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Surgery 2 > ACS Readings > Flashcards

ACS Readings Flashcards

1
Q

Does conjugated or unconjugated bilirubin cause normal-colored urine and stools?

A
  • UNconjugated
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2
Q

What does conjugated bilirubin do to urine and stools?

A
  • dark urine and pale stools
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3
Q

What is cholestatic syndrome?

A
  • cholestasis= decreased delivery of bilirubin into the intestines (w/subsequent accumulation in hepatocytes and in blood), irrespective of the underlying cause.
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4
Q

How does SEVERE cholestasis present?

A
  • CONJUGATED hyperbilirubinemia presenting as jaundice.
  • dark urine, pale stools, pruritis, brusiing, steatorrhea, night blindness, or chronic malabsorption of fat-soluble vitamins (A, D, E, and K).
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5
Q

Are CXRs done in all pts with bowel obstruction?

A

YES to exclude sub-diaphragmatic free air.

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6
Q

What would a gas throughout the entire length of colon indicate?

A
  • ileus or partial mechanical obstruction
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7
Q

What would a paucity of distal colonic gas or an abrupt cutoff of colonic gas w/proximal colonic distention and air-fluid levels indicate?

A
  • complete or near-complete obstruction
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8
Q

What would bowel strangulation show on abdominal radiograph?

A
  • thickened bowel loops, mucosal thumb printing, and free intestinal air
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9
Q

How do you distinguish between small and large bowel gas?

A
  • small bowel outlines the valvulae conniventes, which traverse the entire diameter of the bowel lumen. Usually occupy the central abdomen.
  • large bowel outlines the colonic haustra and usually seen in the periphery.
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10
Q

What will you see with ileus?

A
  • distension usually extending uniformly throughout the stomach, small bowel, and colon.
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11
Q

What should you do if H&P indicates intestinal obstruction, but abdominal radiograph is normal?

A

do US, CT or fast MRI.

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12
Q

Is ultrasound better or worse than XRAY in emergency setting?

A

US

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13
Q

What does the American College of Radiology recommend pt with suspected high grade SBO and plain equivocal film undergo?

A
  • CT with contrast
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14
Q

What situations necessitate URGENT OR?

A
  • failure of water-soluble contrast medium to reach the colon within 24 hours
  • progressive bowel obstruction at any time after nonoperative measure are started.
  • failure to improve with conservative therapy within 36 hrs.
  • early postop technical complications
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15
Q

What situations suggest EMERGENT OR?

A
  • incarcerated, strangulated hernias.
  • peritonitis
  • pneumatosis cystoides intestinalis
  • pneumoperitoneum
  • suspected or proven intestinal strangulation
  • closed-loop obstruction
  • nonsigmoid colonic volvulus
  • sigmoid volvulus associated with toxicity or peritoneal signs.
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16
Q

What situations deem delaying operation is safe

A
  • immediate postop obstruction (just give the bowel some time to recover)
  • chronic, recurrent partial obstruction
  • paraduodenal hernia
  • gastric outlet obstruction
  • postop adhesions
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17
Q

What is important to know about esophagogastroduodenoscopy (EGD)?

A
  • nearly always revelas the source of an UGI bleed
18
Q

What is an indication for emergent EGD within 1 hr of presentation?

A
  • HEMATEMESIS

* use saline lavage to clear the stomach of blood and clots of bleeding rate is very high.

19
Q

With what should you pretreat a pt with hematemesis before EGD?

A
  • erythromycin to facilitate gastric emptying

* decreases need for multiple endoscopies

20
Q

Can most UGI bleeds be controlled endoscopically?

A

YES

21
Q

What other imaging modalities can be used for upper GI bleed?

A
  • tagged RBC scan= can confirm the presence of an ACTIVE bleeding site, but fairly nonspecific at determining the anatomical location.
  • arteriography= can only identify if bleeding is brisk (greater than 1 mL/min).
22
Q

What is the overall diagnostic success of finding an upper GI bleed with EGD + other modalities?

A
  • greater than 90%
23
Q

What is the Blatchford prediction score for upper GI bleeding?

A
  • a screening tool to assess the likelihood that a patient with an acute upper GI bleed will need to have medical intervention such as a blood transfusion or endoscopic intervention. Uses blood urea, hemoglobin, and systolic BP to grade 0-6.
24
Q

What is the Rockall prediction score for upper GI bleeding?

