y r e g r u S Differential diagnosis Cholecystitis Diverticulitis Ectopic pregnancy Salpingitis Mesenteri c adenitis Menstrual cramps Meckel \200\231s diverticulitis Cystitis Crohn \200\231s disease Ovarian cyst or abscess Kidney stone Complications of acute appendicitis Perforation (does not appear to cause later infertility in girls), appendix mass, appendix abscess. An appendix mass may result when an inflamed a ppendix becomes covered with omentum or loops of small bowel. The mass is palpable on exam and easily seen on abdominal CT scan. Some advocate early surgery, but initial management i s usually conservative \200\224NPO and antibiotics (e.g., cefuroxime 1.5 g/8 h IV and metro nidazole 500 mg/8 h IV). Mark out the size of the mass and proceed to drainage if the mass develops into an abscess (see below). If the mass resolves, some perform an interval (i.e., delayed) ap- pendicectomy. See Table 13.21. An appendix abscess may result if an appendix mass fails to resolve. Signs of abscess formation include enlargement of the mass or the pa tient becom- ing more toxic (pain \206\221 , temperature \206\221 , pulse \206\221 , WBC \206\221 ). Treatment usu- ally involves drainage, either surgical or percutaneous (under radiological guidance). Antibiotics alone may bring about resolution (e.g., in >90% of chi ldren). 479 Table 13.21 Appendicitis in pregnancy Appendicitis occurs in 1/1,000 pregnancies. Mortality is higher, espe- cially from 20 wks of gestation. Perforation (15 \200\22320%), and \206\221 fetal mortality from 1.5% (for s imple appendicitis) to 30%. As pregnancy progresses, the appendix migrates, so pain is oft en less well localized. Prompt assessment is vital; laparotomy should be performed by an ex pe- rienced surgeon. Surgical treatment Once decision is made to operate, make patient NPO and hydrate with NS. Metronidazole 1 g/8 h + cefuroxime 1.5 g/8 h, 1 \200\2233 doses IV starting 1 h preop reduc es wound infections. Appendectomy is performed laparoscopi- cally or through a RLQ incision at McBurney \200\231s Point (one-third the distance between the anterior superior iliac cr est and the umbilicus). Some surgical hints include: \212 Laparoscopic appendectomy reduces recovery time and incidence of wound infections, but incr eases risk of intra-abdominal abscesses. If the appendix is perforated, most advocate closi ng the fascia but leaving the wound open for closure by secondary intention. If the appendi ceal stump is difficult to locate and close, and the appendix has ruptured, leave a drain b ecause patient is at risk to develop GI leak and fistula. If the appendix is associated wit h an unusual mass, always think of carci- noid or cystadenoma of the appendix. These tumors may cause luminal obstruction and lead to appendicitis. Larger tumors (>2 cm) will require formal right hemicolectomy, which should be performed at the time of surgery or once patho logy is confirmed. \212 \212 \212 Diverticular disease A diverticulum is an out-pouching of the wall of the gut. The term div erticu- losis means that diverticula are present, whereas diverticular disease implies that they are symptomatic. Diverticulitis refers to inflammation within a diverticulum. Althoug h diverticula may be congenital or acquired and can occur in any part of the gut, by far th e most important type is acquired colonic diverticula, to which this section refers. Pathog enesis Most occur in the sigmoid colon, with 95% of complications at this site, but right-s ided, as well as small bowel diverticula, do occur. Lack of dietary fiber is thought to lea d to high intraluminal pressures that force the mucosa to herniate through the muscular bow el wall near where vessels penetrate the wall. Nearly 50% of the population in the Western world >50 has diverticulosis. Symptoms 15 \200\22330% of patients with diverticulosis have symptomatic diverticular disease. The most common symptoms is LLQ pain. Pain usually occurs after eating and persists. Associated symptoms include low-grade fever, diarrhea or obstip ation, and anorexia. Rarely do patients experience nausea or vomiting. On exam, LLQ point a nd rebound tenderness may be present. Complications of diverticular disease Free perforatio n: A free communication exists between the colon and the peritoneal cavity. There is ileus, peritonitis shock. Free fluid in air is noted on imaging studies. Hemorrhage: Is usuall y sudden and painless. It is a common cause of big rectal bleeds. Bleeding usually stops wi th bed rest. Fistula: \212 480 Colovesical: Complaints of pneumaturia (air in urine stream) or fecaluria (feces in urine s tream) Colovaginal: Complaints of fecal vaginal discharge Coloenteric: Complaints of persis tent diarrhea \212 \212 Abscess: E.g., with swinging fever, leukocytosis, and localizing signs (e.g., b oggy rectal mass). Postinfective strictures may form in the sigmoid colon and present with large bowel obstruction. Studies