Anatomy and Surgery 2 Flashcards
1
Q
Extension of the breast
A
From ribs 2-6
2
Q
Level of the nipple
A
4th ICS
3
Q
Retraction of the nipple is caused by:
A
Pulling on the lactiferous ducts
4
Q
Skin dimpling in Breast Ca is caused by:
A
Shortening of Cooper’s ligament
5
Q
Interference with lymphatic drainage of the breast
A
Peau d’ orange sign - thickened, leather like appearance of the skin
6
Q
Innervation: muscles of facial expression
A
Cervical branch of CN VII
7
Q
Level of hyoid bone
A
C3 or C4
8
Q
Infrahyoid muscle that depresses the larynx
A
Sternothyroid
9
Q
Hyoid muscles innervated by C1 nerve
A
Geniohyoid, Thyrohyoid
10
Q
Weakness of Trapezius muscle - cannot shrug and abduct the arm
A
Accessory nerve lesion - crosses the occipital triangle
11
Q
Triangle crossed by external jugular vein and subclavian artery
A
Subclavian/Suboccipital Triangle
12
Q
Level of Thyroid Gland
A
C5 to T1 vertebra
13
Q
Narrow tube that connects the thyroid gland to the tongue
A
Thyroglossal Duct - normally atrophies and disappears
14
Q
Condition associated with esophageal atresia resulting to Polyhydramnios
A
Tracheoesophageal Fistula
15
Q
Abducts the vocal cords
A
Posterior cricoarytenoid
16
Q
Adducts the vocal cords
A
Lateral cricoarytenoid
17
Q
Relaxes the vocal cords
A
Thyroarytenoid
18
Q
Tenses the vocal cords
A
Cricothyroid - external branch of SLN
19
Q
RLN more commonly injured
A
Left - hooks around arch of the aorta
20
Q
Nerve supply to the diaphragm
A
Phrenic - motor (from C3, C4 and C5)
21
Q
Blood supply of nose
A
Hasselbach’s plexus (anterior), Woodruff’s plexus (posterior)
22
Q
Odontogenic tumor that may erode the bone cortex. Radioluscent soap bubble appearance on xray
A
Ameloblastoma - Tx is resection
23
Q
Innervates the muscles of mastication
A
3rd division CN V
24
Q
Sentinel node of laryngeal SCC
A
Delffian node - prelaryngeal node
25
Facial nerve exits what foramen
Stylomastoid foramen
26
Most common salivary gland malignant tumor
Mucoepidermoid Ca
27
Nerves protected during Mandibulectomy
Hypoglossal nerve inferiorly, Lingual nerve superiorly
28
Location of thyroid isthmus
C2-C4
29
Anatomic landmark where RLNs are prone to injury
Ligament of Berry
30
RAI imaging for lingual thyroid or to search for residual thyroid after thyroidectomy
Iodine 123
31
RAI used to screen and treat differentiated thyroid Ca
Iodine 131
32
Screening method for undifferentiated or anaplastic thyroid Ca
PET scan
33
Most common thyroid Ca and has the greatest tendency to invade LN
Papillary Ca
34
Medullary thyroid Ca: worst prognosis
Familial type - MEN 2B
35
FNAB of Anaplastic Thyroid Ca
Giant multinucleated cells
36
Tx for Thyroid Lymphoma
CHOP regimen - Cyclophosphamide, Doxorubicin, Oncovin/Vincristine, and Prednisone
37
Most common malignancy that metastasize to the thyroid
Renal Cell Ca
38
Sharp indentation that approximates the junction of the body and pyloric part of the stomach
Angular incisure/notch
39
Portal vein is made of:
Superior mesenteric vein + splenic vein
40
Rule out what Ca in gastric ulcer
Gastric adenocarcinoma
41
Most common type of Gastric Ulcer
Type I - found in antral lesser curvature, blood type A
42
Caused by destruction of the pyloric sphincter resulting to abrupt delivery of hyperosmolar load to the small intestines
Dumping Syndrome
43
Most common pancreatic tumor in patients with MEN I
Gastrinoma
44
Diagnosis of ZES
Serum gastrin more than 200pg/mL after a secretin challenge
45
Gastrinoma Triangle or Passaro's Triangle
Pancreatic neck, Porta hepatis, 3rd portion of duodenum
46
Clinical Triad of ZES
Hypersecretion of HCl, severe PUD, Gastrinoma
47
Large, tortuous submucosal artery in the proximal stomach. Pulsations cause ulceration of the overlying mucosa causing intraluminal bleeding
Dieulafoy's Lesion
48
Most common form of Gastric Ca
Gastric Adenocarcinoma - dysplasia as universal precursor
49
Tx for gastric adenocarcinoma <2 cm
Endoscopic Mucosal Resection - tumors limited to mucosa or submucosa
50
Diffuse neoplasm involving the entire stomach giving it a "leather bottle" appearance
Linitis plastica
51
Periumbilical node in Gastric Adenocarcinoma
Sister Mary Joseph's Node
52
Peritoneal nodes in Gastric AdenoCa, palpable on rectal examination
Blumer's Shelf
53
Tx goal of Gastric AdenoCa
Resection of all tumor with 5cms grossly negative margins
54
Standard operation in Gasttic AdenoCa
Radical Subtotal Gastrectomy - remove distal 75%
55
Gastric Lymphoma arises from MALT. Majority are what type?
