Why is the evaluation different for patients with stab wounds versus gunshot wounds? CT Scan vs. Management algorithm for patients with penetrating abdominal trauma.
What are the indications for emergent laparotomy in patients with stab wounds? Hypotension, peritonitis, and obvious signs of abdominal visceral injury hematemesis; proctorrhagia; palpation of diaphragmatic defect on chest tube insertion; radiologic evidence of injury to the gastrointestinal [GI] tract mandate immediate exploration.
Most authorities also advocated prompt exploration for omental or intestinal evisceration. What are the indications for immediate laparotomy in patients with gunshot wounds? Because of the high incidence of visceral injury, early exploration is indicated for all GSWs that violate the peritoneum.
The exception is penetrating trauma isolated to the right upper quadrant; in hemodynamically stable patients with bullet trajectory confined to the liver by computed tomography CT scan, nonoperative observation may be considered. What is the difference between a penetrating wound to the anterior abdomen versus the flank or back? Because the incidence of injury is higher for anterior wounds, and injuries are within the peritoneal cavity, diagnostic evaluation differs.
How is an anterior abdominal stab wound evaluated in asymptomatic patients? The first step is local exploration of the wound to determine peritoneal penetration.
If the tract clearly terminates superficially, above the fascia, no further evaluation is required and the patient is discharged from the emergency department ED. If the fascia is penetrated or the peritoneum violated, further evaluation is warranted. The optimal diagnostic approach remains debated between serial examination, diagnostic peritoneal lavage DPL , and CT scanning.
What constitutes a positive diagnostic peritoneal lavage result after penetrating trauma? How are stab wounds to the flank and back evaluated in asymptomatic patients? SWs to the flank and back should undergo triple-contrast CT to detect occult retroperitoneal injuries of the colon, duodenum, and urinary tract. The most valuable aspect of CT scanning is determining the wound trajectory. How is a lower chest stab wound evaluated? The lower chest is defined as the area between the nipple line fourth intercostal space anteriorly, the tip of the scapula seventh intercostal space posteriorly, and the costal margins inferiorly.
Thus, wounds to the lower chest should also be managed as abdominal wounds to rule out intraabdominal injury. Occult injury to the diaphragm must be ruled out in patients with SWs to the lower chest. Patients undergoing DPL evaluation have different laboratory value cut-offs than standard anterior abdominal stab wounds. Which patients with abdominal gunshot wounds are candidates for nonoperative management?
Hemodynamically stable patients with tangential, subcutaneous missile tracts or those with isolated hepatic trauma. If abdominal operative exploration is indicated, what is the general approach? A midline abdominal incision provides rapid entry and wide exposure; it may be extended as a median sternotomy to access the chest.
Liquid and clotted blood is evacuated with multiple laparotomy pads and suction to identify the major source s of active bleeding. After localizing the source of hemorrhage, direct digital occlusion vascular injury or laparotomy pad packing solid organ injury are used to control bleeding. Hollow visceral injuries are temporarily isolated with noncrushing clamps or are rapidly oversewn. The entire abdomen is systematically explored before undertaking extensive repairs so that injuries can be prioritized for definitive treatment.
GSWs to the abdomen generally require operative exploration; an exception could be right upper quadrant wounds with isolated hepatic injury. Following an SW, patients with hypotension, peritonitis, or evisceration should undergo operative exploration.
Anterior abdominal SWs in stable patients are initially evaluated with local wound exploration; penetration of the peritoneum requires further evaluation serial examination, DPL, or CT scan.
Flank and back SWs in stable patients are evaluated with triple-contrast CT scan. What is the role of laparoscopy and thoracoscopy after penetrating abdominal trauma? Although an intriguing diagnostic modality with additional therapeutic capabilities, laparoscopy thus far appears to have limited application after trauma.
With the exception of suspected diaphragmatic injury, an isolated solid organ injury, or evaluation for peritoneal penetration, laparoscopy has yet to demonstrate advantages over the algorithm delineated previously. The potential for missed injuries, poor evaluation of the retroperitoneum, and expense are major drawbacks.
