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01 Family Medicine > General Surgery > Flashcards

General Surgery Flashcards

AAFP Board Review lecture: Surgical Abdomen

1
Q

What are the main 2 reasons to call surgery for a patient with abdominal pain?

A

Peritonitis

Obstruction

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2
Q

How does the localization of visceral pain v. peritoneal pain differ?

A

Visceral- ill defined location, generalized

Parietal peritoneum- localizes to a specific location

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3
Q

What can cause RUQ pain?

A

Gall bladder pathology

Hepatitis

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4
Q

What can cause LUQ pain?

A

Gastric or spleen pathology

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5
Q

What can cause periumbilical pain?

A

Pancreatitis

Early appendicitis

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6
Q

What can cause RLQ pain?

A

Appendicitis

Gyn pathology (torsion, cysts, PID, ectopic pregnancy)

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7
Q

What can cause LLQ pain?

A

Diverticulitis

Gyn pathology (torsion, cysts, PID, ectopic pregnancy)

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8
Q

What can cause general, ill-defined abominal pain?

A

Ischemia

Obstruction

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9
Q

How does analgesia effect diagnosis and management of abdominal pain?

A

It does NOT

GIve pain medication (morphine 0.1 - 0.2 mg/kg IV)

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10
Q

What bacteria should antibiotics cover when treating peritonitis?

A

Gram negative aerobes and anaerobes

No one regimen is better than another

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11
Q

What is the main indication for placing an NG tube?

A

Small bowel obstruction

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12
Q

Why is abdominal pain more serious in the elderly compared to younger patients?

A

More likely to require hospitalization and to need surgery

Increased risk of misdiagnosis and death

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13
Q

Define incarcerated v. strangulated in the context of abdominal hernias

A

Incarcerated- stuck, does not reduce with firm pressure

Strangulated- bowel has vascular compromise, surgical emergency

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14
Q

Compare direct v. indirect hernias

How do you tell them apart on exam?

A

Indirect: contents enter through deep inguinal ring into the inguinal canal

Direct: contents enter through abdominal wall into inguinal canal

Indirect most common, more likely to incarcerate/strangulate

NO way to differentiate on exam

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15
Q

Where are femoral hernias felt?

A

Below inguinal ligament, medial to femoral pulse

More common in women

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16
Q

What is a Spigelian hernia?

A

Rare, lateral border of rectus muscle, below umbilicus at junction of arcuate line

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17
Q

What is a richter hernia?

A

Less than the full circumfrence of bowel is trapped

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18
Q

Do groin hernias need immediate repair?

A

No if: minimal discomfort, reducible, patient preference

No evidence that physical activity results in incarceration or worsening of hernia

Low chance of presenting as surgical emergency

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19
Q

What is the main reason for surgical inguinal hernia repair?

A

Patient preference due to pain

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20
Q

What is the best test to assess for free air in the abdomen?

A

Upright chest Xray

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21
Q

What is the most common cause of pneumoperitoneum?

A

Perforated peptic or duodenal ulcer

Bowel obstruction

Ruptured diverticula

Trauma

Normal up to 1 week after laparotomy/laparoscopy

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22
Q

Who is at risk for gallstone disease?

A

1st degree relative with hx

Cyclic weight change/recent bariatric surgery/rapid weight loss

DM/HLD

Short bowel syndrome, terminal Ileal resection

Medications: Ceftriaxone, estrogen (post menopause), TPN

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23
Q

Who is at risk for black pigmented gall stones?

A

Hemolytic diseases

Sickle cell disease

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24
Q

What type of gall stones are most common?

A

Cholesterol stones

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25
Q

In patients with gall stones, who needs surgery?

A

Surgery if symptomatic (biliary colic)

No prophylactic surgery if asymptomatic

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26
Q

Where is the stone stuck in cholecystitis? How does it present?

A

Cystic duct

RUQ pain, +/- fever or WBC, +Murphy sign

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27
Q

Where is the stone stuck in ascending cholangitis? How does it present?