A
  • attempts to identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding. Uses shock, comorbidities, diagnosis, and stigmata of recent hemorrhage to grade 0-3.
25
Q

Is radionucleotide scanning SENSITIVE for lower GI bleeds?

A
  • YES, but not specific for anatomic site of bleed (detects rate as low as 0.1-0.4 mL/min).
  • pt’s RBCs are labeled with technetium 99Tc and can be detected up to 48 hours after injection.
26
Q

What is radionucleotide most used to do?

A
  • as a guide to mesenteric angiography after active hemorrhage is confirmed.
27
Q

What is a rare cause of lower GI bleeding that is easily diagnosed with radionuclide testing?

A
  • Meckles diverticulum

* uses pertechnetate, which is taken up by the ectopic gastric mucosa.

28
Q

What should you do if a pt has bleeding from a duodenal or gastric ulcer?

A
  1. initiate PPI
  2. if bleeding continues, repeat attempt at endoscopic control.
  3. if bleeding continues, consider angiography and embolization. Proceed to OR.
  4. if pt has duodenal ulcer, perform duodenotomy and oversew ulcer. Consider vagotomy. If pt has gastric ulcer, treat according to ulcer type.
29
Q

When should you consider Mallory Weiss tears?

A
  • any pt who presents with vomiting that initially is NOT BLOODY but LATER BECOMES BLOODY.
  • no therapy needing, however if bleeding is persistent, do endoscopic repair.
30
Q

What 2 things must you do when evaluating for laparoscopic cholecystectomy?

A
  1. assess likelihood of conversion to open procedure

2. determine which patients are at high risk for CBD stones.

31
Q

How may CO2 pneumoperitoneum of a cholecystectomy affect a pt with cardiovascular disease?

A
  • cardiac output
  • lung inflation pressure
  • acid-base balance
  • ability of lungs to eliminate CO2
32
Q

What will the physical exam help with in regard to trocar (surgical instrument with 3-sided cutting point) placement?

A
  • identify a body habitus that would make laparoscopy difficult by identifying abdominal scars, stomas, or hernias.
33
Q

What is the best test for diagnosing cholelithiasis?

A
  • US
34
Q

What will be performed during ERCP if stones are identified in the CBD?

A
  • endoscopic sphincterotomy
35
Q

What is an advantage of MRCP?

A
  • noninvasive for diagnosis, and does not use contrast solutions
36
Q

When will a pt be discharged following a successful laparoscopic cholecystectomy?

A
  • 6-12 hours after surgery
37
Q

What makes for technically challenging patients for lap chole?

A
  • morbidly obese and small muscular patients
  • peritoneal adhesions
  • peritonitis
  • pts who have undergone prior gastroduodenal surgery, hx of acute cholecystitis, or those with long history of recurrent gallbladder attacks.
  • severe pancreatitis
38
Q

What 3 groups should you classify pts into for choledocholithiasis?

A
  • HIGH RISK: clinical jaundice or cholangitis, visible choledocholithiasis, or dilated CBD on US. Use ERCP with sphincterotomy.
  • MODERATE RISK: hyperbilirubinemia, elevated alk phos, pancreatitis, or multiple small gallstones. Use MRCP, EUS, and intra-operative fluoroscopic cholangiography.
  • LOW RISK: otherwise healthy. Do not need cholangiography.
39
Q

What is the procedure for lap chole?

A
  • 2 incisions for grasping forceps.
  • 1 incision for dissecting forceps and clip appliers.
  • 1 incision for laparoscope.
  • Grasp the hartmann pouch.
  • main operating port is at the same horizontal level as GB or slightly higher.
40
Q

What is the first thing you should do if a patient has severe abdominal pain, has high or prolonged fever, experiences ileus, or becomes jaundiced?

A
  • perform abdominal US
41
Q

After performing an abdominal US, what should you do if you don’t see fluid?

A

HIDA scan:

  • if normal then observe pt
  • if abnormal perform cholangiography.
42
Q

After perfoming an abdominal US, what should you do if you see fluid collection?

A

aspirate fluid:

  • if enteric contents, perform laparotomy.
  • if bile, perform percutaneous drainage. If pt is ill, perform lapartomy. If pt is stable, perform MRCP or ERCP.
  • if blood, observe pt

Surgery 2 (13 decks)

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