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Questions and Answers
What is the treatment for hypomagnesemia in acute cases?
Which condition is characterized by a serum phosphate level greater than 4.5 mg/dL?
What is a common treatment option for hypermagnesemia?
Which clinical presentation is associated with hypomagnesemia?
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What percentage of general surgery patients without prophylaxis are diagnosed with DVT?
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What is the diagnostic test of choice for diagnosing pancreatitis?
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Which of the following signs is associated with hemorrhagic pancreatitis?
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What is the most common cause of cholecystitis?
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What is a common clinical feature of chronic pancreatitis?
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In the context of pancreatitis, elevated lipase levels are significant when they increase by how much?
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Which symptom is least likely to be associated with an acute cholecystitis attack?
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Which of the following is a therapeutic intervention for pancreatitis?
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Which of the following conditions is NOT part of the differential diagnosis for pelvic pain?
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What indicates the need for surgical intervention in a patient with chronic pancreatitis?
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What is a significant sign of potential perforation in a patient with cholecystitis?
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What is a characteristic feature of acute pancreatitis?
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Which examination method is NOT part of the initial workup for pelvic pain?
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Which of the following is a risk factor for developing acute pancreatitis?
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What is the preferred pharmacologic therapy for severe disease?
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Which of the following lifestyle modifications can help manage symptoms?
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Which medications should be avoided due to their effect on lower esophageal sphincter pressure?
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What condition can result from chronic reflux esophagitis?
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What symptom is associated with a significant upper GI bleed?
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What is an appropriate first step in managing a patient with suspected upper GI bleeding?
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Which of the following patient factors predisposes individuals to reflux disease?
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What hemodynamic change can be observed in a patient with moderate hypovolemia due to a GI bleed?
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What is the recommended approach for a patient at low risk of bleeding after surgery?
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When should potassium not be added to IV fluids postoperatively?
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Which condition requires immediate treatment with IV short-acting insulin?
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What is the main risk factor for pulmonary complications during perioperative care?
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What is the preferred method of assessing lung function before surgery?
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In which scenario is the use of IV insulin most critical?
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What is the primary aim of managing fluid volume after surgery?
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What is a major contraindication for elective surgery regarding respiratory issues?
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Which condition might necessitate the placement of a catheter before surgery?
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Which statement about post-operative monitoring in diabetic patients is true?
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What is the main consideration for patients with substance use disorders undergoing surgery?
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Which patient characteristic plays a significant role in the risk of surgical site infections?
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What is the initial approach to optimize pulmonary function in COPD patients before surgery?
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Which is a critical step in maintaining fluid balance after surgery?
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Study Notes
Constipation
- Constipation can be caused by a variety of conditions including diverticulitis, Crohn’s disease, ulcerative colitis, abscess, IBS, celiac disease and GI parasitic infections such as amebiasis and giardiasis.
Pelvic Pain
- Pelvic pain can be caused by ovarian torsion, appendicitis, ectopic pregnancy, ruptured ovarian cyst, pelvic inflammatory disease, bowel infarction or perforation, endometriosis, vaginitis, cystitis, or pyelonephritis.
Cholecystitis
- Cholecystitis is caused by a gall bladder (cystic duct) obstruction by a stone, leading to inflammation or infection.
- Most cases (50-80%) are caused by E.coli.
- Symptoms include episodic right upper quadrant or epigastric pain, nausea, and vomiting which is often precipitated by fatty foods or large meals.
- Patients may also experience low-grade fever and a palpable gallbladder.
- Murphy's sign (pain elicited when pressure is applied to the right upper quadrant during inspiration) and Boas sign (referred pain to the subscapular area due to phrenic nerve irritation) can be helpful in diagnosis.
- Hypoactive bowel sounds, high fever, tachycardia, increased respiratory rate, and increased abdominal pain with rebound tenderness are indicators that a perforation has occurred.
- Ultrasound is the initial test of choice for diagnosis.
- A thickened gallbladder greater than 130bp is associated with a grave prognosis.
- Chronic cholecystitis can lead to fat malabsorption and steatorrhea.
- Hemorrhagic pancreatitis can cause bleeding into the flanks (Grey Turner's sign) or the umbilical region (Cullen's sign).
