absite surgery bored Flashcards
clinical significance of criminal nerve of grassi
can cause persistently high acid levels if left undivided after vagotomy
Normal UES resting pressure vs normal LES resting pressing
UES: 60
LES: 15
Cancer associated with plummer vinson syndrome?
Oral cancer
pathophysiology of zenker’s diverticulum?
increase in pressure due to failure of cricopharyngeus muscle to relax
gold standard for diagnosis of zenker’s diverticulum?
Barium swallow
Traction diverticulum of the esophagus
True diverticulum
most commonly located in the mid lateral esophagus
epiphrenic diverticulum
A false diverticulum most commonly located in the distal 10cm of the esophagus
Mainly associated with motility disorders
pathophysiology of achalasia
destruction of inhibitory neural ganglion cells in muscle wall
manometric findings of achalasia
*high/normal pressure LES
*poor/no peristalsis
pathophysiology of scleroderma
fibrous displacement of esophageal smooth muscles
histopathology seen in barrets esophagus
goblet cells
Ca risk is increased by how much in barrets esophagus
50 times adenocarcinoma
Most common esophageal cancer worldwide
squamous Ca
what T stage of esophageal cancer is still resectable
T4a
invasion of pericardium, pleura and diaphragm is considered what T stage
T4a
Most common site of tumor and most common site of distant metastasis for esophageal adeno vs squamous Ca
- Adenocarcinoma – usually in lower ⅓ of esophagus; liver metastases most common
- Squamous cell carcinoma – usually in upper ⅔ of esophagus; lung metastases MC
Fanconi anemia increases the risk for what type of cancer
squamous cell CA of oral cavity and esophagus
what is TYLOSIS
autosomal dominant disease
● Hyperkeratosis of the palms and soles of feet
● 70% lifetime risk of squamous cell esophageal CA
● Upper endoscopy screening starting at age 20
Most common site of non-iatrogenic (mc boerhaave) esophageal perforation
left posterior lateral intrathoracic esophagus 2–4 cm above EGJ
Most common iatrogenic site for esophageal perforation
cervical esophagus near cricopharyngeus muscle
Meissner’s and Auerbach’s
plexuses location in the esophagus
Meissner’s and Auerbach’s
plexuses, are found in the submucosa and between the muscle
layers of the esophagus, respectively.
swallowing center is located in the
Medulla
The most
common operative finding on repeated fundoplication
herniated wrap
source of bleeding in Mallory-Weiss tears
arterial bleeding
most common problem following vagotomy
diarrhea
Best test for H. pylori eradication
urea breath test
gold standard test for h pylori diagnosis
histological examination of antral biopsy
Type 4 gastric ulcers
lesser curve high along cardia of stomach; ↓ mucosal protection
Type 1 gastric ulcers
lesser curve low along body of stomach; due to ↓ mucosal protection
mutation associated with hereditary diffuse gastric Ca
CDH1 mutation (AD)
Types of chronic gastritis
● Type A (fundus)
● Type B (antral)
GIST is considered malignant if
if > 5 cm or > 5 mitoses/50 HPF (high-powered field)
MALT is associated with
H.pylori
dumping syndrome is most common with
billroth 2 surgery
Duodenal diverticula are false or true?
congenital or acquired?
false
acquired
operative treatment of choice for SMA syndrome?
duodenojejunostomy
An aberrant/replaced left hepatic artery originates
from
left gastric artery
Borchardt’s triad
acute epigastric pain, violent retching without vomiting, and the inability
to pass an NG tube
Associated with gastric volvulus
course of replaced left hepatic artery
within the gastrohepatic ligament medially
how to differentiate portal vein from hepatic vein on u/s
portal vein have hyperechoic walls
The ligamentum teres
extends from
the falciform ligament and carries the obliterated umbilical vein to
the undersurface of the liver
Difference between Hepatic adenoma and focal nodular hyperplasia histologically
Hepatic adenoma lacks kupffer cells
screening for HCC
done via u/s only every 6 months for patients at risk
The Milan criteria for HCC
define HCC tumors in Child’s C cirrhosis
that would benefit from transplantation
Characteristics that further support metastasis over primary
liver cancer include
*history of primary cancer
*peripheral residing
lesions
*multiple lesions
* mass hypovascularity (hence only
slightly enhancing compared with adjacent liver parenchyma).
