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


    • 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


    • 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


    • Outside (by far the most common)

      • Volvulus

      • Adhesion

      • Hernia

    • Wall

      • Crohns

      • TB

      • Tumour

    • Lumen

      • Stone

      • Foreign body


    • 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


    • 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