418 17 Common Surgical Disorders Abdominal Aortic Aneurysm ■ Essentials of Diagnosis • Overall incidence in patients over age 60 years is 2–6.5% • More than 90% originate below the renal arteries • Most asymptomatic, discovered incidentally at physical exami- nation or sonography • Abdominal ultrasound has sensitivity approaching 100% • Back or abdominal pain often precedes rupture • Abdominal aortic aneurysm diameter is the most important pre- dictor of aneurysm rupture • Most rupture leftward and posteriorly; left knee jerk may thus be lost • Generalized arteriomegaly in many patients ■ Differential Diagnosis • Pancreatic pseudocyst, pancreatitis • Multiple myeloma • Musculoskeletal causes of back pain • Renal colic • Bleeding peptic ulcer ■ Treatment • In asymptomatic patients, depending on age and presence of other medical conditions, surgery is recommended when the aneurysm is >5 cm • Resection may be beneficial even for aneurysms as small as 4 cm • In symptomatic patients, immediate repair irrespective of size • Endovascular repair (transfemoral insertion of a prosthetic graft) considered if the anatomy of aneurysm is suitable (ie, graft can be secured infrarenally); long-term durability of endovascular grafts is unknown ■ Pearl In upper gastrointestinal hemorrhage in patients over age 60 with a normal upper endoscopy, consider aortoenteric fistula. Reference Santilli JD et al: Diagnosis and treatment of abdominal aortic aneurysms. Am Fam Physician 1997;56:1081. [PMID: 9310060] Copyright 2002 The McGraw-Hill Companies, Inc. Click Here for Terms of Use. Pharyngoesophageal Diverticulum (Zenker’s Diverticulum) ■ Essentials of Diagnosis • Most prevalent in the fifth to eighth decades of life • Results from herniation of the mucosa through a weak point in the muscle layer proximal to the cricopharyngeal muscle • Dysphagia worsening as more is eaten; regurgitation of undigested food, halitosis • Gurgling sounds in the neck on auscultation • Barium swallow confirms diagnosis by demonstrating the sac ■ Differential Diagnosis • Esophageal, mediastinal, or neck tumor • Cricopharyngeal achalasia (occasionally associated) • Esophageal web • Achalasia or lower esophageal stricture • Epiphrenic diverticulum (lower esophagus) ■ Treatment • There is no medical therapy; all patients should be considered candidates for surgical treatment ■ Pearl Unsuspected Zenker’s diverticulum may be inadvertently perforated at upper endoscopy, a reason to perform contrast radiography prior to esophagoduodenoscopy. Reference Sideris L et al: The treatment of Zenker’s diverticula: a review. Semin Thorac Cardiovasc Surg 1999;11:337. [PMID: 10535375] Chapter 17 Common Surgical Disorders 419 17 Malignant Tumors of the Esophagus ■ Essentials of Diagnosis • Progressive dysphagia—initially during ingestion of solid foods, later with liquids; progressive weight loss ominous • Smoking, alcohol, asbestos, gastroesophageal reflux disease are risk factors • Classic radiographic appearance with irregular mucosal pattern and narrowing, with shelf-like upper border or concentrically nar- rowed esophageal lumen • CT scan delineates extent of disease • Adenocarcinoma (often associated with reflux-induced Barrett’s esophagus) now has incidence similar to that of squamous cell ■ Differential Diagnosis • Benign tumors of the esophagus (< 1%) • Benign esophageal stricture • Esophageal diverticulum • Esophageal webs • Achalasia (may be associated) • Globus hystericus ■ Treatment • In 75–80% of patients, local tumor invasion or distant metastasis at the time of presentation precludes cure • For patients with localized primary, resection (when feasible) pro- vides the best palliation • Adjuvant chemotherapy with radiation therapy or surgical resec- tion results in cure for only 10–15% • Expandable metallic stent placement, laser fulguration, feeding tube placement with or without radiation therapy for additional palliation ■ Pearl True