25.2 Cardiac Risk Factor and Surgery
Recent myocardial infarction (MI) without percutaneous coronary intervention (PCI)
At least 2 months should lapse before considering elective noncardiac surgery
Recent MI with PCI
Elective noncardiac surgery should be delayed for at least:
Bare metal stent
DES (drug-eluting stent)
Congestive heart failure
Surgery should be performed when the patient is euvolemic.
aIf risk of further delay of elective surgery is higher than cardiac risk, elective surgery can be considered earlier (after at least 3 months of DES placement, but not less than 1 month).
Additional info: Perioperatively, continuing dual-antiplatelet therapy, or discontinuing platelet-receptor blocker and giving ASA (acetylsalicylic acid) alone, is determined on a case-by-case basis. If surgery needs to be done within 4 to 6 weeks of stent placement, dual-antiplatelet therapy needs to be continued preoperatively unless the risk of bleeding is considered higher than the risk of stent thrombosis.
25.4 Inguinal and Femoral Hernias
Increased abdominal pressure: Obesity, chronic cough, constipation, etc.
Poor connective tissue strength: Smoking, diabetes, unhealthy diet, etc. Hernia anatomy:
Inguinal triangle is bordered by inguinal ligament, inferior epigastric vessels, and lateral border of rectus abdominis muscle.
Indirect inguinal hernia
Defect in the deep inguinal ring (entry to the inguinal canal)a
• Hernia may completely traverse the inguinal canal and descend into the scrotum.
Direct inguinal hernia
Defect in fascia transversalis of the abdominal wall, which acts as the posterior wall of the inguinal canal
Defect in the femoral ring (entry to the femoral canal)a
aNeurovascular structures pass through femoral and inguinal canals. Due to the above risk factors, the ring and canal may get bigger and weaker, which allow intra-abdominal contents like mesentery or intestines to pass through.
For reducible inguinal or femoral hernias, elective repair is usually offered. These are usually asymptomatic or can be mildly tender in some cases.
Irreducible hernias are incarcerated hernias, which can be complicated by strangulation
Longstanding incarcerated hernias need to be repaired electively.
For acutely incarcerated hernia, NSIM is urgent surgery. In uncomplicated acutely incarcerated hernia, manual reduction may be attempted followed by elective repair.
Trapped hernia → increased venous congestion → edema → increased inflammation → more edema → decreased arterial blood supply and strangulation.
Commonly associated with bowel obstruction
May lead to intestinal necrosis
This usually has severe pain and signs of sepsis.
As a rule in, explorative laparotomy is indicated if any of the following is present:
Signs of peritonitis
Generalized abdominal guarding, rigidity, or rebound tenderness
Signs of intestinal ischemia
Air in the bowel wall (pneumatosis intestinalis)
Signs of perforation
Free air under the diaphragm
Hemodynamic instability with high suspicion for intra-abdominal source
For this chapter, these are called “abdominal danger signs.” Looking out for these during any patient encounter is very important, so remember these danger signs.
25.5 Gastrointestinal Tract
LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
Localized tenderness in the following region
Think of the following
Gastric pathology, pancreatitis, duodenitis, etc.
Cholecystitis, cholangitis, hepatitis, etc.
Appendicitis, ileitis (Crohn’s disease), etc.
Splenic rupture, inflammation of descending colon, etc.
Diverticulitis, sigmoiditis, etc.
Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
25.5.1 Bowel Obstruction
Paralytic (adynamic) ileus
Mechanical small bowel obstruction
Postoperative (most common within 1 week of surgery)
Peritonitis, pancreatitis, local abdominal wound infection, dyselectrolytemia, etc.
Hernia, Adhesions,a Volvulus (cecal),b Intussusception,c Neoplasm, and Gallstone ileus
Hyperactive or borborygmic in early stages; hypoactive in late phase
First initial diagnostic step is X-ray. CT may be done if further information is needed.
Radiologic findings Both small and large bowels are involved (air in the distal colon and rectum typically signals a diff use pathology)
An upright view of the abdomen showing multiple air-fl uid levels in nondilated small and large bowels including the rectum (red arrow) indicating ileus.
Abdominal X-ray. Source: Abdominal pathologies and findings. In: Shi Y, Sohani Z, Tang B et al., eds. Essentials of Clinical Examination Handbook. 8th ed. Thieme; 2018.