CBC, urine analysis and culture. Uncomplicated diverticulitis: \212 \212 Complica ted diverticular disease: \212 \212 \212 \212 \212 Treatment Uncomplicated diverticula r disease: \212 y r e g r u S ABD and pelvic CT scan initially Colonoscopy or barium enema once symptoms resolve to R/O c ancer. AXR to R/O free air CT cystogram to R/O colovesical fistula Barium enema to R/O colovaginal fistula Small bowel series to R/O coloenteric fistula Colonoscopy to R/O cancer. A 7 \200\22314 d course of IV or oral antibiotics (ciprofloxacin 500 mg bid and Flagyl 25 0 \200\223500 mg PO tid) Keep NPO till pain resolves. Avoid narcotics, which may constipate . Encourage a \212 \212 \212 \212Antispasmodics such as Bentyl 10 mg PO 4 \227 a day. \212 high-fiber diet with dietary supplements (Metamucil ) Repetitive attacks requiring hospitalization of documented diverticular disease should be t reated with either laparoscopic or open surgical resec- tion of the diseased colon. Recurre nce of LLQ pain after surgery is more common in patients who have not had a complete resect ion of the distal sigmoid and in patients with irritable bowel syndrome (IBS) as well as di verticular disease. \212 Complicated diverticular disease Free perforation: Laparotomy, a Hartman \200\231s procedur e may be used (tempo- rary end colostomy + partial colectomy or \200\234perforectomy \200 \235). It is sometimes possible to do on-table colon lavage via the appendix stump, then im medi- ate anastomosis (so avoiding repeat surgery to close the colostomy). Hemorrhage: Tran sfusion may be needed. Highly selective embolization or colonic resection may be necessary after locating bleeding points by angiog- raphy or colonoscopy (cautery local epinephrin e injections may obviate the need for surgery). If bleeding site is identified and surgery is necessary, a limited resection can be performed. Otherwise, a total abdominal colec- tom y with either an ileostomy or ileorectal anastomosis is performed. Fistula: Treatment is su rgical (e.g., laparoscopic or open colonic resection, as well as removal of the fistula). S uccessful laparoscopic resection is less likely when a fistula is present. The most common site for a colovesical fistula is the dome of the bladder. The trigone may on occasion be i nvolved and, if so, consider urology consult for stents and reconstruction. Consider urolog y consult for stents and reconstruction. Abscess: Antibiotics CT- or US-guided drainage may be needed. This should be followed by definitive resection in 6 wks or sooner if no cli nical improvement (<25%). Postinfective strictures: Stent colon if necessary and prep if po ssible to per- form a primary anastomosis. 481 Hernias Any congenital or acquired defect in a musculoaponeurotic structure through which a n epithelialized or peritonealized sac protrudes. Hernias involving bowel are said to be ir reducible if they cannot be pushed back into the right place. This does not mean that they are either necessarily obstructed or strangulated. Gastrointestinal hernias are obstructed if bowel contents cannot pass through them \200\224the classical features of intestinal obs truction soon appear. Strangulated hernias are a result of ischemia to the bowel and requir e urgent surgery. See Figure 13.7. Sites of hernias Inguinal hernia: See p. 483. Pantaloon hernia: Both indirect and direct inguinal hernias occurring in the same patient. Femoral he rnia: Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or abo ve the inguinal ligament, where it points down the leg, unlike an inguinal hernia, which po ints to the groin. They occur more often in women than men and are likely to be irreducible and to strangulate . Anatomy: The neck of the hernia is felt below and lateral to the pubi c tuber- cle (inguinal hernias are above and medial to this point). The boundaries of the f emoral canal are anterior and medial to the inguinal ligament; laterally to the femoral vei n and posteriorly to the pectineal ligament. The canal con- tains fat and Cloquet \200\231s node. Treatment: Surgical repair is recommended. Paraumbilical hernias: These occur just a bove or below the umbilicus. Risk factors are obesity and ascites. Omentum or bowel herniat es through the defect. Surgery involves repair of the rectus sheath. Epigastric hernias: Th ese pass through the linea alba above the umbilicus. Incisional hernias; These follow break down of muscle closure after previous surgery (seen in 11 \200\22320%). If obese, repair is not easy. A randomized trial of repairs favored mesh over suture techniques. Spigelian her nias: These occur at the lateral edge of the rectus sheath, below and lateral to the umbili cus. Lumbar hernias: These occur through one of the lumbar triangles. Richter \200\231s her nia: This involves bowel wall only \200\224not lumen. Obturator hernias: These occur throug h the obturator canal. Typically, there is pain along the