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MOH Pocket Manual in General Surgery§ Upper GI series/small bowel series for SBO (if no causeapparent, i.e. no hernias, no previous surgeries) can be used MRI in pregnant patientsTreatment and Management(See flowchart 4)o Initial management (See Table 1) Resuscitation and electrolyte correction (with normal saline/Ringer’s first, then add potassium after fluid deficits arecorrected) NG tube to relieve vomiting, prevent aspiration anddecompress small bowel by prevention of further distentionwith swallowed air Foley catheter to monitor in/outs Antibiotic in case of strangulation or perforationo Definitive management Conservative therapy Especially if adhesions are the cause Indication for surgery: virgin abdomen, peritonitis,perforation and septic shockReference1-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.2- Jesse Klostranec, Toronto Notes 2012: Comprehensive MedicalReference, 28th edition. Toronto: Toronto notes 2012LOWER GIT21

MOH Pocket Manual in General SurgeryFlowchart 4: Bowel ObstructionSuspecting bowelobstruction based on historyand examinationInitial managementCBC, chemistry, ABG, IV lineErect chest x-rayAbdominal x-ray (2 views)Nasogastric tubeFoley m metronidazolePip/Taz forsevere sepsisUrgent ORYesRedflag presentationVirgin abdomen, shock peritonitisNoLarge bowelobstructionon CTVolvulusSigmoidoscopyfailedlaparotomy andresection ostomyFluidadministrationConservative therapyClose monitoringObtain CTabdomenMalignantDivertingostomy vs.formalresection solysis /- resectionSmall bowelobstructionon CTHerniaGroin explorationViable bowelmesh repair.Dead bowelresect hemiorrhaphyHassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: Tow Harbors Press 2013.22LOWER GIT

MOH Pocket Manual in General SurgeryAcute AppendicitisOverviewo Pathophysiology Obstruction of appendiceal lumen from lymphoidhyperplasia in wall of appendix (children) or fecalith (adult)Clinical Presentationo Symptoms Vague, often colicky, periumbilical or epigastric pain thatshifts to right lower quadrant, with steady ache worsened bywalking or coughing In 95% of patients with acute appendicitis, anorexia isthe first symptom, followed by abdominal pain, which isfollowed in turn by vomiting Constipationo Signs Low-grade fever ( 37.8 C) in the absence of perforation Localized tenderness with guarding in the right lowerquadrant and rebound tenderness Psoas sign (pain on passive extension of the right hip) Obturator sign (pain with passive flexion and internalrotation of the right hip) Atypical presentations due to anatomic variations in theposition of the inflamed appendix§ Tenderness may be most marked in the flank§ Pain in the lower abdomen, often on the left; urge to urinate ordefecateLOWER GIT23

MOH Pocket Manual in General Surgery§ Abdominal tenderness absent, but tenderness on pelvic or rectalexaminationo Complications Perforation, appendicular abscess or phlegmon (mass) andpylephlebitis (suppurative thrombophlebitis of the portalvenous system)Differential Diagnosiso Mesenteric lymphadenitis, Gastroenteritis, Crohn’s diseaseo Renal: ureteric stoneo In female: ruptured ovarian cyst, ovarian torsion, ectopicpregnancyo Beware of “crossover” diseases like Sigmoid colon flopped into RLQ mimicking appendicitisWork Upo Laboratory CBC: Mild leukocytosis, (12,000 to 18,000 cells/mm3) Urinalysis can be useful to rule out UTI Pregnancy test if applicable24LOWER GIT

MOH Pocket Manual in General Surgeryo Imaging Ultrasound scan (pelvic) is indicated in young women ofchildbearing age if ovarian pathology is suspected CT scan is indicated: suspecting appendix mass or abscess,unclear Work Up and in elderly MRI in pregnant patiento Invasive Laparoscopy is a useful tool in case all above investigationsfailedo Elderly patients with appendicitis often pose a more difficultdiagnostic problem because of the atypical presentationTreatment and Management(See flowchart 5)o Preoperative antibiotics (See Table 1) All what is needed in case of appendicular mass phlegmon(followed by interval appendectomy) Antibiotic coverage is limited to 24 to 48 hours in cases ofnon-perforated appendicitis. and 7 to 10 days for perforatedappendixo Percutaneous drainage for appendicular abscesso Appendectomy open or laparoscopic.LOWER GIT25

MOH Pocket Manual in General SurgeryRed Flagso Females patient with missed menses or vaginal bleedo Elderly patient with atypical, recurrent symptoms and weightlosso Palpable mass on examinationReference1- Gerard M. Doherty, MD: Chapter 28. Appendix.Current Work up andTreatment: Surgery, 13e, 20102- Bernard M. Jaffe and David H. Berger : Chapter 30. The Appendix .Schwartz’s Principles of Surgery, 9e , 20103- Maxine A. Papadakis, MD , Stephen J. McPhee, MD : MENT , 20134- McLatchie, Greg; Borley, Neil; Chikwe, Joanna. Upper GastrointestinalSurgery . Oxford Handbook of Clinical Surgery, 3rd Edition , 20075-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.26LOWER GIT

