Smoking Cessation Prior to Surgery

Cholecystitis

• Gallbladder (cystic duct) obstruction by gallstones → inflammation/infection
• Majority are caused by Escherichia coli (E. coli).
• Acute acalculous cholecystitis: Usually in critically ill patients, due to biliary stasis and absence of cholecystokinin (decreased gallbladder contraction).
• Chronic cholecystitis: Associated with gallstones, a "strawberry" gallbladder (secondary to cholesterol submucosal aggregation) or porcelain gallbladder (premalignant condition).
• Primary cause: gallstones; chronic alcohol abuse.

Pancreatitis

• Inflammation of the pancreas
• From trauma, hyperlipidemia, drugs, hypercalcemia, penetrating peptic ulcer disease (PUD), certain medications.
• Acute: Sudden, severe, constant upper abdominal pain that may radiate to the back, better with forward leaning or sitting in fetal position. Nausea, vomiting, fever.
• Chronic: Steatorrhea, calcifications, diabetes; recurrent acute pancreatitis episodes
• Labs: Elevated amylase (may be normal after 48-72 hrs) and lipase (more sensitive); mild hyperbilirubinemia/bilirubinuria. Hypocalcemia.
• Imaging: CT is the diagnostic test of choice.
• Treatment: NPO (nothing by mouth), IV fluid resuscitation; pain management (demerol); use abx if needed. ERCP for biliary sepsis suspicion (effective in obstructive jaundice).

Anal Fissure

• Painful linear lesions in the distal anal canal.
• Mostly found in the posterior midline.
• Can involve the entire thickness of the mucosa if untreated.
• Painful bowel movements, leading to constipation and bleeding. Skin tags if chronic.

Anorectal Abscess/Fistula

• Bacterial infection of anal ducts/glands
• Throbbing rectal pain, worse with sitting, coughing, or bowel movements.
• MC posterior midline
• Treatment: I&D (with or without antibiotics); high fiber diet; topical nitroglycerin, silver nitrate or Nifedipine ointment; BoTox.

Appendicitis

• Obstruction of the appendix (MC cause is a fecalith; could be from inflammation, malignancy, foreign body or collagen vascular disease).
• MC in 10-30 year olds
• Initial symptoms: anorexia, periumbilical/epigastric pain transitioning to constant RLQ (McBurney's point) pain; nausea, vomiting, low-grade fever.
• Complications: Perforation/peritonitis (high fever, generalized abdominal pain, increased leukocyte count).
• Imaging: US or CT.
• Treatment: Urgent appendectomy.

Bariatric Surgery

• Maintaining weight loss and reducing obesity-related medical problems (BMI > 40 or > 35 with medical problems; failed other non-surgical programs; must be psychologically stable and able to follow post-op instructions).
• Variety of procedures (e.g., adjustable gastric banding, sleeve gastrectomy or Roux-en-Y gastric bypass)
• Post-op complications: band slippage or erosion; dumping syndrome (from rapid movement of simple sugars from stomach to bowel, leading to fullness, cramping, pain, nausea, vomiting, and diarrhea).

Bowel Obstruction

• Mechanical or functional blockage of the small or large intestine
• Mechanical: Adhesions, hernias, neoplasms, inflammatory bowel disease (IBD), volvulus, fecal impaction, strictures; intussusception.
• Symptoms: Vomiting (follows pain), obstipation (severe); crampy abdominal pain, vomiting, diarrhea (early). Mild pain → severe.
• Imaging: XR (air-fluid levels, dilated bowel loops); CT with contrast if XR inconclusive
• Treatment: NPO; NG suctioning; IVF; if mechanical obstruction likely → urgent surgical consult.
• Volvulus: Twisting of a portion of the bowel, potentially causing necrosis & perforation.

Cholelithiasis

• Asymptomatic formation of gallstones (90% cholesterol)
• Risk factors: Female, fertile, forty, fair, fat, oral contraceptives.
• Causes: Bile stasis, chronic hemolysis, cirrhosis, infection, rapid weight loss, inflammatory bowel disease (IBD), total parenteral nutrition (TPN), or some medications (e.g. fibrates).
• Complications: Biliary colic (episodic upper abdominal or epigastric pain beginning abruptly and resolving slowly, often lasting 30 min-hours after a meal), jaundice, possible cholecystitis or choledocholithiasis.

Diverticular Disease

• Diverticulosis: Non-inflamed diverticula; often associated with a low-fiber diet, constipation, and obesity. Asymptomatic but can cause lower GI bleeding
• Diverticulitis: Inflamed diverticula, secondary to obstruction or fecalith; associated with infection. LLQ pain; Fever; n/v/d/c.
• Diagnosis: CT scan—shows bowel wall thickening, fat stranding and inflamed diverticula.
• Treatment: Diverticulosis: High fiber diet; diverticulitis: oral antibiotics; avoid low fiber diets

Esophageal Neoplasms

• Cancerous growth and development in the esophagus
• Squamous cell carcinoma: Most common in the upper esophagus and associated with tobacco use and alcohol consumption
• Adenocarcinoma: Most common in the lower esophagus, associated with Barrett's esophagus, obesity.
• Symptoms: Progressive dysphagia to solids, weight loss, odynophagia, heartburn, vomiting, hoarseness.

