General Abdomen Flashcards
1
Q
Predominant cause of chylous ascites in Western world
A
malignancy (esp lymphoma), cirrhosis
2
Q
MCC chylous ascites in developing world
A
infectious such as tuberculosis and filariasis
3
Q
Chylous ascites: triglyceride count
A
Usually >200 mg/dL
4
Q
greatest risk for recurrent ulcer bleeding
A
visible vessel
5
Q
most common location of bleeding ulcers
A
posterior duodenal bulb
6
Q
Tx of biliary cystadenoma
A
surgical enucleation or resection (anatomic not required)
7
Q
Tx of PCLD type 1
A
limited number of large cysts
aspiration/sclerosis or unroofing
8
Q
tx of type 2 PCLD
A
moderate sized cysts with intervening normal parenchyma
surgical unroofing or resection
9
Q
tx of type 3 PCLD
A
diffuse involvement of moderate and small cysts without much normal parenchyma
typically requires transplant after failure of medical mgmt
10
Q
hydatid cysts associated with what parasite
A
echinococcus granulosis
11
Q
thick walled, calcified cysts with daughter cells in periphery
A
hydatid cysts
12
Q
tx of hydatid disease
A
PAIR or open surgical pericystectomy + anti helminthic drugs (albendazole or mebendazole) for 2 weeks preoperatively
PAIR = puncture, aspiration, injection of sclerosing agents and reaspiration of contents
13
Q
tx of amebic abscess
A
Flagyl (Due to entamoeba histolytica)
14
Q
narrowing of aortomesenteric angle to <25
A
SMA syndrome
15
Q
normal aortomesenteric angle
A
38-65 degrees
16
Q
annular pancreas is a result of
A
tethering of ventral pancreatic bud to duodenum (failure of CLOCKWISE rotation)
17
Q
tx of annular pancreas in children
A
duodenal bypass
18
Q
annular pancreas a/w
A
down syndrome
19
Q
duodenal atresia cause
A
complete failure of recanalization of duodenum after 7th wee kof gestation
20
Q
prenatal ultrasound in duodenal atresia
A
polyhdramnios
21
Q
“double bubble” sign
A
duodenal atresia
22
Q
diagnose duodenal atresia - waht next?
A
place NG or OG, clinically stabilize and then perform duodenoduodenostomy or duodenojejunostomy
23
Q
spillage of what kind of hepatic cyst can lead to anaphylaxis
A
echinococcal/hydatid
24
Q
what should you do if echinococcal cyst with jaundice, increased LFTs or cholangitis?
A
pre op ERCP to check for communication with biliary system
25
what type of diagnostic testing can be done for echinococcal disease
casoni skin test, serology
26
what kind of infection a/w variceal bleeding
schistosomiasis
| also will see maculopapular rash, increased eosinophils
27
tx of schistosomiasis
praziquantel, contrtol of variceal bleeding if present
28
#1 organism in poyogenic abscess
E.coli
29
what type of diagnostic testing can be used when diagnosing amebic hepatic abscess (E. histolytica)
indirect hemagglutination
ELISA
indirect IF
latex agglutination
30
when should eprcutanoeus drainage be performed for amebic abscess
```
>10 cm diameter
subcapsular
pre rupture status
superinfected
resistance to medical tx
```
31
indications for surgery in pancreatic cysts
worrisome cytology
dilated pancreatic duct in presence of solid component in cyst
Some guidelines include jaundice as well
32
pancreatic cyst size > ___ cm is worrisome per guidelines and warrants additional workupo
3 cm
33
cross-linked mesh
biologic
| increases durability, tensile strength, and resistance to bacterial contamination
34
to be defined as biliary dyskinesia must have episodes of duration lasting at least how long?
