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“When to Call A Surgeon”. Anneliese Schleyer MD Harborview Medical Center. When to Call A Surgeon. Goals: Review medical management of common abdominal diagnoses Identify when to call a surgeon Learn how to communicate concerns effectively. Case #1. - PowerPoint PPT Presentation
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“When to Call A Surgeon”
Anneliese Schleyer MDHarborview Medical Center
When to Call A Surgeon
• Goals:
– Review medical management of common abdominal diagnoses
– Identify when to call a surgeon
– Learn how to communicate concerns effectively
Case #1
• 53 y F generally healthy with diffuse abdominal pain and vomiting x 3 days
• Small loose nonbloody stools. No flatus, fevers/chills, chest pain, SOB
– Surgical history: ventral hernia repair– Medical history: prior IVDU, venous stasis
ulcers– Medications: ibuprofen prn
Case #1
• Exam: T 36.7, HR 106, BP 103/61– Awake and alert– Abdomen: distended and quiet except for
rare high-pitched sounds
• Labs – WBC 6.4, HCT 44. – K 3.1, bicarb 31 creatinine 1.3 – LFTs, amylase normal
• What’s the diagnosis?
Small Bowel Obstruction
• History – Crampy diffuse abdominal pain & distention,
nausea/ vomiting. Some still pass flatus.
• Risk factors– Prior abdominal surgeries, tumors, hernias,
strictures
• Exam – Hypoactive or high pitched sounds
• Diagnosis made by history and exam
Small Bowel Obstruction
• Plain films: – Upright CXR to rule out free air – Abdominal series: air-fluid levels, distended bowel.
Usually no gas in colon/rectum after 24 hrs.
• Abdominal CT: – Different caliber small bowel lumens– Volvulus – Transition point distal to obstruction – Cannot see adhesions
Causes of small bowel obstruction• Top surgical causes:
– 1. Adhesions from prior abdominal or pelvic surgery
– 2. Diffuse carcinoma
• Extrinsic– Volvulus– Hernia
• Intrinsic– Tumors– Strictures or stenoses
• Intussusception• Intraluminal
– Stool, gallstones, bezoars
Small Bowel Obstruction
• Medical Management:– Diagnose and treat underlying cause – Aggressive electrolyte correction– Frequent, serial abdominal exams– No prokinetic agents like metoclopromide
• Decompress with NG tube:– Avoid clamping; can cause vomiting/aspiration– Gravity trial when signs of bowel function:
• Place canister on ground• If < 200 cc output / 4 hrs, remove tube
Case #1
• Hospital course: – Seen and “cleared” by general surgery
in ED; admitted to medicine– Symptoms subsided initially with NGT – Patient noted “lymph node” in right
inguinal region on hospital day #2– 2x3 cm mass, mobile, mildly tender– Nausea/vomiting recurred when NGT
clamped
Case #1
• Hospital course: – HD #3 increased pain, fever and
tachycardia; ↓uop; repeat labs K+ 2.6 – CT scan: showed incarcerated hernia – Surgery urgently re-consulted, hernia
repaired; patient had an uneventful recovery.
Small Bowel Obstruction (SBO)
• Pearls:– Diagnose by history and exam– Normalize K+ and other electrolytes– If not improving, check for signs of volvulus
or ischemia– Don’t forget to check for hernias
Small Bowel Obstruction
• Concerning signs/symptoms– Ischemic signs: crampy pain becomes
constant, tachycardia, +/- hypotension, fever, ↑WBC, ↑ lactate level, ↓uop
– Changing bicarb or increased anion gap– Evidence of volvulus / closed loop– No response to conservative
management in 48 hours
SBO – Lessons Learned
• Seen by surgery in ED does not mean surgical intervention won’t be needed
• NGT to gravity rather than clamping when bowel function returns
• If no response to conservative management in 48 hours, repeat imaging and consider surgical consult
• If any concerning signs or symptoms, consult Surgery immediately
Case #2
• 78 yo man 2 weeks s/p colon resection for carcinoma admitted to surgery with colocutaneous fistula/subfascial abscess• PMH: HTN and CAD
• Habits: rare EtOH; no IVDU.
• Medications: lisinopril, ASA, metoprolol
• Allergies: none
Case #2
• On HD #2 en route to IR for drain placement, had hematemesis and dark tarry stools in colostomy bag
• BP 140/80 HR 88
• HCT: 30 21
• Transferred to ICU
Case #2• Medical management for upper GI bleed:
– Two large bore IVs placed; NPO– NG lavage: did not clear– IVF; 2 units PRBCs; coagulopathy reversed– Pantoprazole gtt initiated
• Emergent EGD by GI: – diffuse severe esophagitis – large (>50%) adherent clot in duodenal bulb with
‘giant’ duodenal ulcer, no bleeding visualized– Attempt at ulcer injection with epi
Case #2• HD #5, abscess drained successfully • Pt transferred to medicine floor• Pantoprazole gtt continued
• SBPs 115-160s• Benign abdominal exam• HCT stable at 30-31 for 48+ hours
Case #2
• Called about SBP 80s; resolves without intervention
• Repeat Hct 26 29• Patient has no complaints; ‘looks good’
• Surgery is called:
“I’ll follow his labs and decide if I need to see him.”