Usually small-bowel involvement (and distal-bowel collapse)
A supine X-ray demonstrating dilated small bowel. To diff erentiate small bowel gas from colonic distention, look at the folds that extend all the way across the lumen, indicating that it is the small bowel. Also, the large bowel only has four parts: ascending, transverse, descending, and sigmoid (a square on the edges Π).
Source: Pathology. In: Gunderman R, ed. Essential Radiology. Clinical Presentation, Pathophysiology, Imaging. 2nd ed. Thieme; 2000.
NPO + IV (intravenous) fl uids + NG (nasogastric) tube decompressiond
If any of the “abdominal danger signs” is present, NSIM is explorative laparotomy.
Avoid opiates and immobility (encourage ambulation)
Surgical exploration, if not improving
aPostoperative adhesions can occur as early as within 1 week of surgery.
bVolvulus of sigmoid colon can cause large bowel obstruction. It typically occurs in an elderly patient when the sigmoid colon gets twisted on its axis. It has a “coffee bean” appearance on X-ray.
NSIM is flexible sigmoidoscopy (to untwist the bowel) and a rectal tube.
cFor intussusception, see Chapter 22 (Pediatrics). Do you remember what is the treatment?
dNG tube is most helpful in patients with pain due to stomach distention and frequent or largevolume vomiting.
I am HAVING mechanical bowel obstruction.
25.5.2 Ogilvie’s Syndrome (Colonic Pseudo-obstruction)
Background: Acute or subacute nonobstructive dilation of large bowel due to impairment of the enteric autonomic nervous system.
Risk factors: Typically occurs in older patients after hospitalization, surgery, etc.
Presentation: Look for large-bowel distention with minimal involvement of small bowel. Patients usually appear comfortable despite significant abdominal distention. Some patients can have nausea, vomiting, and even diarrhea.
Best SIDx: CT abdomen
or water-soluble contrast enema (to rule out obstructive lesions). Plain abdominal X-ray is helpful in follow-up.
Management: Conservative, NPO + IV fluids + NG tube decompression as needed. If cecal diameter is > 12 cm or if conservative management fails, consider neostigmine. (!) If neostigmine fails, NSIM is colonoscopic decompression. If this fails, next is surgical management with cecostomy.
Complication: Ischemia and perforation (If any of the abdominal danger sign develops, NSIM is explorative laparotomy with colonic resection and ileostomy).
25.5.3 Intestinal and Gastric Perforation
Etiology: Any severe gastric or intestinal pathologycan cause perforation.
Presentation: Generalized guarding, rigidity, and/or rebound tenderness. In generalized peritonitis, even a little movement can cause significant pain.
In suspected visceral perforation, first SIM is to start IV fluids and antibiotics.
First SIDx is upright abdominal/CXR. Look for air under the diaphragm.
Do not choose CT scan as the best initial test.
NSIM—immediate explorative laparotomy.
25.5.4 Abdominal Compartment Syndrome
Background: Complicated abdominal surgery, especially requiring administration of large volume of fluids, can lead to severe edema of the abdomen and its contents, resulting in increased intra-abdominal pressure. Other risk factors include early closure of abdominal wound, severe burns, liver transplantation, etc.
Increased abdominal pressure can cause compression of
Shortness of breath
Vena cava and renal vein
Decreased cardiac preload/output and hypotension
Work-up: Intra-abdominal pressure can be measured by different methods. Most commonly used is intrabladder pressure measurement (look for pressure of ≥ 20-25 mmHg).
Treatment: Surgical decompression and temporary abdominal closure with mesh or plastic to protect the bowel. Primary closure is done after 48 to 72 hours.
Pathophysiology: Obstruction of appendiceal lumen can lead to inflammation ± infection. Causes of obstruction include lymphoid hyperplasia (due to viral infection), fecalith, parasites, etc.
(!) One potential side effect of neostigmine is life-threatening bradyarrhythmia.
Presentation: Classic sequence of symptom development: anorexia → vague periumbilical pain → RLQ (right upper quadrant) sharp and severe pain (localized signs of peritonitis, such as rebound tenderness and guarding in RLQ, are usually present at this stage). Other symptoms are nausea, vomiting, low-grade fever, and elevated white blood cells (WBCs).715
Clinical signs of appendicitis:
Deep palpation in LLQ elicits pain in RLQ (increased pressure in the colon is felt in the inflamed appendix)
Extension of hip causes pain in RLQ
Internal rotation of hip elicits pain in RLQ
Abbreviations: LLQ, left lower quadrant; RLQ, right lower quadrant.
