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Surgery > gen surg 12/30/16 > Flashcards

gen surg 12/30/16 Flashcards

1
Q

presentation of acute mesenteric ischemia

A

periumbilical abdominal pain (sudden onset, poorly localized (visceral), often severe, with nausea amd vomiting)

pain out of proportion to exam (severe pain but minimal diffuse tenderness, early)

hematochezia (late), also localized pain peritoneal signs and sepsis if infarct develops

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2
Q

lab findings in acute mesenteric ischemia

A

leukocytosis
amylase and lipase elevated
metabolic acidosis (lactate)

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3
Q

diagnose acute mesenteric ischemia

A

ct preferred to mr angiography

mesenteric angiography if still unclear

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4
Q

pres
labs
dx
mesenteric ischemia

A

periumbilical abdominal pain (sudden onset, poorly localized (visceral), often severe, with nausea amd vomiting)
pain out of proportion to exam (severe pain but minimal diffuse tenderness, early)
hematochezia (late), also localized pain peritoneal signs and sepsis if infarct develops
leukocytosis
amylase and lipase elevated
metabolic acidosis (lactate)
hemoglobin elevated (hemoconcentration)
ct preferred to mr angiography
mesenteric angiography if still unclear

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5
Q

most common causes of acute mesenteric ischemia

A

cardiac embolism (afib, valvular dz/vegetations, cv aneurysm

thrombosis (pad, low cardiac output state)

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6
Q

acalculous cholecystitis

pres

A

usually in critically ill hospitalized pt

jaundice, urq pain and/or mass

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7
Q

tf

urge to defecate is common with acute mesenteric ischemia

A

t

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8
Q

tf

acute severe abdominal pain in alc wdrwl

A 
f
restlessness diaphoresis tachycardia
seizures
hallucinations
ams

acute severe ab pain less likely

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9
Q

presenation of abdominal abscess

A

subacute fever focal tenderness weight loss

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10
Q

bowel sounds in opioid wdrwl

A

increases

gi sx, flu-like sx, sns sx (mydriasis, agitation, anxiety)

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11
Q

postop pt w fev leuk parotid inflammation think…

how to prevent…

A

acute bacterial parotitis
(most common in dehydrated postop pts amd elderly)

prevent w hydration and oral hygiene

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12
Q

most common bug in acute bacterial parotitis

A

staph aureus

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13
Q

tf

incentive spirometry had been shown to reduce postop pulmonary complications by 50%

A

t

uworld 2016

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14
Q

why are beta blocker used perioperatively

A

to reduce the risk of ischemia

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15
Q

tf

perioperative abx for routine abdominal surg

A

t

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16
Q

who gets “polysaccharide vaccine” and what does it prevent?

A

pts ^65yo

strep pneumo

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17
Q

acute bacterial parotitis
pres
prev
tx

A

parotid pain aggravated by chewing
fev leuk tender swollen erythematous parotid common
hydration and oral hygiene
tx staph aureus usually

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18
Q

normal total bilirubin

A

.1-1 mg/dl

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19
Q

chronic mesenteric ischemia aka

A

intestinal angina

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20
Q

intestinal angina aka

A

chrinic mesenteric ischemia

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21
Q

etiology of sphincter of oddi dysfunction

A

any inflammatory process
(post surgical, pancreatitis, etc…)

opioid analgesics can cause sphimcter contraction and precipitate sx

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22
Q 
sphincter of oddi dysfunction
define
pres
dx
tx
A

dyskinesia or stenosis blocking bile flow
recurrent episodic ruq or epigastric pain
ast alt all phos ele
us dilated bile duct no stones
MANOMETRY gold standard
sphincterotomy usually

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23
Q

bile reflux gastritis
pathogenesis
pres

A

incompetent pyloric sphincter (eg postop gastric surg) duod can reflux into stomach and esophagus
vom, freq heartburn, ab pain

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24
Q

define choledocholythiasis

A

gallstones in common bile duct

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25
Q

chronic mesenteric ischemia

pres

A

“intestinal angina”

dull post prandial epigastric pain due to atherosclerotic narrowing

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26
Q

dx ibs

A

ab pain bowel habit change (diarrhea vs constipation) etc

ro other dxs (infection, lactose intolerance…)