dysphagia—food sticking upon swallowing—has nearly 100% association with anatomic lesions. Reference Fox JR et al: Today’s approach to esophageal cancer. What is the role of the pri- mary care physician? Postgrad Med 2000;107:109. [PMID: 108444946] 420 Essentials of Diagnosis & Treatment 17 Obstruction of the Small Intestine ■ Essentials of Diagnosis • Defined as partial or complete obstruction of the intestinal lumen by an intrinsic or extrinsic lesion • Etiology: adhesions (eg, from prior surgery or pelvic inflamma- tory disease) 60%, malignancy 20%, hernia 10%, inflammatory bowel disease 5%, volvulus 3%, other 2%. • Crampy abdominal pain, vomiting (often feculent in complete obstruction), abdominal distention, constipation or obstipation • Distended, tender abdomen with or without peritoneal signs; high-pitched tinkling or peristaltic rushes audible • Patients often intravascularly depleted secondary to emesis, de- creased oral intake, and sequestration of fluid in the bowel wall and lumen and the peritoneal cavity • Plain films of the abdomen show dilated small bowel with more than three air-fluid levels ■ Differential Diagnosis • Adynamic ileus due to any cause (eg, hypokalemia, pancreatitis, nephrolithiasis, recent operation or trauma) • Colonic obstruction • Intestinal pseudo-obstruction ■ Treatment • Nasogastric suction • Fluid and electrolyte (especially potassium) replacement with iso- tonic crystalloid • Most management decisions are based on the distinction between partial and complete obstruction • Surgical exploration for suspected hernia strangulation, or ob- struction not responsive to conservative therapy ■ Pearl Although Osler referred to adhesions as “the refuge of the diagnosti- cally destitute,” they remain the most common cause of small bowel obstruction. Reference Wilson MS et al: A review of the management of small bowel obstruction. Mem- bers of the Surgical and Clinical Adhesions Research Study (SCAR). Ann R Coll Surg Engl 1999;81:320. [PMID: 10645174] Chapter 17 Common Surgical Disorders 421 17 Functional Obstruction (Adynamic Ileus, Paralytic Ileus) ■ Essentials of Diagnosis • History of precipitating factor (eg, recent surgery, peritonitis, other serious medical illness, anticholinergic drugs, hypokal- emia) • Continuous abdominal pain, distention, vomiting, and obstipation • Minimal abdominal tenderness; decreased to absent bowel sounds • Radiographic images show diffuse gastrointestinal organ dis- tention ■ Differential Diagnosis • Mechanical obstruction due to any cause • Specific diseases associated with functional obstruction (ie, per- forated viscus, pancreatitis, cholecystitis, appendicitis, nephro- lithiasis) • Colonic pseudo-obstruction (Ogilvie’s syndrome) ■ Treatment • Restriction of oral intake; nasogastric suction in severe cases • Attention to electrolyte and fluid imbalance (ie, hypokalemia, dehydration) • Prokinetic drugs (metoclopramide, erythromycin) may be tried • Laparotomy should be avoided if at all possible to avert the sub- sequent risk of mechanical obstruction from adhesions ■ Pearl Lower lobe pneumonia may on occasion cause adynamic ileus. Reference Dorudi S et al: Acute colonic pseudo-obstruction. Br J Surg 1992;79:99. [PMID: 1555081] 422 Essentials of Diagnosis & Treatment 17 Acute Appendicitis ■ Essentials of Diagnosis • Consider in all patients with unexplained abdominal pain; 6% of the population will have appendicitis in their lifetime • Anorexia invariable • Abdominal pain, initially poorly localized or periumbilical, then localizing to the right lower quadrant over 4–48 hours in two- thirds of patients • Abdominal plain films and pattern of bowel function are of little diagnostic value • Low-grade fever, right lower quadrant tenderness at McBurney’s point with or without peritoneal signs • Pelvic and rectal examinations are critically important • Mild leukocytosis (10,000–18,000/µL) with PMN predomi- nance; microscopic hematuria