Surgical Problems in the ER Ross F. Goldberg September 30, 2015.

Surgical Problems in the ER

Ross F. GoldbergSeptember 30, 2015

Objectives• Review the most common consults called to the general

surgery service• Review current treatment algorithms for those disease

processes• Discuss ways to improve efficiency and enhance patient care

Who Cares?• Metrics taking over practices• Emergency Room Metrics:– Many are time-based

• Surgical Metrics:– Quality-based, time-based, complication-based

• Push to be faster and cheaper but providing higher quality

Most Common Diseases• Biliary Disease• Appendicitis• Anorectal Disease• Abscesses (briefly)• Hernias (briefly)

Main Resource• Scientific American Surgery (formerly ACS Surgery)– Online book– Updated frequently, using evidence-based medicine– More and more useful as a tool for surgical boards

Biliary Disease• Biliary Colic• Acute Cholecystitis• Acalculous Cholecystitis• Choledocholithiasis• Gallstone Pancreatitis• Cholangitis

Gallstones• Gallstone disease one of the most common problems

encountered by general surgeons• Only 20% of patients with gallstones develop symptoms• Incidence of complications estimated 1-4% per year in clinically

silent gallstones

Asymptomatic GallstonesIndications for Elective Cholecystectomy in Asymptomatic Gallstones

Clear indications:-Suspicion or increased risk of malignancy Gallstones associated with polyps > 1 cm High-risk ethnic groups (American Indians, Mexican) Large (> 3 cm) gallstones – CONTROVERSIAL Calcified (porcelain) gallbladder – LESS LIKELY

-Transplant patients

-Chronic hemolytic syndromes

Relative indications:-Diabetes

-Vague dyspepsic symptoms in presence of gallstones

-Nunfunctioning gallbladder

-Small stones (< 3 mm) with patent cystic duct

Unclear indications:-Patients living in remote areas

-Concomitant cholecystectomy during another abdominal surgery

Biliary Colic• Biliary colic – caused by contraction of gallbladder against a

transiently obstructed cystic duct• Classic symptoms:– RUQ or epigastric pain occurring after eating (especially fatty meals)– Lasts from 30 minutes – several hours– May have diaphoresis, nausea, vomiting

• Most common complications:– Acute cholecystitis– Choledocholithiasis– Gallstone pancreatitis

Biliary Colic

• Imaging:–Ultrasound• Diagnostic test of choice• Stones (size and number), sludge, polyps, thickness of

wall, fluid, dilated ducts• Operator dependent, interpreter dependent

Biliary Colic

• Imaging:–MRCP• Highly accurate• Good for suspected choledocholithiasis

–CT• 60-80% of gallstones are not radiopaque• Not useful for symptomatic gallstones

Treatment of Biliary Colic• Symptomatic gallstones warrant cholecystectomy• After first episode, 70% of patients will experience further

episodes• Managed usually with laparoscopic cholecystectomy

Surgical Consult – Yes or No?• Biliary colic is not an emergency, it is elective• Patient with suspected biliary colic –PO trial – if tolerates, can follow-up as outpatient–Unable to take PO – call general surgery for intractable pain

Surgical Consult – Yes or No?• See if general surgery is readily available to set-up

outpatient OR from ER– If patient is wiling– If resident available to see consult in a timely fashion– If not refer to general surgery clinic

Gallbladder Polyps

Acute Cholecystitis• Cystic duct obstruction gallbladder edema, mucosal

sloughing, potentially leading to ischemia• INFLAMMATORY PROCESS• Symptoms:–RUQ pain, lasting more than 6-8 hours– Leukocytosis–Possible elevation in liver function tests–Murphy’s sign

Acute Cholecystitis• Imaging:–Ultrasound:• Wall edema, > 4 mm [isolated thickness NOT usually acute]• Pericholecystic fluid• Gallbladder distention [can occur with fasting]• Sonographic Murphy’s sign [possibly]

–HIDA:• Takes longer• Shows cystic duct obstruction• More sensitive than ultrasound

