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Objectives to direct the training of emergency medicine residents on off-service rotations: Surgery, part 1
The Journal of Emergency Medicine, Voll3, No 5, pp 687-695, 1995 Copyright 0 1995Elswier ScienceLtd Printed in the USA. All rights reserved 0736-4679/9s
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0736~4679( 95)00083-6
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OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY MEDICINE RESIDENTS ON OFF-SERVICE ROTATIONS: SURGERY, PART 1 Captain Ronald T. Rakowski, MD, Major John M. Wightman, and Glenn C. Hamilton, MD, MSM, FACEM, FACP
MD, MA, FACEP,
Department of Emergency Medicine, Wright State University School of Medicine, Dayton, Ohio Reprint Address: Glenn C. Hamilton, MD, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401-0927
0 Abstract -This is the 34th article in a continuing series of objectives to direct emergency medicine resident experiences on off-service rotations. Abdominal and gastrointestinal complaints are common problems in the emergency department and often lead to consultation with a surgeon. Becausean understanding of the principles of surgical diagnosis and treatment is an essential component of the practice of emergency medicine, residents rotating on surgical services require specific goals and objectives to emphasize early patient assessment,identification of the possible need for surgery, and a basic understanding of definitive management.
Utilization of these goals and objectives will allow both resident and preceptor to identify those entities that will best prepare the future emergency physician. As rotating emergency medicine residents acquire increasing knowledge in fundamental surgical principles, they should be given increasing clinical responsibilities and become members of the surgical team. CONTENTS The numbering system in this article corresponds to topics found in the Core Content for Emergency Medicine ( 1).
0 Keywords -education, medical, graduate; emergency medicine; objectives; residency; surgery
1.O Abdominal and Gastrointestinal Disorders 1.1 Esophagus 1.1.1 Motor abnormalities 1.1.1.1 Esophageal spasm 1.1.1.2 Achalasia 1.1.2 Structural disorders 1.1.2.1 Varices 1.1.2.2 Rupture (Boerhaave’s syndrome) 1.1.2.3 Perforation 1.1.2.4 Tears (Mallory-Weiss syndrome) 1.1.2.6 Foreign body 1.1.2.8 Diverticula 1.1.2.9 Hiatal hernia 1.1.2.10 Webs, strictures, stenosis 1.1.3 Inflammatory disorders
INTRODUCTION This is the 34th article in a series of goals and objectives that can enhance the learning process of residents on off-service rotations. It is the first of three parts covering essential aspects of surgical practice that may be applied in the emergency department (ED). The primary focus is on the pathophysiology of the gastrointestinal system, with emphasis on the assessment,identification, and initial management of the acute surgical patient. Furthermore, knowledge of the eventual surgical treatment is necessary when either rotating on a surgery service or discussing an ED casewith a consultant. 687
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1.1.3.1 Reflux esophagitis 1.1.3.2 Caustic injury 1.15 Tumors 1.2 Liver 1.2.2 Biliary obstructive cirrhosis 1.2.4 Tumors of the liver 1.2.5 Abscess 1.3 Gall Bladder and Biliary Tract 1.3.1 Cholecystitis 1.3.2 Cholangitis 1.3.3 Cholelithiasis and choledocholithiasis 1.3.4 Gallstone ileus 1.35 Tumors 1.4 Pancreas 1.4.1 Inflammatory 1.4.1.1 Acute pancreatitis 1.4.1.2 Chronic pancreatitis 1.4.1.3 Pseudocyst 1.4.1.4 Pancreatic insufficiency 1.4.2 Tumors 1.4.2.1 Islet cell tumors 1.4.2.2 Carcinoma 1.5 Stomach 1.5.1 Structural lesions 1.5.1.1 v01vu1us 1.5.1.2 Foreign bodies 1.5.1.3 Rupture 1.5.1.4 Gastric outlet obstruction 1.5.2 Inflammatory disorders 1.5.3 Peptic ulcer disease(PUD) 1.5.3.1 Duodenal ulcer 1.5.3.2 Gastric ulcer 1.5.3.3 Acute gastrointestinal hemorrhage 1.5.4 Tumors 1.6 Small Bowel 1.6.1 Motor abnormalities 1.6.1.1 Obstruction 1.6.1.1.1 Mechanical 1.6.1.1.2 Adynamic 1.6.1.2 Pseudo-obstruction 1.6.2 Structural disorders 1.6.2.1 Mesenteric vascular disease 1.6.2.2 Aorto-enteric fistula 1.6.2.3 Malabsorption 1.6.3 Inflammatory disorders 1.6.3.1 Acute appendicitis 1.6.3.2 Regional enteritis 1.6.5 Tumors 1.7 Large Bowel 1.7.1 Motor abnormalities 1.7.1.1 Irritable bowel syndrome (IBS) 1.7.2 Structural disorders 1.7.2.1 Diverticular disease 1.7.2.2 Volvulus
1.7.2.3 Vascular dysplasia (angiodysplasia) 1.7.3 Inflammatory disorders 1.7.3.1 Ulcerative colitis 1.7.3.2 Radiation colitis 1.7.4.4 Pseudomembranous enterocolitis 1.7.4.5 Gay bowel syndrome 1.7.5 Tumors 1.8 Rectum and Anus 1.8.1 Structural disorders 1.8.1.1 Anal fissure 1.8.1.2 Anorectal fistula 1.8.1.3 Hemorrhoids 1.8.1.4 Rectal prolapse 1.8.1.5 Foreign body 1.8.1.6 Perianal warts 1.8.1.7 Abscesses 1.8.2 Inflammatory disorders 1.8.3 Tumors 1.9 Abdominal Wall/Peritoneum
GOALS AND OBJECTIVES 1.O Abdominal and Gastrointestinal Disorders 1.1 Esophagus 1.1.1 Motor abnormalities 1.1.1.1 Esophageal spasm 1. Identify the most typical symptoms and signs of diffuse esophageal spasm (DES). 2. Outline the medical and surgical management of DES. References: (2) page 1590; ( 3) pages 670-3. 1.1.1.2 Achalasia 1. State the classic symptom triad of achalasia. 2. Delineate the potential pulmonary complications of achalasia. 3. Outline the diagnostic approach to a patient with suspected achalasia. 4. Select the two most common surgical treatments for achalasia. References: (2) page 1586; (3) pages 666-70. 1.1.2 Structural disorders 1.1.2.1 Varices 1. Match presinusoidal and intrahepatic classifications of variceal etiology to their principal causes. 2. List at least five methods of intervention for acute variceal hemorrhage. 3. Delineate at least three options available for pre-
Objectives-Surgery,
Part I
vention of recurrent upper gastrointestinal bleeding due to esophageal varices. References: (2)pages 1516& 1527; (3)pages 1019-27. 1.1.2.2 Rupture (Boerhaave’s syndrome)
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3. Draw the three sites of esophageal diverticula. 4. Contrast the surgical management of diverticula at each of these three sites. Reference: (3) pages 678-81. 1.1.2.9 Hiatal hernia
1. Describe the presentation of a patient with Boerhaave’s syndrome. 2. Identify the most common radiographic features of a ruptured esophagus. 3. Contrast the surgical management of early versus late presentations of rupture of the thoracic esophagus.
