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PLE > Anatomy and Surgery Part 2 > Flashcards

Anatomy and Surgery Part 2 Flashcards

1
Q

How long is the esophagus?

A

25 cm/ 10 inches

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2
Q

Esophagus joins the larynx (cricoid cartilage) at the pharynx at what vertebral level?

A

C6

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3
Q

Esophagus passes the diaphragm to join the stomach at what vertebral level?

A

T10

Surgery: Cardia is at T11

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4
Q

Esophageal constrictions are important to notes because

A
  1. Site of carcinomas
  2. Development of strictures
  3. Difficult to pass esophagoscope
  4. Foreign bodies commonly lodge
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5
Q

3 esophageal constrictions

A
  1. Upper/pharyngoesophageal - cricopharyngeus (1.5 cm)
  2. Middle/thoracic - left mainstem bronchus (1.6 cm)
  3. Inferior/diaphragmatic - diaphragmatic hiatus (1.6 -1.9 cm)
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6
Q

Anatomic divisions of the esophagus

A
  1. Cervical
  2. Thoracic
  3. Abdominal
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7
Q

What nerve accompanies the esophagus through the diaphragm?

A

Vagus n.

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8
Q

L and R vagi lie where in relation to esophagus?

A

LARP

L vagus anterior
R vagus posterior

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9
Q

Blood supply of esophagus

A

Cervical - inferior thyroid a. from subclavian a.
Thoraxic - esophageal a. from descending thoracic aorta
Abdominal - left gastric from celiac trunk of abdominal aorta and inferior phrenic a.

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10
Q

Venous drainage of esophagus

A

Cervical - inferior thyroid v.
Thoracic - bronchial, azygous and hemiazygous v.
Abdominal - coronary v. (distal esophagus is left gastric v.)

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11
Q

Lymphatic drainage of esophagus

A

Cervical/upper: deep cervical
Thoracic/middle: mediastinal (usual site of nodal mets)
Abdominal/lower: celiac

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12
Q

What structure also passes through esophageal hiatus that may also be compressed by a sliding hiatal hernia?

A

Vagal trunks

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13
Q

Incompetent LES (loss of high pressure zone at the esophagogastric junction), substernal burning that is worse when lying down

A

GERD/heartburn

*LES is not a true anatomic sphincter

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14
Q

Failure of relaxation of the inferior/lower esophageal sphincter

A

Achalasia

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15
Q

Abdominal part of esophagus and part of the stomach herniate into the mediastinum causing hearthburn

A

Sliding hiatal hernia

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16
Q

average distance between external orifices of the nose and stomach

A

44 cm/17.2 inches

Important for Sengstaken-Blakemore Balloon insertion

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17
Q

Test to detect structural abnormalities in esophagus

A

Barium swallow

Endoscopy

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18
Q

Test to detect functional abnormalities of esophagus

A

Manometry

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19
Q

Tests to detect increased exposure to gastric juice in esophagus

A

24 hour ambulatory pH monitoring - gold standard for GERD diagnosis
Radiographic exposure of GER (barium regurgitates when upright)

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20
Q

Complications of GERD

A 
esophagitis
stricture
repetitive aspiration
progressive pulmonary fibrosis
barrett esophagus (30 to 125x increased risk for developing adenoCA)
esophageal adenoCA
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21
Q

Barrett esophagus hallmark of intestinal metaplasia

A

presence of intestinal goblet cells (intestinalization of esophagus)

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22
Q

GERD diagnosis

A

(+) symptoms - start empiric antacids for 12 weeks

persistent symptoms: endoscopy, 24 hr ambulatory pH monitoring, esophageal manometry

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23
Q

Anti-reflux procedures

A 
Nissen fundoplication
Toupet fundoplication
Dor fundoplication
Belsey Mark IV
Hill posterior gastropexy

*T,D,B - partial fundoplication, for patients presenting with dysphagia

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24
Q

Types of diaphragmatic/hiatal hernias and description

A 
Type I (sliding hiatal hernia) - cardia, GERD symptoms - medical tx
Type II (rolling/paraesophageal) - fundus, obstruction, dysphagia, ulcers, strangulation, bleeding, volvulus, infarct - surgical tx
Type III (combined)
Type IV (additional organ herniates aside from stomach)
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25
Q

Borchardt triad (hiatal hernias) SSx indicative of incarcerated intrathoracic stomach