Ann Surg , Laparoscopy is another option to assess peritoneal penetration, and may be followed by laparotomy to repair injuries. If in doubt, it is always safer to explore the abdomen than to equivocate. When is emergency department thoracotomy indicated for a penetrating abdominal wound? Do all patients with a traumatic liver injury require surgery? One third of such patients require blood transfusions, but if the volume exceeds 6 units in the first 24 hours, angiography should be done.
CT scan should be repeated in 5 to 7 days for grade IV and V injuries. Which patients are more likely to fail nonoperative management? Those patients requiring ongoing fluid resuscitation to maintain hemodynamic stability, pooling or blush of contrast seen on CT scan, and those with injuries to multiple solid organs.
What are the options for temporary control of significant hemorrhage in victims of hepatic trauma? Ongoing hemorrhage leads to the vicious cycle of acidosis, hypothermia, and coagulopathy. Manual compression, perihepatic packing, angioembolization, and the Pringle maneuver are the most effective temporary strategies. What is the Pringle maneuver?
The Pringle maneuver is a manual or vascular clamp occlusion of the hepatoduodenal ligament to interrupt blood flow into the liver. Included in the hepatoduodenal ligament are the hepatic artery, portal vein, and common bile duct. Failure of the Pringle maneuver to control liver hemorrhage suggests either 1 injury to the retrohepatic vena cava or hepatic vein or 2 arterial supply from an aberrant right or left hepatic artery see question 9.
What is the finger fracture technique? Finger fracture hepatotomy or tractotomy is the method of exposing bleeding points deep within liver lacerations by blunt dissection.
Pushing apart the liver parenchyma enables points to be identified and ligated. This method is most commonly required for penetrating injuries. What is the role of selective hepatic artery ligation in securing hemostasis in patients with a major liver injury?
Deep lacerations of the right or left hepatic lobe may result in bleeding that cannot be completely controlled by suture ligation of specific bleeding points within the liver parenchyma.
In this situation, either the right or left artery can be ligated for control of the bleeding with little risk of ischemic liver necrosis. Why is retrohepatic vena caval laceration lethal? Exposure requires either extensive hepatotomy, extensive mobilization of the right lobe, or right lobectomy, or transection of the vena cava.
The large caliber and high flow of the IVC results in massive hemorrhage during surgical exposure, whereas clamping of the IVC often results in hypotension attributable to an abrupt decrease in venous return to the heart.
What is the physiologic rationale for use of a shunt in attempted repair of retrohepatic vena caval injuries? Hemorrhage control requires maintenance of venous return to the heart while both antegrade and retrograde bleeding through the laceration is stopped.
These requirements are met by shunting blood through a tube spanning the laceration between the right atrium and lower IVC.
What is the intrahepatic balloon tamponading device? For transhepatic penetrating injuries, a 1-inch Penrose drain is sutured around a red rubber catheter.
This forms a long balloon that is threaded through the bleeding liver injury and inflated with contrast media through a stopcock in the red rubber catheter.
The balloon tamponades liver hemorrhage. The catheter is brought out through the abdominal wall, deflated, and removed 24 to 48 hours later. What are the indications for perihepatic packing?
Liver packing with planned reoperation for definitive treatment of injuries in patients who have hypothermia, acidosis, and coagulopathies is a life-saving maneuver damage control laparotomy. What is the abdominal compartment syndrome? The abdominal compartment syndrome is a potentially lethal complication of perihepatic packing or large volume resuscitation. It may occur when intraabdominal pressure exceeds 20 cm H2O. Intraabdominal pressure increases because of bowel and liver edema secondary to ischemia and reperfusion injury or continued hemorrhage into the abdominal cavity.
As pressure increases beyond 20 cm H2O, venous return, cardiac output CO , and urine output decrease, but ventilatory pressures increase. Patients must return promptly to the operating room OR for decompression of the abdomen.
A manometer attached to the Foley catheter is useful in following intraabdominal pressure. What are the common complications related to liver injury?