1. Identify the two types of hiatal hernia. 2. Describe the potentially life-threatening presentations of each type. 3. List the indications for surgical repair of Type-II hiatal hernia.
References: (2) pages459-63 & 1591; (3) pages701-4.
1.1.2.10 Webs, strictures, stenosis
1.1.2.3 Perforation
1. Indicate the level at which esophageal webs classically occur and describe the histopathology at this location. 2. Outline the medical and surgical management of reflux-induced strictures of the esophagus.
1. List at least eight etiologies of esophageal perforation. 2. Describe Hamman’s sign. 3. Contrast the surgical management of cervical versus thoracic perforation of the esophagus.
Reference: ( 3) pages 704-8.
Reference: (3) pages 681-2 & 713-4.
References: (2) pages 459-63; (3) pages 701-4.
1.1.3 Inflammatory disorders
1.1.2.4 Tears (Mallory-Weiss syndrome)
1.1.3.1 Reflux esophagitis
1. Define the Mallory-Weiss syndrome. 2. Outline the clinical setting, course, and management of a patient with an emetogenic mucosal laceration. References: (2) page 1516; (3) pages 682 &781. 1.1.2.6 Foreign body I. Name the location where the majority of foreign bodies lodge in the esophagus. 2. Identify radiographic features of several foreign bodies listed on plain neck or chest radiographs. 3. State the most life-threatening complication of not removing an esophageal foreign body. 4. List three medical therapies available in the management of esophageal foreign bodies. 5. Describe the complications associated with failure to identify and remove a button battery. 6. Contrast the management of sharp foreign bodies versus impacted food boluses. References: (2) pages 328-31; (3) pages 1204-5; (4) pages 629-40. 1.1.2.8 Diverticula 1. Name the two most common pathophysiological mechanisms leading to diverticula of the esophagus. 2. Describe the classic presentation of a patient with Zenker’s diverticulum.
1. Describe the symptoms, signs, and utility of several tests for diagnosis of gastro-esophageal reflux (GER). 2. Outline the prophylactic and medical management of GER. 3. List the indications for surgical intervention in complicated GER. 4. Differentiate the three most common surgical options for prevention of GER. References: (2) pages 1591-2; (3) pages 708-13. 1.1.3.2 Caustic injury 1. Define the patient population that typically suffers from caustic esophageal injury. 2. Select the four characteristics of an ingested agent that determine the site and severity of injury. 3. Contrast the histopathological difference of acid versus alkali injury. 4. Choose the patient presentation suggestive of mediastinal, intrapleural, or intraperitoneal perforation. 5. List the indications and contraindications of diagnostic modalities used early and late to determine the extent of injury. 6. Identify the early and late complications of caustic esophagitis. 7. Outline the immediate medical and late surgical management of corrosive esophageal trauma. References: (2) pages 2553-4; (3) pages ?15-21”
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1.1.5 Tumors
1.3 Gall Bladder and Biliary Tract
1. Identify five factors that may lead to development of esophageal carcinoma. 2. Describe the presentation of a patient with an esophageal tumor. 3. Indicate the efficacy of esophography as a screening tool. 4. List several definitive and palliative approaches to therapy.
1.3.1 Cholecystitis
Reference: (3) pages 689-700. 1.2 Liver 1.2.2 Biliary obstructive cirrhosis 1. List the three pathological criteria for the diagnosis of cirrhosis. 2. State the classic symptom triad of cirrhosis. 3. Explain the utility of the prothrombin time (PT) as a screening and prognostic tool in patients with cirrhosis. 4. Select additional laboratory tests useful in the management of patients with cirrhosis. 5. Cite the importance of liver biopsy in the initial evaluation of a patient with suspected cirrhosis. 6. Review the clinical application of Child’s classification. 7. List at least three major complications of cirrhosis. References: (2) pages 1608-9 & 2215-6; (3) pages 1015-9. 1.2.4 Tumors of the liver 1. Describe the etiology, presenting symptoms and signs, diagnostic tests, and treatment of each of the following primary tumors of the liver: a. Benign adenoma b. Hepatocellular carcinoma c. Cholangiocarcinoma d. Hepatoblastoma 2. List, in order of frequency, the primary sites of common hepatic metastases. 3. Outline the contraindications to major hepatic resection for tumors. References: (2) page 1614; (3) pages 999-1012. .2.5 Abscess 1. Identify the two primary causesof hepatic abscess and the most important complications of each. 2. List five conditions that predispose to abscessformation. 3. Select the surgical treatment and appropriate antibiotic usage for hepatic abscesses. References: (2) pages 161l-3; (3) pages 992-9.
1. Describe the clinical presentation of acute cholecystitis. 2. List the differential diagnoses for right upperquadrant abdominal pain. 3. Indicate the efficacy of laboratory tests and ultrasonography in the diagnosis of cholecystitis. 4. Name the three bacterial organisms most commonly cultured from infected bile. References: (2) pages 1616-7; (3) pages 747-8 & 1050-63. 1.3.2 Cholangitis 1. Contrast Charcot’s triad and Reynold’s pentad. 2. Outline the key elements of cholangitis diagnosis. 3. Identify any important differences between acute and toxic cholangitis . References: (2) pages 1618-9; (3) pages 1048-9 & 1064-70. 1.3.3 Cholelithiasis and choledocholithiasis 1. Select factors associated with gall stone formation. 2. Cite situations for utilization of intra-operative cholangiography. References: (2) pages 1618-9; (3) pages 1045-6 & 1057-63. 1.3.4 Gallstone ileus 1. Describe the historical features and presenting symptoms and signs of gallstone ileus. 2. Identify the most and least frequent site of obstruction. Reference: (3) pages 1071-2. 1.3.5 Tumors 1. Cite at least five factors associated with development of gallbladder carcinoma. 2. Describe the symptoms and signs that should lead to suspicion of gallbladder tumor. References:(2) page 1619; (3) pages 1047-8 & 1073-5. 1.4 Pancreas 1.4.1 Inflammatory 1.4.1.1 Acute pancreatitis 1. Review the Marseilles Classification. 2. Outline Ranson’s prognostic criteria. 3. List at least eight etiologies of pancreatitis.
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4. Indicate the efficacy of serum amylase and lipase in the diagnosis of acute pancreatitis. 5. Define a sentinel loop. 6. Outline the medical management of acute pancreatitis. 7. Discuss the use of peritoneal lavage in the treatment of pancreatitis. 8. Delineate the indications for surgical intervention in acute pancreatitis. 9. Indicate when pancreatic abscess should be suspetted . References: (2) pages 1619-22; (3) pages 748 & 1080-8.
