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Surgery Shelf > DeVirgilio V > Flashcards

DeVirgilio V Flashcards

1
Q

What do the insidious onset of jaundice, painless jaundice, tea-colored urine or clay-colored stool suggest?

A

Biliary obstruction, likely malignant

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2
Q

What are the three categories of jaundice?

A

Pre-hepatic
Hepatic
Post-hepatic

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3
Q

What conditions cause pre-hepatic jaundice?

A

Hemolytic anemia

Gilbert’s syndrome

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4
Q

What conditions cause hepatic jaundice?

A

Ischemic liver injury
Hepatic viral infection
Toxic ingestion
Primary biliary cirrhosis
Primary sclerosing cholangitis (mixed hepatic and host-hepatic)
Hepatolenticular degeneration (Wilson’s disease)

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5
Q

What conditions cause post-hepatic jaundice?

A 
Choledocholithiasis
Acute cholangitis
Chronic pancreatitis
Mirizzi syndrome
Malignant biliary obstruction
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6
Q

What are the most common causes of malignant biliary obstruction?

A

Pancreatic cancer
Cholangiocarcinoma
Ampullary carcinoma

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7
Q

How is painless jaundice worked up?

A

LFTs (total and direct/indirect bile, AST, ALT, Alk Phos)
Amylase/lipase to rule out pancreatitis

Imaging to evaluate for mass/stricture: RUQ ultrasound, Triple-phase abdominal CT, MRCP, EUS, ERCP

+/- FNA, biopsy, brushings if stricture is seen without mass

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8
Q

What is the role of stenting and biopsies in malignant biliary obstruction?

A

Stenting: not recommended for malignancy prior to resection

Biopsy also not needed if there is a mass causing the obstruction (whatever it is, it’s still coming out)

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9
Q

What serum markers may be used if a malignant biliary obstruction is suspected?

A

CEA/CA 19-9 may be used as a marker
The role of these is controversial and they are not widely used, probably take a baseline and see if they drop after surgery and remain low

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10
Q

What are the three management strategies for malignant biliary obstruction, and how is each managed?

A

Resectable - pancreatoduodenoectomy (possibly pylorus-sparing)
Borderline resectable - Neoadjuvant therapy and repeat imaging to assess for surgical intervention
Unresectable - Biliary stent and palliative chemotherapy OR Surgical bypass (biliary and intestinal)

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11
Q

What might a biliary obstruction associated with fever and pain require?

A

Urgent/Emergent biliary decompression to avoid cholangitis

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12
Q

What is Courvoisier’s sign?

A

A palpable RUQ mass, representing a non-tender, enlarged gallbladder and signifying obstruction of the CBD which causes the biliary tree and gallbladder to distend. Most commonly seen with malignancy, as gallstone disease results in RUQ pain and marked tenderness to palpation.

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13
Q

Why is malignant biliary obstruction painless?

A

Malignant obstruction occurs insidiously, giving the biliary tree time to adjust. Acute obstruction, as with gall stones, happens abruptly and is usually associated with inflammation or infection (acute cholangitis).

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14
Q

What are the major risk factors for pancreatic cancer?

A 
Chronic pancreatitis (strongest factor)
Tobacco
High fat diet
male gender
Family history
Recent onset of T2DM is associated, but not known to be a risk factor or early symptom
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15
Q

What are risk factors for biliary tree malignancies?

A

Ulcerative colitis, esp with PSC = bile duct malignancy
Choledocholithiasis w/ parasites = bile duct malignancy
Long standing gallstone disease = gallbladder carcinomas

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16
Q

Describe the metabolism of bilirubin

A

Breakdown of RBCs: spleen, liver and intravascular space.
Unconjugated Bilirubin: not water soluble, bound to albumin.
Conjugated in the liver, becoming water soluble, excreted into intestines.
C-Bili is converted by bacteria into urobilinogen,
Some is reabsorbed into systemic circulation,
Urobili converted intravascularly to urobilin which gives urine its yellow color
Urobili in intestines -> stercobilin and excreted in stool giving the brown color

17
Q

What give urine the tea-color in obstructive jaundice?

A

Direct bilirubin

NOT urobilin because direct bilirubin never reached the intestines to be converted

18
Q

What imaging is recommended in painful jaundice? In painless jaundice?

