) to rule out hepatocellular carcinoma and colorectal metastasis
- If still uncertain, MRI, in selected cases with angiography
- If hepatocellular carcinoma is a possibility, consider biopsy
- symptomatic or complicated
- suspicion of malignant degeneration
- large
- fast growing
- Enucleation (tumorectomy)
- Atypical resection
- Segmentectomy
- Bisegmentectomy or other major resection
- Transplantation (rarely)
- Embolization (selective)
- Ablation
contraceptive use → most common in woman
T rich arterial supply → ↑risk in pregnncy for rupture w/ intraoperative bleeding
resection
symptomatic
T → associated with congenital vascular malformation
F → no risk
- rupture + superinfection
- Kasbach-Merrit syndrome (Thrombocytopenia + coagulopathy)
- children → AV-shunt in large Hemangiomas → heartfailure
- US
- Isotopic labeled RBC scan
- MRI → peripheral nodular enhancement
T
symptomatic + complicated
→ pringles maneuver 📷+ cyperknife system (focus beams on tumor)
The Pringle maneuver is performed by clamping the hepatoduodenal ligament, which contains the hepatic artery, portal vein, and common bile duct. This can be done to control bleeding during liver surgery or to temporarily stop blood flow in order to perform certain procedures on the liver.
I - small lacerartion, minimal bleeding → drainage
II - moderate laceration, active + signif. bleeding → compression, argon beam coagulation, RF
III- large intrapranchymal hematoma → intra-OP hemostasis + drainage
IV- large laceration + transection of branches of HA, PV, HV, BD → Pringle 📷+ Ligation (suture is not possible) [ØHA bc abscess risk]
V- large laceration + transection (see IV) → resection portion of hepatic parenchyma
VI - Large laceration + injury IVC + retrohepatic vv. with massive hemorrhage → split sternum → suture
packing of the liver 📷
I-III
IV-VI
- US
- CT
- Puncture lavage → esp in unstable patient (Øtime for CT)
- abcess
- biliary fistula
- hemobilia → biliary colic + melena
- liver failure
- secondary bleeding
- necrosis (of parenchyma)
Arteriography → selective embolization
Echinococcus granulosa → cystic echnococcosis 📷
- liver
- lungs
- pericysts → outher inflammatory layer
- inner germinal membrane → produces scolices + daughter cysts
clear liquid → contains parasitic protein
grown scolices on inner surface → fall into liquid = hydatic sand
allergic reaction
- rupture → biliary tree, peritoneum, etc
- infection of the cysts or organs
- compression
- allergic symptoms → might even to anaphylactic shock
- cholangitis (fever, pain, jaundice)
- obstruction (stenosis of oddi due to irritating liquid)
rupture in free peritneum → seeding of peritoneum → multiple cysts =hydatidosis
infection of cyst cavity → hepatic abscess symptoms + urticaria, jaundice, fever, hepatomegaly
- biliary obstruction
- acute hepatitis
- non-parasytic cyst
- Budd-CHiari
- liver tumor or mets
- Biliary obstruction? → Bili, ALP, Leukos
- Eosinophils
- ELISA
US
Gharbi classification: 📷
I - pure fluid
II - fluid + hydatic sand + floating membrane
III - fluid + septa + daughter cyst; (honeycomb image)
IV - heterogenous
V - thick walls (calcified)
CT → DDx cystic lesions
- mutliple cysts
- contraindication surgery
- >1 organ involved
→ Albendazole
Puncture - aspiration - injection (scolicidal agent) - reaspiration (after 15m)
scolices
- contraindication for surgery
CONTRAINIDCATION:
- Gharbi IV
- complcations
- superficial (risk of spillage + seeding)
- >1 organ
- general contraindication to surgical procedures
Gauze pads (soaked with scolicidal agent) →scolicidal agent injected into cyst → evacuated after 15min
- Total pericystectomy → parasite + pericyst; higher hemorrhage risk but Ø post-OP complication (biliary fistula + abcess)
- Hepatic resection → in large cysts
- Cystectomy + partial pericystectomy → parasite + superficial area of pericysts
cysto-biliary fistulas
ERCP
Alveolar echonococcosis (AE) → Echinococcus multilocularis 📷
cirrhosis /HCC + same complications + liver failure
T shit
liver resection + safety magin
chemotherapy (2years) → avoid recurrance
liver transplant
esophageal varices bleeding management
US
F
check for primary site → colonoscopy (colorectal cancer) or CT (from other organs)
xray for pulmonary mets
CT volumentry
rule of 4 (double click)
Child-Pugh score → gives 1-year survival
basically:
A (100%survival)→ OP
B (80% survival)→ OP or ØOP
C (45% survival)→ ØOP
20-30%
but in cirrhosis 50%
Portal HT + MELD Score (→ risk of liver decomensation + 3month mortality)
portal embolization/ligation of diseases part → shrink parenchyma of that part → undiseases parenchyma: hypertrophy → more liver after resection
- LN involv.
