Question

1. What are the five classic causes of a post-operative fever?
2. What are two other clever causes to think of (if I do say so myself)?

Answer

1. The five classic causes of post-operative fever are:
   1. Wind = lungs (atelectasis, pneumonia, aspiration) = POD 1-2
   2. Water = UTI = POD 2-3
   3. Wound = surgical site infection = POD 3-5
   4. Walking = DVT = POD 3-5
   5. Wonder drugs = drug reactions = anytime
2. Another two “W’s” to add to this list:
   1. Withdrawal = typically alcohol
   2. “Wonky” glands = thyrotoxicosis, adrenal crisis

Check out my article in JAAPA from 2016 on “Evaluating Postoperative Fever” for a more in-depth look

***LISTEN TO THE PODCAST HERE***

Epidemiology

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
    • 
    • 

Management

• 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

References

• 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]

This week’s theme is FEVAH

1. What are the five classic causes of a post-operative fever?
2. What are two other clever causes to think of (if I do say so myself)?

Question

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

Answer

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

References

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.