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22 Enterocutaneous Fistulas
69
Second the relationship between enteral feeds (patient
driven or otherwise) and the volume of output needs to be
established. To do this, sepsis should be resolved, and volume should be accurately captured using an ostomy bag. If
the volume of efuent does not change with enteral feeding
(does not go down when enteral feeding is held and does not
go up with goal enteral feeding), then enteral feeding should
continue. Otherwise, enteral feeding should be limited as
the harms related to high-output will not give the best chance
for stula closure (low-output). Total parenteral nutrition
must therefore be used to provide nutritional support.
Octreotide may help reduce output from high volume stulas although the evidence is mixed. Similarly, proton pump
inhibitors should be used to reduce gastric volume and acidity and a motility agent may be prescribed such as loperamide or diphenoxylate.
The management of nutrition includes avoiding dehydration (this may require IV uid resuscitation and hospitalization) and the management of electrolyte abnormalities. This
may require frequent labs initially and nutrition labs should
be obtained monthly to track progress.
Infection/Sepsis Control
As part of the initial diagnosis, most patients present with an
infection, either local or systemic. Source control with drains
and IV antibiotics are key in the acute management of ECFs.
In the early phases, this may require frequent CT scans and
numerous abdominal drains depending on the character of
the stula and the underlying causes.
Table 22.3 Favorable and unfavorable stula characteristics
Factor Favorable Unfavorable
Anatomy Pancreatic
Colonic/rectal
Distal small bowel
Sepsis Absent Chronic
Underlying cause Appendicitis
Diverticulitis
Pancreatitis
Nutritional status Good Bad
Fistula Long tract
Low output
IBD inammatory bowel disease
Duodenal
Proximal small bowel
Abscesses
IBD
Radiation
Malignancy
Foreign body (mesh, stitch)
Short tract, epithelialized
High output
(>500mL/24h)
period fraught with morbidity and mortality and should be
avoided if possible. It is in this period that the stula is
maturing, and numerous factors work against an optimal outcome—malnutrition and infection. Patients who cannot have
an early operation should undergo the SNAP approach:
Sepsis, Nutrition, Anatomy, Plan. As stated above, sepsis
should be controlled early and denitively with drains and
efuent management. Nutrition should be optimized, ideally
enterally. Imaging should be used to characterize the stula
as outlined in Table 22.1. Finally, a plan should be established. This should be multidisciplinary and involve a surgeon who will follow the patient for his or her entire course.
Finally, good patient communication is key in both setting
expectations and clear communication regarding rationale
for management decisions.
Denitive Management
The ideal outcome of an ECF is spontaneous closure. Several
stula and patient factors either favor this outcome or work
against this outcome. Overall, spontaneous closure will
occur in 20–70% of patients. This large range is related to the
difculty in studying the diverse patient population with a
wide range of stula characteristics, Table22.3. Spontaneous
closure, if it will occur, typically happens within the rst 2
months of presentation.
Operative Timing
The ideal time to operate on an ECF is early (<10days after
discovery) or late (6–12months). The early group represents
a specic cohort of patients who develop an early postoperative complication such as missed enterotomy or anastomotic leak and would benet from early operative repair. The
intermediate period, 10days to 6months, represents a time-
Operative Technique
The mainstay of ECF take-downs is resection, restoration of
intestinal continuity, avoidance of enterotomy, and repair of
hernias (if present). Prior to surgery, nutrition optimization
must be conrmed and infection must be cleared. As much as
possible, patient comorbidities should be optimized.
A complete adhesiolysis should take place from the ligament of Treitz to the Terminal Ileum. The stula should be
identied and resected, following restoration of intestinal
continuity. This operation can be tedious and consideration
should be given for the duration or surgery as well as available assistance.
Outcomes
Post-operatively, patients require close monitoring for anastomotic leak and breakdown of repair. Over 80% of patients who
undergo surgery for ECF remain stula free. There is a remarkably high rate of recurrence (up to 20%) which is related to
70
P. Mu rph y
patient factors (nutrition), surgical technique (enterotomies,
lysis) and operative timing (earlier operations have higher
recurrence). In general, outcomes are better for stulas related
to inammatory bowel disease versus those arising from irradiation or mesh complications. Even with surgical repair, ECF
recurrence impacts roughly 15–20% of patients highlighting
the chronic, resilient nature of these challenging wounds.
