PAEA Surgery Study Guide | PAEA Surgery Blueprint Gastrointestinal/Nutritional ; ABDOMINAL PAIN.

PAEA Surgery Blueprint Gastrointestinal/Nutritional (50%) ABDOMINAL PAIN Acute Abdomen  Caused by Perforation o Sudden onset o Constant, generalized, very severe o Tenderness, msl guarding, rebound, silent abdome ...

PAEA Surgery Blueprint Gastrointestinal/Nutritional (50%) ABDOMINAL PAIN Acute Abdomen  Caused by Perforation o Sudden onset o Constant, generalized, very severe o Tenderness, msl guarding, rebound, silent abdomen o Pt lies still o Diagnosis  Free air under diaphragm in upright Xray o Treatment  Emergency surgery  Caused by obstruction of a narrow duct o Ureter, cystic, common o Sudden onset of very severe colicky pain o Location according to source o Pt constantly moving  Caused by inflammatory process o Gradual onset (6-12 hrs) o Constant pain, starts general but becomes localized o Systemic signs (fever, leukocytosis) Treatment for generalized acute abdomen = exploratory laparotomy HEARTBURN/DYSPEPSIA Gastroesophageal Reflux Disease (GERD)  Basics o Transient relaxation of LES (incompetent) => gastric acid reflux => esophageal mucosal injury o Complications  Esophagitis, esophagus stricture, esophageal adenocarcinoma  Barrett’s esophagus: esophageal squamous epithelium replaced by precancerous metaplastic columnar cells  Manifestations o Hallmark = heartburn  Retrosternal, postprandial o Regurgitation o Dysphagia o Cough at night o “ALARM” sx  Dysphagia, odnophagia, weight loss, bleeding  Suspect malignancy  Diagnosis o Clinical o Endoscopy  Often used first o Esophageal manometry  Done is endoscopy normal o 24hr ambulatory pH monitoring  Gold standard 1 PAEA Surgery Blueprint  Not done often  Management o Stage 1: Lifestyle Modifications  Elevation of the head of the bed  Avoid recumbence for three hours after eating  Eat small meals  Avoid certain foods (fatty, spicy, citrus, chocolate, caffeine)  Decrease fat & ETOH intake  Weight loss  Smoking cessation o Stage 2: As Needed” Pharmacological Therapy  Antacids  OTC H2 receptor antagonists (“-tidine”)  ***If “ALARM” sx, do endoscopy o Stage 3: Scheduled Pharmacologic Therapy  Meds  H2RA  Proton Pump Inhibitors (“-azole”) o Drug of choice in severe disease  Cisapride  Nissen Fundoplication  If refractory Achalasia  Basics o Loss of Aurbach’s plexus => increased LES pressure  Failure of LES relaxation  Manifestations o Dysphagia to BOTH solids & liquids o Weight loss o Regurgitation of undigested food o Chest pain o Cough  Diagnosis o Esophageal manometry (gold standard)  Increased LES pressure (> 40 mmHg) o Double-contrast esophagram  Bird’s beak appearance  Management o Decrease LES pressure  Botox injection (temporary relief)  Nitrates  CCBs  Dilation of LES  Esophagomyomectomy JAUNDICE Basics  Yellowing of skin, nail beds, sclera o Due to tissue bilirubin distribution  *Not a disease but a sign of disease  Occurs when bilirubin > 2.5 mg/dL 2 PAEA Surgery Blueprint Types  Hemolytic o Low level (6-8) o Elevated bilirubin is unconjugated (indirect) o Work up should determine what is causing issue with RBCs  Hepatocellular o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (modest) o Hepatitis (direct workup this way)  Obstructive o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (v. high) o Workup => U/S  Look for obstruction HEMATEMESIS Denotes upper GI source Diagnosis: UGI endoscopy Corrosive Esophagitis  Basics o Etiology: ingestion of corrosive substance  Manifestations o Odynophagia, dysphagia, hematemesis, dyspnea  Diagnosis o Endoscopy  Management o Supportive o Pain meds o IV fluids Boerhaave’s Syndrome  Basics o Full thickness rupture of distal esophagus o Associated with repeated vomiting (bulimia), iatrogenic perforation  Manifestations o Retrosternal chest pain worse with deep breathing and swallowing o Hematemesis o PE: crepitus on chest auscultation due to pneumomediastinum  Diagnosis o Chest CT  Management o Surgical repair Mallory-Weiss Syndrome (Tears)  Basics o UGI bleeding due to longitudinal mucosal lacerations @ gastroesophageal junction or gastric cardia (superficial) o Sudden rise in intragastric pressure or gastric prolapse into esophagus  Persistent retching/vomiting  Alcohol binge  Bulimia 3 PAEA Surgery Blueprint  Manifestations o Retching/vomiting => hematemesis after an alcohol binge o Melena, hematochezia, syncope, ab pain, hydrophobia  Diagnosis o Upper endoscopy  Management o Supportive if no active bleeding o Active bleeding => epi injection, sclerosing agent, band ligation, hemo-clipping or balloon tamponade