- Chronic cholecystitis is characterized by a triad of calcifications, steatorrhea, and diabetes mellitus.
- Left-sided exudative pleural effusion can occur.
- Amylase levels may be elevated but can return to normal after 48-72 hours.
- Lipase is more sensitive but only with elevations 3x or greater.
- Abdominal CT is the diagnostic test of choice.
- An abdominal x-ray may show a sentinel loop (dilated small bowel in the left upper quadrant) and colon cutoff sign (localized ileus).
- White blood cell count may be elevated and liver enzymes may increase slightly with mild hyperbilirubinemia and bilirubinuria.
- Chronic cholecystitis is typically associated with calcification on ultrasound and gallstones, while amylase and lipase are typically not elevated.
- Treatment includes stopping oral intake, fluid resuscitation (90% recover with supportive measures alone), pain management with analgesics and Demerol, broad spectrum antibiotics (imipenem specifically for necrotizing pancreatitis), and ERCP if biliary sepsis is suspected.
- Patients with chronic cholecystitis may require oral pancreatic enzyme replacement, a low-fat diet, surgical removal of the damaged gallbladder to control pain, and alcohol cessation.
- Indications for surgery are severe pain that limits functioning, intractable pain despite non-narcotic analgesics, and absence of alcohol intake.
- Patients with cholecystitis should avoid alcohol consumption.
Pancreatitis
- Acute pancreatitis is an isolated episode of abdominal pain accompanied by elevated blood enzyme levels and inflammation of the pancreas.
- Over 80% of cases are related to biliary stones or alcohol use.
- Acute pancreatitis can lead to chronic pancreatitis.
Chronic Pancreatitis
- Chronic pancreatitis is a painful disease of the pancreas characterized by fibrosis, calcification, and ductal inflammation.
- Patients with chronic pancreatitis may experience episodes of acute pancreatitis.
- Initiating scheduled pharmacologic therapy is crucial in severe chronic pancreatitis.
- PPIs are the drug of choice.
- H2 blockers at bedtime and PPIs during the daytime may be helpful for patients with significant nighttime symptoms.
- Patients should avoid beta agonists, alpha adrenergic antagonists, nitrates, calcium channel blockers, anticholinergics, theophylline, morphine, meperidine, diazepam, and barbiturate agents as these can decrease lower esophageal sphincter pressure.
Gastroesophageal Reflux Disease (GERD)
- GERD is multifactorial, involving increased gastric acid production, an incompetent lower esophageal sphincter (LES), esophageal motility disorders, delayed gastric emptying, and +/- hiatal hernia.
- Reflux esophagitis is the result of recurrent reflux of gastric contents into the distal esophagus due to a mechanical or functional abnormality.
- GERD affects approximately 10% of the population and is more common in infants (50%).
- Protective factors against GERD include gravity, lower esophageal sphincter tone, esophageal motility, salivary flow, gastric emptying, and tissue resistance.
- GERD can lead to Barrett’s esophagus, which can predispose individuals to malignancy.
Hematemesis/GI Bleed
- Hematemesis/GI bleed usually presents with upper GI bleeding and symptoms such as vomiting blood, coffee ground emesis, melena (black/tarry stools), orthostatic dizziness, confusion, angina, and severe palpitations.
- Hemodynamic stability should be assessed immediately upon evaluation of a patient experiencing a GI bleed.
- Causes of GI bleed include peptic ulcer, esophageal ulcer, Mallory-Weiss tear, variceal hemorrhage/portal hypertensive gastropathy, and malignancy.
- Physical exam should look for signs of hypovolemia:
- Mild/moderate (15%): orthostatic hypotension
- Severe (>40%): supine hypotension
- Labs needed include CBC, chemistries, liver tests, coagulation tests, and cardiac enzymes/?ECG for those at risk of myocardial infarction.
- Treatment includes:
- NGT lavage if unclear if the patient has ongoing bleeding
- IV access with 2 large bore (18 gauge) IVs and fluids
- Blood transfusion if needed
Hypercalcemia
- Hypercalcemia is defined as a serum calcium level greater than 10.5 mg/dL.