Conclusions
Enterocutaneous stulas (ECFs) remain a challenging clinical entity, demanding a comprehensive and nuanced approach
to management. The complexity of ECFs necessitates a multidisciplinary team and ideally a standardized institutional
approach. Despite advances in management strategies, ECFs
continue to carry signicant morbidity and mortality risks.
The high recurrence rate even after surgical intervention
underscores the chronic nature of this condition and the need
for long-term follow-up and care.
Bibliography
Dubose JJ, Lundy JB.Enterocutaneous stulas in the setting of trauma
and critical illness. Clin Colon Rectal Surg. 2010;23(3):182–9.
https://doi.org/10.1055/s- 0030- 1262986. PMID: 21886468;
PMCID: PMC2967318
Evenson AR, Fischer JE. Current management of enterocutane-
ous stula. J Gastrointest Surg. 2006;10(3):455–64. https://doi.
org/10.1016/j.gassur.2005.08.001.
Fischer PE, Fabian TC, Magnotti LJ, Schroeppel TJ, Bee TK, Maish GO
3rd, Savage SA, Laing AE, Barker AB, Croce MA.A ten-year review
of enterocutaneous stulas after laparotomy for trauma. J Trauma.
2009;67(5):924–8. https://doi.org/10.1097/TA.0b013e3181ad5463.
Gribovskaja-Rupp I, Melton GB. Enterocutaneous stula: proven
strategies and updates. Clin Colon Rectal Surg. 2016;29(2):130–7.
https://doi.org/10.1055/s- 0036- 1580732. PMID: 27247538;
PMCID: PMC4882173
Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor
AJ. An 11-year experience of enterocutaneous stula. Br J Surg.
2004;91(12):1646–51. https://doi.org/10.1002/bjs.4788.
Diverticulitis
JohannaLou andKahyunYoon-Flannery
23
Concept
Recurrent uncomplicated episodes can be managed effectively with resection based on patient preference. A thorough
history and physical exam is essential to accurate diagnosis
and management of diverticulitis.
Way Question May BeAsked?
A 48-year-old woman presents to your outpatient surgical
ofce after three episodes of left lower quadrant pain in the
past year. She was admitted to the hospital during her rst
two episodes and reports she was diagnosed with diverticulitis after receiving a CT scan. Her last episode was 2months
ago and was managed with outpatient antibiotics. Currently,
she is pain-free. She works for the United Nations, travels
frequently, and is interested in surgical options.
How toAnswer?
Full History
• Location and quality of pain
• Prior episodes: how many, severity, response to medical
management
• Changes in bowel habits: diarrhea, partially bloody or
mucousy, more typical or ischemic colitis or inammatory bowel disease
• Recent travel or treatment with antibiotics
• Risk factors for ischemia
• Timing and ndings of last colonoscopy
• Unexplained weight loss
• Family history of malignancy
J. Lou · K. Yoon-Flannery (*)
Cooper University Hospital, Camden, NJ, USA
e-mail: lou-johanna@CooperHealth.edu;
Yoon-Flannery-Kay@CooperHealth.edu
Full Physical Exam
• Fever, chills, malaise
• Abdominal pain: localized to left lower quadrant
• Prior surgical scars
Diagnostic Tests
• Labs: leukocytosis, LFT, serum lactate, coagulation prole, CRP
• Urinalysis
• Pregnancy test in females
• CT scan with IV and PO contrast: assess inammation,
abscesses and underlying strictures
• Colonoscopy to exclude mucosal inammation and
colorectal cancer
Uncomplicated vs. Complicated Diverticular Disease
• Uncomplicated: inammation limited to colon
• Complicated: inammation extends into local structures
or peritoneum
• Modied Hinchey Classication by Wasvary
– Stage 0: mild clinical diverticulitis
– Stage Ia: Colonic wall thickening or conned pericolic
inammation
– Stage Ib: Localized pericolic or mesocolic abscess
(<5cm)
– Stage II: Pelvic, distant intra abdominal or retroperito-
neal abscess
– Stage III: Generalized purulent peritonitis
– Stage IV: Generalized feculent peritonitis
Surgical Treatment
• Uncomplicated diverticulitis
– Bowel rest with IVF and gradual progression to low-
residue diet
– IV antibiotics with gram-negative and anaerobic cov-
erage for 4-days
– Re-image in 5days if symptoms do not improve
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_23
71
72
J. Lou and K. Yoon-Flannery
• Complicated diverticulitis with abscess
