1. Contraindications to whipple:
-Mets: this is an absolute CI. Mets to liver, pancreas, omentum, extra-abdominal sites, celiac LN and other LN not removed by surgery. If you see these on laparoscopy, close and go home.
-Involvement of SMA, IVC, aorta, celiac aa, hepatic aa
-Encasement (>50%) of portal vein-SMV confluence
2. Infections/inflammation can cause ileus: pneumonia, UTIs, nephrolithiasis, appendicits, pancreatitis, sepsis, etc. Someone with a spinal cord injury with distention and obstipation is a UTI until proven otherwise.
3. The incidence of UTI is much higher among people with spinal cord injuries-- the neurogenic bladder leads to urine stasis and frequent caths, which introduces bacteria into the urine. In fact, most of these patients' urine is always colonized with bacteria, rendering the diagnosis of acute UTI difficult. Current diagnosis are >100 cfu/mL; >50 wbc/hpf indicates severe pyuria.
4. Microbiology of UTIs in spinal cord injury: usually polymicrobial, often the bugs form dense biofilms that are difficult to treat: proteus, klebsiella, pseudomonas, serratia, providentia, plus staph and enterococci. There's some data that intentionally colonizing the bladder with less virulent organisms (e.coli) decreases morbidity. Empiric treatment is with fluroquinolones, watch out for the side effects. In-hospital management options; amp/gent, imipen/cilastatin, b-lact/b-lactamase inh, 3g cephalosporin, aminoglycosides. Treat for 7-14 days (as short as 4-5 in those with more clinically benign presentation). If it doesn't get better in that time-frame, evaluate further for stones or aberrant anatomy, re-culture to look for resistant bugs.
5. Prophylaxis and management of asymptomatic bacteriuria in SCI: Because so many are colonized, the threshold to treat is high to avoid overtreatment: some advocate treating >10,000 cfu/mL plus >8-10 wbc/hpf. Prophylactic bactrim reduces incidence of UTI, but may increase resistance. Some advocate alternating methenamine (turns into formic acid which is bacteriostatic) TID with nitrofurantonin BID, alternating q2 mos.
6. Lesions above T6 can result in autonomic dysreflexia to noxious stimuli (such as an over-distended bladder), whereby spinal levels below the injury have uninhibited sympathetic output, resulting in severe vasoconstriction and reflex bradycardia; treat with alpha-blockers.
7. Septic thrombophlebitis: palpable cord on skin, with overlying erythema or pus: incise and pop it out. Ice, elevation, NSAIDs.
8. The small bowel does not tolerate radiation: radiation enteritis occurs in nearly 50% of those irradiated. Radiation causes damage to mucosa (erosion/ulceration, ischemia, fibrosis) which can lead to lifelong symptoms of pain, diarrhea, malabsorption, hematochezia, even obstuction/perforation. A significant portion (20%?) of those who get radiation to the rectum end up incontinent.
9. Hypokalemia worsens ileus
10. In someone who has been vomiting, they lose H+Cl through vomiting, there is also a contraction alkalosis (via aldosterone? lose K and H in urine). Treat with fluids-- NS, to replenish Na-Cl and volume.