- multiple mets
- tumor >5cm
- CEA >200 pre-op
CT portography
Laparoscopy → laparoscopic US → doubts? → PET
Wedge resection + tumorectomies (non-anatomical resection)
- portal branch of resected side is disected + ligated → change of parenchyma color → lines for resection
- pringle maneuver (not over 40min) or short clamping (10min with 1-2min of declamping)
- clamps on IVC above + below liver → avoid bleeding
bleeding, necrosis, hepatic failure
- finger fracture
- Kelly clamp crushing
- ultrasound aspiraton
- ultrasound scissor
- water jet dissectors
- argon beam coagulator
- fibrin glue
catheter into proper hepatic artery → injection of chemo-mix
liver transplant
nope (because immunosuppresive therapy after transplant → explosion of mets)
cirrhosis 80%
- Cirrhosis
- Viral Hepatitis
- Alcohol
- Hemochromatosis
- Aflatoxin
- Glycogen storage disease
- PV
- Hepatic vein
- IVC
- intrehepatic bile ducts
cirrhosis:
- hepatomegaly
- jaundice
- encephalopathy + flapping tremor
- portal HT
- varices + variceal bleeding
- ascitis
- splenomegaly
- weight loss
- spider angiomata
- ↑Liver markers (AST,ALT, ALP,GGT)
- alpha fetoprotein > 20 (>500 characteric for HCC)
- inflammatory + ↑viral markers
- US + biopsy
- CT
- MRI
- Angiography
US
low likelihood of HCC
→surveillance: US every 3 month → no growth in 1-2y → US every 6 month
→ 2 imaging techniques: arterial enhancement + washout
⇒ treat as HCC
! if not typical on imaging ⇒ biopsy(FNA)
- arterial enhancement + washout on 1 imaging techniqie
- OR AFP>200 ng/ml
⇒ treat as HCC
! if not typical on imaging ⇒ biopsy
- bleeding
- seeding
nice rhyme 😎
BCLC staging system : 0,A-D
0 = Very Early stage, Child-Pugh A
Child-Pugh A+B:
A - early stage (≤ 3 nodules <3cm)
B - intermediate (multinodular)
C - advanced (portal invasion)
D = terminal stage, Child-Pugh C
- Resection
- Chemo or radioembolization (TACE / TARE)
- Percutaneous ablation:
- Ethanol injection = PEI
- Radiofrequence ablation = RFA
- Sorafenib→ multikinase inhibitor, prolongs survival
Child-Pugh A
No portal HT
Bili<1mg/dl
HVPG (hepatic venous pressure gradient) ≥ 5mmHg = portal HT
→ if >10mmHg = clinically significant portal HT
HVPG = gradient betw. WHVP + FHPV ⇒ pressure gradient PV+IVC
WHVP = wedged hepatic venous pressure ⇒ hepatic sinusoidal pressure → catheter in hepatic vein → occlused it → mesure proximal statis blood flow (reflective of pressure in sinusoids)
FHPV = free hepatic venous pressure
- mets
- Child-Pugh B+C
- PHT
- Bili>1
Milan Criteria:
- single tumor <5cm (stage 0)
- ≤3nodules each ≤3cm(=stage A)
- no extrahepatic disease (0+A)
means stage 0 and stage A (without extrahepatic manifestation
- BCLC 0-A
- RFA
- <5cm
- PEI
- <2cm
- recurrance after surgery
- residual tumor after chemoembolization
B - multinodular
w/o invasion or mets
contrast imaging - CEUS, CT, MRI,
AFP
Multikinase inhibitors → i.e. Sorafenib
→ ↓cell division, prolif., angiogenesis
- Cholangiocarcinoma (see above)
Mets
- melanoma
- colorectal
- pancreas
Resection, Chemoembolization, RFA, special shit
- Single procedure primary colo-rectal tumor resection + liver mets resection
- Radio-frequency ablation (RFA)
- Saline-Enhanced RFA prior to resection
- Cryotherapy
- High intensity focus ultrasound (HIFU)
- CyberKnife
- Hepatectomy of most affected lobe → remaing part treated with ablation therapy → liver regeneration → another resection of remaining part
- advanced chronic liver disease
- primary unresectable tumor (limited to liver)
- acute hepatitis with liver failure
- extrahepatic malignancy
- extrahepatic infection (severe +uncontrolled) + HIV
- cardio-pulmonary diseases (advanced)
- organfailure (multisystem)
- substance abuse
- cadaveric source
- Split liver transplantation 📷
During a split-liver transplant, a donor’s liver is divided into two pieces. One portion is transplanted into a child and the other portion is transplanted into a larger child or adult on the list
- Living donor liver transplantation[LDLT] (liver regenerates itself)
- Domino liver transplantion (esp in familiar amyloidosis)
🍠 Spleen
- hematopoetic
- filtering (RBC, platelets, germs, antigens, debris)
- storage (platlets + immunecells)
- circulatory (provides aortion+portal blood flow dynamics)
- immunological
exacerbation of function → destruction of blood-elements (i.e. platelets)
splenomegaly
Splenectomy
- Primary
- immune hemolytic anemia
- ITP
- sickle cell
- Secondary: = most common
- Portal HT
- Chronic bacterial infection
- Lymphoma + Leukemia
- .....
decrease + absence
vascular damage
surgical intervention
tissue replacement
⇒ splenic tissue loss
- congenital
- after splenectomy
- splenic irradiation
- repeated splnic infarctions
Encapsulated bacteria:
most important: "SHIN"
- Streptococc. pneumoniae
- Hemophilus influenza
- Neisseria menigococcus
History:
- bleeding disorders??
- anemic sydrome??
- recurrent infections??
- abdominal trauma??
Symptoms:
- discomfort/pain LUQ
- radiation → left shoulder
- jaundice (hemolytic anemia??)
- Palpable spleen → splenomegaly
- Dullness to percussion
→under left costal margin during deep inspiration
→feels crenulated
→moves during respiration
- Tumor: le kidney, pancreas, abdominal wall, stomach
- left hydronephrosis
- CBC → ↓THrombos, ↓leukos, ↓erys??
