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PLE > Anatomy and Surgery Part 1 > Flashcards

Anatomy and Surgery Part 1 Flashcards

General Surgery Topics Stomach Small intestines Pancreas Liver Gallbladder Spleen Vertebrae

1
Q

Vertebral Level : Anatomic Structure

C3-4

A

Hyoid bone

Bifurcation of common carotid artery

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2
Q

Vertebral Level : Anatomic Structure

C5

A

Thyroid cartilage

Carotid pulse palpated

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3
Q

Vertebral Level : Anatomic Structure

C6

A

Cricoid cartilage

Start of trachea

Start of esophagus

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4
Q

Vertebral Level : Anatomic Structure

T2

A

Sternal notch

Arch of the aorta

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5
Q

Vertebral Level : Anatomic Structure

T4

A

Sternal angle

Junction of superior and inferior mediastinum

Bifurcation of trachea

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6
Q

Vertebral Level : Anatomic Structure

T5-7

A

Pulmonary hilum

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7
Q

Vertebral Level : Anatomic Structure

T8

A

Inferior vena cava hiatus

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8
Q

Vertebral Level : Anatomic Structure

T9

A

Xiphisternal joint

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9
Q

Vertebral Level : Anatomic Structure

T10

A

Esophageal hiatus

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10
Q

Vertebral Level : Anatomic Structure

T12

A

Aortic hiatus

Celiac artery

Upper pole of left kidney

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11
Q

Vertebral Level : Anatomic Structure

T12-L1

A

Duodenum

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12
Q

Vertebral Level : Anatomic Structure

L1

A

Superior mesenteric artery

Upper pole of right kidney

End of spinal cord in adults (conus medullaris) and pia mater

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13
Q

Vertebral Level : Anatomic Structure

L2

A

Renal artery

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14
Q

Vertebral Level : Anatomic Structure

L3

A

End of spinal cord in newborn

Inferior mesenteric artery

Umbilicus

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15
Q

Vertebral Level : Anatomic Structure

L4

A

Iliac crest

Bifurcation of aorta

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16
Q

Vertebral Level : Anatomic Structure

S1

A

Sacral promontory

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17
Q

Vertebral Level : Anatomic Structure

S2

A

End of dural sac, dura, arachnoid, subarachnoid space, and cerebrospinal fluid

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18
Q

Vertebral Level : Anatomic Structure

S3

A

End of sigmoid colon

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19
Q

Positional changes of the spinal cord

Embryo

A

Entire length of vertebral canal

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20
Q

Positional changes of the spinal cord

6 months

A

S1

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21
Q

Positional changes of the spinal cord

Birth

A

L3

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22
Q

Positional changes of the spinal cord

Adult

A

L1

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23
Q

Spinal cord region: Cervical
Shape
White matter
Gray matter/lateral horn

A

Oval
Fasciculus cuneatus and gracilis present
Absent lateral horn

Cuneatus - upper body
Gracilis - lower body

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24
Q

Spinal cord region: Thoracic
Shape
White matter
Gray matter/lateral horn

A

Round
Fasciculus cuneatus (T1 and T6) and gracilis present
Present lateral horn

Cuneatus - upper body
Gracilis - lower body

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25
Spinal cord region: Lumbar Shape White matter Gray matter/lateral horn
Round to oval Fasciculus cuneatus absent and gracilis present Present lateral horn Cuneatus - upper body Gracilis - lower body
26
Spinal cord region: Sacral Shape White matter Gray matter/lateral horn
Round Fasciculus cuneatus absent and gracilis present Absent lateral horn Cuneatus - upper body Gracilis - lower body
27
Functions of Dorsal/Posterior column (Ascending tract)
``` Position sense 2-point discrimination Stereognosis Vibration sense Fine, discriminitive ```
28
Functions of spinothalamic tract, anterior
Touch, crude Pressure *Spinothalamic = Contralateral manifestation, everything else is ipsilateral
29
Functions of spinothalamic tract, lateral
Pain Temperature *Spinothalamic = Contralateral manifestation, everything else is ipsilateral
30
Function of column tracts: Ascending Descending
``` Ascending = Sensory Descending = Motor ```
31