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27
Q

lab tests and imagimg studies to dx ibs

A

none

ab pain bowel habit change (diarrhea vs constipation) etc
ro other dxs (infection, lactose intolerance…)

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28
Q

normal hb

A

12-16 f

13.5-17.5 m

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29
Q

blunt abdominal trauma
left sided ab pain
anemia
think…

A

splenic injury

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30
Q

blunt abdominal trauma with evidence of hemorrhage must think…

A

splenic injury

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31
Q

presentation of splenic injury after blunt abdominal trauma

A 
hypotension
pleuritic chest pain
left abdominal wall bruising
luq tenderness
guarding
referred left shoulder pain from hemorrhage irritating left hemidiaphragm, worse w inspiration (kehr's sign)
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32
Q

workup for suspected splenic injury after blunt abdominal trauma

A

cbc for anemia
FAST focused assessment w sonography for trauma, for hemodynamically unstable (eg sbpv90) or stable and alert, ct if fast normal
if not alert can consider straight to ct

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33
Q

manage splenic injury after blunt abdominal trauma

A

hemodynamically unstable, fast positive, or ct positive - operate (repair preferred to removal and immunize against encapsulated bact)

hemo stable, fast neg, ct neg or minimal splenic inj - non-op serial exams and close obs

between, mgmt may vary

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34
Q

splenic inj after blunt ab trauma
pres
dx
tx

A

hypotension, pleuritic chest pain, left abdominal wall bruising, luq tenderness, guarding
referred left shoulder pain
cbc
fast focused assessment w sonography for trauma
ct if fast normal
op (repair preferred to removal and immunize against encapsulated bact) if hemo unstable or imaging positive
conservative serial exams and close obs if stable and imaging negative or minimal splenic inj on ct
gray between…

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35
Q 
tf
bp 113/71
hr 116
hb 11.8
in 25 yo m w blunt abdominal trauma is sufficient to warrant concern for hemorrhage
A

t
male hb nl 13.5-17.5
suspect splenic inj w blunt ab trauma

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36
Q

when is peritoneal lavage used in diagnosis of splenic injury

A

hemodynamically unstable w equivocal fast (focused assessment w sonography for trauma) or emergency us or ct unavailalable

(used to be used more before good us and ct available)

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37
Q

when is urgent exploratory laparotomy performed for pt after blunt abdominal trauma

A

hemodynamically unstable w positive fast (focused assessment w sonography for trauma)

or stable with significant injury on ct ab

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38
Q

presentations of colon cancer

A

asymptomatic screen (colonoscopy)

postmenopausal / man w iron deficiency anemia

change in stool caliber
alternating bowel habits (d/c)
weight loss

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39
Q

colon cancer found on colonoscopy… next steps

A

ct scan to stage
chemo (eg folfox or folfiri)
radiation

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40
Q

what is folfox

A

folinic acid (leucovorin) - supplies cofactor blocked by mtx or here enhances activity of 5fu by stabilizing 5-dUMP binding to thymidylate synthetase, depleting thymidine triphosphate needed for dna synth

f 5fu fluorouracil (pyrimidine antimetabolite)

ox oxaliplatin (alkylating)

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41
Q

what is folfiri

A

folinic acid (leucovorin) - supplies cofactor blocked by mtx or here enhances activity of 5fu by stabilizing 5-dUMP binding to thymidylate synthetase, depleting thymidine triphosphate needed for dna synth

f 5fu fluorouracil (pyrimidine antimetabolite)

irinotecan (binds topo I /DNA complex preventing religation of cleaved DNA strand… s-phase cell death

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42
Q

treat FAP

A

familial adenomatosis polyposis
-prophylactic cholectomy

otherwise tons of polyps, premalignant by age 18, malignant by 28, dead by 38…

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43
Q

good vs bad colonic polyps

A

good
-pedunculated, small, tubular

bad
-sessile, large, villous

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44
Q

how long to repeat colonoscopy

A

normal - 10 years
polyp - 5 years
cis carcinoma in situ - 3 years
dysplasia - 1 year

(worse it soudns, sooner back)

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45
Q

ulcerative colitis
deep vs superficial
continuous vs skip
tx

A

superficial
continuous
medical tx… but 8 years post diagnosis malignant conversion likely so consider q1y screens and prophylactic colectomy

