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13.01.09 Abdominal surgery

Proctalgia fugax
  • Severe, episodic, rectal and sacrococcygeal pain
  • Caused by cramp of the pubococcygeus or levator ani muscles
  • Most often occurs in the middle of the night and lasts from seconds to minutes
    • Differential diagnosis of levator ani syndrome : presents as pain and aching lasting twenty minutes or longer
  • Patient feels spasm-like, sometimes excruciating, pain in the anus, often misinterpreted as a need to defecate
  • Simultaneous stimulation of the local autonomic system can cause erection in males
  • Thought to be a disorder of the internal anal sphincter or that it is a neuralgia of pudendal nerves
  • It is recurrent and there is also no known cure


Mittelschmerz
  • Characterized by lower abdominal and pelvic pain that occurs roughly midway through a woman's menstrual cycle
  • The pain can appear suddenly and usually subsides within hours, although it may sometimes last two or three days
  • In some women, the mittelschmerz is localized enough so that they can tell which of their two ovaries provided the egg in a given month


Choledocholithiasis

  • ERCP probe can't get past + goes up the pancreatic duct
    • => Acute pancreatitis
  • Do an MCRP first
    • The stone may pass by itself anyway
  • Do an immediate cholecystectomy to avoid recurrence


Cholelithiasis complications

  • Carcinoma
  • Empyaema
  • Mirizzi's syndrome
    • Gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the CBD or CHD, resulting in obstruction and jaundice
  • Perforation
  • Mucocele
  • Cholecystitis
  • Biliary colic


Charcot's cholangitis triad
  • Combination of jaundice; fever, usually with rigors; and right upper quadrant abdominal pain
  • Indicates ascending cholangitis


Peptic ulcer causes
  • Zollinger–Ellison syndrome (ZES)
    • Caused by a non–beta islet cell, gastrin-secreting tumor of the pancreas that stimulates the acid-secreting cells of the stomach to maximal activity
      • => Gastrointestinal mucosal ulceration
    • ZES may occur sporadically or as part of MEN 1
  • Curling's ulcer
    • Acute peptic ulcer of the duodenum resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa
  • Cushing ulcer
    • Gastric ulcer produced by elevated intracranial pressure
    • Stimulation of vagal nuclei due to the increased intracranial pressure leads to increased secretion of gastric acid
      • The vagus nerve releases acetylcholine, which stimulates the M3 receptor on the parietal cell
      • Activates the second messenger to stimulate IP3/Ca2+ to stimulate the Hydrogen/Potassium ATPase pump which will increase gastric acid production


SBO

  • Outside (by far the most common)
    • Volvulus
    • Adhesion
    • Hernia
  • Wall
    • Crohns
    • TB
    • Tumour
  • Lumen
    • Stone
    • Foreign body


Obstruction

  • Large bowel can't decompress due to the iliocaecal valve
    • => More serious
  • But small bowel looks worse clinically
    • Vomiting
  • Cancer is most common in the rectum or sigmoid colon, but these sites are unlikely to cause obstruction
    • More likely higher up


Notes

  • Tumours can cause hernias via obstruction
    • Treat the underlying cause!
  • CCK => Gallbladder contraction
  • ERCP scopes are side-viewing to aid cannulation of the CBD
  • Courvosier: Obstructive jaundice + palpable gallbladder is not gallstones (which cause a shrunken, fibrosed gallbladder)
  • Gastric, but not duodenal ulcers may be malignant
  • People with duodenal ulcers get fat, as eating => bile => relief
  • Cancer
    • Sarcoma = Connective tissue
    • Carcinoma = Epithelial tissue
  • Ulcers erode posteriorly to the gastroduodenal artery
  • Kidney stones aren't painful until they enter the ureter
  • Pfannenstiel incision (for gynae stuff) can => incisional hernia above the scar, from the longitudinal second incision
  • If a foreign body has passed the cricopharyngeus (throat) it should pass safely
  • Ursodeoxycholic acid
    • Gallstone treatment
    • But takes 2 years, and they come back
  • Splenectomy => OPSI
    • Overwhelming post-splenectomy infection
  • Only 20% of UC Pts needs surgery
    • Sub-total colectomy (misnomer!)
    • Join caecum to rectum
  • Leakage rate for primary anastomosis is 12%
    • Very serious if it happens (faecal peritonitis)
    • Do defunctioning iliostomy / Hartmann's
  • Ileal conduit for bladder removal
  • 5% of bowel cancers have a concurrent or metachronous second primary
  • Splenic artery embolisation used in trauma
  • Hypersplenism in ITP
    • Not the same as splenomegaly
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