Abdomen Flashcards
inheritance patterns of :
Thalessemias
Her sphero
G6PD
SSD
AD
AD
XLR
AR
What is your dg of exclusion for isolated thrombocytopenia?
7 others to evaluate for
ITP
Viral, autoimm, preg/preecl,TTP, HIT, hypersplenism, cirrhosis
When to transfuse for ITP patients
MC bleeding occurrences
Common non bleeding feature that may be severe
less than 20K or active bleeding
Petechia
Epistaxis
Purpura
fatigue
Recent hx questions for suspected ITP
Recent infection, quinine, medications
Lab difference for TTP vs ITP
special lab for either?
microangiopathic hemolytic anemia vs usually normal
AdamTS13 deficiency
Post op care for splenectomy timing
abx at 14 days
Initial tx for ITP
later?
steroids and IVIG
Splenectomy
Tx for TTP
therapeutic plasma exchange
steroids
rituxumab
Reasoning for splenectomy in ITP
for refractory cases where extended steroid use is problematic
2 genetic syndromes associated with desmoids
what other similarity do these share
fap and Gardners
polyps
intra-abdominal desmoid txs
first best step in management
radiation; negative margin resection
watch and wait
What is the PE for femoral hernia
below inguinal ligament
4 borders of femoral canal
sup - iliopubic
inf - cooper
med - lacunar
lat - fem vein
risk of incarceration per year for aysmpt or min sympt inguinal hernia
.3%
For splenectomy, when are platelets given
if needed and after taking artery
inguinal nerves and sensory distribution
overall parastomal hernia rate
50%
Groin anatomical hernia sites
typical symptoms for obturator hernia
medial thigh pain or paraesthesias due to obturator n compression
what percent of obturator hernias present with sbo
50
Why is there pain with hernia?
These are often sites where n and vessels penetrate the abdominal wall
When does umbilical defect usually close
5
medial umbilical ligaments are remnants of…
round ligament is a remnant of ….. also known as…..
left and right umbilical arteries
umb vein; lig teres
falciform anatomy
perks to laparoscopic hernia repair
better healing, easier for obeses patients, multiple defects, better recurrent hernia operation
Go to open hernia repair type and mesh to be used
rives stoppa with uncoated polypropylene
first step for obese patients with non urgent hernias
weight loss
blood supply of lateral abdominal wall
medial?
lumbars intercostals, deep circumflex ilac
epigastrics
below the arcuate line the rectus lies directly anterior to the ….
transversalis fascia
risk factors for incisional hernia development - 4
smoking, steroids, rads, wound infection
main benefit of lap vs open for hernia
lower infection
incisional hernia staging system
Table 2. Incisional Hernia Staging System
Stage I <10 cm, clean
Risk: low recurrence, low SSO
Stage II <10 cm, contaminated
Risk: moderate recurrence, moderate SSO 10-20 cm, clean
Stage III ≥10 cm, contaminated
Risk: high recurrence, high SSO Any ≥20 cm
SSO, surgical site occurrence.
size cutoff for hernia primary repair – ventral
2 cm
2 congenital diaphragmatic hernias and their positioning
what anatomical features failed in each
Bochdalek — post lat —pleuroperitoneal membrane closure
Morgagni — ant med – fusion of septum transversum
elevated diaphragm after diaphragm repair means…
usual treatment
if refractory or severe
phrenic nerve injury
obs
plication or pacing
preferred diaphragm repair approach according to east trauma
lap or open
abdominal due to concomitant injuries
lap if stable
when to use mesh for diaphragm repair?
10cm CHRONIC
2 hard indications for lap over open inguinal repair
bilateral and prior open recurrence
peritoneal sac location relative to cord structures
ant med
chronic pain post inguinal repair initial tx
refractory tx
nsaids, blocks
mesh removal or neurectomy
recurrence rate for inguinal
5-10%
what type of mesh gives best recurrence rate
permanent prosthetic
Relative cx to ventral hernia repair (4)
obesity
preg
smoking
multiple comorbids
anterior abdominal wall perforator relative positions
Describe anterior component separation
pathophys for choledochal cysts
pancreaticobiliary anomalous junction — pancreatic reflux into biliary tress
Mirizzi Types
1 A - patent CD
1 B - obliterated CD
2 - 1/3
3 - 2/3
4 - 2/3+
How likely is Mirizzi dg on pre op w/u
not likely
At what level of bili do sclera and skin become jaundiced
2.5
5
Charcots triad
fever, RUQ, jaundice
Reynolds pentad
Charcot hypotension, AMS
acholic stools, dark urine, RUQ pain
biliary obstruction
2 labs indicating cholestasis
bili and alp
what does hida stand for
good for identifying 2 things
leaks and CD obstruction
Types of choledochal cysts and their treatments
1 - excison followed by HJ or HD
2 - diverticulectomy
3 - sphincterotomy v trans duodenal excision
4 - HJ possible limited lob resection
5 - transplant
What is Carolis disease
type 5 choledochal cysts all intrahepatics
2 disease processes that may stem from choledochal cysts
Obstruction from cyst debris
Malignancy
Timing if prenatal testing finds choledochal cyst and why
early to prevent hepatic fibrosis
4 pharm interventions that will affect sphincter of ODdi
Morphine - cx
Glucagon - relax
CCK - relax
Secretin - relax
who gets biliary dykinesia
20-50 women
DDX for biliary colic
chronic panc, PUD, GED
Most definitive way to dg SOO disorder
Oddi manometry greater than 40
3 SOO dg criteria
Criteria for biliary pain*
Elevated liver enzymes or dilated bile duct, but not both
Absence of bile duct stones or other structural abnormalities
incidence of CBD injury in lap
.5%
size of biliary duct that can be ligated for leak
circumference of injury that can be amenable to T tube
end to end repair defect length
all others?
