Because gallbladder pain often radiates through to the tip of the scapula, the affected dermatome may be hyperaesthetic, a change detected by lightly drawing a pin down the back of the patient’s chest. This is called Boas’ sign.

-Browse notes
#Surgery

-Beware After 4–6 hours, the acid in the peritoneal cavity becomes diluted and the pain and guarding decrease.
-Patients think they are improving, but they are in fact getting worse.
-The peritonitis is progressing and hypervolaemia is developing.
-An increasing tachycardia and absent bowel sounds associated with increasing abdominal distension and sunken eyes indicate that the patient is becoming extremely ill.

-Browse notes
#Surgery

Hypokalemia is generally defined as a serum potassium level of less than 3.5 mEq/L (3.5 mmol/L).

Moderate hypokalemia is a serum level of 2.5-3.0 mEq/L, and severe hypokalemia is a level of less than 2.5 mEq/L. Hypokalemia is a potentially life-threatening imbalance that may be iatrogenically induced.

#Surgery
#Medicine

Causes of unhealed fistula:

His Friends
H_high output fistula
S_steroid use
F_foreign body
R_radiation
I_IBD
E_epithelialization
N_neoplastic
D_distal obstruction
S_site( gastric, duodenal).

#Surgery

Risk factors for perforation of the appendix:

● Extremes of age
● Immunosuppression
● Diabetes mellitus
● Faecolith obstruction
● Pelvic appendix
● Previous abdominal surgery.

#Surgery

Symptoms of appendicitis

● Periumbilical colic
● Pain shifting to the right iliac fossa
● Anorexia
● Nausea.

#Surgery

Signs to elicit in appendicitis:

● Pointing sign
● Rovsing’s sign
● Psoas sign
● Obturator sign

#Surgery

-Spasm of the obturator internus is sometimes demonstrable when the hip is flexed and internally rotated. If an inflamed appendix is in contact with the obturator internus, this manoeuvre will cause pain in the hypogastrium (the obturator test; Zachary Cope).
-Cutaneous hyperaesthesia may be demonstrable in the right iliac fossa, but is rarely of diagnostic value.

#Surgery

Clinical signs in appendicitis

● Pyrexia
● Localised tenderness in the RIF
● Muscle guarding
● Rebound tenderness.

#Surgery

-The patient is then asked to point to where the pain began and where it moved (the pointing sign).


#Surgery

Effects and complications of gallstones:

● Biliary colic
● Acute cholecystitis
● Chronic cholecystitis
● Empyema of the gallbladder
● Mucocoele
● Perforation
● Biliary obstruction
● Acute cholangitis
● Acute pancreatitis
● Intestinal obstruction (gallstone ileus).

#Surgery

Differential diagnosis of acute cholecystitis:

Common:
● Appendicitis
● Perforated peptic ulcer
● Acute pancreatitis
Rare:
● Acute pyelonephritis
● Myocardial infarction
● Pneumonia – right lower lob.

#Surgery

Features of obstruction:

● In high small bowel obstruction, vomiting occurs early, is
profuse and causes rapid dehydration. Distension is minimal
with little evidence of dilated small bowel loops on abdominal
radiography
● In low small bowel obstruction, pain is predominant with
central distension. Vomiting is delayed. Multiple dilated small
bowel loops are seen on radiography
● In large bowel obstruction, distension is early and
pronounced. Pain is less severe and vomiting and dehydration
are later features. The colon proximal to the obstruction is
distended on abdominal radiography. The small bowel will be
dilated if the ileocaecal valve is incompetent.

Serum trypsin is the most accurate indicator but it is not commonly used in acute pancreatitis.

Serum lactescence (related to triglyceride metabolism)—Most specific in hereditary hyperlipidaemia or alcohol pancreatitis.

Serum lipase is more specific than amylase.

ERCP is usually not done in acute phase of pancreatitis.

Spiral CT (CECT–contrast enhanced CT) is better—gold standard in acute pancreatitis, it is done after 72 hours.

Instrumentation is by far the most common cause of perforation.