NMS. Surgery

392

Part VI ♦ Special Subjects

Quick Cuts • Adhesive SBO can often be managed non-operatively.

• In a patient without prior surgery, acute SBO should be operated on emergently. • Incarcerated hernias are stuck in place; strangulated ones have compromised blood supply. • Ileus and obstruction can be difficult to differentiate.

HEMORRHAGE Terminology I. GI bleeding

A. Common emergent surgical consult. B. Treatment priority is resuscitation and, when necessary, transfusion. II. Hematemesis: Bright red blood or coffee ground colored emesis due to an upper GI bleed. III. Hematochezia: Passage of bright red blood from the rectum from an upper or lower source. IV. Melena: Passage of black stools due to blood in the GI system; can occur with upper or lower GI hemorrhage. V. Currant jelly stool: Mixture of blood and mucus seen in children with intussusception. Evaluation and Diagnostic Studies I. Localization A. First step in evaluation. B. Upper GI bleeding can present as lower GI bleeding in the form of hematochezia, melena, or bright red blood per rectum. C. NG and gastric lavage 1. Evaluates for gastric and duodenal sources. 2. NG lavage must contain bile to be negative; if it does not, a duodenal bleed can be missed. D. Endoscopy: Visualizes the stomach, duodenum, and colon. E. Radiographic imaging: Includes tagged red blood cell (RBC) scan and angiography; more useful in lower GI bleeding. F. Capsule endoscopy or push enteroscopy: Can visualize the small intestine in stable patients with resolved or intermittent bleeds.

Differential Diagnosis I. Upper GI bleed: Bleeding proximal to the ligament of Treitz. A. History of ulcer disease: Bleeding peptic ulcer. B. History of gastroesophageal reflux disease: Esophagitis. C. History of heavy alcohol use: Bleeding varices or gastritis.

D. Recent retching: Mallory–Weiss tear. E. Weight loss: Upper GI malignancy.