Glisson’s Capsule


Other Known AliasesNone

DefinitionOuter capsule of connective fibrous tissue, surrounding the liver, the intrahepatic branches of the portal vein, hepatic arteries, and bile duct

Clinical Significance The is a structure that must be dissected while operating on the liver.  In trauma, you can have subcapsular hematomas from hemorrhage that are contained by Glisson’s capsule.

History – Named after Francis Glisson (1597-1667), who was an English physician, anatomist, and pathologist.  His work on the liver in the late 1600s produced the foremost textbook on the digestive system, The Anatomia Hepatis, where he first described the covering of the liver in detail.




  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com/
  5. Haubrich WS. Glisson of Glisson’s capsule of the liver. Gastroenterology. 2001; 120(6):1362. [pubmed]

#31 – Small Bowel Obstruction




Small bowel obstruction (SBO) is one of the more common surgical emergencies in US, due to the increased intraluminal pressures which can lead to intestinal ischemia and risk of spontaneous rupture.  Overall mortality increases significantly if either of these occur.  It is estimated that over 300,000 surgeries per year occur in the US for bowel obstructions, with the small bowel making up around 80%.  Although it can happen at age, there is a higher trend to older patients and thee is equal incidence with both genders.

Risk Factors

The most common cause of SBO is postoperative adhesions, but there are numerous other causes that you should keep on your differential.

Signs and Symptoms

  • Abdominal pain
    • Paroxysms of periumbilical pain (3-5 minutes)
  • Nausea
  • Vomiting
  • Obstipation

Physical Examination

  • Dehydration
    • Tachycardia, orthostasis, decreased urine output
  • +/- Distension
  • Changes in bowel sounds
    • Hyperactive à muffled à absent
  • Percussion changes
    • Tympanic with distension
    • Dullness with fluid
  • Peritoneal signs if perforation present
  • +/- hemoccult

Laboratory Studies

  • CBC with differential
    • Anemia can point to a chronic condition
  • BMP
  • ABG
    • Acidosis = bowel ischemia, volume depletion
    • Alkalosis = vomiting
  • Serum lactate

Imaging Studies

  • Plain Radiographs
    • Dilated loops of small bowel with air/fluid levels on upright film
    • May also see a paucity of gas in distal intestines
    • Small bowel dilation ≥ 2.5cm is diagnostic

  • Abdominal CT
    • Much more sensitive and can also identify the specific causes
    • Can also identify a transition point
    • Other radiological signs on CT consistent with SBO include:
      • Bowel wall thickening > 3mm
      • Submucosal edema
      • Mesenteric edema
      • Ascites
      • Target sign (intussusception)
      • Whirl sign (volvulus)
      • Venous cut-off sign (thrombosis)
  • Ultrasound
    • Not as good as CT, but better than plain radiography
  • Special Considerations on Radiography
    • Closed-Loop Obstruction
      • High risk for ischemia, perforation, and ischemic bowel
    • Ischemia and Perforation


  • Initial
    • NPO
    • Fluid resuscitation
    • Surgery consultation
    • Gastrointestinal decompression
      • Not in EVERY patient, but good for patients with significant distension, nausea, and/or vomiting
    • Surgery
      • Nonspecific signs of bowel ischemia:
        • Fever
        • Leukocytosis
        • Tachycardia
        • Continuous and/or worsening abdominal pain
        • Metabolic acidosis
        • Peritonitis
      • High likelihood of bowel resection if ≥ 3 of the following:
        • Pain > 4 days
        • Abdominal guarding on exam
        • Elevated CRP > 75 mg/dL
        • Leukocytosis > 10,000
        • > 500cc fluid of intraabdominal fluid
        • Reduced wall contrast enhancement on CT
    • Observation
      • If no high-risk surgical signs present, observation with serial examinations may be used for 12-24 hours in patients with:
        • Early postoperative obstruction
        • Inflammatory bowel disease
        • Gallstone ileus
        • Infectious small bowel disease
        • Colonic diverticular disease
      • Exploration should proceed if no improvement


  • Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel obstruction. American Journal of Surgery. 2000; 180(1):33-6. [pubmed]
  • Markogiannakis H, Messaris E, Dardamanis D. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World Journal of Gastroenterology. 2007; 13(3):432-7. [pubmed]
  • Scott FI, Osterman MT, Mahmoud NN, Lewis JD. Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007. American Journal of Surgery. 2012; 204(3):315-20. [pubmed]
  • Drożdż W, Budzyński P. Change in mechanical bowel obstruction demographic and etiological patterns during the past century: observations from one health care institution. Archives of Surgery (Chicago, Ill. : 1960). 2012; 147(2):175-80. [pubmed]
  • Taylor MR, Lalani N. Adult small bowel obstruction. Academic Emergency Medicine. 2013; 20(6):528-44. [pubmed]
  • Jackson PG, Raiji MT. Evaluation and management of intestinal obstruction. American Family Physician. 2011; 83(2):159-65. [pubmed]
  • Mullan CP, Siewert B, Eisenberg RL. Small bowel obstruction. American Journal of Roentgenology. 2012; 198(2):W105-17. [pubmed]
  • Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta radiologica. 1999; 40(4):422-8. [pubmed]
  • Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction. American Journal of Roentgenology. 2000; 175(6):1601-7. [pubmed]
  • Eltarawy IG, Etman YM, Zenati M, Simmons RL, Rosengart MR. Acute mesenteric ischemia: the importance of early surgical consultation. The American Surgeon. 2009; 75(3):212-9. [pubmed]
  • Schwenter F, Poletti PA, Platon A, Perneger T, Morel P, Gervaz P. Clinicoradiological score for predicting the risk of strangulated small bowel obstruction. The British Journal of Surgery. 2010; 97(7):1119-25. [pubmed]

PAINE #PANCE Pearl – Surgery Edition



What are the boundaries of Calot’s Triangle and what can be found there?




Calot’s Triangle is the area bordered by:

  1. Cystic duct
  2. Common hepatic duct
  3. Cystic artery

A lymph node can be found within this triangle and there is apparently great debate about the name of this node.   I had learned this was referred to as Calot’s node (which makes sense, right), but it is more accurately named Lund’s, or Mascagni’s, node.  This node can be enlarged and inflamed with cholecystitis.

The anatomical area is referred to as the cystohepatic triangle and is bordered by:

  1. Cystic duct
  2. Common hepatic artery
  3. Superior, inferior margin of the liver

The reason for this distinction from Calot’s Triangle is because the cystic artery can be found within this region.

Blue = Calot’s and Red = Cystohepatic



  1. Blackbourne LH.  Surgical Recall.  6th Edition.  2012.
  2. Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002; 123(5):1440. [pubmed]
  3. Miranda, Efrain A., PhD. “Triangle of Calot.” Medical Terminology Daily. N.p., 10 May 2016. Web. 10 June 2017.


Whipple Operation


Other Known AliasesKausch-Whipple procedure

DefinitionRadical pancreaticoduodenectomy with distal antrectomy, cholestectomy, and pancreaticojejunostomy, choledocojejunostomy, and gastrojejunostomy

Clinical Significance Used for resection of carcinoma of the head of the pancreas.

History – The first resection of a periampullary cancer was performed by German surgeon Walther Kausch (1867-1928) in 1909, took four hours to complete, and the patient survived for 9 months.  American surgeon Allen Oldfather Whipple (1881-1963) began working on and refining the procedure in 1935 and in 1940, successfully shortened it to a one-stage procedure.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com/. Accessed March 7, 2017.
  5. Whipple AO. Observations on radical surgery for lesions of the pancreas. Surgery, gynecology & obstetrics. 1946; 82:623-31. [pubmed]

Life and Whatnot

I wanted to send a little post out for those that subscribe to the blog, but also for anyone that is following me on social media.  One of the core tenets of a successful online presence is consistency and predictability.  I have prided myself on producing content fairly regularly over the past year and I will continue to do this…….once I get this thing called life settled out.


As you all know, I started my new position as program director at the University of Tennessee Health Science Center PA Program in January and have been commuting home to Birmingham every weekend for the past 4 months.  I usually have some time worked into the weekends to schedule some of the content (Motivation Mondays, Wednesdays Ep-PAINE-nyms, Saturdays PAINE PANCE Pearls) in advance so it gets outs even if I get busy.


We finally closed on both our houses (Birmingham and Memphis) in the last 2 weeks and we are finally getting one step closer to be a one zip code family.  My amazing wife is still living in Birmingham for the next 2.5 weeks to get the kids finished in school Alabama, but this entails living in hotels or her mother’s house.  Every extra moment of time I have now is devoted to painting and assembling furniture in the new house so it is ready to go when the family arrives at the end of the May.



I will be back in full swing on June 1st.  Again….my apologies for the lack of content for the past few weeks, but we will be up and running again soon.