1. LMCC Review General Surgery Dr. S. Tadros

2. Review Topics • Colo-rectal cancer/GI bleeding • Diverticulitis/Appendicitis/IBD • Peptic Ulcer • Bowel Obstruction • Breast Disease • Hernias • Thyroid disease • Biliary Disease/Pancreatitis/Jaundice • Trauma • Peri-anal Disease

3. Colon Cancer • Risk Factors • Genetics 6% • Presentation • Investigations • Treatment

4. Risk Factors Presentations • Diet • Genetics • Age • IBD’s • Anemia (R) • Obstruction (L) • RLQ Pain • Change in Bowel Habits • Rectal Bleeding • Perforation

5. Adenoma-Carcinoma Sequence • Sporadic - >94% • FAP - <1% • HNPCC - 5%

6. Investigations • FOBT • Digital Rectal exam • Barium Enema • Colonoscopy • CT Scan / MRI • U/S

7. Screening • FOBT annually • Screening Colonscopy: Age > 50 q10 yrs. Exception: Family History History of polyps IBD

8. Treatment(depends on presentation) • Nothing • Chemo-radiation therapy (adjuvant & neo-adjuvant) • Surgery, Surgery, Surgery • Resection (anastomosis) • Resection (stoma i.e.:Hartman’s Procedure) • Delayed reconstruction • Palliative procedures • Intestinal by-pass

9. Surgical resections

10. Diverticulitis • Pathophysiology Increased luminal pressure

11. Risk Factors • High Fat • Geography • Genetics • Weight • Low Fiber (Not)

12. Presentation • Diverticulitis • Phlegmon (micro-perf) • Perforation • Abscess (micro-perf) • Free perforation (macro-perf) • Bleeding • Obstruction • Chronic disease (Sigmoid colon) • Fistulas to adjacent organs

13. Epidemiology • >70% after age 80 • 30% recurrence after 1st attack • >50% recurrence after 2nd attack • Complications usually at first attack

14. Diverticulitis • CT abd/pelvis • Antibiotics • Analgesics • Non-operative treatment • Barium enema/Colonscopy 4-6 weeks post D/C • Surgery after 2 or 3 attack

15. Treatment • ABC’s • Fluids • Antibiotics • Resection (+/- stoma) • Hartman’s (urgent) • Primary anastamosis (elective) • Management of complications

16. Appendicitis • Anatomical variation Accounts for varied presentations and degree of systemic illness

17. Disease of the young • 6% of population • Most common between 20-30 years of age • Most common cause of acute abdomen • Caused by luminal obstruction • Fecolith • Peyer’s patch (distal ileum in the young)

18. Presentation • Vague abdominal pain • Peri-umbilical to localization RLQ • N/V & diminished appetite • Fever / leukocytosis / tachycardia • Progressive symptoms • Phlegmon / abscess / free perforation

19. Investigations • CLINICAL DIAGNOSIS • U/S in females of child bearing age • BHCG important • CT (If you can’t take a good Hx/Px) • Dx Laparoscopy • Observation • No antibiotics

20. Treatment • Surgery • Perc drain • abscess • Antibiotics alone (rarely) • Indicated in delayed diagnosis • Interval appendectomy • After percutaneous drain • After antibiotics

21. Acute Appendicitis

22. Rectal Bleeding • Neoplasm…Benign Vs. Malignant • Diverticular disease • Angiodysplasia • IBD • Infectious • Traumatic • Ano-rectal disorders

24. Upper GI Bleed • Esophageal Varices • Mallory Wiese tear • Peptic Ulcer/Benign or malignant/gastric or Duodenal • Gastritis

25. Upper GI bleed • Resuscitation • Upper Endoscopy/Diagnostic & therapeutic • Surgery

26. PUD • Gastric or Duodenal • Hypersecretion of acid and/or failure of protective mucosal defenses • Symptoms include pain, vomiting, bleeding • Cancer associated with gastric ulcers in older patients

27. Indications for surgery • Intractability (rarer than emergency indications) • Obstruction (pyloric obstruction) • Bleeding (post. duodenum) • Perforation (ant. duodenum) • NOTE: gastric perforations need to R/O cancer

28. Medical Therapy • H2 blockers • PPI • H-Pylori therapy • Endoscopy (Dx and Bx and R/O pre-malignant lesions) • Reduce lifestyle risks (smoking / caffeine etc…)

29. Perforated Ulcer • Most common location - anterior proximal duodenum • Gastric or duodenum • Many be contained by surrounding anatomy • Acute onset abd pain • Sepsis often delayed up to 24 hours • Chemical peritonitis - then bacterial • May present localized RLQ pain • Follows right para-colic gutter

30. Investigations • Upright AXR (best test) • Decubitus • Must be upright / decubitus for at least 10 minutes • Physical exam and history • Diffuse peritonitis with discrete sudden onset • Lab tests (non-specific) • CT abd - most sensitive for free air • Rules out other etiology

31. AXR • Free Air (Upright)

32. Treatment • Fluids • Antibiotics • Correction metabolic derangement's • Correction of coagulation defects • Surgery, Surgery, Surgery • Non-operative treatment in very specific cases

33. Surgical Therapy • Graham’s patch • Omental patch • Serosal patch • jejunum • Billroth I and Billroth II • Bx for cancer & H.pylori • Esp.. gastric for Ca

34. Omental patch

35. Gastroduodenal artery Bleeding Ulcer • 3 point vessel oversew Gastroepiploic artery

36. Billroth I

37. Billroth II Duodenal stump stomach Jejunum (loop) Transverse colon

38. Mesenteric Ischemia • The Great Pretender

39. Risk Factors • Vascular disease • Run of the mill type (CAD / PVD) • Embolic risk factors (a-fib etc…) • Autoimmune diseases (vasculitis) • Prolonged obstruction • Trapped loop • Volvulus • Dehydration • Inotropes (iatrogenic)

40. Presentation • Sub - acute or acute abdominal pain • Pain vs physical findings • Diffuse non-localized abd pain • Volume contracted • Shocky / toxic • Soft abd • Acidosis • Altered LOC

41. Investigations • AXR • pneumotosis, thumb printing • Lactate / CBC / CR / BUN / ABG’s • Non-specific • ECG • A-fib • CT abd • Angiogram

42. Pneumatosis intestinalis

43. Treatment • Reverse underlying cause • Volume restoration • Stop inotropes • Embolectomy / thrombolysis • Correct coagulation defects • Pre-op concern • Surgery (resection) • Nothing

44. Exam key points • Abdominal pain and physical finds do not correlate • Source of embolus or reason for thrombosis • May be acidotic (blood work)

45. Small bowel Obstruction - Etiology • Adhesions- 60% • Hernias - 10-15% • Masses (benign and malignant) - 10-20% • Volvulus - 3% • Intususception - 1-2% • Strictures (ischemic / IBD / other) - 5% • FB - 2% • Gall stone - 2-3%

46. Symptoms • Vomiting / Nausea • Abd distention • Decreased stool and flatus • Dehydration • Antecedent nausea and cramping with meals • Abd pain (cramping) • Localized means advanced disease

47. Diagnosis • History and Physical • AbXR • CT abd/pelvis • Antegrade small bowel enema • Enterosocopy • Small bowel scope seeking tumor • Not indicated in complete obstruction