General Surgery:

Pre-Op:
AMPLE: Allergies, Medications, Past Medical History, Last Meal, Events leading
up

Cardiac Pt.:
After an MI, surgery should be postponed 6 months if possible
W/ the exception of coronary artery bypass, surgery is contraindicated in
unstable angina.
After 20 years all diabetic pts have some kind of cardiovascular problem
Cardiac Medications:
Recommended if on Beta Blocker, Statin, anti-HTN to stay on it
Apirin, Clopidogrel, and ticoplidine D/C 7 days pre-op
Warfin: Hold until INR normalizes
Heparin: D/C 4 hours pre-op
Prophylactic antibiotics for endocarditis indicated for dental work or
respiratory surgery
Other Medications:
D/C MAOIs (Phenelzine, Isocarboxazid, Tranylcypromine)
D/C Estrogen 4 weeks prior due to increase DVT risk
Classification of Surgical Risk: Dripps American Surgical Assoication
Classification
Class I: Healthy pt, limited procedure
Class II: Mild to moderate systemic disturbance
Class III: Severe systemic disturbance
Class IV: Life threatening
Class V: Not expect to live w/ or w/o surgery
Pulmonary: Normally no need for pre op PFTs
*Smoking cessation at least 6 weeks prior.
ASA class of II or higher have more associated Post-op pulmonary problems.
Asthma, COPD, restrictive lung disease* Many anesthetics promote
bronchospasm, higher atelectasis
FRC= RV+ Expiratory reserve volume
Lung resection-PFTS! Goals: post op FEV1 of 800 mL. Multiply % lung tissue
left after resection*FEV1.
Liver: MELD score, Child Pugh
Adrenal Insufficiency:
Cushnoid appearance
Predinose dose of atleast 20 mg/days for 3 weeks can be associated with
HPA axis suppression
Based on Minor, Moderate, Severe surgery
Minor: No supplementation
Moderate: 50 mg hydrocortisone IV prior to procedure 25mg ever 8-24 hrs
after
Major: 100 mg hydrocortisone IV prior and 50 mg every 8-24 hrs after
Hallmark: hypotension refactory to pressors
Corticol stimulation test:

-give synthetic ACTH and see adrenal response. Less than 15 from base line-high
probability that insufficient.
-19-34 divided into increments of 9
-Greater than 34: adrenal will come around
Etiomidate can cause**
Diabetic pt:
Surgical stress releases: glucagon, epinephrine, cortisol, GH that counteract
insulin=potential of hyperglycemia
Cardiac autonomic neuropathy may lead to hypotension
Gastroparesis: delayed gastric empyting increase the risk of aspiration-a
splash heard of the stomach when supposed to be empty may indicate.
Risk if infection*, reduced blood floe retards wound healing. Bc
microvascular, palpable pulses in the face of tissue ischemia is possible.
Goal 120-180. Landge says 140-200 Debate that hyperglycemia is better
tolerated than hypo.
DKA can be mistaken for other post-op complications. Check ketones.
DVT prophylaxis
Surgical pt at risk for DVT due to Virchows Triad: hypercoagulability,
venous stasis, epithelial injurgy.
Low dose unfractioned heparin (cheapest)
Enoxaparin: 40 mg subq., 12 hour prior continute until full
ambulatory or 15 days after, adjust for renal. Preferred in trauma,
abdominal or pelvic cancer.
Compression devices if anti congulation contraindicated
Greenfield filter insertion: invasive procedure for clots in lower
extremities
Risk of HIT-White clot syndrome. Type 1 and Type 2 (4-10 days after).
Antibodies to PF4, platelet factor 4, create clots. TX: Bc at risk for
thrombosis, DTI (Direct thrombin inhibator argatroban. Bicalirudin
approved for PCI.
Mainstay: subQ heparin
IPC: intermittent pneumatic compression devices
Burns:
-Epidermal: first degree-only the epidermis. Blanch. NO blister. Supportive care:
neomyocin sulfate to prevent infection. No scar.
-Partial thickness: 2nd degree burns. Superficial vs. Deep
Superficial: not through the dermis, + blisters, blanch, and painful.
Deep: dry, thick texture. *WHITE. Damaged dermis does no
regenerate-form scar. Deep dermis TX: excision and skin graft.
-Full thickness: all layers of the skin are destroyed. INSENSATE.
-4th degree: extension to the bone.
Inhalation injury:
Severe mortality and morbidity, often occur when fire in an enclosed space.
Intubate to control swelling*

