20 - GI surgery - aa/LL/ha

Question 1

Approximately __% of abdominal operations result in incisional hernias.

Answer 1

10%

Question 2

What type of hernia are men more likely than women to get? What type are women more likely to get than men?

Answer 2

Men > women: inguinal hernia (most common hernia)

Women > men: femoral hernia

Question 3

____ incisional hernias should be repaired right away; ____ incisional hernias can probably be left alone (less likely to incarcerate).
[large, small]

Answer 3

Small incisional hernias: repair right away

Large incisional hernias: can probably leave

Question 4

Your patient is a 72 yo male with an intermittent groin mass that has bowel sounds in it during Valsalva maneuver. What is it?

Answer 4

inguinal hernia

Question 5

Your patient is a 53 yo male alcoholic with cirrhosis and ascites who recently developed an umbilical bulge with sharp pain when coughing. What is it and will you recommend for or against surgery?

Answer 5

~Umbilical hernia
~YES surgery (cirrhosis/ascites are not contraindications for umbilical hernia repair, and actually incarceration/strangulation/rupture are particularly bad in these patients, so do it)

Question 6

Volvulus:
Where is it most likely located?
What imaging will you do and what will you see?

Answer 6

~70% in sigmoid colon
~xray: dilated/distended loops of bowel with loss of haustra
~barium enema: bird’s beak sign

Question 7

~LLQ tenderness and mass with fever and leukocytosis
~NOT really associated with bleeding
~majority of patients respond to conservative treatment with hydration, abx, and NPO
What is it?

Answer 7

diverticulitis

Question 8

~asymptomatic in 80% of pts and detected incidentally
~acute, painless, large volume bleeding in pts over 50
~”sawtooth” apperance on barium enema
~if asymptomatic, increase dietary fiber; surgery necessary if massive hemorrhage
What is it?

Answer 8

diverticulosis

Question 9

Your patient has an abdominal mass and blood in the stool.
What is it?
Will you do conservative/localized surgery?
What lab test will you get before surgery?

Answer 9

~colon cancer
~WIDE resection including regional lymphatic drainage
~CEA levels - monitor this biomarker for recurrence

Question 10

What might you expect to see on an upright film of small bowel obstruction?

Answer 10

Supine and upright plain abdominal films reveal a ladderlike pattern of dilated small bowel loops with air-fluid levels.

Question 11

Surgical management is almost always required in large bowel obstruction, but small bowel obstruction may possibly be treated conservatively with IV fluids and decompression.
T/F

Answer 11

True

Question 12

What might you expect to see on an xray in large bowel obstruction?

Answer 12

The distended colon frequently creates a “picture frame” outline of the abdominal cavity.

Question 13

Name 2 differences in the s/s between diverticulosis and diverticulitis.

Answer 13

~bleeding: diverticulosis

~fever & leukocytosis: diverticulitis

Question 14

What pre-operative abx prophylaxis is recommended for appendectomy?

Answer 14

a cephalosporin

Question 15

What’s your first diagnostic test in acute RUQ pain with referral to back/scapula?

Answer 15

~suspected cholecystitis -> ultrasound for presence of gallstones, sludge, thickening of gallbladder wall

Question 16

Your patient has Kehr’s sign.

What is their problem?

Answer 16

~Kehr’s sign: pain in left shoulder; sign of ruptured spleen (referred pain - blood in abdominal cavity irritating the diaphragm/phrenic nerve)

Question 17

Your patient had sudden onset of agonizing lower abdominal pain and now has signs of shock, fever, and a rigid & tender abdomen.
You suspect what?
What imaging findings would support your diagnosis?

Answer 17

~perforated bowel

~air-fluid levels outside the bowel on imaging indicate perforation

Question 18

Pain that is variable, occurs for a shorter duration of time, often accompanied by bilious vomiting may be a more ________ small bowel obstruction (SBO).

Answer 18

PROXIMAL

Question 19

Pain that lasts as long as several days, is colicky, progressive in nature, and is accompanied by abdominal distention may be typical of a more _______ obstruction of the small bowel.

Answer 19

DISTAL

Question 20

What may be heard on PE of a pt with suspected small bowel obstruction?

Answer 20

peristaltic rushes – manifestations of attempts by the small bowel to propel its contents past the obstruction

Question 21

Although pain with distal SBO and cholelithiasis are both described as “colicky,” how are they different?

Answer 21

~SBO pain - “intermittent pain;” episodes of cramps w/crescendo-decrescendo pattern (seconds-hours) and recurs every few minutes. Between cramps, no pain.
~Cholelithiasis - “steady pain;” begins abruptly & subsides gradually

Question 22

Which of the following is most appropriate step in managing a patient with papillary thyroid cancer?

a. chemotherapy
b. radioactive iodine
c. propylthiouracil
d. surgical removal

Answer 22

D. this is the surgery block after all

Question 23

A female undergoes a cholescystectomy and post-op labs, including CBC and PT and PTT are all normal but bleeding time is still prolonged. What does she have?

Answer 23

von Willebrand disease

Question 24

In early intestinal obstruction, what are the characteristic initial findings on abdominal auscultation?

Answer 24

HYPERactive bowel sounds

Question 25

What is the most common cause of obstruction of the small intestine in adults?

Answer 25

adhesion