General Surgery - Topics

Created by jdobson 

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Gastric Adenocarcinoma

Sx: Anorexia, weight loss, vague epigastric discomfort, early satiety
Dx: Endoscopy + biopsy
Tx: Surgical

Mechanical Intestinal Obstruction

RF: previous laparotomy (adhesions)
Sx: colicky abdominal pain, vomiting, abdo distension, no passage of gas or feces
Signs: high pitched bowel sounds
Dx: Xray dilated loops of bowel + air-fluid levels
Tx: NPO, NG suction, IV fluids, hope for spontaneous resolution

Appendicitis

Sx: Anorexia, periumbilical pain progressing to RLQ
Signs: Febrile, peritoneal signs (guarding, rebound)
Dx: CBC (leukocytosis), CT scan
Tx: Surgery

Colon Cancer

Sx: RIGHT - anemia
LEFT - bloody stools, narrow
Dx: Colonoscopy + biopsy
Tx: Surgery +/- preop chemo/radiation

Pseudomembranous Enterocolitis

AKA C. diff
Sx: Profuse watery diarrhea, abdo pain
Signs: Febrile
Labs: Leukocytosis
Dx: Toxin in stool
Tx: Metronidazole (Vanco 2nd line)

Anal Fissure

Sx: Acute pain ONLY surrounding BM, blood streaks on stool/tissue
Signs: Fissure (anterior or posterior), if lateral suspect Crohns or other (Syphilis, TB, leukemia)
Tx: Stool softeners, bulking fiber, Sitz bath, Nitroglycerine 0.2% ointment QID x 4-6wks, surgery (lateral internal sphincterotomy)

Perforation + acute abdomen
X-ray finding

= Free air under the diaphragm - Diagnostic!

Diverticulitis

RF: older
Sx: Acute abdominal pain LLQ
Signs: Fever, leukocytosis, periotenal signs
Dx: CT scan
Tx: NPO, IV fluids, Abx
Surgery if not improving, elective surgery is >2 attacks

Mesenteric Ischemia

Clot lodged in superior mesenteric artery
RF: CAD, Afib, elderly
Sx/Signs: Acute abdomen, acidosis/sepsis (late)
Tx: Arteriogram and embolectomy

Biliary Colic

= transient occlusion of cystic duct by stone
Sx: Colicky pain RUQ, often triggered by fatty meal, N/V
Dx: U/S
Tx: Elective cholecystectomy

Acute Cholecystitis

= biliary colic, but stone remains in cystic duct and an inflammatory process develops in the obstructed gallbladder
Sx: Constant pain (no longer colicky)
Signs: Fever, Leukocytosis, peritoneal irritation signs RUQ
Dx: U/S (stones, thick-walled gallbladder, pericholecystic fluid)
Tx: NPO, IV fluids, Antibiotics... may cool down and have elective chole, if not emergent (diabetics, men)

Acute Ascending Cholangitis

= stones reaching the common bile duct causing obstruction and ascending infection
Sx: pts much sicker than cholecystitis
Signs: High fever, leukocytosis, high ALP
Tx: IV Abx and emergency decompression of common duct by ERCP

Acute Pancreatitis

RF: Gallstones, Alcohol
Sx: Constant epigastric pain, N/V
Signs: Epigastric tenderness, Amylase/Lipase elevated
Tx: NPO, IV fluids
Note: Edematous type then progresses to hemorrhagic (predicted by Ranson's criteria), become systemically unwell
Complications: Pancreatic abscess, pseudocyst

Chronic Pancreatitis

= pts with frequent bouts of acute pancreatitis develop calcified burned-out pancreas
Sx/Signs: Steatorrhea, new-onset diabetes, constant epigastric pain
Tx: Pancreatic enzymes treats steatorrhea, manage diabetes as per usual, pain is usually refractory to tx

Fibroadenoma

RF: young women
Sx/Signs: Firm, Rubbery, Mobile mass (solitary mass), painless, does NOT change with menstrual cycle
Dx: FNA or U/S
Tx: None or elective removal

Cystosarcoma phyllodes

RF: late 20s
Sx/Signs: Slow-growing, become very large and distort breast, mobile
Dx: Core bx
Tx: Removal bc malignant potential

Fibrocystic disease

Aka mammary dysplasia, cystic mastitis
Sx/Signs: 30s-40s, disappears with menopause, bilateral breast tenderness related to menstrual cycle with lumps that come and go
Dx: Mammogram to r/out tumour (requires work-up if a persisting mass)

Intraductal papilloma

20s-40s
Sx: bloody nipple discharge
Dx: mammogram to r/out other, will not show papilloma (small), galactogram
Tx: Surgical resection

Breast Abscess

ONLY in lactating women
Tx: I and D

Breast Cancer

RF: estrogen exposure (early menarche, late menopause), nulliparity,
Types: Infiltrating ductal carinoma (standard form), also inflammatory (worse prognosis), lobular, medullary, mucinous
Sx/Signs: Ill-defined, fixed mass, retraction of overlying skin, "orange peel" skin, recent retraction of nipple, eczematoid lesions of areola, palpable axillary nodes
Dx: Mammogram (irregular area incr density with fine microcalcifications), core bx
Tx: Resection (lumpectomy vs mastectomy) w axillary node sampling, radiation, chemotherapy, adjuvant systemic therapy (hormonal - tamoxifen for pre-menopausal, anastrozole for post-menopausal)

Thyroid Nodules

If EUTHYROID: FNA--> thyroid lobectomy --> total thyroidectomy if needed
If HYPERTHYROID: nuclear scan --> radioactive iodine/surgical excision

Surgical Hypertension DDx

Primary Hyperaldosteronism (Conn's disease)
Pheochromocytoma
Coarctation of aorta
Renovascular Hypertension (fibromuscular dysplasia in young women, atherosclerotic in older)

Acute Bacterial Parotitis

Post-op complication
Painful swelling of parotid gland with fever, tender, swollen, erythematous gland and purulent discharge through parotid duct
RF elderly and dehydrated patients
Prevent with adequate fluid hydration and oral hygiene
Most often Staph aureus

Management of DVT

Goal is not to lyse the clot, but to prevent extension of it and development of further clots
Tx with therapeutic dose of unfractionated LMWH for bridging then at least 3 months of Warfarin
(Warfarin takes 4-5 days to reach therapeutic levels, thus start with Heparin first)
Do not use tPA, no benefit and goal is not lysis of clot

Dumping Syndrome

Common post-gastrectomy complication
Rapid emptying of hypertonic gastric content into duodenum and small intestine causing autonomic reflexes and fluid shift
Sx: Postprandial abdominal cramps, weakness, light-headedness, diaphoresis
Dx: Clinical (could use provocative tests and contrast x-ray studies to demonstrate rapid gastric emptying
Tx: Diet change (small, frequent meals, avoid simple CHO), usually Sx diminish over time... if resistant: octreotide or reconstructive surgery

Necrotizing Surgical Incision Infection

Signs: intensive pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, tense edema outside involved skin, +/- crepitus, +/-fever/hypotension/tachycardia
Tx: Urgent surgical exploration and debridement, deep wound culture at time of surgery, negative pressure wound therapy

Paget's disease of the breast

Form of breast cancer with:
- Discharge from the nipple
- Eczematous changes of the nipple most characteristic
Dx: biopsy

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