30 min
35
what type of pain is needed to be defined as biliary dyskinesia
crescendo pain not relieved by BM, postural change or antacids
36
2 most significant facrors for hernia recurrence
hernia width
| contamination
37
contrast when suspecting appendicitis
IV only
| enteral does not increase accuracy of diagnosis
38
frequency of port site recurrence in gallbladder cancer
10%
39
McVay/Cooper repair approximates what to what
transversus abdominis aponeurosis (Conjoint) to Cooper's ligament
40
when performing Mcvay repair for possible strangulated femoral hernia what should you be sure to do
incise thigh fascia below inguinal ligament to displace the fat tissue surrounding femoral hernia sac and check contents
41
usually femoral hernia is found where in relation to inferior epigastrics
medial
42
splenic vein - above or below artery
below
43
splenic vein originates within what ligament
splenorenal
44
where does splenic vein unite with SMV
posterior to neck of pancreas/splenic mesenteric confluence (forms hepatic portal vein)
45
median 5 year survival after resection of invasive IPMN
43%
46
branch duct IPMN <1 cm mgmt (no concerning CA sx)
cross sectional imaging annually
47
branch duct IPMN 1-3 cm mgmt (no concerning CA sx)
repeat cross sectional imaging in 6 months then annually if no change
48
branch duct IPMN >3 cm mgmt (no concerning CA sx)
resection to negative margins
49
5 year survival after resection of non invasive IPMN
77%
50
How often do IPMN recur
8% (Doesnt matter if invasive or not)
51
double duct sign
simultaneous dilation of cbd and pancreatic ducts
52
2 MC causes of double duct sign
CA of head of pancreas and ampullary tumors
| could also be impacted gallstone in distal duct with assoc edema
53
Puestow procedure
main pancreatic duct is dilated greater than 8 mm and consists of performing a longitudinal pancreaticojejunostomy.
| creation of retrocolic Roux limb, opening of duct from head to tail, 1 or 2 layer side to side pancreaticojejun
54
Frey procedure
A Frey's procedure is indicated in patients with chronic pancreatitis who have the majority of their disease within the head of the pancreas and involves resecting peripancreatic ductal tissue in the head of the pancreas and performing a longitudinal pancreaticojejunostomy.
55
Beger procedure
local resection of pancreatic head with duodenal preservation ** creation of retrocolic Roux limb, end to end pancreaticojejunostomy with pancreaticojejunostomy to pancreatic head remnant
56
Key to Beger procedure
preservation of posterior branch of GDA to maintain viability of duodenum and distal CBD
57
Diff between Beger and Frey
Frey procedure does NOT transect the pancreatic neck vs Beger does
58
What is the conjoint tendon
transversus abdominis + internal oblique
59
where do the epigastric vessels run in lap hernia repair
lateral umbilical fold
60
what does the medial umbilical fold contain
remnant of umbilical aa
61
what does the median umbilical fold contain
remantn of the urachus
62
MCC pyogenic liver abscess
cholangitis 2/2 gram negative aerobes
| E. Coli, klebsiella pneumonia and proteus spp
63
hepatic abscess following liver txp should raise concern for
presence of hepatic artery thrombosis
64
need for frozen section on desmoid?
yes to ensure complete excision otherwise recurrence up to 80%
65
overall recurrence rate for appendicitis tx with antibiotics
5-38%
66
bile duct excision and hepaticojejunostomy is tx for which types of choledochal cysts
type I and IV
67
early washout during delayed or late phase on multi phase CT scan may indicate 1 of 2 things
hepatic adenoma or HCC
68
modality of choice for pancreatic cysts
MRCP
69
describe peritoneum
bidirectional semipermeable membrane made of simple squamous epithelium
70
parietal peritoneum covers
abdominal wall, portions of pelvis and diaphragm
71
visceral; peritoneum blood supply
splanchnic vessels
72
parietal peritoneum blood supply
branches of intercostal, subcostal, lumbar and ilaic vessels
73
visceral vs parietal peritoneum nerve supply
visceral - few nerves (localization is poor)
| parietal - travels with somatosensory spine nerves, localized pain
74
Retroperitoneal organs
```
SAD PUCKER
Suprarenal (Adrenal) glands
Aorta/IVC
Duodenum (2nd, 3rd)
Pancreas
Ureters
Colon (asc., desc.)