CO poisoning: cotton and wool. Altered mental status leading to coma,

seizure and death. Pulse ox NOT reliable must draw ABG
(carboxyhemoglobin-greater affinity for RBC than O2). Cherry red
appearance to cheeks. TX: 100% ventilation with O2. +/- hyperbaric O2 (may
take too much time-cuts CO halflife from 80 min to 20 min)
Upper airway injurgy: produced by heat that leads to edema. Can progress
over 24 hours
Lower airway injury: damaged cells slough off and produce plugging which
results in segmental collapse and bronchiestasis. Take 24-48 hours.
*Fiberoptic bronschoscopy.

Survey:
Total body surface area affected: Rule of 9s, Palm (helpful if less than
10%), Lund and Browder Chart
Rule of 9s: 11 sections, 9% each.
-Head (4.5 front, 4.5 back)
-Each Arm (4.5% on front, 4.5% on back)

-Trunk (18% on front, 18% on back)

-Leg (9% on front, 9% on back)
-Pernieum (1%)
Pt. palm= 1% TBSA

TX: often divided into

1. Resuscitation: hours last 24-48. Fluids*
Pt will 10-15% TBSA affected require formal fluid resuscitation
Lactated Ringers
Parkland formula: 4cc*kg*TBSA
1st half given in 8hours
2nd half given in 16 hours.
Monitor via urine ouput: greater than 30 cc/hr =adequate. If less increase
fluids by 10%
Calculate requirement.
Respiratory: in the presence of inhalation injury, increase 20-30%.
2. Wound Closure
Early excision of eschar to prevent fluid loss & decrease opportunity to
infection.
Two techniques: fascial vs tangential.

Fascial: Entire skin and subcuntaneous tissue. Good take but often
disfiguring.
Tangential: layers are removed until viable tissue encountered.
Skin graft usually performed at the same time as excision.
Burn wound sepsis: topical available. Silver sulfadiazine.
Adequate wound care-q 2 hours.
Nutrition: Metabolism increase. Problem: build up of nitrates.
3. Rehabilitation begins at the time of injury
Aimed at preventing scar contractions that immobilize extremities.
Scar tissue continues to remold 1 year after
Chemical and Electrical Burns:
Alkalis burns worse than Acidic: produce hydroxide ions which penetrate
deeper
Acids: protein breakdown to produce eschar, thus do not penetrate as far.
Organic solvents: produce injury via fat soluble mechanism-destruction of
cell membrane
Organophospates: bind Ca.
Electrical: current can travel under the skin due to decreased resistance.
Superficial skin may appear undamaged but bone is injured.
Can result in cardiac anomalies
Minor burn
Less than 5% TBSA
Soft Tissue necrotizing fasciitis: Fourniers gangrene, Meleneys gangrene: rapid
progression, severe toxicity, necrosis of involve tissue that spread rapidly.
Immediate surgical excision.
Breast:
Artery: internal mammary off the sublclavian artery
Lateral thoracic arteries
Thoracoacromial pectoral branches
Colon, Rectum, Anus:
Anatomy:
Cecum: largest part, where the small intestine connects
Retroperitoneal: ascending and descending colon. Ascending colon
defined at hepatic flexure. Descending colon defined at the splenic
flexure. Transverse colon is not retroperitoneal.
Rectum defined at the sacrum. Important to determine where the
rectum is covered by peritone-affects the location of a rectal biopsy.
Rectal biopsy higher than 8-9 cm above anal verge at risk for
perforation. Dentate line mark insensate from sensate rectum.
Vasculature:
-Ascending colon & proximal half of transverse=SMA
-Distal half, descending, & sigmoid: IMA.

