General Sugery Flashcards
Tx for GERD that cannot be controlled by medical means or presence of ulcers, stenosis
Laparoscopic Nissen fundoplication
Dx of GERD
pH monitoring and correlation with symptoms
Dysphagia of liquids but not solids
Achalasia
Definitive dx of dysphagia
Manometry
Tx of achalasia
Balloon dilatation by endoscopy
Progressive dysphagia
Weight loss
Hx smoking drinking or GERD
Esophageal cancer
Type of esophageal cancer in smokers and drinkers
Squamous cell
Type of esophageal cancer in GERD
Adenocarcinoma
Dx for esophageal cancer
Barium swallow, endoscopy and biopsy
Tx of Mallory-Weiss tear
Endoscopy and photocoagulation
Tx of Boerhaave syndrome (prolonged forceful vomiting leading to esophageal perforation)
Contrast swallow
Emergency surgical repair
Wrenching epigastric pain
Fever, leukocytosis
Subcutaneous emphysema in neck
Perforation of esophagus
Most commonly by endoscopy
Elderly
Anorexia, weight loss, epigastric discomfort, early satiety
Gastric cancer
Dx and tx for gastric adenocarcinoma
Endoscopy and biopsy, CT
Surgery
Tx of gastric lymphoma
Chemotherapy, radiotherapy
Surgery if perforation
Tx of MALToma
Eradicate H. pylori
Signs of small bowel obstruction
Progressive distention
No gas or feces
High pitched bowel sounds coinciding with colicky pain
Tx of small bowel obstruction
NPO, NG suction, IV fluids
Surgery if strangulated or after several days without spontaneous resolution
Tx for incarcerated hernia
If irreducible and strangulated, emergent surgery
If reducible then elective surgery
Diarrhea, facial flushing, wheezing, right sided heart valve damage, prominent jugular venous pulse
Carcinoid syndrome
Result of liver mets
Dx of carcinoid syndrome
24 hour urine collection for 5-hydroxyindoleacetic acid
Elderly person with anemia and 4+ occult blood
Right sided colon cancer
Dx and tx for cancer of right colon
Colonoscopy and biopsy
Right hemicolectomy
Bloody bowel movements
Narrow caliber
Left sided colon cancer
Dx of cancer of left colon
Flexible proctosigmoidoscopy and biopsy
Full colonoscopy
CT for operability and extent
Initial tx of large rectal cancers
Chemotherapy, radiotherapy
Familial polyposis
Familial multiple inflammatory
Villous adenoma
Adenomatous polyp
Premalignant polyps
Juvenile polyp
Peutz-Jeghers
Isolated inflammatory polyp
Hyperplastic polyp
Benign polyps
Surgical indications for ulcerative colitis
Disease >20 yrs Poor nutritional status Multiple hospitalizations Need for high dose steroids, immune suppressants Toxic megacolon
Surgical tx of ulcerative colitis
Removal of affected colon and all rectal mucosa
Abdominal pain, fever, leukocytosis
Epigastric tenderness, massively distended transverse colon
Gas within wall of colon
Toxic megacolon
Etiology of pseudomembranous colitis
Cephalosporins most commonly
Clindamycin
Any antibiotic
Tx of pseudomembranous colitis
Metronidazole
Or vancomycin
Emergency colectomy if unresponsive and WBC >50k
Difference between internal and external hemorrhoids
Internal bleed. Only painful if prolapsed. Tx with ligation
External are painful. May need surgery
Blood streaked stool
Fear of pain causes avoidance of bowel movement and constipation
Young women
Anal fissure
Common location and tx of anal fissure
Posterior midline
Calcium channel blocker ointment
Botox
Lateral internal sphincterotomy
Unhealing fissure, fistula or ulcer in the anal area
Crohn’s disease
Tx for Crohn’s disease fistula
Drainage with setons
Remicade
Perirectal pain, unable to sit or have bowel movement
Inflammation lateral to anus
Ischiorectal abscess
Tx is I&D
Hx ischiorectal abscess with drainage
Fecal soiling
Fistula in ano
R/o draining tumor
Homosexual
Fungating mass grows out of anus
Inguinal nodes felt
Tx?
