Casefiles 9: hernias, GB disease

Question 1

indirect inguinal hernia goes through where?

presentation in men vs women

Answer 1

through the internal inguinal ring through a patent processus vaginalis into the inguinal canal
In men, the hernia sacs follow the spermatic cord and may descend into the scrotum
In women may present as labial swelling

Question 2

direct inguinal hernia goes through where?

Answer 2

through the Hesselbach triangle and medial to the ipsilateral inferior epigastric vessels

Question 3

The Hesselbach’s triangle is defined by ?

Answer 3

the edge of the rectus muscle medially, the inguinal ligament inferolaterally, and inferior epigastric vessels superiolaterally

Question 4

subtle difference between femoral hernia and inguinal hernia is that the femoral hernia is located ?
borders of femoral canal?

Answer 4

below the inguinal ligament

bound by the inguinal ligament superiorly, the femoral vein laterally, and the pyriformis and pubic ramus medially

Question 5

umbilical hernias result from ? or ?

Answer 5

the improper closure of the abdominal wall defect where the umbilical cord was in utero
OR acquired hernias, where subclinical defects increase in size due to increased intra-abdominal pressures (eg, pregnancy, ascites, or excess weight gain)

Question 6

any type of hernia that contains a Meckel diverticulum

Answer 6

Littre hernia

Question 7

an inguinal hernia that contains the appendix

Answer 7

Amyand’s hernia

Question 8

a femoral hernia that contains the appendix

Answer 8

De Garengeot’s hernia

Question 9

Richter’s hernia

Answer 9

herniation of part of the bowel wall through any hernia defect
unique because it may or may not be associated with intestinal obstruction, and that this type of hernia is often smaller and can be more difficult to diagnose.
The area of incarcerated intestine can develop ischemia and necrosis when the process goes undiagnosed.

Question 10

hernia just lateral to the rectus sheath and located at the semilunar line, or the lower limits of the posterior rectus sheath

Answer 10

Spigelian hernia

Question 11

Obturator hernia

Answer 11

herniation along the obturator canal alongside the obturator vessels and obturator nerve
occurs most commonly in women, particularly multiparous women with history of recent weight loss
A mass can be palpable in the medial thigh, particularly with hip flexed, externally rotated, and abducted.

Question 12

The Howship–Romberg sign is associated with approximately 50% of the patients with ?

Answer 12

obturator hernias, and this is pain along the inner thigh produced by hip flexion, abduction, internal rotation, or external rotation
obturator neuralgia produced by nerve entrapment by an obturator hernia

Question 13

an indirect inguinal hernia with a hernia sac containing either sigmoid colon (left) or cecum (right)

Answer 13

Sliding hernia
-The indirect hernia sac in this type of hernia will contain the attachment of the intestines. -High-ligation of the sac without clearly identifying a hernia as a sliding hernia can cause ischemic injury to the intestine within the sac

Question 14

the femoral canal is between ?

Answer 14

the inguinal ligament, Cooper’s ligament, and the femoral vein

Question 15

watchful waiting vs. repair

Answer 15

safe and cost-effective to observe individuals with minimally symptomatic or asymptomatic inguinal hernias
except for femoral hernias; nearly 1/3rd developed acute events requiring emergency repairs

Question 16

causes of chronic postoperative pain following inguinal hernia repairs

Answer 16

hernia recurrence (generally 1%-5%), mesh-related pain, nerve irritation, and infections

Question 17

When contamination or spillage of intestinal contents occur, don’t use ? in the repair

Answer 17

permanent prosthetic material is usually avoided

Question 18

Gallston disease complications

Answer 18

gallbladder complications: acute and/or chronic cholecystitis
complications related to the passage of stones from the gallbladder into the biliary duct: choledocholithiasis, cholangitis, and biliary pancreatitis or stone passage into the GI tract (gallstone ileus)

Question 19

why should you get a diabetic patient to cholecystectomy quickly if they have cholecystitis?

Answer 19

Diabetic patients are highly susceptible to develop stress-induced hyperglycemia, and with hyperglycemia, leukocyte functions are compromised, thus increasing risk of infectious complications from acute cholecystitis

Question 20

Patient comes in with suspected cholecystitis, what to do?

Answer 20

Admission, NPO, IV fluids, IV antibiotics, followed rather quickly by laparoscopic cholecystectomy (LC)

Question 21

pts have biliary colic because ?

or rarely due to ?

Answer 21

their gallbladders are stimulated to contract but are unable to empty either because there is a gallstone obstruction at the gallbladder neck or cystic duct
cholecystokinin (CCK) stimulation of a dysfunctional gallbladder, such as in the case of biliary dyskinesia

Question 22

The most common organisms involved in acute cholecystitis are ?

Answer 22

Escherichia coli, Klebsiella, Proteus, and Steptococcus faecalis

Question 23

Cholecystitis presents with ?

US findings?

Answer 23

persistent RUQ pain, +/- fever, focal gallbladder tenderness, mild leukocytosis or normal WBC count, and normal LFTs or nonspecific abnormalities in the LFTs

Gallstones in gallbladder; may have pericholecystic fluid; may or may not have CBD dilation

Question 24

acalculous cholecystitis
what is it?
typically affects who?