Acute Cholecystitis• Imaging:–MRCP:• Limited role

–CT:• Wall edema• Pericholecystic fluid• Fat stranding• Gangrenous cholecystitis – air in gallbladder wall

Treatment• Cholecystectomy• Timing of cholecystectomy:– Early laparoscopic cholecystectomy is much better for the patient– 72 hours or less from onset of pain [still being studied]– Otherwise wait 6 weeks resolution of inflammation

• Certain high-risk patients, avoid an operation

Treatment• Non-operative management:– Keep patient NPO decrease gallbladder stimulation– IV fluids– Pain control– Antibiotics (gram-negative and anaerobes) risk of superimposed

infection– Majority respond to this, if not cholecystostomy tube

Cholecystostomy Tube• Decompresses the gallbladder• When output decreases cholangiogram through tube• If cystic duct patent clamp tube for 1 week• If can tolerate clamp with no symptoms either:– Remove tube– Close to 6-week mark laparoscopic cholecystectomy

Surgical Consult – Yes or No?• Suspected acute cholecystitis Call General Surgery• Start IV fluids• Not necessary to start antibiotics• Pain control• Keep NPO

Common Bile Duct Stones• Can be asymptomatic, more commonly see these symptoms:– Upper abdominal or back pain– Nausea, vomiting– Jaundice

• Primary vs. Secondary– Primary: develop spontaneously from biliary stasis– Secondary: more common, from gallbladder

Common Bile Duct Stones• Labs:– Serum liver enzymes, bilirubin, alk phos all elevated– Highest negative predictive value: GGT– Not used in isolation

Common Bile Duct Stones• Imaging:–Ultrasound – most common, but limited; can confirm if

stone seen– EUS – more sensitive, invasive, rarely used for this–MRCP – sensitivity 93%, specificity 94%• Noninvasive• Less accurate in diagnosing stones less than 6 mm compared to

cholangiography

From Scientific American Surgery, Chapter 119, Figure 4.

Common Bile Duct Stones• Treatment:– ERCP with sphincterotomy– Laparoscopic cholecystectomy +/- ultrasound & +/- cholangiography– Common bile duct exploration– PTC [not often used]

– Lap chole should generally be offered as soon as possible after ERCP

Surgical Consult – Yes or No?• Diagnose choledocholithiasis Call General Surgery• NPO• IV fluids• If have multiple medical comorbidities may ask for

Internal Medicine consult/admission

Cholangitis• Secondary to obstruction of distal common bile duct • Charcot’s triad:– RUQ pain– Fever – Jaundice

• Reynolds’ pentad:– Hypotension– Acute mental status change

Cholangitis• MEDICAL EMERGENCY call for emergent drainage– First by ERCP– If not, then PTC– Surgery is the last choice

Gallstone Pancreatitis• Acute pancreatitis acute inflammation of the pancreas• Transient obstruction of pancreatic ductal system from passage

of stone/sludge through biliary system• Attributing etiology of pancreatitis to gallstones can be

challenging• LFTs can be normal in some patients

Gallstone Pancreatitis• Early ERCP not necessarily required• For MOST patients, need lap chole during same admission• Lap chole should be performed as patient STARTS to improve• Different algorithm if has severe acute pancreatitis

Surgical Consult – Yes or No?• Suspect gallstone pancreatitis CALL GENERAL SURGERY– Right of first refusal

• If do not see ANY stones on ultrasound, extremely unlikely caused by gallstones– Usually a large single stone, or many smaller stones

• NPO• IV fluids is a MUST

Acute Acalculous Cholecystitis• Approximately 10% of acute cholecystitis• Occurs in patients who are critically ill, have been NPO,

develop biliary stasis• Also seen in patient with cardiac disease/ischemia• Treatment – usually too sick for an operation chole tube

Acute Appendicitis• Young, healthy males with RLQ pain, if less than 72 hours of

pain concerned for appendicitis may call WITHOUT CT scan• MRI in pregnant patients• More than 72 hours of pain is NOT a typical presentation