5. Describe the WDHA syndrome. References: (2) pages 1623-4; (3) pages 1098-1103. 1.4.2.2 Carcinoma 1. Select risk factors associated with pancreatic carcinoma. 2. List the three most common presenting symptoms of pancreatic carcinoma. 3. Define Courvoisier’s law. 4. Draw the major stagesof Whipple’s procedure. References: (2) page 1623; (3) pages 1093-S. 1.5 Stomach
1.4.1.2 Chronic pancreatitis
1.5.1 Structural lesions
1. State the classic symptom triad of chronic pancreatitis. 2. List three etiologies of chronic pancreatitis. 3. Contrast the differences between chronic pancreatitis and relapsing acute pancreatitis. 4. State the diagnostic utility of available tests. 5. Identify at least four surgical options in the treatment of chronic pancreatitis.
1.5.1.1 v01vu1us
References: (2) page 1622; (3) pages 748 & 1088-90. 1.4.1.3 Pseudocyst 1. Indicate when pancreatic pseudocyst should be suspected. 2. Name the preferred method of diagnosis. 3. List four complications of untreated pseudocyst. 4. Delineate the indications for surgical drainage or resection. References: (2) pages 1622-3; (3) pages 1090-3. 1.4.1.4 Pancreatic insufficiency 1. List the most common etiologies of pancreatic insufficiency. 2. Name three findings that suggest pancreatic insufficiency. 3. Describe the secretin test. 4. Outline available treatments. Reference: (3) page 877-8. 1.4.2 Tumors 1.4.2.1 Islet cell tumors 1. Name the two common islet-cell tumors. 2. Describe the most common methods used for diagnosis. 3. Define Whipple’s triad. 4. Contrast medical and surgical management of islet-cell tumors.
1. Describe the most typical symptoms and signs of gastric volvulus. 2. Name the procedure that may be utilized in the ED for presumptive diagnosis. Reference: (2) pages 1420-I. 1.5.1.2 Foreign bodies 1. Choose at least three situations in which a foreign body should be removed (endoscopically or surgically) once it has passedthrough the esophagus. 2. Outline the appropriate follow up for patients with foreign bodies in the stomach or small bowel not requiring extraction. Reference: (2) pages 330-2. 1.5. I .3 Rupture 1. Describe the symptoms, signs, and utility of several tests for presumptive diagnosis of acute gastric perforation. 2. Describe the symptoms, signs, and utility of several tests for presumptive diagnosis of acute gastric penetration. Reference: (3) pages 747,769, & 771. 1.5.1.4 Gastric outlet obstruction 1. Contrast the management of gastric outlet obstruction due to gastric ulcer, intraluminal tumor, or extrinsic duodenal compression. Reference: ( 3 ) pages 769-70,783,790- 1, & 807-l 3. 1.5.2 Inflammatory disorders 1. Identify the three principal mechanisms by which erosive gastritis may occur. 2. Outline the prophylactic and medical management of acute stress gastritis.
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3. Contrast the surgical options when the etiology of the gastritis is or is not due to caustic alkali ingestion. References: (2) page 1516; (3) pages 779-780 & 797-801. 1.5.3 Peptic ulcer disease(PUD) 1.5.3.1 Duodenal ulcer 1. State the diagnostic accuracy of radiographic studies and side-looking fiberoptic endoscopy in diagnosis of PUD. 2. Identify the three primary indications for gastric analysis in patients with PUD. 3. Describe the initial medical management of nonbleeding PUD. 4. List the four indications for immediate or elective surgical treatment of duodenal ulcer. References: (2) pages 1525-6; (3) pages 762-3 & 765-70. 1.5.3.2 Gastric ulcer 1. Name the most important additional consideration when determining the etiology of gastric, as opposed to duodenal, ulcer and the accuracy of radiographic studies in its diagnosis. 2. Identify at least four surgical options for intractable gastric ulcers. 3. List the four most common late complications of these operations. Reference: (3) pages 763-5,770-l,
& 775-8.
1.5.3.3 Acute gastrointestinal hemorrhage 1. List the six most common causes of upper gastrointestinal (UGI) hemorrhage. 2. State the amount of blood loss required to produce orthostatic changes in a young adult’s vital signs. 3. Discuss the use of blood products in the emergency management of GI bleeding. Reference: (2) pages 1515, 1519, & 1525.
1.6.1 Motor abnormalities 1.6.1.1 Obstruction 1.6.1.1.1 Mechanical 1. Outline the causes of small bowel obstruction (SBO). 2. Identify the origin of gas that distends the bowel proximal to the obstruction. 3. Characterize fluid and electrolyte losses by site of obstruction. 4. Contrast simple mechanical obstruction versus strangulation. 5. Describe the radiographic features of SBO and large bowel obstruction. 6. Compare and contrast the use of nasogastric, Levin, and Miller-Abbott tubes in the initial management of SBO. 7. Discuss potential complications and the timing of surgical intervention for SBO. References: (2) pages 1633-7; (3) pages750 & 835-42. 1.6.1.1.2 Adynamic 1. List three causesof paralytic ileus. 2. Contrast features on plain radiographs that may help distinguish paralytic ileus from SBO. 3. Outline the management of adynamic ileus. References: (2) pages 1636-7; (3) pages 750-1, 835, & 841-2. 1.6.1.2 Pseudo-obstruction 1. Identify the etiology of idiopathic intestinal pseudo-obstruction. 2. Name the diagnostic modality used to distinguish pseudo-obstruction from true mechanical obstruction. References: (2) page 1637; (3) pages 835-6. 1.6.2 Structural disorders 1.6.2.1 Mesenteric vascular disease
1. Describe the most common symptoms and signs that would lead to suspicion of gastric tumor. 2. Match the preferred treatment to each of the following: a. Benign tumor b . Lymphoma c. Carcinoma
1. Explain how bowel activity affects its blood flow. 2. Name the two most common findings in patients with chronic intestinal ischemia. 3. State the diagnostic triad of acute superior mesenteric artery occlusion and contrast it to the presentations of thrombosis and embolus. 4. Choose the appropriate surgical management of mesenteric artery occlusion. 5. Define nonorganic intestinal infarction.
Reference: (3) pages 787-97 & 814-27.
References: (2) pages 1638-41; (3) pages 1650-6.