Complications include bleeding, biliary leaks or fistulae, abdominal compartment syndrome, and infection. Why are complications associated with bile duct leaks? Bilomas i. Biliopleural fistula, a communication between the biliary system and pleural cavity, persists because of the relative negative pressure in the thorax and may result in a bile empyema. Bilhemia results from an intrahepatic fistula between the bile ducts and hepatic veins, resulting in severely elevated bilirubinemia.
Hemobilia occurs from the rupture of an arterial pseudoaneurysm into the biliary system, resulting in upper gastrointestinal hemorrhage.
What is the incidence of bile duct leak? Leak rates are higher for those who undergo operations or angioembolization. Perihepatic fluid collections identified by US suggest a leak, however, they are more accurately identified by hepatobiliary iminodiacetic acid HIDA scan or endoscopic retrograde cholangiopancreatography ERCP.
What is the initial management of a bile leak? ERCP is usually quite useful in diagnosing and treating leaks. Biliary stenting with or without sphincterotomy and percutaneous drainage of bilomas frequently allows spontaneous resolution of bile duct injuries. Extensive injuries require hepaticojejunostomy for reconstruction. Liver injuries are common following BAT and should be considered in all patients who are hypotensive.
Eighty-five percent of patients with liver injuries can be treated nonoperatively. Angioembolization is an important adjunct. Higher grade injuries are more likely to fail nonoperative management and have an increased complication rate.
Damage control laparotomy should be considered for severe hepatic injuries. Biliary injuries can occur with severe hepatic injury, but most are treated by minimally invasive techniques. Crit Care Clin , Moore EE: Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Surg Clin North Am , Br J Surg , The liver is a sturdy organ.
What is the physiologic role of the spleen? In fetal development, the spleen serves as a major site for hematopoiesis. In early childhood the spleen produces immunoglobulin M IgM and tuftsin. The spleen also functions as a filter, allowing resident macrophages to remove abnormal red blood cells RBCs , cellular debris, and encapsulated and poorly opsonized bacteria.
What injury patterns are associated with splenic trauma? Direct blunt force, deceleration, and compression to the left torso. Think spleen after a motor vehicle accident or fall: lower rib fractures, left side-only rib fractures, and high-energy transfer big hits increase the probability of splenic injury.
What are the signs and symptoms of splenic injury? The main sign is pain in the left upper quadrant. This is produced by stretching the splenic capsule. Peritoneal irritation rebound tenderness is caused by extravasated blood. Vital signs vary depending on associated blood loss and are not specific for injuries to the spleen.
Unfortunately, a large number of patients with a significant splenic injury exhibit no signs or symptoms at all. What studies can help in diagnosing splenic trauma? Ultrasound US is routinely performed in the emergency department ED and can rapidly identify as little as ml fluid or blood. When US is equivocal, diagnostic peritoneal lavage DPL is an accurate and sensitive measure of intraabdominal bleeding. How are splenic injuries classified, and why is that important? Management is governed by the hemodynamic status of the patient, but therapy is also influenced by the CT grade of splenic injury.
Nonoperative management is most successful in grades I to III, whereas operative intervention is often required for grade IV injuries. Grade V injuries demand prompt operative intervention see Table What is delayed rupture of the spleen? This is a rare complication that occurs in 48 hours in a patient with a history of abdominal trauma and no overt clinical evidence of intraabdominal injury on initial presentation.
What are the general principles of operative management of the injured spleen? The first priority is to control bleeding. This can usually be accomplished by packing and manual compression of the spleen.
If successful, the abdomen is then thoroughly explored for other injuries. Complete mobilization of the spleen by division of the splenocolic, splenorenal, phrenosplenic, and gastrosplenic ligaments is required for complete assessment of the spleen.
The short gastric vessels can be ligated with division of the gastrosplenic ligament. If splenectomy is required, the splenic artery and vein should be ligated individually before removing the spleen. What early complications arise after splenectomy? Recurrent bleeding, acute gastric dilatation, gastric perforation, pancreatitis the splenic artery courses along the top of the pancreas , and subphrenic abscess. What is splenic autotransplantation? Autotransplantation is accomplished by implanting splenic tissue parenchymal slices into pouches created in the gastrocolic omentum.