Non Hodgkin's B Cell Type
56
Presents like gastric adenocarcinoma with B symptoms (fever, weight loss, night sweats)
High grade MALT lymphoma
57
Tx for low grade MALT lymphoma
H. Pylori eradication
58
GIST arise from the?
Interstitial cells of Cajal - pacemaker in GI tract
59
Tumor markers of GIST
c-KIT (CD 117) and CD 34
60
Most common type of GIST
Epithelial cell stroma
61
Tx for GIST
Wedge resection, Imatinib (Gleevec) for unresectable or metastatic GIST
62
Gastric carcinoids arise from?
Gastric ECL cells
63
Most common type of Gastric Carcinoid
Type I - women with hypergastrinemia, small but multiple, low malignant potential
64
Type of Gastric Carcinoid that occurs in MEN I and ZES
Type II - higher malignant potential
65
Type of Gastric Carcinoid that presents with Carcinoid Syndrome
Type III - solitary, among men
66
Biopsy: diffuse hyperplasia of surface mucus secreting cells and decrease parietal cells
Hypertrophic Gastropathy (Menetrier's Disease) - protein losing enteropathy and hypochlorhydia
67
Presentation is dilated mucosal blood vessels in the distal stomach
Watermelon Stomach (Gastric Antral Vascular Ectasia)
68
Most common position of the appendix
Retrocecal
69
Nerve that can be possibly injured during appendectomy
Iliohypogastric nerve - weakening of anterior abdominal wall
70
Used as a landmark during OR to identify the location of the appendix
Anterior taenia
71
Where is McBurney's Point?
Lateral 1/3 from ASIS to umbilicus
72
Appendicitis: pain on extension of right thigh
Psoas sign - tip of appendix is retrocecal
73
Appendicitis: pain on passive internal rotation of the flexed right thigh with the patient in the supine position
Obturator Sign - tip of the appendix is on the pelvis
74
CT scan findings in Appendicitis
Enlarged enhancing appendix (>6mm), periappendiceal fat stranding, wall thickening
75
Complication of appendicitis. A mass of inflamed, matted intestine and omentum with little or no discrete collection of pus
Phlegmon - complication of gangrenous acute AP
76
Most important pathogen in AP related infection
Bacteroides fragilis
77
When is an incidental appendectomy routinely performed?
