PAEA Surgery Study Guide | PAEA Surgery Blueprint Gastrointestinal/Nutritional ; ABDOMINAL PAIN.

PAEA Surgery Blueprint
Gastrointestinal/Nutritional (50%)

ABDOMINAL PAIN

Acute Abdomen
 Caused by Perforation
o Sudden onset
o Constant, generalized, very severe
o Tenderness, msl guarding, rebound, silent abdomen
o Pt lies still
o Diagnosis
 Free air under diaphragm in upright Xray
o Treatment
 Emergency surgery
 Caused by obstruction of a narrow duct
o Ureter, cystic, common
o Sudden onset of very severe colicky pain
o Location according to source
o Pt constantly moving
 Caused by inflammatory process
o Gradual onset (6-12 hrs)
o Constant pain, starts general but becomes localized
o Systemic signs (fever, leukocytosis)

Treatment for generalized acute abdomen = exploratory laparotomy

HEARTBURN/DYSPEPSIA

Gastroesophageal Reflux Disease (GERD)
 Basics
o Transient relaxation of LES (incompetent) => gastric acid reflux => esophageal
mucosal injury
o Complications
 Esophagitis, esophagus stricture, esophageal adenocarcinoma
 Barrett’s esophagus: esophageal squamous epithelium replaced by
precancerous metaplastic columnar cells
 Manifestations
o Hallmark = heartburn
 Retrosternal, postprandial
o Regurgitation
o Dysphagia
o Cough at night

o “ALARM” sx
 Dysphagia, odnophagia, weight loss, bleeding
 Suspect malignancy
 Diagnosis
o Clinical
o Endoscopy
 Often used first
o Esophageal manometry
 Done is endoscopy normal
o 24hr ambulatory pH monitoring
 Gold standard

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 Not done often
 Management
o Stage 1: Lifestyle Modifications
 Elevation of the head of the bed
 Avoid recumbence for three hours after eating
 Eat small meals
 Avoid certain foods (fatty, spicy, citrus, chocolate, caffeine)
 Decrease fat & ETOH intake
 Weight loss
 Smoking cessation
o Stage 2: As Needed” Pharmacological Therapy
 Antacids
 OTC H2 receptor antagonists (“-tidine”)
 ***If “ALARM” sx, do endoscopy
o Stage 3: Scheduled Pharmacologic Therapy
 Meds
 H2RA
 Proton Pump Inhibitors (“-azole”)
o Drug of choice in severe disease
 Cisapride
 Nissen Fundoplication
 If refractory

Achalasia
 Basics
o Loss of Aurbach’s plexus => increased LES pressure
 Failure of LES relaxation
 Manifestations
o Dysphagia to BOTH solids & liquids
o Weight loss
o Regurgitation of undigested food

o Chest pain
o Cough
 Diagnosis
o Esophageal manometry (gold standard)
 Increased LES pressure (> 40 mmHg)
o Double-contrast esophagram
 Bird’s beak appearance
 Management
o Decrease LES pressure
 Botox injection (temporary relief)
 Nitrates
 CCBs
 Dilation of LES
 Esophagomyomectomy

JAUNDICE

Basics
 Yellowing of skin, nail beds, sclera
o Due to tissue bilirubin distribution
 *Not a disease but a sign of disease
 Occurs when bilirubin > 2.5 mg/dL

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Types
 Hemolytic
o Low level (6-8)
o Elevated bilirubin is unconjugated (indirect)
o Work up should determine what is causing issue with RBCs
 Hepatocellular
o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (modest)
o Hepatitis (direct workup this way)
 Obstructive
o Elevated bilirubin (conjugated & unconjugated), transaminases, alk phos (v. high)
o Workup => U/S
 Look for obstruction

HEMATEMESIS

Denotes upper GI source
Diagnosis: UGI endoscopy



Corrosive Esophagitis
 Basics
o Etiology: ingestion of corrosive substance
 Manifestations
o Odynophagia, dysphagia, hematemesis, dyspnea
 Diagnosis
o Endoscopy
 Management
o Supportive
o Pain meds
o IV fluids

Boerhaave’s Syndrome
 Basics
o Full thickness rupture of distal esophagus
o Associated with repeated vomiting (bulimia), iatrogenic perforation
 Manifestations
o Retrosternal chest pain worse with deep breathing and swallowing
o Hematemesis
o PE: crepitus on chest auscultation due to pneumomediastinum
 Diagnosis
o Chest CT
 Management
o Surgical repair

Mallory-Weiss Syndrome (Tears)
 Basics
o UGI bleeding due to longitudinal mucosal lacerations @ gastroesophageal junction or gastric
cardia (superficial)
o Sudden rise in intragastric pressure or gastric prolapse into esophagus
 Persistent retching/vomiting
 Alcohol binge
 Bulimia

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 Manifestations
o Retching/vomiting => hematemesis after an alcohol binge
o Melena, hematochezia, syncope, ab pain, hydrophobia
 Diagnosis
o Upper endoscopy
 Management
o Supportive if no active bleeding
o Active bleeding => epi injection, sclerosing agent, band ligation, hemo-clipping or balloon
tamponade
Esophageal Varices
 Basics
o Dilation of gastroesophageal collateral, submucosal veins
 Complication of portal vein HTN
o Risk factor: cirrhosis
 Manifestations
o Upper GI Bleed (hematemesis, melena, hematochezia)
o Hypovolemia possible
 Diagnosis
o Upper endoscopy (enlarged veins)
 Management
o Endoscopic intervention
 Ligation
o Vasoconstrictors
 Octreotide, vasopressin
o Balloon tamponade
o Surgical decompression
 Transjugular intrahepatic portosystemic shut (TIPS)
 Prevention of re-bleeds
o Nonselective beta blockers
 Propranolol, Nadolol
o Isosorbide
 ABX prophylaxis
o Fluoroquinolones (Nofloxacin)
o Ceftriaxone

Gastritis
 Basics
o Superficial inflammation/irritation of stomach mucosa (with mucosal injury)
o Causes: H. pylori, NSAIDs, acute stress
 Manifestations
o MC asymptomatic
o Upper GI bleed (hematemesis, melena)
o Epigastric pain, N/V, anorexia
 Diagnosis
o Endoscopy
 Management
o H. pylori +
 CAP: clarithromycin + amoxicillin + PPI
o H. pylori –
 PPI, antacids, H2RA, sucralfate

Others = Gastric Carcinoma
MELENA/HEMATOCHEZIA


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