- Bonemarrow cytology (sternal puncture) → assess regenerative potential
- Coombs + autoanti-ab test
#1 US
→ DD-Tumor
→ collection + hematoma
→ rupture
→ spleen size
→ ↑splenic shadow, ↑elevated diaphram;
→ Doppler: trauma
#2 CT → if US is Ø conclusive
#3MRI → DD tumors
- Therapeutic → Tumors, Trauma, Hydatic cyst, Abcess, Splenic vein thrombosis w/ gastric varices
- Diagnostic → Lymphomas, tumor with unknown etiology
- Tactical → Total gastrectomy, corporea-caudal pancreatectomy, left hemicolectomy
- myeloid leukemia
- acute Leukocytosis
- bleeding
- acute pancreatitis
- thromboembolism (when thrombosis-prophylaxis absent)
- sepsis (by SHIN) [esp in children]
- splenic arteriovenous fistulas (see later)
- polycythemia → ↑Leukos, ↑Thrombos
- Howell-Jolly, Heinz bodies + target RBC
abdominal trauma
- Rupture → immediate or delayed
- Contusion (Quetschung)
- penetrating wounds
- iatrogenic → intra-OP of adjacent organs
bleeding → hematoma or hemoperitoneum
- subcapsular → capsule intact → might develop to rupture (hemoperitoneum) or delayed hemorrhage or perisplenic hematoma or resorption
- perisplenic hematoma → capsular effraction due to trauma or secondary to subcapsular hematoma → might lead to secondary rupture (hemiperitoneum)
get infected → splenic abcess
AB + Splenectomy
T most common complication of splenic injury
splenic parenymal fragmentation → spleen “explosion” 📷
- discomfort/pain LUQ
- radiation → left shoulder
- Hypovolemic shock (intraperitoneal hemorrhage)
- anxiety
- thirst
- faintness
- pale skin
- cold
- hypotension
- oliguria
- Signs of intraperitoneal hemorrhage
- abdominal distension
- Ballance's sign (movable dullness)
- Paralytic ileus *
- Bulging of Douglas pouch *
- ↓RBC - Anemia
- ↑Leukos
- ↑Thrombos
- US → hematoma or hemoperitoneum
- CT
- Volemic rebalancing
- Cardiopulmonary resucitation
- Depending on injury:
- ØBleeding + Øassoc. lesions + stable → Non-surgical spleen preservation treatment → hospitalization (possible delayed rupture)
- Low Parenchymal injury + experienced surgeon → Spleen preserving surgery → capsular suture, tissue adhesive, argon plasma coagulation)
- Bleeding cant be stopped by other means OR total spleen damage → Complete splenectomy
- Splenic arteriovenous fistula
- Splenic vein thrombosis
hemangioma
- splenomegly
- B-symptomatic
- pain (when tumor necrosis becomes superinfected)
splenectomy +- adjuvant chemoT or radioT
splenectomy
or if already splenectomy: vein ligation + resection of communication
PANCREAS + TRAUMA
- pancreatitis
- pseudocysts
- trauma
Splenomegaly + Gastroesophageal variceal bleeding
and Ø hepatic damage
Doppler + selective angiography
splenectomy
- Splenic artery aneurysm
- Splenic infarction
Hematological disorder
- Hereditary spherocytosis
- Splenic neutropenia
- Immune thrombocytopenic purpura
- Thrombotic thrombocytopenic purpura
- Hereditary elliptocytosis
- Sickle-cell disease
- Thalassemia
- Autoimmune hemolytic anemia
- Felty's syndrome
Lysosomal storage diseases
- Gaucher's disease
- Niemann-Pick disease
Myeloproliferative disorders
- Chronic myelogenous leukemia
- Myeloid metaplasia
Lymphoproliferative disorders
- Malignant lymphoma
- Chronic lymphocytic leukemia
- Hairy cell leukemia
🚑Abdominal Emergencies
- severe acute evolution in the abdomen
- lethal if untreated
- promt surgeon diagnostic, therapeutic response required
- Peritonic → peritonitis
- Obstructive → acute Øvascular bowel obstruction
- Hemorrhagic → ruptured ectopic pregnancy, ovarian cyst
- Ischemic→ Mesenterial infarct, fallopian tube torsion)
- perforated peptic ulcer → peritonitis
- ischemic events
- fallopian torsion
- ac. mesenteric infarct (AMI)
- acute appenditis (but can also be sudden)
- cholecystitis
- acute appendicitis
- peptic ulcer
- liver
- biliary
- pancreatic
- female organs: uterus, fallopian tube, ovaries
- Uro: bladder+urethers
- ac. appendicitis →epigastic/periumbilical → RLQ
- perforated peptic ulcer → initiall epigastric (but ↑intensity compared to ac. appendicitis) → RUQ → RLQ → diffuse
Renal colic → follow course of urether caudally (belt shaped )
Ovaries/fallopian → radiates cranially same route
right shoulder (diaphragmatic irritation)
- splenic rupture
- ruptured ectopic pregnancy
- septic intra+retroperitoneal conditions (i.e diffuse peritonitis)
- ischemic events → more intense
(i.e. AMI, fallopion tube torsion, bowel torsion, strangulated hernias)
- intermittend colicky
- after 6-12h → distension + ↓in pain intesity+freq. (muscle exhaustion)
- perforation + rupture → contamination peritoneum
- MOST INTENSE: acute ischemic (AMI)
- might be preceded by abdominal angina
- initially periumbilical
- abrupt brutal onset
- Øresponse to pain killer
- pallor + cyanosis + sweating (sympathetic signs)
- pain diminishes after 10-12h (endorphins + ischemic necrosis) = delusive lull
- acute necrotic pancreatitis
- abdominal ischemic
- reno-uretheral
diffuse peritonitis → movement aggravates pain
- Anorexia + pain
- Nausea + vomiting
- Vomiting does Ø relieve nausea
- prox - freq. vomiting; clear bile
- lower - less freq; voluminous turbid bile
- terminal-ileal - voluminous + fecaloid (12-24h after onset of obstruction)
any peritoneal injury → irritation → reflex paralyisis
- Acute liver failure, (a lot ascitis, cirrhotic patient)
- metabolic pathologies
- acute diabetic ketoacidosis
- uremia
- electrolyte balances
- Pulmo
- pleural effusion
- acute basal pneumona
- severe asthma attacks
- acute + prolonged urinary retention + renal colic
- hip fractures
- partial + lateral bowel strangulation
- femoral or obturatory hernias
- long-lasting unrecognized peritonitis
→ cause "irritation diarrhea"
⇒ might delay surgery because there is Ø "no bowel movement" sign❗
- imflammation
- sepsis
- ischemia
first sub-febrile (<38°)
→ hours-days → appendicular gangrene, perforation or abcess → 38.5-39.5°
- immunosupressed
- advanced cancer
- DM
- age
- Chemo or Steroids
ac. appenditis
hernias
- rupture graafian follicle
- hematic ovarian cyst
- peptic ulcer
- ac. pancreatitis
- acute appendicitis
- pelvic inflammatory disease
- acute cholecystitis
- ectopic pregnancy
- -ectomies❗