Squamous cell carcinoma of anus
Chemoradiation then surgery which is rarely required
Most common sites of GI bleeding
Upper GI between nose and ligament of Treitz
Look in nose and mouth, endoscopy indicated
Causes of lower GI bleeding
In elderly
Angiodysplasia, polyps, diverticulosis, cancer, hemorrhoids
Dx of cause of vomiting blood or melena
Upper GI endoscopy
Where may red blood per rectum arise
How do you dx where
Anywhere, upper or lower
Pass NG tube, if you get normal bile without blood then assume lower. If blood or no bile, do endoscopy
Dx of location of active lower GI bleed
- Anoscopy (r/o hemorrhoids)
- Angiogram if bleeding >2 mL/min
Wait for hemostasis then colonoscopy if <0.5 mL/min
Tagged red-cell study 0.5-2 mL/min
Capsule endoscopy being used more frequently
Dx of location of blood per rectum w/o active bleeding
Young and elderly
Young: upper GI endoscopy
Old: upper and lower GI endoscopy
Blood per rectum in peds pt
Dx?
Meckel diverticulum
Technetium scan
Tx for massive upper GI bleed/stress ulcer
Angiographic embolization
Sudden onset, constant, severe, generalized abdominal pain
generalized signs of peritoneal irritation
Perforation
Dx of perforation
Most common cause?
Tx?
Free-air under diaphragm on upright X-ray
Perforated peptic ulcer most common
Emergency surgery required
Sudden onset, colicky pain with localization and radiation
Pt moves constantly seeking position of comfort
Obstruction
i.e. ureter, cystic duct, etc
Gradual onset, starts ill-defined then localizes
typical radiation patterns
localized signs of peritoneal irritation
Inflammatory process
Fever, leukocytosis common (except pancreatitis)
Severe abdominal pain
Blood in gut lumen
Ischemia
Child: ascites, nephrosis Adult: ascites Mild generalized acute abdomen Possible fever, leukocytosis Dx? Tx?
Primary peritonitis
Dx by ascitic culture
Tx with antibiotics
What needs to be ruled out before exploratory laparotomy on generalized acute abdomen (6)
MI, pneumonia, PE
Primary peritonitis, pancreatitis, nephrolithiasis
Alcoholic
acute upper abdomen with constant pain radiating to back
nausea, vomiting, retching
Dx? Tx?
Acute pancreatitis
Dx by serum (1-2 d) or urinary (3-6 d) amylase, lipase
Tx by NPO, NG suction, IV fluids
LLQ abdominal pain
fever, leukocytosis, peritoneal irritation
Dx? Tx?
Acute diverticulitis
Dx by CT
NPO, IV fluids, antibiotics
Percutaneous drainage if abscess, surgical resection if 2 or more attacks
Elderly, signs of obstruction
distended colon
huge air filled loop in RUQ that tapers down to LLQ in the shape of a “parrot’s beak”
Dx? Tx?
Sigmoid volvulus
Xray
Tx by rigid proctosigmoidoscopy and rectal tube
Recurrence warrants elective sigmoid resection
Acute abdomen predominantly in elderly
Associated A-fib or recent MI
Signs of acidosis, sepsis, blood in gut lumen
Mesenteric ischemia
If caught early, try arteriogram and embolectomy
Cirrhosis
Vague RUQ discomfort, weight loss
Tx?
Primary hepatocellular carcinoma
Resection if possible
Blood marker for hepatocellular carcinoma
AFP
Most common liver tumor
Metastasis
Hepatic lesion caused by birth control pills
Hepatic adenoma
May rupture and bleed requiring emergency surgery
Fever, leukocytosis, liver tenderness
hx acute ascending cholangitis
Dx? Tx?
Pyogenic liver abscess
Ultrasound or CT
Percutaneous drainage
Immigrant
fever, leukocytosis, liver tenderness
Tx?