-Marginal artery of Drummond: collateral containing middle and left

colic systems. *Significant bc during sigmoid or distal descending colon
surgery the left colic artery can be sacrificed
Colon layers: mucosa, submucosa, muscularis, serosa
Teniae coli
Haustra: outpocketing btw teniae coli.
Most gas= N2 from swallowed air
Movements is 18-48 hours compared to SB which is 4 hours

Gallblader:
Cholethiasis (gallstones)
Cholesterol most common. Vs. pigments (bilirubin)
LITH gene-predispose-Native Americans
Aspirin may be protective
Gallbaddler sludge due to fasting (5-10 days after)
Pregnant pts can undergo cholecystectomy-2nd trimester preferred.
Dissolve cholesterol=uresodeoxycholic acid
Acute Cholecystitis:
Impaction of stone in cystic duct
Acalculous cholecystitis: considered when 2-4 weeks post op. Infectious:
CMV, AIDS)
Murphey sign: inspiratory arrest with RUQ palpation.
+/- jaundice=choledocholithiasis
HIDA scane: Tc hepatobiliary imaging can see obstructed duct (avascular
after 4 mins)
Antibiotics-scheduled 2-4 lap chocle
Chornic cholecystis:
Increased inflammation of gallbladder.
Strawberry gallbladder: gallbladder undergo polypoid enlargement due to
villi of gallbladder w/stones
Mirizzi syndrome: stone in neck of gallbladder compress hepatic bile duct
and cause jaundice.
Porecelain gallbladder: calcification of gallbladder associated with
carcinoma.
Choledocholithasis/Cholangitis:
Bile duct stone. Charcots Triad
o Recurrent attacks of URQ pain
o Jaundice
o Fever and chills
o If have altered mental status and hypotension=Reynolds
pentad=acute suppurtaive cholangitis (E. coli, Entercoccous,
Klebsiella. Enterobacteris)
DX: 1. Presense of Charcots triad 2. Signs if inflammation w/ 2 of the
traid

LAB: Increased aminotransferase. Prolonged prothrombin time-responseive

to Vitamin K
Image: dilate bile ducts, impaired bile flow. Bile duct greater than 6 mm.
Bilirubin greater than 4.
TX: ECRP. Cholangitis: Cipro 500 mg IV Q 12 hours.
Primary Sclerosing Cholangitis:
Diffuse inflammation of biliary tree
Associated with UC.
Decreased risk if smoke
Presents with progressive obstructive jaundice-fatigue, anorexia, and
pruritis.
DX of MRCP
Associated with cholangicarcinoma-CA 19-9.
TX: annual RUQ ultrasound
Pancreas:
Retroperitoneal organ
Physiology: exocrine: alkaline juices that neutralize acidic duodenal juices. High
bicarb stimulated by duodenal of ph less than 7.3. CCK also stimulate bicarb
production.
Amylase (only secreted in active form) lipase, protesase.
Endocrine: Islets of Langherhans=beta (insulin) and alpha (glucagon) cells, delta
cells (somastostatin) inhibit exocrine function). Mostly in tail of pancreas.
and endocrie gland.
Acute Pancreatitis: malfunction exocrine/
Atalnta classification system
2 main: alcohol and gallstone
I GET SMASHED: Idiopathic, gallstone, ethanol, truma, scorpion, mumps,
autoimmune, steroids, hyperlipidemia, drugs, ERCP.
Acute attacks lead to chronic pancreatitis
Epigastic pain radiating to the back: Can be relieved by standing or sitting. If
bleed-Grey turners (flank) signs or Cullens (umiblicial) sign.
Lab: elevated amylase and lipase.
Image: Chest X ray, plain upright: Cut off sign= abrupt end at transverse colon,
and US
CT scan best: peripancreas fluid, sentinel loop (segment of air in SB LUQ)
Ransons Criteria: 3 of the follow for admission GA. LAW
Age: greater than 55
WBC: 16,000
Glucose: 200
LDH: 350
AST: 250
Medical TX: Withhold oral feeding
Infected: Carbepenem, 3rd generation cephalosporin