indications for TIPS include
*protracted variceal bleeding
*refractory ascites, *hepatic hydrothorax
*Budd-Chiari syndrome refractory to anticoagulation.
preferred site for needle entry in paracentesis
3 cm medial and 3 cm superior to the ASIS in the left
lower quadrant (LLQ)
Risk factors for Spontaneous bacterial peritonitis
previous SBP
variceal bleeding
low protein ascites
EMPHYSEMATOUS GALLBLADDER DISEASE organism mc involved
Clostridium perferignes
Bacterial infection of bile source
mostly transferred from portal system
most important cause of late
postoperative biliary strictures
Ischemia following laparoscopic cholecystectomy
Bile duct strictures without a history of pancreatitis or biliary surgery You think of
Biliary cancer
Hemobilia
fistula between bile duct and hepatic arterial system
causes of hemobila
- liver trauma
- percutaneous instrumentation
blood supply to the supraduodenal portion of the bile duct has a
primarily axial or longitudinal pattern. The so-called 3- and
9-o’clock arteries and other small vessels arise from?
right
hepatic artery and the retroduodenal artery, which is a branch of
the gastroduodenal artery
hepatic synthesis of new bile is around
300 to 600 mg/day
ileal disease or resection is associated with what type of gallstones
pigmented stones
The three sonographic
criteria for gallstones
- hyperechoic intraluminal structure
- posterior shadowing
- movement of stone with change in position
Ventral pancreatic duct form
inferior portion of the head of pancreas and the unciate process
connected to duct of wirsung
medications associated with pancreatitis
azathioprine, furosemide, steroids, cimetidine
Type of kidney stones associated with ileostomy and why ?
uric acid stones
due to bicarbonate loss
Area most likely to perforate in appendicitis
Midpoint of antimesenteric border
Most common cause of ACUTE abdominal pain in the 1st trimester pregnancy
appendicitis
intramucosal colon cancer
high grade dysplasia within muscularis mucosa (considered carcinoma in-situ as there is no invasion of basement membrane)
Rectal cancer can metastasis directly to bone via
Batson’s plexus
colon ca does not typically go to bone
best test for T and N status for rectal Ca
endorectal u/s
Apex of tube pointing towards on AXR for sigmoid vs cecal volvulus
sigmoid (pointing toward RUQ)
cecal (pointing toward LUQ)
Perforation with ulcerative colitis mc site
Transverse colon
Perforation with Crohn’s mc site
distal ileum
conditions that Gets better with colectomy
most ocular problem
Arthritis
anemia
Most two common causes of large bowel obstruction
- cancer
- Diverticulitis
localisation studies and their sensitivity for lower GI bleeding
● Arteriography – bleeding must be ≥ 0.5 cc/min
● Tagged RBC scan – bleeding must be ≥ 0.1 cc/min
Bleeding caused by diverticulosis is venous or arterial
arterial
bleeding caused by angiodysplasia is venous or arterial
venous
diverticulum layers
only mucosa and serosa
No submucosa
Most common complication of diverticulitis
abscess formation
Typical scenario for ischemic colitis
abdominal pain and bright red bleeding per rectum after AAA repair (ligation of IMA)
SMA and IMA arise at what vertebral levels
SMA– L1
IMA– L3
cephalic phase of acid secretion
vagal dependent gastric acid secretion in response to food related stimuli (smell, taste, though) before food enters the stomach
physical exam findings in anal fissure
anodermal split (90% posterior)
sentinel tag
hypertrophied anal papilla
what do u seen on exam for rectal prolapse?
See full-thickness rectal wall with concentric rings protruding on exam
Anal cancer is associated with
HPV (16 and 18), HIV, XRT, and immunosuppression
Nodal drainage of superior and middle rectum
IMA nodes
nodal drainage of inferior rectum
mainly IMA nodes, also to internal iliac nodes
Anal canal (above dentate line)
internal iliac nodes
anal margin (below dentate line)
inguinal L.N
pharyngeal cancer that goes to anterior cervical L.N
Hypopharyngeal SCCA
painful parotid mass is highly suggestive of
malignancy
Cleft lip time of repair
Repair at 10 weeks, 10 lb, Hgb 10.