Spinal cord lesions Central cord Progressive cavitation around central canal Loss of pain and temperature sensation on hands and forearms (common in cervical)
Syringomyelia
32
Spinal cord lesions Attacks the anterior horn cells leading to LMNL
Poliomyelitis
33
Spinal cord lesions Caused by neurosyphilis Dorsal root involvement with secondary degeneration of dorsal columns (loss of position and vibration sense)
Tabes dorsalis
34
Spinal cord lesions Lou Gehrig's disease Pure motor neuron disease involving degeneration of anterior horn cells (LMNL) and corticospinal tract (UMNL) No sensory loss
Amyotrophic lateral sclerosis
35
Spinal cord lesions Caused by vitamin B12 deficiency Degeneration of posterior and lateral columns (loss of position and vibration sense in legs associated with UMNL)
Subacute combined degeneration
36
Spinal cord hemisection features
Brown-Sequard Syndrome Contralateral loss of pain and temperature Ipsilateral loss of proprioception Ipsilateral manifestation of UMNL and LMNL
37
UMN vs LMN Function
UMN: inhibits muscle stretch reflex LMN: motor component of muscle reflex
38
UMN vs LMN Type of paralysis
UMN: spastic LMN: flaccid
39
UMN vs LMN DTRs
UMN: hyperreflexia LMN: hyporreflexia
40
UMN vs LMN Muscle tone
UMN: hypertonic - Decorticate rigidity: lesion above midbrain - Decerebrate rigidity: lesion bellow midbrain LMN: hypotonic
41
UMN vs LMN Muscle mass
UMN: disuse atrophy LMN: wasting atrophy
42
UMN vs LMN Fasciculations
UMN: absent LMN: present
43
UMN vs LMN Babinski sign
UMN: positive LMN: negative
44
UMN vs LMN Other reflexes
UMN: abdominal and cremasteric lost LMN: N/A
45
UMN vs LMN Voluntary movement
UMN: decreased speed LMN: lost
46
UMN vs LMN Area of body involved
UMN: large LMN: small
47
Sign related to injury to lemniscal pathway
(+) Romberg sign Astereognosis Cannot recognize limb position Loss of two point discrimination and vibration sense
48
Brainstem lesions: What is affected? Wallenberg syndrome
lateral medullary PICA syndrome alternating sensory loss
49
Brainstem lesions: What is affected? Millard Gubler
Pons
50
Brainstem lesions: What is affected? Claude Weber
Midbrain (both)
51
Anterolateral System Loss of pain and thermal sensations on the contralateral side at what level compared to level of lesion?
1-2 segments BELOW the level of the lesion
52
Bilateral cervical spinal cord damage C4-C6 manifests as
Quadriplegia
53
Unilateral spinal cord lesions in thoracic levels manifest as
Paralysis of ipsilateral lower extremity (Monoplegia)
54
Thoracic spinal cord lesion is bilateral
Paraplegia - both extremities may be paralyzed | up toL1
55
Layers traversed in lumbar puncture/spinal needle
``` Skin Subcutaneous tissue/Superficial fascia Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural space Dura mater Arachnoid Subarachnoid space - contains CSF ```
56
Spinal tap landmark and entry
Iliac crest highest point | Above or below L4
57
Intervertebral disc herniations, cervical area
Between C5-C6 or C6-C7 C5 - biceps brachii - lateral arm C6 - brachioradialis - lateral forearm C7 - triceps brachii - digits 2, 3, 4
58
Intervertebral disc herniations, lumbar area
Between L4-L5 or L5 to sacrum L4 - patellar tendon - medial aspect of leg S1 - achilles tendon - lateral aspect of foot
59
IVD herniation between 5th and 6th cervical vertebra compresses what nerve root?
Sixth cervical
60
Strong thigh flexors but weak hamstrings. Where is the lesion?
L5
61
Spina bifida occulta most commonly affected vertebral levels
L5 and S1 No clinical manifestations, just dimple and tuft of hair
62
Severe type of spina bifida
SB cystica
63
Spina bifida + CSF + meninges
SB with meningocoele
64
Spina bifida + spina cord and/or nerve roots
SB with meningomyelocoele
65
Most severe spina bifida, spinal cord is open because of failure of neural fold fusion
SB with myeloschisis
66
What incomplete spinal cord syndrome? Bilateral paresis: upper > lower
Central cord syndrome
67
What incomplete spinal cord syndrome? Bilateral motor paralysis, loss of pain and temperature sensation, autonomic dysfunction below the level of the lesion
Anterior cord syndrome
68
What incomplete spinal cord syndrome? Ipsilateral loss of proprioception, vibration, and touch sensation below the level of the lesion
Posterior cord syndrome
69
What incomplete spinal cord syndrome? Ipsilateral Loss of proprioception, vibration, tactile discrimination below level of the lesion Segmental flaccid paresis at the level of the lesion Spastic paralysis below level of lesion Ipsilateral Babinski sign Contralateral loss of pain and temperature sensation one or two levels below lesion
Brown-Sequard/Hemisection syndrome
70
What incomplete spinal cord syndrome? Flaccidity, areflexia and impairment of bladder and bowel function Regeneration of peripheral nerves is possible (as long as endoneurium is intact, this is possible)