MC complcication: pancreatic fluid-fluid collection can resolve or result in

pseudocyst.
Psuedocyst: collection of fluid in sac w/o epithelia lining, Communication vs
Noncommunication-is it connected to pancreatic duct?
*CT scan best.
TX:
Communication: drain into stomach via surgery
Non communication cyst: aspirated or drained percutaneous
Chronic pancreatitis:
no longer reversible damage.
Steatorrhea: foul smelling stools due to fat malabsorption=measured via fecal fat.
MC symptom is pain. Improved via leaning forward. Food make worse.
Complications: DM type II (due to destruction) cysts.
Pancreatic carcinoma:
MC=adenocarcinoma, 2/3 in head.
*Red flag: new onset DM after 45
K-ras gene associated
Gastrinoma:
DX: Greater than 1000 w/ ph less than 2
Glcagonoma: alpha cels-glucose intoleranve, necrolytic migratory erythema
VIPoma: watery diarrhea, hypok, hypoCL
Esophagus:
A. Heartburn: water bash or pyrosis
a. Due to incompetent LES (lower esophageal sphincter i.e GERD),
strictures, or achalasia.
B. Dysphagia
a. Must determine btw oropharyngeal vs esophagus
b. Orophayngeal: elevation of tongue, close of nasopharynx, relax of
UES, and pharygenal parastalisis. Many causes **Neurogenic or
Muscular main causes
c. Esophageal: mechanical (problems with food) vs motility (problem
with food and liquid)
C. Odynophagia: painful swallow. MC=candiasis.
D. Test: Barium swallow, Upper endoscopy, manometry, PH monitor for 2448 hours.
GERD
A. Reflux of gastric contents=heartburn
B. Factors
a. LES function-most baseline is normal. However, transient
decreased pressure relaxation cause. 10-30 mmHg normal.*Can be
increased by lifting or bending
b. Hiatal Hernia: highly associated with increased GERD and Barrets.
c. Gastric Acidic contents

C.
D.

E.

F.

d. Diminshed perstalistic clearance-Scleroderma, Sjogen Syndrome,

and anticholingeric medications
e. Delayed gastric empty:
S&S: MC= heartburn, 30-45 min following food. Relief from antacids.
Severity not related to tissue damage.
Reguritation +/TX: PPI for 4-8 week course.
If fail or alarm symptoms-Upper endoscopy: W/biospy, Barium, PH.
Reflux esophagitis: mucosal damage due to GERD. Ulcers normally at
squamouscolumnar junction
Complications
a. Barretts: change from squamous to columnar w/ globet cells.
Orange that extends from stomach in an upward tongue like
fashion
PPI do no revert Barretss but help with progression to cancer.
MOST ASYMPTOMATIC
**Progression to adenocarcinoma.
Surveillance endoscopy q 3-5 years; if low grade or higher
dysplasia-repeat endoscopic q 6 monts
High grade-repeat to exclude cancer.
b. Peptic stricture: most at gastroesophageal junction. MOST biopsy
to R/O carcinoma stricture.
Can use catheter to dilate over several times + PPI.
TX:
Mild-lifestyle medication
Troublesome: PPI (Ompreazole 20 mg)
Surgery: extraesophgeal symtoms (pneumonia, or hoarseness), hiatal
hernia

