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Small Bowel Obstruction

1 Name three mechanisms of bowel obstruction, and give examples and incidence of each type a. Extrinsic compression: Adhesions (60%), malignancy (20%), hernias (10%), volvulus and others (5%). b. Internal blockage of the lumen by abnormal materials (obturation): Bezoars, gallstones, worms, or foreign body (usually obstructs at the ileocecal valve). c. Mural disease encroaching on the lumen (inflammatory bowel disease [5%]), fibrous stricture secondary to trauma,…

Acid Peptic Ulcer Disease

1 What is peptic ulcer disease (PUD)? PUD includes gastric and duodenal mucosal defects (ulcerations) extending to the muscularis mucosa. 2 What is the incidence of PUD? The lifetime risk for PUD is about 8%–14%. It usually occurs between ages 20 and 60 years, with peak incidence in the fourth decade of life. It was more common in males but is shifting toward gender equivalence. Hemorrhage…

Esophageal Carcinoma

1 What are the presenting signs and symptoms of esophageal cancer? Presenting symptoms most commonly include progressive dysphagia and weight loss. Notably, a tumor can obstruct over half of the esophageal lumen before dysphagia becomes symptomatic. Symptoms common to gastroesophageal reflux disease (GERD) such as chest or epigastric pain and regurgitation are also reported. Signs and symptoms of more advanced disease include melena and anemia from…

Gastroesophageal Reflux Disease

1 What is the most common cause of gastroesophageal reflux disease (GERD)? Pregnancy. And, it’s not the bowling ball in the abdomen; it’s the estrogen and progesterone that relax the lower esophageal sphincter (LES). 2 What symptoms suggest GERD? Substernal burning after meals or at night, associated occasionally with regurgitation of gastric juices, is a common symptom. Discomfort is relieved by standing or antacids. Dysphagia, a…

Portal Hypertension and Esophageal Varices

1 Describe the common causes of upper gastrointestinal bleeding (UGIB) in US populations Peptic ulcer disease is the number one cause of UGIB in the United States. The gram-negative bacteria Helicobacter pylori plays a significant role in the pathogenesis for many. Esophageal varices (EV) related to portal hypertension (PH) is another leading cause, followed by a number of disorders including Mallory-Weiss tears, and arteriovenous malformations. 2…

Diagnosis and Management of Chronic Pancreatitis

1 What is chronic pancreatitis? The classic description is a prodrome of smoldering abdominal pain and eventual pancreatic insufficiency. Histologically, chronic fibroinflammatory processes result in destruction of the functioning endocrine and exocrine pancreatic cells. 2 What is the most common cause? Alcohol abuse is a common cause in the developed world, accounting for 34%–60% of cases. Because only 3%–10% of those with alcohol use disorder develop…

Acute Pancreatitis

1 What are the common causes and incidence of acute pancreatitis? Gallstones (40%–70%), alcohol (25%–35%), idiopathic (10%), and other (<5%). The incidence of acute pancreatitis is estimated 13–45 per 100,000 people, making it the second highest cause of total hospital stays in the United States. 2 What are the uncommon causes? Hyperlipidemia, hypercalcemia (hyperparathyroidism, multiple myeloma), iatrogenic factors (4% of patients undergoing endoscopic retrograde cholangiopancreatography [ERCP]…

Pancreatic Cancer

1 What is the magnitude of the problem? For the year 2016, there were an estimated 53,000 new cases of pancreatic cancer in the United States, and more than 41,790 deaths, making this arguably one of the most lethal tumors. It is now the third most common cause of cancer death in the United States for both men and women, with an annual incidence of approximately…

Gallbladder Disease

1 What is the prevalence of gallstones in Western society for women and men 60 years of age? Women, 50%; men, 15%, although there is formidable ethnic predilection with gallstones endemic in American Indians. 2 What is the difference between cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis? Cholelithiasis refers to the presence of gallbladder stones. Symptomatic cholelithiasis is the most common indication for cholecystectomy. Cholecystitis is an inflammatory…