- shift focus on other condition (appendectomy female → uro-genital focus)
- if recent: might complicated (cholangitis/pancreatitis after cholecystectomy)
- in obstruction → surgery❓ → obstructive adhesion possible
- irregular dark genital bleeding (1-2month)
- delayed menstrual cyscle
- hypogastric pain
- bilateral lumber irradiation
- respiratory movement → peritonitic → ↓↓movement
- scars → hernias or incisions in the past
- distension → obstruction (late)
point out area of pain
- "noisy abdomen" + colic pain
- late phases (12-24h) → Øsounds + distension
- infarction → "death silence"
- paralytic ileus + distension
away from painful area + superficial
look for patients reaction
→ if tolerated deeper palpation
peritoneal irritation
blumberg sign (rebound tenderness)
Jar tenderness
- patient on his toes → jump abruptly on heals
- bowel distension (air)
- ascitis (fluid)
- masses (tumoral+inflammatory)
rectal (f+m) and pelvic (female)
pharyngo-esophageal junction → duodeno-jejunal ligament (Treitz lig)📷
acute → hemodynamic disturbance
chronic → small amount → anemia, normal hemodynamic
Name | Hemodynamic parameters | Lab |
Small GI bleeding | Blood loss <500ml
BP normal
HR normal | Ht >30%
Hb = 10-12 |
Medium GI bleeding | Blood loss 500-1000ml
sBP >100
HR <100
pallor, cold sweat, tachypnea | Ht 25-30%
Hb = 8-10 |
Large GI bleeding | Blood loss 1500-2000ml
sBP <100
HR >100-120
fainting, coldsweat, tachnypnea, oliguria | Ht <25%
Hb = 5-8 |
Severe GI bleeding | Blood loss 2000-3000ml
sBP <70
Weak pulse | |
Cataclysmic GI bleeding | Massive + rapid bleeding → death before therapeutic intervention possible |
- Esophageal diseases
- tumor
- varices
- diverticula
- iatrogenic
- mallory-weis
- trauma foreign body
- Gastro-duodenal dieseases
- ulcer
- tumor
- hernia
- gastritis
- crohns
- other GI
- cirrhosis
- bilary cancer
- pancreatitis (ac+chronic)
- budd-chiari
- extra-digestive
- Mesenteric infarction
- hematologic diseases (ITP, hemophilia, polycythemia etc)
- arterosclerosis + HT
- stress
- Cushing ulcer (cranial lesion)
- Curling ulcer (burns)
- drugs
- NSAIDS + anticoagulants
- steroids
- hematemesis - high blood loss (800-100ml)
- melanemesis (coffee-grounds) - slow+low blood loss
- melena - low+slow blood loss
- hematochezia - high blood loss (>1000ml)
- anemia (sometimes due to occult bleeding)
- pallor
- fatigue
- fainting
- Hypovolemia
- shock-symptomatic
- thirst
- dizziness
- ↓BP
- peripheral hypoperfusion → cold extremities, cold sweats
- collapse + coma
- history of NSAID, ulcer, liver diseases, anticoagulant
⇒melena + hematochezia confirmed by rectal exam (DRE)
Hemoptysis
- foamy
- Øfood
- after coughing
epistaxis + gumbleed
- ingestion of iron, bismuth or charcoal
- lower Gi bleeding
- Check vital parameter (BP, HR, ECG)
- CBC → Hb + coagulation
- XRay + US → possible perforation
- nasogastric tube aspiration differentation Upper vs. Lower
- EGD → exploration + treatment
- barium swallow
- selective angiography + treatment with embolization
- scincti with labeled RBCs
- Hemoocult test for detection of occult bleeding
- find source
- stop bleeding
- stabilze patient
- i.v. fluids
- consider RBC-transfusion (check Rh+blood group❗)
- oxygen
- History + medication
- physical exam
- naso-gastric probe
- EGD → Tx of bleeding source
- muchos fluids + blood transfusion
- urinary catheter → diuresis monitor
- correct coagulopathy
→ becomes stable → EGD
→ remains unstable → ICU+ emergency surgery
Adrenalin injection (endoscopic)
→ sucessfull → PPI, H2, sucralfate, HP eradication
→Øsucessfull → emergency surgery
→ PREFFERED:Billroth I or Billroth II 📷 partial gastrectomy or total gastrectomy
→OR hemostasis with stiches
Same as chronic gastric (adrenalin injection + antiacid drug +anti-HP)
but if fails → stiches are preferred over billroth I + II
- Endoscopic sclerotherapy or band ligation (in gastric varices ØscleroT)
- Somatostatin (Octreotide) [constriction splanchnic artery → ↓portal pressure]
→ if continous → Balloon tamponade 📷
→ if continous further
→ candiate for liver transplant → TIPS
→Øtransplant-candidate → Porto-caval shunt
→ After bleeding stops: beta-blocker + endoscopic variceal therapy
- usually stop spontaneously
- endoscopic hemostasis (ligation+sclero)
→ if continous → gastrotomy →suture
- Endoscopic hemostasis (sclero+band)
→ continous + resectable → subtotal/total gastrectomy
→ continous + Øresectable → vascular pedicle ligature or embolization or injection
- stop NSAIDs
- PPI, H2 + Sucralfate + Anti-HP
→ continous → subtotal/total gastrectomy
- embolization
→ fails → ligation branch of hepatic artery
→ fails segmental liver resection of affected segment
appendicular artery from SMA
10-40y
Fecaloids or lymphoid hyperplasia → obstruct appendix → secondary bacterial infection
obstruction → continous secretion of appendiceal mucosa → ↑intraluminal pressure → distension → pain
→ rapid multiplication of local appendix bacteria → edema, hyperemia, pentration through musosa = catarrhal appendicitis
→ spreads to serosa + peritoneum(locally) → Pain illiac fossa → Mc-burney's +
→ phlegmonous phase → enlarged congested, purulent fluid on serosa + thickend mesoappendic
→ compression arterial blood flow → necrosis = gangrenous appendicitis
⇒ perforation
→ appendicular abcess,
→ appendicular block,
→ diffuse peritonitis (Rebound tenderness)
sudden or progressive and ↑Intensity (esp with effort)
epigastic/periumbilical → 4-6h: RLQ
⇒variations= but can also be periumbilical, right flank, right hypochondrium or pelvis
first sub-febrile (<38°)
→ hours-days → appendicular gangrene, perforation or abcess → 38.5-39.5°
- constant anorexia
- nausea + vomiting (vomiting doesnt relieve nausea)
- constipation or diarrhea
- fever+pain
- Appendicular block
- Appendicular abcess
- Diffuse peritonitis
→ adhere to cecum,ileum, omentum (3days after onset) due to inflammation+fibrosis
→ AB-therapy→ regression
→ after 6w appendectomy
→ might develop into abcess or generalized peritonitis
→ transformed from appendic. block
→ AB + drainage (percut or surgical)
→ after 6w appendectomy
→ may develop into fistula (skin, bladder, peritoneum)
→ due to direct perforation, or abcess perforation
→ Appendectomy, peritoneal lavage, drainage + AB