Ladd's procedure - correction of intestinal malrotation with volvolus in children
78
Most common malignancy of the appendix
Carcinoid - usually at the tip
79
Tx for adenocarcinoma of the appendix
Right hemicolectomy
80
Diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentum
Pseudomyxoma peritonei - Tx with surgical debulking (appendectomy, omentectomy, TAHBSO)
81
Fatty tags in the large intestine
Appendices epiploicae
82
Longest, largest and most mobile part of the large intestines
Transverse colon
83
Blood supply of cecum
Anterior/posterior cecal artery from ileocolic artery (SMA)
84
Blood supply of appendix
Appedicular artery from ileocolic artery (SMA)
85
Venous drainage of appendix
Appendicular vein to posterior cecal vein (SMV)
86
Blood supply of ascending colon
Ileocolic and right colic artery from SMA
87
Blood supply of transverse colon
Middle colic artery from SMA and L colic artery from IMA
88
Blood supply of descending colon
L colic and sigmoid artery from IMA
89
Blood supply of sigmoid colon
Sigmoid artery from IMA
90
5 inches long, begins in front of 3rd sacral vertebrae and ends in front of the tip of the coccyx
Rectum
91
Blood supply of the rectum
Superior rectal from IMA, middle rectal from internal iliac and inferior rectal from internal pudendal
92
Muscles in internal and external anal sphincter
Internal - circular muscles, external - 3 striated voluntary muscles
93
Dentate/Pectinate/Anorectal Line
Junction between the superior (endoderm) and inferior (ectoderm) parts
94
Muscle that forms a U shaped sling resulting to a 90 degree perineal flexure
Puborectalis Muscle
95
Disease due to absence of ganglionic cells in the myenteric and submucosal plexuses. Mutations of RET proto-oncogene
Hirschsprung Disease (Colonic Aganglionosis) - sigmoid colon and rectum, failure of internal anal sphincter to relax
96
Blood supply to the upper part of the anal canal
Superior rectal artery from IMA
97
Lymphatic drainage of upper part of anal canal
Inferior mesenteric LN
98
Blood supply of lower anal canal
Inferior rectal artery from internal pudendal artery
99
Lymphatic drainage of lower part of anal canal
Superficial inguinal nodes
100
Sensations: Upper vs Lower Anal canal
Upper - stretch, Lower - pain temperature touch pressure
101
Outpouching of a remnant of the proximal portion of the yolk sac
Meckel's Diverticulum
102
Diverticulum located 2ft from ileocecal junction, 2in long, and may contain ectopic gastric or pancreatic cells
True Diverticulum - bleeding with ulceration of ectopic cells
103
True or false: R and L colon are retroperitoneal while transverse and sigmoid colon are intraperitoneal
True
104
Widest portion of the colon with the thinnest wall
Cecum - high risk of perforation
105
Most common area of obstruction in the colon and high risk for volvulus
Sigmoid - narrowest portion
106
Twisting of an air filled segment of bowel about its narrow mesentery
Colonic volvulus - counterclockwise usually, apex is opposite where it twists
107
Abdominal x-ray of sigmoid volvulus
Inverted U shape, sausage like loop
108
Indicates successful reduction in sigmoid volvulus
Passage of air and feces through soft rectal tube
109
Emergent procedure for a septic patient with volvulus (bowel unprepared)
Hartmann's Procedure - resection of sigmoid colon with construction of an end colostomy
110
Proctoscope findings in sigmoid volvulus
Swirl sign or the area where it twists, procedure contraindicated for necrotic tissue
111
Type of colostomy where midline laparotomy needed for take down
Devine's colostomy
112
Plain abdominal x-ray of Cecal Volvulus
Kidney shaped, air filled structure in the LUQ - does not resolve with NGT placement
113
Tx for cecal volvulus
R hemicolectomy with primary ileotransverse anastomosis
114
Transverse colon loops that are interposed between the liver and diaphragm