– Stable and ≤3cm in size can be managed with outpa-
tient antibiotics
– If >3 cm and unresponsive to antibiotics, should be
drained percutaneously
– Failure of nonoperative drainage is 15–32%
– In which case the recommended treatment is surgical
drainage, colectomy, primary anastomosis with proxi-
mal diversion
• Complicated diverticulitis with perforation or peritonitis
– Emergency operation with two options depending on
clinical status
Resection with primary anastomosis ± proximal
diversion
Resection with proximal end colostomy and rectal
stump (Hartmann’s)
– Position in modied lithotomy, arms tucked
– Midline incision and evacuate any free uid
– Mobilize the sigmoid medial and incise the white line
of Toldt from the rectosigmoid junction to the splenic
exure
– Medialize the sigmoid colon to identify the left ureter
– Divide the colon just proximal to the disease segment
with a GIA stapler and distally at the sacral
promontory
– Examine the rectum for obstructing masses—if pres-
ent, create a mucus stula
– If creating primary anastomosis, use EEA stapler and
perform leak test with exible sigmoidoscopy
Anastomosis should sit at upper aspect of rectum
– If Hartmann’s procedure, oversew rectal staple line
and place marking sutures
Bring up end colostomy
• Elective laparoscopic sigmoidectomy should be considered
if impacts lifestyle, resolution of complicated disease with
abscess, smoldering disease, or immunocompromised
– Perform colonoscopy at least 6weeks after acute epi-
sode to assess inammation and rule out underlying
malignancy
– Position in lithotomy, arms tucked
– Can begin laparoscopically with a 12 mm umbilical
port and three 5mm assist ports (two right-sided work-
ing ports, one left-sided assist port)
– Place inferior mesenteric artery (IMA) on stretch,
incise peritoneum underneath, and identify left ureter
from medial perspective—can use pre-operative stents
– Perform high ligation of IMA
– Lateral mobilization of descending colon to the splenic
exure
Assure adequate proximal mobilization for the
anastomosis
Can mobilize splenic exure or ligate inferior mesenteric vein (IMV) at level of the ligament of Treitz
– Identify soft colon proximal to area of diverticulitis
and top of rectum (splaying of taenia)
– Thin out the rectal mesentery and divide rectum
Avoid midline extraction of specimen
– Use EEA stapler to create the anastomosis and per-
form leak test with exible sigmoidoscopy
Common Curveballs
• Underlying malignancy
• History of ulcerative colitis or Crohn’s disease
• Diverticular bleeding
• Redundant sigmoid colon presenting with suprapubic or
right-sided pain
• Colovesicular or colouterine stula
• Patient with percutaneous drainage of abscess develops
worsening symptoms
• Ureteral injury
• Rectal stump leak
• IR drainage will fail
Clean Kills
• Missing the diagnosis
• Segmental resection in patient with UC or Crohn’s
• Not performing colonoscopy prior to elective resection
• Performing anastomosis in a clinically unstable patient or
patient decompensating during the case
Summary
Uncomplicated acute diverticulitis presents with left
lower quadrant pain, fever, and leukocytosis, with a
quarter of patients developing complicated disease.
Complicated diverticulitis encompasses a wide spectrum
of clinical presentations, from localized abscesses that
can be percutaneously drained to peritonitis that
requires emergency surgery. Uncomplicated and complicated diverticulitis with clinical improvement with
antibiotic treatment can be assessed for an elective
sigmoidectomy.
Adult Appendicitis
JohannaLou andKahyunYoon-Flannery
24
Concept
The underlying etiology of acute appendicitis is due to luminal obstruction, leading to bacterial proliferation. About
400,000 cases are diagnosed every year in the United States.
16–40% of patients presenting with perforated appendicitis.
Way Question May BeAsked?
A 23-year-old woman presented to the Emergency
Department with abdominal pain, nausea, and vomiting that
started yesterday morning. Her pain was initially periumbilical but is now in her right lower quadrant. She had no appetite and had a temperature of 38.1C, which prompted her to
come to the hospital.
How toAnswer?