Cleft palate repair
Repair at 12 months
may affect speech and
swallowing if not closed soon enough; may affect maxillofacial growth if closed too
early → repair at 12 months
which type of CAH is salt wasting
21 beta hydroxylase deficiency
which CAH has decrease testosterone levels
17 hydroxylase deficiency
best test for diagnosing pheochromocytoma
24 hour urine metanephrines
radioactive iodine ablation only work for which type of cancer
papillary and follicular
(the well-differentiated thyroid cancers)
Thyroglobulin serum levels is used to follow up what cancer
papillary and follicular
(the well-differentiated thyroid cancers)
pathology of hurthle cell ca thyroid shows
Ashkenazi cells.
sestamibi scan does not work with
4-gland hyperplasia
difference in flow between ICA and ECA
- Normal (ICA) has continuous forward flow (biphasic signal, fast
antegrade, then slower diastolic antegrade signal). - Normal(ECA) has triphasic flow (antegrade, retrograde, then
antegrade again).
1st branch of external carotid artery
superior thyroid artery
1st branch of internal carotid artery
Ophthalmic artery
CEA indications
symptomatic > 50%
asymptomatic > 70% stenosis
most common cranial nerve injury with CEA
Vagus nerve
DeBakey classification
for aortic dissection
- Type I – ascending and descending
- Type II – ascending only
- Type III – descending only
paraplegia cause during repair of descending thoracic aortic surgery
caused by spinal cord ischemia due to occlusion of intercostal arteries and
artery of Adamkiewicz that occurs with descending thoracic aortic surgery
most common organism in graft infection following AAA repair
S.epidermidis
Mycotic aneurysm
Bacteria infect atherosclerotic plaque, cause aneurysm.
Leg compartments and their associated structures
- Anterior – deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes),
anterior tibial artery - Lateral – superficial peroneal nerve (eversion, lateral foot sensation)
- Deep posterior – tibial nerve (plantar flexion), posterior tibial artery, peroneal artery
- Superficial posterior – sural nerve
what do u know about hunter’s canal lower extremity
SFA exits this canal
and it is covered by the sartorius muscle
similar to ABPI but more accurate in patients with calcified vessel walls
toe pressure/Brachial pressure index
TBI
most common site for diabetic foot ulcers
2nd MTP (metatarsal head) joint most common
when to consider prophylactic fasciotomy
for ischemia > 4–6 hours
which leg compartment is most likely to be affected by reperfusion compartment syndrome
Anterior leg compartment
hence the most common finding are foot drop and loss of sensation between first and second toes because deep peroneal nerve is affected
the most common site of
peripheral obstruction from emboli.
Common femoral artery at bifurcation of SFA and profunda is the most common site
Normal subclavian vein course
passes anterior to the anterior scalene muscle
Normal subclavian artery and brachial plexus course
passes between the anterior and middle scalene muscles
The plexus is behind the artery
Most common causes of visceral ischemia:
- Embolic occlusion – 50%
- Thrombotic occlusion – 25%
- Nonocclusive mesenteric ischemia (NOMI) – 15%
- Venous thrombosis –5%
Median arcuate ligament syndrome
Causes celiac artery compression
Migrating thrombophlebitis is associated with
Pancreatic cancer
cisterna chyli is at what vertebral level
L2
a lung lesion is considered a solitary pulmonary nodule and not a mass when its size is less than
3 cm
Most common site of lung cancer mets
brain
types of lung cancers are broadly divided into
Non-small lung ca
Small lung ca
paraneoplastic of squamous cell cancer
PTHrp
Paraneoplastic syndrome of small cell lung cancer
ACTH and ADH
Most common site for lung abscess
RLL
MHC 1 is activates what cell
CD8
MHC 2 activated what cells
CD4
CD4 cell function
- Release IL-2, which mainly causes maturation of cytotoxic T cells
- Release IL-4, which mainly causes B-cell maturation into plasma cells
- Release interferon-gamma which activates macrophages
MC antibody in the spleen
IgM
surgery for PTX
recurrence, persistent air leak > 5 days, non-reexpansion
(despite 2 chest tubes), high-risk profession (airline pilot, diver, mountain
climber), patients who live in remote areas, tension PTX, hemothorax,
bilateral PTX, previous pneumonectomy, large bleb on CT scan
clotting factor with the shortest half life
factor 7
which type of VWF deficiency will DDVAP not work in
Type 3
Tx of bernard soulier and glanzman thrombocytopenia
platelets
tumor marker that is considered the most sensitive of all tumor markers
PSA
(though it not that specific)
colon cancer least likely site of mets
bone
survival rate if colon mets to the liver is successfully
resected
35% 5-year survival
one of the few tumors for which surgical debulking
improves chemotherapy (not seen in other tumors)
ovarian cancer
ABO compatibility is generally required for all organ transplant except
Liver transplant
1 malignancy following any transplant
(squamous cell skin
CA #1)
Mycophenolate and azathioprine (imuran) MOA?