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46
Q

crohn’s dz
deep vs superficial
continuous vs skip

A

transmural (fistula forming, fecal soiling)

skip

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47
Q

how will surgeon treat crohn’s dz

A

may symptomatically remove fistulas (transmural thickness lesions)
but mostly medically managed

(ppx colectomy for ulcerative colitis not crohn’s)

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48
Q

hemorrhoids
which type bleed
which type hurt

A

internal bleed don’t hurt

external hurt itch don’t bleed

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49
Q

dx hemorrhoid

A

gross visual - external

anoscopy - may be needed for internal

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50
Q

treat hemorrhoids

A

creams (preparation h)
sitz baths…

internal - band
external - resect (v50% anal circumference to reduce chance of scarring and stricture)

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51
Q

what is a sitz bath

A

sitz bath is a warm, shallow bath that cleanses the perineum, which is the space between the rectum and the vulva or scrotum. A sitz bath can be used for everyday personal hygiene. It can also provide relief from pain or itching in the genital area

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52
Q

presentation of ulcerative colitis

A

bloody bowel movements

weight loss

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53
Q

where will colon cancer cause constipation vs bleeding

A

right - bleeding (stool loose enough to squeeze by)

left - constipation (stool dry and gets blocked up)

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54
Q 
anal fissure
path
pres
dx
tx
A

tight sphincter… constipation… tears with passage of big lump… scars smaller

pain on defecation that lasts for hours (longer than defecation pain vs relief w IBD…)

grossly visualize / clinical dx

nitroglycerin paste to try to relax
botulinum
topical lidocaine (numbs and loosens)
sitz baths
(good idea to soften stool in addition..)
lateral internal sphincterotomy
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55
Q

LEEP procedure stands for…

A

loop electrosurgical excision procedure

  • removes abnormal tissue by cutting away with thin wire loop carrying electrical current
  • -eg for cervical cancer
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56
Q

2 big cancers colorectal surgeons will treat

A

colon cancer

anal cancer

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57
Q 
anal cancer
path
pres
dx
tx
A

anoreceptive sex - hpv - scc

msm (screen for HIV), mass… brbpr

anal pap, bx

chemo and radiation (nIgro protocol)

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58
Q 
pilonidal cyst
path
pres
dx
tx
A

abscessed hair follicle
(hair follicle grows into cyst?… infects it…)
congenital dz
hairy butt

clinical dx - find the cyst

incision and drainage First
then resect

59
Q

nigro protocol treats

A

anal cancer
(hpv - scc)
((nigro = chemo and radiation))

NOT cervical cancer

60
Q

hhv8 assoc w this cancer

A

kaposi sarcoma

61
Q

common complications of haart

A

pancreatitis

dyslipidemia

62
Q

pathogenesis of anal fissure in elderly

A

not moving, eating much, generally incapacitated…. constipation
…now straining tears a fissure…
…now defecation associated with pain so hold it in…. more constipation…

63
Q

tf

it is reasonable to screen msm w pap smears

A

t
anal pap smears
for anal scc caused by hpv caused by anoreceptive sex

64
Q

define cholelithiasis

A

gallstones

in gall bladder

65
Q 
cholelithiasis
define
path
pres
dx
tx
A

gallstones (in gall bladder)
-mixed (cholesterol) Green - fat forty fertile female fNative American
-pigmented (hemolysis) Black
-colicky abdominal pain (when gb contracts on stones) ruq radiating to shoulder, worse w fatty foods
-RUQ US
-ELECTIVE cholecystectomy
ursodeoxycholic acid if not a surgical candidate

66
Q

in GENERAL, when is US a helpful test

A

when soft tissues of different densities - e.g. soft tissue vs fluid
e.g. spongy liver (solid ish) vs gallbladder (liquid)

67
Q 
cholecystitis
define
path
pres
dx
tx
A

-inflammed gallbladder
-gallstone blocking cystic duct (gb to cbd)
– pericholycystic fluid, thickened wall, gallstones
-Constant pain(blocked… inflamed (not colicky - that is cholelithiasis gallstones In gallbladder only hurt when gallbladder contracts for food espec fatty food)… Murphy sign positive, Iinflammation so Febrile and Leukocytotic
-RUQ US - pericholycystic fluid, thickened wall, gallstones
—HIDA scan (if ruq us equivocal but still suspicious) shows no gallbladder as cystic duct blocked by stone not patent
-NPO IVF IVabx, URGENT cholecystectomy (w/in 72 hours before gb perfs or inflammation makes impossible to visualize well for surg)
cholecystostomy if not a surgical candidate