- Caused by increased parathyroid hormone (PTH) levels, increased calcium levels, and decreased phosphorus levels.
- It is associated with malignancy and hyperparathyroidism.
- Treatment involves IV normal saline, furosemide, and bisphosphonates.
Hypomagnesemia
- Hypomagnesemia definition: serum magnesium < 1.8 mg/dL.
- Presentation includes muscle weakness, hyperreflexia, prolonged QT, PR, and wide QRS intervals on the ECG.
- Patients may also experience ventricular tachycardia and torsades de pointes.
- Treatment: acute hypomagnesemia is treated with IV magnesium sulfate, while chronic hypomagnesemia is treated with oral magnesium oxide.
Hypermagnesemia
- Hypermagnesemia definition: serum magnesium > 2.6 mg/dL.
- Presentation: muscle weakness, prolonged QT, PR, and wide QRS intervals on the ECG.
- Treatment: IV isotonic saline, loop diuretics can be considered.
Hyperphosphatemia
- Hyperphosphatemia definition: serum phosphate > 4.5 mg/dL.
- Etiology: chronic kidney disease.
- Patients are usually asymptomatic.
- Treatment includes calcium carbonate and potassium restriction.
Hypophosphatemia
- Definition: serum phosphate < 2.5 mg/dL.
- Presentation includes weakness, muscle and bone pain, osteomalacia, and rickets.
- Treatment involves IV phosphate replacement.
Hematologic Disease
- Deep vein thrombosis (DVT) is diagnosed in 20% of general surgery patients and 30% of colorectal patients without prophylaxis.
- Treatment includes:
- Compression devices
- Subcutaneous heparin and LMWH (low-molecular-weight heparin) are clinically equivalent in reducing both DVT and PE (pulmonary embolism)
- LMWH has simpler dosing and decreased risk of heparin-induced thrombocytopenia but is more expensive and may have a dose-related increased risk of bleeding.
- Fondaparinux is a new Xa inhibitor with efficacy for prophylaxis.
- Very low risk: early ambulation
- Low risk: mechanical prophylaxis with intermittent compression devices
- Moderate risk: LMWH or low-dose unfractionated heparin or IPC (intermittent pneumatic compression)
- High risk: IPC + LMWH or low-dose heparin
- Extended course (4 weeks) of LMWH may be indicated for patients undergoing abdominal resection or pelvic malignancy.
- Risks associated with treatment include wound hematomas (most common risk), mucosal bleeding, and reoperation.
Fluid/Volume Disorders
- Approximately 1% of patients experience reduced kidney function post-operatively.
- Risks for post-operative renal dysfunction can be reduced by pushing fluids, avoiding NSAIDs, and minimizing/avoiding exposure to IV contrast.
- Blood transfusions may be necessary before surgery, especially with active hemorrhage or anemia.
- Calculating fluids: adult daily sensible/insensible loss = 1500-2500mL depending on age, gender, and weight.
- Patient weight (kg) x 30 = fluid over 24 hours.
- Increase fluids for fever and hyperventilation.
- Measure intake and output and weigh patients daily.
- General rule: 2000-2500mL of 5% dextrose in normal saline or LR (Lactated Ringer's) solution daily.
- Re-evaluate IV orders every 24 hours.
- Post-operative electrolyte monitoring: electrolytes generally don't need to be measured unless there is extra fluid loss, sepsis, pre-existing electrolyte abnormalities, or renal insufficiency.
- Avoid adding potassium during the first 24 hours post-operatively due to increased aldosterone activity and potassium levels.
- Consider adding 20 mEq potassium to each liter of IV fluid if the patient has good urine output.
- Replace post-operative ionized serum calcium in patients with thyroidectomy or parathyroidectomy.
- Indications for catheter placement: long procedures, urologic or low pelvic surgery, and need to monitor fluid balance.
Metabolic Disease
- Assess patients at admission for a history of diabetes and perform blood glucose testing.
- Blood glucose may be elevated preoperatively in patients with diabetes, especially with physical trauma and emotional stress.
- Perioperative hyperglycemia is treated with IV short-acting insulin or SQ sliding scale insulin.
