Surgical Problems in Primary Care Stories from My Life Ronald H. - PowerPoint PPT Presentation

3/17/2015 Surgical Problems in Primary Care: Surgical Problems in Primary Care Stories from My Life Ronald H. Labuguen, MD Ronald H. Labuguen, MD Clinical Professor Associate Clinical Professor UCSF Department of Family and Community Medicine UCSF Department of Family and Community Medicine -o- -o- UCSF Family Medicine Board Review Course UCSF Family Medicine Board Review Course March 17, 2015 March 11, 2014 Faculty Disclosure Objectives • I have nothing to disclose • Tell you as many stories as I can involving surgical problems in 1 hour or less • Try to get you through post-lunch dip Source: Boosting Your Energy, a Special Health Report from Harvard Medical School, 2005 1

3/17/2015 The closest I’ll get to being a surgeon Road Map for Our Journey • Gastrointestinal Problems/Acute Abdominal Pain • Preop/periop/postop care, wounds, and infections • Other surgical specialties: – Trauma surgery – Vascular surgery – Thoracic surgery – Otolaryngology/head and neck surgery – Urology – Neurosurgery Right Upper Quadrant Pain • 42 year old woman with right upper quadrant pain • Worse with eating GASTROINTESTINAL PROBLEMS • Nausea, no vomiting • No fever ACUTE ABDOMINAL PAIN • Exam: – Tender to palpation in the RUQ – Murphy’s sign: reproducible pain & halts breathing on inspiration on palpation at right costal margin at the midclavicular line 2

3/17/2015 If you’re lucky . . . Heilman J. File:StonesXray.PNG [Wikimedia Commons Web site]. March 6, 2011. Available at: http://commons.wikimedia.org/wiki/File:StonesXray.PNG. RUQ Ultrasound = Test of Choice Right Upper Quadrant Pain • 84-year-old woman • 3 month history of diffuse abdominal pain • 40 pound weight loss • Exam: – hard, nontender, baseball-sized mass in the right upper quadrant Heilman J. File:Gallstones.PNG [Wikimedia Commons Web site]. March 18, 2011. Available at: http://commons.wikimedia.org/wiki/File:Gallstones.PNG. 3

3/17/2015 “Porcelain gallbladder”: “Porcelain gallbladder”: Look for cancer Look for cancer Fred H, van Dijk H. Images of Memorable Cases: Case 19 [Connexions Web site]. Fred H, van Dijk H. Images of Memorable Cases: Case 19 [Connexions Web site]. December 4, 2008. Available at: http://cnx.org/content/m14939/1.3/. December 4, 2008. Available at: http://cnx.org/content/m14939/1.3/. Cholangiocarcinoma 4

3/17/2015 Cholangiocarcinoma: Klatskin tumor: Klatskin tumor Palliative stent placement Hellerhoff. File:Klatskintumor-ERC.jpg [Wikimedia Commons Web site]. July 15, 2011. Hellerhoff. File:Klatskintumor-Stents.jpg [Wikimedia Commons Web site]. July 15, Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-ERC.jpg . 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-Stents.jpg. Case: 34 yo man with Right Lower Right Lower Quadrant Pain Quadrant Pain in Urgent Care • Know: • 5 day history – Differential diagnosis – Periumbilical for 3 days, then right lower quadrant for 2 days • Typical story • Physical exam • Distinguishing characteristics • Diagnostics – Tenderness to palpation at McBurney’s point • Initial and definitive treatment • Red flags – Demographics matter: Age, Sex 5

3/17/2015 Case: 34 yo man with Right Lower McBurney’s Point (#1) Quadrant Pain in Urgent Care • 5 day history – Periumbilical for 3 days, then right lower quadrant for 2 days • Physical exam – Tenderness to palpation at McBurney’s point – (-) psoas, (+) obturator signs • Labs – Normal Fruitsmaak S. File:McBurney’s_point.jpg [Wikimedia Commons Web site]. September 24, 2006. Available at: http://commons.wikimedia.org/wiki/File:McBurney%27s_point.jpg. Case: 34 yo man with Right Lower Appendicitis on CT Quadrant Pain in Urgent Care • Appendectomy is treatment of choice • Conservative treatment with antibiotics and watchful waiting? – “Not non-inferior” in an open label RCT – Ref: Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non- inferiority, randomised controlled trial. Lancet 2011; 377: 1573-1579. Heilman J. File:Appy4.jpg [Wikimedia Commons Web site]. April 24, 2010. Available at: http://commons.wikimedia.org/wiki/File:Appy4.jpg. 6

