“When to Call A Surgeon”

Anneliese Schleyer MDHarborview Medical Center

When to Call A Surgeon

• Goals:

– Review medical management of common abdominal diagnoses

– Identify when to call a surgeon

– Learn how to communicate concerns effectively

Case #1

• 53 y F generally healthy with diffuse abdominal pain and vomiting x 3 days

• Small loose nonbloody stools. No flatus, fevers/chills, chest pain, SOB

– Surgical history: ventral hernia repair– Medical history: prior IVDU, venous stasis

ulcers– Medications: ibuprofen prn

Case #1

• Exam: T 36.7, HR 106, BP 103/61– Awake and alert– Abdomen: distended and quiet except for

rare high-pitched sounds

• Labs – WBC 6.4, HCT 44. – K 3.1, bicarb 31 creatinine 1.3 – LFTs, amylase normal

• What’s the diagnosis?

Small Bowel Obstruction

• History – Crampy diffuse abdominal pain & distention,

nausea/ vomiting. Some still pass flatus.

• Risk factors– Prior abdominal surgeries, tumors, hernias,

strictures

• Exam – Hypoactive or high pitched sounds

• Diagnosis made by history and exam

Small Bowel Obstruction

• Plain films: – Upright CXR to rule out free air – Abdominal series: air-fluid levels, distended bowel.

Usually no gas in colon/rectum after 24 hrs.

• Abdominal CT: – Different caliber small bowel lumens– Volvulus – Transition point distal to obstruction – Cannot see adhesions

Causes of small bowel obstruction• Top surgical causes:

– 1. Adhesions from prior abdominal or pelvic surgery

– 2. Diffuse carcinoma

• Extrinsic– Volvulus– Hernia

• Intrinsic– Tumors– Strictures or stenoses

• Intussusception• Intraluminal

– Stool, gallstones, bezoars

Small Bowel Obstruction

• Medical Management:– Diagnose and treat underlying cause – Aggressive electrolyte correction– Frequent, serial abdominal exams– No prokinetic agents like metoclopromide

• Decompress with NG tube:– Avoid clamping; can cause vomiting/aspiration– Gravity trial when signs of bowel function:

• Place canister on ground• If < 200 cc output / 4 hrs, remove tube

Case #1

• Hospital course: – Seen and “cleared” by general surgery

in ED; admitted to medicine– Symptoms subsided initially with NGT – Patient noted “lymph node” in right

inguinal region on hospital day #2– 2x3 cm mass, mobile, mildly tender– Nausea/vomiting recurred when NGT

clamped

Case #1

• Hospital course: – HD #3 increased pain, fever and

tachycardia; ↓uop; repeat labs K+ 2.6 – CT scan: showed incarcerated hernia – Surgery urgently re-consulted, hernia

repaired; patient had an uneventful recovery.

Small Bowel Obstruction (SBO)

• Pearls:– Diagnose by history and exam– Normalize K+ and other electrolytes– If not improving, check for signs of volvulus

or ischemia– Don’t forget to check for hernias

Small Bowel Obstruction

• Concerning signs/symptoms– Ischemic signs: crampy pain becomes

constant, tachycardia, +/- hypotension, fever, ↑WBC, ↑ lactate level, ↓uop

– Changing bicarb or increased anion gap– Evidence of volvulus / closed loop– No response to conservative

management in 48 hours

SBO – Lessons Learned

• Seen by surgery in ED does not mean surgical intervention won’t be needed

• NGT to gravity rather than clamping when bowel function returns

• If no response to conservative management in 48 hours, repeat imaging and consider surgical consult

• If any concerning signs or symptoms, consult Surgery immediately

Case #2

• 78 yo man 2 weeks s/p colon resection for carcinoma admitted to surgery with colocutaneous fistula/subfascial abscess• PMH: HTN and CAD

• Habits: rare EtOH; no IVDU.

• Medications: lisinopril, ASA, metoprolol

• Allergies: none

Case #2

• On HD #2 en route to IR for drain placement, had hematemesis and dark tarry stools in colostomy bag

• BP 140/80 HR 88

• HCT: 30 21

• Transferred to ICU

Case #2• Medical management for upper GI bleed:

– Two large bore IVs placed; NPO– NG lavage: did not clear– IVF; 2 units PRBCs; coagulopathy reversed– Pantoprazole gtt initiated

• Emergent EGD by GI: – diffuse severe esophagitis – large (>50%) adherent clot in duodenal bulb with

‘giant’ duodenal ulcer, no bleeding visualized– Attempt at ulcer injection with epi

Case #2• HD #5, abscess drained successfully • Pt transferred to medicine floor• Pantoprazole gtt continued

• SBPs 115-160s• Benign abdominal exam• HCT stable at 30-31 for 48+ hours

Case #2

• Called about SBP 80s; resolves without intervention

• Repeat Hct 26 29• Patient has no complaints; ‘looks good’

• Surgery is called:

“I’ll follow his labs and decide if I need to see him.”