1.6 Small Bowel
1.6.2.2 Aorto-enteric fistula (AEF)
1.5.4 Tumors
Objectives-Surgery,
Part 1 -__-_
1. Name the most common predisposing condition in the development of AEF. 2. Delineate the emergency management of AEF. Reference: (3) pages 1571-2. 1.6.2.3 Malabsorption 1. ldentify surgical conditions associated with malabsorption. 2. Outline the clinical manifestations of malabsorption. 3. Describe the most useful diagnostic tests for malabsorption, Reference: (3) pages 873-80. 1.6.3 Inflammatory disorders 1.6.3.1 Acute appendicitis 1. Describe the classical presentation of acute appendicitis. 2. State the efficacy of laboratory tests and plain radiographic studies in the diagnosis of appendicitis. 3. Name seven common conditions that may be clinically similar to appendicitis. 4. Define McBurney’s point and Rovsing’s sign. 5. Contrast the features of appendicitis that may differ in children, young women, pregnancy, and the elderly. References: (2) pages 1627-33; (3) pages 748-9, & 884-98. 1.6.3.2 Regional enteritis 1. Describe the characteristic patient and clinical manifestations of Crohn’s disease. 2. List several extra-intestinal manifestations of Crohn’s disease. 3. Name five common conditions in the differential diagnosis of regional enteritis. 4. Outline the medical, surgical, and nutritional management of regional enteritis.
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1.7.1 Motor abnormalities 1.7.1.1 Irritable bowel syndrome (IBS) 1. Define the patient population that typically suffers from IBS. 2. List five historical and five physical findings suggestive of IBS. Reference: (2) pages 1645-6. 1.7.2 Structural disorders 1.7.2.1 Diverticular disease 1. Describe the patho-anatomy of colonic diverticular disease. 2. Outline the medical and surgical treatment of diverticulitis. 3. List the five most common complications of diverticulitis. References: (2) pages 1646-9; (3) pages 749-50,783, & 910-20. 1.7.2.2 Volvulus 1. Name the two conditions necessary for development of sigmoid volvulus. 2. Compare and contrast cecal and sigmoid volvulus with regard to presentation and radiographic findings. 3. Outline the nonoperative management of volvulus. 4. State the indication for surgical intervention in volvulus. References: (2) pages 1649-53: (3) pages 751-2 & 940-4. 1.7.2.3 Vascular dysplasia (angiodysplasia) 1. Identify the two most common locations of angiodysplasia within the GI tract and their most common presenting signs. 2. Select the most accurate method of diagnosis. 3. Delineate the indications for subtotal colectomy.
References: (2) pages 1655-6; (3) pages 843-51 & 968-9.
References: (2) pages 1517-8; (3) pages 925-6.
1.6.5 Tumors
1.7.3 Inflammatory disorders
1. Describe the two categories of presentations for small-bowel tumors. 2. Choose the appropriate surgical management of small-bowel tumors. 3. Name several syndromes associated with neoplasms of the small intestine. Reference: (3) pages 802-7 & 869-73. 1.7 Large Bowel
1.7.3.1 Ulcerative colitis 1. Write the possible causesof ulcerative colitis. 2. Contrast the acute presentations of ulcerative colitis versus regional enteritis. 3. Indicate the association of carcinoma with ulcerative colitis. 4. Describe at least three extracolonic manifestations of ulcerative colitis. 5. State the efficacy of the following medications:
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a. Sulfasalazine b. Azathioprine c. Steroids d. Adrenocorticotropic hormone (ACTH) 6. Delineate complications of ulcerative colitis requiring surgical intervention. References: (2) pages 1653-5; (3) pages 927-40. 1.7.3.2 Radiation colitis 1. List five etiologic factors in radiation colitis. 2. Describe the principle clinical manifestations of radiation colitis. References: (2) pages 1656-7; (3) pages 880-4. 1.7.4.4 Pseudomembranous enterocolitis 1. Identify three classesof antibiotics which are most often associated with colitis. 2. Outline the management of pseudomembranous enterocolitis.
1.8.1.3 Hemorrhoids 1. Describe the pathophysiology of internal and external hemorrhoids. 2. State the two major complications of untreated hemorrhoids. 3. Compare and contrast at least five treatment options available. References: (2) pages 1661-2 & 1664; (3) pages 9625; (4) pages 704-7. 1.8.1.4 Rectal prolapse 1. Name five causesof rectal prolapse. 2. Identify the options for manual and surgical correction of rectal prolapse. References: (3) pages 961-2; (4) pages 712-5. 1.8.1.5 Foreign body
Reference: (2) page 1669.
1. Outline the usual progression of procedures employed in attempt(s) to remove rectal foreign bodies. 2. Name several problems associated with the removal of glass objects. 3. List four indications for inpatient management of rectal foreign bodies.
1.7.5 Tumors
References: (2) pages 1666-9; (4) pages 707-l 1.
1. Indicate the presentation, malignancy potential, and treatment of villous adenoma. 2. Describe the difference in the presentations of right- and left-sided colonic carcinomas. 3. Match six factors of metastasis with their effect on the decision for surgical resection.
1.8.1.6 Perianal warts 1. Indicate the relationship of perianal warts and sexual intercourse. 2. List several treatment options available.
Reference: (3) pages 751-2,921-5, & 944-58.
1.8.1.7 Abscesses
1.8 Rectum and Anus
1. Draw the four most common locations of perirectal abscesses. 2. Name the most common organism cultured from abscessesin this region. 3. Outline indications for admission.
References: (2) pages 1555-6; (3) pages 235-6 & 313. 1.7.4.5 Gay bowel syndrome 1. Define gay bowel syndrome.
1.8.1 Structural disorders 1.8.1.1 Anal fissure 1. Describe the historical features and classical appearance of fissure-in-ano. 2. List three common conditions that should be considered in the differential diagnosis of anal fissure. 3. Delineate the ED management of anal fissure.
References: (2) page 1690; (3) page 969.
References: (2) pages856-8 8z1665; (3) pages965-6. 1.8.2 Inflammatory disorders
References: (2) pages 1662-3; (3) pages 967-8.
1. Match at least four etiologies of proctitis with their presenting symptoms.
1.8.1.2 Anorectal fistula
Reference: (3 ) pages 844,883, 931, 961, & 968.
1. Describe the clinical presentation of fistula-inano. 2. Identify the four anatomic types of anal fistulae. 3. Cite the surgical management of each.
1.8.3 Tumors
References: (2) pages 1662-3; (3) pages 966-7.
Reference: (3) pages 956 & 968-70.
1. List four neoplasms that occur in the perianal region.
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1.9 Abdominal Wall/Peritoneum 1. Draw the borders of Hesselbach’s triangle. 2. Identify the two mechanisms that preserve the integrity of the inguinal canal. 3. Compare and contrast the presentations of incarcerated and strangulated hernias. 4. Name any clinical features that may differentiate
femoral, indirect inguinal, and direct inguinal hernias. 5. Outline the procedure for manual reduction of hernias. References: (2) page 1896; (3) pages 1134-48; (4) pages 691-5.
REFERENCES 1 American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic Emergency Medicine. Core content for emergency medicine. Ann Emerg Med. lVVl;u):!XO-34. 2. Rosen P, Barkin RM, Braen GR, et al., eds. Emergency meditine: concepts and clinical practice. 3rd ed. St Louis: MosbyYear Book; 1992.