3mm
50
1cm
HJ
CBD stricture initial treatment
success rate
dilation
75%
biliary injury repair success rates for surg, IR, GI
88
50
75
solitary hyperplastic mucosal lesion in the gallbladder? management?
adenomyomatosis
nothing
Percent of GB cancer from a distant met?
2%
How to classify cholangioca
what are peripheral cholangioca’s? what is their incidence relative to CCA overall
intra hepatic
5-10%
6 big risk factors for GB cancer
GS >3cm
PSC
Anomalous PBJ
segmental mucosal calc
Polyps> 1cm
Obesity
CCA risk factors
Parasite(opisthorchis
hepatolithiasis
Hep c
PSC
choledochal cysts
staging for GB cancer
CT CAP
CA 19-9
When is tissue required for CCA
non op managment or unclear imaging
4 negative porgnosticator for GB CA
perineural invasion
LV invasion
inability to get R0 resection
T2b(hepatic perimusc side) vs a
GB CA staging
recommendations on incidental polyps on US
Polyps greater than 2.0 cm should be considered malignant, and appropriate workup is warranted to assess for cancer (see Learning Objective 4b), followed by resection.
Polyps 1.0 to 1.9 cm have increased risk of being malignant, and simple cholecystectomy should be recommended.
Polyps less than 1.0 cm that are detected on CT scan are more likely to represent cholesterol polyps.
Polyps 0.6 to 0.9 cm should be followed with yearly ultrasounds (American Society for Gastrointestinal Endoscopy [ASGE] guidelines).
2 requirements for chole as definitive treatment for GB CA
T1a(lamina propria) and neg cyst duct margin
Causes of primary biliary stricture? 3 for secondary?
PSC
Neoplasm, infection, ischemia
Up to 90% of patients with PSC also have____
UC
Elevated labs in PSC
PE exam findings
ALP and bili
Excoriations, enlarged liver or spleen, jaundice
Test of choice for suspected PSC
Alternative
ERCP
PTHC
When does PSC patient get transplant
Cirrhosis
MELD number for transplant
MELD components
15
INR, Na, Cr, bili, dialysis twice per week?
Tx for PSC with meld under 15
Success rate at 5 years
Success of reconstruction
balloon dilation
89%
35%
only medical treatment for PSC and what does it actually help with
ursodeoxycholic acid
helps minimally with symptoms
Screening with PSC diagnosis
Gallbladder/CCA
Colonoscopy for UC
CA 19-9
U/s
Components of CHILD score
Total bilirubin: 1 point for less than 2, 2 points for 2 to 3, and 3 points greater than 3
Serum albumin: 1 point for greater than 3.5, 2 points for 2.8 to 3.5, and 3 points for less than 2.8
INR: 1 point for less than 1.7, 2 for 1.7 to 2.3, and 3 points for greater than 2.3
Ascites: 1 point for none, 2 points for mild or suppressed with medication, and 3 for moderate to severe.
Hepatic encephalopathy: 1 point for none, 2 points for grade I to II, and 3 for grade III to IV
Grade I: trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction
Grade II: lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behavior
Grade III: somnolence to semistupor but responsive to verbal stimuli; confusion; gross disorientation
Grade IV: coma
One year survival per Child class
Treatment for small esoph varices
large?
Propanalol – splanchnic vasoconstriction
Add banding or sclerotherapy, repeat q 6 weeks
PPx for portal htn and GI bleeding
Octreotide or somatostatin – mesenteric or splanchnic VCX
Tx for cirrhotic SBT? Recurrence rate?
Cefotaxime
40-70
epidemiology of hepatic abscesses?
East v west type predominance?
1% pop in 5th decade, sick folks
Pyogenic v entamoaba histolytica
pyogenic hepatic abscess bugs
strep, kleb, e coli
3 big sources for hepatic abscess
portal
arterial
biliary
blood work for hepatic abscess concerns
cbc, cmp, crp, cultures, echinococcus and Entamoeba histolytica
Gold standard imaging for hepatic abscesses?
Appearance: pyogenic v ameobic v ecinocochal
CT IV
multiple
single sub diaphragm
Septated cyst - multiple daughter cysts
Initial tx of pyogenic hep abscess?
size cut off for drainage?
Role for surg
BS abx
3cm
5cm plus, multiples, underlying cause needing resection
Testing for ameobic abscess?
Tx?
serology
flagyl/tinidazole(10d v 5 d)
then
paromycin/iodoquinol(7-20d)
What is echinococcus?
Single cyst tx? surg size?
Multi cyst treatment
helminth
albendozole; cm
PAIR - puncture, aspirate, inject, reaspirate —-28 d albend
underlying causes of hepatic abscesses that need follow up(3)
Diverticulitis
Cholecystitis
Biliary/colon malign
What landmark divide liver in two
Cantlie’s - gallbladder fossa to IVC
What segment drains directly into IVC
Segment 1
3 categories of liver mets
CR
NE
non above
synchronus vs metachronous liver lesions
biology is more aggressive in synch, harder surgery
non chemo, chemo, and cirrhotic FLR %s preferred
25,35,40
option if FLR is not large enough
portal vein embolization
CRC stage 4 % at dg
20-25%
% mets at dg for GI NET
40-95 mostly in liver, strong prognosticator
surveillance for liver mets after CRC
CEA and imaging
CT appearance of liver mets?
hypoattenuating, portal filling with washout in delayed phase
When to bx liver mets
unknown primary or chemo info needed
Hepatectomy mortality and morbidity?
2% ; 30-50%
Acalculous cholecystitis tx in sick patient?
When would this need to be deviated?
Chole tube
In case of perforation or clinical deterioration
Anatomical side for Mattox vs Cattell
right
left
