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

3/26/2013 Surgical Problems in Primary Care: Surgical Problems in Primary Care Stories from My Life Ronald H. Labuguen, MD Ronald H. Labuguen, MD Associate 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 26, 2013 March 26, 2013 Objectives The closest I’ll get to being a surgeon • 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

3/26/2013 Road Map for Our Journey • Gastrointestinal Problems/Acute Abdominal Pain • Preop/periop/postop care, wounds, and infections • Other surgical specialties: GASTROINTESTINAL PROBLEMS – Trauma surgery – Vascular surgery ACUTE ABDOMINAL PAIN – Thoracic surgery – Otolaryngology/head and neck surgery – Urology – Plastic surgery – Neurosurgery Right Upper Quadrant Pain • 42 year old woman with right upper quadrant pain • Worse with eating • Nausea, no vomiting • No fever • 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

3/26/2013 If you’re lucky . . . RUQ Ultrasound = Test of Choice Heilman J. File:StonesXray.PNG [Wikimedia Commons Web site]. March 6, 2011. Heilman J. File:Gallstones.PNG [Wikimedia Commons Web site]. March 18, 2011. Available at: http://commons.wikimedia.org/wiki/File:StonesXray.PNG. Available at: http://commons.wikimedia.org/wiki/File:Gallstones.PNG. “Porcelain gallbladder”: Right Upper Quadrant Pain Look for cancer • 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 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/. 3

3/26/2013 “Porcelain gallbladder”: Cholangiocarcinoma Look for cancer 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/. Cholangiocarcinoma: Klatskin tumor Hellerhoff. File:Klatskintumor-ERC.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-ERC.jpg . 4

3/26/2013 Klatskin tumor: Right Lower Quadrant Pain Palliative stent placement • Know: – Differential diagnosis • Typical story • Distinguishing characteristics • Diagnostics • Initial and definitive treatment • Red flags – Demographics matter: Age, Sex Hellerhoff. File:Klatskintumor-Stents.jpg [Wikimedia Commons Web site]. July 15, 2011. Available at: http://commons.wikimedia.org/wiki/File:Klatskintumor-Stents.jpg. 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 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. 5

3/26/2013 Case: 34 yo man with Right Lower Appendicitis on CT 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 Heilman J. File:Appy4.jpg [Wikimedia Commons Web site]. April 24, 2010. Available at: http://commons.wikimedia.org/wiki/File:Appy4.jpg. Case: 34 yo man with Right Lower Appendicitis: Red Flags Quadrant Pain in Urgent Care • Appendectomy is treatment of choice • Signs of rupture – Change in condition: • Conservative treatment with antibiotics and • Fever watchful waiting? • Increased pain – “Not non-inferior” in an open label RCT • Abdominal rigidity – Ref: Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of – Could see improvement in pain (think of a walled- acute uncomplicated appendicitis: an open-label, non- off ruptured abscess) until peritonitis more fully inferiority, randomised controlled trial. Lancet 2011; 377: develops 1573-1579. 6

3/26/2013 Appendicitis: Red Flags Appendicitis: Final Point • Incidence of ruptured • Atypical presentations are common and appendicitis is higher at potentially deadly the extremes of age – Always consider retrocecal appendicitis (early childhood, – One or more typical findings may be absent elderly) 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 . Chan Ho Park Meckel’s Diverticulum 7

3/26/2013 Meckel’s Diverticulum: Rule of 2’s Left Lower Quadrant Pain • 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 Diverticulitis Diverticulitis • Typical story: • Diagnostics: – Acute constant abdominal pain in LLQ – Leukocytosis – Fever – CT of abdomen and pelvis with contrast – 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

3/26/2013 Diverticulitis Diverticulitis: Treatment • Uncomplicated – Stable, tolerating oral fluids: outpatient PO antibiotics x 7-10 d. metronidazole + [either fluoroquinolone or trimethoprim/sulfasoxazole], or amoxicillin/clavulanate Clear liquid diet – Older or ill pts, not tolerating fluids: admit IV antibiotics, IV fluids, bowel rest/NPO Heilman J. File:Diverticulitis.png [Wikimedia Commons Web site]. June 2, 2011. Available at: http://en.wikipedia.org/wiki/File:Diverticulitis.png. Diverticulitis Diverticulitis • Complicated (sepsis, perforation, abscess, fistula, • Indications for surgery obstruction) – not responding to medical management • stabilize, IV fluids, IV antibiotics, surgical consultation, – repeated attacks percutaneous drainage • IV antibiotics to cover anaerobes, gram negative – more urgent if evidence of abscess, fistula, rods: obstruction, or perforation – Metronidazole or clindamycin (Cleocin) –PLUS one of the following: aminoglycoside, monobactam (aztreonam), or third generation cephalosporin – Second generation cephalosporin – Extended spectrum penicillin/beta-lactamase inhibitor combinations 9

3/26/2013 Case: 62 yo man with painless rectal Diverticulosis bleeding in the ED • 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 Diverticulosis Diverticulosis Hellerhoff. File:Sigmadvivertikulose CT axial.jpg [Wikimedia Commons Web site]. December 23, 2010. Available at: http://commons.wikimedia.org/wiki/Sigmadivertikulose_CT_axial.jpg. 10

3/26/2013 Midgut Volvulus: Volvulus Malrotation of the Gut • Typical story: • Midgut volvulus from malrotation of the gut – 1 st month of life: bilious vomiting, feeding intolerance, sudden onset of • Sigmoid volvulus abdominal pain, upper abdominal distention – More vague sx in older children • Diagnostics – Physical exam: normal, or subtle findings – Abdominal x-ray: “double bubble” sign (gastric and duodenal dilatation); lack gas in lower GI tract; pneumatosis coli (ominous sign) – UGI contrast w/ “bird’s beak”, spiral, corkscrew signs of duodenal obstruction • Treatment: Ladd procedure Sigmoid Volvulus Epigastric Pain • Older patients • Typical story – sx of bowel obstruction/ischemia: – Abdominal pain, distention, inability to pass stool or flatus (obstipation), history of constipation – Vomiting may be late presenting feature • Diagnostics: abdominal x-ray shows distended sigmoid colon • Treatment: sigmoidoscopy/rectal tube placement; resection & primary anastomosis 11

3/26/2013 Case: 34 yo man with epigastric pain Grey-Turner’s Sign • Ranson’s criteria at • Ranson’s criteria at 48 admission: GA LAW hours: Cal(vin) & HOB(BE)S • Glucose > 200 • Calcium < 8 • AST > 250 • Hematocrit drop > 10 % pts • LDH > 350 • pO 2 < 60 • Age > 55 • BUN incr > 5 after fluid hydration • WBC > 16 • Base deficit > 4 (Base Excess < -4) • Sequestration of fluid > 6 L Fred H, van Dijk H. Images of Memorable Cases: Case 21 [Connexions Web site]. December 3, 2008. Available at: http://cnx.org/content/m14942/1.3/. Grey Turner’s Sign Cullen’s Sign 1. The correct eponym for bruising of the flanks caused by acute pancreatitis or other causes is A. Grey Turner’s Sign B. Grey-Turner’s Sign C. Gray Turner’s Sign D. Gray-Turner’s Sign E. Turner’s Sign Fred H, van Dijk H. Images of Memorable Cases: Case 120 [Connexions Web site]. December 8, 2008. Available at: http://cnx.org/content/m14904/1.3/. 12