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gen surg Flashcards

1
Q

gen surg includes these specific areas

A 
Alimentary tract. 
Abdomen and its contents. 
Breast, skin, and soft tissue. 
Head and neck. 
Vascular system,
Comprehensive management of trauma.
Complete care of critically ill patients with underlying surgical conditions
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2
Q

definition of gen surg

A

A central core of knowledge embracing anatomy, physiology, metabolism, immunology, nutrition, pathology, wound healing, shock and resuscitation, intensive care, and neoplasia.

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3
Q

Definition of Hernia

how do you determine what type of hernia it is

A

Protrusion, bulge or projection of an organ or part of an organ through the body wall that usually contains it

WHERE THE DEFECT IS DETERMINES THE TYPE OF HERNIA

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4
Q

Inguinal Hernia are most commonly in the groin

A

Most common type of groin hernia is inguinal (96%)

femoral hernia (4%)

pantaloon hernia

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5
Q

are most direct or indirect ?

A

Approximately two thirds are indirect

most others are direct

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6
Q

what is a indirect hernia

A

lateral to the inferior epigastric artery

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7
Q

risk factors for inguinal hernia

A 
Increased intra-abdominal pressure
Abdominal wall injury
Strain from heavy lifting
Loss of skin turgor with advancing age weakens fascia
History of hernia or prior hernia repair
Male
chronic cough 
constiption
Caucasian

(obesity is NOT)

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8
Q

DIRECT
ACQUIRED HERNIA
HERNIA
travels where

A

direct hernias are less common and travel medial to the inferior epigastric artery within hesselbach’s triangle

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9
Q

which inguinal hernia is least likely to incarcerate

A

direct

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10
Q

which hernia occurs because of weakness in the floor of the inguinal canal

A

direct

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11
Q

which hernia goes through the deep inguinal ring

A

indirect

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12
Q

what is hesselbachs triangle

A

Triangle formed by inguinal ligament inferiorly (poupart’s ligament)

inferior epigastric vessels laterally

and rectus abdominus medially

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13
Q

groin hernias have been associated with what other disease process

A

connective tissue abnormalities like AA

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14
Q

how much more likely are we to see a hernia in men ?

how would a hernia present in women

A

Men 8 times more likely to develop hernia and 20 times more likely to need a repair

vague pelvic discomfort in women

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15
Q

what does a shutter mechanism have to do with a a hernia

A

shutter mechanism

is believed to close internal or deep ring to a slit and may not work properly in patients that have a patent processus vaginalis (communication between the peritoneum and scrotum); then things such as increase in intraabdominal wall pressure can force contents through the widened internal ring resulting in a hernia

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16
Q

what is a very important question to ask pts with a suspect hernia

A

Symptoms of bowel obstruction

Nausea, Vomiting, abdominal distention, abdominal pain

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17
Q

radiation of painful hernia may look like what?

what factors would be relieving and what factors would be aggrevating?

A

Discomfort may radiate to scrotum

Worse with extended activity or standing, improves with rest

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18
Q

what other important questions would you want to as with regards to ROS and social history

A

CONSTIPATION, CHRONIC COUGH, URINARY STRAIN
ASCITES, DM
SMOKER?
OPERATIVE RISKS

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19
Q

PE for a hernia should include what

A 
LOCATION
SKIN CHANGES
TENDER TO PALPATION
REDUCIBLE
EXTERNAL RING SIZE
PALPABLE TESTICLES
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20
Q

BULGE MOVING LATERAL TO MEDIAL IS

A

INDIRECT

need to perform exam with and with valsalva

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21
Q

what us the ring occlusion test

A

+ if no bulging of hernia and indicates a direct

  • if bulging =indirect
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22
Q

what are the risk factors for inca

A

Advancing age
Femoral hernia
Recurrent hernia

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23
Q

PE for inguinal hernia will look like

A

PAIN WITH PALPATION

FEVER

ERYTHEMA OR CHANGES IN SKIN COLOR OVERLYING

BULGE

NAUSEA/VOMITING
ABDOMINAL PAIN OR

BLOATING

TREATMENT IS URGENT

SURGICAL REPAIR FOR STRANGULATED OR

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24
Q

if hernia is symptomatic if

A

PAIN WITH EXERTION

DAILY ACTIVITIES
COMPROMISED
CHRONIC INCARCERATION

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25
Q

asymptomatic hernia mnmgt

A

WATCHFUL WAITING

TRUSS

STRICT PRECAUTIONS FOR MEDICAL ATTENTION IF SX OF INCARCERATION DEVELOP

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26
Q

lap repairs of hernia are associated with

A

with less post p pain and quicker recovery

but open minimizes the risk of bowel injury and can be used for larger hernias

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27
Q

what is a femoral hernia and what must you distinguish it from

A

Femoral canal is below the inguinal ligament
Small bulge in the upper medial thigh