- Elevated post-operative blood glucose in diabetic patients is associated with an increased chance of post-operative infection, longer hospital stays, and a higher risk of heart disease.
- The risk of surgical site infection increases with the degree of hyperglycemia. Levels greater than 140 mg/dL are predictive of surgical site infection.
- IV insulin is the best option for perioperative glucose control due to its rapid onset, short half-life, and immediate availability.
- Post-operative glycemic control:
- Normal: 90-100 mg/dL - control with IV insulin.
- Moderate control: 120-200 mg/dL.
- Post-operative monitoring for hyperglycemia, hypoglycemia, infection, poor healing, wound issues, and cardiovascular disease (CVD) is crucial.
- Patients with diabetes have a double risk of CVD for men and a quadruple risk for women.
Pulmonary Disease
- Pulmonary complications are the most common perioperative complications.
- Risk factors include the operative site and the presence of pre-existing lung disease.
- Ideally, patients should stop smoking at least 8 weeks before scheduled surgery.
- COPD:
- Treat aggressively to achieve the best possible baseline.
- Minimum one week of therapy: smoking cessation, administration of antibiotics for purulent sputum, bronchodilators if indicated.
- Asthma:
- Poorly controlled asthma increases the risk of post-operative complications. Well-controlled asthma confers little additional risk.
- Poorly controlled asthma: step-up in asthma therapy (course of steroids if FEV1 or PEFR are below predicted values).
- Elective surgery: patients should be free of wheezing with a PEFR > 80% of predicted or personal best prior to surgery.
- Intubation: administer inhaled rapid-acting beta agonist 2-4 puffs/neb treatment 30 minutes prior to intubation.
- Systemic steroids may be advised for 1-2 days to prevent acute bronchoconstriction at the time of intubation.
- Pulmonary fibrosis/restrictive lung disease: treat infection, remove sputum, stop smoking.
- Acute lower respiratory tract infection (tracheitis, bronchitis, pneumonia): contraindications to elective surgery.
- Emergency surgery: humidification of inhaled gas, removal of lung secretions, bronchodilators, antibiotics.
- Diagnosis: PFTs before hospital admission are often used for patients with exceptional dyspnea, exercise tolerance, cough, production of sputum, history of smoking, previous pulmonary complications, asthma, age, and body weight.
- Patients with mild pulmonary compromise for non-abdominal/thoracic surgery do not need PFTs.
- Test via simple spirometry with forced expiratory outflow.
- If airflow is reduced, measure response to bronchodilators and obtain an ABG.
- Increased risk if FEV1 < 45.
- Treatment:
- Preoperative: cigarette cessation, optimize underlying condition, patient education.
- Antibiotics for lower respiratory tract infections (purulent sputum or change in sputum character).
- Intraoperative: increased risk for surgeries > 3-4 hours; upper abdominal/open AAA repair, open thoracotomy, and head/neck surgeries have the greatest risk of post-operative complications.
- Lung protective ventilation for those undergoing abdominal surgery - low tidal ventilation with PEEP at 6-8 cm H2O to reduce pulmonary complications.
- Postoperative: lung expansion, incentive spirometry, CPAP for some patients, early mobilization.
- Preoperative: cigarette cessation, optimize underlying condition, patient education.
Substance Use Disorder
- Key features: substance taken in large amounts, over longer periods than intended; unsuccessful attempts to reduce use
- Symptoms: a lot of time spent obtaining the substance or recovering from its effects; craving, recurrent use despite hazards; tolerance; withdrawal.
- 5-10% of the population has alcohol or drug dependence; males are more likely to be affected.
- Surgical issues: venous access; arterial injury; DVT; abscess formation; tissue compression; crush injury; ischemia (compartment syndrome); poor wound healing; altered consciousness; difficulty with pain management.
- Patients with a known opioid use disorder on methadone should continue to use methadone, including on the day of surgery, to avoid precipitating withdrawal.
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Description
Test your knowledge on various clinical aspects of gastroenterology, focusing on conditions such as hypomagnesemia, pancreatitis, and cholecystitis. This quiz covers essential diagnostic tests, common treatments, and clinical presentations associated with these medical conditions.