*3. Sabiston DC, ed. Textbook of surgery: the biological basis of modern surgical practice. 14th ed. Philadelphia: Saunders; 1991. *4. Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 2nd ed. PhiIadelphia: Saunders; 1991.
*Books to be included in the resident briefcase.
$9.50 + .oo
0736~4679( 95)00083-6
Education
OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY MEDICINE RESIDENTS ON OFF-SERVICE ROTATIONS: SURGERY, PART 1 Captain Ronald T. Rakowski, MD, Major John M. Wightman, and Glenn C. Hamilton, MD, MSM, FACEM, FACP
MD, MA, FACEP,
Department of Emergency Medicine, Wright State University School of Medicine, Dayton, Ohio Reprint Address: Glenn C. Hamilton, MD, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401-0927
0 Abstract -This is the 34th article in a continuing series of objectives to direct emergency medicine resident experiences on off-service rotations. Abdominal and gastrointestinal complaints are common problems in the emergency department and often lead to consultation with a surgeon. Becausean understanding of the principles of surgical diagnosis and treatment is an essential component of the practice of emergency medicine, residents rotating on surgical services require specific goals and objectives to emphasize early patient assessment,identification of the possible need for surgery, and a basic understanding of definitive management.
Utilization of these goals and objectives will allow both resident and preceptor to identify those entities that will best prepare the future emergency physician. As rotating emergency medicine residents acquire increasing knowledge in fundamental surgical principles, they should be given increasing clinical responsibilities and become members of the surgical team. CONTENTS The numbering system in this article corresponds to topics found in the Core Content for Emergency Medicine ( 1).
0 Keywords -education, medical, graduate; emergency medicine; objectives; residency; surgery
1.O Abdominal and Gastrointestinal Disorders 1.1 Esophagus 1.1.1 Motor abnormalities 1.1.1.1 Esophageal spasm 1.1.1.2 Achalasia 1.1.2 Structural disorders 1.1.2.1 Varices 1.1.2.2 Rupture (Boerhaave’s syndrome) 1.1.2.3 Perforation 1.1.2.4 Tears (Mallory-Weiss syndrome) 1.1.2.6 Foreign body 1.1.2.8 Diverticula 1.1.2.9 Hiatal hernia 1.1.2.10 Webs, strictures, stenosis 1.1.3 Inflammatory disorders
INTRODUCTION This is the 34th article in a series of goals and objectives that can enhance the learning process of residents on off-service rotations. It is the first of three parts covering essential aspects of surgical practice that may be applied in the emergency department (ED). The primary focus is on the pathophysiology of the gastrointestinal system, with emphasis on the assessment,identification, and initial management of the acute surgical patient. Furthermore, knowledge of the eventual surgical treatment is necessary when either rotating on a surgery service or discussing an ED casewith a consultant. 687
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1.1.3.1 Reflux esophagitis 1.1.3.2 Caustic injury 1.15 Tumors 1.2 Liver 1.2.2 Biliary obstructive cirrhosis 1.2.4 Tumors of the liver 1.2.5 Abscess 1.3 Gall Bladder and Biliary Tract 1.3.1 Cholecystitis 1.3.2 Cholangitis 1.3.3 Cholelithiasis and choledocholithiasis 1.3.4 Gallstone ileus 1.35 Tumors 1.4 Pancreas 1.4.1 Inflammatory 1.4.1.1 Acute pancreatitis 1.4.1.2 Chronic pancreatitis 1.4.1.3 Pseudocyst 1.4.1.4 Pancreatic insufficiency 1.4.2 Tumors 1.4.2.1 Islet cell tumors 1.4.2.2 Carcinoma 1.5 Stomach 1.5.1 Structural lesions 1.5.1.1 v01vu1us 1.5.1.2 Foreign bodies 1.5.1.3 Rupture 1.5.1.4 Gastric outlet obstruction 1.5.2 Inflammatory disorders 1.5.3 Peptic ulcer disease(PUD) 1.5.3.1 Duodenal ulcer 1.5.3.2 Gastric ulcer 1.5.3.3 Acute gastrointestinal hemorrhage 1.5.4 Tumors 1.6 Small Bowel 1.6.1 Motor abnormalities 1.6.1.1 Obstruction 1.6.1.1.1 Mechanical 1.6.1.1.2 Adynamic 1.6.1.2 Pseudo-obstruction 1.6.2 Structural disorders 1.6.2.1 Mesenteric vascular disease 1.6.2.2 Aorto-enteric fistula 1.6.2.3 Malabsorption 1.6.3 Inflammatory disorders 1.6.3.1 Acute appendicitis 1.6.3.2 Regional enteritis 1.6.5 Tumors 1.7 Large Bowel 1.7.1 Motor abnormalities 1.7.1.1 Irritable bowel syndrome (IBS) 1.7.2 Structural disorders 1.7.2.1 Diverticular disease 1.7.2.2 Volvulus
1.7.2.3 Vascular dysplasia (angiodysplasia) 1.7.3 Inflammatory disorders 1.7.3.1 Ulcerative colitis 1.7.3.2 Radiation colitis 1.7.4.4 Pseudomembranous enterocolitis 1.7.4.5 Gay bowel syndrome 1.7.5 Tumors 1.8 Rectum and Anus 1.8.1 Structural disorders 1.8.1.1 Anal fissure 1.8.1.2 Anorectal fistula 1.8.1.3 Hemorrhoids 1.8.1.4 Rectal prolapse 1.8.1.5 Foreign body 1.8.1.6 Perianal warts 1.8.1.7 Abscesses 1.8.2 Inflammatory disorders 1.8.3 Tumors 1.9 Abdominal Wall/Peritoneum
GOALS AND OBJECTIVES 1.O Abdominal and Gastrointestinal Disorders 1.1 Esophagus 1.1.1 Motor abnormalities 1.1.1.1 Esophageal spasm 1. Identify the most typical symptoms and signs of diffuse esophageal spasm (DES). 2. Outline the medical and surgical management of DES. References: (2) page 1590; ( 3) pages 670-3. 1.1.1.2 Achalasia 1. State the classic symptom triad of achalasia. 2. Delineate the potential pulmonary complications of achalasia. 3. Outline the diagnostic approach to a patient with suspected achalasia. 4. Select the two most common surgical treatments for achalasia. References: (2) page 1586; (3) pages 666-70. 1.1.2 Structural disorders 1.1.2.1 Varices 1. Match presinusoidal and intrahepatic classifications of variceal etiology to their principal causes. 2. List at least five methods of intervention for acute variceal hemorrhage. 3. Delineate at least three options available for pre-
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vention of recurrent upper gastrointestinal bleeding due to esophageal varices. References: (2)pages 1516& 1527; (3)pages 1019-27. 1.1.2.2 Rupture (Boerhaave’s syndrome)
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3. Draw the three sites of esophageal diverticula. 4. Contrast the surgical management of diverticula at each of these three sites. Reference: (3) pages 678-81. 1.1.2.9 Hiatal hernia
1. Describe the presentation of a patient with Boerhaave’s syndrome. 2. Identify the most common radiographic features of a ruptured esophagus. 3. Contrast the surgical management of early versus late presentations of rupture of the thoracic esophagus.