children
→ Meckels + Intussiception
Adult
→ perforated ulcer, ac. cholecystitis or pancreatitis, ectopic pregnancy, renal-urinary colic
Elderly
→ cecum cancer, occlusion, AMI
- Right illiac fossa tenderness
- Mc Burney's point 📷
- Blumberg's sign = rebound tenderness (irritation perietal peritoneum)
- Rovsing's sign - palpation LLQ → pain RLQ 📷
- Psoas sign 📷
- Obturator sign 📷
- Voluntary + involuntary guarding(peritoneal irritation)
- Grassmann Mendel's (Bell sign)
- Antalgic position
- Cutaneous hyperesthesia
- young: underdeeloped omentum to block perforation → fast generalized peritonis
- elderly: milder pain, signs, fever, leuko incre → late dg + rapid evolution towards perforation → ↑mortality
enlarged uterus → displacement appendix → altered pain location
also physiologically ↑leukos in pregnancy
- LAB:
- Leukos 10-18k with left shift; if >18⇒perforation
- Urine analysis → DDx kidney patho (ex. Urosepsis)
- US → thickend wall, peri-cecal fluid, DDx genital+urinary pathologies
- CT → if US Ø conclusive
- Xray → for DDx (i.e. occlusion)
Either classic or laproscopic appendectomy
classic →McBurney incision
laparoscopic → 3 trocars
- intraperitoneal examination
- free appendix from cecum
- ligation + transection mesoappendix
- ligation + transection of appendix base
- remove appendix + close wound
- AB (regression block, together with surgery in abcess + peritonitis)
- Symptomatic
- pain killer
- anti-inflammatory drugs
- antispasmodics
INFEKTION + FIBROSIS + BLEEDING
- wound infection
- slipping of ligature → bleeding + peritonitis(generalized/localized)
- intestinal obstruction (post-op adhesions)
- Emboli-thrombotic events
- DVT
- PE
generally good when correct + early Dg
inflammation visc+parietal peritoneum
- Generalized(diffuse) vs. Localized (Abscesses)
- Primary, Secondary + Tertiary (see below)
SBP (spontaneous bacterial peritonitis)
F → mono-microbial (multi in secondary peritonitis)
- E.coli
- klebsiella
- S.pneumoniae
- S.haemolyticus
- Gonococcus
- Tuberculosis
pre-existing ascitis fluid (i.e. cirrhosis, budd-chiari, disseminated malignancies(carcinomatosis))
- trans-mural-intestinal
- hematogenous
- direct asc. contamination (from infection fallopian tubes)
E.coli + klebsiella
Gonococcus in vulvo-vaginitis
→ a lot of green pUs
→ bilateral purulent gonococcal salpingitis
active tuberculosis
TBC + s.pneumoniae
→ pneumococcus during severe penumonia in immuno-compromised patients
s.pneumonia + h.streptococcus
- nephrotic syndrome
- pneumococcal respir. infection (septicemiae)
- juvenile liver cirrhosis (transmural)
scarlet fever or tonsilitis
- acute, diffuse pain
- guarding
- tenderness + rebound tenderness
- nausea, vomiting
- bowel paresis
- higher fever
- irrititative diarrhea
same as children
- progressive, Øacute onset
- only moderate pain
- abdominal distension
- nausea
- Øguarding Øtenderness
- fever + night sweats
- Øsigns for peritoneal irrtation
- unexplained liver decompesation
- alter mental status
- gradual onset
- fever
- metabolic acidosis
- bowel paresis
Paracentesis + culture → PMN >250
↓proteins <1
↓gluc <50
↑lactate >25
↓ph<7.35
F - treat directly when PMN>250 + clinical presentation is accordingly
primary → AB therapy (if surgery ↑↑mortality)
secondary → surgery (if only AB and Ø surgery → RIP ☠️)
empiric AB → Claforan (cefotaxin) or Rocephine(ceftriaxone) for 10-14days
(modify later, according to culture)
- clinical status: improvement after 48h
- ↓↓Leukos in ascitis fluid
intra-abdominal perforation (mainly) due to inflammation or ischemia → bacterial infection (bact. peritonitis)
- #1perforated peptic ulcer + acute appendicitis
- Ischemic events
- Bowel infarcition
- torsion
- diverticulitis
- abscess
- Meckels
- toxic megacolon
- trauma (rupture / perforation)
- GI surgery
- abscess from all abdominal organs
- ext. feeding tubes
- chemical peritonitis (initially sterile)
- ischemic necrosis of gall bladder (diabetic or septic patient)
- acute pancreatitis (initially)
- gastric perforation (initially)
from the upper to the distal segments
(e.g. gastric perforations are initially sterile, while colonic perforations generate peritonitis with severe prognosis, due to a “heavy load” of Gram-negative and anaerobic, exo-and endotoxines-producing germs !).
T anerobics + arobic
- immune-system activate + vasodilation (huge surface) + plasma-influx → fluid-sequestration into 3rd space → hypovolemic shock
- penetration pertoneal membrane → systemic circulation → sepsis + septico-toxic shock → multi-organ failure
- peritoneal irritation → bowel paresis → ↑fluid sequestration
- Pain:
- abrupt onset
- continous
- first localized → diffuse
- immobile, still, antalgic position
- wooden abdomen (guarding + rigidity)
- rebound tenderness (blumberg sign)
- Øbowel sound
- Bell sign (pain to percussion)
- typanism if air
- dullness if fluid (pus, bile infected ascitis
- swollen + painful Douglas pouch on DRE
→ slightest movement provoke pain (shallow breathing)
→after time(6-8h) → distension (wodden abdomen disappears)
Lab → inflammatory markers,
Xray → pneumoperitoneum
US → fluid, distension, peristalsis, cause (lithiasis, perforated appendix)
CT → if Ø conclusive → confirm peritonitis + cause
surgery❗ → laparascopically
- fluid ressucitation
- Blood test + ECG
- AB (broad spectrum)
- analgesics
- nasogastric tube → obtain gastric vacuity
- urinary catheter
sample of pus (or other contaminating agent) → culture
- control source → i.e. appendectomy, cholecystectomy, diverticulectomy, suture of ulcer
- Peritoneal lavage with liters of warm saline (prevents post-op adhesions + abscess-formation)
- Drainage → tubes into le+ri subphrenic spaces, bursa omentalis + douglas pouch → removed after 48-72
- in patients with severe comorbidities or immunocompromised (AIDS, diabetes, cirrhotic, malignancy, aged, etc)
- Intraperitoneal infections → perisits/recur(48h) after initial surgical + AB treatment
- multiresistance noscomial
- Enterococci
- Enterobacter
- Fungi
- check CRP repeatedly
- or re-laparatomy
Relaparotomy + lavage + fluid culture
- Metabolic
- acidosis, uremia, ↓K, ↓Na
- Pelvic irradiation
- Neurologic (brain tumor, MS, etc.)
