Water exchange normally individuals consume 2-2.5 L/Day Loss (250 ml in stool, 0.8-1.5 L in urine and 600 ml insensible loss as sweat and lung vapor) Fever increases loss at 250ml/degree/day Sweat is hypotonic solution, insensible water loss is pure water, GI loss are usually isotonic or slightly hypotonic.

What are volume disorders?

What are sodium disturbances?

Cause CNS devastating consequences, in both hypo or hypernatremia total body Na+ may be increased or decreased, normal natremia is 135-145 mmol/L

Table of hypo and hypernatermia?

What are potassium disturbances?

Table of hypo and hyperkalemia?

What are magnesium disturbances?

Binds ATP Required in: DNA transcription and translation ,nerve conduction , Ion transport and Ca2+ channel activity Approximately 50%-60% of total body magnesium is found in the bones Absorbed by the gut At high concetration Mg2+ acts as a Ca2+ antagonist blocking calcium channels

Table of hypo and hyper Mg?

What are calcium disturbances?

Maintains bone strength Ca2+ homeostasis is influenced by vitamin D,parathyroid hormone, calcitonin, acid-base balance, and PO4 3− homeostasis Total serum ca2+: 50% bound to albumin + 50% ionized Alkalosis promotes the binding of calcium to albumin.

Table of hypo and hypercalcemia?

What are phosphate disturbances?

Like Ca2+ and Mg2+, the majority of PO43− is found in the skeleton. The large majority of the remainder is found intracellularly, where it functions as a constituent of ATP. Like Mg2+, it is essential to energy metabolism

Table of hypo and hyperphosphatemia?

What are the phases of post-surgery/trauma/sepsis water and electrolyte disturbances?

Catabolic, early anabolic and late anabolic

What is the catabolic phase?

AKA adrenergic-corticoid phase, 1-3 days post surgery/trauma, or immediately after Sudden increase in metabolic demand and urinary excretion of nitrogen (azote)

What is the early anabolic phase?

AKA corticoid withdrawal phase, between day 3-8 after uncomplicated elective surgery or weeks inpatient Lasts no more than a day or two coincides with diuresis of retained water. Sharp increase in nitrogen excretion Nitrogen balance is positive indicating synthesis of protein (gain in weight)

What is the late anabolic phase?

Final period of convalescence, lasts weeks-months after injury Gradual restoration of adipose tissue.

What is acute abdomen?

Sudden spontaneous non-traumatic severe abdominal pain <24 hours onset Any delay in dx and management will lead to increased M&M Atypical presentation in elderly (since have other pains and visceral pain becomes shallow) and pregnant women, obesity surgery pt and diabetics Hx and PE determine dx >60-70% Different from surgical abdomen (acute abdomen in need for surgery)

What are types of abdominal pain?

Visceral, Parietal and referred pain.

What is visceral pain?

Mediated by C fibers (demyelinated fibers from C3->S4) w/in wall of hollow organs and capsule of solid organs. Elicited by distention, inflammation, ischemia, contraction of smooth muscles (colic) or by directed movements of sensory nerves Slow onset, centrally percieved sensation, poorly localized and protracted Bilateral sensory supply to spinal cord

What is parietal pain?

By both C and A delta fibers, more localized because somatic afferent fibers are unilateral of nervous system T6-> L1 area Very localized A delta fibers are very fast fibers while C are demyelinated

What is referred pain?

Pain distant from site of affected organ, distorted central perception of the site of pain due to confluence of afferent fibers from disparate areas in posterior horn of spinal cord.

25 years old patient with acute very severe pain that started like stabbing in the periumbilical or epigastric region, then the pain shifts to the right iliac fossa and after several hours he develops abdominal guarding, what is the possible diagnosis?

Acute appendicitis or valentino syndrome

What is Kehr's sign?

Phrenic nerve damage causing left shoulder pain, type of referred pain.

What is valentino syndrome?

Valentino syndrome is a condition where perforated peptic ulcers cause severe abdominal pain that mimics appendicitis due to leakage of gastric contents into the peritoneal cavity, leading to peritonitis and referred pain to the right lower quadrant. This condition requires urgent medical attention and often surgical intervention

How are sensory levels associated with visceral structures?.

What is DD of RUQ pain?

Acute cholecystitis, duadenal ulcer, hepatitis, congestive hepatomegaly, pyelonephritis, appendicitis

What is DD of epigastric pain?