MUST BE DISTINQUISHED FROM INGUINAL HERNIA

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28
Q

when do we normally see umbilical hernia

A

MORE COMMON IN WOMAN
MULTIPLE PREGNANCIES

OBESITY

PRIOR SURGERY NEAR

UMBILICUS

RISK OF INCARCERATION IF NOT REPAIRED

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29
Q

SPIGELIAN HERNIA

A

through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally

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30
Q

what would be concerning for post op hernia

A

Pain worsening

Systemic changes

Incision with overlying skin changes, discharge or pain with palpation

Bulge at incision site concerning for recurrence

Always want to ask about eating, bowel movements, passing gas

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31
Q

review of gallbladder functions

how much bile can it hold?

A

Bile ducts, gallbladder and sphincter of Oddi (pancreas) act together to modify, store and regulate the flow of bile –

gallbladder contracts releasing bile and Sphincter of Oddi relaxes

Gallbladder stores hepatic bile during the fasting state

Gallbladder releases bile into duodenum in response to a meal

During storage state, absorbs water and electrolytes to dilute the hepatic bile

30-60cc of bile

32
Q

prevalence of cholelithiasis and the proportion that become symptomatic

A

10-15% of general population but approx 15-20% of those patients become symptomatic

33
Q

RF for gall stones

A 
North American Indians
Rapid Weight Loss or Gain
TPN
Cirrhosis
Anemia
Hyperlipidemia
Relative with gallstones
Pregnancy (estrogen exposure)
Obesity
Female
40’s
34
Q

MC Type of stone

A

Cholesterol – most common

35
Q

what does black and brown pigment mean in terms of gallstones

A

Black – hemolytic blood dyscrasias

Brown - Bacterial or parasitic infection of biliary tree

36
Q

when would you surgically treat an asymptotic gallstone

A

Patients with an increased risk of GB cancer
Pts with congenital hemolytic disorders
Pts undergoing bariatric surgery

37
Q

complications of galls stones

A

Acute cholecystitis
Choledocolithiasis
Acute Cholangitis
Gallstone pancreatitis

Rare: gallbladder ca, gallstone ileus, Mirizzi syndrome

38
Q

Acute cholecystitis

sxs

A

Pain lasting > 8hrs
Positive Murphy’s sign
Thickened gallbladder wall

39
Q

Choledocolithiasis sxs

A

+/- jaundice
CBD dilated
LFTs elevated

40
Q

Acute Cholangitis

A

Chariot’s triad (fever, RUQ pain, jaundice)
Reynold’s pentad (Chariot’s triad plus altered mental status and shock)
CBD stones

41
Q

Gallstone pancreatitis sxs

A

Epigastric tender to deep palpation

CBD dilation

Elevated white count and serum amylase

42
Q

Abdominal U/S pros and cons gall stone imaging-

A

Initial imaging

Not great study for choledocholithiasis

43
Q

MRCP pros and cons gall stone imaging-

A

MRI study for billiard ducts and pancreatic ducts

Cannot be used for extraction of CBD stones of visualized

44
Q

ERCP pros and cons gall stone imaging-

A

Flexible endoscope

Can be performed for duct clearance

45
Q

HIDA scan pros and cons for gall stone imaging

A

Also known as cholescintigraphy and hepatobiliary scintigraphy

Good study for cholecystitis but also for

cystic duct leaks or gallbaldder dyskinesia

46
Q

Gallstones become symptomatic when …

what does that look like

A

Gallstones become symptomatic when they obstruct gallbladder outlet or cystic duct

Increase in pressure is what leads to pain
Usually constant, not colicky
RUQ but could be epigastrium, or even substernal

Radiating to back (or shoulder blade)
Associated with diaphoresis, nausea and/or vomiting

47
Q

how long does biliary colic usually last

A

30 min – 1 hr, usually less than 6hrs

30% reoccurrence

48
Q

sxs associated with Uncomplicated symptomatic cholelithiasis

A

Chest pain
Epigastric pain or burning
Nonspecific abdominal pain
Gas, bloating, dypepsia, early satiety

seen with normal PE and normal labs
image with US and CT

49
Q

Relevant comorbidities when working up a suspected coliolithiesis

A

Hepatitis? Pancreatitis?
GERD/PUD
OPERATIVE RISKS/SURGICAL CANDIDATE?