- Reflex
- post-operative *
- biliary +renal colic
- acute pancreatitis
- Sterile intraperitoneal fluid → onset of ascitis in cirrhosis, hemoperitoneum, chemical peritonitis
- acute fallopian torsion
- bladder distension
- Septic causes
- Localized/diffused purulent peritonitis
- Septic condition adjacent to peritoneal serosa
T
open the different groups❗
- Tumors from outside
- Adhesions of omentum (i.e. meckels + appendix)
- Intraperitoneal forein bodies
- Tumor or mets
- Inflammatory stenosis (i.e Crohns or TB)
- Intramural hematoma
- congital abnormalities (atresia, stenosis)
- Biliary ileus (large migrated stone through fistula)
- Foreign bodies
- pylorus
- duodenal curvature
- ileo-cecal valve
- rectosigmoid flexure
- anal canal
entrapment in pre-exsiting (paraduodenal, diaphragmatic) or traumaically-generated (transmesocolic (Roux En Y), diaphgramatic) orrificed → strangulation
ischemia (from beginning) → necrosis → perforation
in mechanical it might only lead in later phases to ischemia
silence of death (aperistalsim)
juuup :skull
(also see above)
- Arterial trunk obstructions
- Emboli
- Thromboemboli
- Venous trunk obstruction (thrombosis)
- Impairment microcirculation in bowel wall
↑intraluminal pressure → ↑peristalsis + excessive secretion → exhaustion of muscles → distension
→ intraluminal ion + fluid accumulation + ↓ of absorption ⇒ dehydration (hypovolemic shock)
→ gas accumulation (after absorption suppression + fluid accumulation)
→ venous, capillary + arterial compression → completly abolishmend of absorption (=irreversible now)
→ permable capillaries → albumin into interstitium → bowel wall edema
→ Ascitis
→ mixed (resp+met) acidosis
↑↑↑intestinal pressure (more rapid + severe than above) → collapse microcirculation+arterioles → intraparietal hemorrhage → 6-12h: hemorrhagic intestinal infarct
→ necrosis: bacterial population (favoured by stasis, ischemia, distension) → impaired mucous-epithelial barrirer → spread into general circulation → septico-toxic shock (simple mechanical: hypovolemic shock)
- colicy + intermittend
- ↑in intensity
→ followed by rapid + total ↓↓of intesity
prox. jejunum → 5min
ileum → 5-20m
colon → >20m
- permanent
- high intensity
- Øcontrollable by pain killers
first at level of obstruction → generalized
- diffuse
- continous
- low-moderate intensity
F - doesnt relieve
- high prox → food, early, persistent, clear bile
- low ileal → food, turbid bile → fecaloid
- distal recto-sigmoid → late + Øcommon
appears due to abnormal overgrowth of fecal bacteria after obstruction (Ødue to reflux from colon-content into small bowel)
- Øfecal + gas transit
- subocclusive syndrome (König syndrome)
incomplete obstruction ileocecal segment → colic pain + meteorism → hydroaeric noises(borborigmi) → diarrhea + gas passing → transient relieve
bloody + glaireous(like the white of the egg)
central distension
flanks + epigastric
"most extensive"
asymmetric
from Left illiac fossa → RUQ
⇒ von Wahl triad:
- enormous + asymetric central distension = von Wahl sign 📷
- elastic renitency (resistence)
- high tympanism
- intense distenstion
- → but painless
- early phase
- high (proximal) occlusion → “flat abdomen“
- lateral stricture strangular (richter type hernia 📷)
- Visible persitalsis → esp in lean patients
- Palpation
- Percussion:
- Typanism → meterosim
- Dullness → loops with liquid
- Moving dullness → ascitis (advanced)
- Auscultation:
- Borborygmi → subocclusive
- abdominal quit → paralytic ileus
- death silence → infarction
- DRE:
- empty ampulla
- neoplasm + feacalomas
→ at fixed point → König syndrome
→ masses, inflammatory masses
→ localized tenderness/rigidity → ischemic obstruction (strangulation or infarct)
→ wodden abdomen, fever + shock → when perforated
- initally: anxiety, tachycardia during colic
- "Tormented" facies → characteristic for ischemia (strangulation + infarction)
- septic-toxic or hypovolemic shock
- mamorated skin, collapse
- Signs of dehydration (thist, dry tongue+eyes, cutaneous fold, oliguria/anuria)
- Fever → infected necrosis or diffuse peritonitis→paralytic ileus
- pain → sudden onset
- vomiting → early, frequent + profuse
- initially "flat abdomen"
- gas + stool emission is possible
→ fluid-ion loss → early hypovolemic shock
- less freq. colicky episodes (15-20min)
- vomiting occur later → tubit + fecaloid
- sympetrical central distension
- dehydration later (due to fluid into lumen) → hypovolemic shock
- long tolerated pain (4-7d)
- Øvomiting or late vomiting
- distension flanks + epigastric → later diffuse
- DRE → detect cause pretty often
T → occur in aged patients
- Diastatic perforation: distal obstruction → cecum ↑↑→ diffuse (fecaloid) peritonitis ⇒ do repeated Xray to detect "critical cecal diameter (12-13cm) 📷
- Colic perforation - above tumor
- sudden onset
- continous intense pain
- vomiting (reflex due to mesnteric torsion)
- Distension (central + asymmetrical om sigmoid volvolus)
- sudden onset
- intermittent colic → longer periods of remission
- Vomiting - initially refelx
- distension at late stage
- Rectal bleeding
- Tender mobile tumor
blocked mesentery venous + arterial circulation → adhesion betw. invagination → irreversible → ischemia + necrosis
pediculated tumor
enteral → benign
colic → malignant
- sudden onset
- continous pain
- vomit, pallor, sweating
- EXAMINATION → DETECTS HERNIA
- Reflex bowel paresis due to:
- chest trauma
- pneumona
- MI (right ventricle)
- Bladder distension
- Post-OP gastric distension → do nasogastric suction
- Acute ascitis → do US
- Acute (pseudo-obstructive) pancreatitis → imaging+lab
- Negleted longstanding peritonitis (in late stage just presenting with meteorism)
F → Only Dg of obstrutive type has to be made → etiology (for obstruction) can be established during laparotomy❗
- Xray
- intravascular portal gas → outlining portal tree,
- gas in necrotic bowel walls
→ air-fluid levels (4-6h) after onset 📷
→ paralytic ileus → "♟️chessboard" image 📷
→ small bowel obstr. → numerous, central, large transv. diameter
→ distal colon obstr. → less numerous, outline colon, large vertical diameter
→ Frimann-Dahl sign → sigmoid volvolus 📷
→ Calculus detection + Pneumobilia → biliary ileus
→ Bowel infarction: 📷
2. US
→ distension + wall thickness
→ peristalsis
→ peritoneal fluid
→ evtl etiology (fluid, stone, mass etc.)
