General Surgery Flashcards
At what anatomical landmark does the duodenum end?
Ligament of Trietz
What is the longest portion of the duodenum?
How many sections make up the duodenum?
Transverse
4
When “running the bowel” where do you start?
In what direction do you run the bowel?
Ligament of Trietz
Proximal to Distal
What section of the small intestine is the major site of absorption? and where is Iron absorbed
Where does the absorption of B12, bile, and folate occur?
Jejunum
Duodenum
Ilium
What artery supplies the small bowel?
Superior Mesenteric Artery- SMA
What structures receive blood supply from the IMA?
What are the branches of the IMA?
- 1/3rd Transverse colon
- Decending colon
- Sigmoid colon
- Upper portion of the rectum
Superior rectal artery, middle rectal artery, inferior rectal artery
Where is the marginal artery located anatomically?
Runs along colon margin providing collateral flow
What is the most common GI carcinoma?
What is the most common type?
Colorectal Cancer
Adenocarcinoma
What is the number one risk factor for gastric cancer?
What cancer type is gastric cancer?
H.Pylori Infection
Adenocarcinoma
What are risk factors for GI carcinomas?
- Smoking
- Diet (red meat, low fiber, high fat)
- Family history/genetics
- Inflammatory bowel disease
How does cancer spread?
- Direct extension
- Hematogenous
- Lymphogenous
- Transperitoneal
- Intraluminal
What is the most common site of distant metastasis from colorectal cancer?
1 Liver
Venous drainage distal (mc site of colorectal cancer)
IMV –> Splenic Vein –> Portal vein
Goals of Surgical Resection In Colon Cancer:
What is the goal of treatment if there are multiple mets or unresectable metastasis?
What if isolated to liver or lung met?
Maybe more appropriate for chemotherapy as palliative treatment
Possibly a candidate for resection
Shared decision making, many factors can determine treatment strategy
In an abdominoperineal resection (APR) of colorectal cancer what nerve is at greatest risk for being injured?
What are the longterm effects if damaged?
Pudendal Nerve
Impotence and Bladder Dysfunction
What are the types of anal cancer?
- Squamous
- Adenocarcinoma
- Melanoma
What is the diagnosis work-up for diverticulitis?
- Can be a clinical diagnosis
- CT scan is more often obtained
What are the signs/symptoms of diverticulitis?
- LLQ pain
- Fever
- Increased WBC
- Often precipitated by constipation
What should be considered in order to make the decision if a patient is treated outpatient or admitted for diverticulitis?
What is the treatment when admitted?
- Complicated vs. uncomplicated
- Uncontrolled pain
- Ability to tolerate diet and po abx
- Unreliable, complex or immunocompromised patients
Antibiotics + bowel rest
What qualifies as complicated diverticulitis?
Anything past the sigmoid colon
A 56-year old female is seen in the emergency department and diagnosed with uncomplicated diverticulitis. Upon discharge what should be included in the follow-up plan and recommended once resolved?
Colonoscopy in 4-6 weeks after resolution of acute diverticulitis
Per Lauren, 6-8 weeks is done more commonly clinically
What are characteristic features of Crohn’s Disease?
- Mouth to anus
- Full thickness involvement
- Skip lesions
- Cobble stoning of mucosa
- Granulomas
- Anal involvement (rectal involvement is rare)
What is included in the surgical management of Crohn’s Disease?
- Length preserving
- Surgery reserved for emergencies and patient’s who have failed medical management
- Segmental resections
- Stricturoplasty
What is the hallmark symptom for ulcerative colitis?
What is affected?
Bloody Diarrhea
Colon, anal involvement is rare
What are the surgical indications for ulcerative colitis?
- Massive hemorrhage
- Refractory toxic megacolon
- Obstruction
- Dysplasia
- Cancer
- FTT
- Unable to manage symptoms medically
What is the diagnosis when gallstones are located in the common bile duct?
What is the treatment?
Choledocholithiasis
ERCP is preferred
A 45-year-old female with a history of obesity presents with right upper quadrant abdominal pain and jaundice. Laboratory tests reveal elevated liver enzymes and total bilirubin. Imaging shows gallstones in the common bile duct. What is the most appropriate next step in management?
Elective cholecystectomy, typically laprascopic
What is an important anatomical landmark that is dissected during a cholecystectomy?
Calot’s Triangle
Hepatocystic triangle (aka Calot’s triangle) is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct must be identified before ligation and division to avoid intraoperative injur
What is Mirrizi Syndrome?
- Can mimic choledocholithiasis
- Compression of the common hepatic duct by a stone in the gallbladder or inflammation from the gallbladder
What is a motility disorder that affects the gallbladder?
How is it diagnosed?
Biliary Dyskinesia: motility disorder that affects the gallbladder, presents with biliary type pain and no gallstones
HIDA with CCK, Ejection Fraction (EF) < 35%
Which type of hernia occurs through a defect in the abdominal wall at the site of a previous surgical incision?
Incisional Hernia
Where do Spigellian Hernia’s occur anatomically?