Amebic abscess of liver
Metronidazole or drainage
Unconjugated hyperbilirubinemia
Normal conjugated
Hemolytic jaundice
Elevated conjugated and unconjugated bilirubin
Elevated liver enzymes
modestly elevated alk phos
Dx?
Hepatocellular jaundice
Most commonly hepatitis
dx by serology
Elevated conjugated and unconjugated bilirubin
modestly elevated liver enzymes
very high all phos level
Dx?
Obstructive jaundice
most commonly by gallstones
dx by ultrasound
Next steps after obstructive jaundice from stones is confirmed
ERCP
sphincterotomy to remove stone
cholecystectomy
Tumors that could cause obstructive jaundice (3)
adenocarcinoma of head of pancreas
adenocarcinoma of ampulla of Vater
cholangiocarcinoma of common bile duct
Workup of obstructive jaundice without stones
CT, percutaneous biopsy if tumor suspected
if CT negative, ERCP and biopsy
Obstructive jaundice
anemia
positive blood in stools
dx?
Ampullary cancer
dx by endoscopy
(may not be seen on CT as they can obstruct while still being very small)
Colicky RUQ pain
self-limited up to 30 minutes
triggered by fatty foods, associated nausea, vomiting
no peritoneal irritation
Biliary colic
Elective cholecystectomy if stones confirmed
RUQ pain with signs of peritoneal irritation
fever, leukocytosis
Dx? Tx?
Acute cholecystitis
ultrasound or HIDA scan
NPO, NG suction, IV fluids, antibiotics
elective cholecystectomy
What is Tx for acute cholecystitis when patient is poor surgical candidate
Transhepatic cholecystostomy
High spiking fevers, very high leukocytosis
Very high alk phos
Tx?
Acute ascending cholangitis
IV antibiotics
Emergency decompression of common duct via ERCP
Eventual cholecystectomy
Causes of acute pancreatitis (2)
Alcohol, gallstones
What is pancreatic rest
Tx for pancreatitis which includes
NPO, NG suction, IV fluids
Epigastric midabdominal pain radiating to back nausea, vomiting, retching elevated amylase, lipase elevated hematocrit Tx?
Acute edematous pancreatitis
Tx is pancreatic rest
Epigastric midabdominal pain radiating to back nausea, vomiting, retching elevated amylase, lipase decreased hematocrit Tx?
Acute hemorrhagic pancreatitis
Tx is ICU admission, drainage of pancreatic abscesses, daily CT scans
Poor prognosis
Elevated WBC count Elevated blood glucose Low serum calcium Low, decreasing hematocrit Increased BUN Decreased PO2
Ranson’s criteria for pancreatitis
Tx for necrotic pancreas
How long do you wait
Necrosectomy
Wait 4 weeks before debridement
Signs of suppurative pancreatitis
When does it become evident
Persistent fever, leukocytosis
10 days after pancreatitis begins
Abscess on CT
Etiology of pancreatic pseudocyst
Where does pancreatic juice collect?
5 weeks after acute pancreatitis or pancreatic trauma
Juice collects in lesser sac
What are options for drainage of >6cm pseudocyst
Percutaneous
Surgically into GI tract
Endoscopically into the stomach
Symptoms of chronic pancreatitis
Calcified pancreas, steatorrhea, diabetes, constant epigastric pain
Tx of chronic pancreatitis
Insulin- diabetes
Pancreatic enzymes- steatorrhea
Pain- unresponsive to most therapies
ERCP and stenting if pancreatic duct is obstructed
Which hernias do not require surgery
Umbilical hernias in ages 2 to 5
Sliding hiatal hernias (not true hernias)
Gold standard for breast cancer diagnosis
Mammographically or sonographically guided multiple core biopsies
Need tissue to diagnose breast ca
Young woman
mobile, firm, rubbery breast mass
Dx, Tx?