1. Identify the two types of hiatal hernia. 2. Describe the potentially life-threatening presentations of each type. 3. List the indications for surgical repair of Type-II hiatal hernia.
References: (2) pages459-63 & 1591; (3) pages701-4.
1.1.2.10 Webs, strictures, stenosis
1.1.2.3 Perforation
1. Indicate the level at which esophageal webs classically occur and describe the histopathology at this location. 2. Outline the medical and surgical management of reflux-induced strictures of the esophagus.
1. List at least eight etiologies of esophageal perforation. 2. Describe Hamman’s sign. 3. Contrast the surgical management of cervical versus thoracic perforation of the esophagus.
Reference: ( 3) pages 704-8.
Reference: (3) pages 681-2 & 713-4.
References: (2) pages 459-63; (3) pages 701-4.
1.1.3 Inflammatory disorders
1.1.2.4 Tears (Mallory-Weiss syndrome)
1.1.3.1 Reflux esophagitis
1. Define the Mallory-Weiss syndrome. 2. Outline the clinical setting, course, and management of a patient with an emetogenic mucosal laceration. References: (2) page 1516; (3) pages 682 &781. 1.1.2.6 Foreign body I. Name the location where the majority of foreign bodies lodge in the esophagus. 2. Identify radiographic features of several foreign bodies listed on plain neck or chest radiographs. 3. State the most life-threatening complication of not removing an esophageal foreign body. 4. List three medical therapies available in the management of esophageal foreign bodies. 5. Describe the complications associated with failure to identify and remove a button battery. 6. Contrast the management of sharp foreign bodies versus impacted food boluses. References: (2) pages 328-31; (3) pages 1204-5; (4) pages 629-40. 1.1.2.8 Diverticula 1. Name the two most common pathophysiological mechanisms leading to diverticula of the esophagus. 2. Describe the classic presentation of a patient with Zenker’s diverticulum.
1. Describe the symptoms, signs, and utility of several tests for diagnosis of gastro-esophageal reflux (GER). 2. Outline the prophylactic and medical management of GER. 3. List the indications for surgical intervention in complicated GER. 4. Differentiate the three most common surgical options for prevention of GER. References: (2) pages 1591-2; (3) pages 708-13. 1.1.3.2 Caustic injury 1. Define the patient population that typically suffers from caustic esophageal injury. 2. Select the four characteristics of an ingested agent that determine the site and severity of injury. 3. Contrast the histopathological difference of acid versus alkali injury. 4. Choose the patient presentation suggestive of mediastinal, intrapleural, or intraperitoneal perforation. 5. List the indications and contraindications of diagnostic modalities used early and late to determine the extent of injury. 6. Identify the early and late complications of caustic esophagitis. 7. Outline the immediate medical and late surgical management of corrosive esophageal trauma. References: (2) pages 2553-4; (3) pages ?15-21”
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1.1.5 Tumors
1.3 Gall Bladder and Biliary Tract
1. Identify five factors that may lead to development of esophageal carcinoma. 2. Describe the presentation of a patient with an esophageal tumor. 3. Indicate the efficacy of esophography as a screening tool. 4. List several definitive and palliative approaches to therapy.
1.3.1 Cholecystitis
Reference: (3) pages 689-700. 1.2 Liver 1.2.2 Biliary obstructive cirrhosis 1. List the three pathological criteria for the diagnosis of cirrhosis. 2. State the classic symptom triad of cirrhosis. 3. Explain the utility of the prothrombin time (PT) as a screening and prognostic tool in patients with cirrhosis. 4. Select additional laboratory tests useful in the management of patients with cirrhosis. 5. Cite the importance of liver biopsy in the initial evaluation of a patient with suspected cirrhosis. 6. Review the clinical application of Child’s classification. 7. List at least three major complications of cirrhosis. References: (2) pages 1608-9 & 2215-6; (3) pages 1015-9. 1.2.4 Tumors of the liver 1. Describe the etiology, presenting symptoms and signs, diagnostic tests, and treatment of each of the following primary tumors of the liver: a. Benign adenoma b. Hepatocellular carcinoma c. Cholangiocarcinoma d. Hepatoblastoma 2. List, in order of frequency, the primary sites of common hepatic metastases. 3. Outline the contraindications to major hepatic resection for tumors. References: (2) page 1614; (3) pages 999-1012. .2.5 Abscess 1. Identify the two primary causesof hepatic abscess and the most important complications of each. 2. List five conditions that predispose to abscessformation. 3. Select the surgical treatment and appropriate antibiotic usage for hepatic abscesses. References: (2) pages 161l-3; (3) pages 992-9.
1. Describe the clinical presentation of acute cholecystitis. 2. List the differential diagnoses for right upperquadrant abdominal pain. 3. Indicate the efficacy of laboratory tests and ultrasonography in the diagnosis of cholecystitis. 4. Name the three bacterial organisms most commonly cultured from infected bile. References: (2) pages 1616-7; (3) pages 747-8 & 1050-63. 1.3.2 Cholangitis 1. Contrast Charcot’s triad and Reynold’s pentad. 2. Outline the key elements of cholangitis diagnosis. 3. Identify any important differences between acute and toxic cholangitis . References: (2) pages 1618-9; (3) pages 1048-9 & 1064-70. 1.3.3 Cholelithiasis and choledocholithiasis 1. Select factors associated with gall stone formation. 2. Cite situations for utilization of intra-operative cholangiography. References: (2) pages 1618-9; (3) pages 1045-6 & 1057-63. 1.3.4 Gallstone ileus 1. Describe the historical features and presenting symptoms and signs of gallstone ileus. 2. Identify the most and least frequent site of obstruction. Reference: (3) pages 1071-2. 1.3.5 Tumors 1. Cite at least five factors associated with development of gallbladder carcinoma. 2. Describe the symptoms and signs that should lead to suspicion of gallbladder tumor. References:(2) page 1619; (3) pages 1047-8 & 1073-5. 1.4 Pancreas 1.4.1 Inflammatory 1.4.1.1 Acute pancreatitis 1. Review the Marseilles Classification. 2. Outline Ranson’s prognostic criteria. 3. List at least eight etiologies of pancreatitis.
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4. Indicate the efficacy of serum amylase and lipase in the diagnosis of acute pancreatitis. 5. Define a sentinel loop. 6. Outline the medical management of acute pancreatitis. 7. Discuss the use of peritoneal lavage in the treatment of pancreatitis. 8. Delineate the indications for surgical intervention in acute pancreatitis. 9. Indicate when pancreatic abscess should be suspetted . References: (2) pages 1619-22; (3) pages 748 & 1080-8.