MI Peptic ulcer acute cholecystitis perforated esophagus

What is DD of LUQ pain?

Ruptured spleen gastric ulcer aortic aneurysm perforated colon pyelonephritis

What is DD of RLQ pain?

Appendicitis Salpingitis Tubo-ovarian abscess ruptured ectopic pregnancy renal stone incarcerated hernia mesenteric adenitis meckel's diverticulitis Crohn's disease perforated cecum psoas abscess

What is DD of LLQ pain?

Sigmoid diverticulitis, Salpingitis Tubo-ovarian abscess, ectopic pregnancy incarcerated hernia perforanted colon UC renal stone

What is difference in pain progression between perforation, inflamation and occlusion?

Explosive: perforation Rapid: inflammation Gradual: Occlusion

What is mode of onset and progression of different abdominal pain?

Reflect nature and severity of process causing it Explosive (seconds, perforation), rapid (1-2 hrs, inflammation), gradual (4-6 hours, occlusion) Unheralded (not expected), excrutiating pain suggests intraabdominal catastrophe

What are characterstics of different types of abdominal pain?

How are symptoms associated with abdominal pain?

Vomiting: Medullary vomiting centers stimulated by afferent visceral fibers. Pain in acute surgical abdomen precede vomiting. Absence of bile in vomiting: pyloric stenosis, gastric outlet obstruction, occlusion of biliary duct. Proximal vs distal bowel obstruction Constipation: Reflex ileus: sympathetic ANS (splanchnic nerves) stimulate efferent fibers to reduce peristalsis Obstipation: inability to pass gas and stools  mechanical obstruction

How do we deal with surgical abdomen vomiting?

We start with management of pain first then vomiting, if medical start w/vomiting then pain

A patient comes with an acute abdominal pain and states that during the last 24 hours, he vomited several times. In the beginning, his vomiting included gastro-duodenal secretions, but, in the last 2 times, he vomited blood. What is the diagnosis?

Mallory-Weiss Tear of the esophagus

If a patient had been vomiting with severe epigastric pain and then suffered from acute abdominal pain along with severe dyspnea and oxygen desaturation What is the possible diagnosis?

Boerhaave syndrome is a spontaneous rupture of the esophagus that occurs during intense straining. It most typically occurs during an episode of forceful or repeated vomiting. When the esophagus tears, toxic contents can leak out and cause infection. This is an emergency. Without treatment, it can be fatal within days.

What are other S&S associated with abdominal pain?

Diarrhea: Watery diarrhea: gastroenteritis Blood stained diarrhea: IBD, dysentery, ischemic colitis, intestinal infarction, bacillary infection. Other symptoms and signs : Significant weight loss Jaundice Hematochezia (f severe we have diverticulosis/vascular abnormality) Hematemesis Melena blood clots (if we had 1 episode of upper GI bleed can be visible for 1 week, and seen by occult blood for 3 weeks)

What is median arcuate ligament syndrome?

What are other relevant aspects of hx of acute abdomen?

Past medical history Past surgical history Gynecologic (ex: Mittleshmerz syndrome ) Medication Family history Travel history: Amebic infection, Hydatid, Malaria (sudden arrest either septic shock or spleen rupture), TB, Salmonella Trauma (w/in 1 month)

Patient with severe abdominal pain in the left hypochondrium, hypotension, tachycardia and a travel history to Africa 3 months ago. What is your diagnosis?

Malaria w/spontaneous spleen ruputre

How is physical exam of acute abdomen?

Supine position General observation, systemic signs Fever (cst low grade -> inflammation, if high grade infection of duct) Inspection, palpation, percussion and auscultation DRE, pelvic exam

What are palpation findings in pt w/acute abdomen?

On palpation: Tenderness: localized, diffuse Rebound tenderness Guarding (voluntary vs. unvoluntary guarding) McBurney , Rovsing ,Psoas ,Obturator ,Murphy signs Board like abdomen Renal colic Carnett test Hyperesthesia Abdominal mass (deep palpation)

Image of lesser and greater omentum?

What is the peritoneum?

Serous membrane lining the cavity of the abdomen and covering the abdominal organs Surface 1.7 m² Divides organs into: Intraperitoneal organs: -Liver, spleen, stomach, superior part of the duodenum, jejunum, ileum, transverse colon, sigmoid colon and superior part of the rectum. Retroperitoneal organs : -found posterior to the peritoneum in the retroperitoneal space with only their anterior wall covered by the parietal peritoneum.

