Gen Surg Flashcards
A patient presents with sudden onset of severe, diffuse abdominal pain. Examination reveals peritoneal signs, abdominal radiograph reveals free air under the diaphragm. Management?
Emergent laparotomy to repair a perforated viscus
What is the most likely cause of acute lower GI bleeding in patients > 40 years of age?
Diverticulosis
What is the diagnostic modality used when ultrasonography is equivocal for cholecystitis?
HIDA (hepatobiliary imilodiacetic acid) scan
What are the risk factors for cholelithiasis?
Fat, female, fertile, forty, flatulent
Inspiratory arrest during palpation of the RUQ?
Murphy’s sign, acute cholecystitis
What is the most common cause of small-bowel obstruction in patients with no history of abdominal surgery?
Hernia
What is the most common cause of small-bowel obstruction in patients with history of abdominal surgery?
Adhesions
A 30 year old man with ulcerative colitis + fatigue, jaundice and pruritus?
Primary sclerosing cholangitis
What type of hernia has the highest risk of incarceration - indirect, direct, or femoral?
Femoral
What causes severe abdominal pain out of proportion to the exam?
Mesenteric ischemia
How do you confirm diagnosis of ileus?
Abdominal x-ray (or CT)
50 year old man with hx of alcohol abuse presents with boring epigastric pain that radiates to the back and is relieved by sitting forward. What is the management?
Confirm dx of acute pancreatitis: increased amylase and lipase
Make pt NPO, IV fluids, O2, analgesia, and time
Colon cancer region based on symptoms:
Anemia from chronic disease, occult blood loss, vague abdominal pain
Right sided: rare to have obstruction
Colon cancer region based on symptoms:
Obstructive symptoms, change in bowel movements
Left sided: “apple-core lesion
What presents with palpable, contender gallbladder?
Courvoisier sign (suggests pancreatic cancer)
Barium swallow shows corkscrew-shaped esophagus in what disorder?
Diffuse Distal Esophageal Spasm
What is the definitive test to diagnose distal esophageal spasm?
Esophageal manometry
The musculature of the upper 1/3 of the esophagus is ____ muscle, whereas that of the lower 2/3 is ____ muscle.
Skeletal
Smooth
What is achalasia?
A motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the distal 2/3 of the esophagus.
What condition shows esophageal dilation with a “bird’s beak” tapering of the distal esophagus on barium swallow?
Achalasia
What condition has a cervical out pouching through the cricopharynxgeus muscle and is a posterior, false diverticulum?
Zenker diverticulum
Why does esophageal cancer metastasize early?
Esophagus lack a serosa
What type of cancer occurs in the upper and middle thirds of the esophagus?
SCC
What type of cancer occurs in the lower third of the esophagus?
Adenocarcinoma
What condition shows an irregular Z line (squamocolumnar junction between the esophagus and stomach) due to columnar metaplasia of the lower esophagus on upper endoscopy?
Barrett esophagus
What causes Type A chronic gastritis?
Type A (10%): occurs in the fundus and is due to antibodies to parietal cells; causes pernicious anemia
What causes Type B chronic gastritis?
Type B (90%): occurs in the antrum and may be caused by NSAIDs or H pylori
What is the triple therapy for H pylori infection?
Amoxicillin
Clarithromycin
Omeprazole
What is a Krukenberg tumor?
A gastric adenocarcinoma txt metastasizes to the ovary.
What gastric tumor presents in patients with chronic H pylori infection?
MALT lymphoma
note: it is the only malignancy that can be cured with antibiotics - triple therapy
What cancer presents with Virchow’s node?
Gastric
Pain from what ulcer increases after a meal?
Gastric pain is GREATER after a meal
Duodenal pain DECREASES after meal
What rare condition is characterized by gastrin-producing rumours in the duodenum and/or pancreas, that leads to over secretion of gastrin?
Zollinger-Ellison Syndrome
How do patients with Zollinger-Ellison syndrome present?
Hypercalcemia (associated with MEN1)
Epigastric pain (peptic ulcer)
Diarrhea (due to mucosal damage and pancreatic enzyme inactivation leading to malabsorption)
What is the difference between a partial and complete SBO?
Partial: passing flatus, no stool
Complete: no flatus, no stool
What is Pellagra?
A deficiency of B3 (niacin), secondary to recurrent carcinoid tumor
What is the classic presentation of Pellagra? (4 Ds)
Diarrhea
Dementia
Dermatitis
Death
How is gallstone ileum a form of SBO?
It occurs when a stone lodges at the ileoceal valve
How does ileus present on x-ray?
Air is present throughout the small and large bowel.
