Gen Sx Flashcards
Cx of GERD
damage that might have been done to the lower esophagus (peptic esophagitis) and the possible development of Barrett’s esophagus
When to do Sx for GERD
• Appropriate in long-standing symptomatic disease that cannot be controlled by medical
means (using laparoscopic Nissen fundoplication)
• Necessary when complications have developed (ulceration, stenosis) (using laparoscopic
Nissen fundoplication)
• Imperative if there are severe dysplastic changes (resection is needed)
where solids are swallowed with less difficulty than liquids.
Achalasia
_______ is typically done first to evaluate for an obstructing lesion
Barium swallow
Xray of achalasia
X-rays show megaesophagus.
Tx of achalasia
balloon dilatation done by endoscopy, however recurrence is high and many patients ultimately require an esophagomyotomy (Heller).
Cancer of the esophagus shows the classic progression of dysphagia starting with ________
meat, then other solids, then soft foods, eventually liquids, and finally (in several months) saliva
________ is seen in people with long-standing gastroesophageal reflux
Adenocarcinoma
_________ also results from prolonged, forceful vomiting but leads to esophageal perforation
Boerhaave’s syndrome
______is a mucosal laceration typically at the junction of the esophagus and stomach
Mallory-Weiss tear
_______ of the esophagus is by far the most common reason for esophageal perforation
Instrumental perforation
Tx of gastric lymphoma
treatment is chemotherapy.
Surgery is only indicated if perforation is feared as the tumor melts away.
Low-grade lymphomatoid transformation (MALTOMA) can
be reversed by _______
eradication of H. pylori
_________ is more common in the elderly.
Symptoms include: • Anorexia • Weight loss • Vague epigastric distress or early satiety • Occasional hematemesis
Gastric adenocarcinoma
SSx of SBO
Early on, high-pitched bowel sounds coincide with the colicky pain (after a few days there is silence
patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis
Strangulated obstruction
________ is seen in patients with a small bowel carcinoid tumor with liver metastases.
It includes diarrhea, flushing of the face, wheezing, and right-sided heart valvular damage
(look for prominent jugular venous pulse
Carcinoid syndrome
How to get 5 IAA in pts with suspected carcinoid
Whenever syndromes produce episodic attacks or spells, the offending agent will be at
high concentrations in the blood only at the time of the attack. A blood sample taken afterward
will be normal. Thus, a 24-hour urinary collection is more likely to provide the diagnosis.)
___________ typically presents with anemia (hypochromic, iron deficiency) in the right age group (age 50–70). Stools will be 4+ for occult blood.
Colonoscopy and biopsies are diagnostic; surgery (right hemicolectomy) is treatment of choice
Cancer of the right colon
_________ typically presents with bloody bowel movements and obstruction.
Blood coats the outside of the stool, there may be constipation, stools may have narrow caliber.
Cancer of the left colon
Dx of left colon CA
Flexible proctosigmoidoscopic exam (45 or 60 cm) and biopsies
Colonic polyps may be premalignant. In descending order of probability for malignant degeneration are:
familial polyposis (and variants such as Gardner’s), f amilial multiple inflammatory polyps, villous adenoma, and adenomatous polyp
Polyps that are not premalignant include
juvenile, Peutz-Jeghers, isolated inflammatory, and hyperplastic.
UC surgery indications
present >20 years
severe interference with nutritional status,
multiple hospitalizations,
need for high-dose steroids or immunosuppressants,
or development of toxic megacolon
Definitive surgical treatment of CUC requires______
removal of affected colon, including all of the rectal mucosa (which is always involved).
Pseudomembranous enterocolitis Tx
Metronidazole is the treatment of choice (oral or IV), with vancomycin (oral) an alternative.