A

chest pain
retching with inability to vomit
inability to pass NGT

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26
Q

Esophageal diverticula based on location

A

Pharyngoesophageal (Zenker)
Mid thoracic (para-bronchial)
Epiphrenic

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27
Q

Most common esophageal diverticula with SSx

A

Zenker diverticulum

Dysphagia
Regurgitation of undigested food
Halitosis
Choking
Aspiration
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28
Q

Types of mid thoracic diverticula

A

Traction - TB, histoplasmosis, pulmo diseases

Pulsion - more common, motility disorders

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29
Q

Esophageal diverticula associated with hiatal hernia

A

Epiphrenic (distal end of esophagus)

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30
Q

Triad of achalasia

A

Hypertensive LES
Aperistalsis of esophageal body
Failure of LES to relax

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31
Q

Esophagogram findings in achalasia

A

Bird’s beak esophagus/pencil tip deformity
Air fluid level
Sigmoid esophagus
Esophageal dilatation

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32
Q

Medical management of achalasia

A

botulinum toxin
nitrates
CCBs

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33
Q

Corkscrew deformity on esophagogram

A

Diffuse and segmental esophageal spasm

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34
Q

Most common primary esophageal motility disorder

A

Nutcracker esophagus

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35
Q

Severe neck pain due to spontaneous rupture of esophagus (true surgical emergency)

A

Boerhaave syndrome

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36
Q

Caustic substance injury scale

A

Zargar’s grading classification of mucosal injury caused by ingestion of caustic substances
0 - normal
1 and 2a - good prognosis
2b, 3a, 3b - stricture formation, observe for signs of perforation

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37
Q

Usual location of esophageal carcinoma

A

SquaCA - middle third of thoracic esophagus

AdenoCA - distal esophagus

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38
Q

Risk factors for squaCA of esophagus

A 
tobacco use
alcohol use
history of head and neck cancer
history of breast cancer with radiotherapy
Plummer-Vinson syndrome
caustic injury to esophagus
achalasia
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39
Q

Risk factors for adenoCA of esophagus

A 
barrett esophagus - not in squaCA
weekly GERD symptoms - not in squaCA
history of breast cancer with radiotherapy
obesity - not in squaCA
tobacco
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40
Q

Functional grade of dysphagia

A 
1 - eating normally
2 - liquid with meals
3 - semisolids
4 - liquids only
5 - saliva
6 - cannot swallow saliva
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41
Q

Exclusion criteria for curative surgery or resection for esophageal CA

A

Age > 75years old
FEV1 < 1.25 and EF <40%
>20% weight loss
locally advance tumor

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42
Q

Best way to palliate malignant dysphagia in esophageal CA

A

Surgical

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43
Q

EHJ carcinoma classification

A

I - esophageal
II - cardiac
III - sub-cardiac

44
Q

Dysphagia, atrophic oral mucosa, spoon-shaped fingers with brittle nails, chronic anemia, middle-aged edentulous women, esophageal web (FeSO4-induced), pre-malignant lesions

A

Plummer-Vinson syndrome

45
Q

Thin submucosal ring in lower esophagus

A

Schatzki ring

46
Q

UGIB after repeated vomiting, mucosal tears along GEJ

A

Mallory-Weiss tear

47
Q

85% of esophageal atresia is what type?

A

Type C

48
Q

Segments of the large intestines and their measurements

A 
cecum - 6 cm
appendix - 6 to 10 cm
ascending colon - 13 cm
transverse colon - 38 cm
descending colon - 25 cm
sigmoid colon - 25 to 38 cm
rectum - 13 cm
rectosigmoid junction 17 to 18 cm
anal colon - 4 cm
49
Q

Blood supply and venous drainage of cecum

A

ant. and post. cecal a. from ileocolic a. from SMA

ant. and post. cecal v. from ileocolic v. to SMV

50
Q

McBurney point

A

in relation to the ant. abdominal wall, its base is situated 1/3 of the way up to the line joining the R ASIS to the umbilicus

51
Q

Most common position of appendix (trace the ileocolic a.!)

A

Retrocecal

Pelvic
Ileocecal
Subcecal

52
Q

Causes weakening of anterior abdominal wall when injured during appendectomy

A

iliohypogastric n.