A 
Painful: RUQ ultrasound, will show stones and CBD dilation
Painless: Triple-phase abdominal CT - Shows arterial, early venous, and late venous phases of contrast, shows pancreatic and periampullary masses and helps determine resectability. 
Endoscopic US (EUS) may also be used
19
Q

What is brush cytoscopy? What is the use of FNA?

A

Brush cytoscopy is used to sample cells from CBD strictures to determine presence of malignancy.
FNA not needed in cases of resectable masses in surgical candidates (it’s coming out regardless)

20
Q

How to differentiate Hemolytic anemia from Gilbert’s syndrome?

A

Both have high indirect bilirubin (pre-hepatic)
Hemolysis labs: Low haptoglobin, high LDH points to hemolysis, while nl haptoglobin and LDH point to normal levels of RBC turnover and Gilbert’s syndrome

21
Q

How to differentiate biliary strictures from malignant masses?

A

Presence of peri-ampullary mass on triple phase CT: If there’s a mass, its likely malignant, if there is no mass it’s likely a stricture

22
Q

What makes a tumor (pancreatic in this case) unresectable?

A

Invasion into the hepatic, superior mesenteric, or celiac arteries.
Metastatic disease
Encasement of superior mesenteric or portal veins (relative contra-indication)
Determined by triple-phase CT.
Neoadjuvant therapy may assist borderline cases by shrinking the tumor. Symptomatic unresectable patients may receive palliative procedures (stents??)

23
Q

When should a patient with obstructive jaundice receive preoperative stenting?

A

Only if there are severe symptoms or with evidence of sepsis from cholangitis.
Decompression prior to pancreatic resection has higher post-op infection rates

24
Q

What is removed in a Whipple procedure?

A 
Whipple = pancreaticoduodenectomy 
Head of pancreas
Duodenum
Proximal jejunum
Distal stomach
Gallbladder
Common bile duct
25
Q

What is the most common complication of a whipple procedure? Treatment? Risk of diabetes?

A

Delayed gastric emptying
Treat with metoclopramide
DM risk is related to pre-op glucose levels. If no DM pre-op, then low post-op risk as only the head of pancreas is removed

26
Q

What causes high INR in pancreatic cancer? Tx?

A

Bile is required for Vit K absorption in the gut
Biliary obstruction blocks Bile from reaching gut and causes increased INR.
Treat with Vit K if asymptomatic or FFP if actively bleeding

27
Q

What is the Ddx of bright red blood per rectum?

A

Diverticulosis
Neoplastic (Colorectal carcinoma)
Iatrogenic (Up to 2 weeks post colonoscopy)
Colitis (Infectious, Ischemic, Inflammatory, radiation)
Angiodysplasia (Aberrant venous blood vessels in GI tract, usually right sided)
Anorectal bleeds (Hemorrhoids, anal fissures, rectal varices, rectal ulcers)

28
Q

What does dark maroon blood, possibly mixed with stool, indicate about the type and location of a GI bleed?

A

Likely upper GI, small intestine, or right colon

29
Q

What does copious bright red blood (hematochezia) suggest about the type and location of a GI bleed?

A

Left colon (diverticulum), rectum, anus, massive upper GI bleed with rapid transit

30
Q

What does a rectal bleed consisting of spots of blood on toilet paper or dripping after defamation suggest about the location of a GI bleed?

A

Likely rectum or anal location

31
Q

What does a small amount of dark red blood suggest about the cause or location of a GI bleed?

A

Angiodysplasia

32
Q

What conditions does occult stool blood (i.e., guiac positive) suggest?

A

Polyps or colon cancer

33
Q

What is H-DRAIN and what does it stand for?

A 
A mnemonic for the most common causes of lower GI bleeds:
Hemorrhoids
Diverticulosis
Radiation colitis
Incautious/Ischemic/IBD
Neoplasms/polyps
34
Q

What does a GI bleed in the presence of abdominal pain or diarrhea suggest?

A

Conditions like IBD, ischemic colitis, and infectious diarrhea are more likely.
Diverticulosis and angiodysplasia are not typically associated with abdominal pain.

35
Q

What is the most common cause of acute lower GI bleeds in adults over 50? What percentage of patients with this condition have active bleeds?

A

Diverticulosis (75% of these bleeds stop spontaneously)

Only 3-5% of patients with diverticulosis will ever have a bleed. (60% of US adults over 60 have tics)

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