Esophageal Strictures

• Narrowing of the esophagus, mostly caused by GERD or Barrett's esophagus.

Gastric Carcinoma

• Cancer of the stomach
• Risk factors include H. pylori infection, salted, cured, smoked or processed/cured foods.
• Symptoms: Dysphagia (difficulty swallowing), indigestion, weight loss, early satiety, abdominal distention, pain, Nausea
• Treatment: Endoscopy with biopsy; surgical resection; radiotherapy; chemotherapy

Constipation

• Inability to pass stools regularly
• Caused by various factors including low fiber intake, medications and other underlying diseases
• Diagnosis: Physical exam; medical history

Diarrhea

• Frequent loose, liquid or semi-solid stools for at least 2 to 3 consecutive days
• Etiology: Infection, toxic, diet, Gl dz
• Possible indications: infection (bacterial or viral), medication reactions, inflammatory bowel disease (IBD) or pancreatic insufficiency.
• Diagnosis: Based on symptoms or hx of recent food/ drinks consumed, meds

Hernia

• Protrusion of an organ or body part through an abnormal opening in the muscle or connective tissue that surrounded it
• Hiatal Hernia: protrusion of the stomach through the diaphragm via the esophageal hiatus usually worsened by GERD.
• Sliding hiatal hernia: GE junction and stomach slide into mediastinum
• Rolling/paraesophageal hernia: fundus of stomach protrudes through diaphragm, GE junction remains in anatomic location.
• Inguinal Hernia: Protrusion of abdominal contents through the inguinal canal.
• Direct Inguinal Hernia: intestines pass medially to epigastric artery into inguinal canal
• Indirect Inguinal Hernia: intestines pass laterally to epigastric artery through internal inguinal ring into inguinal canal.
• Femoral Hernia: contents pass through the femoral canal
• Diagnosis: Physical exam and imaging to determine the type and location of the hernia

Hepatic Carcinoma

• Cancer of the liver
• Risk factors include chronic liver diseases and cirrhosis (especially viral hepatitis and alcohol abuse), some medications.
• Treatment: surgery (if tumors are small or limited in number or size); transplant; chemotherapy or radiation therapy depending on the severity of the dz and if distant metastasis is present.

Hematemesis/GI bleed

• Vomiting of blood
• Causes: PUD, esophageal ulcer, Mallory-Weiss tear, variceal hemorrhage, portal hypertensive gastropathy, malignancy.
• Diagnosis: Physical examination, lab investigation to determine if there are any associated causes

Hemorrhoids

• Inflammation or swelling of veins in the rectum and anus
• Can bleed, cause pain, cause itchiness and discomfort, or prolapse out of the anus.

Jaundice

• Yellowing of the skin, sclera and mucus membranes; caused by abnormal levels of bilirubin in the blood.
• ETI: Extravascular hemolysis / ineffective erythropoiesis, Gilbert syndrome, Crigler-Najjar syndrome, Dubin-Johnson, biliary tract obstruction, viral hepatitis, physiologic jaundice of newborn; hepatocellular, obstructive.

Melena/Hematochezia

• Melena: Black, tarry stool indicating an upper GI bleed
• Hematochezia: Bright red blood per rectum (mostly lower GI).

Pilonidal Cysts

• Infection or inflammation in the hair follicles near the natal cleft of the buttocks. -Diagnosis: physical exam.
• Treatment: initial treatment is incision and drainage; definitive treatment requires surgical excision.

Pyloric Stenosis

• Narrowing of the pyloric sphincter, a muscle at the end of the stomach
• Presents with projectile vomiting in infants/young children

Small Bowel Carcinoma/Large bowel Carcinoma

• Cancer in the small/large intestines
• Symptoms: abdominal pain, intermittent and crampy; anemia; overt Gl bleeding; jaundice; weight loss.

Toxic Megacolon

• Severe dilation of the colon, usually secondary to a condition like IBD, and/or some infections
• Signs: fever, distended abdomen, peritonitis, and shock.
• Treatment: Colon decompression; in some cases even complete colonic resection is necessary

Ulcers

• Open sores in the lining of the stomach or duodenum
• Types: Gastric ulcers, Duodenal ulcers
• Risk factors: H. pylori; NSAIDS and Zollinger-Ellison Syndrome
• Treatment: Medications (Acid suppression)

Volvulus

• Twisting of a portion of the intestine, potentially causing necrosis and perforation.
• MC sigmoid and cecum

Portal Hypertension

• Elevated blood pressure in the portal vein - causes: hepatic cirrhosis; portal vein thrombosis
• CM: ascites and GI hemorrhage

This quiz explores the recommended time frame for patients to stop smoking before undergoing surgery. Understanding this critical timeline is essential for minimizing the risk of pulmonary complications during surgical procedures. Test your knowledge on this important aspect of patient care.