or pyuria is common • Consider pelvic ultrasound (in women) and CT scan to differen- tiate surgical from nonsurgical pathologic conditions ■ Differential Diagnosis • Gynecologic pathology (eg, ectopic pregnancy, pelvic inflamma- tory disease, endometriosis, mittelschmerz, twisted ovarian cyst) • Urologic pathology (eg, testicular torsion, acute epididymitis) • Nephrolithiasis • Urinary tract infection or pyelonephritis • Perforated peptic ulcer • Inflammatory bowel disease • Meckel’s diverticulitis • Mesenteric adenitis • Acute cholecystitis • Right lower lobe pneumonia ■ Treatment • Open or laparoscopic appendectomy • Certainty in diagnosis remains elusive (10–30% of patients are found to have a normal appendix at operation) • When diagnosis unclear, observe for several hours with serial examinations, or (if the patient is reliable) schedule return in 8–12 hours for reevaluation ■ Pearl The most common cause of the acute abdomen in every decade of life. Reference Hardin DM Jr: Acute appendicitis: review and update. Am Fam Physician 1999;60:2027. [PMID: 10569505] Chapter 17 Common Surgical Disorders 423 17 Diverticulitis ■ Essentials of Diagnosis • Acute, intermittent cramping left lower abdominal pain; consti- pation in some cases alternating with diarrhea • Fever, tenderness in left lower quadrant, with palpable abdomi- nal mass in some patients • Leukocytosis • Radiographic evidence of diverticula, thickened interhaustral folds, narrowed lumen • CT scan is the safest and most cost-effective diagnostic method ■ Differential Diagnosis • Colorectal carcinoma • Appendicitis • Strangulating colonic obstruction • Colitis due to any cause • Pelvic inflammatory disease • Ruptured ectopic pregnancy or ovarian cyst • Inflammatory bowel disease ■ Treatment • Liquid diet (10 days) and oral antibiotics (metronidazole plus ciprofloxacin or trimethoprim-sulfamethoxazole) for mild first attack • Nasogastric suction and broad-spectrum intravenous antibiotics for patients requiring hospitalization (eg, failed outpatient man- agement, inadequate analgesia) • Percutaneous catheter drainage for intra-abdominal abscess • Emergent laparotomy with colonic resection and diversion for generalized peritonitis, uncontrolled sepsis, visceral perforation, and acute clinical deterioration • High-residue diet, stool softener, psyllium mucilloid for chronic therapy ■ Pearl Left-sided diverticula are more common and more likely to become inflamed; right-sided diverticula are less common and more likely to bleed. Reference Ferzoco LB et al: Acute diverticulitis. N Engl J Med 1998;338:1521. [PMID: 9593792] 424 Essentials of Diagnosis & Treatment 17 Pancreatic Pseudocyst ■ Essentials of Diagnosis • Collection of pancreatic fluid in or around the pancreas; may occur as a complication of acute or chronic pancreatitis • Characterized by epigastric pain, tenderness, fever, and occasion- ally a palpable mass • Leukocytosis, persistent serum amylase elevation • Pancreatic cyst demonstrated by CT scan • Complications include hemorrhage, infection, rupture, fistula for- mation, pancreatic ascites, and obstruction of surrounding organs ■ Differential Diagnosis • Pancreatic phlegmon or abscess • Resolving pancreatitis • Pancreatic carcinoma • Abdominal aortic aneurysm ■ Treatment • Up to two-thirds spontaneously resolve • Avoidance of alcohol • Percutaneous catheter drainage with nutritional support while avoiding oral feedings effective in many cases • Decompression into an adjacent hollow viscus (cystojejunostomy or cystogastrostomy) may be necessary • Octreotide to inhibit pancreatic secretion ■ Pearl There are only two causes of pulsatile abdominal masses: pancreatic pseudocyst and aneurysm. Reference Lillemoe KD et al: Management of complications of pancreatitis. Curr Probl Surg 1998;35:1. [PMID: 9452408] Chapter 17 Common Surgical Disorders 425 17 Hernia ■ Essentials of Diagnosis • Protrusion of a viscus through an opening in