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Physician Assistant Exam: Common Intestinal Surgeries

Every medical professional should know about some common abdominal surgeries. For the Physician Assistant Exam (PANCE), you will need to review evaluating and managing appendicitis, diverticulitis, hernias, volvulus, and spleen problems.

The inflamed appendix

You need to know a lot about evaluating and managing acute appendicitis. Acute appendicitis is a common cause of emergent surgery, especially in the younger population. It typically causes pain in the right lower quadrant. Inflammation of this organ, either via obstruction from lymph glands or fecalomas can be life-threatening if not recognized. Perforation and/or abscess formation are serious complications of acute appendicitis.

You should recognize the typical clinical presentation: pain that begins in the mid-abdomen and migrates into the right lower quadrant. Fever, nausea, vomiting, and anorexia are usually also present.

On physical examination, the affected person can be toxic-looking and febrile. Pertinent physical examination findings include tenderness along McBurney’s point. This point is on the right side of the abdomen, one-third the distance from the anterior superior iliac spine to the umbilical area.

Other common clinical signs of acute appendicitis include the following:

  • Rovsing’s sign: Rovsing’s sign occurs when left lower-quadrant palpation causes right lower-quadrant tenderness.

  • Psoas sign: Psoas sign relates how flexion or extension of the hip causes right lower-quadrant pain. Appendicitis can, in certain people, cause an inflammation of the psoas muscle. If the affected person is supine, flexion of the right hip causes rip-roaring right lower-quadrant pain. If the person is lying on his or her left side, then extension of the right hip can elicit pain.

  • Obturator sign: In obturator sign, rotating the hip internally and externally elicits pain.

  • Blumberg’s sign: In Blumberg’s sign, slow compression and rapid release over a specific site of the abdomen elicits pain. It’s a sign of peritonitis.

Abnormal lab findings for a person with acute appendicitis can include a leukocytosis on a CBC, and you may see abnormal electrolytes, depending on how significant the nausea, vomiting, and anorexia are. Imaging studies can include an ultrasound or CT scan of the abdomen. However, the key to recognizing acute appendicitis is in the history and the findings on physical examination.

An inflamed appendix is often approached surgically, using laparoscopic technique. Pre-operatively, intravenous fluids and antibiotics can be started.

Diverticulitis

Many people, especially older adults, have diverticulosis, an outpouching in the wall of the large intestine. Diverticulitis, or inflammation of this outpouching, is a common cause of left lower-quadrant pain.

A significant risk factor for the development of diverticulitis is the American diet, which is deficient in fiber and high in processed and refined foods. The most common clinical presentation is intense left lower-quadrant pain associated with fever. Constipation and/or diarrhea may be present. On physical examination, you find left lower-quadrant tenderness, and peritoneal signs may be present.

A CT scan with oral contrast is often done to evaluate for possible abscess or fistula.

The affected person is admitted to the hospital, made NPO, and given intravenous hydration, antibiotics, and pain medication. After the first attack, a change in diet is recommended, including an increase in fiber.

Intestinal twists: Volvulus

Volvulus is the intestine’s version of Twister: The intestine literally twists on itself. The most common area for volvulus to occur is the sigmoid colon, although it can occur in other areas as well, including the cecum.

Depending on where the volvulus is, the typical presentation is sudden onset of abdominal pain. Physical examination reveals decreased or absent bowel sounds, focal tenderness, and even peritoneal signs. A volvulus needs be recognized and treated immediately; an intestine that remains twisted is at risk for decreasing its own blood supply, which can lead to a necrotic, gangrenous bowel.

Radiographic signs are important in identifying a volvulus. On a plain radiograph, you can see distended sections of large bowel, especially if a sigmoid volvulus is present.

In most cases, decompressive surgery/therapy is needed. A rectal tube may be used to decompress the affected area of intestine.

Hernias

Hernias are a common surgical problem. If the abdominal wall is weak enough, sometimes a tear or open area becomes large enough for some part of the intestine to slide into places it doesn’t belong. Surgical intervention is needed to treat any hernia.

One of the most common types of hernia is the inguinal hernia. Such hernias can be either indirect or direct:

  • Indirect: An indirect hernia, which is the more common type, refers to a failure of the inguinal ring to close during development. This hernia occurs when the intestine and/or other abdominal contents travel through the deep inguinal ring into the inguinal canal.

  • Direct: With the direct hernia, the intestine travels through a weakened area in the inguinal triangle. Direct hernias don’t commonly go into the scrotal area.

Femoral hernias, which are more common in women, can cause a bulging in the mid-thigh area as the intestine pushes its way through an opening in the femoral canal. On physical examination, the inguinal ligament is medial to the femoral hernia protrusion.

How to remove the spleen

The spleen is an integral part of the lymph system, and of course maintaining a healthy immune system is important. When the spleen is no longer working, you’re at risk for infection with encapsulated organisms.

Why remove this organ? The most common reason is trauma — the spleen is often injured in motor vehicle accidents. Splenic trauma is a surgical emergency. Other causes include various hematologic malignancies, such as lymphoma, polycythemia vera and other myeloproliferative states, hereditary spherocytosis, and other spherocytosis.

Common labs that are monitored pre- and post-surgery are the blood counts as well as the coagulopathy profile. Imaging procedures can include obtaining a CT scan, especially in the case of trauma.

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