5. Describe the WDHA syndrome. References: (2) pages 1623-4; (3) pages 1098-1103. 1.4.2.2 Carcinoma 1. Select risk factors associated with pancreatic carcinoma. 2. List the three most common presenting symptoms of pancreatic carcinoma. 3. Define Courvoisier’s law. 4. Draw the major stagesof Whipple’s procedure. References: (2) page 1623; (3) pages 1093-S. 1.5 Stomach
1.4.1.2 Chronic pancreatitis
1.5.1 Structural lesions
1. State the classic symptom triad of chronic pancreatitis. 2. List three etiologies of chronic pancreatitis. 3. Contrast the differences between chronic pancreatitis and relapsing acute pancreatitis. 4. State the diagnostic utility of available tests. 5. Identify at least four surgical options in the treatment of chronic pancreatitis.
1.5.1.1 v01vu1us
References: (2) page 1622; (3) pages 748 & 1088-90. 1.4.1.3 Pseudocyst 1. Indicate when pancreatic pseudocyst should be suspected. 2. Name the preferred method of diagnosis. 3. List four complications of untreated pseudocyst. 4. Delineate the indications for surgical drainage or resection. References: (2) pages 1622-3; (3) pages 1090-3. 1.4.1.4 Pancreatic insufficiency 1. List the most common etiologies of pancreatic insufficiency. 2. Name three findings that suggest pancreatic insufficiency. 3. Describe the secretin test. 4. Outline available treatments. Reference: (3) page 877-8. 1.4.2 Tumors 1.4.2.1 Islet cell tumors 1. Name the two common islet-cell tumors. 2. Describe the most common methods used for diagnosis. 3. Define Whipple’s triad. 4. Contrast medical and surgical management of islet-cell tumors.
1. Describe the most typical symptoms and signs of gastric volvulus. 2. Name the procedure that may be utilized in the ED for presumptive diagnosis. Reference: (2) pages 1420-I. 1.5.1.2 Foreign bodies 1. Choose at least three situations in which a foreign body should be removed (endoscopically or surgically) once it has passedthrough the esophagus. 2. Outline the appropriate follow up for patients with foreign bodies in the stomach or small bowel not requiring extraction. Reference: (2) pages 330-2. 1.5. I .3 Rupture 1. Describe the symptoms, signs, and utility of several tests for presumptive diagnosis of acute gastric perforation. 2. Describe the symptoms, signs, and utility of several tests for presumptive diagnosis of acute gastric penetration. Reference: (3) pages 747,769, & 771. 1.5.1.4 Gastric outlet obstruction 1. Contrast the management of gastric outlet obstruction due to gastric ulcer, intraluminal tumor, or extrinsic duodenal compression. Reference: ( 3 ) pages 769-70,783,790- 1, & 807-l 3. 1.5.2 Inflammatory disorders 1. Identify the three principal mechanisms by which erosive gastritis may occur. 2. Outline the prophylactic and medical management of acute stress gastritis.
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3. Contrast the surgical options when the etiology of the gastritis is or is not due to caustic alkali ingestion. References: (2) page 1516; (3) pages 779-780 & 797-801. 1.5.3 Peptic ulcer disease(PUD) 1.5.3.1 Duodenal ulcer 1. State the diagnostic accuracy of radiographic studies and side-looking fiberoptic endoscopy in diagnosis of PUD. 2. Identify the three primary indications for gastric analysis in patients with PUD. 3. Describe the initial medical management of nonbleeding PUD. 4. List the four indications for immediate or elective surgical treatment of duodenal ulcer. References: (2) pages 1525-6; (3) pages 762-3 & 765-70. 1.5.3.2 Gastric ulcer 1. Name the most important additional consideration when determining the etiology of gastric, as opposed to duodenal, ulcer and the accuracy of radiographic studies in its diagnosis. 2. Identify at least four surgical options for intractable gastric ulcers. 3. List the four most common late complications of these operations. Reference: (3) pages 763-5,770-l,
& 775-8.
1.5.3.3 Acute gastrointestinal hemorrhage 1. List the six most common causes of upper gastrointestinal (UGI) hemorrhage. 2. State the amount of blood loss required to produce orthostatic changes in a young adult’s vital signs. 3. Discuss the use of blood products in the emergency management of GI bleeding. Reference: (2) pages 1515, 1519, & 1525.
1.6.1 Motor abnormalities 1.6.1.1 Obstruction 1.6.1.1.1 Mechanical 1. Outline the causes of small bowel obstruction (SBO). 2. Identify the origin of gas that distends the bowel proximal to the obstruction. 3. Characterize fluid and electrolyte losses by site of obstruction. 4. Contrast simple mechanical obstruction versus strangulation. 5. Describe the radiographic features of SBO and large bowel obstruction. 6. Compare and contrast the use of nasogastric, Levin, and Miller-Abbott tubes in the initial management of SBO. 7. Discuss potential complications and the timing of surgical intervention for SBO. References: (2) pages 1633-7; (3) pages750 & 835-42. 1.6.1.1.2 Adynamic 1. List three causesof paralytic ileus. 2. Contrast features on plain radiographs that may help distinguish paralytic ileus from SBO. 3. Outline the management of adynamic ileus. References: (2) pages 1636-7; (3) pages 750-1, 835, & 841-2. 1.6.1.2 Pseudo-obstruction 1. Identify the etiology of idiopathic intestinal pseudo-obstruction. 2. Name the diagnostic modality used to distinguish pseudo-obstruction from true mechanical obstruction. References: (2) page 1637; (3) pages 835-6. 1.6.2 Structural disorders 1.6.2.1 Mesenteric vascular disease
1. Describe the most common symptoms and signs that would lead to suspicion of gastric tumor. 2. Match the preferred treatment to each of the following: a. Benign tumor b . Lymphoma c. Carcinoma
1. Explain how bowel activity affects its blood flow. 2. Name the two most common findings in patients with chronic intestinal ischemia. 3. State the diagnostic triad of acute superior mesenteric artery occlusion and contrast it to the presentations of thrombosis and embolus. 4. Choose the appropriate surgical management of mesenteric artery occlusion. 5. Define nonorganic intestinal infarction.
Reference: (3) pages 787-97 & 814-27.
References: (2) pages 1638-41; (3) pages 1650-6.
1.6 Small Bowel
1.6.2.2 Aorto-enteric fistula (AEF)
1.5.4 Tumors
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1. Name the most common predisposing condition in the development of AEF. 2. Delineate the emergency management of AEF. Reference: (3) pages 1571-2. 1.6.2.3 Malabsorption 1. ldentify surgical conditions associated with malabsorption. 2. Outline the clinical manifestations of malabsorption. 3. Describe the most useful diagnostic tests for malabsorption, Reference: (3) pages 873-80. 1.6.3 Inflammatory disorders 1.6.3.1 Acute appendicitis 1. Describe the classical presentation of acute appendicitis. 2. State the efficacy of laboratory tests and plain radiographic studies in the diagnosis of appendicitis. 3. Name seven common conditions that may be clinically similar to appendicitis. 4. Define McBurney’s point and Rovsing’s sign. 5. Contrast the features of appendicitis that may differ in children, young women, pregnancy, and the elderly. References: (2) pages 1627-33; (3) pages 748-9, & 884-98. 1.6.3.2 Regional enteritis 1. Describe the characteristic patient and clinical manifestations of Crohn’s disease. 2. List several extra-intestinal manifestations of Crohn’s disease. 3. Name five common conditions in the differential diagnosis of regional enteritis. 4. Outline the medical, surgical, and nutritional management of regional enteritis.