No need for radiologic imaging in classic presentation. NSIM—IV antibiotics directed against GI (gastrointestinal) pathogens, followed by laparoscopic appendectomy.
In atypical presentation, abdominal CT scan can confirm the diagnosis.
During surgery, even if appendix looks grossly normal, it should be removed (microscopic appendicitis might be present).
Complication: Appendiceal abscess can develop if patient presents late (e.g., > 5 days of hx suggestive of appendicitis):
In an ill-appearing patient, NSIM is appendectomy.
In a well-appearing patient, either early appendectomy OR conservative management followed by late appendectomy can be done (antibiotics ± percutaneous drain, followed by appendectomy after approximately 6 weeks).
Background: Enlarged anorectal veins that commonly occur due to prolonged history of constipation and straining during defecation. Other causes include pregnancy and increased portal pressure in cirrhosis (cirrhosis patients have mostly internal hemorrhoids).
Presentation: Usually painless bleeding associated with defecation. (!) External hemorrhoids may be painful (somatic innervation), whereas internal hemorrhoids are typically painless (even when they cause bleeding).
Rx: Initial step is to prevent constipation with high-fiber diet, adequate fluid intake ± sitz baths. Use oral or topical analgesics for pain. For refractory cases, refer to colorectal surgery (rubber band ligation or surgical hemorrhoidectomy may be needed).
Complication: Vein thrombosis can cause severe pain. Management is immediate hemorrhoidectomy (simple clot removal is not recommended due to a high chance of recurrence).
25.5.7 Other Anorectal Conditions
These signs may or may not be present. Presence of obturator and psoas sign depends on the location of the appendix.
(!) Bleeding independent of bowel movement is likely not due to hemorrhoids.
Fever + perineal pain. Look for “fluctuant mass”b
Surgical drainage. Antibiotics are indicated in all cases. (use antibiotics that cover gram +ve, gram -ve, and anaerobes, e.g., amoxicillin-clavulanate).
Fistula in ano (anorectal fistula)
Most fistulas form as a result of anorectal abscess. They have internal and external openings.
Etiology: Local trauma, infection, inflammatory bowel disease, malignancy, etc.
Feature: These anal tears occur distal to the dentate line, hence are very painful. Anal area exam may require anesthesia. MC location is midline posterior wall.
First step is conservative treatment with topical vasodilators (nifedipine or nitroglycerin), topical analgesic, stool softener, sitz bath, and fiber diet.
Surgical correction is done if conservative management fails.
When hair or debris gets trapped in the pores of skin in the cleft of buttock, this can lead to “foreign- body”-mediated nonhealing and development of cysts ± abscess.
Usually occurs in midline sacrococcygeal area.
Can present as a painless pit or painful cystic mass with fluctuation ± bloody or purulent discharge.
Abscess needs to be incised and drained. In recurrent or chronic cases, excision of cyst and sinus tract is done.
aNew-onset anorectal lesions in elderly or high-risk patients, or in atypical location (e.g., multiple anal fissures that are not in the midline), or all nonhealing lesions should be evaluated for anal cancer by proctosigmoidoscopy ± biopsy.
b“Fluctuant mass” is almost always an abscess.
25.5.8 Anorectal Mass
Squamous cell carcinoma of anus
Look for chronic, nonhealing fungating mass with ulceration/s and irregular surface (+ enlarged inguinal nodes).
Chemoradiation even in localized disease is preferred over surgery, to preserve anal sphincter. (Surgery can be done for recurrent or persistent disease.)
Condylomata lata (secondary syphilis)MRS-1
These warty lesions have moist surfaces and no ulcerations, but multiple superficial erosions may be present.
Look for other features of secondary syphilis (e.g., systemic symptoms, generalized lymphadenopathy)
NSIDx: Serologic testing for syphilis
Rx: Penicillin IM.
Condylomata acuminata (anogenital warts)MRS-1
These warty lesions have dry surfaces and no ulceration.
Primary HPV infection. Extensive disease can occur in immunosuppressed patients.
Rx: Topical imiquimod or podophyllotoxin, cryotherapy, etc.
MRS-1Condylomata lata vs acuminata: Later manifestation of syphilis is Lata. Papilloma virus is accumulated in acuminata.