4. CT → additional work-up
5. AngioMRI → in infarction (vascular obstruction)
3. . Irrigography with Barium
→ invaginations → "trident like" + "golf trouser" image
“The Frimann-Dahl sign is a diagnostic sign demonstrated when three dense lines, representing the sigmoid walls, are seen converging to the site of obstruction in sigmoid volvulus and associated with empty rectal gas”
6. Endoscopy + Laparoscopy → only with care❗ (air insufflation❗)
- Restore fluid, electrolyte and acid-base balance
- Relieve gastrointestinal distension
- Address the cause of enterocolic obstruction
- Prevent future obstructive episodes
- decrease proximal pressure: nasogastric tube
- restoration → acid-base, electrolytes, fluids
- AB broad spectrum
- Alpha + beta blockers (open microcirculation, paincontrol, evtl. restoration of bowel movement)
⇒ IV, CVC, Urinary catheter
- obstruction removal
- toxic non-viable content removal
- peritoneal effusion removal
- strangulations
- certainly or probably ischemic
- colic obstruction with "critical cecal diameter" [12-13cm] (and nasogastric aspir. is Ø effective)
- Already hospitalized bowel obstruction with now onset of water-ion balance
- mechanical Øischemic obstruction with water-ion balance
- Cases with concomitant life-threatening failures (i.e. heart)
- general → in severe cases
- epidural catheter → ischemic cases
- local anesthesia → in extreme cases for surgical decompresion (i.e. cecostomy tube 📷)
- laparotomy #1-line
- selective: in moderate metorism with little adhesions → laparoscopy
resection Øviable tissue
→ anastomosis (t-t, t-l, l-t)
→ OR -ostomie (if severely altered performance index or bad quality of anastomotic ends)
Borderline viability (doubtful appearance) → Novocaine into mesentry + loop enveloped into warm saline compresses → put back into adomen (for 15-20m, under optimal BP + SpO2)
⇒ COLOR (blue→ pink)
⇒ PERISTALSIS
⇒ ARTERIAL PULSATION (can be detect with doppler)
resect
DECOMPRESSION + EVACUATION OF TOXIC CONTENT
- "retrograde milking" → suction by nasogastric/naso-intestinal tubes
- decompression colon → transanal Faucher tubes
- decompression by opening (last resort → ❗high septic complication risk)
- Adhesion → dividing adhesions, resect adherent organs that strangulate/obstruct (i.e. meckels, appendix)
- Invagination → disinvagination
- Volvolus → devolculation
- Hernias (int+ext) → release them
- calculi → enterotomy (cut open) + extraction
- Compressive tumors → excision
- inflamm+malignant stenosis → resection
Invagination
- internal bypass
- OR stomy
- ileo-transversostomy (tumor between them)
- transverso-transversostomy (mid transv. colon tumor)
- transverso-sigmoidostomy (tumor splenic flexure)
- other locations → external stoma (permanent or temporary)
all in one strategiy
- Resection of lesion
- Resection compromised bowel loop
- Anastomosis
→ right hemicolectomy
→ segmental transversectomy
→left hemicolectomy,
→ sigmoidectomy
→ ileo-transverso-anastomosis
→ colo-colo anastomosis
→ colorectal anastomosis
OR temporary external -ostomy
patient general condition → if bad: → delay
Sigmoid tumor → Hartmanns (sigmoidectomy + colostomy + distal rectal stump closure
recto-sigmoid tumor → sigmoidostomy
rectum to left thrid transv. colon → transversostomy
small bowel → ileostomy
almost diastatic cecal perforation → cecostomy
- Volemic, ion + acid base re-equilibration
- AB
- Maintainace of suction catheter until transit resumes
- symptomatic treatment
(see causes again)
- metabolic imbalance correction
- nasogastric suction
- reflex paralytic ileus (renal + biliary colic): analgesia + antispastics
- post-operative paresis → continous peridural infiltration
SURGERY
→ postoperative paresis → might have developed into mechanical obstruction (fibrinous adhesions resection)
→Septic focus generating intestinal paresis (localized peritonitis) → source -ectomie (i.e. appendectomy)
→ Peritonitis → Peritoneal drainage (+lavage)
→ if large distension → transient external -ostomie
- bowel necrosis
- diastatic cecal perforation
- peritonitis (localized + diffuse)
- Septic-toxic shock with multiple organ failure
- Aspiration pneumona
- Bowel perforation → peritoneal contamination
- Anastomotic breaks, fistulas, abcess → peritonitis + sepsis
- recurrent obstructions
- Evisceration
- Gastric dilation
- PE
- Organ failures (cardiac, pulmo, renal, hepatic)
- ARDS
- Blind loop syndrome
- short bowel syndome
- incisional hernias
- external compression → ↑intra-abdominal pressure → rupture
- abrupt decelaration → tears in organs or vessels
- crushings → solid organ against spine/ribs → intra- + retro-peritoneal hemorrhage
- Blunt trauma
- Open abdominal trauma
→ exclusively parietal damage, Øvisceral damage
→ or with visceral damage
→ either non-penetrating (only parietal)
→ or penetrating (abdominal parietal penetrating +/- visceral damage
→ if visceral damage → parieto-visceral wounds
→ if large enough → evisceration
#1 Motoher vehicle collision → 75%
2. Falls from height
3. Aggression (aufs maul)
4. Sport ☠️
- aorta
- heart
- left hepatic lobe
- spleen
- small bowel
- spleen
- le. lung
- le. kidney
- right liver
- right kidney
- right lung
- spleen
- liver
- kidney
- peritoneal irritation (pain, tenderness, guarding)
- intra-abdominal hemorrhage (hypovolemia, pallor, ↓BP, modified pulse)
blood test + imaging normal→ discharge patient 👋
Circumstanced that may mask abdominal lesions:
- altered mental state (brain lesion, shock, intoxication)
- chest wall injuries (Øabdominal pain+tenderness)
- external lesion (focus attention away from abdominal bleeding)
ABC
with high flow oxygen with intubation
venous catheters
RBC + thrombo transfusion → TRansfusion ration 1:1:1 (plasma:RBC:Thrombo)
F only 55%
US → eFAST
⇒ abdominal free fluid
⇒ hemoperitoneum (esp. with blunt trauma anamnesis)
⇒ pericardial + pleural effusion
⇒ pneumothroax
surgery → laparotomy (see later) 📷
- before: naso-gastric tube + urinary catheter
- then catheter through needle → abdomen (subumbilically) → aspiration: >10ml fresh blood → positive hemoperitoneum
- if negative (>10ml) → diagnostic peritoneal lavage → drained: >100.000 RBC OR bile/alimentary particles → positive hemoperitoneum
other possible bleeding sources (thorax, pelvis,fractures)
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- ABC - repeat periodically
- constant monitoring
- persistent i.v. fluid + blood infusion in right ration
- Electrolyte + acid base re-equilibration
- CVC
- Drugs → esp to maintain hemodynamic stability + analgesic
- etc.....