Cauda equina syndrome
71
Round ligament of the liver is also called
Ligamentum teres Remnant of the (left) umbilical vein, between left and quadrate lobe
72
Fetal structures = adult derivatives Umbilical artery
Medial umbilical ligament
73
Fetal structures = adult derivatives Ductus venosus
Ligamentum venosum
74
Fetal structures = adult derivatives Urachus
Median umbilical ligament
75
Fetal structures = adult derivatives Foramen ovale
Fossa ovalis
76
Fetal structures = adult derivatives Ductus arteriosus
Ligamentum arteriosum
77
Enumerate the liver segments | based on bile ducts and hepatic vessels
``` Anatomy: I - Medial superior II - Lateral superior III - Lateral inferior IV - Medial inferior (landmark: Quadrate lobe, beside gallbladder) V - Anterior inferior VI - Posterior inferior VII - Posterior superior VIII - Anterior superior ``` ``` Surgery: I - Caudate II and III - Lateral segment IV - Left medial segment V and VIII - Right anterior lobe VI and VII - Right posterior lobe ```
78
Liver arrangement based on blood flow, a.k.a. Acinus of Rappaport
Liver acinus Diamond-shaped Central veins long axis, portal triads shorter axis Zone 1 most perfused Zone 3 most prone to ischemic injury
79
Liver arrangement with central vein at center, 6 portal triads at side
Hepatic lobule
80
Liver arrangement based on bile flow, triangular in shape, apices are central veins
Portal lobule
81
Contents of porta hepatis
Portal triad: 1. Portal vein (a.k.a. hepatic vein) 2. Hepatic artery 3. Bile duct
82
30% (25% in surgery) of liver blood supply, from celiac artery
Hepatic artery
83
70% (75% in surgery) of liver blood supply, from superior mesenteric and splenic veins
Portal vein
84
Pringle maneuver can control liver hemorrhage since the hepatoduodenal ligament at the epiploic foramen contains
Portail vein Hepatic artery Common bile duct
85
Where is the needle inserted to get a liver biopsy?
R 10th ICS at the MAL
86
Right hepatic vein drains
Segment V and VIII (surgery)
87
Middle hepatic vein drains
Segments IV, V, VIII (surgery)
88
Left hepatic vein drains
Segments II, III (Surgery)
89
IVC drains what segment?
Caudate lobe/ I (surgery)
90
Trace bile drainage
``` Bile canaliculi Intrahepatic ducts Common hepatic duct (+ cystic duct) Common bile duct ```
91
Cantlie/Rex-Cantlie line separates right and left lobes, it passes at the IVC and the
Gallbladder (important for segmentectomy, separates right medial and left medial lobes, middle hepatic veins also falls in this area/line)
92
LFTs for hepatocellular injury
AST - SGOT | ALT - SGPT
93
LFTs for abnormal synthetic functions
Albumin | Clotting factors except for Factor VIII (also made in endothelium, useful for liver failure determination)
94
LFTs for cholestasis
B2 - conj. bili total bilirubin GGTP alk phos
95
Best test to measure liver's synthetic function
Prothrombin time + INR Decreased in Vit K deficiency since there will be nothing to carboxylate the factors used to measure PT
96
Increased in intrahepatic cholestasis, hemolytic disorders, conjugation or hepatic uptake defects of bilirubin
Indirect (unconjudated) bilis
97
Increased in extrahepatic cholestasis or obstructive cholestasis, problems of intrahepatic excretion of bilirubin
Direct (conjugated) bilis
98
Half life of 7 days, synthesized in liver and bone, increase is indicative of biliary obstruction
Alkaline phosphatase
99
Early marker, sensitive for biliary disease but also elevated in a lot of other conditions
GGTP
100
At what serum bilirubin is jaundice detectable?
>2.5 to 3 mg/dl
101
Intra-hepatic causes of jaundice
Crigler-Najar - glucoronyl transferase Gilbert disease Dubin-Johnson/Rotor syndrome Hepatitis from whatever cause
102
Causes of jaundice: Prehepatic Posthepatic
Prehepatic: Acquired or inherited hemolytic anemias, protein loss Posthepatic: Obstruction of bile flow
103
When bile enters vasculature in the setting of abnormal fistulae (ex. Hep C patient)
Hemobilia RUQ pain, jaundice, dec Hgb, FOBT positive
104
7 complications of liver cirrhosis
1. Portal hypertension 2. Malnutrition 3. HCCA 4. Progressive hyperbilirubinemia 5. Hepatic encephalopathy 6. Decreased synthetic function 7. Spontaneous bacterial peritonitis
105
DOC for acute esophageal variceal bleed
Octreotide Splanchnic vasoconstriction
106
No need to biopsy to confirm malignancy in these organs, biopsy only if they seem unresectable on imaging
1. Liver 2. Pancreas 3. Salivary glands 4. Gonads 5. Retroperitoneum
107
Trace origin of cystic artery
Celiac artery --> Common hepatic --> Right hepatic --> Cystic artery Celiac art. - Left gastric - Splenic - Common hepatic - -> Right hepatic - -------> cystic artery - -> Left hepatic - -> Gastroduodenal - -> Right gastric
108
Indications for cholecystectomy (asymptomatic)