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1.7.1 Motor abnormalities 1.7.1.1 Irritable bowel syndrome (IBS) 1. Define the patient population that typically suffers from IBS. 2. List five historical and five physical findings suggestive of IBS. Reference: (2) pages 1645-6. 1.7.2 Structural disorders 1.7.2.1 Diverticular disease 1. Describe the patho-anatomy of colonic diverticular disease. 2. Outline the medical and surgical treatment of diverticulitis. 3. List the five most common complications of diverticulitis. References: (2) pages 1646-9; (3) pages 749-50,783, & 910-20. 1.7.2.2 Volvulus 1. Name the two conditions necessary for development of sigmoid volvulus. 2. Compare and contrast cecal and sigmoid volvulus with regard to presentation and radiographic findings. 3. Outline the nonoperative management of volvulus. 4. State the indication for surgical intervention in volvulus. References: (2) pages 1649-53: (3) pages 751-2 & 940-4. 1.7.2.3 Vascular dysplasia (angiodysplasia) 1. Identify the two most common locations of angiodysplasia within the GI tract and their most common presenting signs. 2. Select the most accurate method of diagnosis. 3. Delineate the indications for subtotal colectomy.
References: (2) pages 1655-6; (3) pages 843-51 & 968-9.
References: (2) pages 1517-8; (3) pages 925-6.
1.6.5 Tumors
1.7.3 Inflammatory disorders
1. Describe the two categories of presentations for small-bowel tumors. 2. Choose the appropriate surgical management of small-bowel tumors. 3. Name several syndromes associated with neoplasms of the small intestine. Reference: (3) pages 802-7 & 869-73. 1.7 Large Bowel
1.7.3.1 Ulcerative colitis 1. Write the possible causesof ulcerative colitis. 2. Contrast the acute presentations of ulcerative colitis versus regional enteritis. 3. Indicate the association of carcinoma with ulcerative colitis. 4. Describe at least three extracolonic manifestations of ulcerative colitis. 5. State the efficacy of the following medications:
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a. Sulfasalazine b. Azathioprine c. Steroids d. Adrenocorticotropic hormone (ACTH) 6. Delineate complications of ulcerative colitis requiring surgical intervention. References: (2) pages 1653-5; (3) pages 927-40. 1.7.3.2 Radiation colitis 1. List five etiologic factors in radiation colitis. 2. Describe the principle clinical manifestations of radiation colitis. References: (2) pages 1656-7; (3) pages 880-4. 1.7.4.4 Pseudomembranous enterocolitis 1. Identify three classesof antibiotics which are most often associated with colitis. 2. Outline the management of pseudomembranous enterocolitis.
1.8.1.3 Hemorrhoids 1. Describe the pathophysiology of internal and external hemorrhoids. 2. State the two major complications of untreated hemorrhoids. 3. Compare and contrast at least five treatment options available. References: (2) pages 1661-2 & 1664; (3) pages 9625; (4) pages 704-7. 1.8.1.4 Rectal prolapse 1. Name five causesof rectal prolapse. 2. Identify the options for manual and surgical correction of rectal prolapse. References: (3) pages 961-2; (4) pages 712-5. 1.8.1.5 Foreign body
Reference: (2) page 1669.
1. Outline the usual progression of procedures employed in attempt(s) to remove rectal foreign bodies. 2. Name several problems associated with the removal of glass objects. 3. List four indications for inpatient management of rectal foreign bodies.
1.7.5 Tumors
References: (2) pages 1666-9; (4) pages 707-l 1.
1. Indicate the presentation, malignancy potential, and treatment of villous adenoma. 2. Describe the difference in the presentations of right- and left-sided colonic carcinomas. 3. Match six factors of metastasis with their effect on the decision for surgical resection.
1.8.1.6 Perianal warts 1. Indicate the relationship of perianal warts and sexual intercourse. 2. List several treatment options available.
Reference: (3) pages 751-2,921-5, & 944-58.
1.8.1.7 Abscesses
1.8 Rectum and Anus
1. Draw the four most common locations of perirectal abscesses. 2. Name the most common organism cultured from abscessesin this region. 3. Outline indications for admission.
References: (2) pages 1555-6; (3) pages 235-6 & 313. 1.7.4.5 Gay bowel syndrome 1. Define gay bowel syndrome.
1.8.1 Structural disorders 1.8.1.1 Anal fissure 1. Describe the historical features and classical appearance of fissure-in-ano. 2. List three common conditions that should be considered in the differential diagnosis of anal fissure. 3. Delineate the ED management of anal fissure.
References: (2) page 1690; (3) page 969.
References: (2) pages856-8 8z1665; (3) pages965-6. 1.8.2 Inflammatory disorders
References: (2) pages 1662-3; (3) pages 967-8.
1. Match at least four etiologies of proctitis with their presenting symptoms.
1.8.1.2 Anorectal fistula
Reference: (3 ) pages 844,883, 931, 961, & 968.
1. Describe the clinical presentation of fistula-inano. 2. Identify the four anatomic types of anal fistulae. 3. Cite the surgical management of each.
1.8.3 Tumors
References: (2) pages 1662-3; (3) pages 966-7.
Reference: (3) pages 956 & 968-70.
1. List four neoplasms that occur in the perianal region.
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1.9 Abdominal Wall/Peritoneum 1. Draw the borders of Hesselbach’s triangle. 2. Identify the two mechanisms that preserve the integrity of the inguinal canal. 3. Compare and contrast the presentations of incarcerated and strangulated hernias. 4. Name any clinical features that may differentiate
femoral, indirect inguinal, and direct inguinal hernias. 5. Outline the procedure for manual reduction of hernias. References: (2) page 1896; (3) pages 1134-48; (4) pages 691-5.
REFERENCES 1 American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic Emergency Medicine. Core content for emergency medicine. Ann Emerg Med. lVVl;u):!XO-34. 2. Rosen P, Barkin RM, Braen GR, et al., eds. Emergency meditine: concepts and clinical practice. 3rd ed. St Louis: MosbyYear Book; 1992.
*3. Sabiston DC, ed. Textbook of surgery: the biological basis of modern surgical practice. 14th ed. Philadelphia: Saunders; 1991. *4. Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 2nd ed. PhiIadelphia: Saunders; 1991.
*Books to be included in the resident briefcase.