Anorectal Disease• Hemorrhoids• Fissures• Fistula-in-ano

Hemorrhoids• Classic orientation of hemorrhoidal cushions – right anterior,

right posterior, left lateral • Excessive straining abnormalities of connective tissue

produce bleeding with or without prolapsing hemorrhoidal tissue

Hemorrhoids

Grade Clinical Signs

I Bleeding

II Protrusion with spontaneous reduction

III Protrusion requiring manual reduction

IV Irreducible protrusion of hemorrhoidal tissue

Hemorrhoids• Bleeding, protrusion and pain most common symptoms• Bleeding: usually bright red blood either on toilet paper or in

toilet after bowel movements– Internal hemorrhoids are usually not painful

• Hemorrhoids enlarge increase bleeding and partially/completely prolapse

• Acute thrombosis can occur

Anal Symptoms Mistakenly Attributed to Hemorrhoids

Symptom Cause

Pain and bleeding after bowel movement Ulcer/fissure disease

Forceful straining to have bowel movement Pelvic floor abnormality (paradoxical contraction of anal sphincter)

Blood mixing with stool Neoplasm

Drainage of pus during or after bowel movement

Abscess/fistula, inflammatory bowel disease

Constant moisture Condyloma acuminatum

Mucous drainage and incontinence Rectal prolapse

Anal pain with no physical findings Caution: possible psychiatric disorder

Treatment Algorithm• Unless Grade IV, start with dietary modification• High-fiber diet:– Males: 30-35 grams fiber/day– Females: 25-30 grams fiber/day

• 64 ounces water/day• Need at minimum 2-3 months of this prior to see effect• Sitz baths TID and PRN• Creams DON’T work• Thrombosed hemorrhoid – enucleation of clot at bedside

Surgical Consult – Yes or No?• Grade I – III hemorrhoids: does not require emergent or urgent

resection usually• High-fiber diet, PO water outpatient surgery referral, start

this BEFORE coming to clinic• Grade IV surgical consult• If complaining of bright red blood per rectum higher chance

will get a colonoscopy first (age and situation dependent)– Males: Screening now starts at 45 years of age– Females: Screening starts at 50 years of age

Anal Fissure• Small tear within anal canal distal to dentate line• 90% located in posterior anal canal• Acute vs Chronic• Acute: small tears in anal mucosa– Usually respond to medical treatment– Resolve within 4-6 weeks

• Chronic: present for longer periods of time– Associated with sentinel tags, rolled mucosal edges and hypertrophic

anal papilla at fissure apex– Less likely to heal with medical management

Anal Fissure• Constipation, diarrhea, straining and heavy lifting leading

causes of fissures• Anal mucosa tears at dentate line underlying internal anal

sphincter muscle exposed irritated with passage of stool

Anal Fissure• Acute:– History of acute pain after passage of constipated stool– Sharp, tearing, searing pain after passage of stool (even soft stool)– Pain can last hours, throbbing – wants to avoid having a BM– Bleeding minimal, noted on toilet paper

• Chronic:– Symptoms that last 8-12 weeks– Frequently a visible external sentinel tag– Throbbing, aching pain after BM (sometimes no pain)– Also complain of difficulty with hygiene and perianal itching

From Scientific American Surgery, Chapter 143, Figure 2.

Anal Fissure• Exam may be difficult due to tender anal canal• Digital rectal exam not necessary if fissure visualized – Would worsen pain

• Treatment:– Medical: 2/3 can be treated conservatively• Increase fiber and fluid first step• May need stool softeners and laxatives• Topical nitroglycerin (0.2% NTG) and nifedipine (2%) have been shown to

decrease pain with variable rates

– Surgical: lateral internal anal sphincterotomy

Surgical Consult – Yes or No?• Anal fissure – not a surgical emergency• High-fiber diet and fluid intake education, along with either

NTG or nifedipine cream, Sitz bath• Outpatient surgery referral• Educate patient that they will have pain

Anorectal Abscess• Most often originate from cryptoglandular infections within

the anal canal• Classified as perianal, ischiorectal, intersphincteric or

supralevator based on location of infection– Perianal – present at the anal verge– Ischiorectal – large and more complex; tender, fluctuant fullness

lateral to anal canal– Supralevator – above the levator ani muscles, rare and difficult to

diagnosis – present with severe rectal pain and may have fluctuant intrarectal mass on DRE

From Scientific American Surgery, Chapter 143, Figure 7.