These are immunosuppressants which inhibits de novo purine synthesis which inhibits growth of T cells
highest concentration of sweat glands are present in
1 soles of foot, palms
pathology of BCC
peripheral pallisading of nuclei
Most aggressive type of BCC and why
Morpheaform type – most aggressive; has collagenase production
Platelet activating factor
is not stored, generated by phospholipase
in endothelium; is a phospholipid
Mainly a chemotactic
strongest angiogenesis factor?
hypoxia
MOA of Nitrous oxide
NO activates guanylate cyclase and increases cGMP, resulting in vascular
smooth muscle dilation
causes vascular smooth muscle constriction (opposite effect of
nitric oxide)
Endothelin
Main initial cytokine response to injury and infection is release of
TNF-α
IL- 1
Main source for both macrophages
pathogenesis of atelectasis
alveolar macrophages release of IL-1
Interferones
are produced by lymphocytes in response to viral infection
activate cytotoxic t cells, NK cells, and macrophages
inhibit viral replication
rolling adhesion is caused by interaction of
L and P selectins with E-selectins
tight adhesion and transendothelial migration is caused by the interaction of
beta-integrins with ICAM, VCAM, PECAM..
Anaphylatoxins complements
C3a, C4a, C5a; ↑ vascular permeability,
bronchoconstriction; activate mast cells and basophils
oBsonin complements
c3B c4B
chemotactic complements
C3a C5a
cyclooxygenase vs lipoxygenase
PGI2 and PGE2 – vasodilation, bronchodilation
LTC4, LTD4, LTE4 – ;
bronchoconstriction, vasoconstriction
what occurs during the remodelling phase of wound healing
● Remodeling (3 weeks–1 year) – decreased vascularity
* Net amount of collagen does not change with remodeling, although
significant production and degradation occur.
* Collagen cross-linking continue with improves strength
Fibronectin
produced by fibroblasts; chemotactic for macrophages;
anchors fibroblasts
most important factor in healing open wounds
(secondary intention)
Epithelial integrity
Cytotoxic drugs – 5FU, methotrexate, cyclosporine, FK-506 have the maximum effect on wound healing in the first
14 days
bacterial wound load that affects wound healing
Bacteria > 10(to the power of 5)/ cm2
how much do u need to wait before scar revision and why
wait for 1 year to allow maturation; may improve with
age
chemotherapy effect on wound healing is for
2 weeks only
parkland formula is used for and capped at
Use for burns ≥ 20% BSA (≥ 2nd degree; capped at 50% BSA) only)
difference between adult and child TBSA burn estimate
take from each lower limb 4.5% (total 9)
and add to head
(head becomes 9+9)
18
inhalational injury mechanism of damage
Caused primarily by inhalation of carbonaceous materials and smoke, not heat
Skin grafts are contraindicated in case of
culture is positive for beta-hemolytic strep or
bacteria > 10(5)
autograft vs homo (allograft)
same person vs cadaver