Mallory Weiss Tear

A. Nonpenetrating tear at gastroesophageal junction from events that
increase intrabdominal pressure (lifting, retching, vomit)
B. Alcohol is a predisposing factor
C. DX via endoscopy
D. TX: fluids and blood. Most stop bleeding in time.
Eosinophilic Esophagitis
A. Food or environment cause inflammation
B. 50% with allergies or atopic manifestations
C. Barium swallow: small caliber esophagus, tapered stricutres, concentric
rings
D. TX: PPI for 2 month. Avoidance of trigger foods, corticosteroids
Esophageal Webs:
A. Thin, diaphragm membranes of squamous mucosa.
B. If with iron deficiency=Plummer Vinson syndrome
C. Schatzki rings=smooth circumferential mucosa at distal esophagus at
squamocolumnar junction. Associated with hiatal hernia, GERD

Zenkers Diverticulum
A. Protusion of pharyngeal mucosa tat develop at pharyngealesophageal
junction btw inf. Phaygneal constrictor and cricopharyngeal
B. S/S: oropharyngeal dysphagia, halitosis, nocturnal chocking, gurgling,
protrusion in neck.
Stomach:
A. Anatomy: 3 sections: Fundus, Corpus-parital cells (HCL), Antrum (G
cells)
B. Phys: 3 phases Cephalic, Gastric, Intestinal.
PUD:
A. Etiology: H. pylori and NSAID (inhibit COX-1 which decrease
prostaglandins which are protective)
B. 4 Types: Gastric
a. Type I: gastric in lesser curvature
b. Type II: gastric + duodenal
c. Type III: gastric in prepyloric region
d. Type IV: near GE junction.
C. S/S: gnawing epigastric pain radiating to the back. Anorexia and weight
loss due to pain.
D. EGD: confirm presence of ulcer. MUST biopsy due to increased chance of
malignancy
E. TX If H. pylori: Clarithomycin 500 mg BID, Metronidazole, 400 mg BID,
Ompreazole 20 mg
Stress Ulcers:
A. Develop within 48 hrs
B. Curlings=burn
C. Cushings= CNS trauma
D. Medical prophyalxis: PPI, H2 blocker, Sucralfate, Misoprostol
E. PH should no drop below 4
Menetries DX:
A. Hypertrophic gastritis: hyperthrophy of stomach rugae.
B. Thought to be autoimmune
C. Can lead to hypoproteinmeia and edema
D. Non operative manangement-rare need gastrectomy
Gastric polyp:
A. MC=hyperplastic, benign.
B. Adenomatous=more malignant
C. Peutz-Jehers syndrome: polpys in the GI tract with melanin spots on lips
and buccal mucosa. Autosomal dominant
Malignant Gastric Disease:
A. Adenocarcioma of stomach** MC
B. Two types: intestinal and diffuse. Intestinal meaning well differentiated
glandular elements. Diffuse= signet cells.
C. Linitis plastic= leather looking stomach=poor prognosis.