Elderly with diabetes Isolation from medical care for extended periods Increased risk of GB cancer
109
Gall stone disease risk factors
``` Female Obese Pregnant Crohn disease Gastric and terminal ileal surgery Hemolytic disorders Biliary stasis ```
110
Major organic solutes in gallstones
Cholesterol Bile salts Phospholipids
111
Prophylactic cholecystectomy indicated in patients with
Hemoglobinopathies (sickle cell disease) Hereditary spherocytosis and thalassemia at the time of splenectomy Transplant patients (cardiac and lung)
112
Acute cholecystitis DOC for analgesia
NSAIDs and Meperidine | Surgery: no evidence that morphine induces spasm of sphincter of Oddi
113
Radiologic sign in gallstone-induced pancreatitis
Smooth narrowing of distal common bile duct
114
Normal INR range
In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung.
115
Adenicarcinoma at bifurcation of hepatid ducts, also perihilar cholangiocarcinoma, a.k.a.
Klatskin tumor (bile duct carcinoma) Elevates: CA125, CEA, CA19-9
116
Common bile duct diameter (normal)
The mean diameter of the normal common duct was 4.1 mm. A common duct greater than 7 mm in diameter can be seen in (a) nonjaundiced patients with gallstones and/or pancreatitis, or (b) jaundiced patients with common duct obstruction by stone or tumor.
117
Occupies area between diaphragm and stomach, corresponds to 9th, 10th and 11th left rib
Spleen
118
Ligament between the hilum and greater curvature of the stomach, carries short gastric and left gastroepiploic vessels
Gastrosplenic ligament/omentum
119
Ligament between spleen and left kidney, carries splenic vessels, a.k.a Lienorenal ligament
Splenicorenal ligament
120
Remnants of the dorsal mesentery of the stomach
Splenicorenal/lienorenal and gastrosplenic ligaments
121
Remnants of the ventral mesentery of the stomach
Lesser omentum and falciform ligament
122
Strongest flexor of the thigh
Iliopsoas
123
Thick, fusiform muscle, muscle of the loin
psoas
124
Large, triangular, lateral side of psoas major
iliacus
125
Quadrilateral muscle
quadratus lumborum
126
Within psoas major muscle, ventral rami of L1 to L4
Lumbar plexus
127
Name and origin of nerve: Supplies skin on lower part of anterior abdominal wall
Iliohypogastric | L1
128
Name and origin of nerve: Supplies skin on lower part of anterior abdominal wall, labia majora and scrotum
Ilioinguinal nerve | L1
129
Name and origin of nerve: Cremasteric reflex, branch of it supplies cremaster muscle, the other supplies skin on thigh
Genitofemoral nerve | L1 and L2
130
Name and origin of nerve: Supplies skin on lateral surface of thigh
Lateral femoral cutaneous L2 and L3
131
Name and origin of nerve: Largest branch of lumbar plexus Supplies muscles of anterior thigh and skin on antero-medial aspect
Femoral nerve L2, L3 and L4
132
Supplies medial thigh and muscles and skin on medial aspect of thigh
Obturator nerve L2, L3 and L4
133
Lies on posterior pelvic wall in front of piriformis, anterior rami of L4, L5 and S1 to S4
Lumbosacral plexus
134
Branches of lumbosacral plexus that go to the lower limb through the greater sciatic foramen
Sciatic (L4, L5, S1, S2, S3) Superior gluteal (L4, L5, S1) - gluteus medius and minimus Inferior gluteal (L5, S1, S2) - gluteus maximus Nerve to quadratus femoris Nerve to obturator internus Posterior cutaneous nerve of the thigh
135
Branches of lumbosacral plexus to the pelvic muscles, viscera and perineum
Pudendal (S2, S3, S4) - perineum Nerve to piriformis Pelvic splanchnic nerves (S2, S3, S4)
136
Branch of lumbosacral plexus that supplies skin on lower medial part of buttock
Perforating cutaneous nerve
137
Forms most of head of pancreas, including uncinate process
Ventral pancreatic bud
138
Dorsal pancreatic bud forms
Head, body and tail
139
Pancreatic duct that extends through entire length of pancreasm joins bile duct to form hepatopancreatic ampulla, empties into second part of duodenum via ampulla of vater, ventral
Main pancreatic duct/ Duct of Wirsung
140
Pancreatic duct that lies at the head of the pancreas, drains into the main duct, may be absent, opens into duodenum via minor duodenal papilla, dorsal
Accessory pancreatic duct, Duct of Santorini
141
Blood supply of pancreas and origins
Superior pancreaticoduodenal artery from gastroduodenal branch of celiac trunk Inferior pancreaticoduodenal artery from SMA Pancreatic arteries from splenic artery (also from celiac)
142
Venous drainage of pancreas from
SMV and splenic vein, most drain into splenic vein
143
Accounts for most cases of obstructive jaundice (extrahepatic)
Pancreatic cancer
144
Pancreatic cancer that may cause portal or IVC obstruction
Neck and body
145
Structures removed in Whipple procedure
Pancreaticoduodenectomy 1. Head of pancreas 2. CBD 3. GB 4. Distal part of stomach
146
Length and weight of pancreas
15-20 cm | Weighs 75 to 100 g in adult
147
