General Surgery Flashcards
Gastroesophogeal reflux
Vague sx, hard to distinguish. pH monitoring best. Typical case- overweight person, burning retrosternal pain, heartburn when bending over/tight clothes/flad in bed, relieved by antacids or h2 blockers. If long-standing history, concern = damage to lower esoph, possible Barret- do endoscopy/biopsy
Surgery for GERD
Appropriate in long-standing sx disease w/ no medical control. Necessary for ulceration or stenosis, or severe dysplastic changes. For latter, do resection, otherwise laparoscopic Nissen fundoplication. Verify acid reflux w/ pH, do endoscopy/biopsy to lower esoph, that lower esoph sphincter weak, do manometry and gastric emptying study, and a barrium swallow to see where esophagogastric jn is
Motility problems
Recognizable clin patterns- crushing pain w/ swallowing = uncoordinated massive contraction, dysphagia = achalasia (solids easier than liquids). D barium swallow then manometry
Achalasia
More common in woman, dysphagia worse for liquids, pt can sit up straight and wait to swallow. occasional regurg of food, x-ray shows MEGAESOPHAGUS. Dx w/ manometry, repeated dilatations or surgical myotomy (heller) for tx
Cancer of esophagus
Classic progression- dysphagia w/ meath, then solids, then soft foods, liquids, then several mo. saliva. Sig weight loss. Squam CC in men w/ somoking/drinking (esp in AA). Adenocarcinoma in long-standing GERD. Dx w/ endoscopy + biopsy, barium swallow first to prevent perforation. CT scan assesses operabiilty, often just palliative :(
Mallory Weiss tear
Prolonged forceful vom => BRB coming up. Endoscopy establishes dx, then photocoag
Boerhaave syndrome
Prolonged forceful vom => esoph perforation. Continous, severe wrenching epigastric/low sternal pain (sudden), then fever, leukocytosis + very sick pt. Swallow gastrografin (barium only if gg no work), then emergency surg repair. Delay is BAD
Instrumental perf of esophagus
Most common reason for perf, post endoscopy, sx develop. Emphysema in neck is dx, do contrast study + prompt repair
Gastric adenocarcinoma
More common in elderly. Arex, weight loss, vague epigastric distress, early satiety, occasional vom blood. Endo/biopsy for dx, then CT scan to assess operability. Surgry is best therapy
Gastric lymphoma
Almost as common as gastric adenocarcinoma. Tx w/ chemo/radiation. Surgery done if perforation feared as tumor melts. Low-graded lymphomatoid trans (MALTOMA) reversed by H. pylori erad
Mechanical intestinal obstruction
From adhesions from prior ex-lap. Colicky ab pain + protracted vom, progressive ab distention (if low obstruction), no poo or fart. Early- high-pitched bowel sounds and colikcy pain, then silence. xray w/ distented small bowel loops, air-fluid levels. Tx NPO, NG suction and Iv fluids, hope for spont resolution, watch for signs of strangu
Strangulated obstruction
Compromised blood supply, pt develops fever, leuko, constant pain, peritoneal irritation => periotnitis/sepsis. Emergency surgery required
Mech intestinal obstruction caused by incarcerated hernia
Same clinic picture as strangula, but with a hernia that’s no longer reducible. Do surgery to elim hernia but- emergently post rehydration if strangulation, electively in those that re reducible and have bowel
Carcinoid syndrome
Seen in pts w/ small bowel carcinoid tumor w/ liver mets. Diarrhea, face flush, wheezing, right-side vave damage. 24 hr urinary collection for 5hydroxyindolacetic acid for dx. If episodic, only high conc during attack
Acute appendicits
Anorexia, vague periumbilical pain => sharp, severe, constant, to RLQ. Tenderness, guarding, rebound to right/below belly. Modest fever and leukocytosis, neutrophilia/immature forms. If not classic pres, do a CT. Then surgery
Right colon cancer
Anemia (hypochromic, iron deficiency) in elderly, stool 4+ occult blood. Colonoscopy/biopsy dx, right hemicolectomy tx
Left colon cancer
Bloody bowel mvts, bload coats outside of stool, constipation, narrow stool. Flexible proctosigmoidoscopic exam + biopsy dx, then full colonoscopy to rule of synchronous secondary primary. CT scan to eval operability/extend. pre-op chemo/rads if large
Colonic polyps
Pre-malig possibility. Malignant potential most in familial polyposis (like Gardener), then villous adenoma, and last adenomatous polyp. Non-malig = juvenile, Peutz-Jegher, inflamm, and hyperplastic