53
Q

Common causes of appendicitis

A

adults - fecalith

children - lymphatic tissue

54
Q

Blood supply and venous drainage of the ascending colon

A

Ileocolic and R colic a. from SMA

Drained by ileocolic and R colic v. to SMV

55
Q

Location of ascending colon

A

Retroperitoneal

56
Q

Longest, largest and most mobile portion of large intestine

A

transverse colon

contains a transverse mesocolon

57
Q

Blood supply and venous drainage of transverse colon

A

middle colic a. and R colic a. from SMA and L colic from IMA

Drained by superior and inferior mesenteric v.

58
Q

Retroperitoneal in location, supplied by L colic and sigmoid a. from IMA and drained by IMV

A

Descending colon

59
Q

Fan-shaped mesocolon, extends from iliac fossa to 3rd sacral vertebra

A

sigmoid colon

60
Q

Structures ant. and post. to sigmoid colon

A

Posterior - rectum and sacrum
Anterior
M - urinary bladder
F - uterus and vagina

61
Q

Blood supply and venous drainage of sigmoid colon

A

sigmoid a. from IMA

drained by IMV

62
Q

Left-sided (R-sided is intussusception) colicky pain, abdominal distention and hematochezia

A

sigmoid volvulus

63
Q

diverticulosis vs. diverticulitis

A

no inflammation vs. with inflammation

64
Q

End of rectum, inside pelvic cavity, has valves of Houston

A

tip of coccyx/ anal canal

65
Q

Surgical anal canal includes

A

internal rectal v.

66
Q

Rectum relations: lateral, ant. and post.

A

lateral: ischiorectal fossa and ischial spines
posterior: sacrum, coccyx, piriformis, coccygeus, levator ani

anterior:
M - sigmoid, ileum, urinary bladder, vas deferens, seminal vesicles, prostate, perineal body, urogenital diaphragm, bulb of penis
F - sigmoid, ileum, rectouterine pouch, vagina, cervix, urogenital diaphragm, perineal body

67
Q

Blood supply and venous drainage of rectum

A

Supplied by:
superior rectal a. from IMA
middle rectal a. from internal iliac
inferior rectal a. from internal pudendal

Drained by:
superior rectal v. - IMV to portal side
middle rectal v. - internal iliac to caval side
inferior rectal v. from internal pudendal to internal iliac to caval side

68
Q

Located in the perineum, begins where rectal ampula narrows at the level of the U-shaped sling of puborectalis muscle, ends at anus

A

Anal canal

69
Q

Separates the anal canal into 2 segments with different embryonic origin, blood supply and innervation

A

dentate/pectinate/anorectal line

70
Q 
Upper/Superior anal canal:
embryonic origin
cell lining
other characteristics
blood supply and drainage
lymphatic drainage
A

Upper/Superior anal canal:
embryonic origin - hindgut endoderm
cell lining - columnar
other characteristics - anal colums of morgagni, stretch
blood supply and drainage - superior rectal a. and n.
lymphatic drainage - inferior mesenteric LN

71
Q 
Lower/Inferior anal canal
embryonic origin
cell lining
other characteristics
blood supply and drainage
lymphatic drainage
A

Lower/Inferior anal canal
embryonic origin - ectoderm
cell lining - strat. squamous
other characteristics - no anal columns, pain, temperature, touch, pressure
blood supply and drainage - inferior rectal a. and n.
lymphatic drainage - superficial inguinal LN

72
Q

Differentiate internal vs. external hemorrhoids

A

Internal hemorrhoids - painless, covered in mucosa, dilated internal rectal venous plexus

External hemorrhoids - painful, covered in skin, dilated external rectal venous plexus

73
Q

Hemorrhoidal cushions

A

Left lat
Right ant
Right post

74
Q

Differentiate degrees of hemorrhoids

A

First - bulge into anal canal, prolapse beyond the dentate line on straining
Second - prolapse through anus but reduce spontaneously
Third - prolapse through anal canal and require manual reduction
Fourth - cannot be reduced, at risk for strangulation

75
Q

In Hirschsprung, the constricted part is

A

abnormal/aganglionic (a.k.a. congenital megacolon)

76
Q

Mimics referred pain of inflamed appendix, may contain ectopic gastric or pancreatic cells - true diverticulum

A

Meckel diverticulum

77
Q

Pain and where the structures are derived

A 
Epigastric = Foregut
Periumbilical = Midgut
Hypogastric = Hindgut
78
Q

Lymphatic structures such as the spleen are derived from

A

Mesoderm

79
Q

SMA blood supply and parasympathetic innervation from vagus in the large intestine

A

Ascending and Transverse colon

80
Q

IMA and parasympathetic fibers from the pelvic splanchnic nerve from sacral nerves S2-S4

A

Descending and sigmoid colon

81
Q

Length of entire colon

A

1 to 1.5 meters

82
Q

Epithelium of colon

A

glandular epithelium with straight crypts, goblet cells and absorptive cells

83
Q

What is absorbed in the colon?