Fibroadenoma
FNA or sonogram
Removal optional
Rapidly growing breast tumor in very young adolescents
Giant juvenile fibroadenomas
Late 20’s
Grow to be very large over years distorting breast
Dont invade or become fixed
Benign but can become malignant
Cystosarcoma phyllodes
Core or incisional biopsy is necessary
30’s-40’s
Bilateral breast tenderness related to menstrual cycle
Multiple lumps that come and go
Fibrocystic disease (mammary dysplasia)
If cystic mass is drained in suspected fibrocystic disease what is next step if
Clear fluid, cyst goes away
Cyst persists
Blood is aspirated
Goes away- nothing
Persists- biopsy
Blood- sent for cytology
20’s-40’s
Bloody nipple discharge
Dx? Tx?
Intraductal papilloma
Galactogram
Surgical resection
Tx for breast abscess
I&D, biopsy of abscess wall
Cancer until proven otherwise
Approach to breast cancer during pregnancy
Same if non-pregnant except
no radiotherapy
no chemotherapy during first trimester
Tx of resectable breast cancer
lumpectomy, axillary sampling, plus radiation
or
modified radical mastectomy with axillary sampling
Tx after breast surgery with positive nodes
Chemotherapy
Hormonal therapy
(Premenopause- tamoxifen, post- anastrozole)
Headache, tender back pain
hx breast cancer
Dx?
Metastases
MRI
Work-up for thyroid nodules
If benign? If malignant?
FNA
benign- follow
malignant- thyroid lobectomy
Which thyroid cancer requires total thyroidectomy
Why?
Follicular cancers
So radioactive iodine can be used for mets
Thyroid nodule in hyperthyroidism
What test? Tx?
Nuclear scan
if hot adenoma- surgical excision
if nothing found- radioactive iodine
Workup for suspected hyperparathyroidism
repeat Ca2+, look for low phos, r/o cancer with bone mets
check PTH
sestamibi scan may locate culprit gland
Tx for hyperparathyroidism
Surgical excision of culprit gland
Workup for Cushing’s disease
Overnight low-dose dexamethasone suppression test
If no suppression- 24 hour urine cortisol
If elevated- high-dose dexamethasone suppression test
If suppressed- pituitary adenoma
If unsuppressed- adrenal adenoma
Extensive peptic ulcers
resistant to usual therapies
watery diarrhea
dx? tx?
Zollinger-Ellison (gastrinoma) measure gastrin, secretin CT scan to locate tumor Surgical resection of tumor Omeprazole for symptoms if mets present
Dx and Tx of insulinoma
Measure insulin, c-peptide (both high)
CT to locate tumor and then resection
Hypersecretion of insulin in the newborn requiring 95% pancreatectomy
Nesidioblastosis
Severe migratory necrolytic dermatitis
mild diabetes
anemia, glossitis, stomatitis
Dx, Tx?
Glucagonoma
CT to locate and then resection
If mets- somatostatin and streptozocin
Hypertension
hypokalemia, not taking diuretics
modest hypernatremia, metabolic alkalosis
low renin
Primary hyperaldosteronism
How to differentiate adrenal hyperplasia versus adenoma in hyperaldosteronism
Hyperplasia- responds appropriately to postural changes (more aldosterone when upright)
Adenoma- inappropriate or lack of response
Tx of primary hyperaldosteronism
Hyperplasia- medical treatment
Adenoma- CT and the resection
Dx of pheochromocytoma
24 hour urinary VMA, metanephrines, or free catecholamines
CT scan for adrenals, radionuclide for extra-adrenal sites
Tx of pheochromocytoma
Resection after careful preparation with alpha and beta blockers
What is seen on CXR in coarctation of the aorta
Scalloping of the ribs
Erosion of ribs from collateral intercostals
Dx and Tx of coarctation of the aorta
CT angiogram
Surgical correction
Medication resistant hypertension
Faint bruit over flank
Dx, Tx?
Renovascular hypertension
Duplex scanning of renal vessels, CT angiogram
Balloon dilatation and stenting of renal arteries
Most common etiology of renovascular hypertension for men, women
Men- atherosclerotic disease
Women- fibromuscular dysplasia
Medical Tx for portal vein hypertension
Octreotide (somatostatin analogue)
Or vasopressin but contra in elderly and CAD
Common historical component in hepatic adenoma
Oral contraceptive use
