SUBCUTIULAR STICH ILEUS o No mechanical cause for impaired bowel motility o Causes= hypokalemia, intrabdominal infections, electrolyte abrnormalities,

opiods SBO o Common causes mechanical: adhesions, incarcerated hernias, IBD, caners o Functional= paralytic ileus LBO o Common mechanical causes= volvulus, diverticulitis/ischemic strictures, colorectal cancers o Functional= Ogilvies Syndrome (Colonic ileus) o Listen for high-pitched rushes or diminished bowel sounds BILIARY TRACT DISEASE o CHOLELITHIASIS o BILIARY COLIC/CHRONIC CHOLECYSTITIS Symptomatic cholelithiasis caused by stone blocking the neck of the cystic duct pain occurs as gallbladder contracts Post-prandial pain Similar episodes in the past o ACUTE CHOLECYSTITIS Stone impacted in the cystic duct leading to inflammation of the gall bladder gallbladder wall becomes thickened History of biliary colic/intermittent RUQ pain Look for potential fevers/chills Inflammation causes elevation of WBCs, Alk Phos (made in bile duct wall) may be elevated Ultrasound Findings= Gallbladder distended, stones present, wall thickening, pericholecystic fluid, sono murphys sign Pathology (help determine timing of disease process) Edema, mucosal changes, Inflammation o Choledocolithiasis stone in common bile duct which becomes impacted Look for jaundice (scleral icterus), acholic stools, urine LFTs elevated (esp bilirubin), Elevated Alk Phos (made in walls of common bile duct), WBCs Ultrasound dilated CBD indicates CBD stones Cholangiogram, Pre-operative ERCP o Cholangitis= choledocolithiasis with super infection of bile Superinfection of bile results in sepsis very high WBCs (20,000s), LFTs (total bili, LDH, AST, ALT elevations), Alk Phos; as patients become septic elevated BUN, creatinine and glucose results o Gall Stone Pancreatitis= choledocolithiasis with blockage of the pancreatic duct leading to inflammation of the pancreas Lab abnormalities of pancreatitis ( AST/ALT, amylase/lipase, WBCs) o Ultrasound Normal Gallbladder should be distended, smooth mucosa, no pericholecystic fluid o HIDA Scan Used when ultrasound is inconclusive

Look for non-filling of gall bladder Absence of duodenal filling indicates DBD stones ACUTE APPENDICITIS o Most common etiology of acute abdominal pain o Obstruction of the lumen of appendix by lymphoid hyperplasia or fecalith continued mucous production results in distension impaired venous return impaired arterial supplyischemiagangrene of appendix perforation peritonitis Plhegmon or abscess may occur instead of perforation Phlegmon = aggregation of inflammatory tissue o The pathophysiology of appendicitis is not uniform across ages. Thus, while appendicitis can occur (much less commonly) due to ischemic, infectious, or oncologic process, the overall prevailing mechanism is lumenal obstruction that causes proximal appendiceal inflammation and subsequent rupture. o + Obturator sign o + Psoas sign o Labs in appendicitis CBC elevated WBC (12-15), check Hgb/hematocrit ( seen in acute bleeding episode or cancer, hematocrit seen in dehydration), platelets (important preoperatively) BMP severe vomiting can cause abnormalities in Na, K, Cl, HCO3 BUN/creatinine ratio normal = 10/1 In dehydration BUN/Creatinine ratio= 20/1 Glucose= abnormally elevated in infections LFTs Should be normal acute appendicitis (LFTs should be elevated in acute hepatitis, choledocolithiasis, cholangitis, acute choleystitis) UA rules in or out kidney stones Look for RBCs in urine No tenderness on exam WBCs (look for pyelo, CVA tenderness on exam) b-hCg helps rule out ectopic pregnancy Amylase/Lipase help rule out pancreatitis o Imaging CT Scan-use IV & oral contrast Most appendixes come out of cecum between 2-6 oclock if you can find the cecum you can find the appendix Look for hyperemia in the wall, inflammation surrounding the appendix, fat stranding NOTE oral contrast does not enter the appendix b/c the appendix is OBSTRUCTED!! BARIATRIC SURGERY o BMI= weight (kg)/height (M)2 o Indications for surgery Patients qualify for bariatric surgery if BMI > 40 or BMI > 35 with comorbidities (diabetes, hypertension, sleep apnea) o Blodwork

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HbA1C, Thyroid function tests (to r/o hypothyroidism) lipids, LFTs, micronutrients (iron, B12, folate) Types of Surgeries Restrictive amount of food patient can eat (patient feels fuller faster, eats less) Gastric band Malabsorptive amt of calories/nutrients patient absorbs from foods Biliary pancreatic diversion Duodenal switch Combination Gastric Bypass more dramatic weight loss than seen with band Post Op Monitoring Monitor for leak o Look for tachycardia o Gastrgafin swallow can be used to look for leak/obstruction Clear liquids for 7-10 days Glucose control Monitor for PE tachycardia, hypoxia Monitor for dehydration