68
Q

RUQ US in cholecystitis

A

pericholycystic fluid
thickened wall
gallstones (although rarely see Obstructing stone itself in cystic duct

69
Q

HIDA scan
stands for
use
aka

A 
hepatobiliary iminodiacetic acid scan
--of liver, gb, biliary tree, small intestine
cholescintigraphy
hepatobiliary scintigraphy
hepatobilliary scan
70
Q

how does HIDA scan work

A

Technetium labeled hepatic iminodiacetic acid (HIDA) is injected intravenously and is then taken up selectively by hepatocytes and excreted into bile
-to visualize liver, gb, biliary tree, small intestine

71
Q 
choledocolithiasis
define
path
pres
dx
tx
A

gallstone in CBD common bile duct
Obstructive Painful jaundice, transaminitis, amylase, lipase up (if gallstone pancrea) Murphy pos, mild fever and leukocytosis
-RUQ US
MRCP if equivocal
-npo IVF abx (cipro/flagyl or amp-gent/flagyl for gnr/anaerobe coverage) - ERCP urgently to get stone, w later cholecystectomy
f/u Bull-Valve… stone blocks, jaundice, transaminitis, pain… unlblocks, goes away allows vs obstructs flow alternately… if turns out was choledocholithiasis w stone that passed spontaneously can watch and wait w serial LFTs, w elective cholecystectomy down the road, ercp if recurs

72
Q 
cholangitis
define
path
dx
tx
A

inflammation of biliary tree
-gallstone stasis in cbd w infection (gut GNRs and anaerbes
-RUQ pain, PAINFUIL jaundice, fever
(charcot’s triad)
add hypotension and AMS (raynaud’s pentad)
-RUQ US - obstruction..
-IVF (septic)
IVabx (cipro/flagyl or amp-gent/flagyl for gnrs and anaerobes)
NPO
ON WAY to EMERGENT ERCP to get stone out and cholecystectomy now or later

73
Q

charcot’s triad

A

RUQ pain,
jaundice
fever
(for cholangitis)

74
Q

raynauds pentad

A

RUQ pain,
jaundice
fever (charcot’s triad)
w hypotension and AMS (raynaud’s pentad)

75
Q

tf

use zosyn for cholangitis

A

f
…even though sen in hosp, easy, convenient
(overcoverage (strep, pseudomonas), only need enteric GNRs and anaeriobes – cipro/flagyl or amp-gent/flagyl)

76
Q

name different gallstone pathologies according to location

A

cholelithiasis (in gb)
cholecystitis (in cystic duct)
choledocolithiasis (in cbd)
cholangitis (in cbd w infaction/inflammation)

77
Q

tf

ascending cholangitis can cause pyogenic abscess in liver

A

t

if ascends far enough an infectios (eg in setting of choledocolithiasis or cholangitis

78
Q 
path
pres
dx
tx
pyogenic abscess of liver in cholangitis
A

choledocolithiasis causes cholangitis,
ascends into liver - pyogenic abscess
-IV abx for cholangitis switched to PO for home, returns 2 days later febrile and leukocytotic (abscess reveals when IV abx stopped… iv abx partially treat and po abx do less)
-RUQ US
-percutaneous drainage (will give iv abx too but insufficient to cure)

79
Q

treat echinococcus cyst

A 
resect it
(risk cyst rupture and anaphylaxis if try percutaneous drain)
80
Q

for what kind of abscess do yo give metronidazole alone

A

entamoeba histolytica abscess

make sure to draw titer before giving abx

81
Q

when to get MRCP before ERCP

A

for choledocolithiasis (stone in cbd) - causing PAINLESS JAUNDICE

NOT for cholangitis (inflammed cbd)
–go straight to ERCP

82
Q

when to do percutaneous drainage or ex lap for cholangitis

A

can consider if ERCP fails or is not possible…

83
Q

mexico plus liver abscess …

A 
entamoeba histolytica
(gets into biliary tree and embeds in liver forming abscess)
-treat with metronidazole (one abscess you don't drain!)
84
Q

tf

aspirate entamoeba histolytica liver abscess prior to starting metronidazole

A

f
draw a titer first (blood titer?)
no aspiration
just metronidazole

85
Q

tf

resect entamoeba histolytica liver abscess

A

f
resect echinococcus cyst (may rupture and spill into anaphylaxis if try to aspirate)

metronidazole for entamoeba histolytica abscess (no drainage necessary)

