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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
Borchardt triad (hiatal hernias) SSx indicative of incarcerated intrathoracic stomach
chest pain retching with inability to vomit inability to pass NGT
26
Esophageal diverticula based on location
Pharyngoesophageal (Zenker) Mid thoracic (para-bronchial) Epiphrenic
27
Most common esophageal diverticula with SSx
Zenker diverticulum ``` Dysphagia Regurgitation of undigested food Halitosis Choking Aspiration ```
28
Types of mid thoracic diverticula
Traction - TB, histoplasmosis, pulmo diseases | Pulsion - more common, motility disorders
29
Esophageal diverticula associated with hiatal hernia
Epiphrenic (distal end of esophagus)
30
Triad of achalasia
Hypertensive LES Aperistalsis of esophageal body Failure of LES to relax
31
Esophagogram findings in achalasia
Bird's beak esophagus/pencil tip deformity Air fluid level Sigmoid esophagus Esophageal dilatation
32
Medical management of achalasia
botulinum toxin nitrates CCBs
33
Corkscrew deformity on esophagogram
Diffuse and segmental esophageal spasm
34
Most common primary esophageal motility disorder
Nutcracker esophagus
35
Severe neck pain due to spontaneous rupture of esophagus (true surgical emergency)
Boerhaave syndrome
36
Caustic substance injury scale
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
37
Usual location of esophageal carcinoma
SquaCA - middle third of thoracic esophagus | AdenoCA - distal esophagus
38
Risk factors for squaCA of esophagus
``` tobacco use alcohol use history of head and neck cancer history of breast cancer with radiotherapy Plummer-Vinson syndrome caustic injury to esophagus achalasia ```
39
Risk factors for adenoCA of esophagus
``` barrett esophagus - not in squaCA weekly GERD symptoms - not in squaCA history of breast cancer with radiotherapy obesity - not in squaCA tobacco ```
40
Functional grade of dysphagia
``` 1 - eating normally 2 - liquid with meals 3 - semisolids 4 - liquids only 5 - saliva 6 - cannot swallow saliva ```
41
Exclusion criteria for curative surgery or resection for esophageal CA
Age > 75years old FEV1 < 1.25 and EF <40% >20% weight loss locally advance tumor
42
Best way to palliate malignant dysphagia in esophageal CA
Surgical
43
EHJ carcinoma classification
I - esophageal II - cardiac III - sub-cardiac
44
Dysphagia, atrophic oral mucosa, spoon-shaped fingers with brittle nails, chronic anemia, middle-aged edentulous women, esophageal web (FeSO4-induced), pre-malignant lesions
Plummer-Vinson syndrome
45
Thin submucosal ring in lower esophagus
Schatzki ring
46
UGIB after repeated vomiting, mucosal tears along GEJ
Mallory-Weiss tear
47
85% of esophageal atresia is what type?
Type C
48
Segments of the large intestines and their measurements
``` 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
Blood supply and venous drainage of cecum
ant. and post. cecal a. from ileocolic a. from SMA | ant. and post. cecal v. from ileocolic v. to SMV
50
McBurney point
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
Most common position of appendix (trace the ileocolic a.!)
Retrocecal Pelvic Ileocecal Subcecal
52
Causes weakening of anterior abdominal wall when injured during appendectomy
iliohypogastric n.
53
Common causes of appendicitis
adults - fecalith | children - lymphatic tissue
54
Blood supply and venous drainage of the ascending colon
Ileocolic and R colic a. from SMA | Drained by ileocolic and R colic v. to SMV
55
Location of ascending colon
Retroperitoneal
56
Longest, largest and most mobile portion of large intestine
transverse colon | contains a transverse mesocolon
57
Blood supply and venous drainage of transverse colon
middle colic a. and R colic a. from SMA and L colic from IMA | Drained by superior and inferior mesenteric v.
58
Retroperitoneal in location, supplied by L colic and sigmoid a. from IMA and drained by IMV
Descending colon
59
Fan-shaped mesocolon, extends from iliac fossa to 3rd sacral vertebra
sigmoid colon
60
Structures ant. and post. to sigmoid colon
Posterior - rectum and sacrum Anterior M - urinary bladder F - uterus and vagina
61
Blood supply and venous drainage of sigmoid colon
sigmoid a. from IMA | drained by IMV
62
Left-sided (R-sided is intussusception) colicky pain, abdominal distention and hematochezia
sigmoid volvulus
63
diverticulosis vs. diverticulitis
no inflammation vs. with inflammation
64
End of rectum, inside pelvic cavity, has valves of Houston
tip of coccyx/ anal canal
65
Surgical anal canal includes
internal rectal v.