Does splenic autotransplantation preserve splenic function? Autotransplantation after splenectomy is controversial. After autotransplantation, immunoglobulin G IgG and IgM levels are increased in response to pneumococcal vaccine compared with patients after splenectomy alone. Does postsplenectomy leukocytosis predict infection? Elevations in white blood cell WBC count and platelet count PC after splenectomy are a common physiologic event. Patients with evidence of ongoing bleeding e.
Isr Med Assoc J , Can J Surg , Clin Exp Immunol , How common are pancreatic and duodenal injuries? What other injuries are typically associated with penetrating pancreatic trauma? How are pancreatic injuries diagnosed preoperatively? Penetrating trauma to the pancreas is usually discovered during exploration for associated injuries. Such patients may present with hemodynamic instability from bleeding, positive focused abdominal sonography in trauma FAST examination, or peritonitis.
Patients with blunt injury who are hemodynamically stable should undergo abdominal computed tomography CT scan, and possible endoscopic retrograde cholangiopancreatography ERCP. Elevated serum amylase concentrations are nonspecific for pancreatic injury and can be normal in a high proportion of patients. What are some of the commonly used surgical options for the treatment of pancreatic injuries? Most low-grade penetrating and blunt injuries are adequately treated by closed suction drains placed at surgery.
In more severe injuries, the integrity of the main pancreatic duct should be evaluated, either by direct inspection or by intraoperative pancreatography. Distal duct injuries are treated with distal pancreatectomy, with or without splenectomy, and closed drainage of the pancreatic stump. Preservation of the spleen is preferable. Injury to the pancreatic duct in the head or neck may require resection of significant portions of distal pancreas and are usually performed in a delayed manner following damage control procedures.
Describe the common complications of pancreatic injuries. Exsanguination is the most common cause of early death, prompting the use of damage control. For patients who survive their initial operation, the two most common complications are pancreatic fistulas and intraabdominal abscesses. Other late problems are pancreatitis, pancreatic pseudocyst, and pancreatic hemorrhage.
Most patients who die after sustaining injuries to the pancreas do so as a result of late complications and not from the pancreatic injury itself. Low-grade injuries are treated with simple closed suction drainage at the time of celiotomy. Associated injuries are common and should be searched for and addressed. Patients who are unstable should undergo debridement of devascularized tissue, hemostatis, and drainage with delayed reconstruction until the patient is stable.
If ductal injury is suspected in a stable patient, visualize with ERCP or cholangiogram. If ductal injury is present in the head or neck of the pancreas, ligate proximally and attempt to preserve pancreatic tissue with Roux-en-Y pancreaticojejunostomy. Consider establishing enteral nutritional access by placing a jejunal feeding tube in patients with more than minor injuries. What is the role of computed tomography scanning in diagnosing blunt duodenal injuries? Although CT is an excellent tool for visualizing solid injuries, CT is less useful with injuries to hollow organs such as the duodenum.
Even the addition of an oral contrast agent to the study has a high specificity but poor sensitivity. Subtle signs of duodenal injury on CT scans include paraduodenal edema, fluid, retroduodenal air, and fat standing with loss of sharp tissue planes, which may usually indicate a duodenal rupture and spillage of small amounts of intralumenal contents into the retroperitoneum.
Such subtle findings in a patient with a high-risk mechanism of injury may warrant operative exploration. What is the importance of the Kocher maneuver? In , Kocher described what has now become a routine maneuver during the exploratory celiotomy to visualize and repair injuries to the duodenum, distal common bile duct, and pancreatic head.
The avascular lateral peritoneal attachments to the duodenum are incised sharply; then the duodenal sweep is elevated and reflected medially, allowing for inspection and palpation of its posterior surface as well as of the head of the pancreas. What are the four portions of the duodenum and their surgical relationships? The first portion of the duodenum starts at the pylorus intraperitoneally and passes backward retroperitoneally toward the gallbladder the remainder of the duodenum is retroperitoneal.