Narrowest portion of the pancreas
Neck
148
Functional obstruction of the duct of Santorini, predisposes to acute and chronic panc, most common congenital anomaly of pancreas
Pancreas divisum
149
Pancreatic veins drain into
portal vein
150
Lymphatic drainage of pancreas
Celiac nodes | Superior mesenteric nodes
151
Celiac plexus blocked in severe pain derived from
T12 (sympathetic and vagal)
152
Duodenal atresia and annular pancreas in children is associated with
Down syndrome
153
Etiology of acute pancreatitis
Miscellaneous Alcohol Gallstone
154
Complications of severe pancreatic inflammation and necrosis, caused retroperitoneal hemorrhage
Large third spacing Hypovolemia Hypotension Tachycardia
155
Pancreatitis, flank ecchymosis
Grey turner sign
156
Pancreatitis, periumbilical echhymosis
Cullen sign
157
Pancreatitis, ecchymosis of inguinal ligament
Fox sign
158
Pancreatitis, bluish discoloration of scrotum
Bryan sign
159
More specific of the panreatic enzymes
Serum lipase, sustained for a much longer period, diagnostic if 3x elevated (like amylase)
160
DDx of pancreatitis, findings of hyperamylasemia
``` Acute cholecystitis CBD stones with or without cholangitis Perforated peptic ulcer Strangulated small bowel Acute alcoholism Cancer of the pancreas Mumps ```
161
Prognosis criteria for pancreatitis
Ranson Signs
162
Ranson sign for severe panc
3 or more
163
Ranson sign for 50% mortality
> 7 signs
164
Ranson sign at admission
``` >55 years old WBC > 16k FBS > 200 LDH > 350 SGOT/AST > 250 ```
165
Ranson sign at initial 48 hours
``` Hct fall >10 BUN elevation >5 Serum Ca < 8 PO2 < 60 Base deficit > 4 Fluid deficit > 6 ```
166
Capacity of stomach
1.5 L
167
Cardiac orifice is at the level of
6th costal cartilage | T10 and T11 vertebra
168
Pyloric antrum
L1 vertebra
169
Pyloric canal
L4 vertebra
170
Gastric disease associated with projectile vomiting
Hypertrophic pyloric stenosis
171
Largest arterial supply of the stomach and the smallest branch of the celiac trunk
Left gastric a.
172
Blood supply of lesser curvature of stomach
Right gastric a. from hepatic a. | Left gastric a. from celiac a.
173
Blood supply of greater curvature of stomach
Right gastroepiploic from gastroduodenal branch of hepatic a. Left gastroepiploic from splenic a.
174
Blood supply of fundus of stomach
Short gastric from splenic a.
175
Venous drainage of stomachand detination
R and L gastric veins to portal v. L gastroepiploic and short gastric v. to splenic v. to portal v. R gastroepiploic v. to SMV to portal v.
176
Sympathetic nerve supply of stomach
T6 to T9
177
Parasympathetic nerve supply of stomach
Ant. vagal trunk from L vagus n. | Post. vagal trunk from R vagus n.
178
Most common site of peptic ulcer and adenocarcinoma in stomach
Lesser curvature at or near/above incisura angularis
179
Most common stomach lesion found at the pylorus
Carcinomas of the stomach
180
NGT insertion: length from nostril to cardiac orifice of stomach
17.2 inches or 44 cm
181
NGT insertion: Sites of esophageal narrowing
1st - 18 cm 2nd - 28 cm 3rd - 44 cm
182
Length of duodenum
25 cm
183
Vertebral level of end of duodenum
L2
184
Duodenal compression at the 3rd/horizontal part of the duodenum from superior mesenteric vessels manifests as
epigastric pain nausea after meal bilious vomiting
185
Venous drainage of stomach
Superior pancreaticoduodenal v. --> Portal v. | Inferior pancreaticoduodenal v. --> superior mesenteric v.
186
Perforation of the duodenum affects which structures?
More often anterior wall ulcers vs posterior wall Erode gastroduodenal a. causing severe hemorrhage May perforate into the pancreas
187
Gastric vs. duodenal ulcers: Origin of bleed
Gastric: L gastric a. Duodenal: Gastroduodenal a.
188
Gastric vs. duodenal ulcers: SSx
``` Gastric: Burning epigastric pain soon after eating Pain increases with food intake Relieved by antacids Incisura angularis ``` ``` Duodenal: Burning epigastric pain 1-3 hours after eating Pain decreases with food intake Relieved by antacids Wakes at night because of pain Ant. wall of first part of duodenum ```
189
Hematemesis vs. Hematochezia Boundary
Hematemesis - proximal to ligament of Treitz | Hematochezia - distal to ligament of Treitz
190
Hematemesis vs. Hematochezia Blood is seen where?
Hematemesis - vomitus | Hematochezia - stool
191
Hematemesis vs. Hematochezia Bleeds into where?
Hematemesis: lumen of esophagus, stomach, duodenum Hematochezia: lumen of jejunum, ileum, colon, rectum
192
Hematemesis vs. Hematochezia Bleeding originates from
Hematemesis: Esophageal varices or gastric or duodenal ulcers Hematochezia: May be from anywhere along GI tract
193
Lies in LUQ, proximal 2/5 of the 6 meters after duodenum
Jejunum Begins at duodenojejunal flexure
194
Lies in RLQ and is distal 3/5 of the 6 meters after duodenum
Ileum Ends at ileocecal junction
195
