PAEA Surgery Study Guide | PAEA Surgery Blueprint Gastrointestinal/Nutritional ; ABDOMINAL PAIN.
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PAEA
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PAEA
PAEA Surgery Blueprint Gastrointestinal/Nutritional (50%) ABDOMINAL PAIN Acute Abdomen Caused by Perforation o Sudden onset o Constant, generalized, very severe o Tenderness, msl guarding, rebound, silent abdomen o Pt lies still o Diagnosis Free air under diaphragm in upright Xray o Treatme...
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PAEA Surgery Blueprint
Gastrointestinal/Nutritional (50%)
ABDOMINAL PAIN
Acute Abdomen
Caused by Perforation
o Sudden onset
o Constant, generalized, very severe
o Tenderness, msl guarding, rebound, silent abdomen
o Pt lies still
o Diagnosis
Free air under diaphragm in upright Xray
o Treatment
Emergency surgery
Caused by obstruction of a narrow duct
o Ureter, cystic, common
o Sudden onset of very severe colicky pain
o Location according to source
o Pt constantly moving
Caused by inflammatory process
o Gradual onset (6-12 hrs)
o Constant pain, starts general but becomes localized
o Systemic signs (fever, leukocytosis)
Treatment for generalized acute abdomen = exploratory laparotomy
HEARTBURN/DYSPEPSIA
Gastroesophageal Reflux Disease (GERD)
Basics
o Transient relaxation of LES (incompetent) => gastric acid reflux => esophageal
mucosal injury
o Complications
Esophagitis, esophagus stricture, esophageal adenocarcinoma
Barrett’s esophagus: esophageal squamous epithelium replaced by
precancerous metaplastic columnar cells
Manifestations
o Hallmark = heartburn
Retrosternal, postprandial
o Regurgitation
o Dysphagia
o Cough at night
o “ALARM” sx
Dysphagia, odnophagia, weight loss, bleeding
Suspect malignancy
Diagnosis
o Clinical
o Endoscopy
Often used first
o Esophageal manometry
Done is endoscopy normal
o 24hr ambulatory pH monitoring
Gold standard
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Not done often
Management
o Stage 1: Lifestyle Modifications
Elevation of the head of the bed
Avoid recumbence for three hours after eating
Eat small meals
Avoid certain foods (fatty, spicy, citrus, chocolate, caffeine)
Decrease fat & ETOH intake
Weight loss
Smoking cessation
o Stage 2: As Needed” Pharmacological Therapy
Antacids
OTC H2 receptor antagonists (“-tidine”)
***If “ALARM” sx, do endoscopy
o Stage 3: Scheduled Pharmacologic Therapy
Meds
H2RA
Proton Pump Inhibitors (“-azole”)
o Drug of choice in severe disease
Cisapride
Nissen Fundoplication
If refractory
Achalasia
Basics
o Loss of Aurbach’s plexus => increased LES pressure
Failure of LES relaxation
Manifestations
o Dysphagia to BOTH solids & liquids
o Weight loss
o Regurgitation of undigested food
o Chest pain
o Cough
Diagnosis
o Esophageal manometry (gold standard)
Increased LES pressure (> 40 mmHg)
o Double-contrast esophagram
Bird’s beak appearance
Management
o Decrease LES pressure
Botox injection (temporary relief)
Nitrates
CCBs
Dilation of LES
Esophagomyomectomy
JAUNDICE
Basics
Yellowing of skin, nail beds, sclera
o Due to tissue bilirubin distribution
*Not a disease but a sign of disease
Occurs when bilirubin > 2.5 mg/dL
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Types
Hemolytic
o Low level (6-8)
o Elevated bilirubin is unconjugated (indirect)
o Work up should determine what is causing issue with RBCs
Hepatocellular
o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (modest)
o Hepatitis (direct workup this way)
Obstructive
o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (v. high)
o Workup => U/S
Look for obstruction
HEMATEMESIS
Denotes upper GI source
Diagnosis: UGI endoscopy
Corrosive Esophagitis
Basics
o Etiology: ingestion of corrosive substance
Manifestations
o Odynophagia, dysphagia, hematemesis, dyspnea
Diagnosis
o Endoscopy
Management
o Supportive
o Pain meds
o IV fluids
Boerhaave’s Syndrome
Basics
o Full thickness rupture of distal esophagus
o Associated with repeated vomiting (bulimia), iatrogenic perforation
Manifestations
o Retrosternal chest pain worse with deep breathing and swallowing
o Hematemesis
o PE: crepitus on chest auscultation due to pneumomediastinum
Diagnosis
o Chest CT
Management
o Surgical repair
Mallory-Weiss Syndrome (Tears)
Basics
o UGI bleeding due to longitudinal mucosal lacerations @ gastroesophageal junction or gastric
cardia (superficial)
o Sudden rise in intragastric pressure or gastric prolapse into esophagus
Persistent retching/vomiting
Alcohol binge
Bulimia
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Manifestations
o Retching/vomiting => hematemesis after an alcohol binge
o Melena, hematochezia, syncope, ab pain, hydrophobia
Diagnosis
o Upper endoscopy
Management
o Supportive if no active bleeding
o Active bleeding => epi injection, sclerosing agent, band ligation, hemo-clipping or balloon
tamponade
Esophageal Varices
Basics
o Dilation of gastroesophageal collateral, submucosal veins
Complication of portal vein HTN
o Risk factor: cirrhosis
Manifestations
o Upper GI Bleed (hematemesis, melena, hematochezia)
o Hypovolemia possible
Diagnosis
o Upper endoscopy (enlarged veins)
Management
o Endoscopic intervention
Ligation
o Vasoconstrictors
Octreotide, vasopressin
o Balloon tamponade
o Surgical decompression
Transjugular intrahepatic portosystemic shut (TIPS)
Prevention of re-bleeds
o Nonselective beta blockers
Propranolol, Nadolol
o Isosorbide
ABX prophylaxis
o Fluoroquinolones (Nofloxacin)
o Ceftriaxone
Gastritis
Basics
o Superficial inflammation/irritation of stomach mucosa (with mucosal injury)
o Causes: H. pylori, NSAIDs, acute stress
Manifestations
o MC asymptomatic
o Upper GI bleed (hematemesis, melena)
o Epigastric pain, N/V, anorexia
Diagnosis
o Endoscopy
Management
o H. pylori +
CAP: clarithromycin + amoxicillin + PPI
o H. pylori –
PPI, antacids, H2RA, sucralfate
Others = Gastric Carcinoma
MELENA/HEMATOCHEZIA
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