A virulent form of Pseudomembranous enterocolitis, unresponsive to treatment, with WBC >50,000/μL and serum lactate above 5mg/dL, requires ___________
emergency colectomy
Hemorrhoids typically bleed when they are_______ (can be treated with rubber band ligation), or hurt when they are _______ (may need surgery if conservative treatment fails). Internal hemorrhoids can become painful and produce itching if they are ____
internal
external
prolapsed
WHat can complicate anal fissures?
Tight sphincter
Tx of anal fissures
stool softeners, topical nitroglycerin, local injection of botulinum toxin, steroid suppositories, or lateral internal sphincterotomy
Anal fissure
_____________s such as
________ ointment 2% TID topically for 6 weeks have had an 80-90% success rate, as compared
to only 50% success for botulinum toxin
Calcium channel blocker
diltiazem
It starts with a fissure, fistula, or small ulceration, but the diagnosis should be suspected when the area fails to heal and gets worse after surgical
intervention
Crohn’s disease
________develops in some patients who have had an ischiorectal abscess drained.
Fistula-in-ano
Fistula-in-ano MOA
Epithelial migration from the anal crypts (where the abscess originated) and from the perineal
skin (where the drainage was done) form a permanent tract
Tx of FIA
treat with fistulotomy.
_________of the anus is more common in HIV, and in patients with receptive sexual practices
Squamous cell carcinoma
Tx of squamous cell CA of anus
Treatment starts with the Nigro chemoradiation protocol,
followed by surgery if there is residual tumor
General statistics of GI bleeding show that 3 of 4 cases originate in the _______
upper GI tract (from
the tip of the nose to the ligament of Treitz).
Vomiting blood always denotes a source in the ____
upper GI tract.
Similarly, melena (black, tarry stool) always indicates digested blood, thus it must originate
high enough to undergo digestion. Start workup with _________
upper GI endoscopy.
In the work up for blood in the rectum, if there is no blooed per NGT decompression and with white output (no bile)_______
the territory from the tip of the nose to the
pylorus has been excluded, but the duodenum is still a potential source and upper GI endoscopy
is still necessary.
Active bleeding per rectum
If the bleeding >2 mL/min (1 unit of blood every 4 hours), an angiogram is useful as it has a very good chance of finding the source and may allow for ______
angiographic embolization
Active bleeding per rectum
If the bleeding is slower, i.e. <0.5 mL/min, wait until the bleeding stops and then do a_______
colonoscopy
Patients with a recent history of blood per rectum, but not actively bleeding at the time of presentation, should start workup with______ if they are young (overwhelming
odds);
but if they are old they need both an ______
upper GI endoscopy
upper and a lower GI endoscopy (typically performed during the same session).
Blood per rectum in a child is most commonly a _________ start workup with a technetium scan looking for the ectopic gastric mucosa in the distal ileum.
Meckel’s diverticulum;
Post op recommended pH
above 4
Acute abdominal pain caused by ______ has sudden onset and is constant, generalized, and very severe
perforation
__________ confirms the diagnosis of perforation
Free air under the diaphragm on upright x-rays
Acute abdominal pain caused by ___________) has sudden onset of colicky pain, with typical location and radiation according to source.
obstruction of a narrow duct (ureter, cystic, or common bile
Acute abdominal pain caused by_______has gradual onset and slow buildup (at the very least a couple of hours, more commonly 6-12 hours).
inflammatory process
_________ should be suspected in the child with nephrosis and ascites, or the adult with ascites who has a “mild” generalized acute abdomen with equivocal
physical findings, and perhaps some fever and leukocytosis.
Spotaneous bacterial peritonitis (SBP)
_______ should be suspected in the alcoholic who develops an “upper” acute abdomen.
Acute pancreatitis
__________ should be suspected in the obese multiparrous female patient ages 30-50
(“fat, female, forty, fertile”) who presents with right upper quadrant abdominal pain
Biliary tract disease
Dx for ureterolothiasis
Non-contrast CT scan is the best diagnostic test.
_______ is one of the very few inflammatory processes giving acute abdominal pain in the left lower quadrant (in women, the fallopian tube and ovary are other potential sources).