Trace blood supply of jejunum and ileum
Abdominal aorta --> Level L1: SMA --> arterial arcades --> vasa recta
196
Jejunum vs. Ileum Color
Jejunum - Deeper red | Ileum - Paler pink
197
Jejunum vs. Ileum Caliber
Jejunum - 2-4 cm | Ileum - 2-3 cm
198
Jejunum vs. Ileum Wall
Jejunum - thick and heavy | Ileum - thin and light
199
Jejunum vs. Ileum Vascularity
Jejunum - greater | Ileum - less
200
Jejunum vs. Ileum Vasa recta
Jejunum - long | Ileum - short
201
Jejunum vs. Ileum Arcades
Jejunum - few, large | Ileum - many
202
Jejunum vs. Ileum Fat
Jejunum - less | Ileum - more
203
Jejunum vs. Ileum Plicae circularis
Jejunum - large, tall (absorption) | Ileum - low, sparse, absent in distal
204
Jejunum vs. Ileum Lymphoid nodules
Jejunum - Few | Ileum - Many (Peyer's patches)
205
Most common site of intussusception in children due to hyperplasia of lymphatic tissue in this area
Ileocecal (ileal lymphatic tissue hyperplasia, ileum is the intusscusceptum/entering)
206
SSx of intussusception
Obstructed bowel, right-sided colicky pain, abdominal distention, hematochezia
207
Another name for plicae circulares
Valvulae conniventes | Valves of Kerkring
208
Duodenum is embryologically derived from
foregut
209
Jejunum and ileum are embryologically derived from
midgut
210
Peritoneal cavity and parietal and visceral peritoneum are derived from
mesoderm
211
Small intestines are connected with the yolk sac to through the
vitelline duct | obliterates on 6th week
212
What happens to the SI embryologically at the 5th week?
Extracoelomic herniation
213
When does the bowel retract back into abdominal cavity and undergo 270 degree counterclockwise rotation around the SMA?
10th week AOG
214
Water and electrolyte absorption and excretion in small bowel Amount of fluid entering? Absorbed? How much enters colon?
Amount of fluid entering? 8-9 L Absorbed? 80% How much enters colon? 1.5 L
215
Extrinsic causes of small bowel obstruction
Adhesions: congenital (Ladd or Meckel bands), postoperative (most common), postinflammatory (after PID) Hernias Volvulus External mass effect
216
Compression of 3rd portion of duodenum since angle between SMA and AA is narrow
SMA Syndrome a.k.a.: Wilkie syndrome- congenital, children Cast syndrome- dieters, loss of mesenteric fat
217
Intrinsic causes of small bowel obstruction
Congenital - Meckel diverticulum, atresia, stricture, stenosis Inflammatory - Crohn, diverticulitis, radion enteritis or stricture, medication-induced (NSAIDs, KCl) Neoplasms - primary (malignant vs benign), secondary (mets and carcinomatosis) Trauma
218
Intraluminal causes of small bowel obstruction
``` Foreign body Parasites Feces, meconium in CF Gallstones Intussusception Polyps and exophytic lesions ```
219
Most common mechanical obstructions causes in chidren, adolescent and elderly
Children - intussusception Adolescent - hernia Elderly - neoplasm
220
Cardinal signs of bowel obstruction (partial or completed)
Vomiting Obstipation Distention Crampy/colicky abdominal pain
221
Signs of strangulated small bowel obstruction
Disproportionate abdominal pain severity to physical findings Acidosis Hyperkalemia Cardinal: Fever, Tachycardia or tachypnea, localized abd tenderness, Leucocytosis
222
Triad of radiographic findings in SBO (70% sensitivity)
Dilated small bowel loops > 3 cm Air-fluid levels Paucity of air in colon
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Radiographic signs of strangulated small bowel obstruction
thickened small bowel loops mucosal thumb printing pneumatosis intestinalis pneumoperitoneum string-of-beads sign (air trapped in valvulae conniventes) coffee bean sign/sentinel loop: closed-loop SBO, fluid and little gas
224
Imaging gold standard for SBO (best for complete onstruction, can diff between closed loop and bowel strangulation)
CT scan with water-soluble contrast
225
Imaging gold standard for SBO (partial)
small bowel series (enteroclysis)
226
Ileus vs small bowel obstruction on UTZ
Ileus - generalized loss of peristalsis | SBO - proximal to site of obstruction, there is increased peristalsis initially
227
Strangulated SBO management
Lap
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Contraindications for non-operative/conservative management of SBO
``` suspected ischemia large bowel obstruction closed loop obstruction strangulated herbia perforation ```
229
Causes of intestinal fistulas
``` Congenital Trauma Infection Perforation Inflammation, irradiation or tumor ```
230
Factors that inhibit spontaneous closure of intestinal fistulas
FRIENDS ``` Foreign body within the fistula tract Radiation enteritis Infection/inflammation at the fistula origin Epithelialization of the fistula tract Neoplasm at the fistula origin Distal obstruction at the intestine Short tract ``` Operate within 10 days of diagnosis or at 4 months
231