Case #2• Two hours later, SBP 80-90s; sustained despite
fluids; HR 105-120s. • HCT 26 29 22 21• Transferred to ICU; transfused to HCT 30 • SBP and HR improved
Case #2
• GI and General Surgery called again• GI repeated EGD: + clot duodenum; no visible
bleeding vessel• HCT initally 30, then 21 on repeat• Pt taken emergently to OR where he underwent
antrectomy with Billroth II gastrojejunostomy
PUD – Lessons Learned
• Consult Surgery early if indicated!• Involve Surgery at initial EGD if warranted• Communicate concerning s/s to Surgeon• In PUD consider surgical consultation for:
– hemodynamic instability (particularly after initial resuscitation)
– recurrent bleeding (unclear bleeding source)– transfusion dependence– any high risk lesion on EGD
PUD – Lessons Learned• High Risk Lesions on EGD:
• “Giant” (duodenal) ulcer >2 cm• Active bleeding• Visible vessel• Adherent clot
• At other hospitals, patients with GI bleeds are often admitted to Surgery
PUD – Lessons Learned
• Interdisciplinary Guidelines for Management of Gastrointestinal Bleeds
at Harborview are under development
Stay tuned….
Case #3• Obese 27 yo woman with 5/10 epigastric pain,
radiating to back, worse with inspiration and french fries. No h/o alcohol or other medical problems.
• Vitals normal; tender in epigastrium/RUQ; diminished BTs
• Labs: AST/ALT 226/416, Alk phos 180, T/D Bili 2.6/1.4; WBC 11, HCT 43, Ca 9.5; amylase 1331
Case #3
• Ultrasound:– Small gallstones but no wall thickening or
ductal dilatation. No sonographic Murphy’s.– Pt received usual medical management– IVF, NPO, pain control
• Hospital course: improved quickly, tolerated full diet at 48 hrs, discharged home
Case #3
• Pt returned 2 months later with abdominal pain radiating to back, worse with fast food, nausea and vomiting.
• Exam: Vitals 38.6; HR 103; o/w normalTender in RUQ with diminished bowel tones. No rebound or guarding.
• Labs:– AST 769, ALT 530, Alk phos 112, T Bili 1.6– WBC 14.6 + bands, HCT 45, Calcium 9.1– Pancreatic amylase 4800
Case #3
• Ultrasound– Gallbladder wall thickening to 5 mm; CBD
grossly normal– Multiple non-mobile gallstones within neck– Liver with diffuse fatty infiltration– No radiographic Murphy’s sign noted
Case #3• Hospital Course
– Fever 39.4, ↑abdominal pain, WBC 28,000
• Abdominal CT: enlarged/ edematous pancreas suggesting necrosis– Gallbladder grossly unremarkable
• GI consulted; not good candidate for ERCP
Case #3
• Surgery: “Why didn’t you call us the last time she was here?”– Patient scheduled for cholecystectomy when
clinically improved
• Laparascopic cholecystectomy w/ intra-operative cholangiogram on HD #9
• HD #13 discharged home; doing well.
Gallstone Pancreatitis: Lessons Learned
• When to Call A Surgeon– Cholecystectomy should be performed after
recovery in all patients with gallstone pancreatitis prior to discharge
• Caveat: if severe/necrotizing pancreatitis, reasonable to wait several weeks until possibility of infection ruled out
– Recurrent acute pancreatitis w/ no evidence of gall stones or EtOH may be secondary to microlithiasis; consider elective cholecystectomy
Working with Surgery Consultation
• Be aware of which patients have potential surgical needs – Bowel obstruction– GI bleed– Gallstone pancreatitis– Any patient with abdominal pain
• Don’t assume that “cleared by surgery” means no surgical input will be needed during hospitalization
Working with Surgery Consultation
• Does this patient need an operation?
• Does this patient need a surgeon now?
• Patient stable or unstable?
• Peritonitis?
Working with Surgery Consultation
• Perform serial abdominal exams• Note changing history
– Loss of flatus– Worsening pain or vomiting
• Note changing vitals and exam– New peritoneal signs
• Note changing labs – dropping bicarbonate or HCT – rising lactate or anion gap
Summary
• Many patients admitted to Medicine have potential surgical needs
• Careful medical management is important
• Call Surgeons early if indicated
• Learn to communicate key issues
• If additional Surgical assistance is needed, ok to call more Senior Surgeons and/or involve your attending
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