Full History
• Location and quality of pain: starts as dull, visceral periumbilical pain progressing to sharp peritoneal right lower
quadrant pain
• Anorexia±nausea, vomiting
• Changes in bowel habits: diarrhea or constipation
• History of ovarian cysts
Full Physical Exam
• Fever
• Tenderness to palpation RLQ (McBurney’s point) with
possible voluntary guarding
• Rovsing sign: pain in RLQ with palpation of left lower
quadrant (LLQ)
J. Lou · K. Yoon-Flannery (*)
Breast Surgery, Cooper University Hospital, Cooper Medical
School of Rowan University, Camden, NJ, USA
e-mail: lou-johanna@CooperHealth.edu;
Yoon-Flannery-Kay@CooperHealth.edu
• Obturator sign: pain in RLQ on internal rotation of right
hip
• Psoas sign:pain in RLQ with extension of the right hip
Diagnostic Tests
• Labs: leukocytosis with neutrophil predominance
• Urinalysis
• Pregnancy test in females
• CT scan: appendix >7mm that is thickened and inamed
with surrounding fat stranding, uid or edema, may have
appendicolith, sensitivity 76–100%, specicity
83–100%
• Ultrasound: thickened appendix that is noncompressible
with surrounding uid, possible target sign, avoids ionizing radiation but is operator dependent, sensitivity
71–94%, specicity 81–98%
Surgical Treatment
• NPO, IVF
• IV antibiotics with gram-negative and anaerobic coverage
• Laparoscopic appendectomy
– Place a foley to decompress the bladder, tuck the left
arm
– Start with a 5mm periumbilical port, 5mm suprapubic
port, and 10–12mm LLQ port
– Position the patient in Trendelenburg with right side up
with surgeon and assistant on the patient’s left
– Atraumatic graspers to identify and elevate the
appendix
– Identify the base of the appendix and make a window
here between the mesoappendix with care to prevent
injury to the cecum
– Divide the mesoappendix with stapler, Ligasure or
Harmonic device with care to ligate the appendiceal
artery
– Divide the appendix at the base with a stapler or
endoloop
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_24
73
74
J. Lou and K. Yoon-Flannery
– Remove the appendix with an endocatch bag through
the largest port
• Open appendectomy
– Incision can be a RLQ (oblique McBurney or trans-
verse Rocky-Davis incision) or lower midline incision
– Use the tinea of cecum to identify the base of the
appendix
– Divide the mesoappendix
– Clamp the base of the appendix, ligate with a heavy
absorbable tie, and divide
– Cauterize the stump and invert with an absorbable
Z-sture or purse string
Common Curveballs
• Retroperitoneal appendix may present with subacute,
atypical ank, back or suprapubic pain
• Ovarian torsion or ruptured ovarian cyst
• Patient is pregnant
– Pain is more cephalad due to displacement of the
appendix
– Can use MRI to conrm diagnosis
• Normal appendix on surgical exploration
– Look for Meckle’s diverticulum
– Perform appendectomy to rule out appendicitis in the
future
• Normal appendix on surgical exploration but ileum is
inamed
– Concern for underlying Crohn’s
– Perform appendectomy as long as base is normal
• Large phlegmon without identiable appendix
– Perform ileocecectomy or R hemicolectomy
• Final pathology with carcinoid tumor
– If at the tip or ≤2cm, no further surgery is needed
– If at the base or >2 cm, will need R hemicolectomy
with lymphadenectomy
Clean Kills
• Missing the diagnosis
• Not taking patient to surgery for appropriate surgical
candidate
• Not looking for alternate causes if the appendix is
normal
Summary
Patients with appendicitis often present with dull periumbilical pain that becomes more severe and migrates to
the right lower quadrant. Associated symptoms can be
nausea, vomiting, anorexia and fever. Often, CT imaging
is already obtained at the time of surgical consultation
and notes a thickened, dilated appendix >7mm with surrounding fat stranding or uid. Antibiotics should be
started at the time of diagnosis, and the patient should
promptly be taken to surgery for either laparoscopic or
open appendectomy.
Words ofWisdom
Don’t discuss non-operative management of appendicitis on
your board exam. While this is practiced at several centers,
this is an outgrowth of pediatric appendicitis (covered in
another chapter) and recent data suggests a relatively high
5year recurrence rate in adults. This would not be considered a “safe” board answer for the adult management of
appendicitis.