3/17/2015 Appendicitis: Red Flags Appendicitis: Red Flags • Signs of rupture • Higher proportion of patients with ruptured – Change in condition: appendicitis at the • Fever extremes of age (early • Increased pain childhood, elderly) • Abdominal rigidity – Could see improvement in pain (think of a walled- off ruptured abscess) until peritonitis more fully develops Psychopoesie. File:Grandma&me_at_my_cousin’s_wedding.jpg [Wikimedia Commons Web site]. October 31, 2011. Available at: http://commons.wikimedia.org/wiki/File:Grandma%26me_at_my_cousin%27s_wedding.jpg . Appendicitis: Final Point Chan Ho Park • Atypical presentations are common and potentially deadly – Always consider retrocecal appendicitis – One or more typical findings may be absent 7

3/17/2015 Meckel’s Diverticulum Meckel’s Diverticulum: Rule of 2’s • 2% prevalence • 2 years of age at presentation • 2 feet from the ileocecal junction • 2 inches in length • 2 types of common ectopic tissue – Gastric – Pancreatic • 2% symptomatic • 2 times more symptomatic in boys Left Lower Quadrant Pain Diverticulitis • Typical story: – Acute constant abdominal pain in LLQ – Fever – Can also see nausea, vomiting, constipation, diarrhea – “Sympathetic cystitis”: dysuria and frequency caused by bladder irritation from inflamed colon • Typical physical exam findings: – LLQ tenderness, guarding, rebound 8

3/17/2015 Diverticulitis Diverticulitis • Diagnostics: – Leukocytosis – CT of abdomen and pelvis with contrast Heilman J. File:Diverticulitis.png [Wikimedia Commons Web site]. June 2, 2011. Available at: http://en.wikipedia.org/wiki/File:Diverticulitis.png. Diverticulitis Diverticulitis: Treatment • Risk factors: Smoking, obesity • Uncomplicated – Stable, tolerating oral fluids: outpatient • Negative risk factor: Increased physical activity Traditionally: PO antibiotics x 7-10 d., clear liquid diet • Associated with complications: More recent evidence questions role of antibiotics – Yes: NSAIDs, opioids, corticosteroids Cochrane review – best available data do not support – No: Recurrences No effect on complications, need for surgery, recurrence, median length of inpatient stay • Recurrences are uncommon (13.3%) & not – Older or ill pts, not tolerating fluids: admit clustered IV fluids, bowel rest/NPO, ? Antibiotics Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid Diverticulitis: A Chabok A, Pahlman L, Hjern F et al. Randomized clinical trial of antibiotics Systematic Review. JAMA. 2014;311(3):287-297. for acute uncomplicated diverticulitis. Br J Surg 2012;99(4):532-539. http://jama.jamanetwork.com/article.aspx?articleid=1814217 Shabanzadeh DM, Wille-Jorgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009092. 9

3/17/2015 Diverticulitis: Treatment Diverticulitis: Treatment • Complicated (sepsis, perforation, abscess, fistula, • Other nonoperative treatments obstruction) – Probiotics: reduce chronic symptoms but not • stabilize, IV fluids, antibiotics, surgical consultation, recurrences percutaneous drainage, intraperitoneal lavage – Antiinflammatory medications: mesalamine + • Antibiotics to cover anaerobes, gram negative rods: – Metronidazole or clindamycin (Cleocin) –PLUS one of the rifaximin reduces recurrences vs. rifaximin alone following: aminoglycoside, monobactam (aztreonam), or third generation cephalosporin – Second generation cephalosporin – Extended spectrum penicillin/beta-lactamase inhibitor combinations – Newer evidence: ertapenem, rifaximin Case: 62 yo man with painless rectal Diverticulitis: Treatment bleeding in the ED • Indications for surgery – Sepsis, acute peritonitis – No improvement with medical therapy, percutaneous drainage, or both – Trend toward minimally invasive surgical techniques Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. Published online January 15, 2014. http://archsurg.jamanetwork.com/article.aspx?articleid=1813806 10

3/17/2015 Diverticulosis Diverticulosis • Most common cause of major lower GI bleeding • Arterial • Typical story: Painless abrupt onset, voluminous bleeding • Diagnostics: nuclear bleeding scan, angiography, colonoscopy • Treatment: colonoscopy; may require surgery Hellerhoff. File:Sigmadvivertikulose CT axial.jpg [Wikimedia Commons Web site]. December 23, 2010. Available at: http://commons.wikimedia.org/wiki/Sigmadivertikulose_CT_axial.jpg. Diverticulosis Volvulus • Midgut volvulus from malrotation of the gut • Sigmoid volvulus 11