Chilaiditi's syndrome - at risk for volvulus
115
Tx of rare, R sided diverticulitis
Segmental ileocecal resection
116
Most common cause of life threatening colonic hemorrhage
Diverticular disease
117
IBD that cannot be cured with surgery
Crohn's Disease
118
Most common location of Crohn's disease
Terminal ileum, but can happen anywhere
119
Pathologic findings of Crohn's Disease
Transmural involvement, skip lesions, non caseating granulomas, perianal fistulas, cobblestoning strictures
120
Most common type of colonic polyp
Hyperplastic, not pre-malignant
121
Colonic polyp that can be malignant if it occurs with a syndrome
Hamartomatous or Juvenile - occurs at any age
122
Colonic polyp where malignancy is related to its size (>2cm)
Adenomatous
123
FAP with extraintestinal manifestations (mandibular osteomas, hypertrophy of pigmented retinal epithelium, desmoid tumors)
Gardner's Syndrome
124
FAP with brain tumors (glioblastoma)
Turcot's Syndrome
125
Polyposis + epidermal changes (alopecia, cutaneous pigmentation, atrophy of nails)
Cronkite Canada Syndrome (AD)
126
Hamartomatous polyps of all 3 embryonal cell layers
Cowden's Syndrome - with breast Ca, leiomyomas, thyroid disease and facial trichilemmomas
127
Polyposis on jejunum, ileum and rectum. With melanin spots on lips and buccal mucosa
Peutz-Jegher's Syndrome
128
Mutation in FAP resulting to 100% lifetime Ca risk
SPC mutation, chromosome 5q
129
Mutations in Hereditary Nonpolyposis Colon Cancer
hMLH1 and hMSH2 mutation - 85% risk Ca, screening colonoscopy at 20 to 25yrs
130
Distinct curvatures that project into the lumen of the rectum
Valves of Houston
131
Retrosacral fascia of rectum
Waldeyer's fascia
132
Anterior fascia of rectum
Denonvillier's fascia
133
Levator ani muscles that make up the pelvic floor
Pubococcygeus, Ileococcygeus, Puborectalis muscle
134
Surgical anal canal
From anorectal ring to anal verge
135
At most risk during lateral mobilization of the rectum
Pudendal nerve - supplies pain, temperature and touch sensation to lower anal canal
136
At most risk during posterior mobilization of the rectum
Hypogastric plexuses - retrograde flow of sperm to the bladder
137
Etiology of rectal prolapse
Internal intussusception, outlet obstruction, long term laxative use
138
Thiersch procedure for rectal prolapse
Use a wire to tighten the sphincter
139
Common locations of hemorrhoids
3, 7 and 11 o'clock position
140
Tear in anoderm just distal to the dentate line
Anal fissure - pain causes spasm of the internal sphincter
141
Surgical Tx for anal fissure
Lateral internal sphincterotomy to relieve spasm
142
Complication of posterior sphincterotomy as a repair of anal fissure
Keyhole deformity - frequent soiling of underwear
143
Chronic form of anorectal abscess
Fistula-in-ano
144
Fistula-in-ano: Goodsall's Rule
Anterior straight, posterior curved
145
Well differentiated keratinizing anal neoplasm often caused by HPV infection
Squamous cell Ca - Tx with wide local excision with 2cm margin, if sphincter affected do APR
146
Intraepidermal squamous cell Ca of anus treated with wide excision
Bowen's Disease
147
From apocrine glands, patients present with severe pruritus. Treat with wide excision of APR for advanced disease
Paget's Disease
148
Treatment for Epidermoid Ca of anus
Nigro protocol - 5 FU, Nitromycin, External Beam Radiation
149
Pain, fever and ileus appearing 2-3 weeks after an attack of pancreatitis
Pseudocyst - fibrous wall surrounding a collection of pancreatic juice and necrotic or suppurative pancreatic tissue
150
Best Tx for pseudocyst of pancreas
Internal drainage
151
Most common pancreatic malignancy
Adenocarcinoma - usually at the head
152
Definitive and potentially curative Tx of periampullary Ca of pancreas
Whipple's surgery - pancreaticoduodenectomy
153
How do you know if the pancreatic head is resectable?