86
Q

tf

you can culture and amoeba

A

f

87
Q

why might sickle cell be relevant in a gallbladder patient

A

risk for pigmented gallstones (hemolysis)

88
Q

what characteristics of lumph nodes on exam suggest breast cancer

A

firm fixed axillary nodes

89
Q

risks for breast cancer

A

estrogen exposure
-early menarche late menopause, nulliparity, hormone replacement therapy (not ocp’s, lower than endogenous exposure?)

chest radiation for lymphoma

brca1/2 genes (and fh otherwise)

90
Q

screen for breast cancer

A

mammogram start age 50 q2yrs (uspstf… 2017) - best answer

per clinical societies, can consider start age 40 q1y

MRI for high risk only (brca1/2, chest radiation for lymphoma, very positive family history maybe)

not self exams – too sensitive, false positives, morbidity and cost of workup
likewise no clinical breast exams for screening

91
Q

best test for breast cancer screening

A

MRI
but very costly, reserved for high risk only (brca1/2, chest radiation for lymphoma, very positive family history maybe)

otherwise mammogram screening is standard
start age 50 q2yrs (uspstf… 2017) - best answer

per clinical societies, can consider start age 40 q1y

92
Q

screening vs diagnostic mammogram

A

pt asymptomatic

vs has lump or obvious cancer

93
Q

diagnose breast cancer

A

positive mammogram
core biopsy

if v30yo, us shows
mass - prob ca get core bx
or cyst – fna shows blood
get core biopsy?

94
Q

ddx breast cyst by fna

A

bloody - prob cancer, get core bx?

pus - abscess

fluid - benign

95
Q

breast lump in woman v30yo how to proceed

A

monitor over 1-2 more menstrual cycles

if persists, us
mass (may be cancer, get core bx)
cyst - fna - if bloody, may be cancer, get core biopsy?

if resolves w menstrual cycling or fluid cyst on fna, don’t worry any further

96
Q

which is more effective local tx for breast cancer

mastectomy w axillary ln dissection
or
lumpectomy w axillary ln dissection and radiation

A

similar efficacy
aka lumpectomy plus radiation = mastectomy

get sentinal ln bx and depending acillary ln dissection with both

97
Q

what to get before axillary lymph node dissection for breast cancer

A

positive sentinel node bx

otherwise morbidity of lymphedema not worth it

98
Q

typical non-targeted chemo regimen for breast cancer

A

doxo
cyclo
pacli

doxorubicin/danorubicin
(get periodic echo to check for dose dependent irreversible chf)
cyclophosphomide
paclitaxel

99
Q

targeted therapies for breast cancer

A

traztuzumab if her2neu positive (watch non dose-dependent reversible chf w echos)

tamoxifen or raloxifen (SERMs) if ER PR positive and premenopausal

aromatase inhibitors (anastrozole) if ER PR positive and postmenopausal

100
Q

difference between chf side effect from

doxo/danorubicin
vs
traztuzumab

A

doxodano dose-dependent, irreversible… so periodic echos to monitor, stopping will halt progression but not reverse

traztu non dose-dependent, reversible… so monitor w echos and will likely recover if stopped

101
Q

manage brca1/2 positive pt

A

prophylactic bilateral mastectomy and salpingoopherectomy

or else annual mri and mammogram to screen

102
Q

tamoxifen vs raloxifen

key differences

A

tamoxifen stronger efficacy but se’s dvt and endometrial cancer
(breast er antag but endometrial er ag)

raloxifen weaker efficacy but not the se’s

103
Q

neoadjuvant vs adjuvant chemo for breast cancer

define the difference

A

neoadjuvant for higher grade to shrink before surgery

adjuvant after to supress mets… after surgery

104
Q

is her2neu posotivity better or worse for breast cancer prognosis?