Large Bowel Obstruction
VictoriaSharp andMaserayS.Kamara
25
Concept
Large bowel obstructions are classied as partial or complete and arise secondary to various intraluminal, intramural, or extrinsic processes. Clinical presentations span
from gradual derangement to acute, life threatening complications. Ultimately, the obstruction leads to proximal
accumulation of uid and gas which can progress to, ischemia, bowel necrosis, and perforation. Appropriate intervention depends on underlying etiology and acuity of
presentation and may include endoscopy (detorsion, stent
placement, etc.) or surgical intervention (colectomy,
diverting ostomy, etc.).
Way Question May BeAsked?
“A 73-year-old man is brought from his nursing home to be
evaluated in the emergency department with a 3 day history
of worsening nausea, new onset feculent emesis, abdominal
pain, and distention. His last bowel movement and atus
were 36hours ago. His has medical history is signicant for
chronic back pain and paroxysmal atrial brillation on therapeutic anticoagulation and a past surgical history signicant for open cholecystectomy and laparoscopic
appendectomy. He reports initial colicky pain which transitioned to a constant abdominal pain.”
How toAnswer?
History
• Personal or family history of GI malignancy or familial
syndromes.
• Changes in bowel character.
• Blood in stool.
• Any recent colonoscopy/colonoscopy history.
Have a DDx in your mind and work through it:
Intraluminal
• Impacted feces (stercoral)
• Intussusception
Intramural
• Malignancy
• Stricture: Inammatory (diverticular disease, Ulcerative
Colitis, Crohns Disease) vs. Anastomotic vs. Ischemic
Extrinsic
• Volvulus
• Acute colonic pseudo-obstruction
Physical Exam
• Key: Assess if patient is at imminent risk of colonic ischemia or perforation.
• Thorough physical exam with special attention to abdomen and rectal.
Diagnostic Tests
• Obtain Abdominal Radiograph to diagnosis LBO and
V. Sharp
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: victoria_sharp@ihacares.com
M. S. Kamara (
Colon & Rectal Surgery, Trinity Health Ann Arbor, Ypsilanti, MI,
USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_25
*)
identify pneumoperitoneum
• CT Abdomen and Pelvis to identify potential complications (transition point, pneumoperitoneum, pneumatosis,
portal venous gas, etc.)
• Water Soluble Contrast Enema useful in diagnosis of
LBO, but cannot differentiate etiology
75
76
V. Sharp and M. S. Kamara
Two most common sites of obstruction sigmoid colon and
splenic exure.
Most common site of perforation cecum (Laplace’s Law).
Initial Management
• Two tenants of initial management: bowel rest + uid
resuscitation.
– NPO + IVF/Bolus PRN
– NGT to decompress proximal bowel and reduce aspi-
ration and provide symptomatic relief
• Obtain complete blood count, renal prole, and electrolyte studies
• Watch UOP, assess electrolyte shift.
Surgical Treatment
• If no signs peritonitis:
– Gastrografn enema
– CT scan abdomen and pelvis
– NGT/Foley/IVF/NPO/Serial exams
– Try to convert to near-obstructing lesion and perform
semi- electively after bowel prep
• If signs of peritonitis or complete obstruction:
– OR after initial evaluation and resuscitation (lines,
IVF, Abx)
Diagnosis Surgical management
Lesions of right and proximal
transverse colon
Lesions obstructing distal
transverse colon/left colon/or
sigmoid
Lesion obstructing left/
sigmoid WITH perforation of
cecum
Lesion obstructing left/
sigmoid WITHOUT
perforation of cecum
Unstable patient with
obstructing sigmoid/rectal
lesion with perforation of
cecum and gross
contamination
Sigmoid volvulus Endoscopic detorsion with
Cecal volvulus Ileocecectomy vs. right
Consider the role of colonic stenting: covered vs. uncov-
ered, palliative vs. bridging.