Answer 24

gallbladder inflammation and infection secondary to biliary stasis, responsible for less than 5%
hospitalized patients undergoing other medical treatments

Question 25

typical acalculous cholecystitis pt

Answer 25

patient in low perfusion state and not taking an oral diet (classically, ICU patients receiving mechanical ventilation who are NPO and receiving vasoactive agents for blood pressure support)
NPO status contributes to GB distension, and with decrease perfusion, ischemic injury of the GB occurs along with bacterial infection

Question 26

chronic cholecystitis may cause increasing ? and decreasing ?
findings on US?

Answer 26

Increasing fibrotic changes and decreasing inflammatory changes
gallstones, thickened GB wall, and possibly a small, contracted GB

Question 27

Cholangitis occurs most commonly due to ?
classic presentation?
serious complications?

Answer 27

stones within the CBD causing either partial or completed obstruction of the CBD
Charcot’s Triad (fever, RUQ pain, and jaundice) or if severe, 
Reynolds pentad (fever, abdominal pain, jaundice, shock, and AMS)
sepsis, septic shock, and distant-organ dysfunction

Question 28

cholangitis management

Answer 28

close monitoring, resuscitation, early broad-spectrum antimicrobial therapy, and biliary decompression

Question 29

what has 98% to 99% sensitivity in identifying gallstones in the GB?

Answer 29

RUQ US
also helps identify the diameter of the CBD, which has a high negative-predictive value for CBDs when the CBD is small (less than 5 mm)

Question 30

a nuclear medicine study involving intravenous injection of nuclear tracer that is taken up by the liver and excreted into the biliary system

Answer 30

biliary scintigraphy (HIDA scan)
if there is a blockage of the CBD, the tracer will visualize the liver and extrahepatic biliary tree with subsequent visualization of the duodenum, but the gallbladder is never visualized

Question 31

an MRI study using a set of sequences that allows for imaging of the biliary ducts and pancreatic ducts

Answer 31

MRCP
Magnetic Resonance Cholangiopancreatography
stones and masses within these ducts will cause signal void and thus can be demonstrated

Question 32

which is better ERCP or MRCP?

Answer 32

The sensitivity and specificity of MRCP is nearly identical to that of ERCP but this technique cannot be utilized for intervention when CBDS are seen.

Question 33

how an ERCP works

Endoscopic Retrograde Cholangiopancreatography

Answer 33

uses a side-viewing flexible endoscope, visualizes and canalizes the ampulla of Vater so contrast can go through and CBD and pancreatic duct can be visualize

Question 34

how can you get stones out with ERCP

Answer 34

through the working channel of the scope, baskets, balloons, and snares can be inserted to help with the extraction of stones and biopsy of tissue

Question 35

goal of common bile duct exploration (CBDE)

Answer 35

remove CBDS in the bile ducts (open or lap)

not commonly done unless less invasive means to remove the CBDS (such as by ERCP) are unsuccessful or unavailable

Question 36

gallstone types

Answer 36

cholesterol stones, black pigment stones, and brown pigment stones. Cholesterol stones make up majority of the gallstones (80%) in Western populations

Question 37

how do cholesterol stones form

Answer 37

an imbalance of cholesterol to bile acid ratio in the bile, only form in the gallbladder when there is underlying GB dysfunction (defects within the GB mucosa)

Question 38

The evaluation for every patient suspected of gallstone disease should include ?
results that should raise suspicion for GB disease

Answer 38

hx, PE, CBC, LFTs, serum amylase, RUQ US

Dilatation of the CBD (greater than 5mm) with elevation in LFTs (eg, bilirubin, alkaline phosphatase, AST, and ALT)

Question 39

Complications of undiagnosed and untreated CBDS include ?

Answer 39

cholangitis, pancreatitis, and biliary cirrhosis

Question 40

Clinical evidence suggests that patients presenting with mild cases of biliary pancreatitis (less than 3 Ranson’s criteria) can safely undergo ?

Answer 40

LC within 48 hours of admission
safe to proceed with LC once their pain and symptoms resolve, and it is unnecessary to wait for normalization of the serum amylase and lipase

Question 41

what should be suspected when patients presents with gallstone-related disease, elevated liver enzymes (especially bilirubin and alkaline phosphatase) and CBD diameter greater than 5 mm based on ultrasound

Answer 41

Choledocholithiasis

Question 42

what should be suspected when patients with gallstones present with nonfocal upper abdominal pain, liver enzyme elevation, dilated CBD, and fever

Answer 42

Cholangitis

Question 43

what should be suspected when patients present with pneumobilia (air in the biliary system) and small bowel obstruction?

Answer 43

Gallstone ileus

Question 44

what should be suspected when patients with gallstones present with biliary colic-like symptoms that fail to resolve after more than 6-8 hours

Answer 44

acute cholecystitis

Question 45

Biliary colic symptoms and choledocholithiasis symptoms are nearly identical; what are key differences?

Answer 45

patients with biliary colic do not have abnormalities in their liver enzymes, whereas choledocholithiasis patients have LFT elevations that can be nonspecific