D. Nodal involvement= Virchows node (left supraclavicular), Sister Mary

Joseph node (umbilical node). Blummers shelf/ascites=peritoneal
invasion. Irish node=left axillary node
E. TX: gastrectomy (subtotal (85%) vs total). Post op chemo: eprubicin,
cisplatin, 5-fluorouracil
Gastic Lymphoma:
A. Non hodgkins dominant
B. Chemo vs surgery
Duodenal Ulcers:
A. Etiology: H. pylori and NSAID: most in duodenal bulb.
B. Rare malignancy
C. Pain 1-3 hours after eating. Accentuated by fasting (worse at night). Food
improves pain.
D. DX: upper GI contrast with barium. H. pylor=urase test. Increased CO2.
Fecal antigen test using antibodies.
E. TX of H. pylori: Clarrithromycin, Amoxcillin (Mitrondiazole if PCN
allergy), PPI. Triple
Quad: add bismuth, metronidazole, tetracycline for 7 days min-most is 14
days.
Complicated Ulcer
A. Perforated: severe pain. Board like abdomen. X ray:
pneumoperitonmeum=diagnostic (air by the liver).
a. Surgical emergency. Graham patch=using omentum over
ulcer
B. Hemmorrhage: Hematemesis, melena, blood.
a. Stabilize: 2 L cystalloid followed by whole blood.
b. Surgical if refractory. 6 or more units over ist 12
hours=indication for surgery.
C. Gastric outlet obstruction: due to chronic scar-projectile vomit
after ear. Hypok, hypoCL metabolic alkalosis. TX: decompress
stomach for 5-6 days
D. Intractable: start to think of rare causes. Decrease acid seccrection
via truncal vagatomy-deinnvercation of parietal cells. However,
gastric motility is disrupted leading to need for drainagepylorplasty. Proximal gasric vagotomy: identify vagus nerve only
lesser curvature-no need drainage procedure
Zollinger-Ellison Syndrome:
A. Gastrinoma. May be associated with MEN Type I (pituitary adenoma,
parathyroid, pancreas)
B. 60% malignancy
C. Often found in gastric triangle (Common duct, head/neck of pancreas,
22d part of duodenum)
D. DX. Gastrin levels greater than 1000.
E. Confirmation is secretin test. Baseline taken-greater than 200 gastrin
rise=diagnostic. (secretin released from duodenum with initiation of
partially digested food)

F. TX: CT to find tumor. Gastrectomy.

Aortic Dissection
A. Type A: arch proximal to left subclavian
B. Type B: arch dital to left subclavian
C. HTN** But can happen in connective tissue disorders.
D. Flap may occlude branches off the aorta resulting in ischemia to vital
organs.
E. Stapping, tearing pain radiating to the back-can develop aortic
regurgitation.
F. EKG: left ventricular hypertrophy. Or normal. Right coronary most often
affected.
G. CT test of choice. CHR=widended mediastinum
H. TX
a. Lower BP: Beta blockers* Labetalol. Esmolol due to short half time.
If not sufficient nitroprusside (vasodilation due to NO)
b. Type A=surgery.
c. Type B= manage medically, CT, grow-operate.
Pressure Ulcers:
A. Primarily due to immobility.
B. Six stages:
a. Stage 1: nonblanchable erythema
b. Stage 2: Through the epidermis
c. Stage 3:Full thickness skin loss
d. Stage 4: Muscle, bone, tendon present
e. Unstagable: considered if eschar or slough (yellow) present
f. Recommended that change/turn q 2 hours.

Recommended turn every

2 hours.

Hepatitis tests Collection: Tiger top tube

Hepatitis A
Anti-HAV Ab:
Total antibody to hepatitis A virus; confirms previous exposure to hepatitis A virus,
elevated for life
Anti-HAV IgM:
IgM antibody to hepatitis A virus; indicative of recent infection with hepatitis A
virus; declines typically 16 mo after symptoms
Hepatitis B
HBsAg:
Hepatitis B surface antigen. Earliest marker of HBV infection; indicates chronic or
acute infection. Used by blood banks to screen donors; vaccination does not affect
this test

Anti-HBc-Total:
IgG and IgM antibody to hepatitis B core antigen; confirms either previous
exposure to hepatitis B virus (HBV) or ongoing infection. Used by blood banks to
screen donors
Anti-HBc IgM:
IgM antibody to hepatitis B core antigen. Early and best indicator of acute
infection with hepatitis B
HBeAg:
Hepatitis Be antigen; indicates infectivity. Order only when evaluating for chronic
HBV infection
HBV-DNA:
Most sensitive and specific early evaluation of hepatitis B; may be detectable when
all other markers are negative
Anti-HBe:
Antibody to hepatitis Be antigen; associated with resolution of active inflammation
Anti-HBs:
Antibody to hepatitis B surface antigen; indicates immunity and clinical recovery
from infection or previous immunization with hepatitis B vaccine. Use to assess
effectiveness of vaccine; request titer levels
Anti-HDV:
Total antibody to delta hepatitis; confirms previous exposure. Use with known
acute or chronic HBV infection
Anti-HDV IgM:
IgM antibody to delta hepatitis; indicates recent infection. Use in known acute or
chronic HBV infection
Hepatitis C
Anti-HCV:
Antibody against hepatitis C. Indicative of active viral replication and infectivity.
Used by blood banks t
HCV-RNA:ucleic acid probe detection of current HCV infection

