Emma Holliday for Surgery: Part V Flashcards
What hepatitis do we suspect with AST being 2x the ALT?
Alcoholic hepatitis that is rversible
If ALT > AST and very high (in the 1000s) and our patient shows signs of hepatitis what do we suspect?
Viral hepatitis
If AST and ALT are high s/p hemorrhage, surgery or sepsis, what do we suspect?
Shock to the liver due to hypovolemia
TIPS relieves portal HTN, but…
Worsens your hepatic encephalopathy.
Tx with lactulose to help rid the body of ammonia
Risk factors for hepatocellular carcinoma?
Chronic Hep B carrier > hep C. Cirrhosis for any reason also an indicator, as is carbon tetrachloride or aflatoxin exposure
How do we diagnose hepatocellular carcinoma?
High AFP in 70% of folks. Also can use a CT or MRI
How can we treat hepatocellular carcinoma?
Can surgically remove solitary mass, use rads or cryoablation for pallation of multiple ones.
We have a female who is on an OCP. We palpate an abdominal mass or maybe she has a spontaneous rupture leading to hemorrhagic shock.
What do we suspect?
Hepatic adenoma
If we suspect a hepatic adenoma, how do we diagnose it?
U/S or MRI
How do we treat hepatic adenoma?
Discontinue OCPs. Resect if large or pregnancy is desired.
This is the 2nd most common benign liver tumor, women more likely to get than men, but it is less likely to rupture:
Focal nodular hyperplasia
How do we treat focal nodular hyperplasia?
No tx is needed
Most common bugs to cause bacterial abscess in the liver:
E.coli
Bacterioides
Enterococcus
How do we treat a bacterial abscess?
Surgical drainage and IV antibiotics
RUQ pain + profuse sweating + rigors + palpable liver =
Entamoeba histolytica
How do we treat entamoeba histolytica?
Metronidazole.
DO NOT DRAIN IT
Patient from Mexico presents with RUQ pain and large liver cysts found on U/S =
Echinococcus
How is Echinococcus transmitted?
Hydatic cyst parasite from dog feces
Lab findings for echinococcus
Eosinophilia
+ Casoni skin test
How do we treat echinococcus?
Albendazole and surgery to remove the entire cyst. Rupture can lead to anaphylaxis
After a splenectomy we worry about a lot of things.
What do we do if someone gets thrombocytosis > 1 million post op?
Give aspirin
What prophylactic preparation will we give our patients prior to splenectomy or when their spleen is for whatever reason toast?
Prophylactic PCN Vaccines: - S. Pneumo - H. Flu - N Meningitidis
When do we consider ITP on our differential?
- Isolated event of thrombocytopenia
- Bleeding gums, petechiae, nosebleeds
- Decreased platelet count
- Increased megakaryocytes in bone marrow
- Spleen NOT enlarged
How do we treat ITP
Steroids first. If relapse, splenectomy.
How will hereditary spherocytosis present?
See sxs of hemolytic anemia like jaundice and (4 labs) ( increased indirect bili, LDH, decreased haptoglobin, elevated retic count)
Smear of spherocytosis
- Spherocytes
- Positive osmotic fragility test
Pt’s with hereditary spherocytosis are prone to:
Gallstones
Tx for hereditary spherocytosis
Splenectomy
When do we consider traumatic spleen rupture?
Lower left rib fracture and intra abdominal hemorrhage. Can have Kehr’s sign (irritates left diaphragm)
Classic presentation of appendicitis:
Umbilical pain that travels to RLQ with N/V
If the appendix perforates or you suspect abscess formation, what do you do?
Drain, give abx to cover E.Coli and bacteroides, and do interval appendectomy
Number one site of a carcinoid tumor:
Appendix
Carcinoid tumor symptoms?
Diarrhea and wheezing
When do carcinoid tumors occur?
When mets to the liver due to first pass metabolism
3 D’s of carcinoid tumor
Diarrhea
Dementia
Dermatitis
What surgery options do we have for a carcinoid tumor
Hemicolectomy
Appendectomy
When do we do a hemicolectomy on a carcinoid tumor?
If > 2 cm, @ base of the appendix, or with positive nodes
When do we do an appendectomy on a carcinoid?
If it is anything other than hemicolectomy qualifiers (If > 2 cm, @ base of the appendix, or with positive nodes)
5 biggest suspect conditions that make us worried about SBO
Hernia Prior GI surgeries leading to adhesions Cancer Intussusception IBD
Sx’s associated with SBO
Pain, constipation, obstipation, vomiting
First step in diagnosing SBO
Upright CXR to look for free air. CT can show point of obstruction
Treatment for SBO
IVF, NG tube.
Only do surgery if there are peritoneal signs, increased WBC, and/or no improvement within 48 hours
Two locations we can get a volvulus
Cecal or sigmoid
Treatment for volvulus
Decompression from below if not strangulated. Otherwise, need surgical removal and colostomy
Post-op Ileus common due to these two scenarios:
HypoK (replete them) and opiates
Dx findings for post-op ileus
Dilated loops of small bowel with air fluid level
Treatment for post-op ileus
Surgery for perforation. Give lactulose and erythromycin
What is Ogilvie’s syndrome?
See massive colonic distension. If > 10cm, need decompression with NG tube and Neostigmine (watch for bradycardia) or colonoscopic decompression
Umbilical hernias adult vs kiddos
In kiddos they close spontaneously by age 2. In adults, we see them 2/2 obesity, ascites, or pregnancy
Indirect hernia defined as
Through the inguinal ring LATERAL to the epigastric vessels in the spermatic cord. R more often than left, and usually 2/2 to congenital issues like a patent proc vaginalis
Direct hernia defined as
Through hasselback’s triangle MEDIAL to epigastric vessels, more often through time and acquired weakness
Femoral hernia most often seen in:
Women.
Treatment for hernias?
Emergent surgical repair if incarcerated to avoid strangulation. Elective if reducible