Anorectal Abscess• Present with variety of symptoms – pain, erythema, fluctuant

mass, fevers• Treatment: drainage– Very superficial – drained in the ER– More complex, deeper abscess and recurrent infections – drained in

the OR– CT may be helpful to ascertain extent of abscess if needed, but not

required

Surgical Consult – Yes or No?• If extremely superficial and feel comfortable and safe, can

drain, if not Call Surgery consult• IV fluids – must be MORE than a liter• NPO• Antibiotics (if needed due to sepsis bundle)

Fistula-in-ano• Anal fistula – chronic form of perianal abscess• Tract from anal canal to perianal skin• Most give history of pervious perianal abscess• Classified based on course relative to anal sphincter: inter-,

trans-, supra- and extrasphincteric• Also classified as simple or complex

Fistula-in-ano• Acute phase drainage of abscess• Treatment will eventually comprise of an operative approach

for the fistula: fistulotomy vs fistulectomy vs Seton placement

Surgical Consult – Yes or No?• Abscess Call surgery• Concerned with a fistula – not a surgical emergency, outpatient

referral

Abscesses• Some quick thoughts about abscesses:– If able to perform a bedside I&D, needs to be COMPLETE– Stab incision is USELESS leads to recurrence– If unable to perform at bedside (pain control, location, etc.) Call surgical consult

Hernias• Some quick thoughts about hernias:–Patient comes in with suspected incarcerated hernia if

unable to reduce after first attempt, call general surgery• Do NOT attempt multiple reduction attempts: causes edema and

reduces ability to reduce hernia– Incarceration is not necessarily a surgical emergency• Incarcerated with fat is not an emergency

–Strangulation (of bowel) is a surgical emergency

Hernias• Some quick thoughts about hernias:–Post-op patients (within 30 days) who return with a

“recurrence”: do NOT attempt to reduce, it is not a hernia, it is a seroma/hematoma• If you attempt to reduce you will potentially destroy the hernia

repair

General Surgery Consults• When can call BEFORE work-up complete:–Post-op patients within 30 days• Do NOT attempt to manipulate incisions, reduce “recurrent”

hernias, etc.–Gas in soft tissues or evidence of extensive cellulitis/possible

necrotizing soft tissue infection– Incarcerated hernia with concern of strangulation–Upper/lower GI bleeding with SBP < 90 mmHg – GI should

have been called first

General Surgery Consults• When can call BEFORE work-up complete:– Free air on imaging – call once on first imaging study– Elderly patient with new onset abdominal pain and acidosis

– suggestive of mesenteric ischemia– Suspected diffuse peritonitis– Younger males with RLQ focal peritonitis and classic history

(<72 hours of pain) for acute appendicitis

Pet Peeves• Do NOT page to 5411 – please page to specific phone number• When paging a consult – name of physician requesting consult,

what the consult is for, MR number• 1 liter bolus of IV fluid for a surgical consult is insufficient• Communicate with nurses to keep patients NPO• Most patients need work-up prior to consults will lead to

quicker dispositions• A differential, if not an exact diagnosis, should be goal of calling

a consult – read/research chart prior to call (briefly)

Also…• When calling a general surgery consult:– If no response in 15 minutes repage consult pager– If no response 15 minutes later page chief resident• During the week – General Surgery Chief Resident• Weeknights/Weekends – Surgery Chief Resident on-call

– If no response 15 minutes later Call attending

QUESTIONS???