Kidneys
Esophagus
Rectum
```
75
gold standard to hypertrophy anticipated future liver remnant
portal vein embolization
76
Tx for somatostatinoma
Usually in head, enucleation is not adequate resection for pts with somatostatinoma given high likelihood of malignancy. Have to do Whipple
77
best test to dx chronic mesenteric iscehemia
CTA
78
abx combo for pyogenic liver abscess
ampicillin + aminoglycoside + flagyl
79
percutaneous drainage for pyogenic liver abscess contra indications
```
abdominal patholgoy
coagulopathy
inaccessibility
massive ascites
small, multiloculated, or multiple abscesses
```
80
fibropolycystic liver disease aka
choledochal cyst
81
2 genetic conditions that increase risk for cholangioCA
Lynch syndrome
| biliary papillomatosis
82
liver flukes a/w
cholangioCA of intrahepatic bile ducts
83
migration of adult Ascaris worms into biliary tree
```
biliary colic or strictures
acalculkous chole
ascending cholangitis
liver abscesses
recurrent pyogenic cholangitis (stone formation around dead A. lumbricoides in the bile duct)
pancreatitis
```
84
two things seen on PBS of post splenectomy pt
howell-jolly bodies
| siderocytes
85
one of key issues with lap ventral hernia repair
fascia often not closed primarily
86
characteristics of chylous ascites
elevated TGs
leukocytosis with lymphocytic predominance
negative fluid cultures
87
sensitivity of ERCP to diagnose pancreatic CA
approaches 90%
88
sensitivity of CT for dx of pancreatic CA
85%
89
bismuth classification: tumor involves common hepatic duct DISTAL to bifurcation
class I
90
bismuth classification: tumor involves confluence of right and left hepatic ducts and extends to RIGHT hepatic duct
class IIIa
91
bismuth classification: tumor involves confluence of right and left hepatic ducts, extends to LEFT hepatic duct
class IIIb
92
bismuth classification: tumor involves confluence of right and left hepatic ducts and extends to both right and left hepatic ducts
class IV
93
klatskin tumor
upper duct (or hilar) cholangiocarcinoma
94
MC organism a/w SBP
aerobic gram negative rods (over 50% are E. coli species)
Top 3:
E coli
Klebsiella pneumo
Pneumococci
95
in utero that majority of pancreas drained by ?
dorsal duct, opens up into MINOR papilla
96
in adults, 70% of pancreas is drained by
ventral duct, opens up into major papilla
97
in pancreas divisum, major drainage of pancreas is done by the
dorsal duct which opens up into MINOR papilla
98
atezolizumab moa
commonly used in unresectable HCC
| monoclonal Ab of IgG1 isotype against protein programmed cell death-ligand 1 (PD-L1)
99
MOA of sorafenib
multikinase inhibitor with activity against VEGF
100
most reliable dx tool for budd chiari
duplex US of liver and vasculature
101
any injury to CBD with ductal tissue loss or when >50% of duct involved, tx of choice
roux en y choledochoj (distal CBD) or hepaticoj (proximal CBD)
102
second line therapy for ITP
rituximab or thrombopoietin receptor agonist ssuch as romiplostim or eltrombopag
103
rituximab MOA
monoclonal Ab that targets CD20 on B cells
104
what pathologic process involving spleen poorly delineated on B mode US
infarction
| can use US contrast (sulfur hexafluoride lipid-type A microspheres)
105
comared with surgical resection alone, surgical resection and adjuvant XRT in tx of GB cancer is a/w
slightly longer survival
106
c peptide levels in insulinoma
c-peptide (marker for insulin secretion) levels are elevated
107
pts with glucagonoma increased risk for
DVT
108
Dx of glucagonoma can be confirmed with glucagon level > than
500 pg/mL
109
glucagonoma - location
head and tail of pancreas, tend to be large with mets at time of dx
110
tx of choice glucagonoma
surgical removal with debulking
111
MCC atraumatic splenci rupture
malignant hematologic disorders
112
repeat cscope in pts with <20 hyperplastic polyps <10 mm
10 years
113
individuals with 1-2 adenomas <10 mm should undergo next surveillance cscope at
7-10 years
114
individuals with 3-4 adenomas <10 mm, surveillance cscope at
3-5 years
115
indiduals with 5-10 adenomas should undergo surveillance in
3 years
116
individuals with adenoma > or = 10 mm should undergo surveillance in
3 years
117
individualks with adenoma with villous component or high grade dysplasia should undergo surveillance in
3 years
118
pts with >10 adenomas should undergo surveillance in
1 year with cosndieratio for genetic testing
119
in case of piecemeal resection of adenoma > or = 20 mm
cscope in 6 months, then 1 year later, then 3 years after second exam
120
individuals with 1-2 sessile serrated polyps
5-10 years
121
indviduals with 3-4 sessile serrated polyps <10 mm should undergo cscope in
3-5 years
122
individuals with hyperplastic polyp > or = 10 mm surveillance in
3-5 years
123
individuals with 5-10 SSPs should undergo surveillance in
3 years
124
individuals with SSP > or = 10 mm should undergo surveillance in
3 years
125
individuals with SSP with dysplasia or traditional serrated adenoma surveillance in
3 years
126
risk of OPSI highest when spleen removed for
malignancy
127
mesh placement with lowest recurrence rates for ventral hernia
sublay
128
location for mesh implantation in TAR (posterior component separation)
sublay in retromuscular position
129
which procedure does acellular dermal matrix mesh demonstrate lower recurrence rates and fewer infectious complications than artificial mesh
VHR with concomitant ECF repair (or in general, presence of heavy contamination)
130
describe polydioxanone suture
slowly absorbable (6-9 months)
131
describe polyglactin suture
rapidly absorbable (2-3 months)
132
adjuvant chemotherapy in pancreatic adenoCA
survival benefit and decreases recurrence
gemcitabine or FU + folinic acid
Gemcitabine favored because of lower toxicity
133
Adjuvant chemoXRT in pancreatic adenoCA indications
residual microscopic disease
| node positive disease
134
after ruling out malignancy and parasitic infection, next step in splenic cyst?