The second portion descends 7 to 8 cm and is anterior to the vena cava. The left border of the duodenum is attached to the head of the pancreas, at the site where the common bile and pancreatic ducts enter; it shares a common blood supply with the head of the pancreas through the pancreaticoduodenal arcades. The third portion of the duodenum turns horizontally to the left, with its cranial surface in contact with the uncinate process of the pancreas, and passes posterior to the superior mesenteric artery and vein.
The fourth portion continues to the left, ascending slightly and crossing the spine anterior to the aorta, where it is fixed to the suspensory ligament of Treitz at the duodenojejunal flexure. How are duodenal injuries classified? An organ injury scale has been adopted that allows for standardized descriptions of duodenal injuries, which extend from grade 1 less severe to grade V most severe.
The grading of duodenal injuries assists surgeons in selecting the appropriate surgical procedure for the repair or reconstruction of these frequently complex injuries see Table What are the main surgical options for penetrating duodenal injuries? Most simple lacerations grade 1 to 2 can be repaired primarily. If tension on the suture line is anticipated because of extensive tissue loss grade 3 to 4 adjunctive techniques such as Roux-en-Y duodenojejunostomy or pyloric exclusion are more appropriate.
Severe duodenal injuries involving the distal bile duct and pancreatic head grade 5 may warrant pancreaticoduodenectomy i. In patients with all but simple repairs, consideration should be given to establishment of enteral access via jejunostomy. Associated injuries are common, particularly to the pancreas, and they should be searched for and addressed. Although penetrating injuries are usually discovered at laparotomy for bleeding or peritonitis, blunt injuries are difficult to diagnose even with CT scan, and the decision to operate must include consideration of subtle clinical signs.
Thorough exploration requires a Kocher maneuver and full evaluation of all anatomic regions of the duodenum.
Operative repair is determined by injury severity classification. Most injuries are managed with simple primary repair, and extensive resections should be delayed in most patients via damage control procedures. Enteral access should be considered in all but the simplest injuries.
Br J Radiol , The role of expectant management. J Pediatr Surg , How do most colon injuries occur? Blunt colonic trauma is rare and usually results from seat belts during motor vehicle crashes. How are colon injuries diagnosed? They are usually diagnosed during laparotomy for penetrating trauma. For patients in whom the need for laparotomy has not been established, chest and upright abdominal radiographs may reveal free air and detect the location of penetrating objects.
Triple-contrast i. Elevated white blood cell counts or enzyme amylase, alkaline phosphatase levels or fecal material in diagnostic peritoneal lavage DPL is highly suggestive of a bowel injury. How are colon injuries graded? Grade I: contusion hematoma without devascularization or partial-thickness laceration. Grade IV: transection of the colon. Grade V: transection with segmental tissue loss. What are three primary surgical options for managing a colon injury?
Primary repair: suturing of simple perforations or resection and primary anastomosis for more complex injuries.
Colostomy: injured colon is resected and the proximal colon is brought out as a colostomy or the injury is repaired but a more proximal ileostomy or colostomy is brought out to divert the fecal stream. What are the advantages and disadvantages of each of these options? Primary repair is desirable because definitive treatment is carried out at the initial operation, and the patient is spared the morbidity of a colostomy and its reversal.
The disadvantage is that suture lines are created in suboptimal conditions, so leakage may occur. Proximal colostomy avoids an unprotected suture line in the abdomen but requires a second operation to close the colostomy. Stomal complications, including necrosis, stenosis, obstruction, and prolapse, may occur.
How are most patients with colon injuries surgically managed? Primary repair is safe and effective in essentially all patients with colon trauma.
Handsewn and stapled anastomoses have equal complication rates. Prophylactic antibiotics are administered for no longer than 24 hours postoperatively. How should the surgical incision and penetrating wound be managed? Wounds should be left open for delayed primary closure to decrease the incidence of wound infection and fascial dehiscence. What complications are associated with colonic injury and its treatment? What is the limitation of using the Ranson score for predicting severity of pancreatitis?