medial side of the thigh in a thi n woman. Levator hernias: These occur when fat or rectum balloons out the levator muscles o f the pelvic floor Other examples of hernias \212 \212 482 Of the nucleus pulposus into the spinal canal (slipped disc) Of the uncus and hippocampal g yrus through the tentorium (tentorial hernia) in space-occupying lesions Of the brainstem a nd cerebellum through the foramen magnum (Arnold \200\223 Chiari malformation) Of the stoma ch through the diaphragm (hiatal hernia [p. 209]) Of the terminal (intravesical) portion of the ureter into the bladder, with cystic ballooning between the mucosa and muscle layers. This is a uretero- cele and results from stenosis of the ureteral meatus. \212 \212 \212 Symptoms \212 Reducible hernias are associated with a dull ache and bulge that go away with recumbency an d worsen with physical activity. A neuralgia can occur from injury to a sensory nerve lying at the site of the hernia (i.e., ilioinguinal nerve and the inguinal hernia or obturator n erve and the obturator canal). Incarcerated or strangulated hernias (5%) will be associated with more severe pain, nausea, and vomiting. \212 y r e g r u S Figure 13.7 Some examples of hernias Treatment \212 Symptomatic hernias should be considered for operative repair. Patients should be encourage d to lose weight and to stop smoking to improve the outcome of hernia repair. Several trial s of laparoscopic repair for large incarcerated hernias using in-lay versus on-lay mesh hav e demonstrated improved outcomes. If incarcerated, a trial of gentle reduction with manual pressure can be attempted. Strangulated hernias should be operatively repaired immediately. \212 \212 Inguinal hernias Indirect hernias pass through the internal inguinal ring as a result of in com- plete closure of the processus vaginalis at birth (see Table 13.22 and Figure 13.8). D irect hernias enter through the posterior wall of the inguinal canal through an acquired de fect in the transverses abdominus aponeurosis and transversalis fascia. Overall, indirect h ernias are more common than direct hernias. However, direct hernias are more common in adul ts and indirect are more common in children. The anatomic landmark distinguishing these her nias is the inferior epigastric artery: Indirect is lateral, direct is medial through Hesse lbach \200\231s triangle: Medial edge of rectus abdominis, lateral edge of inferior epigast ric artery, and inferior edge of inguinal ligament. Predisposing conditions include chronic cough, constipation, urinary obstruction, heavy lifting, ascites, previous abdominal surge ry, prematurity. Relations of the inguinal canal Floor: Inguinal ligament Roof: Fibers of t ransversalis and internal oblique Front: External oblique aponeurosis + internal oblique fo r the lateral Back: Laterally, transversalis fascia; medially, conjoined tendon 483 Table 13.22 Contents of the inguinal canal \212 \212 \212 \212 \212 \212 \212 \212 \212 Spermatic cord in men Round ligament in women Testicular artery Deferential vessel Pampinif orm plexus of veins Ilioinguinal nerve Genital branch of the genitofemoral nerve Cremasteri c artery and muscle Internal spermatic fascia Examining the patient Always look for previous scars, feel the other side, and examine the external genitalia. Then ask: Is the lump visible? If so, ask the patient to reduce it; if he cannot, make sure that it is not a scrotal lump. Ask him to cough. Inguinal hernias appe ar inferomedial to the external ring. If no lump is visible, feel for a cough impulse. If t here is no lump, ask the patient to stand and repeat the cough. Irreducible hernias You may be called because a long-standing hernia is now irreducible and painful. It is always wort h trying to reduce these yourself to prevent strangulation and bowel necrosis (a grave even t, demanding prompt laparotomy). Use the flat of the hand, direct the hernia from below, up toward the contralateral shoulder. Sometimes, as the hernia obstructs, reduction requires perseverance, which may be rewarded with a gurgle from the retreating bowel. This can spare unnecessary surgery. Surgical repairs Advise patients to diet and stop smoking preop. Lapa roscopic and open mesh techniques (e.g., Lichtenstein repair) have replaced other methods b riefly described here: Shouldice repair: Multilayered suture involving both anterior and po sterior walls of the inguinal canal Bassini repair: Floor of inguinal canal approximates th e rectus sheath and to the shelving edge of the inguinal ligament (Poupart ligament) McVay repair or Cooper \200\231s ligament repair approximates the floor of the inguinal canal to Cooper \200\231s ligament between the pubic tubercle to the femoral vein. In mesh repairs, a polypropylene mesh reinforces the posterior wall. Recurrence rate is lower (<2% mesh vs. 10% no mesh). Local anesthetic techniques have led to day-case ambulatory surgery. Laparosc opic