perc aspiration
135
local recurrence in retroperitoneal sarcoma
up to 35-60% of pts after 10 years
136
which fascial closure techniques minimize incidence of incisional hernia after elective midline laparotomy
onlay polypropylene mesh reinforcement
137
RFA in HCC
small <3 cm HCC
138
MC complication after RFA for HCC
hemorrhage
| can combine with chemoembolization to avoid hemorrhagic complications
139
when does retroperitoneal sarcoma get adjuvant chemo?
mets
| typically anthracyclin based
140
what improves overall survival in retroperitoneal sarcoma
grossly negative margins
141
pancreatic tumor that stains positive for beta catenin
solid pseudopapillary neoplasm
142
most precise single predictor of operative mortality at 30 days in pts with liver cirrhosis
MELD
143
indication for CBD resection in gallbladder CA
cystic duct margin +
144
#1 RF for splenic a aneurysm
atherosclerosis
145
mesh placement with lowest recurrence
sublay
146
Class A child pugh class score
5-6
147
Class B child pugh class score
7-9
148
MC chemo agent used in HIPEC
Mitomycin
149
MC chemo agent used in HIPEC
fMitomycin
150
Expected mean survival for pt with stage IV colorectal CA + peritoneal carcinomatosis
6 mos
151
In order to facilitate HIPEC, debulking of any lesions bigger than what size?
>2 mm
152
Chemotherapy in HIPEC is most effective at what temp
41 degrees celsius
153
Howell Jolly Bodies
Nuclear remnant
Asplenic patients
154
Heinz bodies
denatured hemoglobin
Seen in asplenic patients, thalassemias, and G6PD deficiency
155
Pappenheimer bodies
Iron granules found in RBCs in pts with sideroblastic anemia
156
Acanthocytes
Spur cells
157
Schistocytes
Microangiopathic hemolysis as in TTP or DIC
158
2nd most common location of accessory spleen
Tail of pancreas
159
3rd MC location of accessory spleen
Greater omentum
160
Ranson criteria at admission
On admission: Age > 55 years WBC count > 16,000/mm^3 Blood glucose level > 200 mg/dL LDH > 350 IU/L AST > 250 U/L
161
Ranson criteria at 48 hrs
Hematocrit decrease > 10% from admission BUN increase > 5 mg/dL from admission Serum calcium < 2 mmol/L Partial pressure of oxygen < 60 mmHg Base deficit > 4 mmol/L Fluid sequestration > 6 L
162
ranson score >3 pts
severe
163
Indications for resection of pancreatic cystic neoplasm
Main pancreatic duct dilation >10 mm
Cystic lesion >3 cm in size
Presence of mural nodules of >5 mm
Atypical cytology
Associated solid components with the cyst
164
surgical correction of annular pancreas in neonate
Annular pancreas is a congenital anomaly that causes a ring of pancreatic tissue to envelop the second portion of the duodenum. In over 2/3 of cases, patients are asymptomatic, but when they are, it presents as duodenal obstruction. This anomaly can be associated with Down Syndrome and other intestinal atresias. The procedure of choice in neonates is a duodenoduodenostomy
165
surgical correction of annular pancreas in adult
duodenojejunostomy or gastrojejunostomy is preferred.