What is the main role of the peritoneum?

Policeman of abdomen Protection of the abdominopelvic organs Connect organs with each other Maintain the position of organs by suspending them with ligaments Prevent friction while organs move Cicatrisation via TNF alfa, TGF beta, monoxydes d’azotes Elimination of bacteria

How is the division of peritoneum?

What is the omentum?

Sheet of fatty tissue that stretches over the abdomen Role in immune response and the growth of certain cancers One of the human body's largest organs

Image of lesser and greater omentum?

What is the mesentery?

Folds of peritoneum that suspend organs from the posterior abdominal wall. Carry neurovascular bundles through the fat between peritoneal layers to supply organs

Image of mesentery?

What are peritoneal ligaments?

What is peritonitis?

A suppurative response of the peritoneal lining to direct bacterial contamination Symptoms and signs: - Fever and chills -Tachycardia -Acute abdomen -Free air on plain films

What are types of peritonitis?

Primary bacterial peritonitis: - Hematogenous spread - Transluminal invasion in patients with advanced liver disease and reduced ascitic fluid protein concentration - Monobacterial :E.coli, Klebsiella, Strepto Secondary bacterial peritonitis : -Disruption of a hollow viscus -Polymicrobial -Bile, urine, blood, stools Tuberculous peritonitis: -Young women : 0.5 % of TB -White spots on peritoneum -Treatment : medical treatment , surgery if complication

How is dx of peritonitis done?

Diagnosis: Abdominal x-ray : free air and ileus pattern Water-soluble contrast : location of perforated viscus Abdominal pelvic CT scan with intravenous (IV) and oral contrast is best for finding source of bacterial peritonitis Operation should not be delayed to obtain this test in patients with an acute abdomen

What is DD of peritonitis?

Appendicitis Perforated gastroduodenal ulcers Diverticulitis Gangrenous cholecystitis Acute salpingitis Nonvascular small bowel perforation Mesenteric ischemia

What are types of mesenteric ischemia?

How is tx of peritonitis?

Resuscitation with IV fluids and electrolyte replacement Operative control of abdominal sepsis Systemic empiric antibiotics that cover aerobic and anaerobic enteric organisms; directed antibiotic therapy based on operative or aspiration cultures Prognosis: mortality for generalized peritonitis is 40%

What is endometriosis?

Deposits of endometrium outside of the uterus that respond to hormonal cycles Prevalence in United States is 2% among fertile women and 3- to 4-fold greater in infertile women Symptoms and signs: -Dysmenorrhea -Constant aching lower abdominal pain, beginning 2–7 days before the onset of menses and increasing in severity until menstrual flow subsides -Infertility -Dyspareunia Ultrasound often shows complex fluid-filled masses that cannot be distinguished from neoplasms

What is DD of endometriosis?

Pelvic inflammatory disease Uterine myomas Ovarian neoplasms, polycystic ovary disease Acute appendicitis Ectopic pregnancy, threatened abortion

How is tx of endometriosis?

Goal is to ameliorate symptoms and preserve fertility Mainstay of therapy is medical inhibition of ovulation Laparoscopy or laparotomy to resect or ablate lesions, with or without suspension of the uterus for patients <35 years to preserve reproductive function (controversial) Surgery is indicated for failure of medical management Medications: gonadotropin-releasing hormone analogs Prognosis for reproductive function in mild or moderate endometriosis is good with conservative management

What are mesenteric and omental cysts?

Rare lesions Result from sequestration of lymphatic tissue during development Thin walls lined with endothelial cells without surrounding smooth muscle Cysts may be filled with serous lymphatic fluid (common in the mesocolon and omentum) or chyle (common in small bowel mesentery)

What are S&S of mesenteric and omental cysts?

-Bleeding -Rupture -Torsion -Possible infection of the cyst -Soft mobile abdominal mass -Chronic abdominal pain Ultrasound : thin-walled, hypoechoic, homogeneous mass uniloculated or multiloculated CT scan : thin-walled fluid density mass that may be uniloculated or multiloculated

What is DD of mesenteric and omental cysts?

Pancreatic pseudocysts Enteric duplication Echinococcal cysts Retroperitoneal tumors Tumor metastasis Large ovarian cysts Pseudomyxoma peritonei

How is tx of mesenteric and omental cysts?

Simple excision of the cyst without resection of adjacent organs or major neurovascular structures Partial excision with marsupialization is alternative when complete excision is not possible Internal intestinal drainage is an option, particularly if cyst is adjacent to intestinal wall and may be an enteric duplication

What are complications of mesenteric and omental cysts?