repair is also possible and gives similar recurrence rates. This can be done through t he peritoneal cavity or through a pre-peritoneal approach. There is less postoperative pain and an earlier return to work after a laparoscopic repair, and undiagnosed contralateral h ernias can be identified. Care must be taken to avoid injury to the iliohypogastric nerve, which may occur by placing a holding tack too far laterally along the abdominal wall. This results in severe chronic pain. 484 y r e g r u S Figure 13.8 Benign diseases of the biliary tract Bile contains cholesterol, bile pigments (from broken- down Hb), and phos- pholipids. If the concentrations of these vary, different kinds of ston es may be formed. Stones cause chronic inflammation colic. See Figure 13.9. \212Pigment stones: Most common type of stone worldwide; small, friable, and irregular. Causes: Hemolysis \212Cholesterol stones: Most common type of stone in the United States; large, often solitary. Causes: Female sex, age, obesity \212Mixed stones: Faceted (calcium salts, pigment, and cholesterol) Gallstone prevalence 8 % of those >40 yrs. 90% remain asymptomatic and for these no treatment is commonly offered. Biliary colic Follows stone impaction in the neck of the gall bladder (GB), which may caus e epigastric or RUQ pain after eating fatty foods. Acute cholecystitis Pain, fevers, and WB C \206\221 with +ve US findings is suggestive of cholecystitis. Other symptoms include nau sea and vomiting. If the stone moves to the CBD, jaundice may occur. Murphy \200\231s sign: Press over the RUQ. Ask the patient to breathe in. This causes pain and arrest of inspirat ion as an inflamed GB is impinged. It is only +ve if the same test in the LUQ does not caus e pain. Acalculous cholecystitis Pain, fever, and WBC \206\221 with biliary stasis and del ayed GB emptying on hepatic iminodiacetic acid (HIDA) without evidence of stones. Commonly seen in critically ill, immunosuppressed patients and in patients on TPN. Chronic cholecyst itis Vague abdominal discomfort, distension, nausea, flatulence, and intolerance of fats ma y also be caused by reflux, ulcers, irritable bowel syndrome, relapsing pancreatitis, or tu mor (stomach, pancreas, colon, GB). US is used to image stones, and to assess common 485 bile duct (CBD) diameter. Magnetic resonance cholangiopancreaticogram (MRCP, p. 222) is inc reasingly being used to check for stones in the CBD. Complications of gallstones Obstructiv e jaundice with CBD stones: RUQ pain and jaundice; unusual to have a total bilirubin >10 mg /dL. Cholangitis: Bile duct infection usually resulting from a blocked duct. Charcot \200 \231s triad RUQ pain, jaundice, and fevers; Reynolds \200\231 pentad with the addition of h ypotension and mental status changes; worse prognosis. Gallstone ileus: A stone perforates the GB entering the duodenum; it may then obstruct the terminal ileum. X-ray shows air in C BD, small bowel fluid levels, and a stone. Duodenal obstruction is rarer (Bouveret \200\231 s syndrome). Pancreatitis: See p. 487. Empyema of the gallbladder: The obstructed GB fills with pus. Mirizzi syndrome: Impaction of the cystic duct with a large stone causing obstruc tion of the CBD. Tests WBC, RUQ us (thickened GB wall, pericholecystic fluid, and stones), HIDA cholescintigraphy to check for GB emptying (useful if diagnosis uncertain after US). M RCP images the bile duct for the presence of stones. Gallstones are only radiopaque on plai n abdominal films in 10% of cases. Medical management NPO, pain relief (avoid morphine, wh ich may cause sphincter of Oddi dysfunction), IV fluids, and antibiotics if evidence of inf lammation/infection; common organisms include E. coli , Enterococci, and Klebsiella (e.g., cefuroxime 1.5 g/8 h IV and metronidazole 500 mg/8 h IV, or Zosyn 3.375 mg/6 h IV). If US C holecystectomy (e.g., Surgical treatment or MRCP shows a dilated CBD with stones, endoscopi c retrograde cholangiopancreatography (ERCP) with sphincterotomy is used to remove stones, usually prior to surgery or at the time of surgery with CBD exploration (if there is no obs truction/cholangitis). A stone-trapping basket on the end of a choledochoscope introduced t hrough the cystic duct at laparoscopy can be done. In suitable candidates, do laparoscopic cholecystectomy within 72 h; early surgery is associated with fewer complications and lower conversion rates to open cholecystectomy. Mortality: <1%. If delayed, relapse occurs in 18 %. Otherwise, operate after 6 \200\22312 wks. In elderly or high-risk patients unsuitable f or surgery, percutaneous cholecystostomy may be useful; cholecystectomy can still be perfor med at a later date. Complications of laparoscopic cholecystectomy Injury to the right hepa tic duct, accessory duct, or common bile duct: All will require drainage of biloma and poss ible intrahepatic biliary drain. Depending on the site of injury, reconstruction with a Rou x-en-Y choledochojejunos- tomy may have to be performed. laparoscopic). 