Acute diverticulitis
Dx of Acute diverticulitis
• CT scan with oral and IV contrast is diagnostic
Tx of Acute diverticulitis
• Treatment is NPO, IV fluids, and antibiotics
_______ is indicated around 6 weeks after an episode of diverticulitis to rule out
an underlying malignancy
Colonoscopy
Why not do endoscopy in the first 6 weeks
(endoscopy earlier in the presence of active inflammation
increases the likelihood of perforation and decreases the diagnostic sensitivity).
Xrays of volvulus
X-rays are diagnostic, as they show air-fluid levels in
the small bowel, very distended colon, and a huge air-filled loop in the right upper quadrant
that tapers down toward the left lower quadrant with the shape of a “parrot’s beak
Volvulus
_______ resolves the acute problem and asses for mucosal ischemia; leaving a rectal tube allows for complete decompression and prevents immediate recurrence
Proctosigmoidoscopic exam
Marker for primary hepatoma
α-fetoprotein (AFP).
______ may arise as a complication of birth control pills, and is important because it has a tendency to rupture and bleed massively inside the abdomen
Hepatic adenoma
______ is seen most often as a complication of biliary tract disease, particularly acute ascending cholangitis
Pyogenic liver abscess
_______ of the liver favors men, all of whom have a “Mexico connection.” (It is very
common there, and seen in the U.S in immigrants.)
Amebic abscess
Hemolytic jaundice is usually low level (bilirubin of 6-8 mg/dL, but not 35 or 40), and all the elevated bilirubin is______
unconjugated (indirect), with no elevation of the conjugated (direct) fraction
_____ has elevation of both fractions of bilirubin, and very high levels of transaminases with only a modest elevation of the alkaline phosphatase
Hepatocellular jaundice
Obstructive jaundice has elevations o______, modest elevation of _______, and very high levels of alkaline phosphatase
of both fractions of bilirubin
transaminases
The first step in the workup is an ________ as well as further clues as
to the nature of the obstructive process.
U/S looking for dilatation of the biliary ducts,
Obstructive jaundice caused by stones should be suspected in the obese, fecund woman in her forties, who has
1
2
3
high alkaline phosphatase, dilated ducts on sonogram,
and nondilated gallbladder full of stones.
Mx of Gallstones
The next step in that case is an _____
to confirm the diagnosis,
perform a _____, and remove the common duct stone.
Cholecystectomy should usually follow during the same hospitalization
endoscopic retrograde cholangiopancreatography (ERCP)
sphincterotomy
Obstructive jaundice caused by a tumor could be caused by
1
2
3
adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, or cholangiocarcinoma arising in the common duct itself.
Once a tumor has been suspected by the presence of dilated gallbladder in the sonogram, the next test should be ____
CT scan
If no tumor is seen in the CT, next step is
ERCP
Ampullary cancers or cancers of the common duct by virtue of their strategic location produce obstruction when they are still very small, and therefore may not be seen on CT, but ______ will show ampullary cancers and the ________ will show intrinsic tumors arising from the duct (apple core) or small pancreatic cancers.
endoscopy
cholangiography
_______should be suspected when malignant obstructive jaundice coincides with anemia and positive blood in the stools
Ampullary cancer
Reason for anemia in ampullary cancer
Can bleed into the lumen like any other mucosal malignancy, at the same time that it can obstruct biliary flow by virtue of its location.
Pancreatic cancer is seldom cured, even when resectable by the _________
Whipple operation (pancreatoduodenectomy).