A true Ranson score cannot be calculated until after 48 hours of inpatient treatment. The Balthazar score, based on findings from computed tomography CT scanning amount of inflammation, presence and extent of necrosis, and presence of fluid collections , is also acceptable for evaluation of expected morbidity and mortality. What is necrotizing pancreatitis? The inflammation and edema of acute pancreatitis may progress with subsequent devitalization of pancreatic and peripancreatic tissue.
Why is it important to differentiate acute pancreatitis from necrotizing pancreatitis? The presence and extent of necrosis are key determinants of the clinical course. Although there is interest in conservative treatment of biopsy-proven, infected pancreatic necrosis, no studies have shown this to be a safe clinical strategy. What is the optimal method for diagnosing pancreatic necrosis with or without associated infection?
Dynamic CT scans with intravenous contrast allow visualization and differentiation of healthy, perfused parenchyma from patchy, poorly perfused necrotic tissue. Therefore, a CT scan should be obtained in patients that do not clinically improve in response to fluid resuscitation and supportive treatment. CT-guided aspiration of the necrotic tissue may be performed to determine the presence of infection.
When is surgery indicated in patients with acute pancreatitis? Infected pancreatic necrosis is the only absolute indication for surgery. The patient may require multiple trips to the operating room OR for repeated debridement; typically, the abdomen is not formally closed until only viable tissue remains.
Operative intervention for sterile pancreatic necrosis is controversial. The only absolute indications for surgery in sterile pancreatic necrosis are 1 abdominal compartment syndrome, 2 suspected enteric perforation, or 3 bleeding splenic artery pseudoaneurysms can complicate the disease.
When should antibiotic therapy be added? Antibiotics do not alter the course of pancreatitis or decrease septic complications of the disease; therefore, patients with mild cases of pancreatitis should be treated with supportive measures. The literature is confusing regarding antibiotic use in patients with necrotizing pancreatitis. Despite a paucity of class I evidence supporting the use of prophylactic antibiotics, many institutions continue to administer them.
In patients with signs of sepsis, treatment with empiric antibiotics is reasonable while a source of infection is sought i. What is the most common complication of acute pancreatitis? Pancreatic pseudocysts. Patients with pseudocysts typically present with persistent abdominal pain, nausea and vomiting, or an abdominal mass.
CT scan imaging is diagnostic. Intervention is indicated in symptomatic patients or those asymptomatic patients with documented increase in pseudocyst size by serial CT scans. What is the natural history of cholelithiasis following gallstone pancreatitis? Cholecystectomy should be accompanied by an intraoperative cholangiogram or laparoscopic ultrasonography; if a retained stone is seen in the common bile duct CBD , laparoscopic common duct exploration or ERCP should be performed before discharge.
What is the natural history of alcoholic pancreatitis? Attacks recur. Abstinence from alcohol should be encouraged because many patients develop chronic pancreatitis.
Symptoms: acute onset of epigastric pain that radiates to back with associated nausea or emesis. Imaging: CT scan diagnoses pancreatic necrosis, peripancreatic fluid collections, and pseudocysts.
Am J Gastroenterology , A randomized, double-blind, placebo-controlled study. J Gastrointest Surg , Nealon WH, Bawduniak J, Walser EM: Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections.
Pancreatology , Whitcomb DC: Clinical practice. Acute pancreatitis. N Engl J Med 20 , Adam H. Lackey, MD, and C.
What is chronic pancreatitis? The classic syndrome consists of smoldering abdominal pain and evidence of pancreatic insufficiency. Histologically, chronic inflammation results in destruction of the functioning endocrine and exocrine pancreatic cells.
What is the most common cause? Other known causes include posttraumatic strictures, pancreas divisum, genetic mutations, autoimmune disorders, and metabolic disorders hypertriglyceridemia and hypercalcemia. The overall incidence is estimated to be 3 to 10 per , people.
Is chronic pancreatitis the result of acute pancreatitis? Patients may not have had acute pancreatitis, although alcoholism is common to both. One hypothesis is the inflammation from recurrent bouts of acute pancreatitis causes interstitial acinar fibrosis with secondary dilatation of the main pancreatic duct.