A

Common bile duct (choledocholithiasis)

Charcot’s triad: fever, abdominal pain, jaundice

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28
Q

What is the difference between charcot’s triad and Reynolds Pentad? What illness does this indicate?

A

Charcot’s triad: fever, abdominal pain, jaundice

Reynolds pentad: fever, abdominal pain, jaundice, confusion, shock

Ascending cholangitis

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29
Q

Where is the stone stuck in gallstone pancreatitis?

A

Ampulla of Vater

30
Q

Where is the stone stuck in gallstone ileus?

A

Biliary - enteric fistula (large stone obstructing small bowel)

Rare

31
Q

How should gallstone disease be evaluated/ worked up?

A

History and PE

Ultrasound, if negative get HIDA

32
Q

What disease should you consider if patient has evidence of gallstone disease but RUQUS is normal?

A

Functional gallbladder disorder

Gall bladder EF <40% on HIDA

70-90% improve with cholecystectomy

33
Q

What is the most common cause of a surgical abdomen?

A

Appendicitis due to intraluminal obstruction (appendicolith) or extraluminal obstruction (lymphadenopathy)

34
Q

Name the sign: LLQ palpation causes RLQ pain

A

Rovsing’s sign

35
Q

Name the sign: RLQ pain when patient lays in left lateral decubitus position and extends right thigh

A

Psoas sign- suggests inflamed appendix is retrocecal (irritating psoas muscle)

36
Q

Name the sign: RLQ pain with internal rotation of flexed right thigh

A

Obturator sign- suggests inflamed appendix is in pelvis irritating obturator internus muscle

37
Q

Name the sign: pain worsens with abdominal crunch (engaging abs)

A

Carnett sign- suggests abdominal wall pathology

Not likely appendicitis if positive

38
Q

Name the sign: pain worsens with jarring landing (jumping jacks, drop from toes to heels)

A

Markle sign- suggests peritoneal inflammation

39
Q

What is the utility of the rectal exam in evaluating possible appendicitis?

A

Useless, made no difference in outcome

40
Q

What is the utility of lab work in evaluating possible appendicitis?

A

WBC- elevated 80% of adults, only 60% of kids and elderly

Elevated CRP + WBC sensitivity 85%; specificity very poor

In general CRP and WBC are not great tests for appendicitis

41
Q

What is the best imaging for diagnosing appendicitis for adults? For kids?

A

Adults- CT (no contrast needed)

Kids (<14 years old)- US

Pregnant- US

XR not helpful, MRI expensive, time consuming

42
Q

What is the most common cause of Small bowel v. Large bowel obstruction?

A

Small- adhesions

Large- neoplasm

43
Q

Differential for intestinal obstruction in general?

A

Adhesion, neoplasm, herniation, diverticulitis, IBD, volvulus, intussusception

44
Q

Signs and symptoms of small bowel obstruction?

A

Colicky abdominal pain, N/V/D

Distension, tympani, high pitched BS

Late findings: lack of flatulence/constipation

Strangulation (fever/tachycardia/peritonteal signs)

45
Q

Diagnostic test and findings of small bowel obstruction?

A

Abdominal XR

Dilated loops, lack of air in colon, air-fluid levels

If high suspicion and negative XR get CT

46
Q

Treatment of small bowel obstruction?

A

NG tube, IV hydration, analgesia

If 3+ days or if strangulation develops (unstable, peritonitis) -> time for surgery!

47
Q

Signs and symptoms of large bowel obstruction?

A

Elderly patients

Crampy pain, sudden onset (ex: volvulus)

N/V, distention, hypertympanic to percussion, bowel sounds decrease

Fever/abdomen tender or rigid = bad

48
Q

In large bowel obstruction what area is most likely to perforate?

A

Cecum

49
Q

Signs of large bowel obstruction on XR?