Case #2• Two hours later, SBP 80-90s; sustained despite

fluids; HR 105-120s. • HCT 26 29 22 21• Transferred to ICU; transfused to HCT 30 • SBP and HR improved

Case #2

• GI and General Surgery called again• GI repeated EGD: + clot duodenum; no visible

bleeding vessel• HCT initally 30, then 21 on repeat• Pt taken emergently to OR where he underwent

antrectomy with Billroth II gastrojejunostomy

PUD – Lessons Learned

• Consult Surgery early if indicated!• Involve Surgery at initial EGD if warranted• Communicate concerning s/s to Surgeon• In PUD consider surgical consultation for:

– hemodynamic instability (particularly after initial resuscitation)

– recurrent bleeding (unclear bleeding source)– transfusion dependence– any high risk lesion on EGD

PUD – Lessons Learned• High Risk Lesions on EGD:

• “Giant” (duodenal) ulcer >2 cm• Active bleeding• Visible vessel• Adherent clot

• At other hospitals, patients with GI bleeds are often admitted to Surgery

PUD – Lessons Learned

• Interdisciplinary Guidelines for Management of Gastrointestinal Bleeds

at Harborview are under development

Stay tuned….

Case #3• Obese 27 yo woman with 5/10 epigastric pain,

radiating to back, worse with inspiration and french fries. No h/o alcohol or other medical problems.

• Vitals normal; tender in epigastrium/RUQ; diminished BTs

• Labs: AST/ALT 226/416, Alk phos 180, T/D Bili 2.6/1.4; WBC 11, HCT 43, Ca 9.5; amylase 1331

Case #3

• Ultrasound:– Small gallstones but no wall thickening or

ductal dilatation. No sonographic Murphy’s.– Pt received usual medical management– IVF, NPO, pain control

• Hospital course: improved quickly, tolerated full diet at 48 hrs, discharged home

Case #3

• Pt returned 2 months later with abdominal pain radiating to back, worse with fast food, nausea and vomiting.

• Exam: Vitals 38.6; HR 103; o/w normalTender in RUQ with diminished bowel tones. No rebound or guarding.

• Labs:– AST 769, ALT 530, Alk phos 112, T Bili 1.6– WBC 14.6 + bands, HCT 45, Calcium 9.1– Pancreatic amylase 4800

Case #3

• Ultrasound– Gallbladder wall thickening to 5 mm; CBD

grossly normal– Multiple non-mobile gallstones within neck– Liver with diffuse fatty infiltration– No radiographic Murphy’s sign noted

Case #3• Hospital Course

– Fever 39.4, ↑abdominal pain, WBC 28,000

• Abdominal CT: enlarged/ edematous pancreas suggesting necrosis– Gallbladder grossly unremarkable

• GI consulted; not good candidate for ERCP

Case #3

• Surgery: “Why didn’t you call us the last time she was here?”– Patient scheduled for cholecystectomy when

clinically improved

• Laparascopic cholecystectomy w/ intra-operative cholangiogram on HD #9

• HD #13 discharged home; doing well.

Gallstone Pancreatitis: Lessons Learned

• When to Call A Surgeon– Cholecystectomy should be performed after

recovery in all patients with gallstone pancreatitis prior to discharge

• Caveat: if severe/necrotizing pancreatitis, reasonable to wait several weeks until possibility of infection ruled out

– Recurrent acute pancreatitis w/ no evidence of gall stones or EtOH may be secondary to microlithiasis; consider elective cholecystectomy

Working with Surgery Consultation

• Be aware of which patients have potential surgical needs – Bowel obstruction– GI bleed– Gallstone pancreatitis– Any patient with abdominal pain

• Don’t assume that “cleared by surgery” means no surgical input will be needed during hospitalization

Working with Surgery Consultation

• Does this patient need an operation?

• Does this patient need a surgeon now?

• Patient stable or unstable?

• Peritonitis?

Working with Surgery Consultation

• Perform serial abdominal exams• Note changing history

– Loss of flatus– Worsening pain or vomiting

• Note changing vitals and exam– New peritoneal signs

• Note changing labs – dropping bicarbonate or HCT – rising lactate or anion gap

Summary

• Many patients admitted to Medicine have potential surgical needs

• Careful medical management is important

• Call Surgeons early if indicated

• Learn to communicate key issues

• If additional Surgical assistance is needed, ok to call more Senior Surgeons and/or involve your attending