486 y r e g r u S Figure 13.9 Reproduced from Cunningham. Manual of Practical Anatomy, 14th ed., Vol. 2. New York: Oxford University Press, 1997; 138, with kind permission. Pancreatitis Pancreatic inflammation results in injury to the gland and the surrounding ret roperitoneal tissue; most common in adults >30 yrs. Overall mortality is 6 \200\22320%. The re may be rapid progression from a phase of mild edema of the pancreas associated with flui d sequestration to one of necrotizing pancreatitis. In fulminating cases, the pancreas is r eplaced by gray-black necrotic material. Death may be from shock, renal failure, sepsis, or respira- tory failure, with contributory factors being protease-induced activation of comp lement, kinin, and the fibrinolytic and coagulation cascades. May be acute or chronic. Caus es \200\234GET SMASHED \200\235: G allstones, E thanol, T rauma, S teroids, M umps, A utoi mmune (PAN), S corpion venom, H yperlipidemia ( \206\221 Ca 2+ , hypothermia), ERCP(also e mboli), D rugs (e.g., azathioprine, asparaginase, mercaptopurine, pentamidine, didanosine, diuretics); also pregnancy. Often none is found. Symptoms Gradual or sudden severe epigastr ic or central abdominal pain (radiates to back); vomiting with signs of gastric outlet obst ruction are prominent. Signs Tachycardia, fever, jaundice, shock, ileus, rigid abdomen l ocal/ generalized tenderness and periumbilical discoloration Cullen \200\231s sign or, at t he flanks, Gray Turner \200\231s sign . Tests No test is pathognomonic. Serum amylase eleva tion (amylase may be normal even in severe pancreatitis as amylase starts to fall within th e 1st 24 \200\22348 h; levels may be abnormally elevated secondary to renal failure or alte rnative source \200\224salivary gland, fallopian tube). Serum lipase is derived from pancre atic acinar cells, and elevation may indicate acinar cell injury. Blood gasses. Biochemical analysis. Abdominal \201 lms: No psoas shadow (retroperitoneal fluid \206\221 ), \200 \234sentinel loop \200\235 of proximal jejunum (solitary air-filled dilatation). CT helps a ssess severity. US (if gallstones). ERCP. Differential diagnosis: Any acute abdomen (p. 466 ), myocardial infarct. 487 Management \212 \212 NPO (may need NGT) IV fluid resuscitation with 0.9% saline until vital signs are satisfacto ry and urine flows at >30 mL/h. If shocked or elderly, consider CVP. Insert a urinary cathe ter. Analgesia: but may cause Oddi \200\231s sphincter to contract more) + prochlorperazine . Hourly pulse, BP, and urine flow; daily CBC, Comprehensive panel: Glucose, amylase, lipas e, blood gas \200\224about one-third of patients will have respiratory compromise. Suppleme ntal O 2 if P a O 2 \206\223 is low. In (on contrast-enhanced CT), consider parenteral nut rition laparotomy and debridement. Antibiotics may help in severe disease. ERCP + gallst one removal may be needed if there is progressive jaundice. \212 Demerol 75 \200\223100 mg/4 h IM, or morphine (a better analgesic, \212 \212 suspected abscess formation or pancreatic necrosis \212 Prognosis (See Table 13.23.) Several grading systems exist. Presently, the APACHE II score is used to assess the likelihood of mortality. Some patients suffer recurrent pancreatitis so often that near-total pancreatectomy is contemplated. Evidence is accumulating that oxid ant stress is important here, but initial clinical trials of free radical scavengers have b een disappointing. Complications Early: Shock, ARDS (p. 185), renal failure, DIC, Ca 2+ \206\223 (10 mL of 10% calcium gluconate IV [slow replacement] is rarely necessary; albumin replacement has also been tried), glucose \206\221 (transient; 5% need insulin). Later (> 1 wk): Pancreatic necrosis, pseudocyst (fluid in lesser sac, e.g., at 6 wks), with fever , a mass, and persistent \206\221 amylase/LFTs. It may resolve or need drainage, externall y or into the stomach (may be laparoscopically). Abscesses need draining. Bleeding is from elastase eroding a major vessel (e.g., splenic artery); embolization of the artery may be l ife-saving. Thrombosis may occur in the splenic and gastroduodenal arteries, or in the coli c branches of the SMA, causing bowel necrosis. Table 13.23 Ransom criteria On admission \212 Age >55 yrs \212 WBC >16,000/uL \212 Glucose >200 mg/dL \212 LDH >350 IU/L \212 SGOT >250 IU/L After 48 h \212 Hct \206\223 10% \206\221 5 mg/dL \212 BUN \212 2+ <8 mg/dL Ca \212P a 0 2 <60 mm Hg \212 \212 \212 488 Base deficit >4 mEq/L Fluid sequestration >6 L Mortality is 30% if 3 criteria met, 40% for 5 \200\2236 criteria, 100% for 7 \200\2238. Intestinal obstruction This disorder is the result of inability of normal secretions and wa ste to pass through the GI tract. It is best to separate intestinal obstruction into two ma jor sites, small intestinal and large intestinal obstruction. Symptoms Both large and