Malignant small bowel tumors are more common in
Distal bowel | except for duodenum, site of adenocarcinoma
232
Risk factors for small bowel neoplasms
``` FAP HNPCC Gardner syndrome Crohn disease Peutz-Jeghers syndrome Celiac disease Neurofibromatosis Immunosuppressio (IgA dificiency, AIDS) Infection: EBV, H. pylori History of other primary cancer ```
233
5-year survival for small bowel neoplasms Best Worst
Best: Localized carcinoid (75-95%) Worst: Jejunum/ileal adenocarcinoma (5-30%)
234
Tx for unresectable or metastatic GIST
Imatinib (Gleevac)
235
CHOP regimen for small bowel lymphoma
Cyclophosphamide dOxorubicin vHincristine Prednisone
236
Most prevalent congenital anomaly of GIT
Meckel diverticulum Most common site: ileum Persistence of vitelline/omphalomesenteric duct
237
Rule of 2s of Meckel diverticulum
2% of population 2:1 male preponderance 2 feet proximal to ileoceccal valve 2 years old below comprise 50% of patients ``` children = bleeding adults = intestinal obstruction ```
238
Acute and chronic mesenteric ischemia more common in patients with
CVD | Atherosclerosis
239
Non-operative management for acute mesenteric ischemis
Vasodilator (papaverine) infusion
240
Small bowel disorder: Malrotation Manifestation Dx Tx
Manifestation: intermittent vomiting, abdominal distention, tenderness, melena Dx: Abdominal x-ray Tx: Ladd procedure, appendectomy
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Small bowel disorder: Intussusception Manifestation Dx Tx
Manifestation: intermittend colicky abdominal pain, vomiting, lethargy, currant-jelly stool, sausage-shaped mass, hyperactive bowel sounds, (+) dance sign - no bowel in RLQ Dx: Abdominal UTZ - pseudokidney sign, donut/target sign, coiled ring sign on contrast enema Tx: enema, lap, resection and anastomosis
242
Small bowel disorder: Intestinal atresia Manifestation Dx Tx
Manifestation: feeding intolerance, maternal polyhydramnios, bilious emesis, abdominal distantion, non-passage of meconium on first day of life Dx: prenatal UTZ Tx: resection and anastomosis, enterotomy
243
Small bowel disorder: Meconium ileus Manifestation Dx Tx
Manifestation: feeding intolerance, bilious emesis, cystic fibrosis family history, abdominal distention Dx: abdominal x-ray - eggshell pattern, contrast enema - microcolon Tx: ileostomy
244
Double bubble sign usually seen in
Duodenal obstruction - duodenal atresia - duodenal web - annular pancreas
245
Most common and lethal gastrointestinal disorder affecting preterm neonates
Necrotizing enterocolitis (+) pneumoperitoneum - indication for surgery
246
Short bowel syndrom
< 200 cm length malabsorptive symptoms: diarrhea, dehydration, malnutrition usually acquired > congenital Small intestine resection not well tolerated if 50-80% is removed
247
Vitamin B12 deficiency can occur after
gastrectomy - R protein from saliva hydrolyzed by pancreatic enzymes in the duodenum gastric bypass - parietal cell-derived intrinsic factor ileal resection - receptors for cobalamin absorption
248
Stomach innervation is embedded in
lesser omentum
249
Produce protective mucus layer in stomach that contains HCO3 and glycoprotein
surface mucous cells
250
Produces less alkaline mucus layer that contains glycoprotein, pepsinogen
Mucous neck cells
251
Produces hydrochloric acid and intrinsic factor
Parietal/oxyntic cells
252
Produces pepsinogen, gastric lipased and leptin
Chief/zymogenic cells
253
Produces serotonin in stomach
enterochromaffin cells
254
Produces histamine in stomach
enterochromaffin-like cells
255
Produces the lone inhibitor to HCl synthesis
D cells (somatostatin)
256
Produces gastrin in stomach
S cells
257
Compounds that induce stomach acid secretion
Acetylcholine Histamine Gastrin - most potent for HCl secretion
258
Acid-base abnormality in stomach in gastric outlet obstruction, treat first before surgery
hypokalemic, hypochloremic, metabolic alkalosis
259
Trauma --> hospital admission --> UGIB. Cause?
Erosive gastritis from mucosal ischemia
260
Most serious complication of EGD
Esophageal perforation | requires 8 hour fasting as well
261
Better than EGD in detecting diverticula, fistula , hernias
Double contrast upper GI series
262
Gastric secretory analysis is usually evaluated in patients with these conditions:
Hypergastrinemia such as Zollinger-Ellison syndrome (gastrinoma, also associated with MEN I) Refractory ulcer or GERD Recurrent ulcer after operation
263
Focal defects in the gastric or duodenal mucosa which extends into the submucosa or deeper
Peptic ulcer disease | if superficial only, erosion
264
NSAID use more common cause of what kind of PUD?
Gastric
265
Bicarbonate secretion decrease more common cause of what kind of PUD?
Duodenal
266
Method to decrease production of gastric acid
Vagotomy
267
PUD alarm symptoms
``` weight loss bleeding recurrent vomiting anemia dysphagia ```