A

worse

even though succeptible to traztuzumab targeted therapy

105
Q

when are serms and aromatase inhibitors combined for tx of breast cancer?

A

never
eg never raloxifene plus anastrozole

ramoxifen raloxifene for er pr pos pre menopausal

anastrozole for er pr pos post menopausal

106
Q

doxorubicin and danorubicin belong to this class of drugs

A

anthracyclines

107
Q

woman on doxorubicin and traztuzumab among others for systemic tx of breast cancer, gets heart failure after 2 rounds of chemo, which drug is responsible?

A

traztuzumab
-dose-independent, reversible chf… so can get early and unpredictably after few doses

doxo dano dose-dependent, non reversible… get more chf w more doses

108
Q

biggest side effect of cyclophosphamide

A

hemorrhagic cystitis

109
Q

paclitaxel side effects

and how to mitigate

A

typical chemo hair loss diarrhea nausea vomiting

dexamethasone
ondansetron (or other setrons)

110
Q

what kind of lymphoma is most often the reason for chest radiation and increasing risk of breast cancer?

A

hodgkin lymphoma

111
Q

tf

pet ct and ct ab pelv to stage breast cancer

A

f
sentinal ln bx
if pos followed by axillary ln dissection
to stage breast cancer and determine tx, because w breast ca, ct usually positive only when mets already obvious… by h and p?

but most other cancers ct is used to stage

112
Q

pancreatitis
pres
dx
tx

A

-epigastric andominal pain boring to back
worse w spine ext ab stretched
nausea vomiting

-lipase better than amylase-p even,
ct if enzymes equivocal and strong suspicion, or if get sick as shit, hypotensive, septic w fevers and leuko, or early satiety weight loss w cont abdominal pain
ruq us next day after starting mgmt, and triglycerides to eval for risks (alcohol, gallstones, hypertriglyceridemia)

  • npo ivf pain mgmt
  • if soon hours to days sick as shit hypotensive think necrotizing, icu, necrosectomy, imipenem if infection on fna
  • if days to weeks later fev leuko septic think abscess abx i and d
  • if early satiety weight loss think pseudocyst (v6wk6cm wait and watch uncomplicated, ^6wk6cm drain complicated)

-if chronic pancreatitis may need pain mgmt enzymes endo and exo etc but surgery not really and option taking out pancreas just makes worse

113
Q

top risk factors for pancreatitis

A

alcohol, gallstones, hypertriglyceridemia, medication side effects

trinidadian scorpions and black widows
etc

114
Q

when to get ct for pancreatitis

A

not usually
can usually dx by h and p amd lipase better than amylase

ct if enzymes equivocal and strong suspicion, or if get sick as shit, hypotensive; septic w fevers and leuko; or early satiety weight loss w cont abdominal pain

115
Q

when surg for pancreatitis

A

when complocated

  • npo ivf pain mgmt
  • if soon hours to days sick as shit hypotensive think necrotizing, icu, necrosectomy, imipenem if infection on fna
  • if days to weeks later fev leuko septic think abscess abx i and d
  • if early satiety weight loss think pseudocyst (v6wk6cm wait and watch uncomplicated, ^6wk6cm drain complicated)

-if chronic pancreatitis may need pain mgmt enzymes endo and exo etc but surgery not really and option taking out pancreas just makes worse

116
Q

pancreatic pseudocyst

define

A

circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue, typically located in the lesser sac of the abdomen. usually complications of pancreatitis, although in children they frequently occur following abdominal trauma
-classically occur 1-2 weeks after pancreatitis, can cause early satiety and palpable mass, no fev or leuk

117
Q

presentation of necrotizing pancreatitis

and tx

A

occurs within 2 days of pancreatitis
climbing hb (hemoconcentration)
falling calcium (saponification)
ards (inflammation)
hypotension (fluid collection 3rd spacing)
maybe fev leuk
tx w imipenem if infection on fna, necrosectomy

118
Q

hemorrhagic pancreatitis
pres
tx

A 
pretty sick within 2 days of pancreatitis
hypotension
anemia not hemoconc like necrotizing
no fev leuk
tx supportive care
119
Q

chronic pancreatitis
time course
tx

A

years after acute episode
more likely w more past bouts of acute pancreatitis

may need pain mgmt enzymes endo and exo etc but surgery not really an option taking out pancreas just makes worse