Small Bowel Tumors:

A. Most common leiomyoma in jejnuum. Now referred as GIST tumors.
Gastro intestinal stromal tumors. From the cells of Cajal.
B. Adenocarcioma: presentation with obstruction. Surgical wide resection
indicated
C. Carinoid tumors: Appendix is the MC site. Present with carcinoid
syndrome:
a. Carcinoid syndrome:
-Cutaneous flushing
-Bronchospasm
-Intestinal crampy
-Vasomotor instability
-Pellagra due to niacin deficiency
-Right sided herat failure.
*All manifestions of increased 5-HT. (Urine: incrased excretionof 5HIAA. Blood increased 5HT)

D.
E.

F.

G.

H.

b. Liver is very good at eliminated 5 HT. Thus to eneter systemic

circulation most go post portal or from a site not involved in the
portal circulation.
GIST (gastrointestinal stromal tumor)
a. C-kit protein=beign
b. If malignant-leiomyosarcoma
Lymphoma: SB most common site bue not common. Harvest in Peyers
patches.
a. MALT tumors
b. Vague S/S: diffuse abdominal pain, weight loss, fatigue.
Meckels Diverticulum:
a. Rement of the omphalomeseteric duct
b. Rule of 2s: 2% of the population, 2 ft from the ileocecal valve, 2
years of age, 2 different mucosa. Can contain gastric cells that can
result in ulceration.
c. Lower abdominal pain in a child, MC cause of painless rectal
bleeding in child.
d. TX: if complications, surgery.
Malrotation
a. Normal anatomy: 270 degree rotation places the dudoneum
retroperitoneal behind the SMA and the cecum in the RLQ, and the
transverse colon superior to the SMA.
b. With incomplete rotation, everything gets fix in the RUQ. Results in
small bowel volvulus
c. Upper GI
d. Emergent laparotomy.
Short Bowel Syndrome
a. Defined as less than 200 cm.
b. Typically due to surgical resection for Chorns, SBO, ischemia via
an embolism, nectrotizing entercolitis, etc
c. Bowel responds with dilitation and increased viliious.
d. TPN indicated for less than 60 cm of SB or 100 cm of large bowel.
e. Transplant.

Colon, Rectum, Anus

A. Anatomy:
a. Cecum: largest. Identified via the fold of Treves. Intraperitoneal
b. Ascending colon up to hepatic flexure: retroperitoneal
c. Transeverse colon: intraperitonal
d. Descedning colon: spleenic flexure down to the sigmoid colon
e. Sigmoid colon: distal part is retroperitoneal.
f. Rectum: 15 cm long. At the sacral promontory.
i. Poster rectum: retroperitonal
ii. Anterior rectum: intraperiontal
1. Important in perforation-anterior will result in diffuse
peritonits.
g. Anus: anorectial junction=dentate line to the anal verge
i. Dentate line=above is innsensate, below is full of nerves.
ii. Columons of Morgangi: proimxal to dentate line-place of
anal crypts
B. Blood supply: sharged btw the SMA and the IMA.
a. SMA: Ileocolic, right colic, and middle colic. Supples right and
proximal half of the transverse colon.
b. IMA: left colic, sigmoidal arteries, sup. Hemorrhoidal arteries
i. Marginal artery of Drummond: contralateral of middle and
colic artery, 2-3 cm parallel to descending colon. Thus, left
colic can be sacraficed.
c. Venous drainage: IMA into spleenic. Spleenic + SMV=portal vein.
d. Rectum blood supply
i. IMA-superior hemorrhoidals
ii. Middle-iliac arteries, middle hemorrohidal
iii. Lower-off the pudenal inf. Hemorrhoidal arteries.
iv. Hemorrhoids: cushions of veins that connect the two system
(sup and mid/inf)
C. Layers:
a. Mucosa
b. Submucosa
c. Muscularis
d. Serosa
e. 3 improtant things: teniae coli, haustra, appendices epiploica.
D. Function:
a. Absorb water and electrolytes
b. Aide in digestions
c. Storage for feces
d. B. fragilis=primary bacteria** anaerobes
e. Aerboics: E. coli, entercocci
E.
a. Gold standard=colonscopy
b. Techneticum labedled RBC=minor blood loss, slow
c. mesterenric angiography: rapid
F. Diverticular DX