MOH Pocket Manual in General SurgeryFlowchart 5: Acute AppendicitisSuspecting appendicitisbased on historyand examinationInitial managementABC, IV lineCBC, ChemistryNoRed Flag PresentationFemale, elderly, atypical or recurrentsymptoms, long history, or/and palpablemass on examPreoperative antibioticsCefuroxim metronidazoleObtain consentBook for appendectomy(open vs. laparoscopy)Further work upB-hCG (married female)Urine analysisAbdominal ultrasoundCT abdomen (optional)OR findingPerforated appendixIntra-abdominal sepsis(IAS)NoContinuesameantibioticsfor 24hrsYes*Continueantibiotics for7-10 days formild IAS* Pip/taz inmodto severe IASYesPhlegmonor abscessNoManageaccording tothe resultof the abovementionedtestsYes* IV Cefuroximand metronidazole*Percutaneounsdrainage for abscess*Consider intervalappendectomyLOWER GIT27

MOH Pocket Manual in General SurgeryAnal FissureOverviewo Definition: is a tear in the anoderm distal to the dentate lineo Incidence: Most commonly occur in the posterior midline;10% occur anteriorlyo Etiology It is related to trauma from either the passage of hard stoolor prolonged diarrhea A lateral location of a chronic anal fissure suggests:Crohn’s disease, Syphilis, Tuberculosis, HIV/AIDS or analcarcinomaClinical Presentationo Symptoms Severe, tearing pain during defecation Sensation of intense and painful anal spasm lasting forseveral hours after a bowel movement Constipation and hematochezia (less common). Fissuresmay present as painless non-healing wounds that bleedintermittentlyo Signs Acute fissure is a superficial tear of the distal anoderm Chronic fissures: an ulcer with heaped-up edges. The whitefibers of the internal anal sphincter visible at the base of theulcer and associated external skin tag and/or a hypertrophiedanal papilla internally28LOWER GIT

MOH Pocket Manual in General SurgeryDifferential Diagnosiso Thrombosed hemorrhoido Perianal fistula or abscessWork Upo Work Up is confirmed by visual inspection of the anal vergewhile gently separating the buttockso Digital (by touching the anal sphincter, anal spasm will beappreciated) and anoscopic examinations may cause severepain and may not be possibleo Examination under anesthesia (EUA) if in doubt or there issuspicion of another cause for the perianal painTreatment and Management(See flowchart 6)o Medical therapy (See Table 4) Life-style modification, stool softener and sitz bath Local analgesia Local nitroglycerin or calcium channel blocker (nifedipine- less side effects).o Surgical therapy Partial Lateral internal sphincterotomy for refractory andchronic fissureLOWER GIT29

MOH Pocket Manual in General SurgeryRed Flagso New onset in an elderly patiento Unexplained anaemia, tenesmus or weight losso Family history of bowel cancer or inflammatory bowel diseaseo Associated anal mass or enlarged groin masso Positive faecal occult blood testReference1-Lisa Susan Poritz, MD; Chief Editor: John Geibel, MD, DSc. eMedicineof Medscape2-Kelli M. Bullard Dunn and David A. Rothenberger. Schwartz’sPrinciples of Surgery, 9e , 20103-Mark L. Welton, MD, Carlos E. Pineda, MD, George J. Chang,MD, Andrew A. Shelton, MD. CURRENT Work Up & Treatment andManagement: Surgery, 13e , 2010.4-Maxine A. Papadakis, MD , Stephen J. McPhee, MD. Quick MedicalWork Up & Treatment and Management , 20135-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.30LOWER GIT

MOH Pocket Manual in General SurgeryFistula in AnoOverviewo Definition: an abnormal tract or cavity with an external openingin the perianal skin which is communicating with the rectum oranal canal by an identifiable internal opening.o Pathophysiology History of previous anorectal abscess, which was drainedspontaneously or surgicallyClinical Presentationo Symptoms: perianal discharge, pain, swelling and/or bleedingo Signs Perianal exam: an external opening that appears as anopen sinus or elevation of granulation tissue. Spontaneousdischarge of pus or blood via the external opening may beapparent or expressible on digital rectal examination. Digital rectal examination may reveal a fibrous tract or cordbeneath the skin. It also helps to delineate any further acuteinflammation that is not yet drained. Lateral or posteriorinduration suggests deep postanal or ischiorectal extension. The sphincter tone and voluntary squeeze pressures shouldbe assessed before any surgical therapy.LOWER GIT31

