DeVirgilio Flashcards
Richter’s hernia?
Only partial circumference is trapped in the sac
Patient will not have symptoms of SBO. Still a strangulation risk!!
Sliding hernia
indirect hernia with part of a retroperitoneal organ herniates with the bowel. Failure to recognize may lead to injury of the organ. Always open hernia sacs anteriorly!
Diagnosis? Imaging?
Clinical, finding of reducible mass. Ultrasound may be used in obese or to find Spigelian hernias (between abd walls). CT and MRI are equivalent and may be used if necessary or to diagnose if no clinical signs.
Lichtenstein repair?
Reduction of direct inguinal hernia with reinforcement of the floor of the inguinal canal with mesh.
Management of incarcerated hernias?
Attempt to reduce. If it is reducible repair can be done semi-electively. If irreducible, urgent surgical intervention is required.
Unique aspects of hernia repair in infants/children?
Vast majority are indirect
Not usually long standing = internal ring and inguinal floor do not need reinforcement
5-10% of infants will have bilateral hernias
Management of umbilical hernia in infants?
Very common in newborns and spontaneously resolve by age 2. Surgery if: persist past age 4, 2+ cm in diameter, strangulation, progressive enlargement after age 1
Meralgia paresthetica?
Burning pain associated with lateral femoral nerve injury
Reduction of strangulated hernia?
Only in OR after confirmation it is still living tissue. Otherwise reduction will introduce dead or gangrenous bowel into the peritoneum, resulting in sepsis and peritonitis
Loss of cremasteric reflex, sensation in anterior scrotum/labia majora?
Damage to genital branch of genitofemoral nerve
Result of transection of the testicular artery?
Rarely causes testicular ischemia due to blood supply from cremasteric artery and artery of the vas deferens. Testicular artery may be transected to mobilize undescended testicles.
Ddx of inguinal masses? Most common mass?
MINT: Malformations, Infections, Neoplasms, Trauma.
Most common: enlarged lymph nodes (Cloquet’s nodes)
Signs of strangulated hernia?
SIRS symptoms, vomiting, abd pain hypoactive/highpitched bowel sounds.
What’s the significance of an SBO in a patient without any abdominal surgical scars?
Suggest the patient has had no surgeries and removes adhesions (the most common benign cause of SBO) from ddx. Most adhesive SBOs will resolve with conservative tx, but most non-adhesive SBOs will not and may need emergent surgical intervention, as well as more thorough w/u to determine cause (malignancy, hernia, IBD)
Howship-Romberg sign?
Pain in medial aspect of thigh with abduction, internal rotation, or extension of the leg. Suggests obturator hernia is compressing obturator nerve.
4 cardinal signs of strangulated bowel?
Fever, tachycardia, leukocytosis, localized abdominal tenderness
Significance of severe abdominal pain and localized tenderness in pt with SBO?
Suggestive of a strangulated SBO. Emergent surgery required, 50% of SBO deaths are 2/2 strangulation. Continuous (not colicky) abd pain, SIRS signs, peritoneal signs, acidosis, absent bowel sounds, localized abd tenderness/painful mass, or blood in stool.
Pathophys of SBO?
Gas and fluid accumulate proximal to obstruction, bowel dilates, motility increases to push material distal (hyperactive BS and colicky pain), further increase in bowel distention decreases motility and bowel sounds.
Most common causes of SBO?
Crohns's dz Gallstone ileus Hernia Intra-abdominal adhesions (single most common cause in industrialized countries) Intussusception Neoplasm Volvulus Appendicitis and diverticulitis (2/2 infection and inflammation)
How does dehydration develop in SBO?
Increased hydrostatic pressure with the distended lumen causes fluid to accumulate in the bowel wall. This affects starling forces of capillary fluid exchange and leads to a net filtration of fluid, electrolytes, and proteins from the blood stream (third spacing).
Electrolyte specific acid-base effect of repeated emesis?
Often hypokalemic, hypochloremic metabolic alkalosis
Labs for work up of SBO?
CBC, BMP, Lactate.
CBC - hemoconcentration, leukocytosis if infective/ etiology or bowel perforation
BMP - Hydration status, hypokalemia, hypochloremia, BUN:Cr ratio
Lactate: elevation may indicate ischemic bowel
Imaging for SBO?
Upright CXR: Rule out free air
Upright Abdominal XR: Look for air fluid levels
Supine abd XR: width of small bowel to estimate distention
Difference between SBO and Large BO?
LBO causes gradually increasing abd pain, progressive distention and constipation, and occasionally feculent vomiting.