A

1 to 2 L of fluid daily
sodium
chloride
urea

84
Q

GIT forms at what week of gestation?

A

4th

85
Q

Special signs of appendicitis on PE:

Referred pain or feeling of distress on epigastrium or precordial region on continued firm pressure over the McBurney point (RLQ)

A

Aaron sign

86
Q

Special signs of appendicitis on PE:

Bassler sign

A

Sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle (chronic appendicitis)

87
Q

Special signs of appendicitis on PE:

Transient abdominal wall rebound tenderness

A

Blumberg sign

88
Q

Special signs of appendicitis on PE:

Exacerbation of pain when the uterus is shifted to the right side (acute appendicitis in pregnancy, also in acute panc)

A

Bryan sign

89
Q

Special signs of appendicitis on PE:

Cutaneous hyperesthesia

A

In area supplied by spinal nerves on the right (T10, T11, T12)

90
Q

Special signs of appendicitis on PE:

Increased abdominal pain on coughing

A

Dunphy sign

91
Q

Special signs of appendicitis on PE:

Kocher/Kosher sign

A

Migration of pain from the umbilical region to the right iliac region

92
Q

Special signs of appendicitis on PE:

RLQ pain on dropping from standing on toes to heels

A

Markle sign

93
Q

Special signs of appendicitis on PE:

Massouh sign

A

Grimace when examiner performs a firm swish with index and middle finger across abdomen from epigastrium to right iliac fossa

94
Q

Special signs of appendicitis on PE:

Tenderness in RLQ increases when patient moves from supine position to a recumbent posture on left side

A

Rosenstein sign

95
Q

Special signs of appendicitis on PE:

Rovsing sign

A

Pain at RLQ when palpatory pressure exerted at LLQ

96
Q

Special signs of appendicitis on PE:

Patient lies on left side, examiner then slowly extends R thigh, stretching the iliopsoas muscle (positive if extension produces pain)

A

Iliopsoas sign

97
Q

Special signs of appendicitis on PE:

Obturator sign

A

Performed by passive internal rotation of the flexed right thigh with the patient in supine position (positive if with hypogastric pain on stretching the obturator internus muscle)

98
Q

Special signs of appendicitis on PE:

Increased abdominal muscle tome on exceedingly gentle palpation of the right iliac fossa (early appendicitis)

A

Summer sign

99
Q

Special signs of appendicitis on PE:

Ten Horn sign

A

Pain caused by gentle traction on the right spermatic cord (caused by cord tension)

100
Q

Prehn sign

A

testicular torsion, if testicles are lifted, pain is relieved

101
Q

Alvarado score has 85% accuracy for appendicitis. What are its components? Score of 7-8 is high likelihood of appendicitis

A 
Migratory RLQ pain
Anorexia
Nausea or vomiting
RLQ (right iliac fossa) tenderness
Rebound tenderness of R iliac fossa
Elevation in temperature
Leukocytosis
Shift to the left of neutrophils

Another scoring system: Appendicitis Inflammatory Response score (vomiting, RLQ pain, rebound tenderness, elevated temperature, PMN, WBC, CRP), Score of 9-12: Explore

102
Q

Normal appendix on ultrasound

A

Aperistaltic
Blind ending
Compressible
Diametes <5 mm

103
Q

Appendicitis findings on ultrasound

A

periappendiceal fluid

wall thickening

104
Q

Appendicitis CT scan criteria

A 
>6 mm diameter
> 2 mm wall thickness (target sign)
fat stranding
fecalith
arrowhead sign
105
Q

Rupture of appendix is greater in which age groups?

A

<5 and >65 years old

106
Q

Most common findings in erroneous diagnosis of appendicitis

A 
Acute mesenteric lymphadenitis
No organic pathologic condition
Acute PID
Twisted ovarian cysts or ruptured Graafian follicle
AGE
107
Q

Most commonly injured part of the ureter during Gyne and Uro surgeries

A

Distal ureter

PLE (14 decks)

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