small intestinal obstruction are associated with anorexia and colicky abdominal pain with disten sion. In small bowel obstruction, vomiting occurs earlier, distension may be less. In large bowel obstruction, the pain is more constant. Obstipation is common but constipation need not be absolute (i.e., no feces or flatus passed). Fever is an ominous sign and when associ ated with localized peritonitis, always worry about strangulation. Causes Small bowel: Adhe sions are the number one cause in the United States; hernias (external/internal) are the mo st common worldwide. Also, intussusception, Crohn \200\231s disease, radiation enteritis, g allstone ileus, tumor, foreign body. Large bowel: Tumor, sigmoid or cecal volvulus, feces, diverticular or ischemic stricture. Physical exam Examine for distension and borborygmi, au scultate for bowel sounds \200\224no bowel sounds may indicate ileus without obstruction; h igh-pitched bowel sounds are the hallmark of obstruction. Tests \212 \212 \212 y r e g r u S CBC, electrolytes (K Urine analysis and culture \200\224a UTI may cause ileus. AXR (plain A XR) look for abnormal gas patterns (gas in the fundus of stomach and throughout the large b owel is normal). On erect AXR, look for horizontal fluid levels within the small bowel, as well as central gas shadows and no gas in the large bowel. Small bowel is identified by val vulae conniventes that completely cross the lumen (large bowel haustral folds do not cross all the lumen \200\231s width). In large bowel obstruction, AXR shows gas proximal to the b lock (e.g., in cecum) but not in the rectum. Abdominal and pelvic CT scan with oral contras t may demonstrate dilated loops of bowel to a transition point followed by compressed loops of bowel. Be careful in immediately administering IV contrast because often these patients are dehydrated and may have renal insufficiency. + and Mg 2+ ) \212 \212 Management General principles: The site, speed of onset, and completeness of obstruc- tion determine therapy. Strangulation and large bowel obstruction require surgery soon. Paralyti c ileus and incomplete small bowel obstruction can be managed conservatively, at least init ially. \212 489 Pass NGT and give IV fluids to rehydrate and correct Conservative options: electrolyte imba lance (p. 667). Recurrent small bowel obstruction requir- ing hospitalization may be better served with exploratory laparotomy. Strangulation requires emergency surgery, as does clos ed loop Surgery: obstruction \200\224large bowel obstruction with tenderness over a grossl y dis- tended cecum (>8 cm), which occurs when the ileocecal valve remains competent despit e bowel distension. Usually, large volumes of IV fluid must be given. For less urgent large bowel obstruction, there is time for an enema to determine if a complete or partial obstru ction exists and to try to clear the obstruction and correct fluid imbalance. \212 Sigmoid volvulus occurs when the bowel twists on the mesentery, and it can produce a severe , rapid strangulated obstruction. There is a characteristic AXR with an \200\234inverted U \200\235 loop of bowel. It tends to occur in the elderly, constipated patient, and it is o ften managed by sigmoidoscopy and insertion of a flatus tube, but sigmoid colectomy is some times required. If sigmoid volvulus can be decompressed, it is recommended that the colon be prepped and re moved during the same hospitalization. Cecal volvulus is similar but less common than sigmo id volvulus. It is found in patients with a mobile cecum. Treatment is surgical resection o r cecal pexy. Pseudo-obstruction resembles mechanical GI obstruction but no cause for obstr uction is found. Predisposing factors: Malignancy, electrolyte disturbances (e.g., \206 \223 K + ), recent surgery. Presentation: Nausea and postprandial bloating. Acute colonic p seudo-obstruction is called Ogilvie \200\231s syndrome . This is common in the elderly, ins titutionalized patient. Treatment: Manage conservatively. Neostigmine or colonoscopic decom pression is sometimes useful in acute cases. Weight loss is a problem in chronic pseudo-obs truction. There is a case for investigating the cause by colonoscopy or water-soluble contr ast enema in most instances of suspected mechanical obstruction. Rectal prolapse (procidentia) Full-thickness concentric prolapse of the rectum through the anus; in con- trast to mucosal prolapse seen with hemorrhoidal disease. True incidence is u nknown but : ratio is 6:1 in patients >60. In children, be concerned about cystic fib rosis. Symptoms Prolapse of the rectum usually with defecation; patients often have constip ation, fecal incontinence, and uterine and bladder prolapse. Exam Have patient do enema whi le in the clinic and observe prolapse. Assess strength of sphincter muscles and evaluate fo r anterior compartment prolapse. Perform colonoscopy to look for possible lead point and fo r possible