A

Closed loop obstruction

Cecum dilation (>12-14cm inc risk of perforation)

50
Q

Most common area of bowel volvulus?

A

SIgmoid due to long mesentary with narrow base

51
Q

What is the main cause of sigmoid volvulus?

A

Chronic constipation

52
Q

Treatment of sigmoid volvulus?

A

Endoscopic decompression followed by semi-elective surgery (high risk of recurrence)

53
Q

Most common age of sigmoid v. Cecal volvulus?

A

Sigmoid- 8th decade

Cecal- 6th decade

54
Q

What is the cause and treatment of cecal volvulus?

A

Cause- hereditary incomplete fixation of cecum mesentary, women > men

Tx- right hemicolectomy

55
Q

What is the etiology of chronic mesenteric ischemia?

A

Abdominal angina

Atherosclerotic disease

Location: proximal celiac, SMA, IMA (2 out of 3 must be involved due to collateral circulation)

56
Q

Typical presentation of chronic mesenteric ischemia?

A

Around 60 years, W >M

CVD risk factors

Postprandial pain

57
Q

Work up and treatment of chronic mesenteric ischemia?

A

CT angiogram, duplex US, MRA

Tx: Angioplasty, stenting, surgery

58
Q

Presentation of acute mesenteric arterial thrombosis?

A

Sudden pain, out of proportion to exam

Embolus > thrombus, usually to SMA

High mortality

59
Q

What is the etiology of ischemic colitis?

A

Low flow state

Usually occurs in watershed areas:

Splenic flexure, rectosigmoid junction (left colon)

60
Q

What is the typical presentation of ischemic colitis?

A

60+ years old (dehydrated, low BP)

Crampy pain, diarrhea, heme + stool, peritonitis

61
Q

Work up and treatment of ischemic colitis?

A

CT, MRA, colonoscopy

Tx: Liquid diet or IV fluids + antibiotics, possibly surgery

62
Q

Presentation of acute mesenteric venous thrombosis?

A

Hypercoagulable state

7-10 days of vague abdominal symptoms

63
Q

Work up and treatment of acute mesenteric venous thrombosis?

A

XR shows non specific findings and late findings like thumbprinting, pneumatosis, portal venous gas

Duplex US can show early signs

CT can show vessel enlargement, gas in walls, thick walls, fat streaking

Tx: Anticoagulation, thrombolytics- surgery if bowel infarction, peritonitis

64
Q

Intussusception presentation?

A

5-10 months, M > F

Classic triad: colicky abdominal pain, vomiting, currant jelly stool

65
Q

Intussusception diagnosis and treatment?

A

Sausage like mass on exam, US, barium enema

Tx: barium, water soluble or air contrast enema

66
Q

What is the rule of 2’s in Meckels diverticulum?

A

2% of population

2x more common in males

2 feet from ileocecal valve

67
Q

Presentation and diagnosis of Meckels diverticulum?

A

Kids- painless bleeding

Adults- obstruction

Meckels scan- technetium-99m pertechnetate scan

68
Q

Etiology of hypertrophic pyloric stenosis?

A

Hypertrophy and hyperplasia of the muscle layers of the pyloric sphincter

Narrows gastric antrum

69
Q

Presentation of hypertrophic pyloric stenosis?

A

M > F

1-18 weeks (3 wks)

Recent erythromycin/azithromycin use

Symptoms: nonbilious vomiting- infant still hungry, dehydration, weight loss

70
Q

Diagnosis and treatment of hypertrophic pyloric stenosis?

A

Olive like mass felt in RUQ

Order US

Tx: Surgery

71
Q

Presentation of Necrotizing enterocolitis?

A

Risk increases with prematurity

Feeding intolerance, vomiting, diarrhea

Triad: distention, bloody stools, pneumatosis intestinalis

72
Q

Treatment of necrotizing enterocolitis?

A

NG tube decompression

Antibiotics

TPN

01 Family Medicine (16 decks)

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