120
Q

pancreatic adenocarcinoma

pres

A

usually no sx
may cause weight loss, painless jaundice, clay colored stools
may precipitate acute pancreatitis
ct scan shows mass, usually on pancreatic head if symptomatic
no fev leuk
-usually mets by the time found

121
Q

define uncomplicated pancreatitis and treatment

A 
normal vitals and labs (aside from lipase 3x uln)
just pain sx
pain mgmt
npo for bowel/pancreatic rest
ivf
122
Q

how to diff hemorrhagic from necrotizing pancreatitis

A

anemia vs hemoconcentration

123
Q

when cefipime for pancreatitis

A

when necrotizing and infection on fna

-can give iv cefipime or a carbapenem like imipenem

124
Q

goal of ct for pancreatitis

A

to assess complications

not routinely used for uncomplicated pancreatitis

125
Q

pancreatic pseudocyst
pres
tx

A

early satiety and weight loss
2 plus wks after pancreatitis
ct ab demonstrates

if v6cm6wks repeat ct at 6 wks to check for resolution

if ^6cm6wks drain it (ct guided drainage or endoscopic cystogastrostomy)

126
Q

when endoscopic us w biopsy of pancreas

A

assess multiple smaller pseudocysts or ro cancer

127
Q

when is radical pancreatectomy the answer

A

never
(per med ed)

can resect pieces… pseudocysts ot necrosis… taking the whole thing out just makes things worse… don’t even do for chronic pancreatitis

128
Q

normal lipase and amylase

A

lipase 0-160
amylase 23-85, as high as 140

may depend on specific lab a bit

129
Q

pt going into ards from necrotizing pancreatitis

go

A

intubate and peep
central access for pressors

then ct for extent of nec
fna - iv meropenem if infected

(iv vanc/piptazo if hap)

130
Q

what does ards from pancreatitis look like on cxr

A

bilateral pulmonary edema

131
Q

lipase level in chronic pancreatitis

A

often normal

132
Q

sign of

failure of exocrine and endocrine pancreatic function

A

diabetes
steatorrhea
pancreatic calcifications

133
Q

sticky stools difficult to flush in context of pancreatitis suggests

A

steatorrhea from failed pancreatic exocrine function

134
Q

dx chronic pancreatitis

A

clinical

supported w ct for calcification and shrinking of pancreas

135
Q

when is mrcp w ercp the tx for pancreatitis

A

maybe for cheonic pancreatitis to see if can stent a duct open

but evidence not great yet, alc cessation and lain control is still best answer on test

136
Q

when endoscopic us for pancreatitis

A

after ct demonstrates accessible lesions of concern

to assess smaller pseudocysts or rule out cancer

137
Q

tf

get amylase and lipase for chronic pancreatitis

A

f
will be normal in chronic
(may be high if acute on chronic)

138
Q

when to get abdominal us of pancreas

A

not usually,
poor for visualizing pancreas

endoscopic us better but invasive, only for eg accessible lesions on ct - characterize smaller pseudocysts, ro cancer

139
Q

writhing inability to get comfortable in pain suggests

A

obstruction or inflammation

140
Q

classic presentation of nephrolithiasis

A

flank pain radiating to groin, no mass, hematuria

141
Q

define obstipation

A

severe or complete constipation

142
Q

classic presentation sbo

imaging

A

colicky abdominal pain
distension
obstipation
xr w dilated loops of bowel

143
Q

suspect kidney stone

next step? IVF? urine microscopy?

A

noncon CT AP
(because can eval size of stone and impact on ureters (hydroureter/hydronephrosis…)

can use US eg if pregnant and see hyrdro from obstructing stone

144
Q

50 F RUQ P and TTP nausea slight leuk, lft’s normal
3 ddx
2 studies
3 compx

A

*cholecystitis, pud, pancreatitis

RUQ us, HIDA scan

gallstone ileus
acute pancreatitis
Mirizzi syndrome (gallstone impacted on cystic duct or neck of gb compressing cbd or chd – obstruction, jaundice

Surgery (22 decks)

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