solitary rectal ulcer. Management Stool bulking agents (fiber). Surgery is mains tay. Two approaches, either transperineal or transabdominal. Best result with transabdomina l but depends on health of patient. Colonic resection recommended if constipation is presen t. Incontinence improves in 80% of patients with repair of prolapse alone. Transperineal pr ocedures \212 \212 \212 Transabdominal approaches \212 \212 Delorme: Rectal mucosectomy Altemeier: Full-thickness rectal resection transanally Tirsch w ire: Suture around the anus Ripstein rectopexy: Anterior mesh rectopexy Open suture rectopexy or Laparoscopic Wells pro cedure: Presacral suture rectopexy Frykman-Goldberg: Sigmoid resection with presacral sutur e rectopexy Anterior resection 490 \212 \212 Fecal incontinence Inability to control the loss of gas or stool per anus. In women, the ma jor- ity of cases are the result of obstetrical injury (forceps, vacuum, third- and fourth- degree tears). Prevalence is 0.5 \200\22311%. Requires frequent pad usage. Anatomy The inte rnal sphincter is innervated by intestinal myenteric plexus and is under involuntary contro l; it provides a large portion of anal tone, which is further increased by the external sph incters innervated by the pudendal nerve and under voluntary control. Exam Patulous anus and anal excoriation. Tests \212 Pudendal nerve terminal motor latency to document functioning nerves \212 Transrectal US to demonstrate sphincter defects \212 Anorectal manometry to record resting and squeeze tone Management Imodium will increase int ernal sphincter tone. Surgical correction with overlapping sphincteroplasty has a 50% 5-yr suc- cess rate. Can be repeated. Newer options include sacral stimulation and the artificia l bowel sphincter. y r e g r u S Hemorrhoids The anus is lined by mainly discontinuous areas of spongy vascular tissue \200 \224 the anal cushions \200\224which contribute to anal closure. Viewed from the litho- tom y position, their positions are at 3, 7, and 11 o \200\231clock or right anterior and poste rior and left lateral. Hemorrhoids are attached by smooth muscle and elastic tissue to the supporting structure of the anal canal, but are prone to displacement and disruption, eithe r singly or together. The effects of gravity (our erect posture), increased anal tone, and straining at stool may make them become both bulky and loose and so protrude. They are vuln erable to trauma and bleed readily from the capillaries of the under- lying lamina propria, hence their name \200\224 hemorrhoids (meaning \200\234running blood \200\235 in Greek). Because the bleeding is from capillaries, it is bright red. (Hemorrhoids are not varicose v eins.) Symptoms The patient notices bright red rectal bleeding, often coating stools or dri pping into the pan after defecation. There may be mucous discharge and pruritus ani. Severe anemia may occur. Often patients complain of mass that needs to be pushed back into the an us. If patient complains of pain, either fissure or thrombosed hemorrhoid* is present. As t here are no sensory fibers above the dentate line (squamomucosal junction), hemorrhoids are not painful unless they thrombose when protruded. Fissures and hemorrhoids commonly occur together. Exam \212 \212 \212 \212 to R/O other diseases Abdominal examination Rectal examination: Proctoscopy Sigmoidoscopy higher up than the rect osigmoid junction). Prolapsing hemorrhoids are obvious. to see the internal hemorrhoids to identify rectal pathology higher up (you can get no Classification and treatment All patients should be instructed in the use of a high-fiber d iet and refraining from straining and long trips to the bathroom (see Table 13.24). Infrare d coagulation: Applied for 1.5 \200\2232 sec, 3 \200\2238 times to localized areas works by coagulating vessels and tethering mucosa to subcutaneous tissue. Sclerosants: (2 mL of 5% phenol in oil injected above the dentate line) SE : Impotence; prostatitis. Rubber band lig ation: Do fewer than three band-treatments per session; a cheap treatment, but needs skill. Banding produces an ulcer to anchor the mucosa (see: Pain, bleeding, infection). Conventio nal hemorrhoidectomy: Excision and ligation of vascular pedicles. Done as day-case surgery, needing 2 wks off work. SE: Hemorrhage or stenosis. Stapled hemorrhoidectomy: Results in a quicker return to normal activity than conventional surgery because of less pain. Will no t remove large pro- truding anal tags (fourth-degree). 