Immediately superior to the arcuate line
How are hernias diagnosed?
- Clinical exam
- Ultrasound, pros and cons
- CT scan
What are the types of inguinal hernias?
- Direct: directly through Hesselbach’s trianlge, medial to epigastric vessels
- Indirect: Most common, lateral to epigastric vessels, patent prcesessus vaginalis
- Femoral: below inguinal ligament
- Pantaloon Hernia
What are the risks associated with inguinal repair surgery?
- Mesh infection
- Bleeding
- Infection
- Hernia reoccurance
- Injury to surrounding structures
What are the types of hiatal hernias?
When is surgical repair considered?
- Type I: Sliding hernia, often associated with GERD
- Type II: Paraesophageal
- Type III: Combined (GE junction and fundus)
- Type IV: Stomach plus another organ
Significant symptoms present; Surgical repair with Nisson fundoplication
Obstruction, Refractory GERD, Barrets Esophagus are considered significant symptoms
A 59-year old male with a past medical history of gallstones, hypertension and hyperlipidemia and obesity presents for concerns about his weight. His BMI in the office is 36. He is active in his job as a carpenter and goes to the gym twice a week. Despite this he has not been able to properly control his weight. Is he a candidate for gastric bypass surgery?
What is the criteria for gastric bypass surgery?
Yes, because his BMI is > 35 and has at least one comorbidity
BMI > 40 or > 35 w/comorbidity
What is a contraindication to bariatric surgery due to the high risk for marginal ulcers?
Smoking, all patients need to quit smoking prior to undergoing surgery
What is the presentation of appendicitis?
- Epigastric pain that migrates to the RLQ
- Hamburger sign (anorexia)
- N/V
- Sometimes can have change in stools
- +/- Tachycardic or febrile
What physical exams should be used to assess for appendicitis?
- Rosving’s Sign
- Obturator Sign
- Psoas Sign
What are the physical exam findings in appendicitis?
- RLQ tenderness at McBurney’s Point
- Psoas, Obturator, or Rosving’s sign
Where is McBurney’s Point?
located one-third of the distance from the anterior superior iliac spine to the umbilicus
What is the treatment for uncomplicated appendicitis?
What is the treatment for appendicitis with a fecolith present on imagin
- Conservative management with antibiotics
- Laparoscopic vs. open appendectomy
Appendectomy due to high risk of reoccurance
What risks are associated with appendectomies?
- Bleeding
- Infection, post operative abscess
- Scarring
- Conversion to open
- Damage to viscera requiring reoperation
- Staple line leak
What classifies an external hemorrhoid?
- Distal to dentate line
- Can cause pain, swelling, and itching
An internal hemorrhoid cause bleeding and can prolapse
What are conservative treatments for hemorrhoids?
- FIBER! Decrease straining, bulk stools
- Sitz baths
- Squatty potty
What is the presentation of necrotizing soft tissue infections?
- Erythema without sharp margins
- Edema extending beyond visible erythema
- Pain out of proportion to exam
- Fever
- Crepitus
- Skin bullae, necorsis or ecchymosis
- Tachycardia, hypotension with sepsis
What physical exam finding should suggest necrotizing skin infection until proven otherwise?
Crepitus
Just because you don’t have air doesn’t rule it out
What is the treatment for necrotizing soft tissue infections?
What broad spectrum antibiotics are used?
- TRUE EMERGENCY! Surgery should not be delayed
- Surgical debridement, likely multiple
Triple Therapy
Triple therapy includes:
- Carbapenem (Imipenem, Meropenem) OR Piperacillin-tazobactam (Zosyn)
- Vanco
- Clindamycin
What is the treatment for a DVT if anticoagulation is contraindicated?
Inferior Vena Cava Filter
What is atelectasis?
What can be heard on exam?
Collapse of alveoli due to inadequate alveolar expansion
Crackles and decreased breath sounds
What is the most common etiology of small bowel obstructions?
Most common is prior abdominal surgery, including cessarian section
What is the most common form of esophagitis in adults?
Reflux Esophagitis
What is Charcot’s Triad?
What condition is it associated with?
Fever, Jaundice, Abdominal Pain
Cholingitis
What is Reynold’s Pentade
What condition is it associated with what needs to be done emergently?
Fever, Jaundice, Abdominal Pain, Confusion, and Septic Shock (hypotension)
Cholangitis and ERCP Emergently
True or false: if a femoral hernia is asymptomatic, surgery is not always indicated.
False, they should always be fixed due to their high complication rate
What are the four layers of the large intestine?
- Mucosa
- Submucosa
- Muscularus
- Serosa
What electrolyte disturbance is common post thyroidectomy?
Hypocalcemia
What are the treatment steps for esophageal varacies?
What is prescribed to prevent rebleeds?
- Stabalize the patient: 2 large bore IV’s, IV fluids
- Endoscopic Intervention: variceal ligation is initial treatment of choice
- Octreotide is first line medical management can be used alone or adjucent with surgery
Nonselective beta-blockers (Nadolol or Propranalol)