Volvulus of cyst with vascular compromise and infarction of the adjacent intestine Bleeding into the cyst Cyst rupture into the abdominal cavity Cyst infection

What are peritoneal neoplasms?

Secondary implants from intraperitoneal cancers (eg, ovarian, gastric, pancreatic) Primary peritoneal tumors : mesodermal lining of the peritoneum Malignant mesothelioma :History of asbestos exposure in Pseudomyxoma peritonei :low-grade mucinous cystadenocarcinoma of the appendix or ovary

What are S&S of peritoneal neoplasms?

Symptoms and signs: -Weight loss -Crampy abdominal pain -Large abdominal mass -Distention due to ascites Percutaneous biopsy of accessible peritoneal thickening versus diagnostic laparoscopy with biopsy CT scans pleural effusions, ascites, peritoneal and mesenteric thickening

What is DD of peritoneal neoplasms?

Peritoneal mesotheliomas Well-differentiated papillary mesotheliomas Pseudomyxoma peritonei Benign appendiceal mucocele Adeno-carcinomatosis

How is tx of peritoneal neoplasms?

Palliative cytoreductive surgery: -Intraperitoneal chemotherapy, adjuvant intracavitary radiation Cisplatin - or doxorubicin-based adjuvant chemotherapy for malignant mesothelioma, fluorouracil based adjuvant chemotherapy for pseudomyxoma peritonei

How is prognosis of peritoneal neoplasms?

For malignant mesothelioma, long-term survivors (>1 year) have been reported with cytoreductive surgery combined with intraperitoneal chemotherapy For pseudomyxoma peritonei, survival is 50% at 5 years and 30% at 10 years

What are retroperitoneal abscesses?

Primary abscesses :hematogenous bacterial spread, most commonly of Staphylococcus aureus Secondary abscesses :spread of infection from adjacent organs, mainly intestine Symptoms and signs : - Fever -Flank, abdominal, back, thigh pain -Leukocytosis CT scan :differentiate between retroperitoneal hematomas and tumors; abscesses Perform complete blood count; abdominal or pelvic CT scan with IV and oral contrast is essential

What is DD of retroperitoneal abscesses?

Crohn disease Ruptured appendicitis Pancreatitis Perforated diverticulitis Posterior penetrating duodenal ulcer Rule out intra-abdominal process with retroperitoneal extension

How is tx of retroperitoneal abscesses?

Percutaneous drainage may be attempted in well-defined uniloculated abscesses Percutaneous catheter drainage is less successful for retroperitoneal abscesses than for intra-abdominal abscesses Most patients require open surgical debridement and drainage, ideally through an extraperitoneal flank approach, and systemic empiric antibiotics that cover aerobic and anaerobic enteric organisms

How is prognosis of retroperitoneal abscesses?

Retroperitoneal abscesses :difficult to drain completely residual or recurrent abscess formation is common. Mortality approaches 25%

What is retroperitoneal fibrosis?

Extensive fibrotic encasement of the retroperitoneal tissues Diffuse desmoplastic involvement of the retroperitoneum may cause obstructive jaundice or small or large bowel obstruction Classic diagnostic triad : Bilateral hydronephrosis/ hydroureter Medial deviation of the ureters, Extrinsic ureteral compression at the L4–L5 level Ultrasound demonstrates hydronephrosis CT scan or magnetic resonance imaging shows fibrotic process and the classic diagnostic triad

What is DD of retroperitoneal fibrosis?

Retroperitoneal hematoma Retroperitoneal abscess Retroperitoneal sarcoma Retroperitoneal teratoma Rule out underlying malignancy, most commonly metastatic carcinoma or lymphoma

How is tx of retroperitoneal fibrosis?

Perform urinary decompression with ureteral stents or percutaneous nephrostomy Repair abdominal aortic aneurysm if present Discontinue suspect medications Initiate anti-inflammatory medications; prednisone and other immunosuppressants have been used with varying success Prognosis: Gradual resolution is likely if no underlying cancer

What is retroperitoneal hemorrhage?

History of trauma Critically ill patients taking anticoagulation or antiplatelet medications Patients with femoral vascular access, a common cause of clinically silent, large retroperitoneal hematoma Symptoms and signs : depend on location of retroperitoneal hemorrhage include femoral nerve palsy Flank and groin ecchymosis late sign of retroperitoneal hemorrhage Cardinal laboratory finding is a falling hematocrit Perform serial hematocrit evaluations and assess coagulation CT scan differentiates among hematoma, tumor, and abscess

What are traumatic retroperitoneal hematomas?