____ and _____ have a much better prognosis
about 40% cure
Ampullary cancer and cancer of the lower end of the common duct
________ occurs when a stone temporarily occludes the cystic duct.
Biliary colic
_________starts as a biliary colic, but the stone remains at the cystic duct until an inflammatory process develops in the obstructed gallbladder
Acute cholecystitis
HIDA scan of acute cholecystitis
In equivocal cases, a radionuclide scan (HIDA) might be needed, and would show tracer uptake in the liver, duct, and duodenum, but not in the occluded gallbladde
Acute cholecystitis
__________ may be the best temporizing option in the very sick with a prohibitive surgical risk
Emergency percutaneous cholecystostomy
_________ is a far more deadly disease, in which stones have reached the
common duct producing partial obstruction and ascending infection
Acute ascending cholangitis
Charcot triad+ mental status and evidence of sepsis (most commonly, hypotension)
Reynolds Pentad
Tx of ascending cholangitis
IV antibiotics and emergency decompression of the common duct is lifesaving; this is performed ideally by ERCP, alternatively percutaneous through the liver by percutaneous transhepatic cholangiogram (PTC), or rarely by surgery
_______ is seen when stones become impacted distally in the ampulla, temporarily obstructing both pancreatic and biliary ducts
Biliary pancreatitis
Acute pancreatitis may be
1
2
3
edematous, hemorrhagic, or suppurative (pancreatic abscess).
Late complications of Acute pancreatitis include _____
pancreatic pseudocyst and chronic pancreatitis.
________ Can Be seen in Acute Pancreatitis
Grey-Turner Sign
Acute edematous pancreatitis occurs in the______ or _______
alcoholic or the patient with gallstones
Dxtics for acute edematous pancreatitis
Serum amylase and lipase are elevated, and often serum hematocrit levels are high due hypovolemia
It starts as the edematous form does, but an early lab clue is lower hematocrit (the degree of amylase elevation does not correlate with the severity of the disease)
Acute severe pancreatitis
Acute severe pancreatitis DX
Ransons criteria
Organism and ABx for late severe pancreatitis
If drained fluid is positive for bacteria (often gram-negative), the antibiotic of choice is IV carbopenem (imipenem or meropenem)
__________ is the best way to deal with necrotic pancreas, but timing is crucial
Necrosectomy
Timing for Necrosectomy
Patients do far better by waiting at least 4 weeks before debridement of the dead pancreatic tissue
_______may become evident in someone who
was not getting CT scans, because persistent fever and leukocytosis develop ~10 days after
the onset of pancreatitis and sepsis develops.
Pancreatic abscess (acute suppurative pancreatitis)
Timing of discovery of pseudocyst
In either case, ~5 weeks elapses between the original problem and the discovery of the pseudocyst
Cysts ≤6 cm or those that have been present <6 weeks are not likely to have complications and can be __________
observed for spontaneous resolution
People who have repeated episodes of pancreatitis
(usually alcoholic) eventually develop calcified burned-out pancreas, steatorrhea, diabetes, and constant epigastric pain. What condition is this?
Chronic pancreatitis
Hernias that dont need to be repaired
- Asymptomatic umbilical hernia in patients age <5 (they typically close spontaneously)
- Esophageal sliding hiatal hernias (not “true” hernias)
As a regular screening exam, mammography should be started at age________
40 (earlier if there is family history).
_______ is seen in young women (late teens, early twenties) as a firm, rubbery mass
that moves easily with palpation
Fibroadenoma
Dx of Fibroadenoma
Fine-needle aspirate (FNA) or core biopsy is sufficient to
establish diagnosis.
