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12.12.10 Abdominal teaching

HDU admission checklist
  • Level 1 (Step Up/Step Down Unit)
    • Patients at risk of deterioration or those recently relocated from Level 2/3 care whose needs can be met on an acute ward with additional advice and support from specialist teams
  • Level 2 (HDU)
    • Patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care and those stepping down from Level 3 care or up from Level 1 / ward care
    • Level 2 criteria examples
      • A need for more than 50% inspired oxygen
      • Non-invasive ventilation i.e. CPAP or BiPAP
      • Invasive pressure monitoring
      • Haemodynamic instability due to hypovolaemia, haemorrhage, sepsis or other cause
      • Central nervous system depression that threatens to compromise airway and protective reflexes
      • Impaired renal, electrolyte or metabolic function
      • Patients requiring extended postoperative care (i.e. major elective surgery, intraoperative complications)
  • Level 3 (ICU)
    • Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems
    • This level includes complex patients requiring support for multi-organ failure
    • Level 3 criteria examples
      • Respiratory failure from any cause that requires invasive ventilation support, increasing levels of non-invasive ventilation support or extracorporeal respiratory support
      • Surgical high risk patients who, in the context of their medical history and co-morbidity factors, are likely to require advanced respiratory and monitoring/support of organ systems
      • Continuous intravenous medications and supplementary oxygen / airway monitoring to control seizures
      • Vasoactive drugs used to support arterial pressure or cardiac output or intra-aortic balloon pump support
      • Patients resuscitated following cardiac arrest where intensive care is considered clinically appropriate
      • Acute renal replacement therapy with other advanced levels of organ support
      • Patients who have sustained an irreversible brain injury and for whom death is imminent, who meet the clinical criteria for a potential organ donor and/or the family has made an enquiry regarding organ donation during end of life discussions

Bowel cancer red flags
  • Persistent rectal bleeding for 6 weeks without anal symptoms (>60 yrs)
  • Change in bowel habit to looser stools/increased frequency for 6 weeks (>60 yrs)
  • Change in bowel habit to looser stools/increased frequency and rectal bleeding (>40 yrs)
  • Palpable right iliac fossa mass
  • Palpable rectal mass (intraluminal)
  • Unexplained iron deficiency anaemia (Hb<11g/dL men, <10g/dL non-menstruating women)
  • Features indicating a low risk of colorectal cancer include:
    • Rectal bleeding with anal symptoms
    • Rectal bleeding with an external visible cause, such as:
      • prolapsed piles
      • rectal prolapse
      • anal fissures
    • Change in bowel habit (decreased frequency of defaecation and harder stools) for less than 6 weeks
    • Abdominal pain without iron deficiency anaemia or palpable abdominal mass
    • Abdominal pain without evidence of intestinal obstruction

Common cancer markers

  • Alpha fetoprotein (AFP)
    • Germ cell tumor, hepatocellular carcinoma
  • CA15-3 
    • Breast cancer
  • CA27-29
    • Breast cancer
  • CA19-9
    • Mainly pancreatic cancer
    • Also colorectal cancer and other types of gastrointestinal cancer
  • CA-125
    • Mainly ovarian cancer
    • May also be elevated in for example endometrial cancer, fallopian tube cancer, lung cancer, breast cancer and gastrointestinal cancer
    • May also increase in endometriosis
  • Carcinoembryonic antigen
    • Gastrointestinal cancer, cervix cancer, lung cancer, ovarian cancer, breast cancer, urinary tract cancer
  • Glial fibrillary acidic protein (GFAP)
    • Glioma (astrocytoma, ependymoma)
  • Prostate-specific antigen
    • Prostate
  • Thyroglobulin
    • Thyroid cancer (but not in medullary thyroid cancer)

Common post-operative complications

  • Immediate
    • Primary haemorrhage
    • Basal atelectasis
    • Shock
    • Low urine output
  • Early
    • Acute confusion
    • Nausea and vomiting
    • Fever
    • Secondary haemorrhage
    • Pneumonia
    • Wound or anastomosis dehiscence
    • Deep vein thrombosis (DVT)
    • Acute urinary retention
    • Urinary tract infection
    • Post-operative wound infection
    • Bowel obstruction due to fibrinous adhesions
    • Paralytic Ileus
  • Late
    • Bowel obstruction due to fibrous adhesions
    • Incisional hernia
    • Persistent sinus
    • Recurrence of reason for surgery, eg malignancy

Post-operative fever
  • Days 0 to 2
    • Mild fever (T <38 °C) (Common)
    • Tissue damage and necrosis at operation site
    • Haematoma
    • Persistent fever (T >38 °C)
    • Atelectasis: the collapsed lung may become secondarily infected
    • Specific infections related to the surgery, eg biliary infection post biliary surgery, UTI post-urological surgery
    • Blood transfusion or drug reaction
  • Days 3-5
    • Bronchopneumonia
    • Sepsis
    • Wound infection
    • Drip site infection or phlebitis
    • Abscess formation, eg subphrenic or pelvic, depending on the surgery involved
    • DVT
  • After 5 days
    • Specific complications related to surgery, eg bowel anastomosis breakdown, fistula formation
  • After the first week
    • Wound infection
    • Distant sites of infection, eg UTI
    • DVT, pulmonary embolus (PE)

Surgical management of colorectal cancer
  • Colon surgery
    • Open colectomy
    • Laparoscopic-assisted colectomy
    • Polypectomy and local excision
  • Rectal surgery
    • Polypectomy and local excision
    • Local transanal resection (full thickness resection)
    • Transanal endoscopic microsurgery (TEM)
    • Low anterior resection
    • Proctectomy with colo-anal anastomosis
    • Abdominoperineal (AP) resection
    • Pelvic exenteration
  • Colorectal cancer metastases
    • Radiofrequency ablation
    • Ethanol (alcohol) ablation
    • Cryosurgery (cryotherapy)
    • Hepatic artery embolisation

Quinine
  • P. falciparum
    • Inhibits hemozoin biocrystallization => aggregation of cytotoxic heme
    • Free cytotoxic heme accumulates in the parasites, causing their deaths
  • Muscle cramps
    • Raises the threshold for acetylcholine at the motor end plate

Notes

  • Surgery => Pain on deep inspiration => Atelectasis
  • Retroperitoneal organs tend to cause back pain
  • Pain out of proportion to injury suggests cancer
  • Adhesions from previous surgery => Obstruction
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