Appendicitis

1 What is the classic presentation of acute appendicitis? Periumbilical pain that migrates to the right lower quadrant (RLQ) in a patient who is anorexic. Associated symptoms include nausea, vomiting, and bowel changes. 2 What is the pathophysiology of appendicitis? The appendix is susceptible to luminal obstruction via lymphoid hyperplasia, a retained fecalith, tumor, foreign body, or kink. Any of these processes may result in lymphatic…

Pediatric Trauma

1 What is the leading cause of death in children in the United States? Traumatic injuries cause more death and disability in children from ages 1 to 18 years than all other causes combined. Unintentional injury accounts for 65% of all injury deaths in children under 19 years of age. Each year, approximately 20,000 children and teenagers die as a result of injury and 50,000 children…

Burns

1 Where do burn injuries occur? Eighty percent of burn-related injuries occur in the home, mostly in low-income, multifamily dwellings. 2 Who is at risk of suffering burns? The incidence of burn injuries and deaths in the United States is substantially higher than that of the rest of the industrialized world. The male-to-female ratio for burn injuries is roughly 2:1. Alcohol abuse and illicit drug activity…

Hand Injuries

1 How are hand fractures and hand injuries splinted? Immobilization should include splinting the joint above and below the injury. For example, a splint for a metacarpal fracture includes the wrist and metacarpal phalangeal (MCP) joints. 2 Name commonly used splints Volar wrist splint: Ideal resting splint for the hand after burn and soft tissue injuries. Thumb spica splint: Ideal for injuries located on the radial…

Maxillofacial Trauma

1 What is the overall treatment goal in repairing facial fractures? Restoration of form and function to premorbid condition is the primary goal in treatment of facial fractures. In regards to midface and mandibular fractures, restoration of dental occlusion restores function and restoration of facial width and projection restores form. With orbital fractures, restoration of orbital volume and freeing of any incarcerated orbital fat and/or muscles…

Facial Lacerations

1 What distinguishes facial lacerations from other? After facial trauma, restoration of the appearance of the face is of the utmost concern. Successful primary closure of a facial laceration can be best achieved with irrigation, minimal debridement, gentle handling of the tissue, and eversion of the skin edges. Adherence to these principles gives the best chance for the least noticeable scar. The face has abundant blood…

Extremity Vascular Injuries

1 What is the pathophysiology of extremity vascular injury? Peripheral arteries are composed of three layers: outer adventitia, central muscular, and inner endothelial, or intima. Trauma, either blunt or penetrating, can produce hemorrhage (from laceration or puncture), thrombosis (from intimal disruption and exposure of the subendothelial matrix), or spasm—either alone or in combination. The intima is the least compliant of the vascular layers, and it fractures…

Lower Urinary Tract Injury and Pelvic Trauma

1 What are the causes of bladder injury? Bladder injury can be caused by trauma or iatrogenic manipulation. Traumatic bladder injuries can be classified as intraperitoneal or extraperitoneal, blunt or penetrating. The most common sign of bladder injury is gross hematuria. Other signs of bladder injury are pelvic pain, inability to void, or incomplete recovery of catheter irrigation. 2 What types of bladder injury may occur…

Upper Urinary Tract Injuries

1 What is the most common type of renal trauma in the United States, blunt or penetrating? Approximately 90% of renal injuries are caused by blunt mechanism in the United States. 2 Why are pediatric patients more susceptible to major renal injuries? Pediatric patients have weaker abdominal muscle, less ossified thoracic cage, decreased perirenal fat, and increased renal size in relation to the rest of the…

Pelvic Fractures

1 What are the first steps in the evaluation and treatment of a patient with pelvic ring injuries? Severely injured patients with high-energy acute pelvic ring disruptions are at high risk of mortality from associated exsanguinating hemorrhage. Diagnostic workup strategies in the emergency room must be standardized to avoid an unnecessary delay to definitive surgical bleeding control, as the time elapsed between injury and operating room…

Trauma to the Colon and Rectum

Colon Trauma 1 How do most colon injuries occur? Nearly all (>95%) colon injuries are caused by penetrating trauma from a gunshot, a stab wound, an iatrogenic injury, or a sexual injury. Blunt colonic trauma is rare and usually results from seat belts during motor vehicle crashes. 2 How are colon injuries diagnosed? They are usually diagnosed during laparotomy for penetrating trauma. For patients in whom…