hemoperitoneum (well vascularised) → esp liver + spleen
retroperitoneal hematoma → kidney+pancreas
peritonitis (generalized or localized)
intra-/retro-peritoneal bleeding → hemorrhagic shock
- hemodynamically unstable (at presentation or after inistial stabilization)
- severe ongoing bleeding
- requiering massive blood transfusion
"Damage control surgery"
FOUS ONLY OF IMMEDIATE LIFE-THREATENING LESION = HEMORRHAGE + CONTAMINATION
#1 Control hemorrhage:
- pack liver rupture
- splenectomy
- ligation/suturing of vessels
- At the same time massive transfusion protocol
#2 Control septic contamination soruce
- Simple suture ruptured bowel + urinary bladder
- resection largely compromised bowel loops (non-viable) → temporary stappled-closing (Øreconstructive anastomosis)
- peritoneal lavage
- all four abdominal quadrants exteriorized + temporarily packed (prevent intraabdominal post-op diffuse bleeding)
- temporary abdominal close with vacuum device (vac pac) → Øsuture abdominal wall
patient will develop or already has metabolic dysregulation → lethal triad:
- hypothermia
- acidosis
- coagulopathy
→ 24-48h on ICU
→ correct altered lab parameters
→ AB (broad spect)
→ total parenteral nutrition
Take-back final operation
- remove vac-pac
- explore abdominal cavity:
- remove swabs + packs
- repair previously unresolved lesions → i.e. anastomosis
- final peritoneal lavage
- closure of abdominal fascia
🔪Laparascopic and Bariatric Surgery, Organ Transplantology, Informed consent
sleeve,
gastric band,
gastric plication
gastric by-pass,
duodenal switch
BMI > 40
OR >35 + comorbidity (DMII, sleep apnea, HT, Dyipidemia, etc.)
- depression
- substance abuse (alc+durgs)
- pregnancy
- cirrhosis
gastric resection 3cm under esogastric junction
→ distal part is Ø removed❗
→ Y jejunal loop with long or short biliary limb
sweet eater → dietary+vitamin supplements needed after (life-long)
- 🍬Sweet eater → gastric bypass
- ⬆️ Volume eater → sleeve gastrectomy / duodenal switch
- 😵💫 Addiction to food →i duodenal switch
- quit smoking
- psychological assessment + assesment for eating disorders
- gastroscopy + HP test
- pulmonary + cardiac function
- thrombosis prophylaxis (LMWH)
- calf + stocking compression
- PPI or H2
- AB prophylaxis
ring around esogastric junction
→ tube at internal circumference: can be inflated with saline (max 9ml)
→ subcutaneos injection port is connected via tube to the gastric band to inject saline
- Øresection + Øopening
- short recovery
- low complications
- allergy to ring component
- infections that is likely to contaminate ring
- psycho-emotional problems
- liquid diet first week
- max 9ml injection → but only ↑0.5-1ml spaced by 1-2month
- esophageal dilation + esophagitis
- ring slipage
- gastric stenosis
- infection of port
- fistula pouch → fundus
- rupture of the ring
yes trueeeeee
- volume eaters
- primary Op for obesity
- briding to gastric bypass
- replacement of adjustable ring
- also for young + old patient (<14 + >70y)
- weight loss
- high protein intake + shakes 10days pre-op
- avoid sugar + saturated fat
- ↓ghrelin → ↓hunger
- early satiety
- Øforeign material
- bleeding
- fistula (at suture site)
- ulcers (marginal)
- liquid diet (10days)
- Day 2: methoylene bluen ingestion → fistula❓
- Day 6: iodine contrast swallow → fistula❓
- Day 5: total oral rehydration possible
- food discipline❗ → Øcarb-drinks, Øhigh calorie food
- Give Vit B12 → loss of intrinsic factor (usually secreted by gastric parietal cells)
- chew well
- if you regurgitate you eat too much or too fast
- drink enough to avoid portal thrombosis
- if you dont drink 1500ml in 2 days i will give you iv. infusion
- dont drink while you eat (and dont drink while driving 💨)
The Biliopancreatic Diversion with Duodenal Switch, abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. It resembles the gastric bypass, where more of the small intestine is not used.
but ↑↑complication rates than sleeve + bypass
Classic main selection criteria
esp. when food addiction or volume eater
young female moderate obese + able to play sport + willing to change eating habit
2layers which fold the gr. curvature into the lumen of the stomach
First week: freq. vomiting
after 2-3y → stomach dilation → regain inital weight❗
1-2weeks → after dense adhesion → difficult conversion to sleeve
- What is the Pathology
- Why is it necessary to perform the surgery:
- complications if Ø treated
- expected outcome if treated
- How is the surgery performed
- What are alternative procedures, and why do we choose this one?
- Intra- + Post-surgical complication