1. Dr Alem Review Surgery 2

3. DDX :
Perforated viscus
Ruptured AAA
Mesenteric ischemia
Acute pancreatitis >> peritonitis

4. Air under diaphragm on chest x-ray

5. Management of Case 1 Resuscitation ! NPO NG tube
Abx ( not necesssary unless he came to you after more than 6 hours of onset)
Surgery for repair

7. Diagnosis? Intestinal Obstruction
Most likely cause? Adhesions (Hx of surgery)
Appendectomy is the most common cause of adhesions.

8. Management of case 2 ABC ! U&E NG tube IV fluids
Abdominal & chest x-ray

9. Multiple air fluid level on erect abdominal x-ray

10. Dilated small bowel loops Compared to the ileum, the jejunum has more valvulae conniventes (plica circularis) and fewer folds per unit length. The jejunum has a smaller diameter (average 2.5cm) compared to the ileum (3.0cm).

11. Distended bowel loops

12. If he has no tenderness >> conservative
Has tenderness? Surgery ! But before you do that , you may want to request Gastrographine study

14. Gastrographine study

16. Because of his age >> think Tumor (colonic Ca)
Most are found on the left side & Usually left sided tumors are not palpable

17. Distended colon how do you know it’s a colon? Haustra

18. What to do? In the ER , take patient for CT CAP for both Dx & staging.
Management of tumor? Hartmann procedure

20. Cecal volvulus (Bean shaped)

21. Management? Take him to OR Rt Hemicolectomy
Cecopexy? High rate of recurrence

22. Think sigmoid volvulus .. Why ? Huge distended abdomen

23. Omega sign on x-ray

24. Management? Colonoscopy to untwist
Has features of peritonism? Don’t try to untwist
Most patients will come back after 3 months with recurrence

25. Conservative management !

26. Diverticulosis

27. Splenic injury

28. In ER
If hemodynamically unstable >> FAST

29. CT scan of the abdomen showing a shattered spleen

30. How to manage? Admit to ICU Serial hemoglobin Monitor the patient
Still unstable or has other intra-abdominal injuries ? Do Splenectomy.

32. CT scan showing Liver laceration and hematoma

33. Same management as in Splenic injury

35. This could be Ascitis Peritonitis ( SBI )
Or Portal hypertension > mesenteric vein ischemia

36. CT scan showing mesenteric ischemia of bowel loops

39. diaphragmatic rupture

40. Management
NG tube
OR to repair

42. US shows acoustic shadowing (Gallstones)

43. Management?
Cholecystectomy!

45. cholangitis admit NPO do ERCP then cholecystectomy

46. US shows multiple gall stones & dilated CBD

47. ERCP shows multiple stones

48. 2nd tutorial
Data iNTERPRETATION

50. ALP is high
Obstructive jaundice
Most common cause? Stones, neoplasms

52. Cholangitis >> charcot’s triad
Take a blood sample >> culture
Abx
ERCP

54. High amylase >> Pancreatitis High GGT >> alcoholic pancreatitis

55. Hypokalemia because 1-nasogastric tube 2- not getting good supplementation on 2nd day post op 3- tissue damage

57. Hyponatremia

62. ABG shows uncompensated metabolic alkalosis treat with IV fluid

63. Good luck
Maisa , Lama , Fatemah