_________ is seen in very young adolescents, where it has very rapid growth. Removal is needed to avoid deformity and distortion of the breast
Giant juvenile fibroadenoma
_________ (fibrocystic disease, cystic mastitis) is seen in the 30s and 40s (goes away
with menopause), with bilateral tenderness related to menstrual cycle (worse in the last 2
weeks) and multiple lumps that seem to come and go (they are cysts) also following the menstrual
cycle
Mammary dysplasia
_______ is seen in young women (20s–40s) with bloody nipple discharge. Mammogram is needed to identify other potential lesions, but it will not show the papilloma
Intraductal papilloma
Breast cancer during pregnancy is diagnosed exactly as if pregnancy did not exist, and is treated
the same way with the following exceptions:
1
2
- No radiotherapy during the pregnancy
* No chemotherapy during the first trimester
____ has higher incidence of bilaterality, but not high
enough to justify bilateral mastectomy in all cases
Lobular Breast CA
_______ is a clinical presentation of advanced breast cancer. It has a much worse prognosis and is treated with chemotherapy prior to surgery
Inflammatory cancer
Inflammatory breast cancer is also one of the few times where ______
radiation is added following a total mastectomy
______is the common standard form of breast cancer
Infiltrating ductal carcinoma
___________ cannot metastasize (thus no axillary sampling is needed) but has very
high incidence of recurrence if only local excision is done
Ductal carcinoma in situ
Tx for Ductal carcinoma in situ
Total mastectomy is recommended for
multicentric lesions throughout the breast; because of the possibility of missing an invasive focus in
multicentric disease, many practitioners add a sentinel node biopsy in those patients
Chemotherapy
- Premenopausal women receive _____
- Postmenopausal women receive an ____
- Frail, old women with less-aggressive tumors and women with small, low-risk tumors may be offered hormonal therapy alone if their tumors are ____
tamoxifen
aromatase-inhibitor (e.g. anastrozole)
estrogen-receptor positive
Most hyperthyroid patients are treated with radioactive iodine, but those with a _______have the option of surgical excision of the affected lobe
“hot adenoma”
True about hyperparathyroidism
- Asymptomatic patients become symptomatic at a rate of ______ thus elective intervention is justified.
- Ninety percent have single adenoma.
- Removal is curative (_____ may help localize the culprit gland before surgery
20% per year;
sestamibi scan
\_\_\_\_\_\_\_\_\_ shows up as virulent peptic ulcer disease, resistant to all usual therapy (including eradication of Helicobacter pylori), and more extensive than it should be (several ulcers rather than one, ulcers extending beyond first portion of the duodenum)
Zollinger-Ellison syndrome (gastrinoma)
Dx of ZES
Measure gastrin and do a secretin test; if values
are equivocal, locate the tumor with CT scan (with contrast) of the pancreas and nearby
areas and resect it
______ produces CNS symptoms because of low blood sugar, always when the patient is fasting
Insulinoma
________ produces severe migratory necrolytic
dermatitis, resistant to all forms of therapy, in a patient with mild diabetes, mild anemia, glossitis, and stomatitis.
Glucagonoma
In Glucagonoma,______ and ______ can help those with metastatic, inoperable disease.
Somatostatin and streptozocin
________ can be caused by an adenoma or by hyperplasia. In both cases the key finding is hypokalemia in a hypertensive (usually female) patient who is not on
diuretics
Primary hyperaldosteronism
DX of Primary hyperaldosteronism
Aldosterone levels are high, whereas renin levels are low
Appropriate response to postural changes (more
aldosterone when upright than when lying down) suggests ______ (which is treated medically), whereas lack of response (or inappropriate response) is diagnostic of ______
hyperplasia
adenoma
________ is seen in thin, hyperactive women who have attacks of pounding headache, perspiration, palpitations, and pallor (i.e., extremely high but paroxysmal BP).
Pheochromocytoma
Pheochromocytoma Dx
Start the workup with a 24-hour urinary determination of vanillylmandelic acid
(VMA), metanephrines (more specific), or free urinary catecholamines
Other dx Pheochromocytoma
Follow with a CT scan of the adrenal glands and retroperitoneum; if negative, a radionuclide
study may be necessary to identify extra-adrenal sites.
Surgery requires careful pharmacologic preparation with ________ then _____
alpha-blockers, followed by
beta-blockers
CoA
Chest x-ray shows_________. CT angiogram (CTA) is diagnostic and surgical correction is curative
scalloping of the ribs (erosion from large collateral intercostals)
Renovascular hypertension is seen in 2 distinct groups:
1
2
young women with fibromuscular dysplasia, and old men with arteriosclerotic occlusive diseas