Should you do a sigmoidoscopy in the early stages of diverticulitis?
No - should be avoided because of the increase risk of perforation
What is ogilvie syndrome?
Pseudo-obstruction
What does iron deficiency anemia in elderly indicate until proven otherwise?
Colorectal cancer
What are the risk factors for colon cancer?
- Increased age, peak 70-80
- Hereditary polyposis syndromes (FAP, HNPCC)
- Fam Hx (esp first degree relatives <60)
- IBD (U/C > Crohns)
- Adenomatous polyps (villous > tubular; sessile > pedunculated)
- High fat, low fiber diet
How do you differentiate upper from lower GI bleeding?
Ligament of Treitz (anatomic boundary between the duodenum and jejunum)
What is Hasselbach triangle?
Area bounded by inguinal ligament, inferior epigastric artery, and rectus abdomens (relevant in inguinal hernias)
What is the difference in location between direct and indirect hernias regarding the inferior epigastric vessels?
Direct hersais lie Me”D”ial
Indirect hernias lie “L”ateral
to inferior epigastric vessels
“Lead Pipe” colon on barium enema
Ulcerative Colitis
Is there an increased risk in colon cancer for U/C or Crohn’s?
U/C
total proctocolectomy can be curative/ recommended for prevention
What disease are perianal issues, tags, fistulas associated with?
Crohn Disease
The rectum is alway involved in which IBD?
U/C
What medical treatment is used in IBD?
5-ASA; corticosteroids for flare ups; immunomodulators (azathioprine) and biologics (infliximab)
Most gallstones are precipitates of ___.
Cholesterol (therefore radiopaque)
Define cholelithiasis
Stones in gallbladder
Define cholecystitis
Inflammation of the gallbladder, typically due to stone occluding cystic duct
Define choledocolithiasis
Stone in CBD
Define cholangitis
Infection of the CBD, usually due to stone in CBD
Define gallstone ileus
Mechanical obstruction resulting from the passage of a large (>2.5 cm) stone into the bowel through a cholecystoduodenal fistula (obstruction often at ileocecal valve)
Is it common for HCV to become chronic ?
Yes
70-80% of patients will develop chronic hepatitis
Primary sclerosing cholangitis is strongly associated with what IBD?
Ulcerative colitis
MRCP/ERCP that shows multiple bile duct strictures and dilatations, “beading”, is indicative of what disease?
Primary Sclerosing Cholangitis
Lab findings: increased alk phos increased bill \+ antimitochondrial antibody increased cholesterol
Primary Biliary Cirrhosis
Clinical Presentation: RUQ tenderness Abdominal distention Jaundice Easy Bruising Cogaulopathy
With risk factors: high alc intake, chronic hep B
Hepatocellular carcinoma
How does an insulinoma present?
Hypoglycaemia satisfying Whipple Triad:
1) documented hypoglycaemia on a venipuncture
2) with associated symptoms including sweating, palpitations, anxiety, tremor, headache, confusion
3) resolution of symptoms with correction of hypoglycaemia
What is the definitive test for insulinoma?
72-hour fasting test
What is a Vipoma?
Results from VIP-producing tumor, highly malignant
From non B-islet cells of pancreas
What is the most common pancreatic cancer?
Ductal adenocarcinoma in the head of the pancreas
What are the risk factors for pancreatic cancer?
1) Smoking
2) Chronic pancreatitis
3) 1st degree relative with pancreatic cancer
What is Courvoisier sign?
Palpable, nontender gallbladder
What type of organisms are post-splenectomy patients susceptible to?
Encapsulated organisms
What vaccines should be administered post-splenectomy?
1) Streptococcus pneumonia: Pneumovax 23
2) Haemophilus influenzae type B: HibTITER
3) Neisseria meningitides
Age 16-55: Meningococcal (groups A, C, Y, W-135) polysaccharide diphtheria toxoid
conjugate vaccine (Menactra)
Age >55: Meningococcal polysaccharide vaccine (Menomune-A/C/Y/W-135)
What are the findings on u/s in acute cholecystitis?
1) Gallstones
2) Gallbladder wall thickening (5mm or greater)
3) Pericholecystic fluid
4) Positive sonographic Murphy’s sign
What is a HIDA scan?
A nuclear imaging procedure that utilizes a radioactive tracer, technetium-99m, to evaluate GB fxn
In general, is X-ray utilized for workup of biliary disease?
No (only 20% of gallstones will contain sufficient calcium to be seen on x-ray)
What is the average age of patients presenting with ischemic colitis?
70
What nerve give voluntary anal sphincter control?
inferior rectal nerve