491 Table 13.24 Hemorrhoidal classification and treatment Stage I Definition Enlarged with bleeding Treatment Fiber Suppositories Sclerotherapy Fiber Suppositories Banding Fiber Banding Conve ntional or stapled hemorrhoidectomy II Protrusion with spontane- ous reduction III Protrusion requiring manual reduction IV Irreducible protrusion Fiber Stapled hemorrhoidectomy in selected cases Conventional hemorrhoidectomy Treatment of prolapsed, thrombosed hemorrhoid is with excision if <72 h, otherwise analgesi a, sitz baths, and bed rest. Pain usually resolves in 2 wks. Anal fissure Anal fissure is a midline longitudinal split in the squamous lining of the low er anus, often, if chronic, with a mucosal tag at the external aspect \200\224the \200\234 sentinel pile. \200\235 90% are posterior (anterior ones follow parturition) and are perpet uated by internal sphincter spasm. Defecation is very painful and spasm may constrict the r ectal artery, making healing difficult. Causes Primary cause: Diarrhea or hard stools, acqu ired disorder. Rare causes: Syphilis, herpes, trauma, Crohn \200\231s, anal cancer, psorias is; more common in the lateral location. Exam Examine with a bright light. Do a digital rec tal exam sigmoidoscopy. Groin nodes suggest a complicating factor (e.g., immunosuppressi on from HIV). Treatment Try 2% lidocaine ointment, extra dietary roughage + good anal toile t, sitz baths. Glyceryl trinitrate ointment (0.2 \200\2230.3%) or 0.2% nifedipine ointment relieves pain and ischemia caused by chronic fissures and spasm and can prevent need for su rgery, but may cause headache. If conservative measures fail, consider day-case lateral par tial internal sphincterotomy . Manual anal dilatation (under general anesthesia) is also us ed but has fallen out of favor due to increased risk of postop anal incontinence (24.3% vs. 4.8% for lateral sphincterotomy). Pilonidal sinus/cyst Obstruction of natal cleft hair fol licles 6 cm above the anus, with ingrowing of hair; excites a foreign-body reaction and ma y cause secondary tracts that open laterally abscesses, with foul-smelling discharge. Tr eatment is excision of the sinus tract primary closure, but is unsatis- factory in 10% o f patients. Complex tracts can be laid open and packed individually, or skin flaps can be u sed to cover the defect. 492 Anal ulcers are rare. Consider Crohn \200\231s disease, anal cancer, TB, syphilis. Skin tag s seldom cause trouble but are easily excised. Anorectal abscess/fistula is usually caused by enteric organisms (rarely S . aureus or tuberculosis [TB]). Location: Perianal ( 45%), i schiorectal (30%), intersphincteric (>20%), supralevator ( 5%). Redness and swelling may sp read well into the buttock. Do incision and drainage, usually under GA unless small periana l (+ fistulotomy if needed, e.g., in Crohn \200\231s disease). Associations: DM, Crohn \200 \231s, malignancy. Don \200\231t rely on antibiotics. Anal cancer Increased risk: Syphilis, anal warts (herpesvirus [HPV] 16, 6, 11, and 18 implicated), anoreceptive homosexuals (oft en young). Histology: Squamous cell (80%); rarely, basaloid, melanoma, or adenocarcinoma. T he patient may present with bleeding, pain, bowel habit change, pruritus ani, masses, and s tricture. Differential diagnosis: Condyloma acuminata, leucoplakia, lichen sclerosus, Bowen \200\231s, Paget \200\231s, or Crohn \200\231s disease. Treatment: Radiotherapy + 5-FU + m itomycin/cisplatin is usually preferred to anorectal excision and colostomy, and 75% of pat ients retain normal anal function. y r e g r u S Gastric and duodenal ulcer disease Ulcerative disease of the stomach and duodenum has decli ned in incidence sharply from levels seen in 1960. Risk factors include smoking, NSAID use, Helicobacter pylori , and increased acid production or a defect in mucosal defense. Sympto ms Cardinal feature is epigastric pain described as burning, stabbing, or gnawing relieved by eating or antacids. Other associated symptoms include nausea, vomiting, bleeding, weight loss. Differential diagnosis includes cholelithiasis, pancreatitis, pancreatic cancer, MI, and gastric neoplasia. Evaluation \212 Barium swallow and upper GI study H. pylori \212 EGD: Biopsy for neoplasia and Recurrent peptic ulceration in unusual places; think of Zolli nger \200\223Ellison \212 syndrome (gastrinoma). Do secretin stimulation test. Medical management \212 Treat H. pylori \212 Antihistamines \212 Proton pump inhibitors \212 Prostaglandin analogs \212 Sucralfate \212 Antacids Surgical management Operative i ntervention is reserved for the treatment of complicated ulcer disease (intractability, hem orrhage, perforation, obstruction). Operations for benign gastric ulceration Elective opera tion for gastric fundus ulceration is rarely needed as ulcers respond well to medical treat ment, stopping smoking, and avoidance of NSAIDs. Emergency surgery is sometimes needed for hemorrhage or per- foration. Hemorrhage is usually treated by underrunning the bleeding ulc er base or excision of the ulcer. If the former is done, then a biopsy should be taken to e xclude malignancy. Perforation is usually managed by excision of the hole for histology, th en closure. Prepyloric ulceration is considered peptic disease and an anti-acid procedure s hould be considered, especially if the patient has been on acid suppression therapy. 493