MOH Pocket Manual in General SurgeryClassificationo Four main types Intersphincteric: the track is in the intersphincteric plane.The external opening is usually in the perianal skin close tothe anal verge Transsphincteric: The fistula starts in the intersphinctericplane or in the deep postanal space. The track traversesthe external sphincter, with the external opening at theischioanal fossa. Horseshoe fistula is also in this category Suprasphincteric: The fistula starts in the intersphinctericplane in the midanal canal and then passes upward to a pointabove the puborectal muscle. The fistula passes laterallyover this muscle and downward between the puborectalmuscle and the levator ani into the ischioanal fossa Extrasphincteric: The fistula passes from the perineal skinthrough the ischioanal fossa and the levator ani and finallypenetrates the rectal wallDifferential Diagnosiso Perianal abscesso Hemorrhoid32LOWER GIT

MOH Pocket Manual in General SurgeryWork Upo History and Physical Examinatioo Anoscopy is usually required to identify the internal opening.o MRI and Fistulogram in complex or recurrent typeso Proctoscopy or flexible sigmoidoscopy is performed to ruleout other lesions and inflammatory bowel diseaseTreatment and Management(See flowchart 6)o Abscess: incision and drainage (See Table 3)o Simple, superficial: fistulotomyo Crohn’s disease, anterior fistula in female, complex or high:seton, referral to colorectal surgeon for other options.Red Flagso History of Crohn’s disease or HIVo Anterior location or multiple fistulaeo Complex, recurrent or high locationLOWER GIT33

MOH Pocket Manual in General SurgeryReferences1-Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: John Geibel,MD, DSc, MA : Fistula-in-Ano . eMedicine of Medscape2-Kelli M. Bullard Dunn and David A. Rothenberger: Chapter 29. Colon,Rectum, and Anus . Schwartz’s Principles of Surgery, 9e , 20103-Mark L. Welton, MD, Carlos E. Pineda, MD, George J. Chang,MD, Andrew A. Shelton, MD. CURRENT Work Up & Treatmentand Management: Surgery, 13e , 20104-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.HemorrhoidsOverviewo Definition: Hemorrhoids are cushions of submucosal tissuecontaining venules, arterioles and smooth-muscle fibers thatare located in the anal canalo Types External hemorrhoids are located distal to the dentate lineand are covered with anoderm Internal hemorrhoids are located proximal to the dentate lineand covered by insensate anorectal mucosa Combined internal and external hemorrhoids34LOWER GIT

MOH Pocket Manual in General SurgeryClinical Presentationo Symptoms Bright red bleeding per rectum and mucus discharge When very large, a sense of rectal fullness or discomfort Pain during bowel movements (when thrombosed) Anal Itching Thrombosed external hemorrhoid§ Acute severe perianal pain§ The pain usually peaks within 48–72 hours§ It is a purple-black, edematous, tense subcutaneous perianalmass that is quite tender.§ Ischemia and necrosis of the overlying skin, resulting in bleedingo Signs: purple-colored swelling protruding through anuso Complications Incarceration, thrombosis and necrosis Severe bleeding Painful lumps in the anal areaClassificationo Internal hemorrhoids are graded according to the extent ofprolapse First-degree: bulge into the anal canal and may prolapsebeyond the dentate line on straining Second-degree: prolapse through the anus but reducespontaneously Third-degree: prolapse through the anal canal and requireLOWER GIT35

MOH Pocket Manual in General Surgerymanual reduction Fourth-degree hemorrhoids: prolapse but cannot be reduce.Differential Diagnosiso Perianal hematomao Perianal abscesso Rectal prolapseo Anal papillaWork Upo Rectal Examination: visual and digitalo Anaoscopy, proctoscopyo Colonscopy: to rule out colonic pathology especially 40years.Treatment and Management(See flowchart 6)o1st to 3rd degree (See Table 4) Medical therapy: diet/lifestyle modification, flavonoid, sitzbath and stool softener Surgical therapy: banding or sclerotherapy andhemorrhoidectomy 4th degree: hemorrhoidectomy36LOWER GIT

MOH Pocket Manual in General Surgeryo Thrombosed exernal hemorrhoid Medical therapy and analgesia Incision and evacuation of clotRed Flagso Weight loss, change in stool size and bowel habito Abdominal pain, anorexia or unexplained anemiao Family History of bowel cancer or inflammatory boweldiseaseo Elderly, HIV patientsReferences1-Kelli M. Bullard Dunn and David A. Rothenberger: Chapter 29. Colon,Rectum, and Anus . Schwartz’s Principles of Surgery, 9e , 20102-Mark L. Welton, MD, Carlos E. Pineda, MD, George J. Chang,MD, Andrew A. Shelton, MD. CURRENT Work Up & Treatment andManagement: Surgery, 13e , 20103-Maxine A. Papadakis, MD , Stephen J. McPhee, MD. Quick MedicalWork Up & Treatment and Management , 20134-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.LOWER GIT37