the wall of the cav- ity in which it is contained (sac is an outpouching of peritoneum) • Lump or swelling in the groin, sometimes associated with sudden pain and bulging during heavy lifting or straining • Discomfort is worse at the end of the day, relieved when patient reclines and hernia reduces • Clinically distinguishing an indirect from a direct hernia is un- important, since their operative repair is the same • Early symptoms of incarceration are those of partial bowel obstruc- tion; the early discomfort will be periumbilical • A femoral hernia is an acquired protrusion of a peritoneal sac through the femoral ring; smaller, more difficult to palpate and to diagnose ■ Differential Diagnosis • Hydrocele • Varicocele • Inguinal lymphadenopathy • Lipoma of the spermatic cord • Testicular torsion • Femoral artery aneurysm ■ Treatment • In general, all hernias should be repaired unless local or systemic conditions preclude a safe outcome • Elective outpatient surgical repair for reducible hernias • Attempt reduction of incarcerated (irreducible) hernias (when peritoneal signs are absent) with conscious sedation, Trendelen- burg position, and steady, gentle pressure • Emergent repair for nonreducible, incarcerated, or strangulated ■ Pearl The patient tells you he has an inguinal hernia; you tell him he has a femoral hernia. Reference Avisse C et al: The inguinal rings. Surg Clin North Am 2000;80:49. [PMID: 10685144] 426 Essentials of Diagnosis & Treatment 17 Intestinal Ischemia ■ Essentials of Diagnosis Acute: • Causes are emboli (eg, in atrial fibrillation); thrombosis (eg, in patients with atherosclerosis), or nonocclusive insufficiency (eg, in congestive heart failure) • With occlusion, diffuse abdominal pain but minimal physical findings • Lactic acidosis suggests bowel infarction rather than ischemia Chronic: • Results from atherosclerotic plaques of superior mesenteric, celiac axis, and inferior mesenteric; more than one of the above major arteries must be involved because of collateral circulation • Epigastric or periumbilical postprandial pain; patients limit intake to avoid pain, resulting in weight loss and less prominent pain Ischemic colitis: • Occurs primarily with inferior mesenteric artery ischemia; epi- sodic bouts of crampy lower abdominal pain and mild, often bloody diarrhea; lactic acidosis or colonic infarction rare ■ Differential Diagnosis • Diverticulitis and appendicitis • Myocardial infarction • Pancreatitis • Inflammatory bowel disease and colitis due to other causes • Visceral malignancy • Polyarteritis nodosa • Renal colic • Cholecystitis ■ Treatment • Decision to operate is challenging given comorbidities • Laparotomy with removal of necrotic bowel • Pre- and postoperative intra-arterial infusion of papaverine if occlusion is embolic ■ Pearl Abdominal pain in a patient with heart failure receiving digitalis and diuretics is nonocclusive mesenteric ischemia until proved to be otherwise. Reference Brandt LJ et al: AGA technical review on intestinal ischemia. American Gastro- intestinal Association. Gastroenterology 2000;118:954. [PMID: 10784596] Chapter 17 Common Surgical Disorders 427 17 [...]... cervical spine x-ray once during the preschool years I Pearl Chromosome 21 codes the beta-amyloid seen ubiquitously in brains of Down’s patients and Alzheimer’s in adults Reference Saenz RB: Primary care of infants and young children with Down syndrome Am Fam Physician 199 9; 59: 381 [PMID: 99 30130] 18 434 Essentials of Diagnosis & Treatment Respiratory Syncytial Virus (RSV) Disease I Essentials of Diagnosis. .. Petruzzi MJ et al: Wilms’ tumor Pediatr Clin North Am 199 7;44 :93 9 [PMID: 92 86 293 ] 18 438 Essentials of Diagnosis & Treatment Juvenile Rheumatoid Arthritis (Still’s Disease) I Essentials of Diagnosis Three types: pauciarticular, polyarticular, systemic: • Pauciarticular: fewer than five joints involved; younger females can have uveitis, knee