Zone 1 centrally located, associated with pancreaticoduodenal injuries or major abdominal vascular injury Zone 2 in the flank or perinephric region, associated with injuries to the genitourinary system or colon Zone 3 in the pelvis, associated with pelvic fractures or ileal-femoral vascular injury

What is DD of retroperitoneal hemorrhage?

Retroperitoneal tumor Retroperitoneal abscess Intraperitoneal process with retroperitoneal extension Rule out associated vascular or adjacent organ injury : Arteriography .

How is tx of retroperitoneal hemorrhage?

Obtain large-bore IV access Type and cross 6 U packed red blood cells Normalize coagulation factors Patients with spontaneous retroperitoneal hemorrhage and blunt zone-3 injuries with falling hematocrit should have angiogram with focal embolization Surgery : - All zone-1 injuries - Penetrating zone-2 injuries - Blunt zone-2 injuries with expanding hematoma - Penetrating zone-3 injuries, and evidence of femoral nerve palsy

How is prognosis of retroperitoneal hemorrhage?

Depends on location and severity of injury

How is anatomy of pancreas?

Review netter for related structures, regions, arterial supply and venous drainage

What is insulinoma?

The most common PNETs Whipple Triad symptomatic fasting hypoglycemia serum glucose level <50 mg/dL relief of symptoms with the administration of glucose 10% disease 10% malignancy (the least) 10% metastasis to node 10% multiple lesion 10% found in MEN1 Best Prognosis

How is exocrine action of pancreas?

1-2 L/day Clear, watery, alkaline (pH 8.0-8.3) > 20 different digestive enz. Isoosmotic to plasma Principal cations : Na & K (~165 mmol/L)Principal anions : bicarb & Cl - secrete min : Cl high, bicarb low - secrete max : Cl low, bicarb high (active transport) Passive exchange of intraductal bicarb for interstitial Cl at larger pancreatic duct digestive enzymes in acinar cells released in response to CCK and cholinergic stimulation (proteolytic, lipolytic and amylase)

What are tests related to pancreas function?

Tests - Fecal fat (fat stain) - stool trypsin tests - Trypsinogen (Immunoreactive trypsin) - Elastase (in stool) Non-laboratory tests:- ERCP, MRCP, Secretin test (tube in duodenum : amount of certain enzymes and bicarbonate in the pancreatic secretion )

How is endocrine function of pancreas?

Islet of Langerhans:1-2% of pancreatic mass, 20% of total pancreatic blood flow Insulin : Beta-cell : muscle, liver, fat cells Glucagon : alpha-cell Somatostatin : delta cell Pancreatic polypeptide : PP cells acini are exposed to higher conc. of the islet hormones than peripheral tissue

Table of pancreatic islets peptide products?

What is acute pancreatitis?

Definition An inflammatory disease of the pancreas than is associated with little or no fibrosis of the gland Incidence About 300,000 case/yr in US 10-20% = severe about 4,000 Deaths/yr + more than $2billion cost

How is etiology of acute pancreatitis?

Alcohol biliary tract diseases (80-90%) hyperlipidemia, heriditary, hypercalcemia, trauma, surgical, neoplasm, infection, venum, drugs... (10%) Idiopathic

How is etiology by bile tract diseases acute pancreatitis?

Most common, not clear etiology, common channel hypotheis, incompentent oddi sphincter, PD blockage by heminth/tumor, colocalization (trypsin activate other enzymes

How is etiology by alcohol acute pancreatitis?

(2 yr drink, common, absence of other cause, secretion w/blockage mechanism, increased duct permeability, decreased blood flow)

How is other etiologies of acute pancreatitis? (tumor and iatrogenic)

Tumor (1-2% of Pancreatitis found Pancreatic carcinoma Periampullary Tumor Mechanism :Blockage of secreted juice) Iatrogenic (Pancreatic Biopsy , Biliary exploration , Distal gastrectomy , Splenectomy B2 Gastrectomy & Jejunostomy Inc. intraduodenal P. cause backflow of enz. Any Sugery than cause Low Sys. Perfusion ERCP (most common) 2-10% Direct Inj. or Intraductal Hypertension)

Picture of etiologies of acute pancreatitis?