a. True vs False. True=congential and contain all three layers. False:

mucosa and submucosa
b. MC in sigmoid
c. Divericuilitis: infection/inflammation of diverticula. LLQ pain, +/palable mass
1. Fever, tenderness, leukocytosis
2. Perforate
3. Fistula formation-pneumoturia, recurrent UTI, skin.
**BARIUM ENEMA CONTRAINDICATED DUE TO CHANCE OF PERF. CT
scan best
Anus and Rectum
A. Rectal prolapse: rectume through anal opeing.
a. MC in thin women.
b. Must determine difference btw rectal prolapse and
hemorrhoidal prolapse.
c. TX: sigmoid resection, rectopexy
B. Hemorrhoids: vascular cushions in the anal canal.
a. Usually due to increased intrabdominal pressure, pregnancy,
diarrhea, constipation, and portal HTN.
b. Internal: above the dentate line. Painless
i. Graded I-IV
1. I: budlge in anal canaa, no outside lumen
2. II: Protrude with defecation, reduce
spontanesoulst TX: banding
3. III: Protrude with defecation, manually reduced
TX: banding
4. IV: cant be manually reduced TX: Surgical
hemorrhoidectomy
c. External: when thrombosis occur=pain.
i. No grade, either absent or present
ii. If thrombosed: local anestheisa and incision to remove
clot
Abscess:
A. Blockage of perianal glands btw internal and external sphincter.
Anal crypts at the base of the columns of Morganni.
B. Interspinter, ischorectal, supralevator abscess
C. S/S: fever, leuckocytosis, pain, etc
D. TX: I&D. Antibiotics later if immunicompromised.
Fisutal in Ano
A. 50% chance of development after drainage of perianal abscess
B. Abnormal communication btw skin and anus.
C. S/S: drainage of pus onto skin
D. Goodsalls Rule: anteroir follow a stragiht course, posterior follow a
curved cousrse.
E. TX: fistulotomy
Anal fissure: PAIN. Tear in the anal canal below dentate line. Posterior MC.
A. Pain is a manifestation of the spasm of the internal sphincter.

B. Traid: external skin tag, fissure exposing internal sphincter fibers,

and hypertrophied and papilla at the level of the the dentate line.
C. TX: If fail typical medical, can make an incision in the internal
sphincter.
Anal Malignancy:
A. Two types:
a. Epidermoid carcinoma* CHEMO and radiation. 5-FU and
mitomycin
b. Malignant melanoma (after the skin and eyes, anus is the 3 rd
most common spot)
Begingn Prostate Hyperplasia
A. Presents with urinary frequency, hestinany, urgency, weak
stream, etc.
B. Can have gross hematuria due to incomplate empyting of
bladder
C. DRE: enlraged prostate, greater than 20 g
D. Must R/O neurogenic blader
E. Medical: alpha 2 blockers
a. 1st generation: prazosin, terazosin, doxasin, Alfuzosin
b. 2nd generation: tamsulosin, silodosin
OR 5 A reducatse inhibitors
c. Finasteride, Dutaseteride (inhibit the conversion of
testosterone to dihydotestesterone)
F. Surgical: TURP is the goldstadard,