MOH Pocket Manual in General SurgeryFlowchart 6: Anorectal DiseasesSuspecting anorectaldisease based on historyand examinationAnoscopy(If not painful)Hemorrhoid1st, 2nd and3rd degreeMedical therapy*Diet/lifestylemodification*Flavonoid*Sitz bath*Stool softenerBanding andsclerotherapyFailedHemorrhoidectomy38LOWER GITFissure*Incision anddrainage*Cefruxime icNoRed flagpresentationCrohn’s, anteriortype in female,complex,highFistulotomyAcuteLateral referralMedical therapyStool softenerSitz bathLocal topicalnifedipine

MOH Pocket Manual in General SurgeryPilonidal DiseaseOverviewo Definition Acute/chronic recurring abscess or chronic draining sinusover the sacrococcygeal or perianal regiono Incidence: most commonly in people aged 15-30 yearso Etiology Unknown. It is speculated that the cleft creates a suction thatdraws hair into the midline pits when a patients sitsClinical Presentationo Symptoms A painful, fluctuant mass in the sacrococcygeal region withpurulent dischargeo Signs Abscess: red, warm, local tenderness and fluctuation with orwithout induration Sinus: Midline natal cleft pit sinus§ Chronic draining sinuses with multiple mature tracts with hairsprotruding from the pitlike openingsLOWER GIT39

MOH Pocket Manual in General SurgeryWork Upo It is a clinical Work Up best elicited by history and physicalexamination findingsTreatment and Managemento Abscess: incision and drainage with antibiotic therapyo Sinus: excision (without closure or with modified closure ofskin).References1-Kelli M. Bullard Dunn and David A. Rothenberger: Chapter 29. Colon,Rectum, and Anus . Schwartz’s Principles of Surgery, 9e , 20102-Maxine A. Papadakis, MD , Stephen J. McPhee, MD. Quick MedicalWork Up & Treatment and Management , 20133-Mark L. Welton, MD, Carlos E. Pineda, MD, George J. Chang,MD, Andrew A. Shelton, MD. CURRENT Work Up & Treatmentand Management: Surgery, 13e , 20104-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.40LOWER GIT

MOH Pocket Manual in General SurgeryLower GI BleedingOverviewo Definition: bleeding distal to ligament of Treitzo Etiology Upper GI source Anorectal disease: fissure and hemorrhoid Diverticular disease Vascular: angiodysplasia Neoplasm: benign (polyp) or malignant Inflammation: ulcerative colitis, infectious, radiation,ischemicClinical Presentationo Hematochezia, anemia, occult blood in stool and rarely melenaTreatment and Management(See flowchart 7)o Initial management Resuscitation and monitoring (2 large bore IV line, fluid,urinary catheter) Send blood for CBC, cross and type, coagulation profile,electrolytes, liver and kidney functiono Localization Insert NGT to rule out upper GI source if suspected.LOWER GIT41

MOH Pocket Manual in General Surgery Proctoscopy Colonoscopy for mild to moderate bleed RBC scan for stable patient with massive bleeding Angiogram for unstable patient with massive bleedingo Definitive management Colonoscopy and angiogram Surgery rarely indicated if conservative treatment fails.Reference1-Hassan Bukhari. Puzzles in General Surgery. 1st ed. Minneapolis: TowHarbors Press 2013.2- Jesse Klostranec, Toronto Notes 2012: Comprehensive MedicalReference, 28th edition. Toronto: Toronto notes 201242LOWER GIT

MOH Pocket Manual in General SurgeryFlowchart 7: Lower GI BleedingSuspecting Lower GIbleeding based on historyand examinationInitial ManagementABC IV line resuscitationCBC, Chemistry, liver funtion, coagulationNGT for rule out upper GI sourceAnoscopy to rule out anorectal sourceMinimal tomoderatebleedingNoRed flag presentationMassive bleedingYesColonoscopyStableNoAngiogramYesRBC ScanFailedEnteroscopyfailedsurgeryLOWER GIT43

Chapter3HEPATOBILIARY

MOH Pocket Manual in General SurgeryGall StonesOverviewo Risk Factors

MOH Pocket Manual in General Surgery UPPER GIT 1-Andres E Castellanos, MD; Chief Editor: John Geibel, MD, DSc, MA : Gastric Outlet Obstruction . eMedicine of Medscape 2- Daniel T. Dempsey : Chapter 26. Stomach . Schwartz s Principles of Surgery, 9e , 2010 3-Ge