The Associated Press is reporting tonight that Pennsylvania Congressman Bob Brady of Philadelphia has stated that Murtha suffered from injury to his large intestine during the operation at Bethesda Naval Hospital to remove his gallbladder.

The gallbladder was reportedly removed laparoscopically or as it is sometimes described via a minimally invasive technique.

Murtha was apparently discharged to home and then presented to the Virginia Hospital Center complaining of abdominal pain and a fever.

Several days ago he was reported to be in the intensive care unit, indicating that a serious complication had developed which he eventually succumbed to.

Despite being widely performed and viewed as a routine and straightforward operation by patients, laparoscopic cholecystectomy or gallbladder removal can be technically difficult to perform in certain situations.

There are many ways that injury to the intestines can occur in this procedure. An understanding of the anatomy of abdomen and the pathophysiology of gallbladder disease is useful.

The gallbladder is a sac-like structure hanging from a system of ducts leading from the liver in the right upper quadrant to the duodenum.

Immediately adjacent to the gallbladder is the hepatic flexure of the right colon.

When the gallbladder becomes inflamed, the walls of the gallbladder and the surrounding tissue literally becomes red and swollen and the normal tissue planes become obscured, particularly if there have been repeated attacks of cholecystitis or gallbladder inflammation.

To put it simply, “everything gets stuck together” including the gallbladder and colon.

When removing the gallbladder one of the first steps is to peel the colon off the underlying gallbladder wall, without tearing the colon in the process.

While large holes in the colon are fairly easy to notice, smaller perforations in a bed of inflamed tissue are easier to miss.

A second way that the colon can be injured during the procedure is inadvertently perforating it with a retractor or dissecting instrument.

This generally occurs as the tissue is being gently pulled down off of the cystic duct. The sweeping motion of the grasper is towards the area of the colon, which may get “poked” by the tip of the retractor.

A third way the colon can be injured is through a thermal burn from the Bovie electrocautery used to stop localized bleeding from tissues.

This injury may present as a delayed finding and is not uncommon when patients re-present to the hospital with colon injury after being discharged home.

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Laparoscopic Cholecystectomy (Gallbladder Removal)

1) tumor of the chromaffin cells of the adrenal medulla that secrete catecholamines (norepinephrine and epinephrine) and other substances 2) can also arise in extra-adrenal sites (paraganglioma) 3) metastasizes most commonly to regional lymph nodes, liver, bone, lung

1) episodic, unpredictable attacks of intense fear, agitation, and discomfort (especially agoraphobic) 2) onset must occur over a 10 minute period 3) attacks generally occur for < 1 hour 4) exact cause is unknown, but genetic predisposition occurs

Signs and Symptoms

presence of at least four of the following during attack – 1) tachycardia/palpitations 2) trembling/shaking 3) sweating 4) shortness of breath 5) dizziness 6) chest pain 7) choking sensation chills or hot flushes 9) abdominal pain or diarrhea 10) sense of impending doom or death 11) feelings of anxiety

Biochemistry

1) altered autonomic functioning 2) increased noradrenergic discharge from locus ceruleus

Inheritance/Epidemiology

onset is usually in late adolescence to early adulthood

Treatment

1) SSRIs (sertraline and fluoxetine) 2) benzodiazepines for short period of time until SSRIs reach therapeutic levels 3) psychotherapy – behavior modification and relaxation techniques like breathing exercises

Tips for USMLE

if question mentions a 19 year old man who is studying in the college library and suddenly develops feelings of anxiety, sweating, palpitations, paresthesias and 5 minutes later has acute diarrhea and by the time she is seen in student health she is feeling much better and does not know why she experienced this episode, think panic disorder

congenital mental retardation caused by trisomy 21 (an extra chromosome 21)

Signs and Symptoms

1) moderate mental retardation progressing to severe mental retardation (IQ of 30 in adulthood) 2) characteristic mongoloid facies – flat nasal bridge, epicanthic folds, oblique palpebral fissures 3) short stature and obesity 4) spade-like hands with simian creases 5) speckled irises (Brushfield’s spots) 6) hypotonia 7) congenital heart defects – VSD, ASD, tetralogy of Fallot, and patent ductus arteriosus

Associated Conditions

1) increased incidence with advanced maternal age (1/30 live births at age 45 years) and previous child with Down syndrome 2) increased incidence of leukemia (especiallly ALL), Alzheimer’s disease (25-50%) by age 35 years), Hirschsprung’s disease, imperforate anus, duodenal stenosis, and atresia

Histology/Gross Pathology

1) senile plaques 2) neurofibrillary tangles 3) deposition of beta-amyloid protein in the brain

Biochemistry

mechanisms for production of trisomy 21 – nondisjunction during first meiotic division of gametogenesis (94% of cases), translocation of an extra long arm of chromosome 21 (5%), and mosaicism (1%)