Paradoxically, the average age for chronic pancreatitis is 13 years less than for acute disease. What are the signs of pancreatic insufficiency? The form of diabetes associated with chronic pancreatitis is termed IIIc; it can be particularly difficult to manage because of the destruction of both the insulin and glucagon producing cells.
How much of the pancreas must be destroyed before diabetes develops? What is steatorrhea? How does one confirm the diagnosis? Steatorrhea is soft, greasy, foul-smelling stools. A hour fecal fat analysis may be done to confirm the diagnosis. The D-xylose test shows normal results, and the Schilling test is not sensitive for pancreatic insufficiency. Patients with steatorrhea are treated with a variable combination of low-fat diets, pancreatic enzymes, antacids, and cimetidine.
Is serum amylase elevated in patients with chronic pancreatitis? What are the complications of chronic pancreatitis? Pancreatic pseudocyst, abscess, or fistula may occur.
Obstruction of the biliary tree with resultant jaundice may be caused by areas of fibrosis. Malnutrition and narcotic addiction are more likely to coexist than actual complications of pancreatic insufficiency.
What is a possible source of upper gastrointestinal bleeding in a patient with chronic pancreatitis? Although gastritis and peptic ulcer disease are more common causes of upper gastrointestinal bleeding UGIB , splenic vein thrombosis with associated gastric varices and hypersplenism should also be considered. Your attending will love this answer! What are the treatment options for chronic pancreatitis?
Initially, medical therapy includes pain medications, a low-fat diet, abstinence from alcohol, and pancreatic enzyme replacement or insulin therapy as indicated. Patients with evidence of pancreatic insufficiency and persistent abdominal pain requiring repeated hospitalizations should consider more invasive therapeutic options. For patients with a proximal pancreatic duct stricture and upstream ductal dilation, endoscopic treatment sphincterotomy, stricture dilation, stone extraction, stent placement may be successful.
The remainder of patients with refractory symptoms may undergo surgical intervention. What are the indications for surgery? There are no steadfast rules. Relative indications include unabating pain refractory to medical management, a dilated main pancreatic duct, biliary or gastric outlet obstruction, pancreas divisum, symptomatic or enlarging pseudocyst, and suspicion of malignancy. Which operative procedures are commonly performed? A Roux-en-Y lateral pancreaticojejunostomy i.
Pancreaticoduodenectomy i. Distal pancreatectomy may be used for isolated distal disease or retrograde drainage into a pancreaticojejunostomy. What is the result of operative intervention? Symptoms: smoldering abdominal pain and pancreatic insufficiency diabetes, steatorrhea. Lab tests: none. Imaging: computed tomography CT scan diagnoses pancreatic masses, ductal dilation, calcifications, and pseudocysts; ERCP evaluates the pancreatic duct including strictures. Treatment: pain medications, a low-fat diet, abstinence from alcohol, pancreatic enzyme replacement and insulin therapy; unabating pain, refractory to medical management, may be treated with endoscopic or surgical intervention.
American Gastroenterological Association: AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology , N Engl J Med 7 , Heiko W, Apte MV, Volker K et al: Reviews in basic and clinical gastroenterology, chronic pancreatitis: challenges and advances in pathogenesis, genetics, diagnosis, and therapy. Stiegmann, MD 1.
Describe the blood supply to the liver. With portal hypertension, portal flow decreases and the relative contribution of the hepatic artery necessarily increases. How is portal hypertension defined? Direct measurement is risky, so the hepatic venous pressure gradient HVPG is used instead. This is the change in hepatic vein pressure when flow is occluded by wedging a balloon catheter into it analogous to the estimation of left atrial pressure by wedging a pulmonary artery.
What is hepatopetal flow? Physiologic portal blood flow into the liver is termed hepatopetal flow. Reversal of flow in the portal vein can occur with greatly increased hepatic vascular resistance and is called hepatofugal flow. Features revisions throughout to provide you with an up-to-date overview of today's surgical care and practice.
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