If you can palpate the SMA posteriorly
154
Dreaded complication of Whipple's surgery
Leak from pancreaticojejunostomy - peritoneal cavity digested by pancreatic enzymes
155
Most common functional endocrine tumor of the pancreas
Insulinoma - _insulin and C peptide, _ glucose
156
Whipple's Triad of Insulinoma
Symptomatic fasting hypoglycemia, serum glucose <50mg/dL, relief of symptoms with glucose administration
157
Tx for Insulinoma
Enucleation, if >2cm and close to main pancreatic duct Whipple's Procedure
158
Pancreatic tumor located at the tail. Causes watery diarrhea, hypokalemia, and achlorhydia
VIPoma - usually malignant
159
Pancreatic tumor with presence of necrolytic migratory erythema
Glucagonoma - found at body and tail, metastatic
160
Gastrinoma Triangle
Cystic duct, junction of the 2nd and 3rd portions of the duodenum, junction of the neck and body of the pancreas
161
First, shortest, widest and fixed (retroperitoneal) part of the small intestine
Duodenum - C shaped, 25cm long
162
Duodenum: attachment site for hepatoduodenal ligament of lesser omentum
Superior (1st) - anterolateral to L1
163
Duodenum: descends along the R sides of L1 to L3
Descending (2nd)
164
Blood supply upper part of duodenum
Superior pancreaticoduodenal artery (gastroduodenal - hepatic - celiac)
165
Blood supply of lower duodenum
Inferior pancreaticoduodenal (SMA)
166
Venous drainage of duodenum
Superior/Inferior pancreaticoduodenal veins to portal vein
167
Most common location of duodenal ulcers
Anterior wall on first part - most common site of perforation
168
Duodenal wall ulcers that may lead to severe hemorrhage and perforate into the pancreas
Posterior wall ulcer - erode gastroduodenal artery
169
Anatomic landmark of GIT that also supports the duodenojejunal flexure
Ligament of Treitz - demarcates duodenojejunal junction
170
True or false: jejunum lies in RLQ while ileum lies in LUQ
False - Jejunum lies in LUQ, Ileum lies in RLQ
171
Blood supply of jejunum and ileum
SMA - arterial arcades - vasa recta
172
Jejunum vs Ileum
Jejunum - red color, wall thick and heavy, greater vascularity, long vasa recta, few and large arcades, less fat, large and tall plicae circularis, few lymphoid nodules
173
Jejunum vs Ileum
Ileum - pink color, thin and light wall, less vascularity, short vasa recta, many arcades, more fat, sparse plicae circularis, many lymphoid nodules (Peyer's Patches)
174
Most common location of intussusception
Ileocecal - R sided colicky pain, currant jelly stools
175
Mucosal folds in the small intestine
Plicae circulares, Valvulae conniventes, Valves of Kerkring
176
Strongest layer of small intestine
Submucosa
177
Development of small intestines
Duodenum - foregut, Jejunum and Ileum - midgut
178
Lymph node aggregates in the ileum
Peyer's Patches
179
Produce an alkaline secretion to protect the GI against acidic gastric chyme
Duodenal Brunner's Glands
180
Cells in the SI that aids in digestion and absorption of dietary nutrients
Enterocytes
181
Found at the base of the crypts of Lieberkuhn. Role on phagocytosis and mucosal defense
Paneth Cells
182
Found above Peyer's Patches in ileum. For antigen presentation.
Microfold (M) Cells
183
Development of SI
5th week AOG - extracoelemic herniation. 10th week AOG - return to abdominal cavity, rotation around the SMA
184
Absorption of Na, Cl, K, Ca, Mg, Iron and H2O
Jejunum
185
Most common surgical disorder of the SI
Small bowel obstruction - 75% due to adhesions
186
Most common cause of SBO among pediatric patients
Hernias
187
Abdominal Xray SBO:
Dilated small bowel loops (>3cm), air fluid levels, paucity of air in the colon
188
Intestinal housekeeper. Determines the pattern of contraction during the fasting state
Migrating Myoelectric Complex (MMC) - peristaltic contraction every 90 to 120 min
189
Cause of intestinal fistulas
80% iatrogenic - between 5th to 10th day post op, Dx through CT with oral contrast
190
Most common small bowel neoplasm
Adenocarcinoma in the duodenum - 80% metastasis at the time of diagnosis
191
Most common type of lymphoma in small bowel
B cell lymphoma in the ileum
192
Tx for jejunal and ileal tumors
Segmental resection with at least 5cm tumor free margins
193
Most prevalent congenital anomaly of the GIT
Meckel's Diverticulum - true diverticula
194
Etiology of Meckel's Diverticulum
Persistence of the omphalomesenteric duct or vitelline duct
195
Modality of choice to diagnose Meckel's Diverticulum
Tc pertechnetate scan
196
Segmental resection for Meckel's Diverticulum
Bleeding, wide base, inflamed and perforated base
197
Most common etiology of mesenteric ischemia
Arterial embolus - from L atrial thrombi, lodges to SMA
198
Etiology of chronic mesenteric ischemia
Atherosclerotic lesions in the main splanchnic arteries (celiac, SMA, IMA)
199
Gold standard diagnostic modality of choice for mesenteric ischemia
CT scan angiography
