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