Absite Topic Review General Surgery

Nir Hus, MD, PhD. Mount Sinai Medical Center Miami Beach

Topics
1)

Rx Postop Parotitis. 2) Rx Non-healing burn wound. 3) Dx Ruptured tubal pregnancy.

Nir Hus

Parotitis

Can occur in the surgical patient and identified during the postoperative period.

Particularly in elderly Dehydrated individuals.

Therapy should be directed toward

Rehydration Enhancing salivation Ensuring that no mechanical obstruction of the duct of Stensen is present Obtaining stains and cultures Administering antibiotics directed against S. aureus, which is the most common offending organism. In ICU patients who are often colonized with gram-negative bacteria, the possibility of gram-negative bacterial parotitis should be considered and appropriate empiric therapy used. I&D

Nir Hus

Rx Non-healing burn wound.

Q:

30 y.o veteran suffered a burn wound to arm 2nd or 3rd degree over one year ago and the wound is ulcerated. What to do next.
A:

Marjolins tumor need Bx

Nir Hus

Ulcers associated with burns

Curling

s ulcer gastric ulcer that is associated with burns. Marjolin s ulcer highly malignant squamous cell CA.

Nir Hus

Dx Ruptured tubal pregnancy

An

ectopic pregnancy occurs when a fertilized ovum implants at a site other than the endometrial lining of the uterus. Ectopic pregnancies occur in the fallopian tube in 97% of cases, with 55% in the ampulla; 25% in the isthmus; 17% in the fimbria; and 3% of cases within the abdomen, ovary, and cervix.
Nir Hus

Pathophysiology
Ectopic

pregnancies are primarily due to prior tubal/genital infection or surgery, fallopian anatomic abnormalities, or endometrial abnormalities.

Nir Hus

Physical: Physical examination is unreliable for clinicians who face this significant diagnostic challenge. Abbott et al and Stovall et al reported an alarming rate of missed and/or delayed diagnoses in the ED. Although findings at physical examination may be variable, they may include the following:
Vaginal bleeding may be mild or absent. Abdominal pain may be minimal or severe. Shoulder pain is suggestive of peritoneal free fluid (significant hemorrhage). Ectopic pregnancies can be accompanied by sloughing material, which is suggestive of a miscarriage. Adnexal masses may be palpable in only 60% of patients (under anesthesia). Tenesmus or syncope may occur. Clinical shock may occur after rupture. No combination of physical findings may reliably exclude the diagnosis of ectopic pregnancy.

Nir Hus

Lab Studies:

Human chorionic gonadotropin (HCG) levels.

The

discriminatory zone of beta-HCG levels is the level above which a normal intrauterine pregnancy reliably is visualized.

The absence of an intrauterine pregnancy when the HCG level is above the level in the discriminatory zone represents an ectopic pregnancy or a recent abortion. Serial blood cell counts should be determined to quantify blood loss.

Nir Hus

Imaging

A definite ectopic pregnancy is characterized by the presence of a thick, brightly echogenic, ringlike structure outside the uterus, with a gestational sac containing an obvious fetal pole, yolk sac, or both. Pregnancy of unknown location occurs with an empty uterus on endovaginal sonograms in patients with serum beta-HCG levels greater than the discriminatory cutoff value. In this case, an ectopic pregnancy is considered present until proven otherwise. An empty uterus may also represent a recent abortion. Other ultrasonographic findings include an adnexal mass, free culde-sac fluid, and/or severe adnexal tenderness upon palpation with the probe. Patients with no definite intrauterine pregnancy and the aforementioned findings are thought to have a high risk for ectopic pregnancy.

Nir Hus

Tx

Laparotomy is required for ovarian, abdominal, and intraligamentous pregnancy. Careful curettage, packing of the cervix and uterine cavity, possible hysterectomy may be required for a cervical pregnancy. An unruptured tubal pregnancy of less than 4 mm in diameter may be treated by salpingostomy by means of laparoscopy.
Nir Hus