involvement, ANA-positivity; adolescents, usually male, have both... artery from the pulmonary artery are the sole causes of Q wave infarction in childhood Reference Taubert KA et al: Kawasaki disease Am Fam Physician 199 9; 59: 3 093 [PMID: 10 392 592 ] 18 442 Essentials of Diagnosis & Treatment Bacterial Meningitis I Essentials of Diagnosis • Signs of systemic illness (fever, malaise), headache, stiff neck, and altered mental status • In infants under 12 months of age, such... with an intra-arterial femoral line in the ICU on a ventilator, there will be no history—check distal pulses frequently Reference Thrombolysis in the management of lower limb peripheral arterial occlusion— a consensus document Working Party on Thrombolysis in the Management of Limb Ischemia Am J Cardiol 199 8;81:207 [PMID: 95 9 190 6] 17 18 Common Pediatric Disorders* Croup I Essentials of Diagnosis • Viral... Reference Saulsbury FT: Henoch-Schönlein purpura in children Report of 100 patients and review of the literature Medicine (Baltimore) 199 9;78: 395 [PMID: 10575422] 18 444 Essentials of Diagnosis & Treatment Intussusception I Essentials of Diagnosis • The telescoping of one part of the bowel into another, leading to edema, hemorrhage, ischemia, and eventually infarction • Peak is between 6 months and 1 year... provide long-term control • Imipramine not recommended due to side effects and overdose potential I Pearl Hypokalemia suggests Munchausen by proxy due to administration of diuretic to the child Reference Gimpel GA et al: Clinical perspectives in primary nocturnal enuresis Clin Pediatr 199 8;37:23 [PMID: 94 75 696 ] 18 448 Essentials of Diagnosis & Treatment Urinary Tract Infection I Essentials of Diagnosis. .. required 18 I Pearl Systemic Still’s disease is one of the few causes of biquotidian fever spikes Reference Woo P et al: Juvenile chronic arthritis Lancet 199 8;351 :96 9 [PMID: 97 3 495 7] Chapter 18 Common Pediatric Disorders 4 39 Colic I Essentials of Diagnosis • A syndrome characterized by severe and paroxysmal crying that usually worsens in the late afternoon and evening • Abdomen sometimes distended,... parent who did • Afflicts 20% of 5-year-olds, 10% of 7-year-olds, and 5% of 10-year-olds • Secondary enuresis often caused by psychosocial stressors • Medical problems, including UTI and diabetes mellitus, must be excluded I Differential Diagnosis • • • • • I Urinary tract infection Diabetes mellitus Congenital genitourinary anomalies Constipation Diuretic ingestion Treatment • • • • • Therapy for causative... other self-limited infections • Children are no longer infectious once they are afebrile I Pearl No other illness exhibits rash after defervescence Reference Leach CT: Human herpesvirus-6 and -7 infections in children: agents of roseola and other syndromes Curr Opin Pediatr 2000;12:2 69 [PMID: 10836165] 18 436 Essentials of Diagnosis & Treatment Acute Lymphoblastic Leukemia (ALL) I Essentials of Diagnosis. .. structural causes come first Reference Griffin GC et al: How to resolve stool retention in a child Underwear soiling is not a behavior problem Postgrad Med 199 9;105:1 59 [PMID: 99 24501] 18 19 Selected Genetic Disorders* Neurofibromatosis I Essentials of Diagnosis • Occurs either sporadically or on a familial basis with autosomal dominant inheritance • Two distinct forms: Type 1 (von Recklinghausen’s disease), . al: Acute diverticulitis. N Engl J Med 199 8;338:1521. [PMID: 95 93 792 ] 424 Essentials of Diagnosis & Treatment 17 Pancreatic Pseudocyst ■ Essentials of Diagnosis • Collection of pancreatic fluid. occlusion— a consensus document. Working Party on Thrombolysis in the Management of Limb Ischemia. Am J Cardiol 199 8;81:207. [PMID: 95 9 190 6] 430 Essentials of Diagnosis & Treatment 17 18 Common. Acute colonic pseudo-obstruction. Br J Surg 199 2; 79: 99. [PMID: 1555081] 422 Essentials of Diagnosis & Treatment 17 Acute Appendicitis ■ Essentials of Diagnosis • Consider in all patients with