Chronic ulcerative colitis (CUC)
manage medically. Surgical if longer than 20 years, severe interference w/ nutrition, multiple hopsitals, needing high dose steroids/immuno sup, or TOXIC MEGACOLON. Definitive treatment of CUC = remove colon, including rectal mucosa
Pseudomembranous enterocolitis
From c-dif, caused by clindamycin, or cephalos. Profuse watery diarrhea, cramps, fever, leuko. Look for toxin in stool, stop abx, no antidiarrheals, use metro, or vanco as alternate
Anorectal disease
rule out cancer by proper p/e (including proctosigmoidoscopic exam), even if it seems benign
Hemorrhoids
Bleed when internal 9tx rubber band ligation), hurt when external (need surgery if conservative fails). Internal hemmorhoids can be painful/itchy if prolapse
Anal fissure
Young women, pain w/ poop/ blood streaks on stool. fear of pain => not enough pooping, refuse exam, might need anesthesia. Fissue posterior at midline. Tight sphincter cause/perpetuates problem, so relax it w/ stool softener, topical nitroglycerin, botulin, dilatation or lateral internal sphincterotomy
Crohn’s (anal)
Starts w/ fissure/fistula/small ulceration, dx suspected if area fails to heal or gets worse after surgery (normally heals well)
Ischiorectal abscess (perirectal)
Febrile, super perirectal pain (can’t sit down or poop). P/e shows classif abscess lateral to anus, need I&D, rule out cancer w/ proper exam. if idabetes, could get bad necrotizing after, so watch
Fistula in ano
Post perirectal abscess, epithelial migration from anal crypts and perineal skin make a permane ttract. pt has fecal soiling and occasional perineal discomfort. P/e shows opening/openings lateral to anus. Cordlike tract, discharge expressed. rule out necrosis/draining tumor, treat w/ fistulotomy
squam cell carcinoma of anus
more common in HIV+ or homosexuals w/ receptive sex, fungating mass grows out of anus, mets in inguinal nodes. dx w/ biopsy, tx with nigro chemorads then surgery if residual
General GI bleed stats
3/4 upper Gi, 1/4 in colon/rectum, few in jejunum/ileum
Gi colon bleeds from angiodysplasia, polyps, divertic, cancer (old ppl). Hemorrhoids more common w/ age. Old person bleed = could be anywhere
young person GI bleed= upper GI (more likely)
Stats for when blood is per rectum
Vomiting blood
Upper GI (nose to lig of treitz). Also if blood in NG tube when bleeding per rectum. Otherwise upper GI endoscopy
Melena
Digested blood, so it is high up. Uper GI endoscopy
red blood per rectum
Come from anywhere (upper Gi if came down too fast). Dx w/ NG tube if actively bleeding (bloody means its upper Gi).
No blood in NG w/ white flluid? Check duod w/ upper Gi endo.
No blood w/ yellow fluid (bile), then it can’t be upper Gi at all
Active bleeding per rectum, not upper GI
Harder work up. exclud bleeding hemorrrhoids w/ anoscopy, colonscopy not helpful during active bleeding. Two options- if bleeding more then 2ml/min, angiogram + embolization. If less than .5 ml/min, wait till bleding stops, then colonscopy. In-between, do tagged red cell study, if it puddles, angiogram. Slow test though, so pt might not be bleeding by the end. But could guide a hemicolectomy in future. Or do a colonscopy later
Recent hx of blood per rectum?
if young, do Upper Gi, if old, then do full Gi endo
Blood per rectum in child
Most likely Meckel’s. workup w/ technetium scan, look for actopic gastric mucosa
Massive upper Gi bleed
stressed, multiple trauma, or post-op pt from stress ulcers. dx w/ endo, then angio embo, or avoid by maintaining gastric pH above 4
Acute ab pain
perforation, obstruction, inflamm, or ischemia
Perf ab pain
Sudden onset, constant/generalized/very severe. Won’t move, protects abdomen. Except in v old/sick, general peritonitis. Free air under diaphragm in upright x ray = dx. Perf peptic ulcer most common. SURGERY
Obstructive acute ab pain
sudden colikcy pian, typical location/radiation. pt moves constantly, seeking comfortable position. few physical findings
Inflamm acute abdomen
Gradual onset, slow build up at least 6 hrs, constant, starts ill-defined, locates to area over time, typical rads pattern. p/e of peritoneal irritation in affected area + systemic signs (leuko + fever), except in pancreatitis
Ischemic process
Combine severe ab pain + blood in gut lumen