268
PUD rebleeding risk categorization
Forrest Classification for Endoscopic Findings and Rebleeding Risks Grade IA, IB and IIA - high rebleeding risk, surgical correction needed
269
Initial Dx for pneumoperitoneum
upright chest x-ray
270
H. pylori eradication: Bismuth triple therapy | 10-14 days
Bismuth Metronidazole Tetracycline
271
H. pylori eradication: Quadruple therapy | 10-14 days
PPI Bismuth Metronidazole Tetracycline
272
H. pylori eradication: PPI triple therapy | 10-14 days
PPI Amoxicillin Clarithromycin
273
Surgical treatment of PUD for symptom of: Bleeding
Gastric: Oversew and biopsy Duodenal: Oversew
274
Surgical treatment of PUD for symptom of: Perforation
Gastric: Biopsy and patch Duodenal: Patch
275
Surgical treatment of PUD for symptom of: Obstruction
Gastric: HSV + GJ + biopsy Duodenal: HSV + GJ
276
Surgical treatment of PUD for symptom of: Non-healing ulcer
Gastric: HSV and wedge excision Duodenal: HSV
277
Gastric ulcer types
``` Type I: antral lesser curvature - most common Type II: Type I plus duodenal ulcer Type III: pre-pyloric ulcer Type IV: high in the lesser curvature Type V: NSAID-induced ```
278
Patch used for perforated PUD
omental patch
279
Difference between Billroth I and II
I - gastroduodenostomy | II - gastrojejunostomy
280
Pyloroplasty objective
widen pylorus to guarantee stomach emptying even without vagal stimulation Types: Heineke-Mikulies, Finney, Jaboulay
281
Post-gastrectomy problems
``` dumping syndrome diarrhea gastric stasis bile reflux gastritis roux syndrome gallstones weight loss anemia bone disease ```
282
Causes splanchnic vasoconstriction, helps in early dumping syndrome
octreotide
283
Used in late dumping syndrome
alpha-glucosidase inhibitors
284
Non-pharm or surg management for dumping syndrome
No liquids with meals | High fiber diet
285
Surgical managment for dumping syndrome
Conversion of Billroth to Rous en Y anastomosis
286
Bile or alkaline reflux gastritis is associated with
Billroth II (gastrojejunostomy)
287
Risk factors for gastric adenoCA (95% of stomach neoplasms)
``` Family history Diet (preserved, salt) Low Vit A and C diet Familial polyposis and adenomas HNPCC H. pylori infection Previous gastric surgery Atrophic gastritis Cigarette smoking Adenomatous gastric polyps Menetrier disease Pernicious anemia Type A blood ```
288
Most common etiologies for gastric adenoCA
H. pylori | Autoimmune gastritis
289
Most common manifestations of gastric adenoCA
weight loss anorexia early satiety
290
PE findings that suggest gastric adenoCA
``` Virchow node (left supraclavicular lymphadenopathy) axillary lymphadenopathy Krukenburg tumor Sister Mary Joseph nodule Blumer shelf ```
291
With surgery for gastric adenoCA, leave R0 margin of
5 cm
292
How many lymph node groups are present in the stomach?
18 odd number - lesser curvature even number - greater curvature
293
"Leather bottle stomach"
Linitis plastica poor prognosis Signet ring cells
294
95% non-Hodgkin type, B-cell, MALT
Gastric lymphoma
295
Gastric lymphoma risk factors
``` H. pylori gastritis Gene mutations Transplant-related immunosuppression IBD HIV infection ```
296
Management for low-grade gastric lymphoma
H. pylori eradication
297
Management for high-grade gastric lymphoma
Chemoradiation
298
Neoplasms from the interstitial cells of Cajal
GIST ``` Bleeding, early satiety, abdominal pain/fullness Huge tumors Donut sign (submucosal) ```
299
Tumor markers for GIST
CD 34, c-KIT or CD 117 Tx: Imatinib (inhibits tyrosine kinase)
300
Neoplasm that arises from gastric ECL-cells
Gastric carcinoids Type I - inflammatory (most common) Type II - gastrinoma (ZES, MEN 1) Type III - Sporadic, worst prognosis
301
Carcinoid syndrome clinical manifestations (gastric)
``` secretory diarrhea flushing telangectasia valvular heart disease pellagra cramping edema bronchial constriction ```
302
Management for carcinoid syndrome
``` debulking surgery somatostatin analogue (octreotide) ```
303
Middle-aged man with epigastric pain, weight loss, diarrhea, hypoproteinemia (protein losing enteropathy, hypochlorhydria)
Hypertrophic gastropathy (Menetrier disease)
304
A.k.a. watermelon stomach | Elderly woman with chronic GI blood loss
Gastric antral vascular ectasia
305
Congenital AVM | Men with intermittent UGIB
Dieulafoy lesion | submucosal vessel bleed
306
What to do when patient is unable to swallow and expected to not improve/no intervention more than a month?
percutaneous endoscopic gastrostomy (PEG)
307
Seen in children, regurgitation of feeding, projectile non-bilious vomitus, peristaltic gastric waves, olive-shaped mass in right upper epigastrium, hypokalemic, hypochloremic metabolic alkalosis
Pyloric stenosis Tx: Correct acid-based abnormalities, Fredet-Ramstedt pyloromyotomy

PLE (14 decks)

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