Right hemicolectomy with primary
anastomosis
Left hemicolectomy ± primary
anastomosis
Subtotal colectomy with primary
anastomosis
Defunctioning stoma (transverse
loop colostomy)
Right hemicolectomy/ileostomy/
mucous stula
decompression tube left in place for
1–3days followed by
sigmoidectomy during index
admission
hemicolectomy with primary
anastomosis
Common Curveballs
• Signs of peritonitis
• Perforation of right colon with mass on left
• Rigid sigmoidoscopy won’t nd cause for obstruction
• Pt will be unstable intra-op
• Pt will have AAA
• Pt will develop post-op abscess or abdominal compartment syndrome
• Pt will develop ischemia at colostomy site
• Patient will become coagulopathic during operation
• Inability to pass rectal tube for volvulus or keep in place
to give pt. bowel prep
• Cecum will get overdistended in follow-up of pseudo
obstruction or will perforate
• Distal cancer will be xed to pelvic structures
• Ureter/duodenal/liver injury while mobilizing right colon
• Splenic injury will mobilization splenic exure
• Hard peripheral liver lesion identied at time of emergency operation for peritonitis
• Patient will have had prior abdominal/colonic surgery
• No identied point of obstruction → management of
acute colonic pseudo obstruction
Clean Kills
• Doing anastomosis in face of frank contamination
• Not knowing how to construct ileostomy/mucous stula/
Hartman pouch
• Talking about on-table bowel lavage
• Performing long operation in elderly/unstable patient
• Using Barium enema rather than water soluble contrast
when concerned about cause of obstruction and possible
perforation
• Getting CT scan on patient with peritonitis
• Discussing cecostomy tubes or IV neostigmine with identied point of obstruction
Summary
Large bowel obstruction has a wide spectrum of clinical presentations. Acquiring relevant history can help pinpoint
underlying etiology. If hemodynamically unstable or presence of peritonitis, optimize for and proceed to OR.If neither, proceed with a systematic initial management and
workup that includes establishing IV access and drawing
labs, NPO, NGT, uid resuscitation, and AXR.Depending
on ndings and inserted curveballs management may include
further imaging or endoscopic versus surgical intervention.
25 Large Bowel Obstruction
Bibliography
Betrelson NL, Etzioni DA.Large bowel obstruction from colon cancer.
In: Clinical scenarios in surgery. 2nd ed. Wolters Kluwer; 2019.
Feingold DL, Fleming FJ.Large bowel obstruction. ASCRS textbook of
colon and rectal surgery. ASCRS U; 2022. www.ascrsu.com/ascrs/
view/ASCRS- Textbook- of- Colon- and- Rectal- Surgery/2285033/all/
Large_Bowel_Obstruction.
77
Intussusception
VictoriaSharp
26
Concept
Most questions will be related to obstruction and the correct
surgical or non-surgical management of the condition. Most
pediatric intussusception occurs at the ileocecal junction
with no identiable pathological lead point and the cause is
often unknown. In adult intussusception, there is more likely
a pathological lead point that will require surgical resection.
Denitions to remember: intussusceptum (the proximal segment that invaginates into the distal segment, known as the
intussuscipiens).
Way Question May BeAsked?
“A 4-year-old boy presents to the emergency department
with severe, cramping abdominal pain. He is laying with his
legs drawn up to his abdomen but will intermittently relax.
He has been vomiting with decreasing bowel movements,
which are now dark in color and appear gelatinous.”
How toAnswer?
History
• History of the same pain.
• History of recent surgery (can occur early postoperatively
in children who have undergone abdominal surgery).
• Recent viral illness or vaccination (can be associated with
recent upper respiratory infections, gastroenteritis, or the
rotavirus vaccine).
• Recent diarrhea.
• Jelly-like stools (currant jelly stool).
V. Sharp (*)
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: victoria_sharp@ihacares.com
History Should Also Focus on Symptoms, Being Sure to
Rule Out Other Possibilities
• Foreign body ingestion.
• Intestinal perforation.
• Family history of colon cancer or polyposis syndromes.
Physical Examination
• Check vital signs.
• Look for peritonitis (guarding, rebound).
• Palpate for possible abdominal mass (can palpate the
intussuscepted bowel in slender children).
Diagnostic Tests
• Lab values include CBC, BMP, Mg, Phos to modify
electrolytes.
• Plain abdominal X-rays:
– Presence of mass, sparse gas in the colon, complete
distal small bowel obstruction.
• Abdominal US:
– Target sign (Intussuscepted layers of bowel on trans-
verse view).
– Pseudokidney sign (On longitudinal view).
• CT Scan:
– Target sign.
– Crescent sign (Apex of the intussusceptum, which is
outlined by a crescent of gas).
– Absent liver edge sign (absent subhepatic angle).
– Evidence of bowel obstruction.
Treatment
• Non-operative Management:
– Air or contrast (barium) enema:
Both diagnostic and therapeutic.
Contraindications: peritonitis or hemodynamic
instability.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_26
79