50
Q

advantages of a lap cholecystectomy

A

Less post operative pain

Better cosmetic

Shorter hospital stay

Less time off work

51
Q

cons of a lap cholecystectomy

A

Increased risk of common bile duct injury

May require conversion to open

52
Q

indications for a open cholecystectomy

A

Patients unable to tolerate pneumoperitoneum

Refractory coagulopathy

Suspect gallbladder cancer

Additional abdominal pathology needing gb r

removed as part of procedure
Complications

53
Q

complication of a cholecystectomy

A

Bleeding

Bowel or bile duct injury
Infection

Diarrhea/loose stool

Retained common bile duct stone

Post cholecystectomy syndrome

54
Q

what is expected following a cholecystectomy

A

Pain usually improving
Lap v Open
Numbness near incision sites, especially with open procedure
Loose stool

55
Q

what is concerning following a cholesytectomy

A

Pain that is worsening

Fever/chills, tachycardia (systemic signs)

Incision sites with erythema

56
Q

what is the appendix made out of and what does it secrete

A

lymphoid tissue

Secretes immunoglobulins as part of the colonic system

Appendectomy does not alter immune function**

57
Q

RF for appendicitis

and special populations

A

10-30 year old
Males
Dependent on amount of lymphoid tissue in appendix

special pops
WOMEN OF REPRODUCTIVE AGE
ELDERLY AND SICK

58
Q

Obstruction of appendix lumen/orifice followed by inflammation

A

Fecalith

Lymphoid hyperplasia

Foreign body

Tumor

59
Q

GI symptoms associated wiht appendicitis

A

Constipation or diarrhea

60
Q

PSOAS SIGN

associated with what type

A

PAIN ON PASSIVE EXTENSION OF RIGHT THIGH

Associated with retrocecal appendix

61
Q

OBTURATOR TEST

associated with what type

A

Flexing patients right hip and knee with internal rotation of right hip causes RLQ pain
Associated with pelvic appendix

62
Q

ROVSINGS SIGN

A

PAIN IN RLQ WITH PALP OF LLQ

63
Q

DUNPHY’S SIGN

A

INCREASED PAIN WITH COUGHING

64
Q

Pain elicited in abdomen when patient drops from standing on toes to heels

A

MARKLE SIGN

65
Q

Rebound tenderness

A

BLUMBERG SIGN

66
Q

alvarado score

A

Migratory RLQ pain (1 pt)

Anorexia (1 pt)

Nausea or vomiting (1 pt)

Tenderness in RLQ (2 pts)

Rebound tenderness in RLQ (1 pt)

Fever >37.5°C (99.5°F) (1 pt)

WBC > 10,000 (2 pts)

67
Q

SCORING evaluation of alvarado

A

< 4 - Safe to observe

> 4 - Imaging and surgical evaluation

68
Q

other than appendix obstruction

A

Localized ischemia, bacterial overgrowth and eventually necrosis

69
Q

labs

A

WBC, serum CRP and pregnancy test

70
Q

PSOAS SIGN

A

PAIN ON PASSIVE EXTENSION OF RIGHT THIGH

Associated with retrocecal appendix

71
Q

ddx of appendicitis

A 
Pelvic inflammatory disease (PID) or tubo-ovarian abscess
Endometriosis
Ovarian cyst or torsion
Ureterolithiasis and renal colic
Diverticulitis
Crohn’s disease 
Colon cancer
Cholecystitis
Bacterial enteritis
Mesenteric adenitis
72
Q

advantages of a appendicial lap

A

Lower rate of infection

Less pain

Shorter duration of hospital stay

Pts with uncertain dx, obese patients, or older patients

73
Q

oepn lap

A

Lower rate of intra-abdominal abscesses

Shorter operative time

Open may convert to Lap

74
Q

f/u for appendicitis

A

Pt returns to clinic approx 2 weeks post lap appy and reports that he is feeling much better

75
Q

concerns for appendix post op

A

Pain that is worsening
Severe constipation or not passing gas
Fever/chills, tachycardia (systemic signs)
Incision sites with erythema, drainage

Surgery (18 decks)

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