Inheritance/Epidemiology

most common cause of congenital mental retardation

Treatment

surgery for congenital heart defects

Tips for USMLE

1) if Brushfield spots are mentioned, think Down’s 2) if question mentions a Down’s child, look for development of leukemia (ALL) or Alzheimer’s in the case scenario 3) if question mentions a Down’s child, look for the presence of congenital heart defects

1) cause is infection with obligate intracellular Chlamydia trachomatis 2) occurs in primary, secondary, and tertiary phases

Signs and Symptoms

1) primary phase – small painless vesicle at area of inoculation, which forms several days to several weeks after infection (vesicle may ulcerate) 2) secondary phase – in men, usually bilateral (but sometimes unilateral), matted, and suppurative inguinal lymph nodes; in women, rectal inflammation occurs 3) tertiary phase – systemic manifestation of headache, fever, myalgia, and arthralgia

Histology/Gross Pathology

1) caused by L type serotypes only (L1-L3) 2) involved lymph node tissue shows necrotizing granulomata with striking inflammation of neutrophils with a necrotic central area

Associated Conditions

if untreated can progress to – 1) lymphatic scarrring and fibrosis 2) genital elephantiasis 3) rectal scarring 4) rectovaginal fistulas 5) urethral strictures

Epidemiology/Inheritance

1) affects colon in male homosexuals through anal sex 2) sexually transmitted and endemic in tropical areas 3) introduced via break in the epithelial surface

Treatment

tetracycline

Tips for USMLE

if patient has stellate abscesses formed by granulomas with suppurative bases, think lymphogranuloma venereum

1) type of stress disorder with delayed, recurrent development of anxiety after experiencing a traumatic event 2) involves threat of or actual death, injury, or loss of integrity to self or others that is responded to by fear, horror, or helplessness

Signs and Symptoms

1) detachment and loss of emotional responsiveness 2) depersonalization 3) intrusive dreams, thoughts, and flashbacks 4) cues of epidode provoke anxiety 5) active avoidance of stimuli or cue 6) increase startle response, increased arousal, hypervigilance 7) difficulty concentrating irritability 9) variable inability to recall all or part of traumatic event 10) restricted range of affect

Associated Conditions

1) increased incidence of – other anxiety disorders, substance abuse, mood disorders 2) increased incidence with – past psychiatric history, neuroticism

Biochemistry

increased norepinephrine release from locus ceruleus in response to stress

Inheritance/Epidemiology

1) more common in women 2) affects 5-10% of adult Americans

Treatment

Drug intervention – 1) SSRIs (sertraline, fluoxetine) 2) MAOIs (phenelzine) 3) tricyclic antidepressants (imipramine, amitriptyline) 4) sedatives (trazodone) Psychotherapy – 5) dismantling the avoidance behaviors in a progressive manner

Tips for USMLE

if question mentions a 33 year-old woman with a history of two previous psychiatric admissions for depression who is seriously wounded in a bank robbery and two months after the episode is unable to return to her job as a tollbooth attendant, and her family reports that she is withdrawn and irritiable, think PTSD

1) plasma K+ > 5.0 mmol/L (if > 7.5 mmol/L, becomes life threatening 2) caused by increased release from cells (intravascular hemolysis, tumor lysis syndrome, rhabdomyolysis), decreased clearance by kidney due to acute or chronic kidney failure, excess intake (often iatrogenic)

Signs and Symptoms

1) weakness up to flaccid paralysis 2) cardiac excitablity

Characteristic Test Findings

EKG – 1) peaked T waves 2) prolonged PR interval 3) widening of QRS 4) absent P waves 5) ventricular arrhythmias (ventricular tachycardia, ventricular fibrillation)

Associated Conditions

1) metabolic acidosis (due to intracellular buffering of H+) 2) hyperglycemia 3) digitalis toxicity 4) hemolysis 5) hyperaldosteronism (Conn’s disease) 6) Addison’s disease 7) K+ sparing diuretics (spironolactone) ACE inhibitors 9) NSAIDs 10) cyclosporine 11) trimethoprim 12) pentamidine

Biochemistry

hyperkalemia partially depolarizes cardiac cell membranes

Treatment

1) aim is to shift K+ into cells and promote K+ loss 2) 25-50 g of Kayexalate (sodium polystyrene sulfonate) with 100 mL of 20% sorbitol by mouth or enema (cation exchange agent) 3) 1 ampute of calcium gluconate (decreases membrane excitability), 50 g IV glucose, and 10-20 units of regular insuline IV (causes K+ to shift into cells) 4) beta2-adrenergic agonists via IV of nebulizer (effect lasts 2-4 h) 5) dialysis with low K+ dialysate 6) alkali therapy with 3 ampules of NaHCO3 per liter IV

Tips for USMLE

if question mentions peaked T waves on EKG, think hyperkalemia or anterior cardiac ischemia