66
Rectum relations: lateral, ant. and post.
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
Blood supply and venous drainage of rectum
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
Located in the perineum, begins where rectal ampula narrows at the level of the U-shaped sling of puborectalis muscle, ends at anus
Anal canal
69
Separates the anal canal into 2 segments with different embryonic origin, blood supply and innervation
dentate/pectinate/anorectal line
70
``` Upper/Superior anal canal: embryonic origin cell lining other characteristics blood supply and drainage lymphatic drainage ```
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
``` Lower/Inferior anal canal embryonic origin cell lining other characteristics blood supply and drainage lymphatic drainage ```
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
Differentiate internal vs. external hemorrhoids
Internal hemorrhoids - painless, covered in mucosa, dilated internal rectal venous plexus External hemorrhoids - painful, covered in skin, dilated external rectal venous plexus
73
Hemorrhoidal cushions
Left lat Right ant Right post
74
Differentiate degrees of hemorrhoids
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
In Hirschsprung, the constricted part is
abnormal/aganglionic (a.k.a. congenital megacolon)
76
Mimics referred pain of inflamed appendix, may contain ectopic gastric or pancreatic cells - true diverticulum
Meckel diverticulum
77
Pain and where the structures are derived
``` Epigastric = Foregut Periumbilical = Midgut Hypogastric = Hindgut ```
78
Lymphatic structures such as the spleen are derived from
Mesoderm
79
SMA blood supply and parasympathetic innervation from vagus in the large intestine
Ascending and Transverse colon
80
IMA and parasympathetic fibers from the pelvic splanchnic nerve from sacral nerves S2-S4
Descending and sigmoid colon
81
Length of entire colon
1 to 1.5 meters
82
Epithelium of colon
glandular epithelium with straight crypts, goblet cells and absorptive cells
83
What is absorbed in the colon?
1 to 2 L of fluid daily sodium chloride urea
84
GIT forms at what week of gestation?
4th
85
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)
Aaron sign
86
Special signs of appendicitis on PE: Bassler sign
Sharp pain elicited by pinching appendix between thumb of examiner and iliacus muscle (chronic appendicitis)
87
Special signs of appendicitis on PE: Transient abdominal wall rebound tenderness
Blumberg sign
88
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)
Bryan sign
89
Special signs of appendicitis on PE: Cutaneous hyperesthesia
In area supplied by spinal nerves on the right (T10, T11, T12)
90
Special signs of appendicitis on PE: Increased abdominal pain on coughing
Dunphy sign
91
Special signs of appendicitis on PE: Kocher/Kosher sign
Migration of pain from the umbilical region to the right iliac region
92
Special signs of appendicitis on PE: RLQ pain on dropping from standing on toes to heels
Markle sign
93
Special signs of appendicitis on PE: Massouh sign
Grimace when examiner performs a firm swish with index and middle finger across abdomen from epigastrium to right iliac fossa
94
Special signs of appendicitis on PE: Tenderness in RLQ increases when patient moves from supine position to a recumbent posture on left side
Rosenstein sign
95
Special signs of appendicitis on PE: Rovsing sign
Pain at RLQ when palpatory pressure exerted at LLQ
96
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)
Iliopsoas sign
97
Special signs of appendicitis on PE: Obturator sign
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
Special signs of appendicitis on PE: Increased abdominal muscle tome on exceedingly gentle palpation of the right iliac fossa (early appendicitis)
Summer sign
99
Special signs of appendicitis on PE: Ten Horn sign
Pain caused by gentle traction on the right spermatic cord (caused by cord tension)
100
Prehn sign
testicular torsion, if testicles are lifted, pain is relieved
101
Alvarado score has 85% accuracy for appendicitis. What are its components? Score of 7-8 is high likelihood of appendicitis
``` 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
Normal appendix on ultrasound
Aperistaltic Blind ending Compressible Diametes <5 mm
103
Appendicitis findings on ultrasound
periappendiceal fluid | wall thickening
104
Appendicitis CT scan criteria
``` >6 mm diameter > 2 mm wall thickness (target sign) fat stranding fecalith arrowhead sign ```
105
Rupture of appendix is greater in which age groups?
<5 and >65 years old
106
Most common findings in erroneous diagnosis of appendicitis
``` Acute mesenteric lymphadenitis No organic pathologic condition Acute PID Twisted ovarian cysts or ruptured Graafian follicle AGE ```
107
Most commonly injured part of the ureter during Gyne and Uro surgeries
Distal ureter

PLE (14 decks)

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